**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed develop a comprehensive resident-centered care plan. This was true for 1 of 21 residents (Resident #18) whose care plans were reviewed. This failure placed Resident #18 at risk of unmet care needs when he did not have a care plan for pneumonitis. Findings include: Review of the facility's Care Plans policy, dated 10/15/22 revealed, A comprehensive care plan is developed consistent with the residents' specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice including measurable objectives, interventions/services, and timetables to meet the resident's needs as identified in the resident's assessment or as identified in relation to the resident's response to the interventions or changes in the resident's condition . Resident #18 was admitted to the facility on [DATE], with multiple diagnoses including paraplegia (paralysis of the legs and lower body) and diabetes mellitus. A quarterly MDS assessment, dated 5/24/24, documented Resident #18 was cognitively intact. A physician's order dated 5/23/24 documented the following laboratory request for Resident #18: complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis (UA) with culture and sensitivity (C&S) A physician's assistant progress notes dated 5/23/24 documented Resident #18 had a diagnosis of pneumonitis versus urinary tract infection. Resident #18's record documented his UA result was negative for urinary tract infection. A nursing progress notes dated 5/23/23 documented Resident #18 had fever, elevated heart rate, and cough. An order was received for Resident #18 to receive intravenous fluids and Rocephin (antibiotic). Review of Resident #18's care plan revealed no documentation concerning these orders. During an interview on 8/6/24 at 4:12 PM, the MDS Nurse confirmed that a care plan should had been developed to reflect these new orders for Resident #18. During an interview on 8/6/24 at 4:12 PM, the DON confirmed that a care plan should have been updated with the change of condition on 5/23/24 when Resident #18 presented with a fever, cough and elevated heart rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. The facility's policy titled, Oral Medication Administration, dated [DATE], included instructions for staff preparing medications to validate the medication order against the medication packaging and confirm correct dose. Resident #52 was admitted to the facility on [DATE] with multiple diagnoses including fibromyalgia (a disorder characterized by widespread pain accompanied by fatigue, sleep, memory, and mood issues), dysphasia (inability to use or understand language), and had an abnormal gait (a walking abnormality) and problems with mobility. A laboratory result dated [DATE], documented Resident #52 had a low level of Vit D. An order dated [DATE], was received to give Resident #52 cholecalciferol 2,000 mg three times a day for 8 weeks. Resident #52's MAR dated [DATE] through [DATE] documented Resident #52 received cholecalciferol 2,000 mg three times a day. On [DATE] at 8:07 AM, LPN #3 administered one tablet of D3 50mcg/2,000 IU to Resident #52. On [DATE] at 10:26 AM, LPN #3 stated she gave Resident #52 one tablet of Vit D, and it was ordered three times a day. When asked what the order for Resident #52's Vit D was, LPN #3 then reviewed the order and stated it was 2,000 mg TID. LPN #3 then stated she did not give Resident #52 the right amount of Vit D because she only gave one tablet of Vit D 50 mcg. LPN #3 stated, I think it was an entry error. LPN #3 then asked the DON who was just exiting a resident's room. The DON looked at the order and stated, Let me go clarify that. On [DATE] at 10:40 AM, the DON stated Resident #52 received the right dose of Vit D which was 50mcg/2000 IU and not 2000 mg of Vit D. The DON stated the dose was entered wrong in the computer. The DON stated she expect the nurse to contact the physician for clarification if they noticed any discrepancy in the physician's order. On [DATE] at 4:05 PM during a follow-up interview, the DON stated the [DATE] physician's order written for Vit D administration for 8 weeks was expired and Resident #52 should not have continued to receive this order. b. The facility's policy titled, Pharmacist Consultation, dated [DATE], documented the responsibility of the pharmacist to conduct monthly medication regimen review (MRR) for each resident in the facility, including whether the medication dose, frequency, route of administration, and duration are consistent with the resident's condition, manufacturers recommendation, and applicable standards of practice. The May, June and [DATE] MRR, did not include recommendation from the pharmacist regarding Resident #52's medications. On [DATE] at 10:41 AM, during a phone interview, the pharmacist stated he conducted the MRR for the facility once a month and during the review he would check the physician's orders for every resident. The pharmacist stated he should have caught the 2,000 mg dosage of Vit D. He stated it was an oversight. Based on record review, policy review and interview, it was determined the facility failed to ensure medication orders were written accurately per current standards of practice. This was true for 2 of 21 residents (#52 and #710) whose physician's orders were reviewed. This failure created the potential for residents to receive the wrong dosage or receive the medication via the wrong route. Findings include: The facility's Eight Rights of Medication Administration policy, undated documented the following: right resident, right medication, right dose (confirm the appropriateness of the dose using a current drug reference), right route (confirm that the resident can take or receive the medication by the ordered route), right time, right documentation, right reason and right response. 1. Resident #71 was admitted to the facility on [DATE] with multiple diagnoses including tracheostomy (a surgically created hole in the windpipe for breathing), dementia, and gastrostomy (presence of surgical opening into the stomach for nutritional support). An admission MDS assessment dated [DATE], documented Resident #71 had a short term and long-term memory problems and severely impaired in decision making. Review of Resident #71's Physician Orders dated [DATE], documented Resident #71 was to received Depakote sprinkles 125 milligrams four capsules by mouth two times a day for seizures. Review of Resident #71's care plan dated [DATE], documented Resident #71 was NPO [nothing by mouth] and medications were administered in liquid or crushed forms and given by gravity as ordered by the physician. During an interview on [DATE] at 4:33 PM, LPN #1 stated, I gave the medication like I do all of his other meds [medicines], per the peg [percutaneous endoscopic gastronomy tube, feeding tube inserted through the skin into the stomach] tube. When asked if LPN #1 clarified the route in which the order stated the medication was to be given, LPN #1 stated, No, I didn't but I should have. During an interview on [DATE] at 4:35 PM, RCM #1 stated, He [Resident #71] doesn't get his meds [medicines] by mouth. The RCM #1 stated the process that was followed once a physician places the order in the computer, the order was flagged as Pending. The nurse would then confirm the order. RCM #1 stated, I check the dosage, time route and what it is used for . When asked if the route was correct for the ordered medication Depakote Sprinkles, RCM #1 stated, No, I will have to fix this right now. During an interview on [DATE] at 4:53 PM, the DON, The nurse is to check the order prior to giving the medication to make sure it is the right drug, the right dose, the right route and the right time. If it is wrong, the nurse is to clarify the order with the doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, it was determined the facility failed to ensure physician's order was followed regarding dressing changes for 1 of 2 residents (Resident #84). This failure created the potential for infection to spread to Resident #84's open areas to his left arm if it was not covered as ordered by the physician. Findings include: Resident #84 was admitted to the facility on [DATE] with multiple diagnoses including stroke, acute respiratory failure with hypoxia (low level of oxygen in the body tissues), and left hemiparesis (weakness) and hemiplegia (paralysis). An admission MDS assessment dated [DATE], documented Resident #84 was severely cognitively impaired. A Physician Order dated 8/6/24, directed staff to cleanse Resident #84's open rash to his left arm with wound cleanser, cover with boarder gauze and change two times a week and as needed. Resident #84's care plan dated 8/7/24, documented Resident #84 had a rash on his left arm. Interventions included: avoid scratching and keep hands and body parts from excessive moisture, monitor skin rashes for increased spread or signs of infection, seek medical attention if skin becomes bloody or infected, and try to identify skin allergies and avoid them. On 8/7/24 at 11:30 AM and 1:49 PM, Resident #84 did not have a dressing on his left arm. At 1:49 PM, RCM #1 accompanied surveyor to Resident #84's room and confirmed Resident #84 had no dressing present to his left arm. During an interview on 8/7/24 at 2:00 PM, LPN # 2 confirmed Resident #84 was to have a dressing to the left arm, and it was to be changed two times a week and as needed. When asked if the dressing came off, was the dressing to be redressed, LPN #2 stated, Yes. LPN #2 then accompanied the surveyor to Resident #84's room and confirmed Resident #84 did not have a dressing on the left arm. During an interview on 8/7/24 at 4:12 PM, the DON stated if Resident #84's dressing to his left arm came off, it was to be redressed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and record review, it was determined the facility failed to obtain physician ordered laboratory testing. This was true for 1 of 21 residents (Resident #18) whose records were reviewed. This failure created the potential for a physician to inaccurately diagnose and/or treat a resident appropriately due to lack of information. Findings include: Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including paraplegia (paralysis of the lower limbs below the navel) and cerebral palsy (CP is caused by abnormal brain development or damage to the developing brain that affects a person's ability to control their muscles). Resident #18 did not have any cognitive deficiencies and could make his own medical decisions. Resident #18's record contained physician orders, dated 5/23/24, for 3 laboratory tests: 1. Complete Blood Count (a CBC examines the number and types of cells in a person's blood); 2. Comprehensive Metabolic Panel (a CMP measures 14 substances in a person's blood to provide information about multiple body systems); 3. Urinalysis with Culture and Sensitivity (a UA with C&S checks for bacteria in a person's urine that could cause infection). Resident #18's record contained laboratory testing results for the ordered CBC and UA with C&S. Results for the CMP were not able to be located in his record. On 8/6/24 at 11:45 AM, the RCM stated the facility used a form to document if laboratory test results were pending, and the form was discussed at their morning clinical meeting. During the discussion, the team would ensure laboratory test results were followed-up on. On 8/6/24 at 2:25 PM, the DON stated she was not aware they had not received results of the CMP laboratory test for Resident #18 and contacted the lab to follow-up. She added, the lab reported the sample of blood for the CMP was collected in the wrong blood sample tube required for this type of blood test and the test was not able to be conducted. The DON stated the facility had not followed-up on ensuring the blood test was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's policy titled, Documentation of Resident Health Status Needs and Services, dated 10/14/22, documented directions to document services provided after the encounter has concluded and do not document in advance or prior to providing treatments. Resident #84 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (lack of oxygen in the blood and body tissues), hypertension, heart disease, and stroke. Resident #84 was severely cognitively impaired. Resident #84's record contained a physician order, dated 8/6/24, that directed staff to cleanse the open rash on his left arm with wound cleanser, cover with bordered gauze, and change two times per week and as needed. On 8/7/24 at 11:30 AM, Resident #84 was observed in his room, he did not have a dressing on his left arm. On 8/7/24 at 1:28 PM, LPN #2 documented in a progress note, [Rash on left arm] was cleaned, and foam dressings applied. No other new skin issues noted at this time. On 8/7/24 at 1:49 PM, the Resident Care Manager (RCM) observed Resident #84 and stated he did not have a dressing present on his left arm. On 8/7/24 at 2:20 PM, LPN #2 stated, I got this messed up in my head. I did not do his [dressing] today. On 8/7/24 at 2:24 PM, the RCM stated the nursing notes should reflect the care the nurse gives to the resident. On 8/7/24 at 4:12 PM, the DON stated, she expected the nurses to perform treatments as ordered and to document after the treatment was provided, not prior. Based on staff interview, record review, and facility policy review, it was determined the facility failed to have accurate and complete clinical records for 2 of 21 residents (Resident's #33 and #84) whose clinical records were reviewed. 1. Resident #33's record did not contain information related to the discontinuation of an antibiotic; and 2. Resident #84's record documented a dressing change had been completed when it had not been. These failures created the potential to cause failures in communication amongst the interdisciplinary team Findings include: 1. Resident #33 was re-admitted to the facility on [DATE] with multiple diagnoses including calculus of the ureter (mineral deposits lodged in the tubes that connect the kidneys to the bladder), urosepsis with Methicillin Resistant Staphylococcus Aureus infection (an extreme inflammatory response to a urinary tract infection caused by MRSA that spreads to the kidneys). Resident #33's record contained a physician order from an infectious disease physician, dated 7/25/24, instructing he receive daptomycin 350 mg (an antibiotic), intravenously (IV), for 42 days, through 8/10/24 due to MRSA urosepsis. The order documented instructions to not stop or change the use of daptomycin without consulting the infectious disease physician. On 7/30/24 at 11:41 AM, a progress note written by the DON, documented Resident #33 was diagnosed with pneumonic consolidation (a condition in which lung tissue fills with liquid instead of air) in the base of his right lung. The DON documented the infectious disease physician was consulted and ordered azithromycin (an antibiotic). The progress note did not document information regarding the order for daptomycin. Resident #33's record documented the order for daptomycin was discontinued on 8/3/24. Documentation the infectious disease physician had discontinued the daptomycin could not be located in the record. On 8/6/24 at 4:40 PM, the DON stated, on 7/30/24, when she spoke with the infectious disease physician and they ordered the azithromycin, they gave instructions to discontinue the daptomycin after 48 hours, and that's my error, and she should have documented the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and nursing competency review, it was determined the facility failed to observe infection control guidelines during a wound care dressing change for 1 of 2 residents, (Resident #71) whose wound care was observed. This failure placed the resident at increased risk of contracting an infection in their wound. Findings include: Resident #71 was admitted to the facility on [DATE] with multiple diagnoses including acute and chronic respiratory failure with hypoxia (lack of oxygen in the blood and body tissues), dementia, and a stage 4 pressure ulcer (localized damage to the skin and underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure, a stage 4 pressure ulcer has full thickness tissue loss exposing bone, tendon, or muscle) on his sacral region (the area located between the lower back and the tailbone). Resident #71 was dependent on a gastric tube (g-tube) for all of his nutrition, hydration, and medications, and he had a tracheostomy (a surgically created opening in the windpipe that provides an alternative airway for breathing). Resident #71's record contained a physician order from 7/24/24 directing staff to, cleanse and place wet to dry and cover, daily to the wound on his right buttock. Resident #71's care plan, dated 7/15/24, documented he had a stage 4 pressure injury to his right buttock present on admission. His care plan documented he used a pressure relieving mattress and directed staff to administer medications and treatments as ordered, assess/record/monitor wound healing, and report improvements and declines to the medical director. Lippincott's nursing standards of practice for basic wound cleaning, dated 12/2008, directed, For an open wound, such as a pressure ulcer, gently wipe in concentric circles, starting directly over the wound and moving outward. The facility's undated skills competency titled, Clean Dressing Change, documented when cleaning a wound, staff should clean from center of wound to the edge. On 8/7/24 at 8:20 AM, LPN #1 was observed cleaning Resident #71's wound bed by patting the wound with gauze, moving without pattern, patting from areas outside the wound then inside the wound bed, increasing the risk of bringing contaminants from Resident #71's skin into the wound bed. On 8/7/24 at 10:33 AM, LPN #1 stated, The dirty to the cleanest. I don't remember how I cleaned it. On 8/7/24 at 10:45 AM, the DON stated, the nurse should clean the wound from the inside of the wound to the outer region of a wound. On 8/7/24 at 11:01 AM, the Staff Development Coordinator/Infection Preventionist (SDC/IP) stated the nurses were to clean the wound in a circular motion from the inside out of the wound bed to prevent bringing bacteria into the wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observation, and resident and staff interview, it was determined the facility failed to ensure residents were assessed for safety and care-planned to self-administer medication. This was true for 2 of 3 residents (#4 and #7) reviewed for self-administration of medication. This failure created the potential for adverse outcomes if residents self-administered medications inaccurately and received too much or too little of the medication. Findings include: Findings include: The facility's policy, Self-Administration of Medications, dated 11/28/17, states residents may self-administer drugs if the interdisciplinary team has determined that it is safe. The policy states the interdisciplinary team periodically reviews residents' self-administrations of drugs according to the resident's status. lf the medication is to be stored in the resident's room, a method of storing and securing the medication is prearranged and approved for storing medications, such as a locked cabinet. Appropriate notation is included in the resident's care plan and care plan documentation includes: a. Which drugs may be self-administered, b. Who is responsible (resident or nursing staff) for storage and documentation of the drug administration, and c. Location of the drug administration, such as the resident's room or nurses' station. 1. Resident #4 was admitted on [DATE], with multiple diagnoses including respiratory failure (a condition in which the blood does not have enough oxygen). A quarterly MDS Assessment, dated 1/16/24, documented Resident #4 was cognitively intact. On 3/19/24 at 9:39 AM, Resident #4 was in bed with her tracheostomy (surgically created hole in the windpipe that provides an alternative airway for breathing) in place. Resident #4 was observed holding two small medication cups on her overbed table. One cup had four larger pills in it and a second cup had multiple smaller pills in it. Resident #4 was asked about the cups with medications. Resident #4 stated they [the nursing staff] always left her pills with her and provided two cups for her to take them. Resident #4 stated she took her time taking the pills with water. Resident #4 stated she divided her pills herself with one cup holding the smaller pills and the other cup with the larger pills. Resident #4 stated this is how she took her medications all of the time. Resident #4's record did not include an assessment to self-administer medications, care plan to self-administer medications, or a physician's order prior to 3/19/24. 2. Resident #7 was admitted on [DATE], with multiple diagnoses including congestive heart failure (when the heart does not pump blood as effectively as it should). A quarterly MDS Assessment, dated 8/28/23, documented Resident #2 was cognitively intact. A physician's order, dated 1/26/24, documented to administer Flonase Allergy Relief Nasal spray, 2 sprays in both nostrils one time a day for nasal congestion. Resident #7's March 2024 MAR, documented Flonase nasal spray, 2 sprays in both nostrils one time a day for nasal congestion and it was marked as administered in the evenings 3/1/24 through 3/19/24. Resident #7's record did not include an assessment to self-administer medications, care plan to self-administer medications, or a physician's order prior 3/19/24. On 3/18/24 at 10:52 AM, Resident #7 was in her room and a bottle of Flonase nasal spray was observed on Resident #7's overbed table next to her. Resident #7 was asked about the Flonase. Resident #7 stated she had it because she had breathing and allergy issues. During an observation on 3/19/24 at 8:33 AM, Resident #7 was awake in bed and a bottle of Flonase was observed on Resident #7's bedside table. During an interview on 3/21/24 at 3:44 PM, the CNO confirmed that neither Resident #4 or Resident #7 had an order, an assessment completed, or a care plan for self-administration of medications until 3/19/24 when it was brought to the facility's attention that medications for both residents were routinely left at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and staff interview, it was determined the facility failed to ensure a resident's MDS assessment documented his nephrostomy tube (a thin flexible tube surgically placed into a kidney to drain urine). This was true for 1 of 19 residents (Resident #17) reviewed for accuracy of MDS assessments. This failure had the potential for Resident #17 to not receive care and services necessary to prevent infection and damage to her kidney. Findings include Findings include: The facility's policy, Resident Assessment and RAI, revised 10/15/22, documented a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity, needs, strengths, goals, life history and preferences using the Resident Assessment Instrument (RAI), was used which directed the care of the resident based on his or her individual needs. Resident #17 was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Hydronephrosis (when one or both kidneys swell) with Renal and Ureteral Calculus Obstruction and Hemorrhage due to Genitourinary Prosthetic Devices. On 3/29/24 at 2:13 PM, Resident #17 was in bed with a nephrostomy tube sutured into her right side connected to a collection bag with urine inside the bag. A quarterly MDS assessment, dated 12/14/23, did not include documentation Resident #17 had a nephrostomy tube in place. On 3/19/24 at 2:13 PM, LPN #1 stated Resident #17 had a nephrostomy tube in her right kidney which drained urine into a collection bag. On 3/21/24 at 10:32 PM, the MDS Coordinator confirmed the section of the quarterly MDS for Resident #17 should have been coded with a yes for a nephrostomy tube and it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and staff interview, it was determined the facility failed to ensure interventions were in place on a resident's care plan for the care of her nephrostomy tube (a thin flexible tube surgically placed into a kidney to drain urine) and biliary tube (a thin flexible tube surgically placed into the bile duct of the liver to drain bile). This was true for 1 of 19 residents (Resident #17) whose care plans were reviewed. This failure had the potential for Resident #17 to not receive care and services necessary to prevent infection and damage to her kidney and liver. Findings include: The facility's policy for Care Plans, dated 10/15/22, documented A comprehensive care plan is developed consistent with the residents' specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice including measurable objectives, interventions/services, and timetables to meet the resident's needs as identified in the resident's assessment or as identified in relation to the resident's response to the interventions or changes in the resident's condition. Resident #17's was admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Hydronephrosis (when one or both kidneys swell) with Renal and Ureteral Calculus Obstruction and Hemorrhage due to Genitourinary Prosthetic Devices. On 3/29/24 at 2:13 PM, Resident #17 was in bed with a nephrostomy tube sutured into her right side connected to a collection bag with urine inside the bag. A biliary tube was also in place on her right side. A physician order, dated 4/3/23, documented Resident #17 had a right-sided nephrostomy tube and staff were to monitor the nephrostomy output every shift and document the drainage every shift. A physician order, dated 10/11/23, documented staff were to cleanse Resident #17's nephrostomy site as needed with normal saline, and cover the insertion site with split gauze and secure with tape. The order stated to change the dressing every 72 hours and as needed and ensure device was secure and in place. Resident #17's care plan for the nephrostomy tube, dated 4/20/23, did not include interventions for care of her nephrostomy tube. Resident #17 care plan did not include care needed for her biliary tube. On 3/19/24 at 2:13 PM, LPN #1 stated Resident #17 had a nephrostomy tube in her right kidney which drained urine into a collection bag. LPN #1 confirmed Resident #17 had a second biliary tube in her gall bladder that drained bile into a collection bag. On 3/22/24 at 11:00 AM, the RCM stated Resident #17's care plan should include the needed care for her nephrostomy and biliary tubes. On 3/22/24 at 11:05 AM, the CNO confirmed Resident #17 was admitted to the facility with both the biliary and nephrostomy tubes and there should be a plan of care for the care of both tubes on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and family and staff interview, it was determined the facility failed to provide communication assistance as needed to 1 of 2 residents (Resident #54) reviewed for activities of daily living. This failure placed Resident #54 at risk for decreased quality of life and psychosocial distress related to inability to communicate effectively. Findings include: The facility's Communication policy, revised 10/15/22, documented information about the facility was communicated to the residents by using materials printed in the primary language of the resident and using an interpreter or interpreter services. Resident #54 was admitted to the facility on [DATE] and readmitted [DATE], with multiple diagnoses including chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues). A quarterly MDS assessment, dated 1/2/24, documented Resident #54 was cognitively intact and his primary language was Nepali. Resident #54's care plan, revised 4/24/23, documented Resident #54 had an impaired communication problem related to being from [NAME] and only speaking Nepalese. The care plan goal was for Resident #54 to be able to make his basic needs known by using communication sheets with pictures, translators, translator app[lication] and sons/niece if needed on a daily basis. An Activities Evaluation, dated 2/23/24, documented Resident #54 did not speak the English language. Resident #54 liked to listen to Nepali music and watched Nepali television programs. On 3/18/24 at 11:26 AM, Resident #54 was observed awake in bed. When asked how he was doing, Resident #54 smiled at the surveyor. When asked if his needs were being met by the staff, Resident #54 looked at the surveyor. When asked if he liked the TV program being shown on the TV, Resident #54 smiled at the surveyor. When asked if he spoke English, Resident #54 smiled at the surveyor. It was unclear if Resident #54 understood the surveyor. There were no communication tools in Resident #54's room such as pictures or communication sheet/papers observed in his room as documented in his care plan. There was no information or signage posted in his room regarding the availability of an interpreter for him to communicate with the physician or healthcare staff. On 3/18/24 at 12:26 PM, during a telephone interview, Resident #54's representative stated Resident #54 did not speak or understand the English language. Resident #54's representative stated Resident #54 liked to watch Nepali TV programs and listen to Nepali music, and asked [name of the facility staff] if they could provide music or TV shows in Nepali for Resident #54. On 3/20/24 at 9:03 AM, the Resident Support Services Assistant stated Resident #54's representative spoke to her regarding getting Nepali TV programs and music through YouTube for Resident #54. The Resident Services Assistant stated getting YouTube on the TV was not an easy process. She stated she talked about it with the facility's Maintenance Director. On 3/20/24 at 8:38 AM, the CNO stated the facility had translation services available and the information was posted at the nurse's station. The surveyor then asked the CNO to come and look at Resident #54's room. The surveyor asked the CNO why there was no information regarding translation services in Resident #54's room. The CNO stated Resident #54's representative agreed to be the translator for the resident. When asked about the communication sheets with pictures as stated on Resident #54's care plan, the CNO looked around, opened the drawers and stated she did not see communication tools in Resident #54's room as stated in his care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to ensure residents received treatment and services to prevent skin injuries. This was true for 1 of 5 residents (Resident #308) who were reviewed for pressure injuries. This placed residents at risk of adverse outcomes if care and services were not provided due to skin assessments not being completed as ordered. Findings include: Resident #308 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease and a non-pressure chronic ulcer of lower leg. On 3/19/24 at 3:12 PM, Resident #308 was observed during peri care. A large dark purple/dark red area was observed on the inner side of his right buttock, by the scrotum. A physician's order, dated 3/14/24, documented staff were to update, evaluate, and document all ongoing and new skin alterations for Resident #308 with scheduled skin checks weekly. Resident #308's care plan, revised 3/14/24, directed staff to complete weekly licensed nurse skin assessments, document location, size, and treatment of his skin injury and report abnormalities to the physician. A skin inspection evaluation, dated 3/14/24, did not include documentation of the wound on Resident #308's buttock. On 3/20/24 at 10:34 AM, the CNO stated CNAs were to report a change of condition of a resident in the record and to tell the resident's nurse. On 3/20/24 at 10:46 AM, LPN #5 stated Resident #308 had a foam dressing to his right buttock. She stated Resident #308 was admitted from the hospital with the dressing on his right buttock. The nurse from the hospital told LPN #5 the dressing was for wound prevention. LPN #5 further stated there was no dressing ordered for Resident #308's right buttock and there was no assessment of the wound on the right buttock. She stated the policy for a new wound was to do a risk management assessment and to notify the DON and physician. On 3/21/24 at 11:22 AM, the CNO stated after a CNA told a resident's nurse about a skin injury, the nurse was to notify the physician, get orders to treat the skin injury, complete an assessment, and document it in a progress note. She stated the care plan was then to be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #53 was admitted on [DATE], with multiple diagnoses including paraplegia (paralysis of the lower legs and body) and altered mental status. On 3/18/24 at 3:25 PM, a can of Biofreeze (a medication used topically to relieve pain) was observed on Resident #53's bedside table. On 3/18/24 at 3:28 PM, LPN #4 stated medication should not be left at the bedside unless the resident had an order for it to be left at bedside. 3/21/24 at 11:21 AM, the CNO stated medications were allowed at a resident's beside if the resident was approved to self-administer the medication. She stated the can of Biofreeze should have been stored on the medication cart and not left at Resident #53's bedside. Based on policy review, observation, and staff interview, it was determined the facility failed to ensure medications were secured when they were unattended by staff. This was true for 1 of 7 residents (Resident #20) observed during medication passes and for 1 of 19 residents (Resident #53) observed in their room. This failure created the potential for harm if the medications were taken by another resident, visitor or staff. Findings include: The facility's Storage and Expiration Dating of Medications, Biologicals, revised 8/7/23, documented all medications and biologicals including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 1. On 3/21/24 at 8:10 AM, an Ampicillin - Sulbactam (antibiotic) Sodium Injection Solution was observed on top of the medication cart while LPN #4 prepared Resident #305's medications. LPN #4 then closed the medication cart drawers and entered Resident #305's room. LPN #4 left the Ampicillin - Sulbactam medication on top of the medication cart unattended. When LPN #4 exited Resident #305's room, she stated she would get a warm blanket for Resident #305. The medication remained unattended on top of the medication cart. On 3/21/24 at 8:20 AM, the Physical Therapy Director walked by the medication cart and talked to the surveyor then walked away. The Physical Therapy Director then quickly came back and picked up the medication of top of the medication cart. The Surveyor told the Physical Therapy Director she was keeping her eye on the medication that was left unattended by LPN #4. The Physical Therapy Director then put the medication back on top of the medication cart. On 3/21/24 at 8:25 AM, LPN #4 stated she should not have left the medication unattended on top of the medication cart. LPN #4 then took the medication and placed it inside the medication cart. 03/21/24 11:20 AM, the CNO stated medications should be kept inside the medication cart and not be left unattended on top of the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure a resident was provided an appropriate adaptive call light due to physical limitations or ensure the call light was within reach. This was true for 1 of 27 residents (Resident #21) reviewed for resident rights. This deficient practice had the potential to cause harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention. Findings include: The facility's expectations were documented in their Quality of Life policy, revised 10/15/22, which included call lights were adapted to accommodate the individual needs of the resident. It also documented staff ensured the call light was available and staff were responsive to residents' needs. The facility did not accommodate Resident #21's needs based on assessment and plan of care as follows. Resident #21 was readmitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, cognitive communication deficit, need for assistance with personal care, and generalized muscle weakness. A quarterly MDS assessment, dated 8/2/23, documented Resident #21 was severly cognitively impaired and required total staff assistance for bed mobility, transfers, ADLs including eating, showering, and dressing. Resident #21's care plan, initiated 11/30/20, documented staff were to ensure his call light was within reach and encourage Resident #21 to use it for assistance as needed. Resident #21 was observed in his bed with his call light cord coiled up and taped to the wall behind him out of his reach on the right side of the bed on the following dates: - On 9/18/23 at 11:08 AM - On 9/18/23 at 3:11 PM - On 9/19/23 at 8:20AM On 9/19/23 at 9:10 AM, LPN #2 stated Resident #21 could not reach the call light due to his physical limitations. She also stated it would be more appropriate if resident #21 had a touch pad call light due to his limitations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, it was determined the facility failed to develop and implement a comprehensive resident-centered care plan when a resident expressed suicidal thoughts. This was true for 1 of 27 residents (Resident #78) whose care plans were reviewed. This deficient practice placed Resident #78 at risk for a negative outcome if his emotional needs were not identified and interventions documented in his care plan. Findings include: The facility's policy for Care Plans, revised 10/15/22, documented a comprehensive care plan was developed consistent with residents' specific conditions, risks, needs, behaviors, cultural expectations, preferences and with standards of practice .to meet the resident's needs as identified in the resident's assessment or as identified in relation to the resident's response to the interventions or changes in the resident's condition. The policy documented the care plan collaborated for interventions to address mental and psychosocial needs, to include behavior management and recovery concepts for trauma informed care. It stated in situations where a resident's choice to decline care or treatment posed a risk to the resident's health or safety, the comprehensive care plan should identify the care or services declined, the risk the declination posed to the residents, and efforts by the interdisciplinary team to educate the resident and the representative as appropriate. Resident #78 was admitted to the facility on [DATE]. with multiple diagnoses including tracheostomy (an opening into the trachea [windpipe] where a tube is inserted to help air and oxygen reach the lungs) care, acute and chronic respiratory failure, quadriplegia (unable to move from the neck down), major depressive disorder, anxiety disorder, poisoning by Fentanyl (possible suicide attempt), and other psychoactive substance abuse. A quarterly MDS assessment, dated 7/12/23, documented Resident #78 had thoughts he would be better off dead. The MDS documented the resident was cognitively intact. A Suicide Risk Evaluation, dated 4/8/23, documented Resident #78 had behavioral or symptoms of anxiety-high risk or panic state, depression-severe, isolation/withdrawal-hopeless and self-depreciating, coping strategies-predominately destructive, suicidal plan-vague [with] fleeting thoughts. The summary of the risk evaluation stated Resident #78's current medical condition was a result of an overdose of Fentanyl (strong opioid used for pain relief) and he reported it was intentional. The evaluation documented Resident #78 verbalized he questioned if he wanted to live and was unable to express further without becoming very upset and unintelligible. The evaluation further documented he was conflicted about taking an antidepressant because he felt he let people down and deserved to suffer. The evaluation stated Resident #78 was paralyzed from his collar bones down, did not have a plan for his suicidal ideation, and was physically unable to carry out a plan. The evaluation concluded the risk of suicide attempt was very low to impossible, and his suicidal ideation was care planned and reported to the providers including psychiatric physician assistant. Resident #78's care plan, dated 4/8/23, documented when Resident #78 verbalized statements of suicidal ideation, staff were to administer and monitor the effectiveness and side effects of medications per physician order, and provide a psychiatric and Licensed Clinical Social Worker (LCSW) consult as indicated. The care plan did not include direction for staff on how to verbally respond and emotionally support Resident #78. A care conference, dated 7/10/23, documented Resident #78 was using his ventilator (machine to assist a person with breathing) quite often. Resident #78 acknowledged he should use the ventilator only when he needed it. The care conference documented Resident #78 was declining meals and therapies. Resident #78 was encouraged to continue working with the team and not give up. The care conference documented Resident #78 agreed to try again. A progress note, dated 9/10/23 at 12:42 PM, documented Resident #78 was refusing to come off the ventilator for lunch. He stated he would not eat or take his medications because he did not want to be here. Resident #78's family member was contacted, and spoke to him and was also unable to convince him to change his mind. The note documented Resident #78 was reminded of the importance of eating and taking his medications. A progress note, dated 9/10/23 at 1:56 PM, documented Resident #78 was refusing all medications, stated he would rather be dead as there was no point living the way he is. The note documented Resident #78 was asked if he had a plan and he stated he was going to starve himself and refuse all of his medications. A progress note, dated 9/11/23 at 11:27 AM, documented Resident #78 stated he was depressed and he doesn't want to do life anymore. The note documented Resident #78 took all of his medications that day and did get off of the ventilator that morning. The note stated he was educated on the importance of taking all medications. Resident #78 stated he was bored and the nurse spoke with him about getting up and out of his room more often. The note further documented Resident #78 was getting up throughout the day a bit more, and now was not. The nurse spoke with him about making the best out of the life he currently had regardless of his situation. On 9/20/23 at 2:51 PM, CNA #2 was asked what she said to Resident #78 when he talked about suicide. CNA #2 stated if Resident #78 said he wanted to die, she tried to encourage him to talk to his friends, gave good advice, and explained to him everyone had issues and there were people to help him. She said she would try to make him happy with jokes and change the subject to comedy. On 9/21/23 at 11:10 AM, the Resident Care Manager stated offering advice or changing the subject when Resident #78 spoke of suicide was not an appropriate intervention. She stated the way for nursing staff to respond to Resident #78 when the subject of suicide came up should be care planned and it was not in the current care plan. She said there should be interventions for staff about how to respond when Resident #78 expressed suicidal desires. On 9/22/23 at 10:09 AM, the CNO stated Resident #78 was a very unique situation and there was no direction in his care plan on how to respond if Resident #78 spoke about his lack of will to live or suicide. She said there should be a section in the care plan directing staff to monitor verbalization of suicide feelings or comments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #21 was admitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, cognitive communication deficit, need for assistance with personal care, and generalized muscle weakness. The ADL record for bed mobility, dated August 2022, documented Resident #21 required a 2 person assist for bed mobility for 16 of 31 days. A quarterly MDS assessment, dated 5/24/22, documented Resident #21 was cognitively severely impaired. It also documented the following care needs were identified: -Extensive assist with 2-person assistance for bed mobility. -Substantial/ maximum assistance to roll in bed onto either side. -Total dependent with transfers and Resident #21 required 2-person physical assistance. A quarterly MDS assessment, dated 8/15/22, documented Resident #21 was cognitively severely impaired. It also documented the following care needs were identified: -Extensive assist with 2-person assistance for bed mobility. -Dependent to roll in bed onto either side. -Total dependent with transfers and Resident #21 required 2-person physical assistance. The care plan, revised on 11/19/21, documented Resident #21 was a 1-person physical assist to turn and reposition in bed. It also documented Resident #21 was a 2-person physical assist with a Hoyer lift for transfers. The care plan did not include documentation the need for 2-person physical assist with repositioning in bed identified on the quarterly MDS assessment dated [DATE] and 8/15/22. On 9/21/23 at 9:34 AM, the MDS nurse stated if the MDS assessment identified a change in care, the care plan should be revised. On review of the MDS assessment dated [DATE] and 8/15/22, the MDS nurse stated the care plan did not reflect the care identified on the MDS assessment and it should have been revised. Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 2 of 27 residents (#1 and #21) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed. Findings include: The facility's Care Plan policy, revised 10/15/22, documented when developing the care plan, the facility staff used MDS assessments to assess the resident's clinical condition, cognitive, functional status, and use of services. The care plans were to be monitored and revised quarterly, annually, with a significant change or as more frequently as needed with the input of the resident and the representative. 1. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including non-pressure chronic ulcer to the right calf with a fat layer exposed and needed assistance for personal care. Resident #1's annual MDS, dated [DATE], documented he was cognitively intact and presented with a urine catheter. He required two person's extensive assistance for bed mobility, transfer, and toileting. He was dependent on bathing. Resident #1's skin risk care plan, revised 4/11/23, included interventions as follows: - Apply protective barrier cream after each incontinence and with AM and PM care, start 2/23/22. - Avoid friction and shearing. Using a turn sheet for repositioning, start 3/14/23. - Darco shoe (provides the foot with solid protection and accommodates bulky bandages) to left lower extremity, start 7/10/23. - Encourage good nutrition and hydration to promote healthier skin, start 3/14/23. - Left lower extremity Velcro wrap, start 7/10/23. - Off-load heels or use prevalon boots (boots that reduce pressure on the heels) when in bed, Resident #1 will refuse prevalon boots at times, start 8/26/22. - Skin inspection during CNA care opportunities. Report alterations to the licensed nurse, start 2/23/23. - Utilized pressure-relieving mattress. Low air loss mattress per physician orders, revised 4/17/23. - Weekly licensed nurse skin assessment, to include review, check of footwear, start 3/14/23. On 9/18/23 at 3:47 PM, Resident #1 stated he developed a new pressure ulcer on his left buttock one week ago. On 9/19/23 at 3:02 PM, Resident #1 stated he came back from the wound clinic appointment. The wound doctor told him he had a new pressure sore on his right heel. On 9/20/23 at 9:06 AM, Resident #1 was observed to have a 4 x 4 cm foam dressing to his left inner buttock, with dime-sized dark brown discharge. RN #1 stated she did not know how many active wounds Resident #1 had; she was new to taking care of Resident #1, and she needed to check his medical records. On 9/20/23 at 3:00 PM, Resident #1's record was reviewed including the wound clinic visit notes as follows: - A wound clinic visit note, dated 9/12/23, documented Resident #1 sustained a new suspected deep tissue injury to the left medial buttock. - A wound clinic visit note, dated 9/19/23, documented Resident #1's deep tissue injury to the left medial buttock from September 12, 2023, became a Stage III pressure injury to left medial buttock region and he sustained a new suspected deep tissue injury to his right posterior heel. Resident #1's care plan did not include the wounds documented in the wound clinic notes. During an interview on 9/21/22 at 8:15 AM, the CNO stated Resident #1's care plan was not updated, and it should be updated and investigated as soon as there was a new skin condition.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and dated. This was true for 2 of 3 medication carts inspected. This failure created the potential for residents to receive medication used for another resident presenting a risk for cross-contamination or to receive expired medications with decreased efficacy. Findings include: The facility's House Supply Medications policy, dated 11/28/17, stated medications should be initialed and dated when opening. This policy was not followed. On 9/19/23 at 2:49 PM, 1 Advair inhaler and 1 bottle of carbamide 6.5% ear drops were in the top drawer of the medication cart located on the rehabilitation wing. They were not labeled with an opened date. LPN #2 stated she did not know when the inhaler was opened, and she was not able to determine if it was expired. She also stated the carbamide was no longer an active order, and the bottle should have been dated when it was opened, and the medication discarded when the order was discontinued. On 9/19/23 at 3:05 PM, 1 bottle of saline nasal spray was in the top drawer of the medication cart located on the long-term wing. The nasal spray was not labeled with an opened date. LPN #3 stated the bottle should have been dated when it was opened, and she was unsure of the opened date. On 9/22/23 at 11:27 AM, The CNO stated best practice was to remove medication from the cart when the order was discontinued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. Resident #91 was admitted to the facility on [DATE], with multiple diagnoses including stroke and chronic pain. Resident #91's MDS assessment dated [DATE], documented he was cognitively intact. A physician order, dated 8/8/23, directed staff to document a pain rating scale at the start of each shift using verbal/non-verbal 0-10 scale for monitoring of comfort, if Resident #91 reported pain or had signs and symptoms of pain, encourage non-pharmacological interventions, and if ineffective use current pain medications to resolve pain. Resident #91's care plan for pain initiated on 8/9/23, stated Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function. A physician order, dated 8/10/23, directed staff to administer Norco 10-325 mg (opioid pain medication), 1 tablet by mouth to Resident #91 every 6 hours for pain management. Resident #91's MAR, dated September 2023. documented he received Norco every 6 hours. Resident #91's MAR and TAR, dated September 2023, did not include documentation non-pharmacological interventions were offered prior to the administration of the Norco. Resident #91's MAR and TAR, dated September 2023, did not include documentation for monitoring potential adverse side effects from the use of an opioid medication. On 9/21/23, at 2:45 PM, the CNO stated non-pharmacological interventions should be offered and documented whenever a PRN pain medication was administered, and the residents' records did not include documentation non-pharmacological interventions were provided. The CNO stated side effect monitoring was not documented in residents' records for the use of opioid medications and she was unaware this was requirement. c. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including a duodenal ulcer with perforation (a condition in which an untreated ulcer has burned through the mucosal wall in the upper part of the small intestine, allowing food and digestive juices to get out of the digestive tract). Resident #29's admission MDS assessment, dated 8/3/23, documented he was cognitively intact. The assessment documented Resident #29' s pain was occasionally present but did not impact his daily living activities. Resident #29's care plan, initiated on 7/28/23, documented he had chronic pain due to his duodenal ulcer with perforation to abdomen. The interventions included the following: -Administer medication as ordered and monitor for effectiveness and side effects. -Monitor, document, and report as needed to the physician side effects or evidence of ineffectiveness of pain medication. -Provide non-pharmacological interventions for pain relief such as heat, cold, massage, positioning, music, relaxation, imagery, or diversion. A physician order, dated 7/28/23, directed staff to give Norco (opioid pain medication) 5-325 mg, give 1 tablet by mouth every 6 hours as needed for moderate pain. Resident #29's August and September 2023 MARs documented he received Norco 1-4 times a day for 44 consecutive days. Resident #29's record did not include assessment for side effects or that non-pharmacological interventions for pain were offered. Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents were monitored appropriately and offered non-pharmacological interventions while receiving opioid pain medications. This was true for 4 of 5 residents (#29, #44, #91, and #350) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to a lack of appropriate monitoring or increased pain due to not offering non-pharmacological interventions. Findings include: The facility's policy for Pain Management, revised 10/15/22, directed staff to provide non-pharmacological interventions for breakthrough pain management and to monitor for any adverse effects of opioid medication use. a. Resident #44 was admitted to the facility on [DATE], with diagnoses including traumatic brain injury, quadriplegia, chronic pain, chronic respiratory failure, and had a tracheostomy. A physician order, dated 2/3/23, directed staff to indicate non-pharmacological interventions attempted prior to administering PRN pain medications to Resident #44 including repositioning, reduced stimuli, warm towel/ice, relaxation techniques, distraction, music, massage, or if he refused the non-pharmacological pain management interventions offered. A physician order, dated 9/1/23, documented to administer Oxycodone Hcl (opioid pain medication) 20 mg, 1 tablet by mouth to Resident #44 every 6 hours as needed for chronic pain. Resident #44's MAR documented he received his Oxycodone for breakthrough pain 1-4 times a day, every day, from 9/1/23-9/21/23. Resident #44's TAR for the month of September 2023 did not include documentation non-pharmacological interventions were provided. Resident #44's MAR and TAR for the month of September 2023 did not include side effect monitoring for opioid medications. b. Resident #350 was admitted on [DATE], with multiple diagnoses including a fracture in her neck, congestive heart failure, and was on hemodialysis for end stage renal (kidney) disease. A physician order, dated 9/15/23, directed staff to indicate non-pharmacological interventions attempted prior to administering PRN pain medications to Resident #350 including repositioning, reduced stimuli, warm towel/ice, relaxation techniques, distraction, music, massage, or if she refused the non-pharmacological pain management interventions offered. A physician order, dated 9/16/23, documented to administer Tramadol Hcl (opioid pain medication) 100 mg by mouth every 6 hours as needed for pain. Resident #350's MAR documented she received Tramadol as needed on 9/19/23. The MAR did not include documentation non-pharmacological interventions were provided. Resident #350's MAR and TAR for 9/19/23 did not include side effect monitoring for opioid medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not perform hand hygiene. This was true for 4 of 27 residents (#21, #29, #67, and #83) observed during resident care. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The facility's policy for Hand Hygiene, revised 2/11/22, stated opportunities for hand hygiene were before moving to a clean body site after caring for a soiled body site. This policy was not followed. 1. Resident #21 was readmitted to the facility on [DATE], with multiple diagnoses including Alzheimer's disease, cognitive communication deficit, need for assistance with personal care, and generalized muscle weakness. On 9/22/23 at 5:18 AM, NA #2 and CNA #3 were observed providing peri-care for Resident #21. Both CNA #3 and NA #2 performed hand hygiene and put on gloves. CNA #3 initiated peri-care then turned Resident #21 onto his left side. NA #2 left the bedside and removed her gloves to get additional supplies. She then sanitized her hands and put on gloves and continued with care. CNA #3 and NA #2 then proceeded to put a clean adult brief on Resident #21. CNA #3 did not perform hand hygiene before applying Resident #21's clean brief. On 9/22/23 at 5:30 AM, CNA #3 stated she should have changed her gloves and performed hand hygiene when going from dirty to clean areas. On 9/22/23 at 8:25 AM, the IP nurse stated CNA #3 should have performed hand hygiene at the beginning of providing care and when going from dirty to clean areas, and after care was completed. She stated providing peri-care with no change of gloves was a breach in infection control. 2. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including a duodenal ulcer with perforation (a condition in which an untreated ulcer has burned through the mucosal wall in the upper part of the small intestine, allowing food and digestive juices to get out of the digestive tract). An admission MDS assessment, dated 8/3/23, documented Resident #29 was cognitively intact. On 9/18/23 at 2:55 PM, LPN #2 entered the room with supplies to clean Resident #29's surgical abdominal wound. She placed the supplies directly on the bedside table, performed hand hygiene, put on gloves, and removed Resident #29's wound dressing. She then reapplied the dirty dressing and turned around to close the window blinds. LPN #2 returned to the bedside and removed the dressing for the second time. She proceeded to apply water to the gauze observed on the wound bed. She then removed the gauze and began cleaning the wound site with clean gauze. LPN #2 applied a clean dressing to the wound and assisted Resident #29 with blankets. LPN #2 did not change gloves or perform hand hygiene after closing the window blinds, removing the soiled dressing and before cleaning the wound site and appying a clean dressing to the wound. On 9/18/23 at 3:11 PM, LPN #2 stated she performed wound care with one pair of gloves, and she should have changed them when going from dirty to clean areas. On 9/22/23 at 8:26 AM, the IP nurse stated hand hygiene should be done before starting wound care, when going from dirty to clean, and at the end of wound care. She stated the lack of hand hygiene was a breach in infection control. 3. Resident #67 was readmitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and diabetes. Resident #67's quarterly MDS, dated [DATE], documented she was cognitively intact. On 9/22/23 at 5:41 AM, NA #1 was observed responding to Resident #67's call light and walked into the room with a set of clean clothes. NA #1 put on gloves, removed Resident #67's wet bedding and clothing, removed her wet incontinence brief, put a clean sheet on the left side of Resident #67's bed, then provided peri-care and applied barrier cream on her left buttock area, and applied a clean incontinent brief for Resident #67 and assisted her to put on a clean shirt. NA #1 did not change her gloves before or after changing Resident #67's wet bedding, clothing, removing her incontinent brief, putting a clean sheet on her bed, providing peri-care, and applying a clean incontinent brief and clothing for Resident #67. NA #1 did not use wipes or towels to clean Resident #67's urine residue on her upper body before assisting her with a clean shirt. On 9/22/23 at 5:52 AM, CNA #1 came in to help NA#1. CNA #1 put on a pair of clean gloves while NA #1 wore the same dirty gloves to finish the bedding change on the right side of Resident #67's bed. On 9/22/23 at 6:01 AM, when asked, NA #1 said she did not dry or clean the urine residue from Resident #67's upper body before helping her put on the clean shirt, and she did not change her gloves and perform hand hygiene from dirty to clean during the bedding change, before peri-care, and after putting on the barrier cream. NA #1 said she forgot. 4. The facility's policy, Transmission-Based Precautions Conventional Plan, revised on 5/31/21, stated infections should be identified to determine the need for transmission precautions, and staff were to obtain a physician order for the type of precautions. The policy further stated for contact surfaces in a resident's room included routine cleaning and disinfection of a resident's overbed table. Resident #83's was admitted to the facility on [DATE], with multiple diagnoses including quadriplegia (condition in which both the arms and legs are paralyzed and lose normal motor function), a left heel deep pressure tissue wound (persistent non-blanchable deep red, purple or maroon areas of intact skin or blood filled blisters caused by damage to the underlying soft tissues), and non-pressure ulcer of to his right heel and mid foot. An MDS assessment, dated 8/30/23, documented Resident #83 was cognitively intact, and required extensive assistance of two staff members with activities of daily living. a. Resident #83's lab report, dated 9/17/23, documented he had Methicillin Resistant Staphylococcus aureus (MRSA, a bacterial infection). A physician's order, dated 9/19/23, documented Resident #83 be placed in contact isolation (to prevent transmission of infectious agents, which could be spread by direct or indirect contact from an infected area from the patient or in the patient's environment) for the MRSA to his right heel, two days after the lab result. On 9/22/23 at 10:03 AM, the CNO confirmed the facility received Resident #83's lab result on 9/17/23, but the order for the contact isolation for MRSA was not written until 9/19/23. The CNO said she received the lab results on 9/17/23 and updated Resident #83's care plan and it was an oversight not writing the contact isolation order on the same day. b. On 9/20/23 at 10:16 AM, wound care for Resident #83 was observed in his room. LPN #4 and LPN #5 put on gloves, placed a clean pad on Resident #83's over the bed table where wound supplies were laid. The clean pad was placed over a fly swatter and what appeared to be a dried spilled substance. On 9/22/23 at 10:55 AM, the IP stated when preparing for wound care using an over the bed table for supplies, the table should be wiped down and a barrier (clean chuck, paper towel, or clean cloth towel) should placed, and then the wound care supplies should be prepared. When asked if it would be an acceptable infection control practice to not wipe the surface of the over the bed table, then lay the barrier on the table, on top of a fly swatter, the IP replied, No.