**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility policy, the facility failed to ensure appropriate care and services for urinary catheters were provided to prevent infection for one (Resident #455) of one resident sampled for urinary catheters. Findings included: A review of Resident #455's medical record revealed Resident #455 was admitted to the facility on [DATE] with diagnoses of urinary tract infection, retention of urine, and flaccid neuropathic bladder. A review of Resident #455's physician's orders revealed an order, dated 11/1/2023 for Ciprofloxacin 500 milligrams (mg) by mouth every 12 hours for 7 days for a diagnosis of urinary tract infection. An observation was conducted on 11/6/2023 at 10:04 AM of Resident #455 in his room. Resident #455 was observed resting in bed with his urinary catheter drainage bag stored inside of a privacy bag hanging from the left side of the bed. The privacy bag was observed resting on the floor and the tubing for Resident #455's urinary catheter was observed resting on the floor next to the resident's bed. An observation was conducted on 11/7/2023 at 1:17 PM of Resident #455 in his room. Resident #455 was observed resting in bed with his urinary catheter bag hanging from the left side of the bed. The catheter drainage bag and catheter tubing were not stored inside of the privacy bag hanging from Resident #455's bed and the tubing for Resident #455's urinary catheter was observed resting on the floor next to the resident's bed. An interview was conducted on 11/7/2023 at 1:21 PM with Staff B, Certified Nursing Assistant (CNA), Resident #455's assigned CNA for 11/7/2023 during the 7 AM to 3 PM shift. Staff B, CNA stated when she had a resident with a urinary catheter under her care, they were to ensure the catheter drainage bag and catheter tubing were kept off of the floor when hanging from the side of the resident's bed and should be stored in the privacy bag. Staff B, CNA observed Resident #455's urinary catheter tubing and addressed the catheter tubing was resting on the floor and she did not notice previously the urinary catheter tubing was resting on the floor. An interview was conducted on 11/7/2023 at 2:36 PM with Staff A, Registered Nurse (RN), Resident #455's assigned nurse on 11/7/2023 for the 7 AM to 3 PM shift. Staff A, RN stated when caring for a resident with a urinary catheter, they were to ensure the resident's catheter drainage bag and catheter tubing were kept off of the floor. Staff A, RN observed Resident #455's catheter tubing on the floor and stated the tubing should not be on the floor and should be stored in the privacy bag on the side of the bed. An interview was conducted on 11/9/2023 at 11:43 AM with the facility's Director of Nursing (DON). The DON stated if a resident with a urinary catheter was in their bed, the catheter drainage bag should be stored in the privacy bag provided with the catheter tubing tucked into the bag so it was not touching the floor. The DON also stated if the urinary catheter drainage bag and catheter tubing was stored inside of the privacy bag and the privacy bag was touching the floor it would be acceptable because the privacy bag is acting as a barrier to protect the catheter drainage bag and catheter tubing from any potential infection issues. The DON stated if catheter tubing or the catheter bag were observed resting on the floor she would expect it to be changed out by the nursing staff and it was best practice to ensure the catheter bag and catheter tubing were kept off of the floor. A review of the facility policy titled Catheter Care, Urinary, last revised in August 2022, revealed under the section titled Purpose the purpose of the procedure is to prevent urinary catheter-associated complications, including urinary tract infection. The policy also revealed under the section titled Infection Control staff are to ensure the catheter tubing and drainage bag are kept off of the floor. Photographic evidence was obtained.

Based on observation, interview, and review of facility procedures, the facility failed to ensure proper storage of respiratory equipment in accordance with professional standards of practice for two (Resident #92 and Resident #32) of two residents sampled for respiratory care. Findings included: A review of Resident #92's medical record revealed Resident #92 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD) and pneumonia. A review of Resident #92's physician's orders revealed an order, dated 10/26/2023 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. A review of Resident #92's care plan revealed a focus area initiated on 6/27/2023, Resident #92 had a potential for complications of respiratory distress related to COPD and shortness of breath when lying flat with an intervention to store respiratory equipment in an infection control bag when not in use and change every week and as needed. An observation was conducted on 11/6/2023 at 12:46 PM in Resident #92's room. Resident #92 was observed sitting in a wheelchair in front of his bed and wearing a nasal cannula. Resident #92 stated he used oxygen because he had COPD and he also received breathing treatments when needed. A nebulizer mask was observed on Resident #92's bedside table, which was attached to a nebulizer machine. The nebulizer bag was not stored inside of an infection control bag. A nasal cannula attached to an oxygen concentrator was observed next to Resident #92's bed. The oxygen cannula and tubing were observed tucked between the bed rail and mattress on Resident #92's bed and not stored inside of an infection control bag. An observation was conducted on 11/7/2023 at 1:15 PM in Resident #92's room. Resident #92 was observed resting in bed with an oxygen nasal cannula applied to his face. A nebulizer mask was observed on Resident #92's bedside table, which was attached to a nebulizer machine. The nebulizer bag was not stored inside of an infection control bag. A review of Resident #32's medical record revealed Resident #32 was admitted to the facility with diagnoses of COPD and traumatic brain injury. A review of Resident #32's physician's orders revealed an order, dated 3/14/2023 for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. A review of Resident #32's care plan revealed a focus area initiated on 9/26/2023, Resident #32 had a potential for complications of respiratory distress related to COPD with an intervention to store respiratory equipment in an infection control bag when not in use and change every week and as needed. An observation was conducted on 11/7/2023 at 10:45 AM in Resident #32's room. Resident #32 was observed resting in bed. An oxygen concentrator was observed at Resident #32's bedside. An oxygen nasal cannula was observed inside of a storage bag hanging from the oxygen concentrator and resting on the floor. The storage bag was dated 11/2/2023. An interview was conducted on 11/7/2023 at 2:44 PM with Staff A, Registered Nurse (RN). Staff A, RN stated respiratory equipment, such as nebulizer masks and oxygen tubing, were stored in a bag when not in use by the resident and were usually changed on a weekly basis or as needed. Staff A, RN also stated he ensured nebulizer masks were stored in the appropriate bag after administering a breathing treatment to a resident. An interview was conducted on 11/9/2023 at 11:32 AM with the facility's Director of Nursing (DON). The DON stated oxygen tubing and nebulizer masks were changed out on a weekly basis by a third party company and on an as needed basis by the facility nursing staff if the item was soiled or dropped on the floor. Respiratory equipment was stored inside of an infection control bag when not in use, which was also changed out on a weekly basis. If facility staff observed a resident did not have an infection control storage bag for their respiratory equipment, it should be replaced. The DON stated if respiratory equipment was stored in an infection control bag and the bag was resting on the floor, there would not be any issues related to infection control because the bag was protecting the respiratory equipment. The DON also stated she would expect facility staff to ensure the infection control bags were kept off of the floor but they would not need to replace the bag if it had been on the floor as long as the infection control bag was not compromised. A review of the facility procedure titled Administering Medications through a Small Volume (Handheld) Nebulizer, last revised in October 2010, revealed under the section titled Purpose the purpose of the procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. The procedure also revealed under the section titled Steps in the Procedure after obtaining post-treatment pulse, respiratory rate, and lung sounds, discard any left over solution and allow container to air dry. When equipment is completely dry, store in a plastic bag with the resident's name and date on it. A policy related to storage of oxygen tubing was requested on 11/8/2023 at 12:35 PM from the facility's Director of Nursing. A policy was not provided by the facility.

Based on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and eleven errors were identified for one (Resident #355) of three residents. These errors constituted a 44% medication error rate. Findings Include: On 11/08/23 at 10:55 a.m., an observation of medication administration with Staff C, Registered Nurse (RN) was conducted for Resident #355. Staff C dispensed the following medications: -Multivitamin tablet (one) -Aspirin 81 milligrams (mg) chewable (one) -Iron 65 mg tablet (one) -Lisinopril 5 mg tablet (one) -Plavix 75 mg tablet (one) -Cymbalta 30 mg tablet (one) -Meloxicam 7.5 mg tablet (one) -Miralax 75 grams (gr) (one) Ketoralac 0.5% eye drops (one drop in each eye) A review of Resident #355's November Medication Administration Record (MAR) revealed medications were scheduled for 9:00 a.m. An interview with Staff C was conducted immediately after medication administration of Resident #355. Staff C admitted the medications were outside the allotted time to give the medication, She stated the expectation was to administer medication one hour prior to and up to one hour after the scheduled time ordered by the physician. When asked what should be done if medications are out of the time allotted for medication, Staff C said the physician should be notified immediately prior to medication being administered for further update or orders. Staff C did not call the ordering physician prior to administration of late medications. Resident #355 swallowed the prescribed chewable Aspirin along with her other medications from one medication cup. The resident was never instructed to take the Aspirin as a chewable per physician orders. Staff C admitted to not following physician orders by instructing Resident #355 to chew the Aspirin. Resident #355 had a physician order for [brand name] oral capsule (Multiple Vitamins with Minerals). Resident #355 received a multivitamin tablet. An interview was conducted with Staff D, RN/Unit Manager (UM) for the [NAME] wing on 11/08/23 at 11:24 a.m. regarding timeliness of medication administration. Staff D stated medications should be dispensed one hour up to scheduled time and up to one after scheduled time per physician orders. Staff D stated the ordering physician should be notified of the late time frame either for notification purposes or for new orders. Staff D stated time management should have been factored in and if this nurse was behind on medication administration, she, Staff D, would have assisted Staff C. A review of Resident #355's November Medication Administration Record (MAR) identified the following physician orders: Aspirin 81 mg Chewable, give one by mouth one time a day related to Transient Cerebral Ischemic Attack, [brand name] oral capsule (Multivitamin with Minerals), give one tablet by mouth one time a day for vitamins. An interview was conducted on 11/09/23 at 2:20 p.m. with the contracted pharmacist consultant. The pharmacy consultant was updated on the medication incident and stated the expectation was to administer medication on a timely basis. The pharmacy consultant also stated [brand name] was a special multivitamin which included Vitamin A added for vision health. An interview with the Director of Nursing (DON) was conducted on 11/09/23 at 12:17 p.m. regarding the timeliness of residents' medication administration. The DON's expectations were for the medications to be pulled based on the physician's orders and based on the Five Rights of Medication: Right resident, Right drug, Right time, Right dose, and Right route. The DON stated timeliness of medication administration was one hour prior to and up to one hour after scheduled ordered time. This time frame would be considered timely and any time after would warrant a call to the physician and family. The DON stated medications should be administered by the correct route in which case Resident #355's Aspirin should have been separated from the other medication with the instructions for the resident to chew the medication as ordered. The DON stated [brand name]oral capsule (Multiple Vitamins with minerals) was in the medication cart but Staff C, RN inadvertently gave a multivitamin. The DON stated she would run the Dashboard from the electronic charting to look to see how medication pass could be more effective and manageable. The DON stated Staff C should have asked for assistance from fellow coworkers. A review of the facility's policy, Administering Medication, revised April 2019, states the following in relation to medication administration: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one hour of their prescribed time unless otherwise specified, for example before and after meal orders. 10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method or route of administration before giving the medication. A review of the facility's policy, Medication Administration Schedule, revised December 2012 states the following in relation to scheduling of medication(s). Daily medications scheduled for 9:00 a.m. and medications that are two times daily are scheduled for 9:00 a.m. and 5:00 p.m.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards by 1.) failing to ensure medications were securely stored and dispensed for two (Resident #83 and Resident #355) of thirty five sampled residents, 2.) failing to ensure one of six medication carts in the facility were kept locked when unattended by staff, 3.) failing to ensure medications were properly dated when opened in three of three medication carts, and 4.) failing to ensure medication carts were free of expired medications in one of three medication carts. Findings included: An observation was conducted on 11/7/2023 at 10:14 AM in Resident #83's room. A medication bottle containing over-the-counter medication was observed on Resident #83's bedside table. Resident #83 was not observed in the room at the time of the observation. An interview was conducted on 11/7/2023 at 1:27 PM with Resident #83. Resident #83 stated she brought the over-the-counter medication into the facility when she was admitted to the facility. An observation was conducted on 11/6/2023 at 11:46 AM on the 600 unit of the facility. A medication cart was in the unit hallway and was unlocked. No staff members were in the proximity of the unlocked medication cart. Staff A, Registered Nurse (RN), who was assigned to the medication cart, was observed at the unit nurse's station sitting in a chair. An interview was conducted on 11/7/2023 at 2:50 PM with Staff A, RN. Staff A stated all medications should be stored in the medication cart and if a resident brought a medication from home it would be stored inside of the medication room. Staff A also stated residents were not permitted to have medications in their rooms. Staff A stated medication carts should be locked if they were left unattended and should not be left unlocked. An observation was conducted on 11/8/2023 at 11:07 AM in Resident #355's room during medication administration with Staff C, RN. A medication bottle containing over-the-counter medication, a bottle of nasal spray, and a tube containing a topical medication was observed on Resident #355's bedside table during medication administration. Resident #355 stated she brought the medications from home when she was admitted to the facility. Staff C observed the medications on Resident #355's bedside table and informed the resident the medications needed to be taken out of the room and secured due to not having a physician's order to self-administer medications. Staff D, RN Unit Manager (UM) entered the room and informed Resident #355 she would contact the resident's physician to get approval for having the medications with her in the room and the medications would be secured in the medication cart until then. An interview was conducted following the observation with Staff D, RN UM. Staff D stated residents who wish so self administer medications must be assessed for their ability to self administer the medications and the resident's care plan must be update. Staff D also stated medications must be kept secured at all times, even if the medications were approved to be located in the resident's room. An inspection of a medication cart on the 200 unit was conducted on 11/9/2023 at 9:42 AM with Staff E, RN. The inspection of the medication cart revealed the following: - An open Humalog insulin KwikPen stored in a plastic bag with a hand written date of 10/11/23 on a label affixed to the bag. Pharmacy directions on printed on the label read once opened, store at room temperature for 28 days. Staff E verified the KwikPen was opened on 10/11/2023 and the medication expired after 28 days. Staff E addressed the insulin KwikPen expired on 11/8/2023 and the insulin pen should be removed from the medication cart. - A card containing seven tablets of Alprazolam 1 milligram (mg) with a printed expiration date of 10/31/2023. Staff E verified the medication was expired and should be removed from the medication cart. An inspection of a medication cart on the 300 unit was conducted on 11/9/2023 at 10:07 AM with Staff F, Licensed Practical Nurse (LPN) UM. The inspection revealed an open insulin glargine KwikPen stored inside of a plastic bag with a white Date Opened label affixed. No date was documented on the Date Opened label. Staff F was not able to state when the insulin KwikPen was opened and stated the medication should be dated when opened. An inspection of a medication cart on the 500 unit was conducted on 11/9/2023 at 10:22 AM with Staff G, LPN. The inspection revealed an open Lantus insulin pen stored inside of a plastic bag with a white Date Opened label affixed. No date was documented on the Date Opened label. Staff G was not able to state when the insulin pen was opened and stated the medication should be dated when opened. An interview was conducted on 11/9/2023 at 11:47 AM with the facility's Director of Nursing (DON). The DON stated when a resident was admitted to the facility, an inventory of the resident's belongings was taken and the resident's nurse would ask the resident or representative if any medications had been brought into the facility. If a resident brought medications into the facility, the medication was sent home with the resident's family unless the resident was assessed and was able to self administer the medications. If a resident wished to self administer medications, the resident's physician was notified and an order for the medication would be obtained. The resident was provided a locked box or drawer to ensure the medications were secured inside of the room because medications could not be left out at the resident's bedside. The DON stated she would expect nursing staff to keep the medication carts clean, ensure medications were not expired, and to discard medications appropriately if an expired medication was discovered. Insulin vials and pens should be dated when they were opened and the expiration date of the medication should also be documented. Expired medications should be returned to the pharmacy and expired controlled medications should be taken to the DON's office after the pharmacy was notified. The DON also stated she would expect nursing staff to ensure medication carts were locked at all times. An telephone interview was conducted on 11/9/2023 at 3:08 PM with the facility's Consultant Pharmacist (CP). The CP stated a nurse from the pharmacy conducted regular visits to ensure medication carts were clean, medications were all dated when opened, and no expired medications were in the medication carts. All insulins were good for 28 days after they were opened with the exception of Levemir, which had a 42 day expiration window. Expired medications should be removed from the medication cart and reordered from the pharmacy. The CP stated medications should not be left out in a resident's room and should be stored securely. The CP also stated medication carts should not be left unlocked unless the nurse is present at the medication cart. A review of the facility policy titled Administering Medications, last revised in April 2019, revealed under the section titled Policy Statement medications are administered in a safe and timely manner, and as prescribed. The policy also revealed the following under the section titled Policy Interpretation and Implementation: - The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. - During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. - Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary team, has determined that they have the decision-making capacity to do so safely. A review of the facility policy titled Self-Administration of Medications, last revised in February 2011, revealed under the section titled Policy Interpretation and Implementation self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. A review of the facility policy titled Medication Labeling and Storage, last revised in February 2023, revealed under the section titled Policy Statement the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. The policy also revealed the following under the section titled Policy Interpretation and Implementation: - If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. - Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. - Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, record review, and staff interview, the facility failed to ensure the sanitizer solution reached the low temperature dish machine by way of pump and tubing, failed to maintain the chlorine concentration between 50-100 ppm (parts per million) per manufacturer recommendations, and failed to maintain the ice machine in one of two nourishment rooms in a clean and sanitary manner. Findings included: On 11/06/2023 at 9:07 a.m., a general tour of the kitchen was conducted. While conducting the tour, the Dietary Manager was observed operating the dish machine. The dish machine log was reviewed for the week of (10/30-11/05) and revealed daily water temperatures as well as sanitizer concentration logged three times a day except for 11/05 at 1:00 p.m. and 7:00 p.m. The log revealed water temperatures of 150 degrees F and sanitizer concentration of 200 ppm (parts per million) for each day the log was completed. The instructions at the bottom of the form showed chlorine concentration must be between 50-100 ppm. Per the instructions, the logged sanitizer concentration was outside of range requirements. The Dietary Manager revealed they have and operate a Low temperature dish washing machine with wash temperatures to reach at least 120 degrees F and the rinse temperatures to reach at least 120 degrees F. The dish machine was observed with the Dietary Manager running empty crates through the dish washing machine. The Dietary Manager stated you must prime the dish machine three or four times to reach the required range for the sanitizer concentration and she was usually the one to get it started in the morning. Observations of the front of the machine revealed the specification place which indicated the sanitizer requirement was 50 ppm. The first dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The second dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The third dish machine operation demonstration revealed the paper used to test the chlorine sanitizer changed to a very dark black/purple and did not meet the color requirement to show there was sanitizer reaching 50-100 ppm. The Dietary Manager stated that was too high. The fourth dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The fifth dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The sixth dish machine operation demonstration revealed the Dietary Manager placed the paper used to test the chlorine sanitizer on a plastic container and the color changed to a very light color of purple and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The seventh dish machine operation demonstration revealed the paper used to test the chlorine sanitizer changed to a very dark black/purple and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The eighth dish machine operation demonstration revealed the paper used to test the chlorine sanitizer stayed a color of white and did not change to meet the color requirement to show there was sanitizer reaching 50-100 ppm. The Dietary Manager stated she had never had the machine not reading accurately this many times and that she would give the dish machine company a call. The Dietary Manager stated they would not use the dish machine and they would use the three compartments sink to wash dishes. On 11/06/2023 at 10:53 a.m., the Dietary Manager reported the dish machine was fixed. There was a crack in the line, and it was causing negative pressure. The sanitizer was getting to the machine, but the machine was not allowing it to flow through. On 11/06/2023 at 11:33 a.m., dining was observed in the main dining room. Staff H, Dietary Aide, was observed placing utensils (spook, fork, and knife) on the table and on a white napkin for each resident. The utensils were observed wet. Staff H, Dietary Aide, stated the utensils were wet because they had just finished washing dishes because the dish machine was broken. We had to rush rush, stated Staff H, Dietary Aide. The utensils were observed in a crate, and they were all wet. The cart that the crate was sitting on was wet also. On 11/08/2023 at 11:45 a.m., a tour of the nourishment room on the east wing was conducted with the Dietary Manager. A pink and black buildup was observed underneath the dispenser on the ice machine (photographic evidence obtained). This was confirmed by the Dietary Manager. On 11/09/2023 1:44 p.m., an interview was conducted with the Dietary Manager and the Administrator. The Dietary Manager reported they switched to a new form to document water temperatures and sanitizer concentration so that was probably where the confusion came in and why staff were documenting 200 ppm. She said she was responsible for checking the forms to ensure staff were documenting and testing sanitizer accurately. The policy provided by the facility Ware Washing revised October 2019 revealed the following: 3. The Dining Services Director is responsible for insuring appropriate completion of temperature and/or sanitizer concentration logs as appropriate. 4. The Dining Services Director ensures that all dishware is air dried and properly stored. The policy provided by the facility Ice Machines and Ice Storage Chests revised January 2012 revealed the following: Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. Policy Interpretation and Implementation 3. Our facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and a review of the policy and procedure Resident Mistreatment, Neglect and Abuse Prohibition Guidelines, the facility failed to ensure an alleged allegation related to abuse for one resident (Resident #32) out of the sampled twenty-nine residents was reported immediately to the governing agency in accordance with the State law. Findings included: A review of the admission Record for Resident #32 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of osteomyelitis. Other diagnosis included but was not limited to generalized anxiety disorder. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #32 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that he was cognitively intact. On 09/01/21 at 9:05 a.m., Resident #32 was observed in his room sitting in the wheelchair next to the bed. Resident #32 reported about a week and a half ago, Staff T, Certified Nursing Assistant (CNA), pushed his room door while he was standing behind the door and slammed him against the cabinet behind the door. He stated Staff T then started arguing with him and said that the door had to be opened. Resident #32 stated he went to close the door, but Staff T did not want the door closed and knocked him into the cabinet with the door. He stated he was trying to close the door because he did not want to disrobe in the front of staff in the hallway. Resident #32 stated that the Social Services Director (SSD) told him to write everything on paper, but never came back to get his statement. A review of the Grievance /Concern Report dated 08/14/21 indicated that the resident reported that the staff did not want him to close the door as he changed his shirt. The Resolution section of the report indicated that the writer spoke with staff regarding recent concern. The Follow-Up section indicated that the writer spoke with resident and explained the reason why the door had to be open. A review of the Abuse/Exploitation/Neglect Tracking for August 21 did not reveal an allegation related to this incident. On 09/01/21 at 12:02 p.m., the SSD reported that Resident #32 reported that he wanted the door closed to his room to change his shirt. He did not want to leave the door open, and females were around. Staff were passing trays during breakfast and the CNA explained to him that he needed to leave the door open because he needed to check on the roommate while he was eating his breakfast. Staff T wanted him to go into the restroom and Resident #32 got upset and started screaming. The SSD reported that during her investigation process she spoke to Resident #32, the nurse, and the CNA. She stated Resident #32 did not turn in his written statement. On 09/01/21 at 12:36 p.m., the SSD reported that the incident happened on 08/14. The SSD reported that there was another CNA in the hallway during the time of the incident, but she did not have a statement from her. The SSD reported that when she went to follow up with Resident #32, he stated that he did not have a concern. He was only concerned that he could not close his door. The SSD presented a statement from staff T that revealed that Resident #32 accused him and another CNA of verbally assaulting him. On 09/01/21 at 4:13 p.m., Staff T stated that he did not remember the day the incident happened. He was asked to write a statement. Resident #32 kept closing the door to the room. The resident in bed B needed assistance with his meal due to aspiration and choking risk, so the door needed to be open to observe him. He always closes the door and he's been told multiple times that they needed clear sight to B bed stated Staff T. While getting ready to take in bed B's tray, Resident #32 was behind the door. The resident said he was changing and asked if he could come back. Staff T stated he told him to pull the curtain or go to the bathroom. Resident #32 went off on a rant that the door hit him which it didn't stated Staff T. He said he was going to report to the cops about the abuse and two other coworkers were immediately outside of the door. Both coworkers Staff V, CNA, and Staff U, CNA, chimed in because Resident #32 gets loud fast. They reiterated to Resident #32 to go to the bathroom or change behind the curtain. The resident was recording with his phone, and he stated to him that's ok that you're recording but we need access to bed B. Resident #32 proceeded to use racist words. The SSD asked him to write a statement about the incident. Staff T asked, Why is it happening now? Why are they doing the investigation now and this happened weeks ago, asked Staff T. Staff T reported that he was never suspended. He was just told this evening that he had to leave while the investigation was going on. Stated he asked the Administrator why he was just now getting suspended. Staff T stated he was never educated after the incident happened. He stated he was assigned to Resident #32 on that day of the incident and had worked with him whenever he was assigned to work. On 09/03/21 at 2:07 p.m., Staff U, CNA, stated on the day of the incident she heard words and raised voices, asked them to keep it down. A staff member was talking to another staff member, and he said he didn't have a right to close his door. They were talking at the same time. Another staff member was telling Resident #32 the same thing. She did not know what happened during or after the incident. Resident #32 stated he was known to snap necks. On 09/03/21 at 10:19 a.m., Staff V, CNA, was contacted. A voicemail was left for a return call. On 09/03/21 at 12:15 p.m., in an interview with the Administrator and the SSD, the SSD reported that the resident only complained that he wanted the door closed because he was changing his shirt, but the CNA wanted the door opened to watch the roommate. After that she went to the nurses' station and asked the staff what was going on. Spoke with the nurse and Staff T. The nurse said they explained to the resident that the door had to be opened. Staff T stated that the resident was very mean to him and started yelling. The SSD reported that she had Staff T to write a statement. Another resident came to her office and said she heard Resident #32 in the hall and Resident #32 was not very nice. The SSD stated that Resident #32 never mentioned that he was verbally assaulted and that he only wanted to close the door. The SSD reported confirmed that Staff T's statement read that the resident stated he was verbally assaulted, but she did not report the allegation as abuse because the resident stated he did not have a concern when she went to talk to him. When you get an allegation of abuse, it should be reported and investigate stated the Administrator. The policy provided by the facility, Resident Mistreatment, Neglect and Abuse Prohibition Guidelines dated August 2018 revealed the following: Purpose All allegations of abuse, neglect, injuries of unknown origin and misappropriation or mistreatment of resident property are to be reported immediately and investigated per state and federal regulations. Reporting/Response Regulations require employees that provide services to elderly persons or dependent adults (mandated reporters) to report instances of abuse, neglect, or misappropriation/exploitation of resident property to the state survey agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if the alleged violation involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in serious bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that facility responsibilities to protect residents and promptly investigate occurrences may be met. The facility administration is required to report to the State licensing authority any knowledge of actions by a court of law which would indicate an employee is unfit for services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to take the appropriate actions in response to an alleged violation related to abuse inflicted by direct care staff such as thoroughly investigate the alleged violations to prevent further abuse, neglect, and mistreatment from occurring for one resident (Resident #32) out of the sampled twenty-nine residents. Findings included: A review of the admission Record for Resident #32 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of osteomyelitis. Other diagnosis included but was not limited to generalized anxiety disorder. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #32 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating that he was cognitively intact. On 09/01/21 at 9:05 a.m., Resident #32 was observed in his room sitting in the wheelchair next to the bed. Resident #32 reported about a week and a half ago, Staff T, Certified Nursing Assistant (CNA), pushed his room door while he was standing behind the door and slammed him against the cabinet behind the door. He stated Staff T then started arguing with him and said that the door had to be opened. Resident #32 stated he went to close the door, but Staff T did not want the door closed and knocked him into the cabinet with the door. He stated he was trying to close the door because he did not want to disrobe in the front of staff in the hallway. Resident #32 stated that the Social Services Director (SSD) told him to write everything on paper, but never came back to get his statement. A review of the Grievance /Concern Report dated 08/14/21 indicated that the resident reported the staff did not want him to close the door as he changed his shirt. The Resolution section of the report indicated that the writer spoke with staff regarding recent concern. The Follow-Up section indicated that the writer spoke with resident and explained the reason why the door had to be open. A review of the Abuse/Exploitation/Neglect Tracking for August 21 did not reveal an allegation related to this incident. On 09/01/21 at 12:02 p.m., the SSD reported that Resident #32 reported that he wanted the door closed to his room to change his shirt. He did not want to leave the door open, and females were around. Staff were passing trays during breakfast and the CNA explained to him he needed to leave the door open because he needed to check on the roommate while he was eating his breakfast. Staff T wanted him to go into the restroom and Resident #32 got upset and started screaming. The SSD reported that during her investigation process she spoke to Resident #32, the nurse, and the CNA. She stated Resident #32 did not turn in his written statement. On 09/01/21 at 12:36 p.m., the SSD reported the incident happened on 08/14/21. The SSD reported there was another CNA in the hallway during the time of the incident, but she did not have a statement from her. The SSD reported when she went to follow up with Resident #32, he stated that he did not have a concern. He was only concerned that he could not close his door. The SSD presented a statement from Staff T that revealed that Resident #32 accused him and another CNA of verbally assaulting him. On 09/01/21 at 4:13 p.m., Staff T stated he did not remember the day the incident happened. He was asked to write a statement. Resident #32 kept closing the door to the room. The resident in bed B needed assistance with his meal due to aspiration and choking risk, so the door needed to be open to observe him. He always closes the door and he's been told multiple times that they needed clear sight to B bed stated Staff T. While getting ready to take in bed B's tray, Resident #32 was behind the door. The resident said he was changing and asked if he could come back. Staff T stated he told him to pull the curtain or go to the bathroom. Resident #32 went off on a rant that the door hit him which it didn't stated Staff T. He said he was going to report to the cops about the abuse and two other coworkers were immediately outside of the door. Both coworkers Staff V, CNA, and Staff U, CNA, interjected because Resident #32 gets loud fast. They reiterated to Resident #32 to go to the bathroom or change behind the curtain. The resident was recording with his phone, and he stated to him that's ok that you're recording but we need access to bed B. Resident #32 proceeded to use racist words. The SSD asked him to write a statement about the incident. Staff T asked, Why is it happening now? Why are they doing the investigation now and this happened weeks ago, asked Staff T. Staff T reported that he was never suspended. He was just told this evening that he had to leave while the investigation was going on. Stated he asked the Administrator why he was just now getting suspended. Staff T stated he was never educated after the incident happened. He stated he was assigned to Resident #32 on that day of the incident and had worked with him whenever he was assigned to work. On 09/03/21 at 2:07 p.m., Staff U, CNA, stated on the day of the incident she heard words and raised voices, asked them to keep it down. A staff member was talking to another staff member, and he said he didn't have a right to close his door. They were talking at the same time. Another staff member was telling Resident #32 the same thing. She did not know what happened during or after the incident. Resident #32 stated he was known to snap necks. On 09/03/21 at 10:19 a.m., Staff V, CNA, was contacted. A voicemail was left for a return call. On 09/03/21 at 12:15 p.m., in an interview with the Administrator and the SSD, the SSD reported that the resident only complained that he wanted the door closed because he was changing his shirt, but the CNA wanted the door opened to watch the roommate. After that she went to the nurses' station and asked the staff what was going on. Spoke with the nurse and Staff T. The nurse said they explained to the resident that the door had to be opened. Staff T stated the resident was very mean to him and started yelling. The SSD reported she had Staff T write a statement. Another resident came to her office and said she heard Resident #32 in the hall and Resident #32 was not very nice. The SSD stated that Resident #32 never mentioned that he was verbally assaulted and that he only wanted to close the door. The SSD reported confirmed that Staff T's statement read that the resident stated he was verbally assaulted, but she did not report the allegation as abuse because the resident stated he did not have a concern when she went to talk to him. When you get an allegation of abuse, it should be reported and investigate stated the Administrator. The policy provided by the facility, Resident Mistreatment, Neglect and Abuse Prohibition Guidelines dated August 2018 revealed the following: Purpose All allegations of abuse, neglect, injuries of unknown origin and misappropriation or mistreatment of resident property are to be reported immediately and investigated per state and federal regulations. Reporting/Response Regulations require employees that provide services to elderly persons or dependent adults (mandated reporters) to report instances of abuse, neglect, or misappropriation/exploitation of resident property to the state survey agency (AHCA), Department of Children and Families (DCF) and local law enforcement agency within 2 hours if the alleged violation involves abuse or results in serious bodily injury or as soon as practically possible within 24 hours of detection if the alleged violation does not involve abuse and does not result in serious bodily injury. All employees are required to promptly report the facts of known or suspected instances of abuse to their direct supervisor on duty, Abuse Coordinator, Administrator, and/or Director of Nursing (either directly or anonymously), so that facility responsibilities to protect residents and promptly investigate occurrences may be met. The facility administration is required to report to the State licensing authority any knowledge of actions by a court of law which would indicate an employee is unfit for services.

Based on observation, interview and record review, the facility failed to ensure the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and two errors were identified for two (Resident #81 and #258) of five residents observed. These errors constituted a medication error rate of 8.00 percent. Findings included: On 09/02/2021 at 8:45 a.m., an observation was conducted of Staff A, Licensed Practical Nurses (LPN) administering medication to Resident #81. During the observation Staff A, LPN was observed administering Metoprolol Succinate ER (Extended-Release) 24 Hour 50 milligrams (MG) Give one (1) Tablet by one time a day for Diagnosis of Hypertension. The medication had on the pharmacy label Do not Crush. Staff A, LPN was observed to place the tablet in a clear packet and crushed the medication, and then placed them in apple sauce in a clear medication cup with other 9:00 a.m. medications and administered them to Resident #81. An immediate interview was conducted with Staff A, LPN, who revealed that she did realize they were Extended-Release medications and should not be crushed. She stated, I didn't see that. On 08/11/2021 at 10:07 a.m., an observation was conducted of Staff B, LPN, on the 300 Hall, administering medications to Resident #258. Staff B, LPN was observed administering Humalog Kwik-Pen Solution Pen Injector 100 Unit/milliliter (ML) (Insulin Lispro 1 Unit) Dial Inject 12 Units Subcutaneously with meals for Diabetes Mellitus (DM). Record review of active Physician Orders and the Medication Administration Record (MAR) for Resident #258, revealed that the medications administered to the resident were given late, and scheduled to be administered at 8:00 a.m. On 09/02/2021 at 12:05 p.m. an interview was conducted with the Staff C, LPN, Unit Manager (UM) for the 100-300 Halls. Staff C, UM was informed of the observations made of Staff B, LPN administering insulin late and stated, The staff that work here know the importance of giving insulin on time, because it can mess everything up. An interview was conducted on 09/02/2021 at 12:13 p.m. with the Regional Nurse Consultant, she was informed of observations made during medication administration for Resident #81 and #258. She stated, the physician was in just now, and he reviewed all the medications for Resident #81, because ER should not be crushed. She further indicated the physician changed all the of Resident #81's medications to be crushed. The Regional Nurse Consultant stated, For Resident #258 the insulin medication was late, and that is an error. On 09/03/2021 at 12:52 p.m., a telephone interview was conducted with the facility's Pharmacy Consultant. He was informed of observations made of Staff A, LPN and Staff B, LPN administering medications late and crushing an Extended-Release medication, both of which were not administered according to the Physician orders. He stated Did she (Staff A) not read the label on the card of crushing the Extended-Release medication? That is bad, and the insulin was given incorrectly not at the correct time, they are both medication errors. A facility provided policy titled, Administering Medications, revision date April 2019, Page 01 of Page 03 reads under Policy and Procedure, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 10. The individual administering medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) before giving the medication.

Based on observation, interviews and record review the facility failed to ensure medications were secured appropriately, as evidenced by: 1) an unsecured and unattended box of medications on top of one (300 hall) of three medication carts observed; 2) loose and unidentified medications in two (100 hall and 300 hall) of three medication carts observed; and 3) staff personal items stored in one (100 hall) of three medication carts observed. Findings included: On 09/02/2021 at 9:45 a.m., Staff J, Certified Nursing Assistant (CNA)/Central Supply Technician was observed placing a box of Nicotine Transdermal System Step One Patches on top of the 100-hall medication cart and walking away. There were no staff nearby or in the vicinity of the medication cart. Several residents were observed to be self-propelling in wheelchairs nearby the medication cart which was located in a high traffic area on the 300 Hall. The surveyor was observed by Staff F, Regional Nurse Consultant and went over to the cart, and removed the medication from the top of the medication cart. In an immediate interview during the observation, she said the medication should not be left out. On 09/03/2021 at 10:30 a.m., observation of the medication cart on 300 Hall included in the second draw from the top of the medication cart, 1 ½ a loose tablets. Staff D Registered Nurse (RN) confirmed the presence of the unsecured white tablets On 9/03/2021 at 11:15 a.m., an observation was conducted of the 100 Hall medication cart. During the observation a loose yellow capsule was observed in the third draw from the top of the medication cart, and a bottle of Fuji water was observed in the fourth draw. Staff E, Licensed Practical Nurse (LPN) confirmed the presence of the loose capsule, and the water bottle. She stated, That's my water, I put it there because I was thirsty. On 09/03/2021 at 11:58 p.m. an interview was conducted with Staff J, related to leaving the medication out on top of the 300-medication cart. Staff J stated I know I am not supposed to put the nicotine patches on the cart, I thought she (Staff B, LPN) was coming to get the patches, and she did not, I should have looked to see if she was getting them. Normally I give it to them, and they put it in the draw. On 09/03/2021 at 12:52 p.m., a telephone interview was conducted with the facility's Pharmacy Consultant. He was informed of the observations made and stated, there should be no loose medications in the medications carts, no medications should be left out, and there should not be any personal items of the nursing staff, left in the medication carts. On 09/03/2021 at 2:00 p.m. a subsequent interview was conducted with Staff F. She was made aware of further observations made of the 100 and 300 Hall medication carts. Staff F stated The Bubble Packs are paper thin. The pharmacy consultant was here the other day, and there should be no loose pills, or water or personal items in the medication carts. She further revealed that no medications should be left out on top of the medication carts too. A facility provided policy titled, Storage of Medications, with Revision Date November 2020, was reviewed and read under Policy Heading The Facility stores all drugs and biologicals in a safe secure and orderly manner. Policy Interpretation and Implementation: 2. Drugs and biologicals are stored in the packaging containers or dispensing systems in which they are received. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 09/01/21 at 09:22 a.m., a tour of hall 100 was conducted. An observation was made of Staff Z, CNA going room to room picking up breakfast trays from 09:22 a.m. to 09:32 a.m. Staff Z, was observed without wearing a gown in rooms noted with droplet precautions posted on the doors. Staff Z, went to room [ROOM NUMBER] walked out without tray, went to room [ROOM NUMBER] and grabbed a tray, then room [ROOM NUMBER], 105 and 107, grabbing trays. Staff Z then went back to room [ROOM NUMBER] and was there for 5 minutes and walked out with a tray. Staff Z was observed without a gown during the entire process and did not change gloves or use ABHR between room to room encounters. An interview was conducted with Staff Z on 09/01/21 at 09:32 a.m. Staff Z stated that she was going in to pick up trays and assist the residents who are finishing up with breakfast. Staff Z stated that she was an agency staff. When asked what the PPE expectation was, Staff Z said, I am supposed to put on a new gown and change gloves between each room. Staff Z said, I was in a hurry trying to get to all these people, my bad. I should have changed gloves. Staff Z said she forgot to wear the right PPE. Review of a pink sign posted on all the doors in rooms 101, 105, 106, 107 and 108 showed droplet precautions STOP attention please carefully review the instructions below Everyone clean their hands, including before entering and when leaving the room with ABHR [alcohol-based hand rub] PPE requirement: Gown and gloves, face shield or goggles. N95 mask or higher-level respirator must be worn at all times while in patient room. Photographic evidence was obtained. An interview was conducted on 09/01/21 at 10:30 a.m., with Staff L, CNA. Staff L stated they had been trained to wear full PPE, change gowns and gloves between rooms and use sanitizer. On 09/03/21 at 10:02 a.m., an interview was conducted with Staff R, RN, IP. Staff R stated that his expectation would be that staff will don new PPE before going into each room and doff before they exit. Staff R said, They [staff] should not go room to room wearing the same PPE. They should not go into a droplet precautions room without a gown. Staff R stated they have educated all staff and are giving the agency staff training materials right at the door. Staff R said, they know. Based on observations, interviews, policy review, photographic evidence, and CDC (Centers for Disease Control) guidelines the facility failed to ensure appropriate infection control standards were followed related to: 1) PPE (Personal Protective Equipment) use and storage for five staff members (Staff L, N, P, Q, and Z) on two of four days observed and; 2) appropriate storage of personal items in one of one laundry rooms observed. Findings included: On 9/01/21 at 12:36 p.m. an observation was conducted. Staff N, CNA (Certified Nursing Assistant) exited room [ROOM NUMBER] wearing a gown, mask, and eye protection; she was carrying a lunch tray. Staff N, CNA walked down the 400 hall with the tray and brought it to the dining cart that was located outside room [ROOM NUMBER]. Staff N, CNA placed the lunch tray on the dining cart. Staff O, LPN (Licensed Practical Nurse) told Staff N she had to take the gown off in the room. In an interview with Staff N, CNA conducted during the observation, she said she was supposed to take the gown off in the room, but she didn't know how she could take the tray out if she took the gown off. On 9/01/21 at 9:32 a.m. an observation was conducted in the staff break room. Staff P, Floor Technician was observed in the staff break room removing a lunch bag from the refrigerator. On a table nearby was a KN95 mask and a pair of goggles. Staff P put the lunch bag on the table. An interview was conducted during the observation. Staff P said he can clean the goggles. Staff P said there isn't anywhere to put the mask and goggles. He can throw the mask away. They either clean them or throw them away. Staff P removed a mask from his pocket and disposed of the mask that was on the table in the trash receptacle nearby. On 9/01/21 at 9:33 a.m. an observation was conducted in the staff break room. Staff Q, Housekeeper entered the breakroom with an N-95 mask on top of her head. Staff Q placed her face shield on a table. An interview was conducted during the observation through translation by Staff P, Floor Technician. Staff Q said there isn't a designated area to place the mask or face shield. Staff Q also said she was not aware that putting the mask on top of her head was unsanitary. On 9/02/21 at 3:39 p.m. an interview was conducted with the unit manager. The unit manager said the gown has to be taken off inside the room. On 9/03/21 at 9:56 a.m. an observation was conducted in the laundry room. Staff P, Floor Technician and Staff Q, Housekeeper were in the clean laundry folding room with the Social Services Director (SSD), a Laundry Attendant, and Staff AA, Housekeeper. The room was approximately 8x10 feet. Staff P and Staff Q were not wearing a mask or eye protection. There were clean linens and resident personal clothing on carts, bins and a folding table in the room that were uncovered. Staff F, Regional Nurse Consultant was present during the observation and confirmed the observation. She instructed Staff P and Staff Q that they must wear their PPE. Staff AA, Housekeeper stated she was the supervisor. Staff AA said the last Covid education was about two weeks ago. Further observation of the clean folding room revealed a lunch bag and two beverages sitting on one of the clean folding tables; photographic evidence was obtained. Staff AA, Housekeeper confirmed they should not be there. On 9/03/21 at 10:50 a.m. an interview was conducted with Staff R, RN (Registered Nurse), the Infection Preventionist (IP), and the Regional Director of Clinical Services (Staff F). They stated the agency staff are educated prior to coming into the facility and when they arrive in the building, they are provided a document to read and sign specifically related to infection control. They are informed the facility is on droplet precautions, and the PPE requirement. Staff R, RN said he monitors throughout the day also, and stated, We sent the one walking around in the gown from room-to-room home. He further said, every shift is educated, and there are signs on every door. Staff R, RN said he thinks they are using the brown paper bags for PPE storage. He also said he asked the staff in the laundry room about the observations, and they didn't have an answer. On 9/03/21 at 3:58 PM an interview was conducted with the NHA (Nursing Home Administrator) and Staff F, Regional Nurse Consultant. The NHA said Staff P, Floor Technician is not usually in the laundry room. The SSD was in there looking for a resident's belongings because she was being discharged in an hour. Staff P, Floor Technician and Staff Q, Housekeeper were getting ready to go to lunch and the SSD asked for their help. They set their things on the table and began helping her get the resident's things together. The NHA stated staff can throw the masks and eyewear away. We have plenty of masks and eye protection. They are everywhere. They don't have to keep the same mask. They can bag it or throw it away during their break. Review of the policy, Coronavirus Disease (Covid-19)-Infection Prevention and Control Measures, updated October 2020, revealed the following information: Policy Statement This facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of Covid-19 within the facility, Policy Interpretation and Implementation 1. This policy is based on current recommendations for standard and transmission-based precautions, environmental cleaning, and social distancing for Covid-19. 2. While in the building personnel are required to strictly adhere to established infection prevention and control policies, including: Hand hygiene; Appropriate use of PPE; Transmission-based precautions where indicated; Laundry Practices 3. To address asymptomatic and pre-symptomatic transmission, universal source control is being implemented. Anyone entering the facility is required to wear face covering regardless of symptoms. 1. Cloth face coverings for source control are not considered PPE. Staff and visitors should wear a facemask at all times when in the facility. Upon review of the policy, Isolation-Categories of Transmission-Based Precautions, revised October 2018, the following information was discovered: Policy Statement Transmission based precautions are initiated when the resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection and is at risk of transmitting the infection to other residents. Contact precautions 1. Contact precautions may be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or resident care items in the resident's environment. 5. Staff and visitors well wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. The following CDC guidelines were found on 9/7/21 at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#ppe: Source Control and Distancing Measures Implement Source Control Measures HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. Personal Protective Equipment Ensure Proper Use and Handling of Personal Protective Equipment Any reusable PPE must be properly cleaned, decontaminated, and maintained after and between uses. Implement Universal Use of Personal Protective Equipment Transmission from asymptomatic or pre-symptomatic residents with SARS-CoV-2 infection can occur in healthcare settings, particularly in geographic areas with moderate to substantial community transmission. One of the following should be worn by HCP while in the facility and for protection during resident care encounters: A well-fitting facemask (e.g., selection of a facemask with a nose wire to help the facemask conform to the face; selection of a facemask with ties rather than ear loops; use of a mask fitter; tying the facemask ' s ear loops and tucking in the side pleats; fastening the facemask ' s ear loops behind the wear ' s head; use of a cloth mask over the facemask to help it conform to the wearer's face)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure meals were served in a dignified manner related to: 1) Staff standing when assisting residents with a meal for four (#81, #16, #15, and #19) of four residents observed; and 2) waiting for greater than 30 minutes for meal assistance for one resident (#19) of four residents observed. Findings included: During a facility tour on 09/02/21 at 09:12 a.m., an observation was made of Resident #81 being assisted with a breakfast meal. Staff W, CNA (Certified Nursing Assistant) was observed standing by the resident's left side of the bed, while assisting her with meal. On 09/02/21 at 09:19 a.m., an interview was conducted with Staff W, CNA. Staff W stated she works this hall and knows the residents well. Staff W stated when assisting a resident, you don't have to sit. Staff W said, it is staff's preference, you can sit or stand if you like. When asked if she had received training related to assisting residents with meal, Staff W said, yes. I was told it is what I prefer. Staff W stated that she received training a long time ago and could not remember who provided training. A review of Resident #81's admission record revealed admission to the facility on [DATE] with diagnoses to include, hemiplegia and hemiparesis following cerebral infarction affecting right side dominant side, aphasia, legal blindness, generalized anxiety disorder and atherosclerotic heart disease of native coronary artery without angina pectoris. An initial MDS (Minimum Data Set) dated 07/30/21 showed: Section C, cognitive patterns showed unassessed BIMS (Brief Interview for Mental Status) indicating severe impairment; Section G - functional status showed Resident #81 required extensive assistance for ADL's (Activities of Daily Living) including eating, with one-person physical assistance. A care plan for Resident #81 dated 07/29/21 showed Resident #81 was at risk for nutritional and/or hydration and received a mechanically altered diet. Resident #81 has a variable P.O. (by mouth) intake, visual impairment and is nonverbal. Interventions include to provide hands on assistance with eating meals. On 09/02/21 at 09:26 a.m., a tour was conducted of Hall 100. An observation was made of Staff X, CNA assisting Resident #16 with breakfast while standing over her. Staff X was observed standing on the left side of the bed, spooning food into the resident's mouth. In an interview conducted at 09:29 a.m. on 09/02/21, Staff X stated she was agency staff, and it was her first day at this facility. Staff X stated she did not know about this facility's policies. Staff X stated that it did not matter if she stood over the resident when providing feeding assistance. Staff X further stated, I guess I could get a chair if you want me to. Staff X was asked if she had received training related to assisting a resident meal. Staff X stated, I don't work here. A review of Resident #16's admission record revealed admission to the facility on [DATE] with diagnoses to include unspecified Dementia with behavioral disturbance, unspecified protein-calorie malnutrition, chronic obstructive pulmonary disease with acute exacerbation, anemia, vitamin deficiency, schizoaffective disorder, idiopathic progressive neuropathy and adult failure to thrive. An initial MDS dated [DATE] showed: Section C, cognitive patterns showed unassessed BIMS score indicating severe impairment; Section G - functional status showed Resident #16 was totally dependent and requires extensive assistance for ADL's including eating, with one-person physical assistance. A care plan for Resident #16 with a quarterly review date 08/26/21 showed Resident #16 was at risk for nutritional and/or hydration and has a swallowing problem. Resident #16 received a mechanically altered diet. Interventions included to provide hands on assistance with eating meals. An interview was conducted with Staff Y, LPN (Licenses Practical Nurse) on 09/02/21 at 09:29 a.m. Staff Y stated that staff should not be standing over residents during meal assistance. Staff Y said, They are supposed to be eye level, comfort for the resident. Staff Y said she was agency staff, and she knows this from her training. On 09/02/21 at 09:32 a.m., an interview was conducted with Staff L, CNA. Staff L stated that they [CNA's] had been trained on meal supervision expectations. Staff L said, we should not be standing. It is overpowering the resident. Staff L stated they were trained that staff should sit at bedside and have eye contact with the resident. A follow up interview was conducted with Staff H, LPN/Unit Manager on 09/02/21 at 09:41 a.m. Staff H stated the expectation related to meal assistance is to bring a chair to the resident's room and sit. Staff H said, We encourage them to sit unless there is specified resident's preference. Staff H stated there are residents who prefer staff stand when assisting with meal. When asked which residents had expressed that staff should stand during meal assistance, Staff H said, I don't have anyone in mind. I can't remember. Staff H stated that it was not a staff's preference if they should sit or stand during meal assistance. Staff H confirmed that neither Residents #81 nor #16 had made that choice. Staff H further said that Resident # 81 was non-verbal and did not have the ability to make such a choice. Staff H said that if a resident wanted a staff to stand during meal assistance, it would be indicated in the care plan. Staff H stated, this as a dignity concern. An interview was conducted with the Nursing Home Administrator (NHA) on 09/02/21 at 02:54 p.m. The NHA stated staff should sit, preferably at eye level during meal assistance. The NHA said, the expectation is for staff not to be standing over a resident. The NHA stated that they have folded chairs in the nurse's station for them [staff] to grab if there is no chair in the room.Resident #19 was admitted on [DATE] with diagnoses of protein-calorie malnutrition, hemiplegia and hemiparesis, adult failure to thrive, and dementia, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] reflected a BIMS of 0 indicating severe cognitive impairment. Further review revealed Resident #19 required supervision of one person for eating. A review of the Care Plan dated 8/26/21 reflected a nursing diagnosis of at risk for alteration in nutrition and/or hydration r/t [related to] receives mechanically altered diet. Dx [diagnosis] of adult failure to thrive. Interventions included provide tray set up; assist as needed. Provide hands assist with eating at meals and as needed. On 8/31/21 at 12:23 p.m., an observation was conducted. The dining cart was delivered to the 400 Hall. There were three staff serving the lunch trays to the rooms on the 400 Hall. At 12:32 p.m. on 8/31/21 all the trays had been delivered to the residents on the 400 Hall. On 8/31/21 at 12:48 p.m., Resident #19 was observed sitting in a Broda chair at the right side of her bed, awake, clean and groomed. The lunch tray was on the opposite side of the bed out of the Resident's reach and had not been set up. On 8/31/21 at 12:54 p.m., an observation was conducted. Staff L, CNA put on a gown and gloves and entered Resident #19's room. Resident #19's roommate was already finished eating her lunch. Staff L, CNA moved Resident #19 to the left side of her bed after moving the lunch meal that was sitting on the bedside table out of the way. She left the bedside table at the foot of the bed. Staff L, CNA removed the gown and gloves and performed hand hygiene upon exiting the room. During an interview conducted at that time, Staff L, CNA said Resident #19 eats with her hands all the time. She doesn't know who put the tray in the room. Staff L, CNA then asked Staff M, CNA if she would feed Resident #19 while she assists another resident. Greater than thirty minutes had passed since the dining cart had been delivered to the 400 Hall. A further observation was conducted on 8/31/21 at 1:04 PM. Staff M, CNA was in Resident #19's room wearing full PPE (Personal Protective Equipment). Staff M, CNA moved the bedside table with the lunch tray in front of Resident #19 and set it up. Staff M, CNA stood over Resident #19 and began assisting her with the lunch meal. Thirty-two minutes had passed since all the lunch meals had been delivered. There was not a chair observed in the room during the observation. On 9/01/21 at 12:38 p.m. an observation was conducted. Resident #19 was sitting in a Broda chair on the right side of her bed, awake, dressed, and groomed. On the left side of her bed was a lunch tray sitting on the bed side table out of the resident's reach. Resident #19's roommate was already finished with her lunch. During the observation Staff O, LPN (Licensed Practical Nurse), MDS (Minimum Data Set) said the CNA asked her if she would help feed Resident #19. Staff O, LPN, MDS brought a chair to the doorway, put on a gown and gloves, entered the resident's room, and moved Resident #19 to the left side of the bed and began assisting her with the lunch meal. Resident #15 was admitted to the facility with diagnoses of dementia, protein- calorie malnutrition, and dysphagia, according to the face sheet in the admission record. A review of the MDS assessment dated [DATE] Section C reflected a BIMS score of 0, indicating severe cognitive impairment. Review of Section G, Functional Status of the MDS assessment revealed Resident #15 required extensive assistance of one person for eating. A review of the 9/1/21 Care Plan revealed a nursing diagnosis of at risk for alteration in nutrition and/or hydration r/t [related to]: has a swallowing problem, receives mechanically altered diet, has variable po [by mouth] intake, total dependent on staff. Interventions included provide tray set up; assist as needed and provide hands on assist with eating at meals and as needed. On 9/01/21 at 12:31 p.m. an observation was conducted. Staff N, CNA was standing in front of Resident #15, who was sitting at the bedside in a wheelchair with the lunch meal in front of her. Staff N, CNA was providing feeding assistance to Resident #15. There was not a chair in the room. On 9/01/21 at 12:36 p.m. an interview was conducted with Staff N, CNA after she exited Resident #15's room. Staff M, CNA confirmed there wasn't a chair in the room, so she had to stand to feed Resident #15. On 9/02/21 at 3:39 p.m., an interview was conducted with the Unit Manager for the 400 Hall. The Unit Manager said it's unacceptable for them to be standing. We saw that some of the agency staff needed to be re-educated on that. They are supposed to be eye level with the patient. I would say five to ten minutes max to wait for assistance. Any longer and they need to reorder the tray. The trays should stay on the cart to keep them warm until they are ready to assist. The trays should be served at the same time. You don't want someone to eat while the roommate has to wait. Resident #19 has schizoaffective disorder, and she has outburst moments. There are times where she has outbursts and will refuse. Other times you put the tray in front of her and she will eat right away. If she refuses, we reapproach and try to assist. The tray should not have been left sitting there because obviously after a half an hour the food is cold. We have had her a long time. We know to reapproach her if she refuses. On 9/03/21 at 3:44 p.m., an interview was conducted with the NHA and Staff F, Regional Nurse Consultant. The NHA said a lot of times the residents don't want the chair in their room because the space is limited. We have folding chairs in an alcove that are available. The agency staff will be educated that they are available. A review of the policy, 'Assistance with Meals,' dated July 2017, revealed the following: Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation Residents Requiring Full Assistance: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. Not standing over residents while assisting them with meals.

Based on observations, record review, and staff interviews, the facility failed to ensure the kitchen was maintained in a sanitary manner, and food was stored appropriately related to maintenance of the ice machine, maintenance of the microwave, maintenance of the dish machine, and dating opened foods in the walk-in cooler. Findings included: On 08/31/21 at 9:35 a.m., an initial tour of the kitchen was conducted with the Kitchen Manager. During the tour, the inside of the ice machine was observed to have brown stains on both sides of the ice machine (photographic evidence obtained). The inside of the microwave was observed with a splattered brown substance (photographic evidence obtained). The policy provided by the facility Ice dated October 2019 revealed the following: Policy Statement It is the center policy that ice is prepared and distributed in a safe and sanitary manner. 2. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. 4. The Dining Services Director will ensure that the ice bins are cleaned monthly and as needed. The policy provided by the facility Equipment dated October 2019 revealed the following: Policy Statement It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order. Action Steps 1. The Dining Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials. 2. The Dining Service Director will ensure that all staff members are properly trained in the cleaning and maintenance of all equipment. 4. The Dining Services Director ensures that all non-food contact equipment is clean. The temperature for the dish machine was observed at 114 degrees Fahrenheit for wash. The dietary aid ran the dish machine three times and the temperature gauge for wash did not move. This was confirmed by the Kitchen Manager, and he stated that he would contact the chemical company. The policy provided by the facility Ware washing dated October 2019 revealed the following: 2. The Dining Services Director ensures that all the dish machine water temperatures are maintained in accordance with manufacturer recommendations for high temperature or low temperature machines. An opened package of hotdogs and diced ham was observed without a date in the walk-in cooler. The policy provided by the facility Food Storage: Cold dated October 2019 revealed the following: Policy Statement It is the center policy to ensure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code. 5. The Dining Services Director/ Cook(s) ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. On 08/31/21 at 2:07 p.m., the Certified Dietary Manager (CDM) reported that the dish machine was up and running. She stated the relay switch on the dish machine was out. On 09/02/21 at 12:20 p.m., the CDM reported that an outside company comes to break down the ice machine for cleaning. The kitchen staff were responsible for the general cleaning of the ice machine. She stated the ice machine should be cleaned every day or every other day. The CDM stated the microwave should be cleaned daily. The microwave was used to heat up sauce that morning it was not cleaned after it was used. She reported that the dish machine was a low temperature machine, and the temperature should be at 140 degrees Fahrenheit for wash. The staff member that sets the machine up and doing the washing was responsible for documenting the temperature and making sure it was running appropriately. The CDM stated all staff was responsible for making sure foods in the walk-in cooler were labeled and dated.

Based on review of Resident Council Meeting minutes and the grievance log, interviews, and facility policy, the facility did not ensure they acted upon a grievance voiced by the Resident Council related to food alternatives, for one of six Resident Council Meeting minutes reviewed. Findings included: Resident Council Meeting minutes were reviewed for six months to include the months of October 2019, November 2019 and December 2019. Upon review of the November 21, 2019 meeting minutes, a concern was voiced by members indicating the menu and meal alternates were not being delivered as ordered. Further review revealed the Certified Dietary Manager (CDM) would meet with the receptionist, who takes the orders for special requests, alternates, etc. Residents who attended the meetings, also said they would like more variety in the food. The Activities Director noted that he told residents the meals are corporately planned, but we would look into the issue. Review of the meeting minutes for October 16, 2019 revealed Resident Council members reported, then, that alternate meals were not being provided. There was no commentary from the Activities Director, who documented the concern, as to how the concern would be addressed. A review of the grievance tracking logs for the months of October 2019, November 2019, and December 2019 showed the facility had not annotated the concerns related to the alternate meals on the log, or the concern about the variety offered. An interview was conducted with the CDM on 12/20/19 at 9:44 a.m. She said the alternates are listed on the menu. She said the alternates menu included any menu items the facility had from two days ago, that needed to be used up. It would be the entree from two days ago. The sides would be different, or whatever the resident asked for. She said the facility always has egg salad, pizza, chicken pot pie, loaded baked potatoes, cottage cheese fruit plates, and grilled cheese available. The CDM said concerns would be handled through the Activities Director, however, if there is something for dietary, it would be given to herself and the dietary staff. She said there have been times there were dietary grievances. The Activities Director would write it up or verbally let the dietary staff know. Then she, or the kitchen manager would go down and see the resident who reported the concern. The CDM said, No, she was not aware the Resident Council reported they were not getting the alternates. She reported that alternates were always available. The CDM said one of the dietary staff would go down and offer something else to the residents. She also said, Yes, a grievance should have been made. On 12/20/19 at 10:00 a.m. an interview was conducted with the Activities Director. He said he is the facilitator for the Resident Council meetings, and he writes the minutes. He said if there is a concern, he puts it on a form. He showed the surveyor a form titled, Resident Council Issues to be Addressed. The Activities Director also said he writes the issue, the date, the disciplines, plus the date of the meeting on the form. Then he puts the form in the appropriate department head's mail. The form is labeled with nursing, dietary, or whatever department is responsible for the concern. He said there were no issues in November. When the surveyor inquired about the alternate meals, residents reported they had not been receiving, the Activities Director said, No, I did not write a concern for the Resident Council. He said he did speak to the department head, and it says in there what she was going to do. He said dietary services reported there was a breakdown between the receptionist who takes the orders, and the kitchen. He had a form filled out with the dietary concern dated 10/22/19. The resolution was to have discussion with the receptionist because she was not turning in the alternate sheet. The resolution date had to be by 10/25/19. The Activities Director said he went back to the CDM who said she would meet with the receptionist. She said it was resolved. An interview was conducted with the Nursing Home Administrator (NHA) on 12/20/19 at 10:18 a.m. She was asked if a concern reported by Resident Council members should be documented on the grievance log. She said it depends if it rises to the level of the grievance. The Director of Nursing (DON), who was present during the interview, said a grievance is usually handed out to the department head. At that point, we come up with a resolution. He said a grievance should have been generated. The NHA said generally yes, a grievance would be initiated. The facility will do whatever means they need; to resolve the issue. She added, the facility does not always generate a form. It depends on the issue. She was not aware a concern form had not been filled out for the concern in November 2019. The DON said it wasn't resolved the first time, so it was something that should have been addressed immediately. He said it should have been brought to us so we could address it. Review of the facility policy titled, Grievance Policy and Procedure, undated, reflected the following information: The resident/representatives has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination of reprisal and without the fear of discrimination or reprisal. The resident/resident representative has the right to and the facility must make prompt efforts to resolve grievances the resident/resident representative may have. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their long-term care stay. These may be expressed any time, both verbally and in writing. Staff have been trained on the policy and instructed on how to assist residents and resident representatives to write or complete a grievance form. A grievance may be presented anonymously if so chosen by the resident/resident representative. Residents or representatives are encouraged to report grievances as a positive step in arriving at a satisfactory resolution and outcome. A grievance form is provided for use, although a grievance may be expressed in any written or verbal format. These grievance forms may be found on each nursing unit or in a box on the wall outside of the social service office. The social worker has been given the authority of the grievance official. The grievance official is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion; leading necessary investigations by the facility: maintaining confidentiality of all information associated with grievances, issuing written grievance decisions to the resident/resident representative, and coordinating with state and federal agencies as necessary in light of specific allegations. Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. All grievances will be dated when received, filed in a grievance log and assigned to the appropriate department within 24 working hours. The director of the involved department will personally investigate the expressed issue or assign investigation to inform staff member for investigation. This person will speak with all necessary personnel in the complaining party to obtain details and make every attempt to reach a resolution that is satisfactory to the person who expresses the grievance. The department director or his/her designee will document his/her actions, the resolution, sign and date the form and return the form to the grievance official within 5-10 days of having received it. The grievance official will follow up with the resident/representative to ensure that the concern is fully resolved. The complainant has the right to receive a written response containing the results of any investigation and any corrective actions to be put in place. Should resolution not be reachable the concern party will be advised of his/her right to file a grievance with one or all of the following advocacy agencies. Grievances will be reported to the QAPI committee. Any patterns or trends will be investigated and systems identified that require corrective action will be reviewed and appropriate changes and updates will be made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan for one resident (#305) of twenty-nine residents sampled related to a change in the level of cognitive status and the ability to smoke independently, and keep smoking supplies of a lighter with him at all times. Findings included: A review of facility policy titled, Care Planning-Interdisciplinary Team, with a revision date of September 2013, Page 03 of 03 read as follows under the section of Policy Interpretation and Implementation: 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The care plan, with an initiated date of 12/16/19 and a target date of 3/16/2020, for Resident #305 included a focus area which read, [Resident #305] desires to smoke. Resident has been assessed as able to smoke: independently. Interventions/Tasks included, Maintain smoking materials on self safely. Review of the clinical record revealed Resident #305's most recent smoking evaluation was dated 12/3/19 an indicated the resident was a safe smoker. An Unsupervised/Independent Smoker could retain smoking materials on his person per the facility policy titled, Smoking Policy, revised on June 2015. Further record review revealed that on 12/8/19, Resident #305 was found to be an elopement risk and read, A. (5) Alert and Continuous Confusion and D. (5) Actively Exit Seeking. The elopement risk score was 14, which on a scale of 0-14 scale, indicated he was to wear an electronic alarm device with a picture placed in the facility's elopement book. On 12/17/19 at 12:56 p.m. a random observation of Resident #305 was conducted. The resident had a lighter, and cigarettes in his hand, and utilized a cane. He was in the hall wandering and appeared confused. An unidentified staff member was observed to approach the resident and told the resident to wait where he was, he would go get him help. The Director of Nursing (DON) went over to the resident and saw that he wanted to smoke and accompanied him to the 300 Hall. The DON left the resident on the smoking patio On 12/17/19 at 2:48 p.m., an observation and interview was conducted with Resident #305. He indicated that he kept his own cigarettes, he kept his lighter in his pocket, and at night put it in a drawer in the bedside table, and that he sometimes takes his oxygen off. Interview with Staff C, Certified Nursing Assistant (CNA) for Resident #305 was conducted on 12/20/19 at 9:00 a.m. During the interview Staff C was asked about the resident's level of cognition and oxygen usage. Staff C stated, He usually is confused. He packs his stuff up forgets he is not leaving and says good morning to me multiple times. She revealed that Resident #305 had been using and wearing oxygen since he was admitted to the facility (12/3/19). Record review for Resident #305 indicated he was admitted to the facility on [DATE] with multiple diagnoses that included chronic obstructive pulmonary exacerbation, disorder of urea cycle disease, schizoaffective disorder, bipolar type major depressive disorder, generalized anxiety disorder, and alcohol abuse and unspecified dementia without behavioral disturbance. Review of laboratory results revealed that Resident #305 had a high ammonia level results on a reference scale range of 9-35 mcmol/L (micromoles per liter). Resident #305's ammonia level on 12/10/19 was high at 91 mcmol/L. Subsequent laboratory ammonia levels were drawn, and they were as follows: 12/11/19 was high at 138 mcmol/L, 12/16/19 was high at 101 mcmol/L, and 12/19/19 was high at 50 mcmol/L. During an interview conducted with the (DON) on 12/20/19 at 11:00 a.m. The DON revealed that the resident is sometimes confused with moderate cognitive impairment. He confirmed the resident should not have smoking supplies, of a lighter on him until the confusion resolves. The DON also confirmed the care plan should have been updated to reflect the resident's change in level of cognitive status, and another smoking evaluation should be initiated by Staff A, Unit Manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, it was determined the facility failed to provide appropriate supervision related to oxygen usage and failure to limit the accessibility of smoking supplies for one resident (#305) with a decrease in cognitive status of four residents sampled. Findings included: On 12/17/19 at 10:00 a.m., an observation was conducted of Resident #305's room. The resident was not in the room at the time. It was observed that an oxygen converter set at 2.5 Liters was running and the nasal cannula was on the resident's bed. Further observation on 12/17/19 at 10:45 a.m. revealed Resident #305 to be sitting on his bed with the nasal cannula on, looking out of the room into the hall. A follow-up observation later in the day, at 2:00 p.m., of Resident #305's room revealed that he was not in the room, and the oxygen converter was running while the nasal cannula was left on the resident's bed. There was no indication of any signage posted inside the room, or on the outside of the room for oxygen in use, do not smoke while oxygen is in use, similar too other residents who used oxygen in the facility. On 12/17/19 at 12:56 p.m. a random observation of Resident #305 was conducted. The resident had a lighter, and cigarettes in his hand, and utilized a cane. He was in the hall wandering and appeared confused. An unidentified staff member was observed to approach the resident and told the resident to wait where he was, he would go get him help. The Director of Nursing (DON) went over to the resident and saw that he wanted to smoke, and accompanied him too the smoking patio and left him. It was observed that the resident lit his cigarette and began to smoke independently with no facility staff present. On 12/17/19 at 2:48 p.m., an observation and interview was conducted with Resident #305. He indicated that he kept his own cigarettes, he kept his lighter in his pocket, and at night put it in a drawer in the bedside table, and that he sometimes takes his oxygen off. On 12/17/19 at 3:20 p.m. an interview was conducted with Staff A, Unit Manager (UM), Licensed Practical Nurse (LPN). She was informed of the observations for Resident #305 and asked specifically what the facility policy was regarding both lighters in a resident's room while the resident was using oxygen. She indicated that she did not know where the resident got the oxygen concentrator because Resident #305 did not have an active physician order to use oxygen. Review of the physician orders for December 2019 for Resident #305 did not reveal an active physician order for oxygen. Review of facility policy titled, Oxygen Administration, Level III with a revision date of 2010, Pages 1 and 2 of 3 pages, read as follows: Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Steps in the procedure: .2. Place an Oxygen in use sign on the outside of the room entrance door.4. Remove all potentially flammable items (e.g. lotions, oils, smoking articles, etc.) from the immediate area where the oxygen is to be administered. Record review for Resident #305 indicated he was admitted to the facility on [DATE] with multiple diagnoses that included chronic obstructive pulmonary exacerbation, disorder of urea cycle disease, schizoaffective disorder, bipolar type major depressive disorder, generalized anxiety disorder, and alcohol abuse and unspecified dementia without behavioral disturbance. Review of the admission Minimum Data Set (MDS) dated [DATE], identified in Section C for Cognitive Patterns, that Resident #305's Brief Interview for Mental Status (BIMS) score was 11, which indicated moderate cognitive impairment. Section O for Special Treatments, Procedures, Programs, showed the resident was not receiving oxygen therapy. The care plan, with an initiated date of 12/16/19 and a target date of 3/16/2020, for Resident #305 included a focus area which read, [Resident #305] desires to smoke. Resident has been assessed as able to smoke: independently. Interventions/Tasks included, Maintain smoking materials on self safely. The care plan, with an initiated date of 12/16/19 included a focus area which read, [Resident #305] has a potential for complications of respiratory distress r/t (related to) dx (diagnosis) of: COPD. Interventions/Tasks included, Administer medications as ordered; observe for effectiveness . Review of the clinical record revealed Resident #305's most recent smoking evaluation was dated 12/3/19 an indicated the resident was a safe smoker. An Unsupervised/Independent Smoker could retain smoking materials on his person per the facility policy titled, Smoking Policy, revised on June 2015. Further record review revealed that on 12/8/19, Resident #305 was found to be an elopement risk and read, A. (5) Alert and Continuous Confusion and D. (5) Actively Exit Seeking. The elopement risk score was 14, which on a scale of 0-14 scale, indicated he was to wear an electronic alarm device with a picture placed in the facility's elopement book. Review of laboratory results revealed that Resident #305 had a high ammonia level results on a reference scale range of 9-35 mcmol/L (micromoles per liter). Resident #305's ammonia level on 12/10/19 was high at 91 mcmol/L. Subsequent laboratory ammonia levels were drawn, and they were as follows: 12/11/19 was high at 138 mcmol/L, 12/16/19 was high at 101 mcmol/L, and 12/19/19 was high at 50 mcmol/L. A review of the provider progress notes revealed a clinical psychologist consult was conducted on 12/18/19 and read, The resident does not have the capacity to make medical decisions for himself with intermittent confusion. Also, Resident #305 was noted to have moderate cognitive impairment. An interview was conducted with Staff B, LPN, on 12/18/19 at 8:55 a.m., regarding Resident #305 using oxygen and the converter observed running in his room. Staff B, LPN stated, The other day, I removed it when you noticed it, I was told by the UM (LPN) and DON to do so. I don't recall seeing it previously. Interview with Staff C, Certified Nursing Assistant (CNA) for Resident #305 was conducted on 12/20/19 at 9:00 a.m. During the interview Staff C was asked about the resident's level of cognition and oxygen usage. Staff C stated, He usually is confused. He packs his stuff up forgets he is not leaving and says good morning to me multiple times. She revealed that Resident #305 had been using and wearing oxygen since he was admitted to the facility (12/3/19). During an interview conducted with the (DON) on 12/20/19 at 11:00 a.m. The DON revealed that the resident is sometimes confused with moderate cognitive impairment. He confirmed the resident should not have smoking supplies, of a lighter on him until the confusion resolves. The DON also confirmed the care plan should have been updated to reflect the resident's change in level of cognitive status, and another smoking evaluation should be initiated by Staff A, UM.