**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled, Patient's Plan of Care, the facility failed to follow a care plan related to oxygen (O2) use for one of 23 residents (R) (R184). Specifically, the facility failed to ensure the care plan for R184 was followed pertaining to the rate of oxygen ordered. Findings included: Review of the facility's policy titled, Patient's Plan of Care dated 12/27/2024 revealed, Guideline: each patient will have a person-centered comprehensive care plan developed and implemented to address the patients' medical, physical, mental, and psychosocial needs while also honoring their preferences and goals. Procedure-The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. Review of the medical record for R184 revealed diagnoses including but not limited to chronic obstructive pulmonary disease, atrial fibrillation, heart failure, and dependence on supplemental O2. Review of the physician orders revealed an order for O2 dated 1/10/2025, Oxygen: nasal canula (NC) 2 liter per minute (LPM) nasally every 8 hours. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section O (Special Treatments and Programs) indicated R184 was receiving O2 therapy and hospice. Review of the care plan initiated on 1/10/2025, revealed that R184 had respiratory difficulties and risk for further decline, as evidenced by Oxygen: nasal canula (NC) 2 liters per minute nasally every 8 hours. Interventions: Administer medications and treatment as ordered. Observation and rounding on 1/30/2025 at 9:01 am with the Director of Nursing (DON) revealed the resident lying in bed receiving oxygen at a rate of three liters per minute (LPM). The DON confirmed the resident's oxygen to be on 3 LPM. The DON checked the electronic health record and confirmed the order was for 2 LPM. It is her expectation that staff review and follow care plan. Interview on 1/30/2025 at 3:50 pm with Minimum Data Set (MDS) Coordinator revealed her expectations of staff were to follow the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled, Patient's Plan of Care, the facility failed to revise a care plan related to oxygen (O2) use for one of 23 residents (R) (R184) receiving O2. Findings included: Review of the facility's policy titled, Patient's Plan of Care dated 12/27/2024 revealed, Procedure-The patient's care plan should be reviewed after each MDS assessment and revised based on changing goals, preferences and needs of the patient and in response to current interventions. The comprehensive care plan should also be updated as ongoing clinical assessments identify changes. Review of the physician orders revealed an order for O2 dated 1/10/2025 oxygen: nasal canula (NC) 2 liter per minute (LPM) nasally every 8 hours. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment. Section J (Health Conditions) indicated shortness of breath, and Section O (Special Treatments, Procedures, and Programs, indicated R184 was receiving O2 therapy. Review of the care plan, initiated on 1/10/2025, revealed that R184 had respiratory difficulties/risk for further decline, as evidenced by, Oxygen: nasal canula 2/LPM nasally every 8 hours. Interventions included: administer medications and treatment as ordered. Observation and rounding on 1/30/2025 at 9:01 am with the Director of Nursing (DON) revealed R184 lying in bed receiving O2 at a rate of 3/LPM. The DON confirmed the O2 was set on 3 LPM and confirmed the order was for 2 LPM. The DON revealed R184 was known to change the O2 rate. She accessed the care plan and verified R184 was not care planned for adjusting the O2 rate and should be. The DON revealed that her staff should be checking the O2 more frequently since R184 is known to adjust the rate. It was the DON's expectation that staff review and follow the care plan. The DON left the interview and later provided a revised care plan dated 1/30/2025 that included patient noted to adjust her own liter flow on O2, with no interventions added. Interview on 1/30/2025 at 3:50 pm with the Minimum Data Set (MDS) Coordinator revealed that nurses and different interdisciplinary team members contribute to the comprehensive assessment and individualize the care plan to fit the resident's ongoing needs. She revealed they have weekly and morning meetings and discuss updates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled, Use of Oxygen (O2) Therapy, the facility failed to ensure that the physician's order was followed for one of 23 Residents (R) (R184) reviewed for O2 administration. The deficient practice had the potential to place the resident at risk for medical complications related to O2 not being administered as ordered by the physician. Findings included: Review of the facility's policy titled, Use of Oxygen Therapy dated 12/27/2024, revealed under Guideline: Physician's order for O2 should be obtained and include: O2 with the flow as ordered. Review of the medical record for R184 revealed diagnoses including but not limited to chronic obstructive pulmonary disease, atrial fibrillation, heart failure, and dependence on supplemental O2. Review of the physician orders revealed an order for O2 dated 1/10/2025 Oxygen: nasal cannula (NC) 2 liter per minute (LPM) nasally every 8 hours. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating little to no cognitive impairment. Section J-shortness of breath and Section O-oxygen therapy and hospice. Observations on 1/28/2025 at 10:50 am, and on 1/29/2025 at 8:25 am, revealed R184 lying in bed receiving O2 therapy via NC at 3 LPM. Observation and rounding on 1/30/2025 at 9:02 am with the Director of Nursing (DON) revealed R184 lying in bed receiving O2 via NC at 3/LPM. The DON confirmed R184's O2 was set on 3 LPM. The DON checked the electronic health record and confirmed the O2 order was for 2/LPM. The DON revealed her expectation that staff followed physician orders.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Skilled Nursing Services: Transmission-Based Precautions, the facility failed to ensure staff applied (don) and removed (doff) Protective Personal equipment (PPE) appropriately for Droplet Precautions in two of 12 rooms. The deficient practice had the probability to increase the spread of infection to other residents in the facility. Findings included: A policy was requested but the facility did not have a policy to address doffing and donning PPE. Observation on 1/28/2025 at 3:00 pm revealed doffing (removing) receptacles outside the room filled with gowns, masks, gloves, and face shields. Certified Nurse Assistant (CNA) FF was observed leaving a droplet precaution room wearing gloves, face shield, mask, and gown. She then doffed PPE outside the room into a receptacle (wastebin). Interview on 1/28/2025 at 3:16 pm with CNA FF confirmed she was providing care to residents that were on droplet precautions and removed the PPE that was worn during care outside of the room door instead of inside. Interview on 1/30/2025 at 10:08 am with the Director of Nursing (DON) confirmed and verified she observed CNA FF leaving the droplet precaution room and removing the PPE outside the room. An interview on 1/30/2025 at 9:25 am with the Infection Preventionist confirmed and verified that she also observed CNA FF leave the room with PPE on. She stated her expectations were that PPE was to be doffed inside the room and the outside receptacles were for masks.

Based on observations, staff interviews, and review of the facility's policies titled, Storage Areas, and Personal Hygiene, the facility failed to discard food in the walk-in cooler by the expiration date and failed ensure dietary staff wore hair restraints while in the food prep area of the main kitchen. The deficient practice had the potential to effect 86 of 92 residents receiving an oral diet. Findings included: Review of the facility's policy titled, Storage Areas revealed, with a review date of 12/29/2023 revealed, Intent: It is the intent of this center to store food in a manner that maintains quality and safety. Guideline: Items should be inspected for quality and temperature control upon receipt. Items should be covered, sealed, labeled, and dated appropriately. Review of the facility's undated policy titled, Personal Hygiene revealed, Intent: It is the intent of this center to establish guidelines for dining and nutritional services associates that promote personal hygiene and infection prevention measures. Guideline: Hair restraints- a hairnet and/or beard restraint should be worn while in the food prep, production, and serving areas. During the tour of the kitchen on 1/28/2025 starting at 8:45 am with the Dietary Manager (DM), the following concerns were identified during the tour: Walk in cooler- A bag of lettuce with a received date of 1/17/2025 and an expiration date of 1/24/2025. A box of 17 potatoes, one that was green in color and several others that were rotting evidenced by them being black with a fuzzy white and dark brown substance. The potatoes had a received date of 12/24/2024 and an expiration date of 1/24/2025. Observation and interview on 1/28/2025 at 9:30 am with the DM confirmed the expired bag of lettuce, expired box of potatoes, and discarded them. She revealed that she and her staff were responsible for labeling and dating items when they are received, when opened, and when they are expired. The DM revealed her expectations for staff were to discard expired items and not leave them in the cooler, pantry, or freezer. Observation and interview on 1/29/2025 at 12:10 pm revealed Dietary Aide CC had a hairnet partially covering her head of hair. Dietary Aide CC's hair was tied up into a bun with only the bun being covered, exposing the rest of her hair. The corporate Registered Dietician confirmed that the dietary aide, and all kitchen staff, should have their entire head of hair covered and asked Dietary Aide CC to cover her entire head of hair. Observation and interview on 1/29/2025 at 12:55 pm revealed [NAME] DD with a hairnet partially covering her head of hair. Dietary Aide DD's hair was tied up into a ponytail with only the ponytail covered, exposing the rest of her hair. The DM confirmed that all hair should be covered and that it was her expectation that all staff while handling and serving food have their entire head of hair covered. She asked [NAME] DD to cover her entire head of hair with a hair covering.