Based on observations, interviews, and record reviews, the facility failed to implement a person-centered comprehensive plan of care for 2 of 4 residents reviewed for respiratory care services. (Resident #212 and #24) Findings include: 1.) Review of Resident #212's admission record documented diagnoses that included chronic respiratory failure, disease of pulmonary vessels, and chronic obstructive pulmonary disease (COPD). During an observation on 4/14/25 at 10:45 AM, Resident #212 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an observation on 4/15/25 at 8:30 AM, Resident #212 was observed sitting up in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an interview on 4/15/25 at 8:32 AM, Resident #212 stated, I have not changed my oxygen level. I need it to breath; it is my lifeline. Review of the resident centered comprehensive plan of care for Resident #212 read, [Resident name] is at risk for respiratory complications r/t [related to] chronic respiratory failure and COPD. Administer oxygen as ordered. Review of Resident #212's physician order dated 4/3/25 reads, Oxygen at 4 liters / min via Nasal Cannula. Humidification every shift for COPD. During an interview on 4/15/25 at 8:45 AM, Staff A, Licensed Practical Nurse stated, The oxygen is set at 3[liters], it should be 4 [liters], we check the levels throughout the day, I just haven't gotten to her yet. 2.) Review of Resident #24's admission record documented a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD). During an observation on 4/14/25 at 11:15 AM, Resident #24 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. During an observation on 4/15/25 at 7:30 AM, Resident #24 was observed lying in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. Review of Resident #24's physician order dated 3/18/24 reads, Oxygen at 3 liters/minute via nasal cannula every shift related to Chronic Obstructive Pulmonary Disease. Review of the comprehensive plan of care for Resident #24 dated 4/4/25 reads, Resident is at risk for respiratory complications r/t [related to] chronic respiratory failure and COPD. Administer oxygen as ordered. During an interview on 4/16/25 at 9:05 AM, the Director of Nursing stated, We should always follow the physicians orders, and the care planned interventions when running oxygen. Review of the policy titled, Oxygen Administration with a review date of 1/21/2025 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency.

Based on observations, interviews, and record reviews, the facility failed to ensure that respiratory care and services were provided consistent with professional standards of practice for 2 of 4 Residents (Resident #212 and Resident #24). Findings include: Review of Resident #212's admission record documented a diagnosis that included chronic respiratory failure, disease of pulmonary vessels, and chronic obstructive pulmonary disease (COPD). During an observation on 4/14/25 at 10:45 AM, Resident #212 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an observation on 4/15/25 at 8:30 AM, Resident #212 was observed sitting up in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3 liters per minute. During an interview on 4/15/25 at 8:32 AM, Resident #212 stated, I have not changed my oxygen level. I need it to breath; it is my lifeline. Review of Resident #212's physician order dated 4/3/25 reads, Oxygen at 4 liters / min [minute] via Nasal Cannula. Humidification every shift for COPD. During an interview on 4/15/25 at 8:45 AM, Staff A, Licensed Practical Nurse, stated, The oxygen is set at 3 [liters], it should be 4 [liters], we check the levels throughout the day, I just haven't gotten to her yet. 2) Review of Resident #24's admission record documented a primary diagnosis of chronic obstructive pulmonary disease. During an observation on 4/14/25 at 11:15 AM, Resident #24 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. During an observation on 4/15/25 at 7:30 AM, Resident #24 was observed lying in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 2 liters per minute. During an interview on 4/15/25 at 8:32 AM, Resident #24 stated, I do not know how to change my O2 [oxygen] level. If I have trouble breathing, I call the nurse. Review of Resident #24's physician order dated 3/18/24 reads, Oxygen at 3 liters/minute via nasal cannula every shift related to chronic obstructive pulmonary disease. During an interview on 4/17/25 at 8:30 AM, the Director of Nursing stated, Oxygen should be running at the physician ordered rate. Nurses should check the levels when giving meds [medications]. Review of a policy titled, Oxygen Administration with a review date of 1/21/2025 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's physician and resident's representative were notified of a change in condition for 1 of 3 residents reviewed for change in condition, Resident #1. Findings include: Review of Resident #1's admission record showed the resident was admitted on [DATE] with the diagnoses to include encephalopathy, muscle weakness, anemia, dementia, and osteoporosis. During an interview on 10/3/2024 at 10:47 AM with the Director of Nursing (DON), review of the facility's documentation showed on 9/15/2024 at 11:30 AM Resident #1 was found on the floor with a knot on the left side of head, and the resident had previous fall on 9/13/2024 at around 3:00 PM. Review of nursing progress notes for 9/15/2024 did not contain documentation that Resident #1's physician or representative was notified of the resident's fall and injury. Review of Resident #1's hospital transfer form dated 9/16/2024 at 7:45 AM read, s/p [status post] fall x 2. During an interview on 10/3/2024 at 3:07 PM, Staff A, Registered Nurse (RN), stated, I was taking care of the resident [Resident #1] and I thought that [Staff B, LPN's name] called the doctor and family member. I did not call the doctor or the family. During an interview on 10/3/2024 at 3:20 PM, Staff B, LPN, stated, I was getting off of shift and did not call the doctor or the family. [Staff A, RN's name] was the resident's nurse and I thought he called the doctor and family. During an interview on 10/3/2024 at 3:44 PM, the DON stated, The doctor and the family are to be notified of any change in condition and an additional fall is a change in condition. No call was placed to the doctor or to the family to inform of the fall on 9/15/2024. Review of the facility policy and procedure titled Notification of Changes revised in January 2024 read, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notifications. Circumstances requiring notification include: 1. Accidents a. Resulting in injury, b. Potential to require physician intervention. 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status . 4. A transfer or discharge of the resident from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure resident assessments were completed accurately to reflect the resident's status for 1 (Resident #31) of 4 residents reviewed for respiratory care and 1 (Resident #96) of 4 residents reviewed for discharge. Findings include: During an observation on 1/29/24 at 12:00 PM, Resident #31 had a C-PAP [continuous positive airway pressure] machine at her bedside. During an observation on 1/30/24 at 8:00 AM, Resident #31's face was reddened around the nose and cheeks. During an interview on 1/30/24 at 8:00 AM, Resident #31 stated she had just taken her C-PAP off from wearing it during the night. During an interview on 1/31/24 at 10:10 AM, Resident #31 stated that she does not know how long she has been using a C-PAP, but the staff come in the evening and put water in the C-PAP and help her get in on her face and she sleeps with it every night. Review of Resident #31's admission record documented an admission date of 12/5/20 with diagnoses that included congestive heart failure and obstructive sleep apnea. Review of Resident #31's physician's orders dated 11/14/23 read, CPAP setting 8.0 cmH20 [centimeter of water] at bedtime related to obstructive sleep apnea. Review of Resident #31's care plan dated 9/22/23 and revised on 11/16/23 documented Resident exhibits or is at risk for respiratory complications R/T (related to) respiratory distress due to OSA (obstructive sleep apnea) with interventions that include C-Pap as ordered for OSA. Review of Resident #31's Minimum Date Set (MDS) Quarterly assessment dated [DATE], Section O, Special Treatments, Procedures, and Programs documented Resident #31 used a non-invasive mechanical ventilator but the type of ventilator support [CPAP] was left unchecked. During an interview on 1/31/24 at 9:43 AM, the MDS Coordinator, RN, stated, the coding was a mistake due to incorrectly documenting non-invasive mechanical ventilator which disabled further questioning for a CPAP. She confirmed that the Quarterly MDS assessment dated [DATE] was inaccurate. Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual reads O0110G3. C-PAP. Check if the non-invasive mechanical ventilator support was CPAP. 2.) Review of the admission record for Resident #96 documented the most recent admission date was 9/10/23 and discharged date was 11/5/23 to another nursing facility. Review of Resident #96's Minimum Data Set (MDS) Assessment Homepage documented Next Trckng/Dschrg (Tracking/Discharge): Discharge - ARD (Assessment Reference Date) 11/5/2023. Complete by: 11/19/2023 - 73 days overdue. There was no documented discharge assessment completed. Review of Resident #96's facility census report documented stop billing on 11/5/23. Review of Resident #96's discharge summary documented discharge date of 11/5/23 to a long-term care facility located closer to family. During an interview on 1/31/24 at 9:30 AM, Staff B, RN, MDS Coordinator, stated, The discharge MDS was not completed, and I see he [Resident #96] discharged on 11/5/23. Review of the policy and procedure titled MDS 3.0 Completion, last reviewed on 1/23/24 read, Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. f. Discharge Assessment - completed using the discharge date as the ARD. Must be completed within 14 days of the discharge date /ARD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that residents who required blood glucose monitoring receive treatment in accordance with professional standards of practice for 1 of 3 residents review for insulin administration (Resident #77) and failed to promptly notify a physician for critical high laboratory results for 1 of 3 resident reviewed for laboratory results ( Resident #108) Findings include: Review of the admission record for Resident #108 documented diagnosis that include essential primary hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, hypothyroidism, unspecified atrial fibrillation, unspecified protein calorie malnutrition, dysphagia, adult failure to thrive, and chronic kidney disease. Review of the physician's order dated [DATE] reads, CBC (complete blood count), CMP (complete metabolic profile), serum magnesium, prealbumin every night shift for failure to thrive for 1 day. Review of the Lab results report for Resident #108 dated [DATE] reads, Collection date [DATE] at 6:35 AM, received date [DATE] at 11:19 AM, reported date [DATE] at 1516 (3:16 PM) Comprehensive Metabolic Panel: Critical result called to [Staff name] on [DATE] 3:04 PM by [Laboratory Staff name] Results were read back to caller. Sodium 156 meq [milliequivalent/l (liter)]. Review of the nursing progress notes for Resident #108 from [DATE] through [DATE] documented no progress notes indicating call to physician or nurse practitioner for notification of critical lab results. Review of the physician's order for Resident #108 dated [DATE] reads, Stat BMP (basic metabolic profile), CBC for hypernatremia (high sodium levels). Review of the physician's order for Resident #108 dated [DATE] reads, May insert IV (intravenous catheter). Review of the physician's order for Resident #108 dated [DATE] reads, Dextrose Intravenous Solution 5% use 2 liters intravenously every shift for abnormal labs d/c (discontinue) when complete. During an interview on [DATE] at 9:55 AM the Director of Nursing (DON) stated, I don't know why the critical lab wasn't called. I was not aware of this. All critical labs should be called immediately. I was not told that the nurse practitioner had any concerns about him or that we didn't call him about these. I don't see documentation that anyone was informed of these results before the 27th [[DATE]]. We should have called them immediately. During an interview on [DATE] at 10:19 AM, the Advanced Nurse Practitioner (APRN) stated, I was not called about these lab results, they were not called to anyone. I expect all critical labs should be called. I was displeased that was not dealt with. In hypernatremia you would expect progressive altered mental status declines and that is what I was seeing on that day. I saw him [Resident #108], I wanted the labs immediately rechecked and it [the sodium level] was the same and so I started the fluids. It is unlikely that it would have corrected itself. But I still wanted to recheck it. His diagnosis was failure to thrive, I spoke to nephew as POA (power of attorney), his sister [the resident's] had recently died and he was declining and got very depressed and was giving up. The hypernatremia was likely a result of dehydration and insufficient intake. They gave the 2 liters of fluid. I should have been notified on the 25th when the critical lab came in. It was a delay in his treatment, but I can't say whether it would have altered his course. I know with the recheck of the sodium it had not worsened; it was still 156. 2. Review of the admission record for Resident #77 documented diagnosis that included type 2 diabetes mellitus, essential primary hypertension, diverticulosis, neoplasm of ovary, cholelithiasis, fatty liver, acute kidney failure, and hyperlipidemia. Review of the physician's order for Resident #77 dated [DATE] reads, Humalog KwikPen 100 units/ml (milliliter) solution pen injector. Inject as per sliding scale; if 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 352-400 = 10 units, 401-450= 12 units. Notify provider if greater than 450, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. Review of the Medication Administration Record (MAR) for [DATE] through [DATE] documented on [DATE] at 4:30 PM a blood sugar of 488 with a chart code 9. Chart code 9 = Other / See progress notes. Review of the nursing progress notes for [DATE] document no progress note or physician notification of the elevated blood sugar. During an interview on [DATE] at 9:30 AM, the Director of Nursing (DON) stated, All physician orders should be followed, and they all should be documented correctly. They should have called the 488 [blood sugar to the doctor] and documented that they did. During an interview on [DATE] at 10:15 AM, the APRN stated, I was not aware that the blood sugar was 488 and was not called about it. I may have added additional insulin had I been called. During an interview on [DATE] at 8:45 AM, the Medical Director stated, I was not notified of a blood sugar of 488. They should have done that. Review of the policy and procedure titled Notification of Changes last review date of [DATE] reads, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial conditions such as deterioration and health, mental or psychosocial status. This may include: a. Life threatening conditions or b. Clinical complications. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment.

Based on observations, interviews, and record reviews, the facility failed to administer oxygen according to physician's orders and professional standards of practice for 2 of 4 residents reviewed for respiratory care. (Resident #82 and #30) Findings include: Review of Resident #82's admission record documented diagnosis that included acute respiratory failure with hypercapnia, chronic obstructive pulmonary disease, emphysema, nicotine dependence, non ST elevation myocardial infarction, fibroblastic disorder, and rheumatoid arthritis. Review of Resident #82's physician's order dated 11/22/2023 reads, Oxygen at 6 L (liters) N/C (nasal cannula) continuous with humidification. During an observation on 1/29/2024 at 12:46 PM Resident #82 was sitting in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 4 liters per minute. During an interview on 1/29/2024 at 12:46 PM Resident #82 stated, I have not changed my oxygen level. I need it set at 6 liters and don't change it myself. During an observation on 1/31/2024 at 8:36 AM Resident #82 was observed sitting up in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 4 liters per minute. During an interview on 1/31/2024 at 2:10 PM Staff D, Registered Nurse stated, The oxygen is set at 4, it should be 6 liters, maybe he changed it. I should check on the amount running when I give meds [medications]. During an interview on 1/31/2024 at 4:05 PM the Director of Nursing stated, Oxygen should be running at the physician ordered rate. Nurses should check when giving meds. 2. Review of Resident #30's admission record documented diagnosis that include chronic obstructive pulmonary disease, age related osteoporosis, iron deficiency anemia, major depressive disorder, and anxiety disorder. Review of the physician's order for Resident #30 dated 7/16/2023 reads, Oxygen at 2 liters/minute via nasal cannula every shift related to COPD (chronic obstructive pulmonary disease). During an observation on 1/29/2024 at 9:31 AM, Resident #30 was observed sleeping in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters per minute. During an observation on 1/30/2024 at 7:43 AM, Resident #30 was observed sleeping in bed with oxygen infusing via nasal cannula. The oxygen concentrator was set at 3.5 liters per minute. During an interview on 1/31/2024 at 2:15 PM, Staff D, RN stated, Her oxygen should be at 2 liters. I think maybe she turned it up. I have not checked it until now. No oxygen policy and procedure was provided prior to exit from facility.

Based on observations, interviews, and record review, the facility failed to label and store medications according to professional standards of practice in 2 of 4 medication carts. Findings include: During an observation of medication cart #1 with Staff E, Licensed Practical Nurse (LPN) on 1/29/2024 at 9:05 AM, there was one medication cup that contained 11 medications which had no resident identifier and no indication of what the medications were. One opened bottle of artificial tears with no opened date or expiration date. During an interview on 1/29/2024 at 9:10 AM, Staff E, LPN stated, I just left those pills in the cart because the resident was not in their room. The eye drops should be dated. During an observation of medication cart #3 with Staff F, LPN on 1/29/2024 at 9:22 AM, there was one medication cup in the drawer that contained 13 pills which had no resident identifier and no indication of what the medications were. There was one opened bottle of Dorzolamide ophthalmic solution with no opened date or expiration date. During an interview on 1/29/2024 at 9:28 AM, Staff F, LPN stated, That resident was not available right now, I shouldn't have left them, they should be labeled. I can't tell when the eye drops were opened. During an interview on 1/29/2024 at 1:30 PM, the Director of Nursing stated, All medications should be labeled. Review of the policy and procedure titled, Labeling of Medications and Biologicals last reviewed date 1/23/2024 reads, Policy: All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. Policy Explanation and Compliance Guidelines: 2. Medication labels must be legible at all times. 4. Labels for individual drug containers must include: a. The resident's name; c. The medication name. h. The expiration date when applicable.

Based on interview, record review and review of the facility policy and procedure the facility failed to accurately and completely document within the medical record for 2 out of 3 residents reviewed for insulin administration (Resident #77 and #95). Findings include: Review of the admission record for Resident #77 documented diagnosis that included type 2 diabetes mellitus, essential primary hypertension, diverticulosis, neoplasm of ovary, cholelithiasis, fatty liver, acute kidney failure, and hyperlipidemia. Review of the physician's order for Resident #77 dated 9/26/2023 reads, Humalog KwikPen 100 units/ml (milliliter) solution pen injector. Inject as per sliding scale; if 0-150 = 0 units, 151-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 352-400 = 10 units, 401-450= 12 units. Notify provider if greater than 450, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus without complications. Review of the physician's orders for Resident #77 dated 12/7/2023 reads, Lantus Solostar subcutaneous solution pen-injector 100 unit/ml (milliliter) (insulin glargine) inject 30 unit subcutaneously one time a day for T2DM (type 2 diabetes mellitus). Review of the Medication Administration Record (MAR) for Resident #77 dated 12/1/2023 through 12/31/2023 documented no blood sugar recorded on 12/23/2023 at 6:30 AM and 12/25/2023 at 6:30 AM. Both of these dates and times were blank. Review of the MAR for Resident #77 dated 1/1/2024 through 1/31/2024 Staff B, LPN documented on 1/16/2024 at 9:00 PM chart code 4 and no blood sugar was documented. Chart code 4 = Vitals outside parameters for administration. During an interview on 2/1/2024 at 8:15 AM, the Director of Nursing (DON) stated, All blood sugars should be documented. I don't know why they aren't. All documentation should be accurate. The nurse did call the doctor and got orders to hold the insulin. During an interview on 2/1/2024 the Medical Doctor (MD) stated, I was called each time that the insulin was held. 2. Review of the admission record for Resident #95 documented diagnosis that included unspecified open wound, left foot, occlusion stenosis of right anterior cerebral artery, hemiplegia affecting left dominant side, essential primary hypertension, unspecified atrial fibrillation, osteomyelitis, hyperlipidemia, cerebral infarction, and type II diabetes mellitus with hyperglycemia. Review of the physician's order for Resident #95 dated 8/11/2023 reads, Lantus Solostar 100 unit/ml (milliliter) solution pen-injector Inject 20 unit subcutaneously one time a day related to type 2 diabetes mellitus with hyperglycemia. Review of the MAR for Resident #95 dated 12/1/2023 through 12/31/2023 staff documented on 12/19/2023 at 6:30 AM 'chart code 4 for Lantus 20 Units subcutaneously. Blood sugar was documented as 134. Chart code 4 = Vitals outside of parameters for administration. Review of the nursing progress notes for Resident #95 documented no progress notes related to holding insulin or physician notification on 12/19/2023. Review of the MAR for Resident #95 dated 1/1/2024 through 1/31/2024 staff documented on 1/7/2024 at 6:30 AM chart code 4 for administration of Lantus 20 units subcutaneously. Blood sugar was documented as 108, on 1/8/2024 at 6:30 AM Staff documented chart code 4 with no blood sugar documented, and on 1/11/2024 at 6:30 AM Staff B, LPN documented chart code 9 with no blood sugar documented. Chart code 4 = Vitals outside of parameters for administration, Chart code 9 = Other/see progress notes. Review of the nursing progress notes for Resident #95 from 1/7/2024 through 1/12/2024, there were no progress notes related to holding insulin or physician notification. During an interview on 2/1/2024 at 8:15 AM, the Director of Nursing (DON) stated, All blood sugars should be documented. I don't know why they aren't. All documentation should be accurate. The nurse did call the doctor and get orders to hold the insulin. During an interview on 2/1/2024 the Medical Doctor (MD) stated, I was called each time that the insulin was held. Review of the policy and procedure titled Medication Administration last reviewed date of 1/23/2024 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination for infection. Policy Explanation and Compliance Guidelines: 8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. 11. Compare medication source (bubble pack, vial, etc). with MAR to verify resident name, medication name, form, dose, route, and time. a. Refer to drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. 14. Administer medication as ordered in compliance with manufacturers specifications.

Based on observations, interviews, and record review the facility failed to perform hand hygiene during medication administration in 2 out of 5 observations consistent with accepted standards of practice. Findings include: During an observation of medication administration for Resident #78 conducted on 1/31/2024 at 8:31 AM, Staff D, Registered Nurse (RN) did not perform hand hygiene when returning from room and returning to the medication cart. Staff D unlocked medication cart, poured medications, entered Resident #78's room, checked blood pressure, and administered all medications. Staff D, RN exited the resident's room without performing hand hygiene and returned to the medication cart. During an observation of medication administration for Resident # 82 conducted on 1/31/2024 at 8:36 AM, Staff D, RN did not perform hand hygiene and prepared the residents medications, locked the medication cart, entered Resident #82's room without performing hand hygiene and administered medications. Staff D, RN exited the room and without performing hand hygiene began preparing medications for another resident. During an interview on 1/31/2024 at 12:30 PM Staff D, RN stated, Oh, I did not use hand sanitizer or wash my hands. I should have. During an interview on 1/31/2024 at 12:55 PM, the Director of Nursing (DON) stated, All staff should perform hand hygiene when giving medications. Review of the policy and procedure titled Medication Administration last reviewed date of 1/23/2024 read, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination for infection. Policy Explanation and Compliance Guidelines: 4. Wash hands prior to administering medications per facility protocol and product. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. Review of the policy and procedure titled Hand hygiene last reviewed date of 1/23/2024 read, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table. Hand hygiene table: before preparing and handling medications.

Based on observations, interviews, and record review, the facility failed to maintain equipment to be in a safe operating condition for 1 reach in refrigerator in the main kitchen. Findings include: On 1/29/24 at 9:30 AM during the initial tour of the main kitchen with the Certified Dietary Manager (CDM), an observation of the seal (gasket) was noted to be falling off of the top right-hand corner, and down the right side of the reach in refrigerator. The refrigerator was noted to have 8 oz milk cartons, Ensure nutritional supplements, vanilla pudding, and various juices sitting on the shelves. There was a thermometer that read 40 degrees in the back of the refrigerator. During an interview on 1/29/24 at 9:30 AM with the CDM, she stated, I'm not gonna [going to] hide it, the seal had just come off a couple of days ago, and the new one is on order I think. Review of a purchase order for an Arctic Air Refrigerator was obtained on 1/30/24 that showed an order was submitted on January 29, 2024 at 4:49 PM by the Maintenance Director. The purchase is pending approval. During an interview on 1/31/23 at 10:30 AM the Maintenance Director stated, I only keep work logs relating to the compressors on the refrigerators. The dietary department would keep the logs on the upkeep of the gaskets. On 1/31/23 at 12:30 PM, a request was made for the logs relating to gasket condition of the facilities refrigerators. The information was not provided. Review of the policy and procedure titled Refrigerators and Freezers with a review date of 1/23/24 reads, Policy Statement. This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation. 9. Culinary Service Manager will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure foods and beverages were stored in a safe and sanitary manner in 2 of 2 nourishment areas. Findings Include: A tour of the facility nourishment rooms was completed on 1/29/24 beginning at 9:48 AM with the Certified Dietary Manager (CDM). On 1/29/24 at 10:15 AM in the east nourishment room freezer there was an opened, unlabeled, undated container of Mystic Bahama Blueberry drink, an unlabeled, undated ½ eaten bar of a chocolate [NAME] Daz Ice cream on a stick, 3 bags of unlabeled, undated brown frozen bananas, 1 unlabeled, undated cheddar broccoli casserole, 2 unlabeled Styrofoam cups filled with an unidentifiable substance, and there was a reddish-brown sticky substance on the interior of the freezer bottom shelf. On 1/29/24 at 10:30 AM in the west nourishment room there were 11 pudding cups with an expiration date of 1/25/24 written in blue ink on the lid, there were 10 applesauce cups with an expiration date of 1/25/24 written in black ink on the lid, there was one unlabeled, undated piece of Chocolate pie with whipped topping on the top shelf of the refrigerator. In the bottom left drawer of the refrigerator there was 1 Taco Bell paper bag undated and unlabeled with an unidentifiable substance inside. There was a brownish sticky substances on the top and bottom glass shelves of the refrigerator, and on the bottom shelf of the refrigerator door (Photographic Evidence Obtained). On 1/29/24 at 10:45 AM during an interview Staff C, Licensed Practical Nurse, Unit Manager stated, It is the certified nursing assistant's responsibility to keep the nourishment rooms clean. Sometimes the house keepers will tidy it up, and Dietary is responsible for the cleaning of the refrigerators and freezers. On 1/29/24 at 10:15 AM during an interview, the CDM stated, The nursing staff is responsible for cleaning the nourishment rooms, dietary will stock the items, and remove the expired items. I expect the Dietary staff to go and check those rooms daily, and wipe down anything that needs it. Review of the policy and procedure titled Use and Storage of Food Brought in by Family or Visitors with a reviewed date of 1/23/24 reads, Policy: It is the right of the resident of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. Policy Explanation and Compliance Guidelines: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and date. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. B. The prepared food must be consumed by the resident within 3 days. c. If not consumed within 3 days, food will be thrown away by facility staff. Review of the policy and procedure titled Refrigerators and Freezers with a review date of 1/23/24 reads, Policy Statement. This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation. 10. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Pantry refrigerators/freezers should be monitored by all facility staff and cleaned at least daily and more often as necessary. A cleaning schedule for the nourishment rooms was requested, information was not provided.

Based on record review and interview, the facility failed to conduct and submit a discharge Minimum Data Set (MDS) assessment within 14 days after completion to the Centers for Medicare Services System, including a subset of items upon a resident's transfer, or discharge for 2 (Resident #1 & Resident #2) out of 3 residents sampled for MDS assessment completion. Findings include: Review of the admission Record for Resident #1 documented an admission date of 03/30/22 with diagnoses including cerebral infarction (disruption of blood flow to the brain), Type II Diabetes Mellitus (high levels of sugar in the blood), cardiomyopathy (heart muscle disease), depression and muscle weakness. Review of Resident #1's progress notes documented on 04/21/22, [Resident #1's Name] will discharge home accompanied by son . Review of Resident #1's Minimum Data Set (MDS) assessments documented an admission Medicare - 5 Day Assessment completed on 4/19/22 and accepted on 04/25/22. There was no discharge MDS Assessment located in Resident #1's electronic file. Review of the admission Record for Resident #2 documented an admission date of 3/28/22 with diagnoses including unspecified fracture of third lumbar vertebra, spinal stenosis (spinal narrowing) lumbar region, Type II Diabetes Mellitus (high levels of sugar in the blood), asthma, acute kidney failure and atrial fibrillation (irregular heart beat). Review of Resident #2's SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Note dated 4/25/22 at 2:00 PM documented Recommendations of Primary Clinicians- send out to hospital. Review of Resident #2's Minimum Data Set (MDS) assessments documented an admission Medicare - 5 Day Assessment completed on 4/20/22 and accepted on 04/25/22. There was no discharge MDS Assessment located in Resident #2's electronic file. During an interview conducted on 08/09/22 at 01:42 PM with the MDS coordinator she confirmed that Residents #1 and #2 did not have a discharge MDS in their electronic files. Review of the facility policy titled MDS 3.0 Completion undated and reviewed on 01/11/22 read, .f. Discharge Assessment - completed using the discharge date as the ARD (Assessment Reference Date). Must be completed within 14 days of the discharge date /ARD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services that meet professional standards of quality related to the application of compression stockings for 1 (Resident #86) out of 1 resident sampled for use of compression stocking and performing wound dressing care for 1 (Resident #202) out of 3 residents sampled for wound care. Findings Include: 1. Review of the admission Record for Resident #86 documented the resident was initially admitted to the facility on [DATE] and has a diagnosis of heart failure (a condition that causes fluid buildup in the feet, arms, lungs, and other organs). Review of the physician orders for Resident #86 documented an order placed on 05/12/2022 that read compression stockings two times a day for edema. During an observation on 08/08/2022 at 9:47 AM, Resident #86 was not wearing compression stockings. During an observation on 08/09/2022 at 9:23 AM, Resident #86 was not wearing compression stockings. During an interview on 08/09/2022 at 8:29 AM, Resident #86 stated, I have noticed increased swelling in my lower legs, especially my ankles and feet. My doctor told me that it is essential to wear compression stockings to help reduce the swelling in my legs, but I need help putting them on. Unfortunately, I never receive assistance from the nursing staff, and I want to wear them. During an interview on 08/09/2022 at 1:29 PM, after reviewing the physician's order, Staff C confirmed Resident #86 was not wearing compression stockings and stated, I was not aware of the order for [Resident #86 name] to wear compression stockings twice a day. During a follow-up interview on 08/09/2022 at 1:35 PM Staff C stated, I went in to put the compression stockings on [Resident #86 name], but they did not fit. During an interview on 08/09/2022 at 1:41 PM, the Director of Nursing confirmed the orders and stated, It is my expectation [Resident #86 name] should be wearing compression stockings as the physician ordered. When asked for the facility's policy regarding following physician orders, on 08/10/2022 at 9:46 AM, the Director of Nursing stated, There is no policy regarding following physician orders because it is a standard of care. 2. During an observation conducted on 8/8/2022 at 12:41 PM Resident #202 was sitting in bed with a right lower leg dressing dated 8/4/2022. During an interview conducted on 8/8/2022 at 12:41 PM Resident #202 stated, I haven't had that changed in a couple of days. They can't put the wound vac on until they check for something. I had the wound vac in the hospital and haven't had one on since I got here. Review of the admission Record for Resident #202 documented the resident was admitted to the facility on [DATE] with the following diagnoses: cellulitis of right lower limb, type 2 diabetes mellitus with foot ulcer, gastro esophageal reflux disease, gastrointestinal hemorrhage, peripheral vascular disease, peripheral vascular angioplasty, acute kidney failure, essential (primary) hypertension, and acquired absence of left leg above knee. Review of the Physician Orders dated 8/3/2022 reads Wound Vac (negative-pressure wound therapy) in place to right ankle and anterior RLE (right lower extremity). every day shift every Mon, Thu, Fri (Monday, Thursday, Friday) for Wound. Cleanse area with NS (normal saline). Place foam into wound. Apply skin prep to intact skin on periwound. Cover with occlusive dressing and secure tubing per manufacturer's guide. Wound vac setting at 125mmHG (millimeters of mercury) intermittent suction and as needed for leaking or loss of suction. Cleanse area with NS. Place foam into wound. Apply skin prep to intact skin on periwound. Cover with occlusive dressing and secure tubing per manufacturer's guide. Review of Physician Orders dated 8/3/2022 reads, If wound vac needs to be turned off for any care, tests/procedures, or for transport: remove the dressing in its entirety, cleanse wound with NS and apply hydrogel gauze and secure with abd (abdominal) pad as needed for temporary removal. Review of Treatment Administration Record for August 2022 revealed no documented dressings for wounds. Review of the medical provider note dated 8/4/2022 reads: L (left) AKA (above the knee amputation), dressings to RLE (right lower extremity) are clean, dry, and intact. Wed-to-dry dressing removed and replaced by author today using saline moistened gauze, Abd pads, and gauze roll dressing. Wound bed on anterior R leg and foot is pink/red with white fascia showing. Minimal serosanguinous drainage noted. No odor. No surrounding erythema, edema, or tenderness. Assessment/Plan: 6 mm (millimeter) ringed PTFE (polytetrafluoroethylene) graft with additional debridement of skin, subcutaneous tissue of right leg and foot wound with wound VAC placement: F/U (follow up) with vascular surgery in 2-3 wks (weeks). Wound care nurse and provider to evaluate. Wound vac at intermittent -125mmhg. Daptomycin (an antibiotic) 450mg IV (intravenously) daily until 09/05/22. Wet-to-dry wound dressings daily and PRN (as needed) until wound vac supplies obtained. During an interview conducted on 8/8/2022 at 1:15 PM Staff A, Licensed Practical Nurse (LPN) stated, The dressing is dated 8/4/2022 and I don't know his wound care orders, I will need to check them. They are for a wound vac, I don't know why he has not gotten the wound vac, I would need to check on that. I don't know what wound care orders we need if we can't put on a wound vac. During an interview conducted on 8/10/22 at 3:30 PM the Director of Nursing (DON) stated, We have not done the dressings daily, the wound vac has not been on, and we should be completing dressings and letting the doctor know that we can't put the wound vac on and obtain orders for daily dressings. I do not see the wound measurements on the admission assessment, they should be documented. Review of the policy and procedure titled, Negative Pressure Wound Therapy approval date of 1/11/2022 reads, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced based treatments in accordance with current standards of practice and physician orders. This policy addresses the use of negative pressure wound therapy (NPWT) for the treatment and management of wounds. Policy Explanation and Compliance Guidelines: 10. Whenever therapy cannot be resumed within 2 hours, remove the dressing, and apply a moist wound dressing. Notify physician for specific orders. 12. The physician shall be notified of any complications associated with the use of NPWT.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide care for central venous access devices in accordance with professional standards of practice for 1 (Resident #25) of 2 central venous access devices out of a total sample of 43 residents. Findings include: During an observation on 8/9/2022 at 9:27 AM Resident #25 was sitting in a wheelchair and there was a right upper arm midline catheter with 4 x 4 gauze under a transparent dressing that was dated 8/6/2022. During an observation on 8/9/2022 at 10:40 AM Resident #25 was sitting up in a wheelchair. Resident had a right upper arm midline catheter with 4 x 4 gauze under a transparent dressing dated 8/6/2022. During an observation of medication administration conducted on 8/9/2022 at 10:40 AM Staff C, Licensed Practical Nurse (LPN) was observed administering 0.9% normal saline flush to Resident #25's midline catheter. Staff C, LPN cleaned the needleless connector for 2 seconds with alcohol and immediately administered the normal saline. Staff C, LPN did not let the needleless connector air dry or verify line placement prior to administering the medication. Review of the admission Record documented that Resident #25 was admitted to the facility on [DATE] with the following diagnoses type 2 diabetes mellitus, mood disorder, unspecified dementia, osteoarthritis, anemia, essential (primary) hypertension, hypothyroidism, hyperlipidemia. anxiety disorder, and major depressive disorder. Review of the Physician Orders dated 8/6/2022 reads, Insert midline with lidocaine one time for 1 day. Review of the Physician Orders dated 8/8/2022 reads, Observe midline catheter site during dressing changes. Review of the Physician Orders dated 8/8/2022 reads, Normal Saline Flush Solution 0.9% (Sodium Chloride Flush). Use 10 cc (cubic centimeter) intravenously every shift for midline to right arm every shift. During an interview on 8/9/2022 at 10:55 AM Staff C, LPN stated, The dressing is dated 8/6/22 and doesn't need to be changed. Well, it does have a gauze under the dressing, but it is in date. Sometimes the wound nurse does the dressing change, so I really don't know. I should have cleaned the needleless connector for longer and I should have checked for a blood return, and I didn't. I should have. During an interview on 8/9/2022 at 11:00 AM the Director of Nursing (DON) stated, The gauze should not be under the dressing, it should be changed within 48 hours. The dressing should have been changed yesterday. Review of the policy and procedure titled PICC/Midline/CVAD dressing change approval date 1/11/2022 reads, It is the policy of this facility to change peripherally inserted central catheter (PICC), midline or central venous access device (CVAD) dressing weekly or if soiled, in a manner to decrease potential for infection and/or cross-contamination. Physicians' orders will specify type of dressing and frequency of changes. Review of the policy and procedure titled Central Venous Catheter Flushing, Locking, Removal approval date of 1/11/2022 reads, Policy: It is the policy of this facility to ensure that central venous access catheters are flushed, locked, and removed consistent with current standards of practice. Policy Explanation: Central venous access devices are catheters that are placed into central circulation with the tip located in the superior vena cava or the inferior vena cava depending upon location. These are commonly known as 'central lines.' These devices may be used for longer durations of time but are not without their inherent risk of infection. Compliance Guidelines: 3. Central venous access catheters will be flushed and aspirated for blood return prior to each infusion to assess catheter functionality and prevent complications. Flushing: 1. Perform hand hygiene. 2. Gather supplies. 3. [NAME] gloves. 4. Disinfect needleless connector with an antiseptic solution using a vigorous mechanical scrub for 5 seconds and allow to air dry completely. 7. Slowly aspirate for a blood return to confirm device patency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 08/08/22 at 8:32 AM Resident #47 was observed lying on her left side in bed with oxygen being administered at 1 liter via nasal cannula. During an observation on 08/09/22 at 10:27 AM Resident #47 was observed sitting in bed with oxygen being administered at 1 liter via nasal cannula. Review of the admission Record for Resident #47 documented the resident was admitted to the facility on [DATE] with the following diagnosis: chronic respiratory failure (Low oxygen levels that impact breathing) and congestive heart failure (the heart cannot pump enough blood to meet the body's needs). Review of the Physician Orders for Resident #47 dated 6/7/22 reads: Oxygen 2-4 liters/min to maintain oxygen % (percentage) saturation above 92% as needed for shortness of breath/low oxygen level. During an interview on 8/10/22 at 11:57 AM Staff D, LPN confirmed that the order was for oxygen at 2-4 liters of oxygen for Resident #47. During an interview on 8/10/22 at 2:07 PM the DON stated, Nurses are to check and adjust oxygen rate as per physician orders during resident assessments on each shift. Based on observation, interview, and record review the facility failed to provide respiratory care services in accordance with professional standards of practice for 2 (Resident #201 and #47) of 3 residents reviewed for oxygen administration out of a total sample of 42. Findings include: 1. During an observation on 8/8/22 at 10:40 AM Resident #201 was sitting in bed with oxygen being administered at 4 liters per minute via nasal cannula. The oxygen concentrator was set on 4 liters per minute. During an observation on 8/9/22 at 7:40 AM Resident #201 was resting in bed with oxygen running at 4 liters via nasal cannula. Review of the admission Record for Resident #201 documented the resident was admitted to the facility on [DATE] with the following diagnoses: atrioventricular block, complete (a condition that occurs when the electrical impulses that control the beating of the heart muscles are disrupted), chronic obstructive pulmonary disease, Non-Hodgkin lymphoma (a cancer of the white blood cells), dysphagia (inability to swallow), fibromyalgia, chronic pain syndrome, Sjogren syndrome (a disorder of the immune system), and essential (primary) hypertension, polymyositis (an inflammatory disease that causes muscle weakness), and anemia. Review of the Physician Orders for Resident #201 dated 8/4/22 reads, Oxygen at 2 liters/min (minute) via nasal cannula every shift and as needed. Review of the nursing progress notes for Resident #201 do not document any change in condition that would require an increase in oxygen rate. During an interview on 8/9/22 at 8:05 AM Staff B, Licensed Practical Nurse (LPN) stated, I don't know what the oxygen is supposed to be set on. I will check. It is ordered at 2 liters. I will check the amount of oxygen my residents get when I give my medications and I haven't given them yet. During an interview on 8/10/22 at 11:25 AM the Director of Nursing (DON) stated, I expect that all staff will follow physician orders as they are written. Review of the policy and procedure titled, Oxygen Administration approval date of 1/11/22 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to prevent the possible development and transmission of communicable diseases and infections. The facility failed to ensure staff performed hand hygiene during medication administration in 5 of 6 observations of medication administration. Findings include: During an observation of medication administration on 8/9/2022 at 8:19 AM Staff A, Licensed Practical Nurse (LPN) prepared medication for Resident #67 without performing hand hygiene, donned personal protective equipment (PPE), and put on gloves without performing hand hygiene, entered the resident's room and administered the medications. Staff A did not perform hand hygiene after removing PPE, returned to the medication, and began preparing medications for another resident. During an interview on 8/9/2022 at 10:25 AM Staff A, LPN stated, I should have used the hand sanitizer before I got the PPE and gloves on, I should have washed my hands when I took it [PPE] off. During an observation on 8/9/2022 at 8:28 AM Staff C, LPN was observed in hallway checking Resident #56's blood pressure, staff was observed removing gloves and without performing hand hygiene began preparing medications for Resident #56 and administered the medications in the hallway. After administering the medications Staff C did not perform hand hygiene and began preparing medications for another resident. During an observation of medication administration on 8/9/2022 at 8:33 AM Staff C, LPN began preparing medications for Resident #54 without performing hand hygiene. Staff C administered the medications to the resident at the medication cart per resident request and did not perform hand hygiene after administering medications and beginning to prepare medications for another resident. During an observation of medication administration on 8/9/2022 at 8:55 AM Staff C, LPN began preparing medications for Resident #11 without performing hand hygiene. Staff C entered the resident's room without performing hand hygiene, assisted Resident #11 to reposition in bed and administered the medications. Staff C, left the room, returned to the medication cart, and began preparing medications for another resident without performing hand hygiene. During an observation of medication administration on 8/9/2022 at 10:40 AM Staff C, LPN completed an accucheck on Resident #25, staff assembled all equipment and entered the resident's room without performing hand hygiene, donned gloves, performed the accucheck, removed gloves, and without performing hand hygiene returned to the medication cart, obtained the medications from the cart, and returned to the resident's room. Staff C donned gloves without performing hand hygiene administered insulin subcutaneously in the right abdomen, pulling up the resident's shirt with a gloved hand. After administering the insulin, Staff C opened the 0.9% normal saline syringe, cleaned the resident's right midline catheter needleless connector for 2 seconds and administered 0.9 % normal saline, without changing gloves or performing hand hygiene between the administrations. During an interview on 8/9/2022 at 10:55 AM Staff C, LPN stated, I should have cleaned the needleless connector for longer. I should have changed my gloves and washed my hands before I flushed the midline dressing. I should use hand sanitizer before I poured meds [medications] and when I go in or out of the resident's rooms to give them meds. Review of the policy and procedure titled Hand Hygiene approval date of 1/11/2022 reads Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations in the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your tasks requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of the policy and procedure titled Medication Administration approval date of 1/11/2022 reads Policy. Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 4. Wash hands prior to administering medications per facility protocol and product.