Based on observations, record review, and interviews, the facility did not ensure one of two community shower rooms were maintained in a clean and sanitary condition. Findings included: On 01/14/2025 at 9:15 AM the following observations were made of the community shower room located on Unit 4: - Shower curtains on the two showers in the room had a black substance on the lower part of both the out-facing and in-facing portions of the curtain. - A caked black substance was observed on the tile floor behind the toilet and the floor in front of and around the toilet was also caked with black substance. - The rim under the toilet seat had a yellow liquid substance on it. The inside of the toilet bowl had a rust-colored stain in the portion where the water drains when flushed. - There were two shower stalls in the room. In the second shower stall closest to the far wall, the floor of the shower, the drain, and the shower head all had a yellow substance on them. There were areas of cement-like porous, uncleanable spots where the tiles were missing on the floor. - The wall vent fan for the room had a thick layer of dust on the fan blades. - Across from the showers there was a large area of cement-like, porous, uncleanable material on the floor along with missing tiles. This area also had a rust-colored stain on one side and parts of the cement-like material were crumbling. - The sink had rust-coloring around the drain and thin rust-colored streaking in the bowl of the sink. - There was one shower bed in the room. On top of the shower bed cushion, near the head portion, there was a comb and a pillow. Brownish-black spots were observed on the top of the shower bed cushion toward the foot end of the cushion. On the under-side of the cushion of the shower bed there were black, brown, and yellow dried substances. - On the top of the shower bed mesh covering there were dried yellow, brown, and black flaky substances. - There was one bedside commode next to the shower bed which had a dried brown substance on the lid. An interview was conducted with the Housekeeping Director on 01/16/2025 at 12:44 PM and she stated her expectation was for the housekeeper assigned to the shower room to spray and clean the walls, sink, toilet, mirror, and mop the floors. She said the shower curtains are cleaned every three weeks and wiped down daily. The Housekeeping Director said there is one housekeeper on each unit, and the shower rooms should be cleaned once per day and more often if needed. She said the Certified Nursing Assistants (CNA) are responsible for cleaning any shower equipment they use. Upon review of the pictures of the shower room on Unit 4, she agreed the shower room did not look appealing. An interview was conducted with Staff G, Registered Nurse/Unit Manager (RN/UM) on 01/16/2025 at 4:00 PM and he said the CNA's are responsible for and should be cleaning all of the equipment they use when giving residents showers. He said he has not been routinely looking at the shower room equipment to ensure the CNA's are cleaning them. An interview was conducted with the Maintenance Director on 01/16/2025 at 4:22 PM. The interview was conducted while viewing the pictures taken of the shower room on Unit 4. The Maintenance Director said the facility is in the process of renovating the facility, specifically Unit 3 and Unit 4, which will include the shower rooms. He said the units are being painted and new flooring will be installed. He agreed the floor of the shower room on Unit 4 is in poor condition and he said it will be a top priority in the renovation project. He said the time frame for completing the renovation of the shower room is projected to be at the end of February. He said he did not realize the shower room on Unit 4 was in such bad condition and he should check it more often. He said the Maintenance Department has three employees, two who work first shift and one on the second shift. The Maintenance Director said he has schedules of monthly and bi-monthly projects throughout the facility. Bi-monthly his staff will look at room conditions and right now the priority is batteries in the hand soap dispensers, clocks, and toilets. A review of the facility's Safe and Homelike Environment policy, undated, showed: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Under the Definitions portion of the Safe and Homelike Environment policy, Sanitary is defined as includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living. The policy also revealed under Policy Explanation and Compliance Guidelines, Section 1 number 3: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Photographic Evidence Obtained

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #19's admission Record showed an admission date of 12/4/24. The record included diagnoses with onset dates including but not limited to cognitive communication deficit (CCD), onset date 12/5/24, unspecified bipolar disorder, onset date 12/4/24, unspecified recurrent major depressive disorder, onset 12/4/24, and generalized anxiety disorder, onset date 12/4/24. Review of Resident #19's Psychiatry Evaluation Note dated 12/30/24 showed the provider signed the document on 1/4/25. The evaluation revealed the resident's chief complaint as depression, anxiety, and bipolar disorder. The Assessments and Plan revealed, The patient's history suggests that the patient has chronic episodes of depression and manic-like symptoms. These symptoms cause significant distress and functional impairment to the patient. As bipolar disorder is a lifelong disorder, mood stabilizer medicine needs to be continued on a long-term basis. The patient is on psych meds because non-pharmacological interventions are not sufficient to manage the symptoms of the patient. The evaluation showed the provider recommended the resident to continue Bupropion and Sertraline to tackle depression and Alprazolam for anxiety. Review of Resident #19's Level I PASRR dated 1/13/25, completed by the facility's ADON, included mental illness diagnoses of anxiety disorder, bipolar disorder, depressive disorder, and schizophrenia. The screening did not include any intellectual disorders and showed the resident was receiving services for mental illness based on documented history and medications. The decision-making evaluation revealed the resident did not have any indication of having a disorder resulting in functional limitations of major life activities, no interpersonal functioning difficulties, no concentration, persistence, and pace difficulties, no adaptation to change difficulties, any recent outpatient/inpatient treatments, or have experienced an episode of significant disruptions. The screening completion showed the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated and a Level II PASRR evaluation was not required. 4. Review of Resident #73's admission Record showed the resident was admitted on [DATE]. The admission Record included secondary diagnoses and onset dates including but not limited to cognitive communication deficit, onset 1/1/25, unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, onset 12/10/24, and brief psychotic disorder, onset 12/10/24. Review of Resident #73's acute care documentation revealed a consultation note from a physician dated 12/7/24, [Resident #73] has dementia and worsening memory loss. The note showed the resident was Positive for dementia and recent fall. An acute care facility physician note dated 12/9/24 revealed the resident presented to the emergency room (ER) from an assisted living facility with a past medical history including diagnoses of dementia and depression. The acute care facility's therapy note, dated 12/7/24, revealed the resident had a cognitive deficit and had previously resided on a memory care unit at an assisted living facility and normally utilized a rolling walker (RW) with supervision to ambulate. The therapy assessment, dated 12/7/24 revealed the resident's barrier to learning was cognitive deficit, [and] difficulty concentrating. Review of Resident #73's Level I PASRR screen dated 12/10/24 and completed at an acute care facility, revealed the resident did not have any mental illness, suspected mental illness, intellectual disability and/or suspected intellectual disability based on documented history. The decision-making screening showed the resident did not have any indication of having a disorder resulting in functional limitations of major life activities, no interpersonal functioning difficulties, no concentration, persistence, and pace difficulties, no adaptation to change difficulties, any recent outpatient/inpatient treatments, or had experienced an episode of significant disruptions. The screening revealed the resident had not exhibited actions or behaviors that may make them a danger to themselves or others or validating documentation to support the dementia diagnosis, and the admission was not provisional. The screening revealed the resident could be admitted to a Nursing facility as there was no diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated and a Level II PASRR evaluation was not required. Review of Resident #73's Psychiatry Evaluation Note dated 12/23/24 showed the provider was consulted for psychiatric evaluation and treatment of depressed mood, disorganized, and confused thinking. The note revealed the resident had a past psychiatric history of depression, anxiety, dementia, and brief psychotic disorder. The provider noted, As per collected information, resident has been anxious and confused. [Resident #73] is difficult to redirect due to increased confusion. The patient limitations were described as Being in the facility, Away from home. The assessment revealed, As per collected information and interview, it appears that the patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying anxiety disorder. The history suggests that this patient has suffered from episodes of depression lasting for more than 2 weeks. The symptoms have caused significant distress and functional impairment to the patient. The rationale behind the dementia without behavioral disturbance diagnosis showed the resident had a gradual decline in memory, executive function, language, concentration, and fund of knowledge. These symptoms have caused distress and have affected the quality of life and activities of daily living. The resident's depression assessment revealed moderate depression, has situational exacerbation of depression due to health and situation of being in a facility and a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Review of Resident #73's comprehensive assessment dated [DATE] showed a BIMS score of 13 out of 15, indicating an intact cognition. The assessment also revealed the resident had disorganized thinking that was continuously present and does not fluctuate. Review of Resident #73's Level I PASSR completed by the facility's ADON on 1/13/25 showed the diagnoses of anxiety, depressive disorder, and brief psychotic disorders had been added as MI or suspected MI. The decision-making continued to indicate the resident had no disorder resulting in functional limitations in major life activities that would otherwise by age appropriate, did not have any continuing or intermittent issues with interpersonal functioning, concentration, persistence, and pace, or an issue with adapting to change. The revised Level I PASRR did not show the resident had any validating documentation to support the dementia diagnosis and the resident did not have a diagnosis or suspicion of Serious Mental Illness or Intellectual Disability and a Level II PASRR evaluation was not required. An interview was conducted on 1/16/25 at 10:16 a.m. with the ADON and SSD. The ADON reported reviewing psych notes whenever she gets them, the admission department reviews the hospital records to see if residents have a psych diagnosis, and the uploaded PASRR. She stated she looks at psych notes for diagnoses to ensure the PASRR's have the same diagnoses. The staff members revealed the resident's history is reviewed to see if they have been involuntarily hospitalized and see if they have anything that effects daily interactions, behaviors, and if a psych diagnosis placed them in the hospital. The SSD reported the facility has meetings daily and behaviors are discussed. The ADON reported validating dementia was any documentation the resident has and the hospital History & Physical (H&P) with documentation of a dementia diagnosis would be considered validating documentation. The ADON reported looking at psych notes and stated just because Resident #19 had bipolar and schizophrenia doesn't mean they need a Level II. She also stated a Level II was to identify anyone with a mental illness or behaviors and to see if they need to receive services or if they need extra ones. Review of the policy - Resident Assessment - Coordination with PASARR Program, implemented 9/7/22 showed the following: This facility coordinates assessments with the pre admission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The compliance guidelines revealed the following: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the States Medicaid rules for screening. a. PASARR Level I - an initial prescreening that is completed prior to admission. i. Negative Level I screen - permit submission to proceed and ends the PASARR process unless if possible, serious mental disorder or intellectual disability arises later. ii. Positive Level I screen - necessitates a PASARR Level II evaluation prior to admission. b. PASARR Level II - a comprehensive evaluation by the appropriate state designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the state mental health or in the lateral disability authority has determined as appropriate for admission. 4. Exceptions to the pre admission screening program include those individuals who: a. Are readmitted directly from a hospital. b. Or admitted directly from any hospital requires nursing facility services for the condition of which the individual received here in the hospital and has been certified by the attending physician before admission that the individual is likely to require less than 30 days of nursing facility services. 5. If a resident who has not screened due to an exception above and the resident remains in the facility longer than 30 days: a. The facilities must screen the individual using the states Level I screening process and refer any resident who has or may have MD, ID or a related condition to the state designated authority for Level II PASARR evaluation and determination. b. The Level II resident review must be completed within 40 calendar days of admission. 6. The social service director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition would be referred promptly to the state mental health or intellectual disability authority for a Level II resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis). b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. c. Any resident transferred, admitted , or readmitted to the facility following an inpatient psychiatric state or equally intensive treatment. 2. Review of Resident #79's admission Record revealed she was admitted to the facility on [DATE] with medical diagnoses of undifferentiated schizophrenia, bipolar disorder, and major depressive disorder. Review of Resident #79's Level I PASRR screen dated 5/31/24 revealed qualifying mental health diagnoses of bipolar disorder, depressive disorder, and schizophrenia with no recommendation for a Level II PASRR. An interview was conducted on 01/13/25 at 10:23 a.m. with Resident #79. She said, the people throw dirt and water on me. The resident was observed wiping her sheet as she was interviewed and was observed clean without dirt or water on her or her sheets. Resident #79's roommate walked next to the resident's bedside and said, [Resident #79] thinks people put dirt and water on her, but they are people that aren't real. I have to threaten calling 911 on the imaginary people throwing dirt and water on her or I have to scare them. Resident #79 continued to repeat, they put dirt and water on me. Resident #79 was observed crying as she was repeating, they put dirt on me. She then looked at the television, stopped crying, and watched television. A follow up interview was conducted on 01/14/25 at 1:33 p.m. with Resident #79. Upon entering the resident's room, a physical therapist exited the room. The resident was observed in bed, clean, and without odors. She said she just got done exercising her legs, lunch was good and she was going to relax now after her exercising. Review of Resident #79's Psychiatry Subsequent Note dated 11/18/24 revealed: History of Present Illness: This is a [AGE] years old patient with a past psychiatric history of depression, bipolar disorder and schizophrenia. Prior to last visit, patient was screaming in hallways. Patient had mood swings. During last visit, patient was doing well. Patient was sleeping and eating well. No anxiety related symptoms noted. No medication changes were done. Today, I saw the patient as it was reported to me that patient is unstable requiring psychiatric assessment. As per collected information, resident continues yelling randomly and talking to herself. Patient denies sleep and appetite related problems. No other psychiatric symptoms are observed. No side effects to current psych meds were reported . Abnormal thought processes: Has hallucinations .Assessments and Plan: [patient] is unstable but requires no med changes: As per collected information and interview, it appears that the patient is unstable. I feel the symptoms are occurring due to exacerbation of underlying mood disorder. However, the symptoms are not causing significant distress to require psychiatric medication changes. Ongoing medical stabilization, emotional support, and closer monitoring from our side would be good enough. We will do follow-up appointments as needed Rational behind diagnoses: Bipolar disorder: The patient's history suggests that the patient has chronic episodes of depression and manic-like symptoms. These symptoms cause significant distress and functional impairment to the patient Schizophrenia (Confirmed [diagnosis]): The history of this patient shows that the patient has chronic and consistent psychosis. These symptoms cause significant distress and functional impairment to the patient . Review of Resident #79's care plan with an initiation date and a revision date of 1/3/22 revealed a Focus, [Resident #79] is here for Long Term placement d/t [due to] need for 24 hour supervision/care r/t [related to] type 2 dm [diabetes mellitus], bipolar, depression, morbid obesity, inability to care for self at former ALF [assisted living facility]. the Goal revealed, Resident's psychosocial needs will be met daily with assist from staff thru the next review date. The Interventions included, Encourage family and friends to visit or call as often as they can-as resident allows. Encourage socialization with peers in the facility. Invite and escort to activities of preference. Involve resident, family, or friends (as allowed) to participate with care as applicable. Praise the efforts of the resident participation in cares. Review of Resident #79's Behavior Care Plan with a revision date of 11/30/23 revealed, Potential for impaired or inappropriate behaviors related to diagnosis of Bipolar and Schizophrenia. [Resident #79] talks out loud during the night. The Goal revealed, Resident will have a decrease in negative behaviors thru next review. The Interventions revealed, Administer medications as ordered. Observe/document for side effects and effectiveness. Anticipate and meet the resident's needs. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Praise any indication of the resident's progress/improvement in behavior. An interview was conducted with the Assistant Director of Nursing (ADON) and Staff K, Social Services Director (SSD) on 1/16/25 at 10:28AM. The ADON said when she did the PASRR assessment for Resident #79 she completed the questions for that specific time. Staff K, SSD and the ADON confirmed Resident #79 does have behaviors of talking to herself at night and yelling out. They confirmed she had mental illnesses of depressive disorder, bipolar disorder, and schizophrenia and came to the facility from a mental disorder assisted living facility. They reviewed Resident #79's PASRR and Staff K, SSD said they can have a Level II PASRR assessment done for Resident #79. Staff K, SSD said the reason for the Level II assessment is to identify a resident with a mental illness, determine correct placement, and determine the resident is receiving the appropriate services for their mental illness. Based on observations, record review, and interviews, the facility failed to ensure resident's with diagnosed mental illness or suspected mental illness were referred to the State's Mental Health authority for a Level II Preadmission Screening and Resident Review (PASRR) screenings for four residents (#47, #79, #19, and #73) out of 29 residents sampled. Findings included: 1. Review of Resident #47's admission Record revealed an admission date of 12/30/24 and an initial admission date of 07/01/23. Resident #47 was admitted to the facility with diagnoses of paranoid schizophrenia, schizoaffective disorder, depressive type, major depressive disorder, recurrent, and anxiety disorder Review of the Level I PASRR screen dated 07/01/24 showed the following: Section I, Part A - MI (Mental Illness) or suspected MI: Anxiety Disorder, Depressive Disorder, Schizoaffective Disorder, and Schizophrenia were checked. Section III: PASRR Screen Provisional admission or Hospital Discharge Exemption Not a Provisional admission was marked no. Section IV: PASRR Screen Completion, Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to develop and implement care plan interventions for four residents (#19, #24, #32, and #133) of thirty-nine sampled residents, related to; 1. Fluid restrictions, 2. Self-administration of oxygen, 3. Discharge planning, and 4. Fall interventions. Findings included: 1. On 1/14/25 at 3:40 p.m., Resident #19 was observed lying in bed. A 16 ounce (oz) foam cup and a wine-colored coffee cup was observed on the over-bed table. The resident picked the foam cup up and reported there was a little bit of fluid in it. On 1/15/25 at 1:31 p.m., Resident #19 was observed lying in bed, wearing street clothes and shoes with her eyes closed. A 16-oz foam cup was observed sitting on the resident's over-bed table next to the bed. Review of Resident #19's admission Record revealed the resident was admitted on [DATE] with diagnoses including but not limited to hypo-osmolality and hyponatremia and essential (primary) hypertension. Review of Resident #19's care plan revealed Special Instructions: Fluid Restriction: 1500 milliliter (ML) every (q) 24 hours (24H). Dietary to provide a total of 840 ML/24H, Nursing to provide a total of 660 ML 24H: 7a-7p shift: 420 ML/24, 7p-7a shift: 240 ML/24H. The care plan showed the resident was at risk for impaired nutrition related to (r/t) diagnosis (dx) of hypertension (HTN), sprain lateral collateral ligament left knee, bipolar, depression, anxiety, HTN, hyperlipidemia (HLD), history (hx) hyponatremia, and weight changes and was on a fluid restriction. This Focus was initiated on 12/6/24 and revised on 1/10/25. The interventions informed Certified Nursing Assistants and Dietary staff of Fluid Restriction per physician orders. No bedside water cup. Nursing providing & Dietary as ordered per MD. Review of Resident #19's January 2025 physician orders revealed an order dated 12/5/24, Fluid Restriction: 1500 milliliter (ML) every (q) 24 hours (24H). Dietary to provide a total of 840 ML/24H, Nursing to provide a total of 660 ML 24H: 7a-7p shift: 420 ML/24, 7p-7a shift: 240 ML/24H. The dietary order showed the resident was on regular texture, thin liquids consistency, and *1500 mL Fluid Restriction. Review of Resident #19's Kardex included the following: - Activities: Additional Fluids. - Eating/Nutrition: Fluid Restriction per physician orders. No bedside water cup. Nursing providing & Dietary as ordered per MD. - Eating/Nutrition: Fluids offered every shift. - Eating/Nutrition: Resident on 1500 mL fluid restriction daily, no bedside fluids. An interview was conducted with Staff Q, Certified Nursing Assistant (CNA) on 1/15/25 at 2:02 p.m. The staff member reported staff can check the resident's Kardex for everything and the resident's care plans are in the computer. Staff Q, CNA explained the Kardex will let you know how to take care of the residents and will indicated if a resident is on a fluid restriction. An interview was conducted with Staff R, Registered Nurse (RN) on 1/15/25 at 2:08 p.m. The staff member confirmed being the nurse for the back portion of the hall, including Resident #19's room. The staff member stated a male resident (not Resident #19) was on fluid restrictions and no one else was on fluid restrictions. An interview and observation was conducted with Staff Q, CNA on 1/15/25 at 2:20 p.m. The staff member confirmed Resident #19 had a foam cup on the over bed table. Staff Q, CNA picked up the cup and said it was empty, removing the lid and straw, then confirmed the cup was empty with a few drops of clear liquid, stating it was empty now. An interview was conducted with the Director of Nursing (DON) on 1/16/25 at 8:43 a.m. The DON stated staff should be aware of a resident being on a fluid restriction, it should be in the Kardex for the aides and in the computer for nurses. The DON stated she was aware of Resident #19 having a cup at bedside and there should not be a cup left at the bedside. The DON provided on 1/16/25 at 9:31 a.m. a list of four residents in the facility on a fluid restriction. The list included Resident #19. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 1/16/25 at 9:10 a.m. The coordinator stated of course staff should follow the Kardex and nurses should know the care plan. The MDS Coordinator confirmed Resident #19 was on a fluid restriction and had been on one since admission. The staff member acknowledged staff should follow the care plan. 2. On 1/13/25 at 9:53 a.m., Resident #24 was observed in his room. An oxygen concentrator and oxygen tubing in a bag was observed sitting against a wall near the resident's bed . At the time of the observation the resident was not using oxygen and the oxygen concentrator was turned off. The resident stated he uses oxygen when he needs it and he puts on, takes off the nasal canula, and turns the oxygen concentrator on himself. On 1/16/25 at 12:13 p.m. Resident #24 was observed sitting in his motorized wheelchair in his room wearing his oxygen. He said he came to his room to relax for a little while before lunch was delivered. He said he turned on the concentrator himself and put the nasal canula in his nostrils without assistance. The resident said he wasn't short of breath or having any difficulty breathing, he just wanted to put the oxygen on. He said he will take the oxygen off when he feels better. Review of the admission Record showed Resident #24's initial admission date to the facility was 1/17/23 with an additional admission date of 2/8/23. The admitting diagnoses included but not limited to chronic obstructive pulmonary disease (COPD) with acute exacerbation and chronic respiratory failure with hypoxia. Review of the MDS Quarterly assessment dated [DATE] for Resident #24 showed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 15, showing the resident's cognition was intact. Review of Resident #24's Care Plan dated 1/18/23 showed: Focus: The resident has oxygen therapy related to COPD. Goal: The resident will have no signs or symptoms of poor oxygen absorption through the review date. Interventions: Give medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for signs and symptoms of respiratory distress and report to Medical Doctor (MD) as needed: respirations, pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle usage, and skin color. OXYGEN SETTINGS: Oxygen via nasal canula as ordered. Review of Resident #24's Care Plan did not show an entry for self-administration of oxygen by the resident. Review of Resident #24's Evaluations did not show an evaluation for self-administration of medication or oxygen. Review of the January 2025 physician orders for Resident #24 showed: Oxygen 2 Liters via nasal canula as needed (PRN) related to COPD. Review of the physician orders for Resident #24 did not reveal a physician order to self-administer oxygen. An interview was conducted with Staff J, RN, on 1/15/25 at 11:13 a.m. Staff J, RN stated she regularly has Resident #24 on her assignment and is very familiar with him. She said the resident has an order for oxygen at two liters per minute (LPM) PRN. She said the resident does not ask to have the oxygen put on, he just takes it off and on himself. She said she was not sure if he had an order for self-administration. An interview was conducted with Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM) on 1/16/25 at 12:05 p.m. Staff L, LPN/UM said residents cannot self-administer medications unless they have a self-administration assessment to make sure the resident knows about the medication and how to administer it. She said sometimes they will find residents who are on oxygen will take their oxygen on and off without the order or assessment. When the staff discovers this is happening, it is corrected immediately. The doctor is called and if they write an order for self-administration, an assessment is done and the resident's care plan is updated. Staff L, LPN/UM said if the resident shows the capacity and understanding to do it, they can operate the concentrator and put on their oxygen themselves. She said if a staff member sees the resident taking on and off their oxygen they should document the observation and notify the doctor. She stated the facility would then go through the proper steps in order for the resident to be able to self-administer their oxygen. An interview was conducted with the DON on 1/16/25 at 1:15 p.m., who said residents are allowed to self-administer medication after they pass an assessment for self-administration and the physician must approve the self-administration, and if applicable, the medication will be put in a lockbox at the resident's bedside. She said the resident has to sign out the medication before taking it and the nurse would notify the resident when it was time to administer the medication. She said oxygen is a medication and it would be the same process as the self-administered medication, but it would not include a lockbox. The DON said she was alerted to the fact Resident #24 was self-administering his oxygen shortly before the interview began. 3. On 1/14/25 at 9:20 a.m., Resident #32 was observed in his room. The resident was dressed, groomed and independently walking around the room. The resident was alert, oriented, and pleasant. Resident #32 had a tracheostomy (trach) with a collar. An interview was conducted with Resident #32 during the observation. Resident #32 stated he can take care of the trach himself, and it was observed the trach and trach site was clean. He said he is getting physical therapy four times per week and because of the physical therapy he can walk longer distances with a walker. He said the facility is okay, but he is ready to go home. He feels he is able to take care of himself now and is mostly independent. Resident #32 stated he spoke to the Social Worker several times about finding an Assisted Living Facility (ALF) for him to transfer to, but nothing has happened yet. Review of the admission Record showed Resident #32 was admitted to the facility on [DATE] with diagnoses including encounter for attention to tracheostomy, COPD, malignant neoplasm head/face/neck, dysphagia oral phase, acquired absence of larynx, muscle weakness, unsteadiness on feet, and dyspnea. Review of the MDS Quarterly assessment dated [DATE] for Resident #32, Section C - Cognitive Patterns showed the resident had a BIMS score of 14, showing the resident's cognition was intact. Review of Resident #32's care plan dated 5/7/24 did not show a Discharge Plan for the resident. Review of Resident #32's Social Service Progress Notes dated 6/10/24 revealed the Social Services Director (SSD) received a call from a representative from Elder Affairs informing her Resident #32 voiced interest in applying for Medicaid with the intent to transition to the community. The Social Service Progress Notes dated 7/9/24 revealed Resident #32 voiced interest in ALF placement. The SSD wrote she contacted a local ALF and the representative at that ALF said she would go to the facility that day to assess Resident #32 for possible placement. During an interview on 1/16/25 at 9:19 a.m., Staff E, LPN said she regularly takes care of Resident #32 and has taken care of him since he was admitted to the facility. She said the resident has been educated on his care and he is able to independently take care of his tracheostomy. She said the plan for Resident #32 is to have the trach removed, which will happen within the next several weeks. Staff E, LPN said the resident is independent and she knows he is ready to either go home or to an ALF as soon as possible. She said he has good family support and will do well in the community. An interview was conducted with the SSD on 1/16/25 at 9:44 a.m. The SSD said she had several conversations with Resident #32 regarding his discharge plan. She said the resident wants to discharge to an ALF. The SSD said she knows the resident is interested in discharging to a local ALF and the representative of the ALF has visited the resident several times in the facility. She said she doesn't remember the exact dates the ALF representative visited the resident, but she knows the representative has been in the facility several times. She said the representative from the ALF said the ALF can't take the resident because he still has the trach and once the trach is removed the ALF should be able to take him. The SSD said Resident #32 is aware of the decision of the ALF, but she will go back and speak to him again to make sure he would still like to discharge to the ALF. She said she did not remember if she put the discharge plan on Resident #32's care plan. During an interview on 1/16/25 at 1:10 p.m. with Staff C, Lead MDS Coordinator, she stated it is the responsibility of the SSD to enter a discharge plan onto the resident's care plan. 4. On 1/14/25 at 3:10 p.m. Resident #133 was observed sleeping in bed. The resident's enabler bars/side rails were in the down position and the resident's call light was on the floor under his wheelchair. A review of the admission Record showed Resident #133 was admitted to the facility on [DATE] with diagnoses including pain in the left knee, muscle weakness, other reduced mobility, unspecified lack of coordination, cognitive communication deficit, repeated falls, and history of falling. A review of Resident #133's Baseline Care Plan dated 11/3/24 showed: Potential Concerns: Resident is at risk for falls box is checked and the related to section is filled in with hx of (history of). Goal: Risk factors will be decreased for fall related injury over next 30 days box is checked. Approach: no boxes are checked in this section which included: place call bell within easy reach, cue for safety awareness, assist for toileting/transfers PRN, bed in low position, safety devices and other. A review of Resident #133's History and Physical completed in the hospital prior to admission to the facility revealed the resident was admitted to the hospital on [DATE] presenting to the Emergency Department with complaints of worsening positional lightheadedness over past many months. The resident was seen in the hospital in September 2024 or October 2024 for positional lightheadedness. Since he was discharged , he reported slowly progressive positional lightheadedness which is worse in the morning when he wakes up from bed. He fell from bed two days prior to this hospitalization after a fall where he injured his left upper extremity. Review of a Narrative Nurses note for Resident #133 dated 11/10/24 at 4:30 a.m. revealed Resident #133 was observed sitting on floor between the dresser and air conditioning unit with his back towards the wall. The resident stated he was trying to use the urinal while standing at bedside holding onto the bedside table when the table rolled away causing him to fall forward. The resident was noted with a laceration to the bridge of his nose with a moderate amount of bleeding. Pressure was applied and the bleeding was easily controlled. The resident was also noted with a small abrasion to the left inner elbow with scant bleeding. Review of Post Fall Review dated 11/10/24 at 11:38 a.m. for Resident #133 showed the resident's injuries were fracture to nose, skin tear to left antecubital, and bruising left eye. The interventions listed included bed in low position, call light within reach, and patient teaching to ask for assistance with Activities of Daily Living (ADL). An interview was conducted on 1/14/25 at 3:42 p.m. with Staff H, LPN. Staff H, LPN said he takes care of Resident #133 regularly and knows him well. He said he didn't know if Resident #133 was a fall risk, but after looking at the resident's record in the electronic medical record (EMR), Staff H, LPN said the resident was a fall risk. Staff H, LPN went to the resident's room and observed the resident sleeping and the call light on the floor under the resident's wheelchair. He also observed the resident's enabler bars/side rails in the down position. Staff H, LPN put the call light on the bed within the resident's reach and put the enabler bars/side rails in the up position. He agreed the call light should always be within reach of any resident and enabler bars/side rails should be in the correct position as ordered by the physician. During an interview with Staff E, LPN on 1/16/25 at 9:19 a.m., Staff E, LPN said she knows Resident #133 well and regularly takes care of him. She said he is a fall risk because of his decision making and safety is an issue. She said the resident needs reminding not go get up and walk without assistance. She said she uses the resident's Care Plan for the interventions, and she monitors him closely to see if anything changes with his mobility. An interview was conducted on 1/16/25 at 1:15 p.m. with the DON. She stated the nurse who admitted Resident #133 to the facility should have completed the Baseline Care Plan. She said the Baseline Care Plan was not completed correctly as the approach was not filled out. The DON said she was on call when Resident #133 fell and received a call informing her the resident had fallen. She said she was told the resident stood up to use the urinal, leaned over the bedside table, which is on wheels, and the bedside table rolled away from him. She said the maintenance person who was on call went to the facility immediately to install enabler bars/side rails to the resident's bed. She said the expectation for the admitting nurse is to completely fill out the Baseline Care Plan or get help if they need to. She said all RN's in the facility have been trained to complete the Baseline Care Plans. Review of the policy titled Baseline Care Plan dated 8/25/22 and revised on 3/27/24 showed the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care. The policy also revealed the following Policy Explanation and Compliance Guidelines: 1. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including but not limited to: therapy services. 2. The admitting nurse or supervising nurse on duty shall gather information from the admission physical assessment, hospital transfer information, physician orders and discussion with the resident. Interventions shall be initiated that address the resident's current needs including: any health and safety concerns to prevent decline or injury such as fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one resident (#118) of two residents sampled for non-pressure related skin conditions received wound care as prescribed by the physician. Findings included: On 1/13/25 at 9:06 a.m., Resident #118 was observed lying in bed. The left lower extremity of the resident had been amputated below the knee and four to five steri-strips were covering the surgical incision. A brown/tan color elastic bandage was observed sitting on the resident's dresser wrapped up and not within reach of the resident. The right ankle was wrapped with white rolled gauze from the toes to above the ankle and secured with paper tape. The right ankle gauze was not dated as to when the dressing had been applied. Resident #118 stated staff changed it every couple of days. On 1/13/25 at 9:21 a.m., Resident #118's dressings were observed with Staff T, Registered Nurse/Unit Manager (RN/UM). The staff member lifted the resident's right ankle and confirmed the dressing was not dated and absolutely should be dated. Staff T, RN stated he would check when it was last done and believed the dressing was to be changed three times a week. On 1/13/25 at 9:26 a.m. Staff T stated the dressing change was documented on Saturday as being completed. Review of Resident #118's admission Record showed the resident was admitted on [DATE] with diagnoses including but not limited to encounter for orthopedic aftercare following surgical amputation, other acute osteomyelitis (of) left ankle and foot, unspecified local infection of the skin and subcutaneous tissue, and acquired absence of left leg below knee. Review of Resident #118's January 2025 Treatment Administration Record (TAR) revealed Staff S, RN documented the right medial ankle treatment of skin prep and cover of rolled gauze was completed on Saturday 1/11/25. The dressing did not reveal the completed treatment date. Review of Resident #118's January TAR revealed an order for staff to cleanse surgical site with wound cleanser of choice, apply betadine paint, cover with 4x4 gauze, wrap with rolled gauze, and light (elastic) wrap every day shift for wound care. The documentation showed the dressing was completed daily. During an interview on 1/16/25 at 8:30 a.m. the Director of Nursing (DON) stated dressings should be dated when changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure the intravenous (IV) access of one resident (#5) of three residents with IV access was maintained in accordance with professional standards. Findings included: On 1/13/25 at 10:35 a.m., Resident #5 was observed with a single lumen peripherally inserted central catheter (PICC) inserted into the right upper arm. The dressing was dated 1/9/(25) and not fully attached to the skin of the resident. Resident #5 reported having an infection in the spinal cord. Review of Resident #5's admission Record showed the resident was admitted on [DATE] and diagnoses included but was not limited to pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of disease classified elsewhere and unspecified gram-negative sepsis. Review of Resident #5's Admission/readmission Nursing Evaluation, effective 12/27/24, revealed the admitting diagnosis was bacteremia and had a right upper extremity (RUE) midline. The evaluation did not include a measurement of the RUE midline external catheter or arm circumference. Review of Resident #5s January 2025 Medication Administration Record (MAR) included the following orders: - Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 gram (GM) - Use 3.375 gram intravenously every 6 hours for bacteremia until 2/7/25, started on 12/30/24 and discontinued on 1/5/25. - Piperacillin Sod-Tazobactam So Solution Reconstituted 3-0.375 GM - Use 3.375 gram intravenously every 6 hours for Bacteremia/Osteomyelitis of the spine until 2/7/25, started on 1/6/25. - Measure arm circumference 2 inches above insertion site with each dressing change, RUE every night shift every Thu[rsday] for Bacteremia. The order started on 1/2/25. The documentation showed staff were to use the measurement of centimeters (cm) for the resident's RUE circumference. Review of Resident #5's January 2025 MAR showed on 1/2/25 staff documented 30 and on 1/9/25 staff documented NA, which according to the chart codes meant medication not available, for the circumference of the resident's RUE circumference with no numerical measurement. Review of Resident #5s January Treatment Administration Record (TAR) included the following orders with documentation: - IV PICC change primary intermittent tubing every 24 hours every night shift for Bacteremia, started on 12/30/24. The documentation showed staff had completed every night shift. - IV PICC RUE change transparent dressing on admission, then weekly and as needed (prn) thereafter every night shift every Thu(rsday) for Bacteremia, started on 1/2/25 and discontinued on 1/9/25. - IV PICC RUE change transparent dressing on admission, then weekly and as needed (prn) thereafter every night shift every Thu(rsday) for Bacteremia, started on 1/9/25. - IV PICC RUE Measure catheter length on admission and with each dressing change thereafter every night shift every Thu for Bacteremia, stated on 1/2/25. The documentation revealed the completion of task on 1/2/25 and 1/9/25, however, did not include measurement of the external catheter. - IV PICC RUE change transparent dressing on admission, then weekly and as needed (prn) thereafter every 24 hours as needed for when soiled or missing dressing, started on 1/9/25. The documentation showed the as needed dressing change was completed on 1/13/25 at 1:44 p.m. The order did not include an area to document the length of the external catheter. Review of Resident #5's December 2024 MAR did not include an order for dressing the RUE PICC on admission or to measure the external catheter length on admission. Review of Resident #5's December 2024 TAR included the following orders with corresponding documentation if applicable: - IV PICC - change primary intermittent tubing every 24 hours every night shift for Bacteremia, started on 12/30/24. The order was scheduled for night shift. The documentation had X throughout, without documentation of staff administering the order. - IV PICC RUE monitor site every (q) shift for signs/symptoms of infection and/or infiltration every shift for Bacteremia, started on 12/30/24. The documentation had X throughout, without documentation of staff administering the order. The documentation of the resident's scheduled treatments did not show the resident received any scheduled treatments after readmitting on 12/27/24. The as needed orders on the December 2024 TAR showed they did not start until 1/9/25 and 1/15/25. The TAR did not include orders to change the RUE PICC line dressing at the time of admission or to measure the external catheter. Review of Resident #5's progress notes revealed the following: - A late entry Skilled note 12/28/24 at 1:01 p.m. did not reveal documentation of the resident's PICC line. - A late entry Skin Observation progress note, effective 12/28/24 at 3:50 p.m. showed the resident did have existing pressure injuries but did not include documentation of the resident's IV external catheter or arm circumference. - A Skilled progress note, effective 12/29/24 at 11:31 p.m. revealed the resident's skin was not intact. The note did not mention the condition of the resident's PICC catheter. - A Skin Observation progress note effective 12/30/24 at 9:11 p.m. showed the resident had existing pressure injuries and a right ankle vascular wound. The staff member did not mention the resident had an IV site. - A Skilled progress note effective 12/30/24 at 9:18 p.m. revealed the resident had a PICC line, was receiving IV antibiotics, and the site was clean dry and intact. The note did not have a measurement of the PICC line external catheter or arm circumference. - An Antibiotic Time out note effective 12/30/24 at 9:30 p.m. revealed the resident was receiving an IV antibiotic. The resident had positive blood cultures on 12/21/24, was sent to hospital, then readmitted on [DATE]. The note did not include information regarding the condition of the IV site. - An Advanced Registered Nurse Practitioner (ARNP) note effective 12/31/24 at 11:00 a.m. revealed the resident was sent to the hospital on [DATE], returning to the facility on [DATE]. The note showed a PICC line was placed and the resident was started on IV antibiotics while at the hospital. - A Skilled progress note effective 1/2/25 at 12:29 a.m. revealed the resident was receiving IV antibiotics, but did not include a measurement of the external length of the resident's PICC, despite documentation (TAR) revealing the PICC dressing was changed and the catheter length was measured. - A Skilled Progress note effective 1/4/25 at 2:54 a.m. revealed the resident was receiving IV antibiotics via a PICC line, and the site was clean, dry, and intact. The note did not reveal the length of the external catheter. -A Skilled Progress note effective 1/5/25 at 2:21 p.m. showed the resident was receiving IV antibiotics, had a PICC line, and the site was clean, dry, and intact . The note did not include a measurement of the external catheter. -A Skin observation note effective 1/6/25 at 3:11 p.m. showed the resident had an existing skin impairment and a PICC line to the RUA. The note did not include a measurement of the length of the external IV catheter. - A general note dated 1/6/25 at 6:27 p.m. revealed the resident was on IV antibiotics and had a PICC line with no abnormal signs or symptoms displayed. The note did not include a measurement for the length of the external IV catheter. - A Skilled progress note effective 1/7/25 at 2:54 a.m. revealed the resident had a PICC line and was receiving IV antibiotics. The note did not include a measurement of the length of the external IV catheter. - A Skilled progress note dated 1/9/25 at 1:42 a.m. did not show the resident had an IV site. - A Skilled progress note effective 1/10/25 at 2:41 a.m. showed the resident had a PICC line and was receiving IV antibiotics. The note did not include a measurement of the length of the external IV catheter. - A Skilled progress note effective 1/11/25 at 2:18 a.m. did not reveal the resident had any skin impairments, any IV site, or was receiving an antibiotic. The note did not include a measurement of the external length of the IV catheter. - A Skilled progress note effective 1/12/25 at 2:08 a.m. revealed the resident was not receiving medications or antibiotics. - A Skilled progress note effective 1/13/25 at 2:41 a.m. showed the resident had no medications, antibiotics, or adverse med side effects. The note did not reveal the resident had a PICC line or was receiving IV antibiotics. - A Skilled progress note effective 1/14/25 at 2:14 a.m. revealed the resident had no current skilled nursing/rehab status including medications, antibiotics, and/or adverse med side effects. - A Skilled progress note effective 1/15/25 at 1:11 a.m. revealed the resident had a PICC line and was receiving IV antibiotics. The note did not include a measurement of the external IV catheter. - A Skilled progress note effective 1/16/25 at 1:41 a.m. revealed the resident had a PICC line and was receiving IV antibiotics. The note did not include a measurement of the external IV catheter. An interview was conducted with Staff S, Registered Nurse (RN) on 1/16/25 at 1:37 p.m. The staff member stated Resident #5's PICC dressing was becoming dislodged on 1/13/25. Staff S, RN reported measuring the external catheter, but did not document the numbers because she didn't think about it. The staff member stated the measurements were usually documented in the dressing change note. Staff S, RN stated the length of the catheter should be documented, but she would have to check the specific policy. An interview was conducted with Staff T, Unit Manager (UM) on 1/16/25 at 1:42 p.m. The staff member stated the documentation of the PICC line length would be in the hospital records and confirmed staff were documenting the length with the dressing change and as needed. Staff T, UM also stated staff should be documenting the length with the dressing changes. The staff member stated the order was not put in correctly and should have added ancillary information allowing for the documentation of the measurement. An interview was conducted with the Director of Nursing (DON) on 1/16/25 at 2:37 p.m. The DON state staff should be measuring PICC catheters and the stock orders do not ask for length. Review of the policy titled PICC/Midline/Central Venous Access Device (CVAD), copyrighted 2024, revealed, It is the policy of this facility to change peripheral 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. Physician's orders will specify type of dressing and frequency of changes. The Compliance Guidelines included: 6. Inspect the catheter skin junction in surrounding area, palpating through the intact dressing for redness, tenderness, swelling, and drainage. Be attentive to any reports of pain, paresthesia, numbness, or tingling. 13. Use sterile measuring tape to measure external length of the catheter from hub to skin entry to ensure that it has not migrated. 24. Document the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure effective communication with the Dialysis center that provides treatment services for one resident (#119) of three sampled residents. It was determined review of fourteen Dialysis service visits, the Dialysis nursing staff failed to collaborate with the nursing facility by not providing and documenting post weights, vital signs, Dialysis vascular access site status, and what Dialysis treatment was provided. Findings included: On 1/13/2025 at 8:50 a.m., Resident #119 was observed seated on the side of his bed in his room. The resident was alert and able to speak about his medical care and daily decision making. Resident #119 confirmed he goes to an End Stage Renal Disease (ESRD) Dialysis center three times a week for Dialysis treatment and he was getting ready to go to his chair treatment appointment today, which was at 12:00 p.m. Resident #119 confirmed he goes to the Dialysis center on Mondays, Wednesdays, and Fridays. Resident #119 revealed the nurse will give him a yellow book to have the Dialysis center document his care, upon his leaving the Nursing facility. He confirmed staff at the Dialysis center are supposed to fill out medical information in this book, but he does not remember the last time the Dialysis staff did that. Resident #119 revealed he just gets the yellow book back and takes it back to the Nursing center. On 1/14/2025 review of Resident #119's medical record revealed he was admitted to the facility on [DATE] and readmitted from the hospital on 3/13/2024. Review of the advance directives revealed Resident #119 was his own responsible party and able to make his own medical decisions. Review of the diagnosis sheet revealed diagnoses to include but no limited to end stage renal disease, anemia, and cognitive communication deficit. Review of Resident #119's current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed; Cognition: Brief Interview Mental Status or BIMS score 10 of 15, which indicated Resident #119 had mild cognitive impairment. Active Diagnoses: Renal Insufficiency, Obstructive Uropathy Special treatment: Checked yes for Dialysis services. Review of Resident #119's progress notes dated from 11/1/2024 - 1/15/2025 did not indicate any documented concerns regarding Dialysis or Dialysis services. There was also no indication of refusals or missed Dialysis service days. Review of Resident #119's Physician's Order Sheet dated for January 2025 revealed orders to include but not limited to: 1. Complete Dialysis communication forms and send with resident to dialysis center, order date 1/15/2024. 2. Location Dialysis access site. 3. If declines Dialysis refuses dialysis notify attending MD and nephrologist. 4. If Dialysis site bleeding, apply direct pressure to sit to help control bleeding and notify physician. 5. Monitor Dialysis catheter site to right chest for bleeding and monitor dressing is intact. 6. Check access site for signs and symptoms of infection when performing routine care. 7. Check access site post Dialysis. 8. May hold meds when resident is Leave Of Absences (LOA) to dialysis. 9. Diagnosed for Dialysis: ESRD. 10. Send snack with resident on dialysis days. 11. Dialysis days are Mondays-Wednesdays-Fridays, medication times and schedule may be revised with Dialysis days. 12. Complete post communication dialysis form on return Mondays-Wednesdays-Fridays. 13. Liberal Renal diet, Regular textured, thin liquid diet. Review of Resident #119's SUN Dialysis Communication Book revealed: Please record post weight on worksheet everyday. The book contained only one Pre/Post Dialysis Evaluation dated 1/13/2025. The form was blank in section B. Dialysis Nursing Information. The book also contained informational sheets that read, 1. Please fill out Dialysis weight worksheet every dialysis day, 2. Dialysis book *Face sheet, *Most recent labs, *Dialysis information, *Pre and Post dialysis evaluations, *Medication list, * Weight sheet (pre and post). The last sheet in the book revealed a Dialysis weight worksheet for the month of 1/2025. Review of the book did not reveal any past SUN Pre/Post Dialysis Evaluations other than the last visit on 1/13/2025. This was verified by Staff B, Licensed Practical Nurse (LPN) on 1/14/2025. She revealed once the communication sheets are reviewed they are charted in the Electronic Medical Record and scanned into the Electronic Medical Record. Staff B, LPN also confirmed section B of the SUN Pre/Post Dialysis Evaluation, which was the section for the Dialysis center staff to fill in, was blank. She revealed often times they receive this section blank, and the Dialysis center will not fill this section in. She confirmed she and other Nursing facility nurses would not know what Resident #119's medical and vitals status would be while at the Dialysis center. On 1/15/2025 Resident #119's electronic medical record (EMR), to include the Evaluations tab, revealed all the past Dialysis visits SUN Pre/Post Dialysis Evaluations. The past fourteen visits reviewed and all SUN Pre/Post Dialysis forms dated 1/13/25, 1/10/25, 1/8/25, 1/6/25, 1/3/25, 1/1/25, 12/30/24, 12/27/24, 12/25/24, 12/23/24, 12/20/24, 12/18/24, 12/16/24, 12/13/24 revealed only completed information from the Nursing facility, including pre and post weight, vitals, and notes. Section B did not reveal any information, nor any signature from Dialysis staff, to include assessment of weight, vital signs, or notes. Review of Resident #119's current care plans with a next review date 3/8/2025 revealed the following problems areas. Dialysis care plan: Dialysis 3 x week M-W-F (Monday-Wednesday-Friday) chair time 12 noon, with interventions in place to include: 1. Administer meds as ordered; 2. Complete Dialysis communication form and send with resident to dialysis center; 3. Complete post communication dialysis corm upon return, one time a day x Mon-Wed-Fri (Monday-Wednesday-Friday) complete [electronic health record brand] post Dialysis communication form if available; 4. Fill in complete dialysis portion based on return form save and lock; 5. Dialysis days M-W-F med times and schedule may be revised with Dialysis days; 6. Meds not to be given on Dialysis days M-W-F, prior to Dialysis; 7. Monitor dialysis catheter site for bleeding or signs of infection; 8. Notify MD (Medical Doctor) of signs and symptoms; 9. Observe dialysis site for infection, bleeding, edema; and 10. Observe labs as ordered. On 1/15/2025 at 9:40 a.m., an interview with the 200 Unit Manager Staff A, RN revealed for each resident who utilizes Dialysis services, there is a communication form sent with the resident from the facility to the Dialysis center and then brought back when the resident returns from Dialysis treatment. She revealed there is a section of the communication form the facility is responsible for and includes pre-weights, vital signs, medication notes, and other notes. She also revealed there is a second section of the form to be filled out by the Dialysis center staff to include weights, vital signs, medication notes, and other notes prior the resident leaving the center. Staff A, RN also revealed the form had a third section the facility staff must fill out to include post weights, vitals, medication notes, and other notes. Staff A, RN confirmed Resident #119's communication sheets dated from 12/12/2024 through to 1/13/2025 were not filled out by the Dialysis center staff. She revealed they have not been getting the Dialysis center information for Resident #119. Staff A, RN said she along with other nursing facility management have called the Dialysis center staff and they had told them they do not provide and send out information to include post weights, vitals, notes, access site evaluation, and signature of staff who cared for the resident. Staff A, RN revealed they are explained that the Dialysis center would not fill out the sheets and send them along in the communication book. On 1/16/2025 at 8:45 a.m. another interview with Staff A, RN revealed the expectation for receiving Dialysis information. While the resident is at the Dialysis center, the following happens: 1. A Dialysis communication book with a form to include nursing home evaluation expectations pre Dialysis center visit, Dialysis center evaluation expectations while at the Dialysis center, and post evaluation expectations when the resident returns to the facility from the Dialysis center; and Weight and vitals logs. Staff A, RN revealed the book with the evaluation page is carried to the facility by the resident. 2. Once the resident is at the Dialysis center, the Dialysis nursing staff are to take and record post-weights, vital stats, and any information related to the Dialysis access site. 3. Once the resident returns to the facility from the Dialysis center, the nursing staff are to fill out post-weights, vitals, and assess the Dialysis access site. Staff A, RN revealed the facility nursing staff are to evaluate the information from the Dialysis center in order to know how the resident was while at the Dialysis center. 4. After the communication form is completed by both the facility and Dialysis center, the form is uploaded into the Electronic Medical Record. On 1/15/2025 at 1:00 p.m., during an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON), both confirmed they have been having problems with the Dialysis center staff filling out their portion of the communication form and have been told they will not document medical information on that form. The DON and NHA also confirmed after they have communicated with the Dialysis Administrator on 1/15/2025, and was told State was in the nursing home facility, the Dialysis staff immediately faxed all the required communication information for review and sent that information to the facility. The DON confirmed they did not have any of this information prior to 1/15/2025. On 1/16/2025 at 9:45 a.m., the Director of Nursing provided the Hemodialysis policy and procedure with a last review date of 8/25/2022 for review. The Policy revealed; The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician's orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The Purpose section of the policy revealed; The facility will assure that each resident receives care and services for the provision of Hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: - The ongoing evaluation of the resident's condition and monitoring for complications before and after dialysis treatment received at a certified dialysis facility. - Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The Compliance Guidelines section of the policy revealed; 1.) The facility will inform each resident before or at the time of admission of dialysis services available. 2.) The facility will coordinate and collaborate with the dialysis facility to assure that: a.) The resident's needs related to dialysis treatment are met; b.) There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. 4.) The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a.) Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; b.) Physician/treatment orders, laboratory values, and vital signs; c.) Nutritional/fluid management including documentation of weights; d.) Dialysis treatment provided and resident's response; e.) Dialysis vascular access site status; f.) Changes and/or declines in condition related to dialysis; g.) The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility. On 1/16/2025 at 9:45 a.m., the Nursing Home Administrator provided the Long Term Care Facility Outpatient Dialysis Services Coordination Agreement, which was signed by both the Nursing Home Administrator and the Dialysis center Regional Operations Director on 2/15/2021. Section (E) Mutual Obligations of the agreement revealed; 1. Collaboration of Care. Both parties shall ensure that there is documented evidence of collaboration of care and communication between the Long Term Care Facility and ESRD Dialysis Unit. Documentation shall include, but not limited to, participation, as members of interdisciplinary team, in care conferences, continual quality improvements program, annual review of infection control of policies and procedures, and the signatures of team members from both parties on a Short Term Care Plan (STCP) and Long Term Care Plan (LTCP). Team members shall include the physician, nurse, social worker and dietitian from the ESRD Dialysis Unit and representative from the Long Term Care Facility. The ESRD Dialysis Unit shall keep the original STCP and LTCP in the medical record of the ESRD Resident and the Long Term Care Facility shall maintain a copy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to follow Enhanced Barrier Precautions and don Personal Protective Equipment in accordance with facility policy for one resident (#118) of thirty-nine sampled residents. Findings included: On 1/13/25 at 9:06 a.m., Resident #118 was observed lying in bed. The observation revealed a surgical incision with four to five steri-strips to a left below knee amputation and rolled gauze covering the right ankle from toes to above the ankle. The resident was wearing a nasal cannula delivering three liters per minute (lpm) of oxygen. The observation also revealed the room was not posted for Enhanced Barrier Precautions. On 1/13/25 at 12:28 p.m., Staff U, Certified Nursing Assistant (CNA) asked Staff V, CNA to assist in repositioning Resident #118 in bed for the noon meal. The observation showed the staff members repositioned the resident while wearing gloves, but neither staff member was observed donning a protective gown prior to lifting the resident. Staff U, CNA was observed adjusting the resident's blankets. Review of Resident #118's admission Record showed the resident was admitted on [DATE] with diagnoses including but not limited to encounter for orthopedic aftercare following surgical amputation, sepsis due to methicillin susceptible staphylococcus aureus (MRSA), Methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, unspecified local infection of the skin and subcutaneous, and sepsis due to other specified staphylococcus. Review of Resident #118's Admission/readmission Nursing Evaluation dated 12/3/24 revealed the admitting diagnosis was sepsis left lower extremity (LLE) cellulitis with the special needs of intravenous (IV) therapy and wound care. Review of Resident #118s December 2024 Treatment Administration Record (TAR) revealed the following: - IV peripherally inserted central catheter (PICC) (all types) - change primary intermittent tubing every 24 hours every night shift. The treatment was discontinued on 12/10/24. - Apply skin prep to right medical ankle and wrap with (rolled gauze) 3 times weekly and as needed (prn), every day shift every Tuesday, Thursday, and Saturday for wound care. The order was started on 12/19/24 and discontinued on 1/13/25. - Cleanse surgical incision to left lower extremity with betadine, cover with abdominal (abd) pad, wrap with rolled gauze then wrap with elastic bandage daily and prn, every day shift for post-surgical care. The order started on 12/5/24 and continued to 1/3/25. Review of Resident #118s January 2025 TAR revealed the following: - LLE Below knee amputation (BKA): Cleanse surgical site with wound cleanser of choice. Apply Betadine paint, cover with 4x4 gauze, wrap with rolled gauze and light elastic wrap every day shift wound care. The order was started on 1/4/25 and discontinued on 1/15/25. - Apply skin prep to right medial ankle, wrap with rolled gauze three times weekly and prn, every day shift every Tuesday, Thursday, and Saturday for wound care. This order started on 12/19/24 and discontinued on 1/13/25 at 9:25 a.m. - Apply skin prep to right medial ankle and wrap with rolled gauze three times weekly and prn every day shift every Tuesday, Thursday, (and) Saturday for wound care. The order started on 1/14/25 and was discontinued on 1/15/25 at 7:29 a.m. The documentation showed the treatment was not completed on 1/14/25 due to the resident being hospitalized . Review of Resident #118's care plan revealed the following Focus areas: - Potential for alteration in comfort related to recent amputation/arthritis. - Altered skin integrity: non pressure location: right ankle, created on 1/5/25. - A focus created on 1/13/25 showed the resident required EBP (Enhanced Barrier Precautions): Risk for impaired psychosocial status and other complications. Enhanced Barrier Precautions per CDC (Centers for Disease Control and Prevention) guidelines due to : Colonized Multi-Drug Resistant Organism (MDRO)(MRSA). The interventions showed Persons caring for the resident and providing high contact resident care activities will require personal protective equipment (PPE), the use of gowns and gloves. The intervention was created by the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) on 1/13/25. On 1/13/25 at 3:13 p.m., Staff U, CNA stated during an interview regarding EBP, if working with residents or repositioning residents on EBP, staff needed to wear a gown and gloves. Staff U, CNA reported EBP were for residents with wounds, infections, and catheters. The staff member stated staff should have used PPE when repositioning Resident #118 at lunch and the understanding was the resident did not have wounds, so would not need to be on EBP. On 1/13/25 at 3:17 p.m., Staff S, Registered Nurse (RN) was observed standing at Resident #118's bedside with a pulse oximeter on the finger of the resident. The staff member stated residents require enhanced precautions for any sort of opening in the skin or have an increased potential for infection. Staff S, RN reported the resident had a closed surgical incision. A further review of Resident #118's clinical record showed an order for Enhanced Barrier Precautions was initiated on 1/13/25 at 4:29 p.m., Enhanced Barrier Precautions related to (r/t) MDRO (MRSA) every shift. During an interview on 1/16/25 at 8:30 a.m., the Director of Nursing (DON) stated residents were put on EBP for open wounds, gastrostomy tubes (g-tube), peripherally inserted central catheter (PICC) lines, suprapubic catheters, and did not know about indwelling catheters. The DON stated organisms had to have a way to get in and staff should be aware of EBP. The DON reported Resident #118 should have been on EBP. An interview was conducted on 1/16/25 at 3:10 p.m. with the Assistant Director of Nursing/Infection Preventionist (ADON/IP). The IP reported EBP was for residents who may have a wound with heavy drainage, IV's, indwelling catheters, G-tubes, Dialysis catheters, or any type of invasive equipment or opening. The IP revised their statement, saying a wound doesn't necessarily needs heavy drainage or anything that has an opening in the skin. The staff member reported Resident #118 was originally on EBP due to being on IV therapy then it was discontinued. Treatment was only for skin prep due to no opening and the surgical incision was also healed and the dressing was for preventative measures. The ADON reported they did not have a chance to review diagnoses at time of the observation and staff members should have been wearing PPE when assisting Resident #118 due to the MDRO diagnosis. Review of the policy titled Enhanced Barrier Precautions, revised 9/1/22, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy defines Enhanced Barrier Precautions as the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The Compliance Guidelines included: 1. Prompt recognition of need: c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gowns and gloves. 2. Initiation of Enhanced Barrier Precautions a. Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/ or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. ii. Infection or colonization of any resistant organisms targeted by the CDC and epidemiologically important MDRO when contact precautions do not apply. 3. Implementation of enhanced barrier precautions a. Make gowns and gloves available immediately outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray. b. Ensure access to alcohol based hand rub in every resident room (ideally both inside and outside of the room). c. Position a trash can inside the resident room in near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. d. The infection preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. e. Provide education to residents and visitors. f. Do not restrict room placement or out of room activities due to enhanced barrier precautions. 4. High-Contact resident care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. h. Wound care: any skin opening requiring a dressing. 6. Examples of targeted an epidemiologically important MDRO's include but are not limited to: f. Methicillin-resistant Staphylococcus aureus (MRSA). 7. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling medical device is removed for the high risk residents. Review of the CDC guidelines titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated July 12. 2022 (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html) revealed the following key points: 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: o Wounds or indwelling medical devices, regardless of MDRO colonization status o Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 5. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. The guidance's background described Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who, by definition, have no symptoms of illness. MDRO colonization may persist for long periods of time (e.g., months) [10] which contributes to the silent spread of MDROs. The CDC guideline revealed examples of high-contact resident care activities requiring the use of gowns and gloves for EBP included: o Dressing. o Bathing/showering. o Transferring. o Providing hygiene. o Changing linens. o Changing briefs or assisting with toileting. o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. o Wound care: any skin opening requiring a dressing. The implementation instructed providers When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies. To accomplish this: o Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). o For Enhanced Barrier Precautions, signage should also clearly indicate the high contact resident care activities that require the use of gown and gloves. o Make PPE, including gowns and gloves, available immediately outside of the resident room. o Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). o Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. o Incorporate periodic monitoring and assessment of adherence to recommended infection prevention practices, such as hand hygiene and PPE use, to determine the need for additional training and education. o Provide education to residents and visitors. Photographic Evidence was Obtained

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, and the facility did not respond to grievances in a timely manner for one (Resident #131) of 51 sampled residents. Findings included: Resident #131 was a [AGE] year old female admitted to the facility from an acute care hospital after experiencing a fall at home. She was living independently prior to her fall. The Resident's Brief Interview for Mental Status score was 15 which indicated intact cognition. An interview with Resident #131, on 10/31/2022 at 9:43 a.m., revealed she filed a grievance with the Social Worker on 10/19/2022 and the grievance was taken care of today, 10/31/22. Resident #131 stated the grievance was about the frequency of her dressing changes and she was not receiving some of her psych meds. A follow up interview was conducted on 11/01/22 at 2:53 p.m. and Resident #131 stated, I filed a grievance on the 19th [October 2022] and yesterday when you [surveyor] arrived they came and wanted me to sign saying I agreed with what they wrote. The Social Worker made me feel like I had to sign it so I did. An interview was conducted with the Social Worker on 11/02/22 at 1:48 p.m. She reviewed the October grievance log. The log indicated on 10/19/22 Resident #131 filed a grievance about missing psych and pain medications and on 10/31/22 filed another grievance about not receiving daily dressing changes. The Social Worker stated they had five days to resolve grievances, so this one (10/31/22) was still in process. The Social Worker said the psychiatry Advanced Practice Registered Nurse (APRN) was at the facility yesterday,11/01/2022, and she would make sure to send a note for her to get seen. The Social worker did not give a reason for the delay. Resident #131 was interviewed in her room on 11/02/22 at 2:10 p.m. and stated, Since the grievance on 19th [October 2022], I haven't seen psych. I'm missing two bipolar meds. They were supposed to have psych see me, but I haven't seen them. On 11/03/22 at 10:05 a.m. the APRN was interviewed and stated she was aware of the resident's question to restart meds. The APRN stated the resident was not receiving those meds in the hospital and she gave a verbal order for a psych consult. Resident #131's medical record was reviewed with the APRN for a psych consult order. The APRN confirmed there was no order in the medical record for a consult. The APRN was able to show the Psychiatry APRN had conducted an initial evaluation of Resident #131 on 10/13/22. The Unit Manager was interviewed on 11/03/22 at 11:02 a.m. Unit Manager stated the Psychiatry APRN came twice a week. The Unit manager was unable to locate a more recent psychiatry progress note. A review of the Grievance/Concern Report done on 11/03/22 at 8:33 a.m. confirmed Resident #131 filed a grievance on 10/19/22. The form indicated the resident concern was resolved on 10/26/22 and showed: Spoke with resident advised psych would see with next visit regarding meds. Meds were not on discharge medication list provided to facility. Resident was seen by psychology. On 10/31/22 the document was signed by Resident #131 and Social Worker indicating Resident #131 was satisfied with the resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to implement the care plan related to interventions to manage resident wounds for one (Resident #55) of two residents sampled for wounds. Findings included: Review of Resident #55's record revealed the resident was re-admitted to the facility on [DATE], with diagnoses that included Idiopathic Peripheral Autonomic Neuropathy, Hemiplegia and Hemiparesis Following Cerebral Infraction Affecting Right Dominant Side and, Arterial fibrillation. Observations on 11/03/22 at 8:23 a.m., revealed the resident lying in bed. He was noted to have a left foot wound dressing and no Podus boot. Closer observation of the room revealed the Podus boot was lying in the residents reclining chair by the window. In an interview with the resident at this time, he denied taking the boot off and denied having the boot on during the night. In an interview with Staff B, Certified Nursing Assistant (CNA) who entered the resident room with his meal tray, she reported she was assigned to the resident and did not know why the boot was not on. She reported the night shift might have forgotten to put it on. During an interview on 11/03/22 at 8:24 a.m., Staff D, Licensed Practical Nurse (LPN) revealed the resident should have the boot on while in bed to prevent any additional `skin breakdown. Review of the care plan related to skin impairment dated 8/28/19 revealed an intervention to float heels while in bed as tolerated. Review of the Weekly pressure wound note dated 10/13/22 revealed a Wound Support Intervention that included 3. Offloading boots. Review of the Weekly pressure wound note dated 10/27/22 revealed a Wound Support Intervention that included 3. Offloading boot(s) Request was made for a policy related to implementation of the care plan, but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure the administration of enteral nutrition was completed according to physician orders and facility policy for one (Resident #88) of one resident sampled for the administration of liquid nutrition via a percutaneous endoscopic gastrostomy (PEG). Findings included: An observation was conducted on 11/2/22 at 2:04 p.m. with Staff F, Licensed Practical Nurse (LPN) of the administration of liquid nutrition for Resident #88. Staff F removed a 60 cubic centimeter (cc) syringe from the package, picked up the end of the PEG where it lay near the side of the bed, inserted the syringe into the tube, flushed the tube with 30 cc's of water, then inserted the end of nutrition tubing into the PEG, and turned on pump. The pump was programmed to deliver the liquid nutrition at 75 milliliter (mL) per hour and a water flush at 150 mL/hr. Staff F pulled back the residents blanket and observed the PEG's insertion site. The staff member confirmed that checking the nutrition residual had been forgotten, usually checks. Resident #88 was initially admitted on [DATE] and recently on 6/28/22. The admission Record included diagnoses not limited to gastrostomy malfunction, tracheotomy status, and anoxic brain damage not elsewhere classified. A review of the Medication Review Report, identified an order dated 6/29/22 that instructed staff to Check residual every shift and record quantity. If more than 100 cc's hold feeding for 1 hour and notify MD, every shift. The report indicated this order had been discontinued. The report also indicated that staff were to Check G-tube placement. Notify MD if dislodged, every shift for Tube management. The October and November Medication Administration Records (MAR) included documentation that the order to check and record the quantity of residual had been completed without the recording the amount of Resident #88's residual. The documentation indicated that the order was written on 6/29/22 and discontinued at 12:03 p.m. on 11/3/22. The Medication Report included two physician orders dated 11/3/22 (the day after the observation) which instructed staff as follows: - Check residual at 2 p.m. prior to administration, one time a day. - Check residual every shift if more that 100 cc's hold feeding for 1 hour and notify MD, every shift. The care plan for Resident #88 identified the resident was at risk for complications associated with enteral feedings due to nothing by mouth (NPO) status and received enteral feeding to meet nutritional and hydration requirements, initiated 8/23/2019. The interventions related to the care plan included: Administer enteral feeding and flushes as orders; observe for tolerance and check enteral feeding residuals as ordered. A review of Resident #88's progress notes dated 10/4 to 11/1/22 did not include any documentation of residual amounts. An interview was conducted on 11/3/22 at 9:22 a.m. with Staff F regarding Resident #88's enteral nutrition. The staff member stated that the electronic record did not include an area to document residual. On 11/3/22 at 11:49 a.m., the Director of Nursing (DON) reviewed Resident #88's physician order to check and document residual and confirmed there was no area to record the amount. The Assistant DON stated the order was from June and the DON replied missed it. The DON stated the expectation was to check for residual prior to medications and starting nutrition and placement should be verified prior to administration. The policy - Care and Treatment of Feeding Tubes, implemented 9/23/22, identified that It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. The policy included the following explanations and guidelines: - Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush. - The resident's plan of care will address the use of feeding tube, including strategies to prevent complications. - In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location (e.g., stomach or small intestine, depending on the tube); a. Tube placement will be verified before beginning a feeding and before administering medications.

Based on observation, interview, and record review, the facility did not ensure the medication error rate was below 5.00%. A total of twenty-eight medications were observed administered and four errors were identified for three (Resident #13, #113 and #597) of four residents observed. These errors constituted a medication error rate of 14.29 percent. Findings included: On 11/02/2022 at 8:56 a.m., an observation of medication administration with Staff D, Licensed Practical Nurse, (LPN)-Agency, was conducted with Resident #597. Staff D, LPN was observed administering the following medication: -Oxcarbazepine Extended Release (ER) Tablet (Oxtellar XR), 150 Milligrams Orally twice a day for diagnosis of mood disorder. Staff D placed the medications in a clear envelop and then crushed the medications with a pill crusher. The medication had a pharmacy label instruction which indicated to not Chew or crush the medication. A record review of Resident #597's active physician orders dated 10/26/2022 read May crush medications and combine unless contradicted. A facility provided policy titled, Medication Administration, date 09/07/2022, Page 01 and 02 reads under Policy Explanation and Compliance Guidelines: 14. Administer medication as ordered in accordance with manufacturer specifications. c. Crush medications as ordered. Do not crush medications with do not crush instructions. Example guidelines for Medication Administration (unless otherwise ordered by physician), this list is not all-inclusive. Do Not Crush Medications: Slow Release On 11/02/2022 at 9:26 a.m., an observation of medication administration with Staff D, (LPN)-Agency, was conducted with Resident #13. Staff D, (LPN)-Agency was observed administering Breo-Ellipta 100-25 Micrograms (MCG)- Aerosol Powder, Breath Activated one Puff by mouth one time a day for Shortness of Breath (SOB). The pharmacy label read the following highlighted in yellow rinse mouth after use. Resident #13 was observed swallowing the water that Staff D, (LPN)-Agency gave him, and did not rinse his mouth after one puff of the medication. Staff D, (LPN) did not wait five minutes, prior to administering the other aerosol medication of Combivent Respimat Aerosol Solution 20-100 MCG/ACT. During an immediate interview with Resident #13, he confirmed he did not rinse his mouth, and did swallow the medication. On 11/02/2022 at 09:30 a.m., an observation of medication administration with Staff E, (LPN), was conducted with Resident #113. Staff E, LPN was observed administering the following medication: -Combivent Respimat Aerosol Solution 20-100 MCG/ACT 2 puff inhale orally two times a day for diagnosis of SOB -Flovent HFA Aerosol 220 MCG/ACT (Fluticasone Propionate HFA)- 2 puff inhale orally two times a day for diagnosis of asthma. The label on medication Flovent HFA Aerosol 220 MCG/ACT read Rinse mouth/gargle after use, wait one minute between puffs, and five minutes with different inhalers. During the observation, Staff E, (LPN) did not follow the pharmacy label instructions, to wait one minute between puffs, and did not have Resident #113 gargle, and rinse their mouth after they were given the medication. Staff E, (LPN) was immediately interviewed. She looked at the pharmacy labels of the Flovent HFA Aerosol 220 MCG/ACT medication and revealed that she did not know she was supposed to follow the directions on the pharmacy label. She further indicated she would follow the pharmacy label instructions to wait five minutes in between administering both medications, and to tell Resident #113, to gargle and rinse their mouth, the next time she administered the medications to them. On 11/02/22 at 10:11 a.m., an interview was conducted with Staff D (LPN), -Agency related to the Resident #13 not rinsing his mouth after inhalation of the medication (as per directed on the pharmacy label). Staff D (LPN) stated I do not remember; I will give him education. (Photographic Evidence Obtained.) An interview was conducted with the Director of Nursing (DON), on 11/02/2022 at 12:01 p.m. During the interview the DON was notified of observations made during medication administration with Staff D (LPN-Agency and Staff E (LPN). The DON stated, Extended Release (ER) medications should not be crushed, we will get a alternative, and all staff should be following the instructions on the pharmacy labels of medications. On 11/02/2022 at 04:58 p.m., a telephone interview was conducted with Senior Care Pharmacy Consultant. The Pharmacy consultant was informed of the observations made of both Staff D (LPN)-Agency and Staff E, (LPN). He stated, It's pretty simple, give the medications in the correct way, as per manufacturer's instructions. A facility provided policy titled, Oral Inhalation Administration, with revision date 08-2020, Pages 156 and 157, revealed under Policy: Medications will be administered in a safe and effective manner. Procedures: Sequencing of Inhaler Medications- 7. A wait time of 5 minutes (or manufacturer's recommendation) should be observed between inhalers of different types.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to honor resident rights for four (Residents #55, #80, #124, #11) of 51 residents sampled for dignity related to residents wearing wristbands to identify various health needs/status; Residents provided care in view of the public; and random observations of staff referring to residents as feeders. Findings included: 1. A review of Resident #55's record revealed he was re-admitted to the facility on [DATE], with diagnoses which included Idiopathic Peripheral Autonomic Neuropathy, Hemiplegia and Hemiparesis following Cerebral Infraction affecting right dominant side, and arterial fibrillation. An observation of Resident #55 on 11/01/22 at 11:42 a.m., revealed him lying in his bed with a faded pink wrist band on his left wrist. Closer observation of the the wrist band revealed information about the resident's prescribed diet order An observation of Resident #55 on 11/02/22 at 7:36 a.m., revealed the resident lying in his bed. The resident was still noted to be wearing a faded pink wrist band on his left wrist which revealed the residents prescribed diet order. 2. Review of Resident #80's record revealed he was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease, Spinal Stenosis, Spondylosis, and Neurocognitive Disorder with Lewy Bodies. An observations of Resident #80 on 10/31/22 at 10:52 a.m., revealed him lying in bed. He was noted with a yellow wrist band on his right wrist which revealed information that he was a fall risk. An interview with the resident at this time revealed he was not sure why he had the wrist band on. An observation of Resident #80 on 11/02/22 at 7:36 a.m., revealed the resident lying in bed. He was observed to still be wearing the wrist band on his right wrist. In an interview with the resident at this time he reported he still was not sure why he had a wrist band on. 3. Review of Resident #124's record revealed she was admitted to the facility on [DATE] and had diagnoses that included Cerebral Infraction, and Schizoaffective Disorder, Bipolar Type. An observation of Resident #124 on 10/31/22 at 10:44 a.m., revealed she was wearing four wrist bands. One name band on her right wrist, one name band on her left wrist, one yellow wristband indicating Fall Risk, and one pink wristband with no writing on it. At this time, the resident said These are my tags. The resident reported she was unaware as to why she had them on. Observation of Resident #124 on 11/02/22 at 7:35 a.m. revealed the resident lying in bed. The resident was noted to still be wearing her wristbands. At this time, she reported no one had taken her tags off. 4. An interview on 11/02/22 at 7:38 a.m., with Staff A Registered Nurse (RN) and Staff D, Licensed Practical Nurse (LPN), revealed they were unsure of the nature of the wristband. They reported the wristbands might be used as name tags, identification of code status, or were on the resident when they were admitted to the facility. An interview on 11/02/22 at 10:23 a.m., with the Director of Nursing (DON), revealed if residents had on wristbands those were from the hurricane because the entire facility had to evacuate to their sister facility and the wristbands were in place to help identify all residents during the transitions during the evacuation. She reported the residents had been back in the facility for about 2-3 weeks as they were evacuated for 3 days. 5. Dining observations on 11/02/22 at 8:50 a.m., during the passing of meal trays on the 300 hall, revealed staff I, Certified Nurses Assistant (CNA) and Staff J, CNA passing trays. The two staff members questioned a tray on the cart and both indicated the tray was to stay on the cart as it was for a Feeder In an interview on 11/02/22 at 8:51 a.m., Staff J revealed the word Feeder meant someone that had to be fed. In an interview on 11/02/22 at 8:52 a.m., Staff I revealed a Feeder was a person who needed to be fed by staff. On 11/02/22 at 8:55 a.m., the Certified Dietary Manager (CDM) who was present in the 300 hallway said, I will check to see if she is a feeder, he left and went to the nurse and returned to the cart and said Yes she is a feeder. In an interview with the CDM at this time, the CDM said the nurse has to check for feeders. The CDM revealed that when he referred to feeder he meant someone who needed to be fed by staff. 6. During an observation on 11/3/22 at 7:30 a.m., a female staff member assisting a male resident, who was dressed only in an incontinent brief, was seen through a window of the facility from the parking lot that faced a nearby apartment building. The staff member was dressed in green scrubs. The privacy curtain was pulled between the beds in the room and the head of bed was against the wall closest to the facility entrance. The resident had his arms above his head. The Social Worker (SW) was at the entrance of the building and was asked to confirm the observation. The SW confirmed the observation, let this writer into the facility, and stated she was going back to the window. On 11/3/22 at 7:33 a.m., an observation revealed that Resident #11's door was closed. On 11/3/22 at 7:40 a.m., Staff G, Certified Nursing Assistant (CNA), was observed wearing green scrubs in Resident #11's room, Staff G left the room and took a bag toward the soiled utility room. The Staff G stated, at 7:43 a.m. on 11/3/22, normally she did close the blinds (in resident rooms). The SW stated, at 7:44 a.m. on 11/3/22, the Director of Nursing had been notified and the CNA informed the SW the resident did not want the blinds closed. The SW stated she had informed the Staff G the blinds to the room had to be closed during personal care. The Quarterly Minimum Data Set, dated [DATE], indicated that Resident #11 required limited assistance from 1-person for dressing and extensive assistance from 1-person for toileting and personal hygiene. The policy - Promoting/Maintaining Resident Dignity, implemented 9/23/22, indicated that It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. The policy identified that All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights and Maintain resident privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 10/31/22 at 10:20 a.m., a family member of a resident in room [ROOM NUMBER] reported the room was not clean and there was mold in the room. She stated she had reported the concerns to the Assistant Administrator a few days ago and nothing had been done. The following was observed in the rooms: room [ROOM NUMBER]: missing baseboard with black bio growth and deteriorated sheetrock, discolored and heavily stained flooring underneath the sink in the room, discolored grout and tile in the shower, discolored toilet seat, deteriorated door frame, broken sheetrock, discolored and heavily staining flooring in the room and underneath the air conditioner, broken floor tile, and broken dresser. (photographic evidence obtained) room [ROOM NUMBER]: hole in the wall and broken sheetrock with exposed insulation and electrical wiring on the baseboard (photographic evidence obtained) room [ROOM NUMBER]: discolored and heavily stained flooring, unfinished and deteriorated sheetrock on the wall, and missing baseboard (photographic evidence obtained) Rooms 326: deteriorated door frame with cracked and chipped paint (photographic evidence obtained) On 11/03/22 at 9:46 a.m., the Administrator reported they discussed environmental concerns especially on the 300 and 400 units, but they had not formulated a Quality Assurance and Improvement Plan (QAPI). The plan was to do a room sweep and audit everything from beds, walls, curtains, and sinks. They were going to start repairing these items immediately. Based on observations, record reviews, and interviews, the facility failed to maintain a safe, clean, and sanitary environment on two (300 and 400) of four hallways including repairing a ceiling that had been damaged due to rain for one (Resident #115) of two residents in room [ROOM NUMBER] and ensuring the mattresses fit onto a bed frame for one (Resident #88) of three residents who were identified as needing bolsters. Findings included: 1. On 10/31/22 at 10:25 a.m., an observation was made of room [ROOM NUMBER]. The textured ceiling was peeling off and discolored on the window side of the privacy curtain. A portion of the ceiling sheetrock paper was hanging. Resident #115 stated it (the ceiling) had been like that for awhile and after the last storm the facility had gone up to the roof and fixed the leak. The footboard of the bed near the window had deteriorated to show the particle board underneath the veneer finish. Above the bed, near the door, the ceiling was peeling and discolored. The wall next to the privacy curtain appeared to be melting, the paint was rippled from the top of the wall to the call light box. In the bathroom, which was shared by rooms [ROOM NUMBERS], the tile near the toilet was missing and discolored. Photos were obtained. An observation was conducted on 10/31/22 at 10:38 a.m., of the ceiling in room [ROOM NUMBER]. The textured ceiling was cracked and discolored near the privacy curtain. Photo was obtained. On 10/31/22 at 10:49 a.m., an observation was made of the doorway into room [ROOM NUMBER]. The rubber-like moulding outside of the door frame near the floor was torn and bent away from the wall. Photo obtained. An observation was conducted on 10/31/22 at 11:04 a.m. of room [ROOM NUMBER]. The floor under the resident's bed had a tan-colored substance dried to the floor in a path approximately 8-10 inches. The substance had dried to the floor mat that was lying on the floor beside bed next to the privacy curtain. An outlet across from the second bed in the room was missing a cover and the wall above the packaged terminal air conditioner (PTAC) unit was cracked and bubbled. The box fan, that was directed toward Resident #88, had dust/dirt/lint encrusted in the grate. A gap was observed of greater than 4 inches between the footboard and air mattress of Resident #88. Photos were obtained. On 11/1/22 at 10:05 a.m., an area of tan-colored substance continued to be observed under the bed in room [ROOM NUMBER]. The area along the side of the floor mat had a dried tan-colored substance on it. The nutrition feeding pole next to the bed in room [ROOM NUMBER] had a tan-colored substance dried to it. Photo was obtained. The tan-colored substance was observed on 11/2/22 at 8:23 a.m. under the window bed of room [ROOM NUMBER] and next to the floor mat. An observation was made, at 12:26 p.m. on 10/31/22 of room [ROOM NUMBER]. The veneer of a bedside dresser in the room was chipped revealing the particle board. Further observations of room [ROOM NUMBER] identified two outlet covers were dirty and broke and the rubber-like baseboard was broken, dirty and screwed to the wall. The tile next to the baseboard was discolored and dirty. The wall above the PTAC unit appeared to be water stained. Photos were obtained. On 10/31 at 1:03 p.m., the textured ceiling was cracked and tile was missing next to the doorway in the bathroom. Photos were obtained. An observation was conducted, on 10/31/22 at 12:31 p.m., of room [ROOM NUMBER]. The window frame of room [ROOM NUMBER] was discolored with a tan-colored substance. The sheetrock in the room was cracked and pushed in near the window bed. The rubber-like baseboard was unattached to the wall next to the PTAC unit. A dresser in the room had chipped veneer revealing the uncleanable surface of particle board. In the bathroom of room [ROOM NUMBER] was missing tile and a deteriorated door frame. Photos were obtained. On 10/31/22 at 2:18 p.m., an observation was conducted of room [ROOM NUMBER]. In room [ROOM NUMBER] was a dresser that had the finish bubbled and detached. Another dresser in room [ROOM NUMBER] had the veneer edging missing. Photos were obtained. On 10/31/22 at 2:27 p.m., an observation was made of room [ROOM NUMBER]'s sink vanity located within the room. The areas of the vanity's veneer were missing and the counter was chipped. Photo obtained. On 11/2/22 at 9:52 a.m., Staff H, Housekeeper, stated a machine was needed in room [ROOM NUMBER] to clean up the tan-colored substance. The staff member reported telling everyone of the liquid nutrition on the floor of room [ROOM NUMBER] and a floor technician had to come with a special machine to get it up. Staff H confirmed the box fan sitting on the dresser and blowing towards Resident #88 was dusty. The Director of Housekeeping reported, on 11/2/22 at 9:56 a.m., she was unaware the liquid nutrition had been on the floor of room [ROOM NUMBER] for three days. She stated the liquid nutrition needed to be taken up immediately or it turned into paste and turned rock hard. The Housekeeping Director stated they have worked with nursing to clean up any spilled liquid nutrition immediately. She stated housekeeping did not clean personal fans. A tour and interview was conducted at 4:00 p.m. on 11/2/22, with the Maintenance Director. He reported he started with the facility in June (2022) and two weeks ago the Nursing Home Administrator (NHA) had identified a couple rooms on the 300 hall that needed repairs. The maintenance assistants had been going room to room repairing issues, starting on the 300 hall. The Director indicated the ceiling in room [ROOM NUMBER] looked like it had started to be repaired but was not finished (unpainted) and the rotted window sill should have been brought to his attention. He stated the furniture on the two units were old and he would have to start requisitioning it. An observation was conducted with the Maintenance Director of room [ROOM NUMBER]. He said, I didn't realize it looked like that (ceiling). He reported the facility had a roof leak which had been fixed and the sagging paint on the wall was due to the roof leak. During the observation of room [ROOM NUMBER], he reported it needed a lot of sheetrock work and needed new outlet covers. The director identified Resident #88's mattress was crooked, he straightened the mattress and adjusted the footboard. He stated he did not do bed audits and depended on nursing to ensure that the mattresses fit. The director stated, regarding room [ROOM NUMBER]'s ceiling, the textured ceiling was heavy and it was starting to peel away (cracks in ceiling). He looked at the brown spot on the ceiling and stated it could have come from a previous roof leak. He agreed with the findings of room [ROOM NUMBER] and stated the uncleanable surfaces were not particle board and would not absorb (liquid) like particle board would. He stated each unit had a binder that was checked daily and the items were addressed by the department. He stated they depend on communication from nursing staff to let maintenance know of issues within the building. On 11/2/22 at 4:27 p.m., the director provided audits that maintenance would start to use as they go room to room. A policy - Resident Environmental Quality, implemented 9/23/22, indicated that It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy identified the following: - Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. - Identify areas of possible entrapment by conducting regular inspections on all bed frames, mattresses, and bed rails. These inspections will be apart of the facility's routine maintenance program. - All facility personnel are responsible for reporting broken, defective, or malfunctioning equipment or furnishings immediately upon identification of the issue. 2. An initial room observation was conducted on 10/31/22 at 10:00 a.m. for room [ROOM NUMBER] which revealed the following: (a) Missing plaster board on bedroom wall facing the sink, cove base not adhered to the wall, floors were upswept and dirty with debris on the floor. (b) Closet door not on hinges ripped off from right side of the closet slider, corner of closet door not attached and wide-open gap between wall and closet door. (c) Textured ceiling over the bed in disrepair; photographic evidence obtained. (d) Continuous running water faucet and severe buildup of calcium and iron around base of the faucet. (e) Ceramic tile floor behind toilet cove base was not properly attached to the floor and wall leaving open areas. (f) Damaged drywall holes with missing and loose plaster at entry of the room. 4. Observations of room [ROOM NUMBER] on 11/03/22 at 12:08 p.m., revealed there was black bio-growth on the wall below the window and directly above the wall mounted air conditioning unit. Interview with the Director of maintenance at this time revealed he was not aware of the area and was not sure what the black area was.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey, on 11/03/2022 and was cited at F656 and F759. On 12/13/2022 a revisit survey was conducted and the facility was recited at F656 and F759. The facility had developed a Plan of Correction with a completion date 12/03/2022. The facility had not comprehensively implemented the plan of correction for the identified quality deficiencies. Findings included: 1. On 12/13/22 at 11:47 a.m., Resident #1 was observed in bed. The resident answered questions by nodding her head yes or no. She nodded yes she was ok, yes staff were taking good care of her, no she was not in pain, and no she had not had a fall. A review of the [NAME] Abuse Log provided by the facility revealed a neglect incident for Resident #1 dated 11/26/22. The incident occurred in the resident's room, and it was reported per the log. The Incident-by-Incident Type document dated 10/01/22 to 12/13/22 provided by the facility indicated Resident #1 did not have an incident during this time period. A review of the admission Record for Resident #1 revealed her most recent admission date was 11/30/22. Resident #1's diagnoses included but were not limited to muscle weakness, abnormal posture, anxiety disorder, unspecified dementia, unspecified abnormalities of gait and mobility, major depressive disorder, history of falling, unspecified lack of coordination, and age-related osteoporosis without current pathological fracture. A review of Section C-Cognitive Patterns of the 5 Day Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicating severe cognitive impairment. A review of Section G-Functional Status revealed the following: Bed Mobility- Extensive assistance with one-person physical assist Transfer- Total dependence with two plus person physical assist Walk In Room- Activity did not occur Walk in Corridor- Activity did not occur Locomotion On Unit- Total dependence with one-person physical assist Locomotion Off Unit- Total dependence with one-person physical assist Dressing- Extensive assistance with one-person physical assist Eating- Supervision with setup help only Toilet Use- Extensive assistance with one-person physical assist Personal hygiene- Extensive assistance with one-person physical assist A review of the Progress Notes revealed the following: 11/25/22 Nursing Note- Upon removal of resident's socks to get her washed up for the day, the staff Certified Nursing Assistant (CNA) noticed a healing bruised area and localized swelling to the right outer ankle. Nurse was immediately at the bedside to assess. Resident denies pain or discomfort. The area is as described above. There are no open areas or trauma signs and symptoms noted. Vital signs were stable. Elevating this extremity. When asked what happened, resident does not recall. Doctor was notified and new orders were received for x-rays of the foot and ankle to rule out an acute process. There are no further signs and symptoms of acute distress. Pain management in place is effective. Nursing will communicate any results or concerns with doctor for further orders. 11/26/22 Nursing Note- Resident noted to have a bruised area over her left ankle on 11/25. Xray results revealed right ankle fracture involving the lateral malleolus with mild displacement. Physician called and gave an order to send her out to the hospital for evaluation and treatment. 11/27/22 Nursing Note- Resident not complaining of pain on her right ankle during the shift but complaining about pain level 4 on her left knee, knee assessed there is some swelling and warm to touch. Attending physician contacted and new order obtained for left knee x ray, Keflex 500 mg, and Voltaren Gel 1% or lidocaine patch if gel refused. A Change in Condition Evaluation dated 11/27/22 revealed the resident had new or worsening pain. Nursing observations, evaluation, and recommendations indicated to reposition to alleviate pain and medicated with pain cream to knee. X-rays were ordered. 11/30/22 Physician Progress Note- At baseline she is bedbound, minimally interactive only with staff (only expresses her needs) not with any other residents. She needs assist with transfers and position changes, she remains total care except able to feed self. On 11/26, received call from nurse regarding right ankle swelling, redness, and patient in pain with range of motion while CNA was doing their routine care, stat x-ray was ordered. Xray came back with right ankle fracture, patient was transferred to hospital for orthopedic evaluation and further care. There are no reports of fall/injuries from nursing team, patient did not complain of pain in her legs until CNA witness above finding and patient complained of foot pain during care, which prompted to take necessary steps. However, her current x-ray findings and based on her underlying comorbidities this fracture could be likely unavoidable fracture secondary to osteopenia/osteoporosis. Resident went out to the hospital as nursing noted redness and swelling of the left knee with pain with range of motion, x ray of left knee revealed likely fracture. Patient was sent to hospital for further evaluation. Diagnostic test revealed left distal femur fracture. She was seen by orthopedics and had cast placed to LLE. Left distal femur fracture no surgical intervention done. Ortho wanted to go with conservative measures in view of her underlying medical comorbidities and patient being non ambulatory (also her fracture was minimally displaced expecting to heal) will need to follow up with Ortho as outpatient. Patient with left distal femur fracture/right bimalleolar fracture in view of her current clinical status and underlying medical comorbidities and from discussion with patient's nurse no recent injury or fall witnessed by team she also regularly has skin checks which are basically normal so overall picture apparently looks like could be likely fracture secondary to osteoporosis. 12/06/22 (Advanced Registered Nurse Practitioner) ARNP Note- This patient has a palliative diagnosis of dementia. Total dependence with Activities of Daily Living (ADLs), non-ambulatory/wheelchair bound, and incontinent of bowel and bladder. On 11/26/22, this patient presented to a local hospital with complaints of right ankle pain, swelling, and fracture of the lateral malleolus with mild displacement on the outside right ankle. This patient returned to the facility on [DATE] with a boot for her fracture that the hospital staff could not put on due to patient not cooperating with the procedure and yelling out. Nursing home staff was informed that this patient is not a surgical candidate due to comorbidities and nonambulatory status. Fracture to heal on its own. On 11/28/22, presented to a local hospital with acute left leg pain due to left femur fracture. Patient was admitted . Casts were applied to bilateral lower extremities. Patient discharged to nursing home on [DATE]. The patient's fractures are pathological. This provider spoke with attending physician at length regarding patient's pathological fractures, decline in function, and failure to thrive. A review of the Comprehensive Care Plan related to risk of pain due to osteoporosis and fracture of the right lateral malleolus, right fibula, and distal left femur revealed the following interventions: Administer medications for discomfort as ordered; observe for effectiveness Assess pain level as needed Check circulation, sensation, and movement to bilateral toes Encourage resident to voice discomfort at onset as needed Observe for nonverbal signs and symptoms of discomfort Provide rest periods throughout the day as needed Report changes in comfort level to physician as needed There were no interventions in place related to precautions when providing care to prevent unavoidable fractures. On 12/13/22 at 12:10 p.m. Staff E, CNA, reported she was taking care of the resident on the day of the initial fracture. When she was getting ready to give her a bed bath, she was undressing her, she took her socks off, and saw the swelling on the left foot and it was bruised. No pain noticed. She covered the patient and went to the nurse to let her know what was going on. The doctor went into the room. After that, they finished the bed bath to put clothes on her, put a pillow underneath the leg, and then the nurse came in and said wait to see what the doctor has to say about if the patient is staying or being sent out to the hospital. Staff E, CNA, reported she did not take care of the resident the day prior to the bruising. She stated Resident #1 never mentioned she was in pain but would always say she's tired. Staff E, CNA, reported Resident #1 had not had a fall and she never got her out of bed for anything. A telephone interview on 12/14/22 at 9:32 a.m. with Staff F, Licensed Practical Nurse (LPN), revealed she worked Saturday and got report from the nurse a CNA found a bruise on the resident's ankle and the doctor was called. The lab came in to do x-rays on Thursday and Friday on her shift. The resident returned to the facility the same night she was discharged . Per hospital records, she was not a candidate for surgery, and she was not cooperating with the boot. She reported the resident was always screaming during care and she does not like to be moved around and she always complains of being very tired. The resident just wants to be left alone. She does not like to be moved at all. Staff F, LPN, reported she found the inflammation on the left knee. She received orders for pain and an x-ray. The x-rays were done that night. Monday when she returned to work, she received report the resident had another fracture, and she was discharged to the hospital again. Staff F, LPN, reported before the fractures, she would always scream when you moved her. On 12/13/22 at 12:40 p.m., the Director of Nursing (DON) stated it was reported to her by the nurse the resident had a mild fracture. They called the doctor and did the immediate report. The doctor gave orders to send the resident to the hospital. The DON reported she got statements from staff that worked the day the fractures were found and the day before. Per the statements, there were two CNAs that noticed the swelling and reported to the nurse. Other statements from nurses indicated they did not notice any changes. On 11/25/22, Resident #1 was getting a bed bath when the swelling was noticed. The resident did not leave the bed and they did not notice any skin impairments on 11/24/22. Nothing was noticed the day prior from all staff interviewed and they reported the resident did not fall. After they got findings from the doctor that the resident had the fractures, it was determined it could have happened while they were turning her or changing her. They updated her care plan related to preventative measures as far as checking for circulation and to use a Hoyer Lift. This was implemented due to the fracture. The doctor said the fractures were unavoidable due to osteopenia/osteoporosis and they are most likely pathological fractures secondary to osteopenia/osteoporosis. The DON reported Resident #1 does not get out of the bed much and she needs a Hoyer Lift to get out of the bed. Resident #1 was readmitted with two casts. An ADL assessment was completed related to transferring her. Staff was educated on how to report in the system any findings on a resident. They did not educate staff on how to turn the resident. The education was related to skin impairments because of the bruising and some staff were saying they didn't see the bruising. The DON reported the CNAs are not doing anything differently related to take caring of the resident. 2. An observation was made on 12/13/22 at 1:22 p.m. of Resident #5 sleeping comfortably in bed with bilateral heel protectors on. An interview was conducted on 12/13/22 at 1:28 p.m. with Staff A, Certified Nursing Assistant (CNA). He stated the heel protectors are placed in the orders. Stated it would not be in the care plan. Stated the nurses are the ones who usually put the heel protectors on not the aides. An interview was conducted on 12/13/22 at 1:31 p.m. with Staff B, Licensed Practical Nurse (LPN). She stated Resident #5 is always in bed and rarely gets out of bed and that could be the reason for the heel protectors. She indicated she would have to check the chart to see if there is an order for the heel protectors. Observed Staff B check in Resident #5 chart to indicate if she needs bilateral heel protectors. Staff B stated there is no order for the resident to have heel protectors on. Observed Staff B look in the resident's care plan. She stated the heel protector use was not in the care plan. She stated the morning nurse must have put them on, as they were on the resident when she came in. She confirmed there is supposed to be an order and a care plan area discussing the heel protectors. She noted the resident should not have the heel protectors on. She indicated she would be talking to the unit manager. An observation was made on 12/13/22 at 1:36 p.m. of Staff B approach the Unit Manager about the heel protectors for Resident #5. A review of Resident #5's admission Record revealed an initial date of 1/15/22 and readmission date of 08/20/22 with diagnoses including dysphagia following cerebral infarction, and chronic obstructive pulmonary disease. A review of Resident #5's orders did not indicate an order relating to the use of heel protectors. A review of Resident #5's care plan did not reveal a focus area or interventions relating to the use of heel protectors. The policy provided by the facility Care Plan Revisions Upon Status Change implemented on 10/23/22 revealed the following: Policy-The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 3. Observation of Staff C, Licensed Practical Nurse (LPN) on 12/14/2022 at 9:24 a.m. entered Resident #6's room with a pink plate with an Accucheck machine, Accucheck strip bottle, lancet, syringe, and alcohol wipe on it. She also had two bottles of insulin which were inside of two medication bottles and a Combivent Aerosol solution box with both the Combivent inhaler and the Flovent HFA inhaler inside. Staff C, LPN sat the insulins and inhaler box on the resident's overbed table. The resident was sitting up in bed. The nurse handed the resident the cup of oral medications. She applied gloves without hand sanitizing and performed the Accucheck by puncturing the right ring finger. The resident's blood sugar was 192. The nurse removed the Glargine insulin bottle from the medication bottle and drew up 25 units and administered into the right thigh. Staff C told the resident to use one of the inhalers, while she stepped out to retrieve another insulin syringe. The nurse removed her gloves but performed no hand sanitizing. The resident inhaled the Combivent inhaler 2 puffs. The nurse returned and told the resident to wait 5 minutes before she used the next inhaler (Flovent). The Resident stated, That was the first time she had heard of waiting 5 minutes between her inhalers. She did not know that. It was new to her. The nurse had the resident rinse her mouth and spit the water out. The nurse told the resident to take one puff of the Flovent and wait a minute for the next puff. In the meantime, she donned gloves, removed the Aspart insulin bottle from a medication bottle and drew up 10 units of insulin. She administered it into the right thigh. The resident stated it had been one minute and puffed the second dose of the Flovent. The resident was given water to rinse her mouth. The resident appeared confused about the minutes in between the puffs and medications. The nurse removed her gloves and did not hand sanitize, again. She exited the room and placed the items she had taken into the room on the top of the medication cart. Before she could replace the medications (insulin) into the cart she was stopped. When asked, she stated the room was dirty so the medication containers would be contaminated and would need to be wiped down. When asked about the inhalers in the same box, she stated the Flovent does not have the resident's demographics to ensure it was the residents. She called over Staff D, LPN, Unit Manager (UM) and she verified Staff C should not have taken the Combivent box nor medicine bottles with the insulin inside into the room. The insulin should be drawn up at the medication cart. Staff D stated they now needed to be cleaned with bleach wipes before replacing them into the medication cart drawer. She also included the Accucheck strip bottle. Staff D stated the Flovent would have to be thrown away and another one ordered for the resident due to lack of demographics showing it was the resident's. Staff D confirmed the nurse should have hand sanitize between glove changes. An interview with the Director of Nursing (DON) on 12/13/2022 at 2:15 p.m. included the medication pass for Resident #6. She agreed the Aspart insulin was given late as a medication error and the Flovent given without identification was also an medication error. Regional Nurse entered the conference room and was informed of the observation of medication pass for Resident #6. The Regional nurse agreed with the findings and stated they needed to do some education with the staff. A review of Resident #6's clinical record revealed she was admitted on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to acute and chronic respiratory failure with hypercapnia, COPD (Chronic Obstructive Pulmonary Disease), metabolic encephalopathy, Diabetes, morbid obesity, weakness, asthma, Myocardial Infarction, aortic valve stenosis, cognitive communication deficit, and atrial fibrillation. A review of the physician orders and December Medication Administration Record revealed the following: Aspirin (ASA) 81 mg (milligrams) daily delayed release for CAD (Coronary Artery Disease) Calcium and D3 600 mg / 10 meq (milliequivalents) daily hypokalemia Colace 100 mg daily for constipation Eliquis 5 mg BID (twice a day) for atrial fibrillation Lasix 20 mg BID for HTN (Hypertension) Aspart insulin 10 units with meals for DM at 8 a.m. Glargine insulin 25 units BID for DM at 9 a.m. Combivent Respimat Aerosol solution 20-100 mcg/act 2 puffs inhale orally two times a day for sob (shortness of breath) Flovent HFA aerosol 220 mcg (micrograms)/act 2 puffs inhale orally two times a day for asthma (not labeled, in the Combivent box) A review of the facility's policy, Medication Administration, dated 10/23/22, indicated the following: Medications are administered by licensed nurses .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: 1. Keep medication cart clean, organized, and stocked with adequate supplies. 4. Wash hands prior to administering medication per facility protocol and product. 11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time. 13. Remove medication from source, taking care not to touch medication with bare hand. 14. Administer medications as ordered in accordance with manufacturer specifications. 15. Observe resident consumption of medication. 16. Wash hands using facility protocol and product. Medication requiring a waiting period between inhalations or drops: Metered dose inhalers- follow manufacturer's product information or administration instructions including acceptable wait times between inhalations. A review of the facility's policy, Administering Medications through a Metered Dose Inhaler, dated October 2010, indicated the following: Steps in Procedure: 1. Wash hands. 2. Arrange supplies in the medication room, the medication cart outside the resident's room. 13. Check the label on the inhaler and confirm the medication name, and dose with the MAR. 15. Confirm the identity of the resident. 17. Place inhaler (s) on the bedside table or tray. 21. Administer medication. 22. Repeat inhalation, if ordered. Allow at least one minute between inhalations of the same medication and at least two minutes between inhalations of different medications. 25. Wash hands. An interview was conducted on 12/13/2022 at 1:23 p.m. for Quality Assurance with the Nursing Home Administrator (NHA). The NHA stated the facility completed audits for residents wearing offloading devices and completed education and training with nursing staff related to wearing offloading devices. The NHA stated the faciltiy was performing daily rounds and the unit managers were monitoring any boots that were applied. The NHA stated the faciltiy had looked at the care plans for adaptive devices. The NHA stated the facility had reviewed the orders for medications that can be crushed and they had not had any concerns. The NHA stated education on medication administration with inhalers and wait time in between double dosages had been completed and no concerns had been identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to honor residents' right to smoke for 2 of 14 (#11, #86) residents who smoke. Findings included: Interview on 05/18/21 at 10:59 AM with Resident #86 revealed that she is allowed to smoke at night only when there is no one around, but that she is not allowed to smoke during the day and that she is dying for a cigarette right now. She reported that she will be off of isolation in 4 days and will be able to smoke during the day. Review of Resident #86's record revealed that this resident was admitted to the facility on [DATE], has a current physician order dated 4/7/21 for droplet precautions and has a Brief Interview for Mental Status (BIMS) score of 13 (Cognitively intact). The resident was assessed to be able to smoke safely and independently on 4/7/21 and was care planned to be able to smoke independently on 4/9/21. The resident signed a smoking policy on 4/9/21. The residents record did not contain any documentation that would indicate that the resident was offered or educated on the use of alternate nicotine substitutes. An attempt was made to interview Resident #11, however the resident was unable to stay on topic. Review of Resident #11's record revealed that this resident was admitted to the facility on [DATE], has a current physician order dated 5/17/21 to follow droplet precautions every shift, and has a Brief Interview for Mental Status (BIMS) score of 3 (Moderate impairment). The resident was most recently assessed to be able to smoke safely and independently on 4/9/21 and was care planned to be able to smoke independently on 3/12/21. The resident signed a smoking policy on 3/10/21. The resident's record did not contain any documentation that would indicate that the resident was offered or educated on the use of alternate nicotine substitutes. On 05/18/21 at 11:24 AM an Interview was conducted with the NHA who revealed that the facility had no smoking schedules as the residents can go out anytime. Interview on 05/18/21 at 11:32 AM with Staff V, RN reported that she was assigned to the 200 hall which is an isolation unit and has not been allowing residents who smoke to go out to smoke as they are on isolation. She reported that she has nicotine patches in her drawer but no one has orders for them yet. She reported residents #11 and #86 both smoke and have not been allowed to go out to smoke. Interview on 05/18/21 at 11:28 AM with the Activities Director who revealed that there is no scheduled smoking time, that residents can go out as they like. He reported that at this time there are only 2 people who need to be supervised while smoking. He reported that those residents who are on isolation are not allowed to smoke, they assist those residents with there smoking needs by shopping for the cigarettes for the resident. Interview on 05/18/21 at 01:45 PM with the NHA (Nursing Home Administrator) revealed that the residents who are under isolation and smoke can still smoke and they are offered the patch. Review of the facility policy titled Resident Rights with a revision date of December 2016 revealed that 1. Federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to:: e. self-determination; g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States;

Based on interview and record review the facility failed to appropriately investigate the concerns of the resident council group and keep them apprised of the resolution of the concern bought up by the resident council group. Findings included: Review of the Resident Council meeting minutes for the months of March, April, and May 2021 identified concerns related to rude staff on the 11:00 PM-7:00 AM shift. Review of grievance dated 3/1/21 revealed that the activities director received a grievance from the Resident Council group related to Residents state the 11-7 staff are rude to them. The form indicated that the action that was taken to resolve the issue was In-serviced staff on customer service. Review of the facility education revealed that staff were in-serviced on 3/2/21 and 3/3/21 related to customer service and treating resident with respect and dignity. The grievance form indicated that the concern was resolved on 3/3/21, however there was no documentation that would indicate that the concern had been investigated and the area on the form that indicated that the residents were notified of the resolution and their satisfaction with the resolution was left blank. Review of grievance dated 4/6/21 revealed that the activities assistant received a grievance from the Resident Council group related to Residents state the 11-7 staff is rude. The form indicated that the action that was taken to resolve the issue was customer service (See attached). Review of the attached document revealed a facility education dated 4/9/21 related to customer service. The grievance form indicated that the concern was resolved on 4/9/21, however there was no documentation that would indicate that the concern had been investigated and the area on the form that indicated that the residents were notified of the resolution and their satisfaction with the resolution was left blank. Review of grievance dated 5/3/21 revealed that the Resident Council group filed a grievance related to Residents state the staff on the 11-7 shift are rude. The form indicated that the action that was taken to resolve the issue was Education given to staff related to customer service. Review of the facility education revealed that staff were in-serviced on 5/10/21 related to customer service. The grievance form indicated that the concern was resolved on 5/10/21, however there was no documentation that would indicate that the concern had been investigated and the area on the form that indicated that the residents were notified of the resolution and their satisfaction with the resolution was left blank. Interview with a group of 5 alert and oriented residents on 05/19/21 at 10:00 AM revealed that staff on the 3:00 PM-11:00 PM and the 11:00 PM-7:00 AM shift have bad attitudes and are rude to the residents. The group reported that they have brought this concern up multiple times during their Resident Council Meetings but have had no resolution and the staffs' bad behavior has continued. The group report that the staff involved are mostly agency staff who they believe are working at the facility only for a paycheck. An interview was conducted on 05/20/21 at 06:33 PM with the Activities Director who reported that when a concern is brought to the council meeting, he writes it up as a grievance and submits it to the social worker as she is the grievance coordinator. He reported that if the issues are still present at the following meeting he will file another grievance. An interview was conducted on 05/20/21 at 06:54 PM with the Director of Social Services/Grievance Coordinator who said that when she gets the grievance from resident council she will forward it to the appropriate department and in this case it was nursing. She reported that nursing does the in-service and then it comes back to her and she logs it back in and then she meets with the Administrator to go over it and then during angel rounds will check with the residents to see how things are going. She reported that for the months of March, April and May 2021, education of staff was the resolution related to the resident councils concerns. An interview was conducted with on 05/20/21 at 07:21 PM with the Director of Social services and the Activities Director. The Director of Social Services confirmed that the follow-up section of the grievance form was left blank. She was unable to verbalize if an investigation into the concerns was made and if the residents were aware of the resolutions and if they were satisfied with the resolution. The Director of Social Services was unable to provide any documentation that would indicate that an investigation into the resident council concerns had occurred. The Director of Social Service reported that she understood that she should be ensuring resident satisfaction of the resolution of their concerns. Review of the facility policy titled Grievances/Complaints, Filing with a revised date of 5/2020 revealed that The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.

Based on observation, interview, medical record review, and manufacture's directions the facility failed to ensure three (400 unit cart #1, 100 unit cart #1, and 300 unit cart #2) of four sampled medications carts had medication and biologicals stored not past the expiration date, and/or failed to document an open on date. Findings Included: 1. On 5/17/2021 at 1:00 p.m. medication cart #1 on the 400 unit was observed with the following: An oral inhaler Combivent. The inhaler did not contain an open on date. The instructions on the inhaler read to discard three months after opening. A second oral inhaler labeled Breo-ellipta did not contain an open on date. The label indicated to discard 6 weeks after opening. A bottle was labeled assure platinum strips. The bottle did not contain an open on date. vial labeled NovoLog contained an open on date 4/8/2021. The labeled on the bottle read expired 28 days after opened. Indicated last day on 5/6/2021. An insulin vial labeled Lantus was identified and did not have an open on date. Prescription Lantus is a long-acting insulin used to treat adults with type 2 . After 28 days, throw your opened Lantus pen away-even if it still has insulin in it. www.lantus.com. The Regional Nurse H was present at the time during the findings and confirmed the observations. 2. On 5/19/2021 at 10:10 a.m. medication cart #1 on the 100 unit was observed to contain a box of glucose gel in a tube. The box was opened and revealed the tube original seal had been removed and was covered with a piece of white tape. Staff U, Unit Manager was present and confirmed the observation and stated, it should not be in the cart. 3. At 11:00 a.m. medication cart #2 on the 300 unit was observed with the following: Three vials of NovoLog insulin. All the vials contained an open on date. All the vials were expired. A box labeled ear wax softener was identified that had been opened. The box did not contain an open on date nor did it include a resident identifier. A box that contained blood sugar testing solutions had been opened. The box did not contain an open on date. Staff F, Unit Manager was present during the findings. She confirmed that the insulin vials had expired and should have been removed from the cart. She indicated that the open box of ear drops is not used for multiple residents. That a resident name should have been on it. The facility provided a copy of their policy titled Storage of Medications dated 09-20218. Policy: medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. Procedures: General Guidance: 8. Outdated, are immediately removed from inventory, disposed of according to procedures for medications disposal, and reordered from pharmacy if current order exists. III. Expiration Dating (Beyond-Use Dating) 1. Expiration dates of dispensed medications shall be determined by the pharmacist at the time of dispensing. 3. Certain medications or package types, multiple dose injectable vials, and blood sugar testing solutions and strips require an expiration date shorter than the manufactures expiration date once opened to ensure purity and potency. 8. All expired medications will be removed from the active supply and destroyed in accordance with the facility policy, regardless of amount remaining.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure three (#88, #124, #102) of 54 residents sampled were provided services to maintain grooming, and personal and oral hygiene. Findings included: 1) On 5/17/21 at 2:55 p.m. Resident #88 was observed self-propelling his wheelchair in the hallway of his unit. He was wearing a pair of white shorts and presented with a dark yellow colored stain just below his waistline and on both sides of his groin. A staff member was in the hallway and was asked about his soiled clothing. She looked at the resident and stated, you need to go to your room and get your shorts changed before you go outside. She then turned his wheelchair around and transported him to his bedroom. At 3:35 p.m. Resident #88 remained in his bedroom when Staff Member B, Certified Nursing Assistant entered the bedroom with a blood pressure cuff, and temperature probe. She was observed as she was performing his blood pressure check. She was overheard telling the resident he needed to wait to go outside. She then stated, I have to finish getting vital signs and then I'll be back to help you change your clothes. At that time, the resident's roommate was overheard asking for a blanket. Staff B then left the bedroom. Resident #88 was approached and was receptive to an interview as he was sitting in his wheelchair. He was still wearing the white shorts with the dark yellow colored stains. He said that he likes to go outside but had to wait until his shorts were changed. The resident said that he was not able to change his shorts on his own. He said he even needed help to get on the commode. At 3:40 p.m. an interview was conducted with Staff B as she confirmed she was caring for Resident #88 and his roommate. She stated, When I came on my shift, I seen him, and I was trying to find the day shift staff member who left him like that. Staff B was asked, and she confirmed that he had asked for help in changing his clothes. She stated, I told him I would be back after I finished getting all of my vital signs. She additionally confirmed the roommate had asked for a blanket. Staff B stated, he already had a blanket. I'll get him another one after am done with my vital signs. Staff B said her shift started at 2:45 p.m. At 3:45 p.m. an interview was conducted with Staff Member J, Unit Manager as she confirmed it was her expectation when a resident asks for assistance they are assisted in a timely manner. She stated, that the vital signs are not due until 5:00 p.m. Staff J was overheard as she spoke to staff B that she needed to prioritize her duties. That would be in assisting the resident and their needs. At 4:00 p.m. Staff J was observed as she entered Resident #88's bedroom, one hour and fifteen minutes after first observed with soiled/incontinent clothing. Medical record review was conducted for Resident #88 which revealed on the admission Record form a diagnosis of diabetes and hypertension. The Minimum Data Sheet, dated on 4/13/2021, indicated he received diuretic therapy daily. The Data Sheet revealed he was frequently incontinent of bladder. Review of Care Plans with a focus on an alteration in elimination AEB (date initiated 8/14/18 and revised 4/17/20) (as evidenced by): is incontinent of bowel and bladder r/t (related to) recent decline in mobility, staff to assist with incontinence needs, wears a brief. Goal: resident will be clean, dry and odor free. Check resident upon rising, before/after meals and at HS (bedtime) for incontinence: perform incontinence care prn. On 5/20/21 at 11:56 a.m., an interview was conducted with the Nursing Home Administrator and the Regional Nurse H. When asked, the NHA indicated she was not aware that the resident had to wait in soiled clothing over an hour for assistance. 2) On 05/17/21 11:33 a.m. Resident #124 was observed lying in his bed. He made eye contact when approached and was non-verbal. He appeared comfortable receiving oxygen through a tracheostomy, while a feeding machine was running at his bed side. His hair was unclean. His scalp and hair follicles presented with copious amounts of dried flaky pale yellow fragments. On closer observation his left ear contained moderate amount of the flaky yellow fragments. Medical record review of the admission Record revealed a diagnosis of respiratory failure, aphasia and dysphasia following cerebral infarct. Current Physician orders (May, 2021) were reviewed. There was no current treatment was in place for his scalp. Further record review of his care plan (Initiated 8/14/2018, Revised 4/17/2020) revealed a Focus, has a self-care deficit with dressing, grooming, bathing and requires total assist with all care. Goal: resident will have clean, neat appearance daily. Interventions: Provide total staff assistance with dressing, grooming, bathing. Staff to anticipate residents needs with ADLS (activities of daily living). On 05/18/21 at 3:55 p.m. Resident #124 was observed lying in bed. More than 24 hours later, his scalp and hair remained unchanged with a copious amount of dried flakes/scales of pale yellow fragments. At 4:12 p.m. Staff Member I, Licensed Practical Nurse was asked about the resident and stated, I did not know when his shower day was. Staff B was in the hallway and stated out loud I gave him a shower last night. When asked about his hair she stated, I washed his hair with a special shampoo the nurse gave me. I scrubbed his head really hard to get off the flakes. She said the shampoo was orangish red in color. Staff Member I said that he was new to the unit, and was transferred from a different hall. He indicated he did not know the resident. Staff I said that he did not know if the resident had an order for a special shampoo. After reviewing the Physician orders, he stated, he did not have an order for medicated shampoo. Staff I opened the treatment cart that revealed two bottles of Ketoconazole 2 % shampoo for the resident. Directions stated to apply topically on Monday and Thursday. The pharmacy delivery date was 3/29/21 and on 2/26/21. Staff I confirmed that both bottles had been opened, and both bottles contained over seventy five percent of shampoo. At 4:25 p.m. an interview was conducted with Staff Member J, Unit Manager as she provided Resident #124's shower sheet. The shower sheet was dated 5/17/2021 that revealed handwritten documentation bed bath. At that time staff B approached the desk and was asked about the documentation on the shower sheet that reflected a bed bath. Staff B confirmed she had given a bed bath and not a shower. She went on to state me personally I like to put them in the shower. But when I ask for a portable oxygen tank as he needs to be hooked up on oxygen, the nurses are like he has a trach and needs oxygen. Staff B was asked and stated, I take a face rag and get it really wet. I put shampoo on it. So, I did a shampoo and bath in bed. I do my best. Review of the skin sheet showed, this sheet is to be completed by the C.N.A. twice weekly on the residents shower days. On days if C.N.A. notices ANYTHING unusual on the resident's skin. Staff B was asked about his hair, she stated, the nurses see what I see. I don't feel like I need to document it they already know about it. Staff J, Unit Manager (UM), was asked and confirmed she was unaware of any issues with the resident. At that time staff J and the Regional Nurse W went to Resident #124's bedroom and confirmed that his scalp was concerning, and indicated a treatment would be needed. Staff J stated, he had been seen by our wound physician who is a dermatologist. His hair had not been like that before he went to the hospital. She said that she had not seen the resident for a while. Staff J proceeded to look at the resident's current orders and stated, the shampoo order was a 30 day order, and then it falls off. Further medical record review found Ketoconazole shampoo 2% apply to scalp topically every day shift Monday, Thursday for tinea versicolor for 30 days ended on 5/1/2021. Tinea versicolor is a common fungal infection of the skin. The fungus interferes with the normal pigmentation of the skin, resulting in small, discolored patches. These patches may be lighter or darker in color than the surrounding skin and most commonly affect the trunk and shoulders. Signs and symptoms include: Patches of skin discoloration, usually on the back, chest, neck and upper arms, which may appear lighter or darker than usual. Mild itching, Scaling. Tinea versicolor often recurs, especially in warm, humid weather. Causes: The fungus that causes tinea versicolor can be found on healthy skin. It only starts causing problems when the fungus overgrows. A number of factors may trigger this growth, including: Hot, humid weather, Oily skin, Hormonal changes, and a weakened immune system. https://www.mayoclinic.org/diseases-conditions/tinea-versicolor/symptoms-causes/syc-20378385. On 5/20/2021 at 11:00 a.m. an interview was conducted with Staff J, UM. Staff J stated, there had been a full time nurse caring for resident #124. But she no longer works here. 3) On 5/17/21 at 10:50 a.m. Resident #102 was lying in his bed and was receptive to the interview process. He appeared comfortable as he said that he was the facility Resident Council President, and had been at the facility for a few years. When he smiled, he was observed missing a couple of his front teeth. He was asked if staff provided him set up in the morning for his oral care. He smiled, again, and stated I can't do it myself as he slightly lifted his arms and hands from his chest. The joints to his hands were noted with deformity. He was then asked if staff brush his teeth for him daily. He stated, No, but when my dad visits once a week I will sometimes ask him. When asked he stated, I haven't had a dental cleaning in years. I have bad insurance. Medical record review revealed an admission Record form that indicated he was in his mid-forties. Diagnosis information contained lack of coordination, early onset cerebellar ataxia, and pain in joint. Further record review revealed diagnosis of [NAME] ataxia. The Minimum Data Sheet was reviewed that was dated 4/6/2021 that revealed Brief Interview for Mental Status score of 15. The score of 15 indicated Intact cognitive response. Friedreich's ataxia (FA) is a neuromuscular disease that mainly affects the nervous system and the heart. FA's major neurological symptoms include muscle weakness and ataxia, a loss of balance and coordination. FA mostly affects the spinal cord and the peripheral nerves that connect the spinal cord to the body's muscles and sensory organs. FA also affects the function of the cerebellum, a structure at the back of the brain that helps plan and coordinate movements. (It does not affect the parts of the brain involved in mental functions, however.) Onset is typically between 10 and [AGE] years of age, but FA has been diagnosed in people from ages 2 to 50. FA progresses slowly, and the sequence and severity of its progression is highly variable. https://www.mda.org/disease/friedreichs-ataxia. On 5/20/21 02:10 p.m. Resident #102 was approached and invited the surveyor into his room. He was asked about the facility providing oral care. He stated, no one has brushed my teeth today. He was asked if he had a toothbrush he stated no. The Resident's teeth were observed with a small amount of pink debris between the left canine. He was asked if he was having any problems with his teeth. He stated, they all hurt. I just want to get them all taken out. At 2:15 p.m. an interview was conducted with Staff Member K, Certified Nursing Assistant who confirmed he provided care and services to Resident #102 at least 4 days a week. He was asked at that time if he provided oral care for him. He stated yes. He was asked if he could find the resident's toothbrush. He said, yes. He entered the resident bedroom and walked up to the tall dresser that the television sat on top of. He opened the top drawer and rummaged through the drawer for a few seconds. Staff K then looked over to the resident and stated, where your toothbrush? The resident that remained lying in bed stated, I don't have a toothbrush. Staff K looked a second time inside of the drawer and removed a tube of toothpaste. The tube appeared unused. Staff K was asked if he brushes the resident's teeth. He stated, a few days ago. Resident #103 stated, No you didn't. Review of Physician orders, dated 9/27/2018, May consult podiatry, dental, audiology, optometry, wound services as needed. Review of the care plans (Initiated 3/6/2019 and revised 4/17/2020) revealed focus in alteration in dentition AEB (as evidenced by) he is some missing teeth. He requires staff assist with oral care. Interventions: provide assist with oral care. Care plan for self-deficit in dressing, grooming, bathing, and eating r/t impaired mobility dx Friedrich's ataxia (Initiated 3/5/2019 and Revision on 10/20/20). He has impaired Upper Extremity /Lower Extremity (UE/LE) range of motion (ROM) r/t to generalized weakness, spasticity, and muscle weakness. Resident does not participate in most ADLs Interventions: Provide total staff assistance with dressing, grooming, bathing. Further review of the care plans identified the resident with strength in cognitive function AEB is oriented to person. Place and time (Initiated 12/11/0218, Revision on 12/11/2018). Short term/ long term (ST/LT) memory are intact. Is able to make daily decisions independently. On 5/20/2021 at 2:30 p.m. an interview was conducted with Nursing Home Administrator and the Staff Member J, Unit Manager. When asked staff J confirmed that his teeth should be brushed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observations, and interviews the facility did not ensure appropriate treatment and services were in place for a central line and did not ensure that practice standards were followed related to the a central intravenous catheter for one resident (#83) of three residents with central lines. Findings included: Resident #83 was admitted to the facility most recently on 4/23/2021 with a diagnosis of UTI (urinary tract infection), according to the face sheet in the admission record. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form (AHCA form 3008), dated 4/19/21 reflected a left Mid line IV (intravenous) access inserted 4/22/21. Review of the physician's order dated 4/23/21 revealed Resident #83 was receiving Ertepenem Sodium solution reconstituted 1 Gm use 1 gram intravenously one time a day for UTI for 3 days. The order status reflected it was completed on 4/25/21. A review of the physician's orders in the electronic medical record revealed an order that had been discontinued on 5/13/21, change transparent dressing to IV site as needed for IV site care, use securement device with each dressing change. Further review revealed another IV site care order dated 5/13/21, change transparent dressing to IV (intravenous) site every day shift every 7 days for IV site care, use securement device with each dressing change. Review of the MAR (medication administration record) for the month of April 2021 revealed the dressing change on the Mid line IV site was signed on 4/28/21. Further review showed the IV antibiotic, Ertapenem, had been administered on 4/24/21, 4/25/21, and completed on 4/26/21. Review of the TAR for the month of May 2021 showed the IV dressing change to the Midline was signed on 5/5/21 and 5/12/21. There were no further dressing changes signed. Review of the physician's orders for the month of May 2021, revealed there were no further IV medications ordered. Review of the policy, Central Venous Catheter Dressing Changes, revised April 2016, revealed the following: Purpose The purpose of this procedure is to prevent catheter related infections that are associated with contaminated, loose, soiled, or wet dressings. Preparation 1. Check the state's nurse practice act for LPNs regarding scope of practice for changing a central venous catheter dressing. 2. A physicians order is not needed for this procedure General guidelines 1. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. 2. Change dressings if any suspicion of contamination is suspected 4. After original insertion of central venous access device (CVAD), the dressing will consist of gauze and TSM. This must be changed within 24 hours a. Replace with sterile transparent dressing. b. Use gauze under the TSM if there is drainage from the catheter insertion site. 5. change transparent semi permeable membrane TSM dressings at least every 5 to 7 days and PRN when wet, soiled, or not intact. On 5/18/21 at 9:52 AM an observation was conducted. Resident #83 was in his room watching television in his bed. His left upper arm had a single lumen central catheter line visible below his sleeve. The dressing was not intact at the bottom where it was lifting away. The only portion of the date visible due to faded ink at the time was the first number, which was a four, indicating the dressing was last changed in April. On 5/19/21 at 9:44 AM an observation and interview was conducted with Staff X, RN (registered nurse) unit manager (UM). Staff X, RN UM said Resident #83 was admitted on IV antibiotics. He has completed those. Staff X, RN UM confirmed the first number on the date on the single lumen Midline dressing was a four. The full date was visible and upon closer observation, it was a very faded 4/22. Staff X, RN UM said she was not sure what the second number was. Staff X, RN UM also confirmed the dressing was not intact. Staff X, RN UM said she believed the dressing changes are once a week. There is a house order to change it every seven days. On 5/19/21 at 10:27 AM an interview was conducted with the ADON (assistant director of nursing), who was the acting interim DON (director of nursing). The ADON said the central line dressings have to be changed every seven days. On 5/19/21 at 10:31 AM an interview was conducted with the NHA (nursing home administrator). The NHA said she vaguely heard about the concern. The ADON is the risk manager. On 5/19/21 at 10:57 AM a follow up interview was conducted with Staff X , RN UM. She said they have a call out to the physician to see if they can discontinue the mid line IV catheter. Staff X, RN UM also confirmed the IV antibiotic was discontinued in April. On 5/20/21 at 2:21 PM an interview was conducted with Staff Y, LPN (licensed practical nurse). Staff Y, LPN said he had a central line to the right upper arm. It was for IV antibiotics. She thinks the central line was for one or two more doses of IV antibiotics. She said if the central line was inserted at the facility then twenty-four hours later the dressing has to be changed. If they came with it, we assess it. We put an order in for every seven days from the day of admission if it was dated the same day. Staff Y, LPN reviewed the April and May MAR with surveyor and confirmed she signed the dressing change on April twenty-eighth and May twelfth. She said she was not aware the dressing was dated 4/22 yesterday. She wasn't here yesterday so she can't speak to that. She does not recall what happened in April. She said there was an emergency on May twelfth. She brought the dressing change supplies to the room and got called away to an emergency. She must have forgotten the dressing change and signed the treatment in error. She doesn't know if the physician was aware the antibiotic was discontinued a day or so after Resident #83 came to the facility. She said she signs the treatments after she does them. She said she must have signed the treatment in error. According to the Centers for Disease Control and Prevention Checklist for Prevention of Central Line Associated Blood Stream Infections at https://www.cdc.gov/hai/pdfs/bsi/checklist-for-clabsi.pdf Clinicians should: Handle and maintain central lines appropriately Comply with hand hygiene requirements. Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis. Scrub the access port or hub with friction immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol). Use only sterile devices to access catheters. Immediately replace dressings that are wet, soiled, or dislodged. Perform routine dressing changes using aseptic technique with clean or sterile gloves. · Change gauze dressings at least every two days or semipermeable dressings at least every seven days. · For patients [AGE] years of age or older, use a chlorhexidine impregnated dressing with an FDA cleared label that specifies a clinical indication for reducing CLABSI for short-term non-tunneled catheters unless the facility is demonstrating success at preventing CLABSI with baseline prevention practices. Change administrations sets for continuous infusions no more frequently than every 4 days, but at least every 7 days. · If blood or blood products or fat emulsions are administered change tubing every 24 hours. · If propofol is administered, change tubing every 6-12 hours or when the vial is changed. Promptly remove unnecessary central lines Perform daily audits to assess whether each central line is still needed. Healthcare Organizations should: Educate healthcare personnel about indications for central lines, proper procedures for insertion and maintenance, and appropriate infection prevention measures. Designate personnel who demonstrate competency for the insertion and maintenance of central lines. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of central lines. Provide a checklist to clinicians to ensure adherence to aseptic insertion practices. Reeducate personnel at regular intervals about central line insertion, handling and maintenance, and whenever related policies, procedures, supplies, or equipment changes. Empower staff to stop non-emergent insertion if proper procedures are not followed. Ensure efficient access to supplies for central line insertion and maintenance (i.e. create a bundle with all needed supplies). Use hospital-specific or collaborative-based performance measures to ensure compliance with recommended practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 05/17/2021 11:55 a.m. Staff Member A, RN was observed as she gathered supplies for a blood glucose procedure for Resident #27. She removed the glucometer from the medication cart and placed it on a white foam tray along with alcohol pads, a lancet and a glucose strip. After the procedure was performed while still in the bedroom, she cleaned the meter with a alcohol wipe and placed the meter inside of her right uniform pocket. She was asked about the process and she said, I clean it with an alcohol wipe. Staff A exited the bedroom and returned to the medication cart where she cleaned the meter with a bleach wipe and immediately placed it inside of the medication cart top drawer. No disinfecting was observed. On 05/18/21 at 03:41 p.m. Staff Member I, Licensed Practical Nurse was asked and stated I can show you a glucose check right now as he pushed his medication cart to Resident #9's bedroom door. Staff I removed the glucometer from the medication cart and placed it on a white foam plate, along with a cup and an bleach wipe. After the procedure was performed he placed two bleach wipes around the meter and placed it back on the foam tray that was now sitting next to the sink. No cleaning was identified at that time. Staff I was observed as he prepared medications, sanitized his hands and donned clean gloves. Staff I placed the vial of insulin inside of the cart, a set of keys inside of his pocket and locked the cart with his gloved hands. After the medications were administered Staff I walked over to the glucometer and removed the bleach wipe from the meter, doffed his gloves and donned clean gloves without practicing hand hygiene. Staff I exited the bedroom and with a new bleach wipe cleaned the meter. At 3:54 p.m. Staff I removed a second glucometer from the cart, placed it on top new foam tray. He said that each cart has two meters and confirmed they are used on multiple residents. He indicated that he had a second glucometer test for Resident #12. Staff I donned clean gloves and removed a bleach wipe from its container and placed it inside a cup. He doffed the gloves and then donned clean gloves without practicing hand hygiene. After the procedure was performed, he placed a bleach wipe around machine. After the meter sat for approximately 3 minutes, he removed the wipe and performed the same procedure by wiping the meter. Staff I was asked and stated, the process after use is that it's wrapped for 3 minutes, then cleaned, and let it air dry for 2 minutes. On 5/19/2021 at 11:15 a.m. Staff Member G, Licensed Practical Nurse gathered the supplies for a glucometer procedure for Resident #77. She entered the bedroom holding the meter in her right hand. The meter was placed on the bed side table without a barrier. She donned clean gloves without practicing hand hygiene. The lancet was used on the resident's finger. Staff G then placed her right hand inside of her uniform right pocket and removed a bottle of glucose strips. The bottle was opened, and one strip was removed. The bottle was placed back inside her pocket. After the procedure was completed Staff G removed her gloves and with bare hands cleaned the meter with a bleach wipe. She then placed the meter in a cup. Staff G was asked at that time and stated It has to sit 3 minutes in the cup. It has to be completely dry. No disinfecting process was observed. On 5/20/2021 at 10:20 a.m. Staff Member F, Unit Manager was asked and verbalized the process of cleaning and disinfecting the glucometer. She stated, its cleaned with a bleach wipe and with a second wipe it is wrapped for 3 minutes. She confirmed the meter is to remain wet for a contact time of 3 minutes. Staff F asked was that not observed, stating I had my back to the procedure. I was on the computer. She confirmed that she was able to overhear the process. And stated I heard you ask her about the process. She told you the meter has to sit for 3 minutes in the cup to be completely dry. The facility provided a policy titled Blood Sampling- Capillary (finger sticks), revised September 2014. Purpose The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne disease to residents and employees. General Guidelines 1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident use. Steps in the procedure: 1. Wash hands. 2. [NAME] gloves. 3. Place blood glucose monitoring device on a clean field. Review of Recommended Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in Healthcare Settings revealed, Blood Glucose Meters: Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html Based on observation interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in regards to not following appropriate infection control related use of PPE (personal protective equipment) for rooms under contact and droplet precautions, failure to ensure that a cleaning and disinfecting process was utilized after use of a multiuse glucometer device for 4 (#27, #9, #12, #77) residents, and failure to practice hand hygiene prior to donning and after doffing gloves. Findings included: 1. Observation of the 200 hall on 05/17/21 at 10:10 AM revealed that every room door on this unit had a pink laminated sign which indicated Please see nurse before entering room Before entering you must apply: The following items were checked for each room: Apply gloves; Apply Face Mask; Apply gown; Apply goggles. Observations on 05/17/21 at 10:12 AM of Staff N, CNA (Certified Nursing Assistant) revealed that the staff donned full PPE (gown, gloves, face mask and goggles) and entered room [ROOM NUMBER] where the nurse and another aide were providing care and asked them if they needed assistance. When the pair said no the aide left room [ROOM NUMBER] and entered room [ROOM NUMBER] without changing her PPE. Observations on 05/17/21 at 10:15 AM of Staff O, LPN (Licensed Practical Nurse, Agency Staff) who said that the entire 200 unit was on isolation, one room for scabies, one room for a rash (possibly shingles), 5 rooms are on isolation due to the residents leaving the facility, one room for isolation for ESBL (Extended Spectrum Beta-Lactamase) in the urine, everyone else on the 200 unit was on droplet precautions. She reported that all staff should wear appropriate PPE and remove isolation gowns prior to exiting the room. She reported that no one should come out of the rooms with the gowns on. On 05/17/21 at 10:20 AM an observation was conducted of a maintenance man, Staff P, entering room [ROOM NUMBER] with a maintenance cart. He was observed to engage the window bed in conversation and he changed her T.V and set it up. The maintenance man did not don any PPE other than a surgical mask. Observation on the room door showed a pink isolation sheet indicating the PPE needed for that room was: gloves, gown, mask and goggles. During an interview with Staff P, Maintenance Assistant he said that he does not need to wear anything special to go into the room on this unit just his surgical mask. On 05/17/21 at 10:26 AM a staff person was observed to exit room [ROOM NUMBER], come down the hall to the nurses cart and ask the nurse for a pen. Interview with Staff Q, PT (physical therapist) confirmed that he left room [ROOM NUMBER] that was under isolation to speak to the nurse and did not remove his PPE before exiting the room. He reported that the facility had a positive Covid case about a week and a half to 2 weeks ago. On 05/17/21 at 10:53 AM an observation of Staff R, CNA revealed that she left room [ROOM NUMBER] dressed in full PPE (gown, gloves, face mask and goggles), walked down the hall and entered room [ROOM NUMBER]. She reported that she forgot to take off the PPE before exiting room [ROOM NUMBER] because she was in a rush to obtain a cell phone charger that was left in room [ROOM NUMBER]. On 05/17/21 at 12:26 PM observations revealed that Staff R, CNA left room [ROOM NUMBER] with full PPE on and when she saw this surveyor she went back into the room and took off the PPE. Observation on 05/17/21 at 12:32 PM with Staff N, CNA walked out of room [ROOM NUMBER] in full PPE, and took off her gloves and gown in the hallway and placed the soiled PPE in the regular garbage at the nurses station. Observation on 05/17/21 at 12:35 PM of Staff N, CNA walked out of room [ROOM NUMBER] with full PPE on. When she saw this surveyor, then stepped back into the room and took the PPE off. On 05/17/21 at 12:52 PM Staff N, CNA reported all isolation gowns should go into the garbage in the resident room. She reported that she always takes off the gown in the room but does not remember taking the gown off in the hallway and placing it in the garbage can at the nurses station. Interview on 05/17/21 at 12:58 PM with Staff O, RN (Registered Nurse), reported that staff should not be coming out of the isolation rooms with the isolation gowns on. She reported that gowns should be discarded in the trash can in the resident room prior to exiting the room. Observations on 05/17/21 at 01:15 PM of the 200 hall, a staff person was noted to enter room [ROOM NUMBER], then exit the room and then enter room [ROOM NUMBER]. He was observed to not be wearing any PPE other than a surgical mask. Interview with the staff revealed he was Staff S, Rehab Director. Interview with the staff at this time he reported that full PPE to include the isolation gowns and gloves should be worn when entering the rooms on this unit. He reported that he did not really go into the rooms he just stepped in, but did not reach all the way to the patient. On 05/19/21 at 08:42 AM an observation of a staff person was noted entering rooms [ROOM NUMBER] twice to retrieve meal trays, and then exiting the rooms with trays. The staff person did not don any PPE other than the surgical mask that she was wearing. Interview with the staff at this point revealed that she was Staff T, CNA from an agency and when asked what the pink sign posted on each of the doors meant she reported that it means to put on gown and shield and gloves but that she did not need that because she was not providing care she was only picking up the trays. The staff reported that she did not know what type of precautions were in place. Interview on 05/19/21 at 08:45 AM with Staff U, RN/unit manager revealed that all staff are to wear full PPE, gown, gloves, mask and goggles when entering resident rooms on the 200 hall. She reported that she will educate staff. Review of the facility policy titled Personal Protective Equipment-Using Gowns with a revised date of September 2010 under the sub-heading of Miscellaneous revealed the following: 1. Use gowns only once and then discard into an appropriate receptacle inside the exam or treatment room. 8. After completing the treatment or procedure , gowns must be discarded in the appropriate container located in the room. 10. Soiled gowns must not be worn in break rooms, lobbies, or into any area in which contamination of equipment is likely to occur.