Based on observations, staff interviews, and review of the facility's policy titled, Glucometer Disinfection, the facility failed to ensure proper infection control measures were followed for cleaning and disinfecting a glucometer (a device used to measure blood glucose) on one of one resident (R) (25) reviewed during a glucometer test. In addition, the nurse did not use a barrier before placing the glucometer on the surface of the medication cart. The deficient practices placed residents at risk of potential exposure to infections due to cross-contamination. Findings included: Review of the facility policy titled Glucometer Disinfection dated 9/28/2010 indicated Procedures: Disinfecting Instructions: To disinfect, use a germicidal disposable cloth to remove heavy soil, unfold a second clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full two minutes. Use additional wipes if needed to assure continuous two minutes. Use additional wipes if needed to assure continuous two minutes wet contact time. Let air dry. Glucometer must be disinfected before and after each using new wipes every time. Observation on 11/9/2024 at 12:05 pm of Licensed Practical Nurse (LPN) AA perform a blood sugar check and glucometer reading on R25. The LPN removed the glucometer from the medication cart and placed the glucometer on top of the medication cart without a barrier. The LPN gathered additional supplies and carried the supplies to the resident's room. After obtaining the residents blood sugar the LPN exited the room and placed the glucometer on the top of the medication cart without a barrier. The LPN wipe the glucometer with one alcohol pad and placed the glucometer in the top drawer of the medication cart. The LPN stated that is how the glucometer was cleaned after each use. Interview on 11/9/2024 at 12:10 pm the Director of Nursing Service (DNS) revealed the glucometer device should be cleaned with a germicidal disposable wipe. She also revealed a barrier must be used when placing the glucometer and supplies on any surface. The DNS revealed she would start educating staff on the proper way to disinfect the glucometer and use a barrier. Interview on 11/9/2024 at 2:35 pm the DNS revealed that the facility had five residents with a physician order for blood sugar reading. She revealed R25 had an order for a fingerstick blood sugar check. Four of the residents' blood sugar was obtained by using the continuous glucose monitor system (a wearable device that tracks blood sugar levels in real time). She revealed if the readings appeared to be inaccurate, or the sensor was not scanning, the alternative was to use the glucometer device to obtain the residents blood sugar.

Based on record review, staff interview, and review of the facility's policy titled, Use of Psychotropic Medication, the facility failed to ensure a stop date was implemented, not to exceed 14 days, for psychotropic medications for three residents (R) (R1, R29, and R7) of six residents reviewed for unnecessary medications. Findings included: Review of the facility's policy titled Use of Psychotropic Medication, revised 1/1/2024, revealed that if the attending physician or prescribing practitioner believed that it was appropriate for PRN (as needed) order to be extended beyond the 14 days, he or she shall document their rationale in the resident's medication and indicate the duration for the PRN order. 1. Review of Physician Orders dated 9/23/2024 for R1 revealed an order for Valium 1 mg by mouth (PO) daily as needed (PRN) for anxiety. The order had no end date. Review of Note to Attending Physician/Prescriber dated 5/1/2024 revealed the pharmacist sent a note to the prescriber regarding R1's diazepam 2 mg PRN for anxiety; indicated the CMS limitation of PRN psychoactive medications. The note stated all PRN psychotropic medication orders, even for Hospice patients, had a 14-day limit. The physician indicated he agreed and changed the order to 180 days, however, the order was not changed. A review of the Medication Administration Record (MAR) revealed R1 was administered Valium 1 mg PO on 9/15/2024 at 7:14 pm, 9/20/2024 at 10:17 am, 10/1/2024 at 10:00 pm, 10/2/2024 at 9:15 pm, 10/3/2024 at 9:18 pm, 10/4/2024 at 9:41pm, 10/7/2024 at 8:25 pm, 10/8/2024 at 8:53 pm, 10/9/2024 at 8:12 pm, 10/10/2024 at 9:36 pm, 10/12/2024 at 8:51 pm, 10/13/2024 at 9:00 pm, 10/14/2024 at 9:30 am, 10/16/2024 at 7:29 pm, 10/17/2024 at 8:30 pm, 10/18/2024 at 7:50 pm, 10/19/2024 at 2:05 pm, 10/20/2024 at 9:09 am, 10/21/2024 at 7:20 pm, 10/22/2024 at 8:12 pm, 10/23/2024 at 8:00 am, 10/24/2024 at 5:42 pm, 10/27/2024 at 8:00 pm, 10/28/2024 at 9:34 am, 10/30/2024 at 7:30 pm, 10/31/2024 at 7:30 pm, 11/4/2024 at 8:00 pm, 11/5/2024 at 8:00 pm, 11/6/2024 at 8:10 pm, and 11/7/2024 at 7:30 pm. 2. Review of Physician Orders dated 9/16/2024 for R29 revealed an order for Xanax 1 mg by mouth (PO) every eight hours as needed for anxiety. The order had no end date. Review of Note to Attending Physician/Prescriber dated 10/3/2024 revealed the pharmacist sent a note to the prescriber regarding R29's alprazolam 1 mg PRN for anxiety; indicated the CMS limitation of PRN psychoactive medications. The note stated all PRN psychotropic medication orders, even for Hospice patients had a 14-day limit. The physician indicated other and did not make a change to the medication on the form. Review of the Medication Administration Record (MAR) revealed R29 was administered Xanax 1 mg PO on 9/19/2024 at 9:15 pm, 9/20/2024 at 2:15 pm, 9/25/2024 at 7:05 pm, 9/27/2024 at 6:52 pm, 9/28/2024 at 8:16 pm, and 9/30/2024 at 8:28 pm, 10/2/2024 at 8:23 pm, 10/3/2024 at 8:56 pm, 10/4/2024 at 9:35 pm, 10/7/2024 at 8:27 pm, 10/8/2024 at 8:28 pm, 10/9/2024 at 4:18 pm, 10/10/2024 at 8:17 pm. 10/11/24 at 7:29 pm. 10/12/2024 at 8:00 pm, 10/13/2024 at 3:30 pm, 10/14/2024 at 10:09 pm, 10/15/2024 at 9:37 pm. 10/16/2024 at 8:00 pm, 10/17/2024 at 8:00 pm, 10/18/2024 at 8:54 pm, 10/20/2024 at 5:06 pm, 10/21/2024 at 8:36 pm, 10/22/2024 at 11:13 pm, 10/24/2024 at 5:00 pm, 10/26/2024 at 8:42 pm, 10/27/2024 at 8:00 pm, 10/28/2024 at 8:37 pm, 10/29/2024 at 8:00 pm, 10/30/2024 at 8:00 pm, 10/31/2024 at 8:00 pm, 11/4/2024 at 7:27 pm, 11/5/2024 at 8:00 pm, 11/6/2024 at 8:00 pm, and 11/7/2024 at 8:00 pm. 3. Review of Physician Orders dated 8/18/2024 for R7 revealed an order for Xanax 0.5 mg by mouth twice per day as needed for anxiety disorder due to known physiological condition. The order had no end date, and no duration indicated. Review of Note to Attending Physician/Prescriber dated 10/15/2024 revealed the pharmacist sent a note to the prescriber regarding R7's Xanax 0.5 mg PRN for anxiety. The note documented all PRN psychotropic medication orders, even for Hospice patients, had a 14-day limit. The physician indicated he agreed and changed the order to 120 days, however, the order was not changed and indicated no new orders. A review of the MAR revealed R7 was administered Xanax 0.5 mg by mouth PRN on 8/12/2024, 8/14/2024, 8/15/2024, 8/18/2024, 8/21/2024, 8/23/2024, 8/25/2024, 8/27/2024, 8/29/2024, 8/30/2024, 9/1/2024, 9/2/2024, 9/6/2024, 9/9/2024, 9/10/2024, 9/13/2024, 9/15/2024, 9/17/2024, 9/19/2024, 9/23/2024, 9/25/2024, 9/26/2024, 9/29/2024, 9/30/2024, 10/1/2024, 10/2/2024, 10/3/2024, 10/4/2024, 10/7/2024, 10/8/2024, and 10/10/2024. Interview with the Director of Nursing (DON) on 11/9/2024 at 9:00 am revealed that all psychotropic medications were supposed to have a 14-day stop date. If the medical doctor (MD) determined there was a clinical rationale to extend the medication beyond 14 days, the MD would write a progress note noting the clinical indication, and the note would be added to the resident's chart. Per the DON, she or the unit manager would add the indicated duration date to the orders and the MAR. The DON acknowledged there was no stop date for R1's, R29's, and R7's psychotropic medications.

Based on observations, interviews, and review of the facility's policy titled, Labeling Food Product, the facility failed to ensure that opened food items were labeled, dated, and secured from open air. The deficient practice had the potential to affect 34 residents who received an oral diet and were served food from the kitchen. Findings included: Review of the facility policy, Labeling Food Product, revised 1/3/2024, revealed that all prepared foods, leftovers and opened products stored for later use would be labeled according to food safety standards along with local and state regulations. All labels would contain the complete name of the product, the date the product was prepared or opened, and the date the product must be utilized by. Observation on 11/8/2024 at 8:16 am of the stand-alone freezer revealed the following: One box of [brand name] pork patties not secured, and the food was open to the air; one box of [brand name] pork links not secured and open to the air. Observation on 11/8/2024 at 8:20 am of the walk-in refrigerator revealed the following: One cinnamon spice cake opened and not labeled or dated; two boxes of chicken tenders open to the air and not labeled or dated; one open tray of tres leches cake covered in clear plastic wrap not labeled or dated. Observation on 11/8/2024 at 8:25 am of the walk-in freezer revealed the following: One package of bratwurst was opened, unlabeled, and undated; one box of [brand name] pork chops was opened and not labeled or dated; one clear plastic bag of grit balls was opened and not labeled or dated; one clear plastic bag of tortellini was opened and not labeled; one large plastic bag of pepperoni was opened and not labeled; one 9 round cheesecake covered in plastic wrap was not labeled or dated; one plastic bag of green beans was opened and not labeled or dated; one bag of battered okra was opened and not labeled or dated; and one bag of wheat rolls was opened and not labeled or dated. Observation on 11/8/2024 at 8:31 am of the stand-alone freezer in the main kitchen revealed the following: One clear plastic bag of French fries was opened and not labeled or dated; one clear plastic bag of broccoli was opened and not labeled or dated; one clear plastic bag of okra was opened and not labeled and dated; one clear plastic bag of hashbrown patties was opened and not labeled or dated; and one clear plastic bag of grit balls was opened and not labeled or dated. Observation on 11/8/2024 at 8:34 am of the stand-alone refrigerator on the front line revealed the following: One bag of [brand name] Bread was opened and not labeled or dated; opened salmon dip covered in clear plastic wrap was not labeled or dated; and one small pan of chutney covered in a clear plastic wrap was not labeled or dated. Interview on 11/8/2024 at 8:40 am, with the Executive Chef (EC) revealed that dietary staff were supposed to label and date all opened and prepared food items stored in the refrigerators and freezers. Interview on 11/8/2024 at 10:43 am the Dietary Manager (DM) revealed that he expected dietary staff to ensure all items stored in the freezers and refrigerators were covered and secured from the open air. Additionally, he said all staff was supposed to make sure all prepared and opened foods stored in the freezers and refrigerators were labeled and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Resident Self-Administration of Medication, the facility failed to assess one resident (R) R#11 sampled for the ability to self-administer medications prior to leaving medications at the bedside. The deficient practice had the potential to allow access to medications otherwise not prescribed by a physician to other residents. Findings include: Review of the facility policy titled, Resident Self-Administration Medications revised date 11/11/2022 revealed: Policy: It is the policy of Spring Harbor to support each resident's right to self-administer medication. A resident may only self-administer medications after the Spring Harbor's interdisciplinary team has determined which medications may be self-administered safely. 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by Spring Harbor's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following: a. The medications appropriate and safe for self-administration, g. The resident's ability to ensure that medication is stored safely and securely. 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration assessment Form, which is placed in the resident's medical record. 5. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the Medication Administration Record (MAR). 8. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of policy and procedures regarding resident self-administration when necessary. Observation on 6/2/2023 at 8:36 a.m. of R#11's room revealed one bottle of Mylanta sitting on the bedside dresser. An interview with R#11 revealed the nurse normally leaves the medication for him to take when he desires. Further observation of the bedside table revealed one (1) container of VapoRub, one (1) bottle of Vicks [NAME] Severe Nasal Decongestant, one (1) bottle of Clear Eyes lubricant eye drops, and one (1) container of Penetrex Intensive Concentrate Roll-on Gel Joint & Muscle Therapy. Observation on 6/3/2023 at 9:35 a.m. in R#'11's room revealed the bottle of Mylanta, container of VapoRub, bottle of Vicks [NAME] Severe Nasal Decongestant, bottle of Clear Eyes lubricant eye drops, and container of Penetrex Intensive Concentrate Roll-on Gel Joint & Muscle Therapy continues to be present in residents' room. Observation and interview on 6/3/2023 at 1:27 p.m. with R#11 revealed resident stated he had taken a sip of the Mylanta for occasional indigestion. R#11 told surveyor, he has neuropathy in his foot and ordered the joint cream off the internet, he uses the [NAME] nasal spray at night before he goes to sleep for allergies, his eyes were bothering him a couple of weeks ago so he started self-administering the eye lubricant, he has sinus headaches from time to time, so he applies a small amount of the VapoRub on his forehead to relieve his headache. R#11 further stated that the facility's staff is aware of the medications in the room, and he is allowed to have the medications because it is over the counter stuff. During an interview on 6/3/2023 at 1:30 p.m. with Certified Nurse Aide (CNA) BB revealed that she only enters R#11's room to make his bed because resident is able to perform his own ADLs at this time. CNA BB also stated that she did not notice any medications in residents room today. During an interview on 6/3/2023 at 1:39 p.m. with Registered Nurse (RN) AA revealed that R#11 uses nasal spray, and she has it on her medication cart. RN AA further stated that resident does not have orders to keep medications at bedside and should not have medications in his room. RN AA also stated that she had been in the residents' room several times on 6/2/2023 and today and she did not observe any medications in his room. During an interview and observation on 6/3/2023 at 1:48 p.m. with RN AA and Director of Nursing (DON) verified medications in resident's room. DON stated currently there is not a resident residing in the facility who had been assessed and deemed appropriate to self-administer medications. DON further stated that there should not be any medications at resident's bedside. DON further stated that the process of allowing residents to self-medicate involves the licensed nurse completing the self-medication form, obtaining an order from the physician, and updating the plan of care. DON stated that she has only worked at the facility for 4 weeks and conducted daily rounds and had not seen the medications. DON stated R#11 had the ability to order stuff and have sent to the facility himself. DON reviewed the electronic and paper record and was unable to locate any orders or a form to self-administer medications. DON and RN AA also confirmed R#11 did not have a physician order for the medications located at resident's bedside. Record review of the Electronic Medical Record (EMR) for R#11 revealed diagnosis including but not limited to type 2 diabetes mellitus, sleep apnea, displaced fracture of condyle of right femur, and morbid (severe) obesity due to excess calories. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating R#11 was cognitively intact, and required limited to extensive assistance with activities of daily living (ADLS). Resident received an antidepressant seven of seven days. Review of the physician's orders revealed medication orders to include: Amiodarone tablet 100 milligrams (mg) take one tablet by mouth daily, orig. date 2/13/2023, amlodipine 10 mg tablet take 1 tablet by mouth daily, orig. date 2/13/2023, aspirin adult low strength 81 mg take 1 tablet by mouth daily, orig. date 2/13/2023, atorvastatin 20 mg tablet take 1 tablet by mouth at bedtime, orig. date 2/13/2023, calcium 500 mg tablet take 1 tablet by mouth twice daily, orig. date 3/28/2023, carvedilol 12.5 mg tablet take one tablet by mouth twice daily, orig. date 4/20/2023, doxazosin mesylate 4 mg take 1 tablet by mouth twice daily orig. date2/13/2023, Eliquis 2.5 mg take 1 tablet by mouth daily orig. date 2/13/2023, gabapentin 300 mg capsule take one capsule by mouth twice daily orig. date 2/13/2023, hydralazine 10 mg tablet take one tablet by mouth every eight hours orig. date 6/1/2023, hydrocortisone 2.5% cream apply on left arm on red and itchy sores for seven days twice daily orig date 6/2/2023, Insulin Lispro 100U/ML KWIKPEN Inject 7 units three times daily with meals orig. date 3/28/2023, Lantus Solostar. Inject 10 units subcutaneously at bedtime orig. date 4/13/2023, pantoprazole 40 mg tablet take one tablet by mouth at bedtime orig. date 2/13/2023, senna plus 8.6-50 mg tablet give 2 tablets by mouth twice daily orig. date 5/8/2023, Thera-M tablet take one tablet by mouth every morning orig date 2/13/2023, Venlafaxine ER 75 mg capsule take one capsule by mouth daily orig date 2/13/23, Victoza Pen 18 MG/3 ML. Inject 1.8 mg (0.3 ml) subcutaneously daily orig date 2/13/2023, vitamin B-12 1000 mcg tablet take one tablet by mouth daily orig date 2/13/2023, vitamin D3 125 mcg capsule take one capsule by mouth daily orig date 2/13/2023, vitamin D3 50,000 mcg take one capsule by mouth every week orig date 5/23/2023, acetaminophen 325 mg tablet take 2 tablets by mouth every 4 hours as needed for pain orig date 2/13/2023, bengay ultra-strength cream 45 cream apply 2 grams to affected areas on right lower leg every 6 hours as needed orig date 5/29/2023, guaifenesin AC 100-10 mg/5 ml syrup give 10 ml by mouth every 6 hours as needed for congestion and cough orig date 3/31/2023, Ipratropium-albuterol 0.5-2.5 (3) MG/ 3ML Soln Inhale 1 vial every 6 hours as needed for shortness of breath and wheezing orig date 3/31/2023, Oxycodone/APAP 5/325 Take 1 tablet by mouth every eight hours as needed for pain orig date 5/23/2023, polymethyl glycol powder take 17 gm by mouth once per day as needed for constipation orig date 2/13/2023. There was not a physician's order for the medications which were observed at bedside. Review of the clinical record revealed there was no assessment for medication self-administration. During an interview on 6/4/2023 at 9:30 a.m. with R#11 revealed he was not asked or has not been assessed to be able to self-administer medications.

Based on observations, staff interviews, record review, and a review of the facility's policies titled, CPAP/BIPAP Cleaning, and Nebulizer Therapy the facility failed to ensure oxygen equipment was properly stored while not in use and failed to have a current physicians order for Continuous Positive Airway Pressure (CPAP) for one (1) of Four (4) residents (R) (#11) receiving treatment for respiratory care. The deficient practice had the potential to increase the probability of respiratory infection for R#11 by not properly storing oxygen equipment when not in use. Findings include: Review of policy titled, Nebulizer Therapy revised 7/11/2022, Policy Explanation and Compliance Guidelines: 16. Disassemble and rinse the nebulizer with sterile or distilled water and allow it to air dry. Care of the Equipment: 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 5. Shake off excess water. 6. Air dry on an absorbent towel. 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag. Review of policy titled CPAP/BiPAP Cleaning revised 7/11/2022, Policy Explanation and Compliance Guidelines: 2. Respiratory therapy equipment can become colonized with infectious organisms and serve as a source of respiratory infections. 6. Clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. Review of the clinical record for R#11 revealed he was admitted to the facility with diagnoses including but not limited to sleep apnea and morbid (severe) obesity due to excess calories. Record review of the June 2023 Physician orders for R#11 revealed an order dated 3/31/2023 for ipratropium-albuterol 0.5-2.5 mg(milligrams) /3ml (milliliters) SOLN inhale 1 vial every six hours as needed for shortness of breath and wheezing. Further review of the physician orders revealed there was not a current physicians order for the CPAP which resident was using. Record review of R#11's June 2023 Medication Administration Record (MAR) from 5/1/2023 through 5/31/2023 and 6/1/2023 through 6/3/2023 revealed there was not a physician's order for the CPAP. Observation on 6/2/2023 at 8:36 a.m. and 6/3/2023 at 9:35 p.m. of R#11's room revealed a CPAP on the bedside dresser alongside of the bed with the mask lying on the table not properly bagged while not in use. Further observation revealed a nebulizer on the floor beside the bedside dresser. Observation and interview on 6/3/2023 at 1:27 p.m. with R#11 revealed he further stated he uses the CPAP at night, every night, for sleep apnea and has used it for the last 12 years. R#11 further stated he previously had a touch of pneumonia and used the nebulizer for a while to help with that. During an interview on 6/3/2023 at 1:39 p.m. with Registered Nurse (RN) AA revealed she is aware R#11 uses the CPAP at night, but she was not aware that resident did not have a current physicians order for the CPAP usage. RN AA told surveyor that the nebulizer should not be on the floor at any time and the CPAP mask should be cleaned and stored in a plastic bag when not in use. During an interview on 6/3/2023 at 1:48 p.m. with the Director of Nursing (DON) she verified the CPAP mask not being properly stored while not in use and the nebulizer on the floor. DON stated there should be an order for the CPAP and the mask should be bagged when not in use and the nebulizer should not be stored on the floor at any time.

Based on record review, staff interviews, and review of the facility policies titled, Infection Prevention and Control Program and Antibiotic Stewardship Program, the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices, and to document follow-up measures in response to the data for 11 of 12 months of infection control data reviewed (May 2022 through April 2023). The deficient practice had the potential to affect any resident who was prescribed an antibiotic. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program with a revision date of 11/11/2022 Antibiotic Stewardship: a. An antibiotic stewardship program will be implemented as part of the overall infection prevention and control program. b. Antibiotic use protocols and a system to monitor antibiotic use will be implemented as part of the antibiotic stewardship program. c. The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the antibiotic stewardship program. d. The Medical Director, consultant pharmacist, and laboratory manager will serve as resources for the antibiotic stewardship program. Review of the facility's policy titled, Antibiotic Stewardship Program with a revision date of 11/11/2022 reads it is the policy of Spring Harbor to implement an Antibiotic Stewardship Program as part of Spring Harbor's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. 4. The program includes antibiotic use protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess residents who suspected to have an infection and notify the physician. ii. Laboratory testing shall be in accordance with current standards of practice. b. Monitoring antibiotic use: i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated, or adjustments should be made. ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to Spring Harbor shall be reviewed for appropriateness. iii. Antibiotic orders obtained from counseling, specialty, or emergency providers shall be reviewed for appropriateness. iv. Monitor during each monthly medication regimen review when the resident has been prescribed or is taking an antibiotic or any antibiotic regimen review. Review of the facility's Infection Monitoring Logs revealed that they did not capture information monthly that included the resident's name; room number; date of S/S (signs and symptoms); I/C (infection control) Cat. (category); and ABT Tx (antibiotic treatment). Further review of these monthly line listings revealed that they did not contain information such as the resident's signs and symptoms; if a culture or x-ray was done; and if the organism was sensitive to the ordered antibiotic. There was not a line listing of the antibiotics/infections, no mapping of infections, and the facility's infection rate was not calculated for months May 2022 through April 2023. During an interview on 6/3/2023 at 1:16 p.m. with Infection Control Preventionist (ICP) it was revealed that she is new to the position at the facility. She further stated that she consults with the Director of Nursing (DON) for guidelines related to the facility's policy and protocol related to the infection control practices and the Antibiotic Stewardship Program. During interview, ICP stated that she was aware that prior to her coming to the facility mid-April 2023 there were not any infection assessment tools to assess the minimum criteria for initiation of antibiotics. She further reported that the Physician and nurses should have looked at the resident's signs and symptoms, vital signs, lab reports, etc. before ordering an antibiotic, but she has been unable to locate any documentation of this. The Infection Control Nurse stated during continued interview that the pharmacy provides the facility with a monthly report that included antibiotic usage. During an interview on 6/3/2023 at 2:09 p.m. with DON revealed that she was not aware that the Infection surveillances and monthly calculations rates were not being done. DON further stated that she has only worked at the facility for four 4 weeks. DON stated that it is her expectation that residents should be monitored, signs and symptoms documented, and followed up with any labs or diagnostic test completed, and followed up with the physician.

Based on observation, interviews, record review, and review of the facility policy titled, Comprehensive Care Plan the facility failed to develop a comprehensive care plan related to use of oxygen for one resident (R) (#2) of 13 residents sampled. Findings include: Review of the facility policy titled, Comprehensive Care Plan effective date 4/20/2021 revealed '6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented as needed.' Review of the admission Minimum Data Set (MDS) for R#2 dated 11/2/2021 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Diagnoses include but not limited to metastatic prostate cancer, colon cancer, and benign prostatic hyperplasia. Section O - Special Treatments and Programs revealed oxygen therapy was documented/marked. Review of the Physician Orders for R#2 revealed an order dated 10/22/2021 for 'O2 (oxygen) via NC (nasal canula) to keep sats (oxygen saturation) above 92% and change oxygen tubing every Wednesday night. Review of the comprehensive care plan completed 11/9/2021 did not reveal a care plan for oxygen use or respiratory diagnoses. During an observation on 11/30/21 at 9:10 a.m. R#2 was observed lying in bed with oxygen (O2) via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an observation on 12/1/21 at 11:04 a.m. R#2 was observed lying in bed with O2 via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an observation on 12/2/21 at 7:52 a.m. R#2 was observed lying in bed with O2 via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an interview on 12/2/21 at 10:25 a.m. with MDS/Care Plan Coordinator confirmed R#2 did not have a care plan for oxygen. During an interview on 12/2/21 at 10:27 a.m. with Director of Nursing revealed she expects resident care plans to reflect current conditions. Further revealed R#2 should have a care plan to address his oxygen use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility policy titled, Comprehensive Care Plan the facility failed to revise the comprehensive care plan related to advance directives for one of 13 residents (R#2). Findings include: Review of the facility policy titled, Comprehensive Care Plan revealed: 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Review of the admission Minimum Data Set (MDS) for R#2 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact and diagnoses including but not limited to metastatic prostate cancer, colon cancer, and benign prostatic hyperplasia. Section J - Health Conditions revealed J1400-Prognosis revealed resident has a condition or chronic disease that may result in a life expectancy of less than six months. Section O - Special treatment and programs revealed resident receiving hospice services. Review of a Hospice care plan dated [DATE](from the hospice provider) revealed a care plan for: Patient experiences peaceful death with dignity and symptoms managed within limits of disease process-dyspnea, pain, anxiety. Interventions include do not resuscitate. Review of 'Report Sheet' dated [DATE] revealed R#2's code status was Do Not Resuscitate (DNR). Review of the 'Profile Face Sheet' dated [DATE] revealed a Living Will, No CPR/DNR. Review of Living Will located in the resident's chart dated [DATE] revealed resident wants natural death to occur without intervention. However, review of the facility's care plan for R#2 dated [DATE] revealed a care plan for 'Advance Directives' with approaches that included: Social Services will place MPOA and living will on chart; Communicate resident's living will/advance directives to interdisciplinary team; resident does wish to be resuscitated. During an interview on [DATE] at 9:39 a.m. with the Social Worker revealed R#2 had recently reinstated his Living Will. States she is responsible to update this information on the care plan and in the electronic health record. Review of R#2 medical records did not reveal documentation that R#2 revoked his Living Will.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of the facility policy titled, Oxygen, the facility failed to ensure that physician's orders were followed for one of two residents (R) #2 receiving oxygen therapy. Findings include: Review of the facility policy titled, Oxygen effective 4/20/21 revealed 'Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician, except in the case of an emergency 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon resident's assessment and orders. Record review revealed R#2 was admitted to the facility on [DATE] with diagnoses including but not limited to metastatic prostate cancer, colon cancer, and benign prostatic hyperplasia. Review of the admission Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating intact cognition. Section O - Special Treatments and Programs revealed oxygen therapy documented/marked. Review of the physician orders for R#2 dated 12/1/21 revealed an order for O2 (oxygen) via NC (nasal canula) to keep sats (oxygen saturation) above 92% for diagnosis of hypoxia. Further review revealed there was no order for a flow rate for the oxygen. During an observation on 11/30/21 at 9:10 a.m. R#2 was observed lying in bed with oxygen (O2) via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an observation on 12/1/21 at 11:04 a.m. R#2 was observed lying in bed with O2 via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an observation on 12/2/21 at 7:52 a.m. R#2 was observed lying in bed with O2 via nasal canula at 2 liters per minute from a concentrator located at the bedside. During an interview on 12/2/21 at 10:22 a.m. with Registered Nurse Unit Manager (UM) confirmed the physician order did not specify a flow rate for R#2's oxygen. UM stated the order should specify a flow rate and this should have been clarified on admission.