Based on observations, staff interviews, and record review, the facility failed to ensure oxygen (O2) administered by nasal cannula (NC) was set at the prescribed rate for one of 19 residents (R) (R49) receiving O2 therapy. The deficient practice has the potential to cause respiratory distress for R49. Findings include: Review of the electronic medical record (EMR) for R49 in the Minimum Data Set (MDS) under Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Under the MDS Section J-Health Conditions revealed R49 has a condition or chronic disease that may result in a life expectancy of less than 6 months. The medical diagnoses include malignant neoplasm of body of pancreas, anemia, unspecified, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, essential (primary) hypertension, other seizures, pneumonia, unspecified organism. Review of a Physician Order with a start date of 4/7/2024 revealed Oxygen: Nasal Cannula (Oxygen: Nasal Cannula) 2 lt liter per Minute (LPM) nasally every 8 hours As Needed OTHER (document in order notes) 2Lt [sic] per minute via nasal cannula as needed for shortness of breath and/or o2 [sic] saturation below 90 for comfort. The care plan revealed Resident at risk for adjustment difficulty, limited mobility, self-care deficit, needs assistance participating in activities due to terminal diagnosis / end-of-life, and respiratory difficulties/ risk for further decline. Observation and interview on 4/9/2024 at 1:43 pm with R49, she was lying in bed, answering verbal questions with one word, talking softly. Her sister was at her bedside. O2 was on at 3 LPM via NC with no distress noted. Observation of wound care on 4/11/2024 at 10:10 am, R49 was on O2 at 3 LPM. The Resident was sleeping during the treatment with no distress noted. Interview on 4/11/2024 at 11:00 am with Licensed Practical Nurse (LPN) AA revealed R49 received morphine this morning that could be contributing to R49's lethargic state. LPN AA confirmed O2 at 3 LPM via NC was on R49, but the physician order states 2 LPM via NC. LPN AA turned the O2 down to 2 LPM. Interview on 4/11/2024 at 11:20 am with the Director of Nursing (DON) revealed they do not have a respiratory therapist; the nurses manage respiratory care. She expects the nurses to follow the physician's orders. Interview on 4/11/2024 at 5:22 pm with the Administrator revealed her expectations include getting the order right and providing the correct amount of O2 for the resident.

Based on observations, staff interviews, record review, and the document titled, Logbook Documentation, the facility failed to ensure the dryer lint trap and the vent located in the ceiling that circulates hot air from the dryer were not clean. This deficient practice has the potential to cause adverse consequences, including fire, for all residents residing in the facility. The census was 65. Findings include: Review of the Logbook Documentation dated 1/30/2024, 2/14/2024, and 3/7/2024 indicated the vent in the Laundry Room passed review. There was not a review for April 2024. The Maintenance Supervisor stated the review was done each month and the specific day of the month was determined by the last day of the review from the previous month. During a tour of the Laundry on 4/10/2024 at 1:30 pm with the Director of Nursing (DON) and Housekeeping BB revealed there were two dryers in the clean room; lint traps were not clean in these dryers. Housekeeping BB stated she cleaned the lint out of the bottom of the dryers every hour. The vent in the clean room that faces the dryer was there to circulate hot air from the dryer. There was dust located on the vent. There was one blanket and cloth lift slings lying directly below the vent. They were not covered. The Laundry staff stated Maintenance is responsible for cleaning the vent. Interview on 4/10/2024 at 2:00 pm with the Maintenance Supervisor, she stated Housekeeping cleaned the vent in the laundry dryer every hour. During observation of the large vent in the ceiling after being cleaned by the Maintenance Supervisor, there was an accumulation of dust seen on the vent. The Maintenance Supervisor confirmed there was still dust on the vent. She stated she will clean it again. Observation of the dryer indicated the lint trap had not been cleaned; there was still an accumulation of lint in the dryer.

Based on observation, interview, and facility policy review, the facility failed to ensure one of three medication carts were locked when not under the direct control of a licensed nurse. The failure could have led to residents or unauthorized staff having access to medications stored in the medication cart. Findings include: Observation of the 100-hall on 04/28/22 at 8:43 AM revealed an unlocked medication cart pushed against the wall with the drawers facing the hallway. The cart was against the wall to the right of Resident (R) 36's room with no nurse or medication aide in the area. Licensed Practical Nurse (LPN) 1 was observed down the hall entering R138's room with medications. LPN1 was away from the cart for four minutes, during which the cart was not under the direct supervision or sight of an employee with the qualifications to supervise a medication cart. At 8:47 AM on 04/28/22, LPN1 returned to her medication cart, she locked the cart as this surveyor approached her to conduct an interview. During the interview at 8:48 AM on the same day, LPN1 stated the cart should have been locked before she walked away from it. When asked why the cart had not been locked, she replied, I forgot to double check myself. LPN1 confirmed the cart should have been locked before she walked away to administer R138's medications or when she was not physically in the presence of the medication cart. During an interview on 04/28/22 at 9:32 AM, the Director of Nursing (DON) stated her expectation was that the medication cart should have been locked before LPN1 walked away to administer medications. The DON confirmed medication carts were to be locked when unattended or not under the direct supervision of the nurse or medication aide assigned to the medication cart. Review of the facility policy titled, Pharmacy Services Medication Administration-General with a copyright date of 2019 stated, . During routine administration of medications, the medication cart is kept locked or under direct observation of licensed staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview. and record review, the facility failed to have all personal protective equipment (PPE) readily available for staff use for one of one resident (Resident (R) 137) reviewed for transmission-based precautions. Additionally, PPE that was readily available was stored for use in the patient room where it could become contaminated. R137 was in quarantine due to being a new admission and unvaccinated for coronavirus disease 2019 (COVID-19). This failure had the potential to allow spread of infections, including COVID-19, to 22 residents on the first floor who were cared for by the same staff as R137. Findings include: During an observation on 04/25/22 at 10:30 AM, one resident (R137) was located in the COVID-19 quarantine unit. The quarantine unit was located on the first floor at the end of the hallway. The quarantine unit was blocked off from the other residents by a plastic wall with a doorway. There were three signs placed on R137's door stating, STOP Droplet Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or Remove face protections before room exit; STOP Contact Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person .; COVID-19 Personal Protective Equipment (PPE) for Healthcare Personnel Preferred - Use N95 of Higher Respirator Face shield or goggles, N95 or higher respirator, Isolation gown, one pair of clean non-sterile gloves . There was not any PPE or hand sanitizer located immediately outside of R137's room or in the hallway. The door to R137's room was open and on a table inside the room were several gowns. Surveyor looked in the adjacent two rooms and there was no PPE readily available for use. One of the rooms was being used as a storage room and had numerous boxes in it, but the surveyor was unable to determine what was in the boxes. Surveyor left the quarantine area to locate a staff member to discuss the lack of PPE in the quarantine unit. During an interview on 04/25/22 at 10:38 AM, with Licensed Practical Nurse (LPN) 2, when asked about the PPE on the quarantine unit, LPN2 noted there were some gowns in R137's room and stated additional PPE must be the adjacent room. LPN2 went into the adjacent room and looked around but could not locate PPE that was readily available for use. LPN2 acknowledged the PPE should be available to don prior to entering R137's room. LPN2 left the quarantine unit and returned carrying a PPE door hanging unit with filled with PPE but stated she did not have access to the stickers to enable her to hang the holder on R137's door. LPN2 left the unit and returned with a rolling bedside table and laid the door hanger on the table. Surveyor questioned how staff were to sanitize their hands prior to donning gloves (there was no sanitizer located in the hallway) and LPN 2 stated she would obtain the hand sanitizer. Surveyor questioned LPN2 who was responsible for placing the required PPE for a resident who was under quarantine, and she said replied, Anybody. During an interview on 04/25/22 at 10:45 AM, on the quarantine unit, the Director of Nursing (DON) said she was surprised the PPE had not been available for staff to don prior to entering R137's room. The DON stated there was a red cart stocked with PPE that should have been placed outside of R137's room and she did not know why the staff did not utilize the cart. The DON stated she was responsible to ensure that PPE was in place for use with a resident on the quarantine unit. Review of R137's EMR under the Face Sheet tab indicated R137 was admitted to the facility on [DATE] with the diagnoses of wedge compression fracture third lumbar vertebra, chronic bronchitis, age related osteoporosis, abnormalities of gait and mobility and underweight. Review of R137's EMR under the Orders tab indicated an order 04/24/22 droplet precautions 9 days, diagnosis: COVID screening, start date 04/24/22 end date 05/02/22 Review of R137's EMR under the Test Results tab revealed R137 received COVID-19 tests on 04/22/22 and 04/24/22 and both test results were negative. Review of the facility's policy titled, admission and Placement of Patients dated 02/22 stated, Purpose To provide guidance to centers regarding admission and readmission of patients during COVID-19 pandemic . Managing New admission and re-admission Patient Placement . 2. New admissions . whose COVID-19 status is unknown or not up to date on all recommended COVID_19 vaccine doses should be placed in the observation unit. 3. New admissions regardless of vaccination status should have a series of two viral test for SARS-Cov-2 infection; immediately . Review of the facility's policy titled Transmission-Based Precautions (Contact, Enhanced Barrier Precautions, Droplet, Airborne) dated 2020 stated, Intent It is the policy of this facility to use transmission-based precautions for patients who have infectious or communicable diseases that may necessitate the use of barriers in addition to those used for Standard Precautions . Contact Precautions This facility uses Contact Precautions . for patients with known or suspected infection . with highly transmissible . pathogens for which additional precautions are needed to prevent transmission . Use of PPE Gloves . Gowns . Droplet Precautions This facility uses Droplet Precautions as recommended . for patients with known or suspected to be infected with pathogens transmitted by respiratory droplets . Use of PPE . For patients with suspected or proven . pandemic influenza refer to the following websites for the most current recommendations at the time (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.Html . Review of the Centers for Disease Control and Prevention, above mentioned, website revealed COVID-19. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 Pandemic updated 02/02/22 indicated, . Personal Protective Equipment HCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).