**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled Urinary Catheter Care, the facility failed to ensure urinary catheter drainage bags were covered to protect the dignity of two of four sampled residents (R) (R71 and R94) with indwelling urinary catheters. This failure had the potential to diminish R71 and R94's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A review of the facility's policy titled Urinary Catheter Care, revised 12/27/2023, revealed 2. Catheter tubing and bag: d. Use a catheter bag cover to protect the resident's dignity. 1. A review of R71's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section H (Bladder and Bowel) documented the resident did not have an indwelling urinary catheter. A review of the Physician's Orders revealed an order dated 9/14/2024 for a urinary catheter and catheter care every shift. A review of the comprehensive care plan revealed a focus area for an indwelling urinary catheter with a diagnosis of neuromuscular dysfunction of the bladder. An observation on 9/17/2024 at 11:49 am revealed R71 lying in bed with a catheter drainage bag uncovered, exposing R71's urine to other residents and visitors During an interview and observation on 9/19/2024 at 10:10 am, Licensed Practical Nurse (LPN) BB confirmed that R71's urinary catheter drainage bag was not in a privacy bag. 2. A review of R94's Quarterly MDS dated [DATE] revealed section H (Bladder and Bowel) documented that R94 had an indwelling urinary catheter. A review of the Physician's Orders revealed an order dated 9/9/2024 to change the urinary catheter every month. A review of the comprehensive care plan revealed a focus area for an indwelling urinary catheter with diagnoses of benign prostatic hyperplasia and obstructive and reflux uropathy. Observations on 9/17/2024 at 11:21 am and 9/18/2024 at 8:52 am revealed R94 lying in bed with a urinary catheter drainage bag uncovered, exposing R94's urine to other residents and visitors. During an interview and observation on 9/19/2024 at 10:10 am, LPN BB confirmed that a privacy bag was not on R94's urinary catheter drainage bag on 9/17/2024 or 9/18/2024 and revealed she placed the privacy cover over the catheter drainage sometime on 9/18/2024. LPN BB stated urinary catheter drainage bags should be in a privacy bag. In an interview on 9/19/2024 at 10:30 am, the Assistant Director of Nursing (ADON) AA revealed that all residents with urinary catheters should have the drainage bag in a privacy bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to implement care plan interventions for two of 48 sampled residents (R) (R94 and R66). This failure had the potential for R94 and R66 to not receive treatment and/or care according to their needs. Findings include: 1. A review of R94's medical record revealed diagnoses included but was not limited to, pulmonary disease. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section O (Special Treatments, Procedures, and Programs) documented that R94 received oxygen while a resident. A review of the care plan revealed that R94 received oxygen therapy and had diagnoses of chronic obstructive pulmonary disease (COPD) and asthma. Interventions included oxygen as ordered. A review of the Physician Orders revealed an order dated 9/9/2024 to check oxygen saturation and apply oxygen at 2 liters per minute (LPM) via nasal cannula (NC) for oxygen saturation below 92 percent. Observation on 9/17/2024 at 12:05 pm and 9/18/2024 at 8:52 am revealed R94 was receiving oxygen at 3 LPM. In an interview on 9/19/2024 at 10:10 am, Licensed Practical Nurse (LPN) BB verified R94's physician's order for oxygen at 2 LPM and verified the oxygen was set on the wrong flow rate. She confirmed that R94's care plan included administering oxygen as ordered by the physician and that if the oxygen was not administered as ordered, staff were not following the resident's care plan. 2. A review of R66's medical record revealed diagnoses included but was not limited to, hypertension. A review of the Quarterly MDS dated [DATE] revealed Section O (Special Treatments, Procedures, and Programs) documented that R66 received oxygen while a resident. A review of the care plan revealed the resident had hypertension. Interventions included administering oxygen as ordered. A review of R66's Physician's Orders revealed an order dated 3/25/2024 for oxygen at 2 LPM via NC as needed for shortness of breath. Observations on 9/17/2024 at 3:00 pm, 9/18/2024 at 10:41 am, and 9/19/2024 at 8:49 am revealed that R66 was receiving oxygen with the flow rate set above 3 LPM. In an interview on 9/19/2024 at 10:24 am, LPN CC verified R66's physician's order for oxygen at a rate of 2 LPM. She confirmed that R66's oxygen flow rate was above 3 LPM. She confirmed that R94's care plan included administering oxygen as ordered by the physician and that if the oxygen was not administered as ordered, staff were not following the resident's care plan. In an interview on 9/19/2024 at 3:40 pm, MDS Coordinator FF stated nursing staff was responsible for ensuring resident care plans were followed. Cross-Reference F695

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Therapy, the facility failed to ensure that two of 48 sampled residents (R) (R94 and R66) were administered oxygen therapy in accordance with the physician orders. This failure had the potential to affect the necessary respiratory care and services that are in accordance with professional standards of practice. Findings include: A review of the facility policy titled Oxygen Therapy, dated 12/28/2023, revealed the Purpose section included 1. There must be a physician's order for oxygen use which includes the route and liter flow or specific oxygen concentration and how long the oxygen is to be administered. 5. The Unit Nurse must instruct staff members that they must not . c. change the flow rate of the oxygen. 1. A review of R94's medical record revealed diagnoses included but was not limited to, pulmonary disease. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section O (Special Treatments and Programs) documented that R94 received oxygen while a resident. A review of the Physician Orders revealed an order dated 9/9/2024 to check oxygen saturation and apply oxygen at 2 liters per minute (LPM) via nasal cannula (NC) for oxygen saturation below 92 percent. Observation on 9/17/2024 at 12:05 pm and 9/18/2024 at 8:52 am revealed R94 was receiving oxygen at 3 LPM. In an interview on 9/19/2024 at 10:10 am, Licensed Practical Nurse (LPN) BB verified R94's physician's order for oxygen at 2 LPM and verified the oxygen was set on the wrong flow rate. She stated the medication nurses were responsible for checking the oxygen flow rates daily to ensure the flow rate was correct. 2. A review of R66's medical record revealed diagnoses included but was not limited to, hypertension. A review of the Quarterly MDS dated [DATE] revealed Section O (Special Treatments and Programs) documented that R66 received oxygen while a resident. A review of R66's Physician's Orders revealed an order dated 3/25/2024 for oxygen at 2 LPM via NC as needed for shortness of breath. Observations on 9/17/2024 at 3:00 pm, 9/18/2024 at 10:41 am, and 9/19/2024 at 8:49 am revealed that R66 was receiving oxygen with the flow rate set above 3 LPM. During an interview and observation on 9/19/2024 at 10:24 am, LPN CC verified R66's physician's order for oxygen at a rate of 2 LPM. She confirmed that R66's oxygen flow rate was above 3 LPM and adjusted the rate to 2 LPM. She stated risks to the resident when receiving the wrong oxygen flow rate included breathing and heart rate problems. In an interview on 9/19/2024 at 10:30 am, Assistant Director of Nursing (ADON) AA revealed that she expected nursing staff to check oxygen rates frequently. She further stated she expected all oxygen flow meters to be set at the rate prescribed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled, MDS: OBRA Assessments the facility failed to develop a person-centered care plan related to oxygen use for one of three residents (R) (R#113). Specifically, the facility failed to ensure that a care plan was developed for R#113 pertaining to the prn use of oxygen therapy. Findings include: Review of facility policy titled, MDS: OBRA Assessments dated 10/3/2022 under procedures 7. The information gathered for the OBRA assessments will be used to develop, revise, and review each resident's individual plan care. Record review for R#113 revealed resident was admitted to the facility with the diagnoses not all inclusive of obesity, chronic obstructive pulmonary disease, Occlusion and stenosis of unspecified carotid artery, hypokalemia, and anemia. Review of the physicians' orders dated 3/6/2023 revealed oxygen at (2) liters per minute via nasal cannula as needed for shortness of breath, oxygen filter washed with soap and water. Wipe down the outside machine with sanitizer as needed every Sunday night shift 7P- 7A, if used on the past week. There was no indication on R#113 plan of care pertaining to oxygen use. Minimum Data Set (MDS) Quarterly assessment dated [DATE] Section C (Cognitive Patterns) C0500 Brief interview for Mental Status (BIMS) score was 14 indicating resident was cognitively intact. Section O (Special treatments) indicated the resident was receiving oxygen therapy during the seven day look back period for assessment. Review of residents' weights and vitals summary report for March 2023, April 2023, and May 2023 for R#113 revealed resident used oxygen on the following dates since order was obtained. 3/22/2023, 3/23/2023, 3/25/2023, 3/26/2023,3/27/2023, 4/13/2023, 4/19/2023, 4/22/2023, 4/23/2023. A follow-up interview on 5/5/2023 at 12:15 p.m. with Minimum Data Set (MDS) Coordinator revealed that R#113 has an order for oxygen at 2 liters per minute as needed and has been using it sometimes at night. The dates the resident used the oxygen therapy were 4/24/2023, 4/27/2023, 4/28/2023, 5/2/2023, 5/3/2023, and 5/5/2023. The continued interview also revealed that if the resident is not routinely using oxygen, then a care plan would not be initiated for that care area and that R#113 did not have a care plan for oxygen use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to ensure oxygen equipment was properly clean and stored when not in use for two (2) of 50 residents (R) (R#113, and R#159). The deficient practice had the potential to increase the probability of R#113, and R#159 of contracting respiratory infections. Findings include: Record review for R#113 revealed resident was admitted to the facility with the diagnoses not all inclusive of obesity, chronic obstructive pulmonary disease, Occlusion and stenosis of unspecified carotid artery, hypokalemia, and anemia. Review of the physicians' orders revealed oxygen at (2) liters per minute via nasal cannula as needed for shortness of breath, oxygen filter washed with soap and water. Wipe down the outside machine with sanitizer as needed every Sunday night shift 7P- 7A, if used on the past week. There was no indication on R#113 plan of care pertaining to oxygen use. Minimum Data Set (MDS) Quarterly assessment dated [DATE] Section C (Cognitive Patterns) C0500 Brief interview for Mental Status (BIMS) score was 14 indicating resident was cognitively intact. Section O (Special treatments) indicated the resident was receiving oxygen therapy during the seven day look back period for assessment. 1. Observation on 4/25/2023 at 11:38 a.m. revealed R#113 oxygen concentrator tubing was not being stored in bag while not in use. Observation on 4/26/2023 at 8:59 a.m. revealed R#113 oxygen concentrator not in use with nasal cannula tubing lying on the floor and not covered. Observation on 4/27/2023 at 8:45 a.m. revealed R#113 oxygen concentrator not in use with nasal cannula tubing lying on the floor and not covered. Interview on 4/27/2023 at 10:15 a.m. during walking rounds with an Assistant Director of Nursing (ADON) AA, confirmed that oxygen was lying on the floor and not properly stored. A further interview also revealed that if it falls on the floor, they need new tubing. During the interview it was disclosed that the facility currently does not have a policy for storing oxygen equipment. 2. Record review for R#159 revealed resident was admitted to the facility with the diagnoses not all inclusive of Pulmonary fibrosis, Malignant neoplasm, dependence on supplemental oxygen, shortness of breath, and chronic obstructive pulmonary disease. Review of resident physicians' orders revealed continuous oxygen at 3 liters per minute via nasal cannula. Review of Quarterly MDS assessment dated [DATE] section C0500 revealed a BIMS score of 15 indicating resident was cognitively intact. Section O (Special treatments) indicated the resident was receiving oxygen therapy during the seven day look back period for assessment. Observation on 4/25/2023 at 10:36 a.m. revealed R#159's oxygen tank filter dirty, nebulizer machine on floor uncovered, portable oxygen tank has an exposed nasal cannula. Observation on 4/26/2023 at 8:42 a.m. revealed oxygen tank filter dirty, nebulizer machine on floor uncovered, and portable oxygen tank with an exposed nasal cannula. Observation on 4/27/2023 at 9:15 a.m. revealed oxygen concentrator filter was dirty, nebulizer machine on floor uncovered, and portable oxygen tank with an exposed nasal cannula. Interview on 4/27/2023 at 1:00 p.m. with Licensed Practical Nurse (LPN) EE revealed she was responsible for maintenance and cleaning of equipment. She mentioned the resident always refuses her assistance, but she failed to document it. She further revealed care orders were changed to PRN since the resident does it herself now and the portable oxygen tank personally belongs to the resident, and it was brought to the facility by a family member. Interview on 4/27/2023 at 10:45 a.m. with the Administrator revealed there was not a policy for storing respiratory equipment when not in use, but Best practice is to store items in a plastic bag and hang at the head of the bed. Interview on 4/27/2023 at 1:20 p.m. with DON and Administrator confirmed the nurse assigned to that resident's hall is responsible for the maintenance and cleaning of the oxygen concentrator filter, ensuring the nebulizer machine is stored properly when not in use, and ensuring that the oxygen tubing is stored in a bag when not in use.

Based on observation, staff interviews, and review of facility policy titled, Infection Preventionist the facility failed to designate at least one qualified Infection Preventionist (IP), who is responsible for the facility's Infection Prevention, Control & Immunizations (IPCP). Findings include: Review of facility policy titled, Infection Preventionist revised 9/16/2021 indicated Policy Statement: The Infection Preventionist is responsible for coordinating the implementation and updating of our established infection prevention and control policies and practices. An observation on 4/27/2023 at 11:00 a.m. revealed the facility does not have a designated Infection Preventionist (IP) nurse. An interview with Director of Nursing (DON) and Administrator on 4/27/2023 at 11:10 a.m. also confirmed the facility does not have a qualified IP nurse. Further interview with Administrator on 4/27/2023 at 11: 20 a.m. revealed the previously qualified IP nurse voluntarily resigned on 4/18/2023.