Based on observation, and interview the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in the kitchen and that food was stored, prepared, and served under sanitary conditions. This has the potential to affect the 138 residents living in this facility. Findings include: On 2/13/2024 at 9:12 AM, in the refrigerator there were 12 cases of milk stacked in crates containing 4 gallons in each milk in each container stacked 3 crates high. The milk was sitting directly on the floor. On 2/13/2024 at 9:15 AM, in the refrigerator, next to the milk was a pull-out cart that had a large clear container of cabbage and a clear plastic bag of green onions. Both items were cut into small pieces, and there was no date and/or label. On 2/13/2024 at 9:18 AM, in the refrigerator there was a large industrial metal pan that had turkey inside of it, but the plastic was missing partially on the one side and the turkey meat was being exposed to the air in the refrigerator. On 2/13/2024 at 9:15 AM, in the freezer area there was a large industrial 13-pound box labeled breadsticks that was sitting directly on the floor. On 2/13/2024 at 9:15 AM, in the freezer on the opposite side of the breadsticks was a large industrial box labeled white meat sitting directly in the floor. On 2/13/2024 at 9:18 AM, V12, Dietary Manager stated I would expect all items to be dated and labeled and no items to be sitting directly on the floor. I would expect all items to be completely covered. I just pushed the cabbage on the cart back into the refrigerator when I heard that you all were in the building. The cabbage and onions are fresh, I am cooking them today, but it does not have a date and or label. Everything should be dated and labeled. On 2/13/2024 at 9:22 AM, in the dry storage area there was large industrial bin of white substance that had the scoop inside touching the powdery substance. On 2/13/2024 at 9:24 AM, V12 stated, I would not expect the scoop to be inside the container, and it should be hanging and not inside the thickener. On 2/13/2024 at 9:26 AM, the ice machine in the dry storage area had no air gap present. The metal drainage hose from the ice machine went directly into a screen under the machine and there was no air gap present. This allows for potential backflow into the ice machine from the sewage drain. On 2/13/2024 at 9:33 AM, V12 stated I do not know anything about air gaps. We use the ice for everyone in the facility. You will need to talk to the maintenance man. On 2/15/2024 at 8:32 AM, V1, Administrator stated, We pulled the ice machine and there was no air gap, and we are fixing it now. The Water and Sewage Code Section 890 documents, Air Gap: The unobstructed vertical distance through the free atmosphere between the lowest opening from any pipe or faucet supplying water to a tank or plumbing fixture and the flood-level rim of the receptacle. An air gap in a drainage system is a piping arrangement in which a drain from a fixture, appliance or device discharges indirectly into another fixture, receptacle or interceptor at a point above the flood level rim. The air gap between an indirect waste and the drainage system shall be at least two (2) times the diameter of the fixture drain or drainage pipe. The Food Storage and Labeling Procedure with a revision date of 9/22 documents, To provide staff with guidelines for food storage and labeling of foods. Store food at least 6 inches off the floor. Labeling of refrigerated foods: The label should include Product name, date, and discard date. The Long-Term Care Facility Application for Medicare and Medicaid form, CMS 671, dated 2/13/2024 documented the facility had a census of 138 residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R288's Care Plan, dated 11/10/22, documents (R288) Resident is at increased risk for skin breakdown related to decreased mobility, generalized muscle weakness following recent illness and hospitalization, malnutrition/low H&H (Hemoglobin and Hematocrit), and B&B (Bowel and Bladder) incontinence. Interventions: Provide incontinent care after each incontinent episode. It continues R288 has a UTI (Urinary Tract Infection). Interventions: Assist (R288) with perineal care/incontinence care as needed, Encourage fluids, administer antibiotic as ordered. R288's MDS, dated [DATE], documents that R288 has a moderate cognitive impairment and requires extensive assistance from two staff members for most of his ADLs (activities of daily living). R288 requires extensive assistance from two staff members for toileting. On 12/13/22 at 10:35 AM, V18 (Certified Nursing Assistant/CNA) and V16 (Certified Nursing Assistant/CNA) went into R288's room to perform perineal care for R288. R288 was inquiring about why they are doing this and V18 stated that they had to show how they do perineal care. Both CNAs donned gloves without performing hand hygiene prior. R288 rolled over, and her brief/underwear pulled down and incontinence pad rolled under her. V18 doffed her gloves, donned clean gloves with no hand hygiene done. V18 wiped once across top of pubic area, once down each groin, once down R288's vagina, and then wiped the right and left outer buttocks. V18 did not wipe between R288's buttocks and anal area and there was no drying of R288 after any cleansing. V18 did not change her gloves after performing perineal care and began putting a clean incontinence pad onto the bed. R288 was rolled to her side and the soiled linen was removed. R288's underwear and pants were pulled up using the same soiled gloves. V16 and V18 then doffed their gloves and hand hygiene performed. R288 was still asking why they were doing this and V18 repeated to her that they had to show how they do perineal care. V18 stated that R288 was not incontinent and wore her own underwear and that she was not even wet, but they just wanted to show how to do perineal care. Based on observation, interview and record review, the facility failed to perform complete catheter and incontinent care for 5 of 7 residents (R4, R14, R74, R119, R288) reviewed for toileting in the sample of 57. Findings include: 1. R14's Care Plan, dated 12/12/2022, documents Problem: Resident Care Information it also documents Approach: Bowel and Bladder: Incontinent of both. Incontinence Products: Large brief. R14's Minimum Data Set (MDS), dated [DATE], documents that R14 is cognitively intact, always incontinent of bowel and bladder, and requires extensive physical assist of 1 staff member for toileting. On 12/12/22 at 9:40 AM, V4 (Certified Nursing Assistant/CNA), performed incontinent care. R14 was incontinent of urine. R14 voided on toilet as well. V4 assisted R14 into the standing position. Using cleaning wipes, V4 cleansed R14's buttocks and peri area. V4 did not cleanse R14's inner labia and inner thighs. On 12/12/2022 at 9:43 AM, V4 stated that R14 was incontinent of urine. 2. R4's Care Plan, dated 12/13/2022, R4 has a (indwelling urinary) catheter related to obstructive uropathy. It continues Resident Care Information documents APPROACH: Provide catheter care as needed. R4's MDS, dated [DATE], documents that R4 has a catheter and requires limited physical assist of 1 staff for toileting. On 12/13/2022 at 8:50 AM, V5(Certified Nursing Assistant/CNA) and V6 (Certified Nursing Assistant/CNA) assisted R4 with toileting. R4 was incontinent of a small amount of bowel. R4 then had a bowel movement on the toilet. V6 then, using a personal cleansing cloth, performed peri care. V6 cleansed both sides of R4's groin. V6 then cleansed R4's outer and inner labia wiping from dirty to clean. V6 cleansed R4's inner labia and noted to have a large amount of stool on personal cleansing cloth. V6 did not provide any further peri care. V4 then cleansed R4's buttocks. V4 cleansed R4's anal area and stool noted on personal cleansing cloth. V4 placed cloth in trash can and assisted R4 with pulling up R4's brief and pants. V4 and V6 did not perform catheter care. 3. R74's Care Plan, dated 11/17/2022, documents PROBLEM: Resident Care Information. It continues APPROACH: Bowel and bladder: Continent of both. Incontinency product: Underwear. R74's MDS, dated [DATE] documents that R74 is continent of bowel and bladder and requires extensive physical assist of 1 for toileting. On 12/13/2022 at 9:10 AM, V5 (CNA) and V6 (CNA) assisted R74 with incontinent care. R74 was incontinent of a large amount of soft bowel. V6, using personal cleansing cloths, cleansed R74's penis, scrotum and groin area. V5 and V6 turned R74 onto his left side and cleansed R74's right buttock and partial left buttock. V5 and V6 then placed clean incontinent brief under R74. V5 and V6 then turned R74 onto his back and fastened R74's incontinent brief. V5 and V6 did not cleanse R74's entire left buttock. On 12/15/2022 at 11:30 AM, V2 (Director of Nursing/DON) stated that she would expect the CNAs to perform catheter care when performing incontinent and peri care. 5. On 12/13/2022 at 9:35 AM, V30 (Certified Nursing Assistant/CNA) took a Personal Cleansing Cloth with left hand, and with right hand held open R119's abdominal fold and cleansed R119's abdominal fold. V30 threw cloth away, got another wipe, and then cleansed right groin area, with her left hand, and then retrieved another cleansing cloth, and cleansed R119's left groin area. V30 asked V31 (CNA) to help hold open R119's labia and V30 took a cleansing wipe and cleansed down the center of R119's perineum. None of these areas were dried after staff used a Personal Cleansing Cloth. V30 then took a Personal Cleansing Cloth, cleansed R119's right hip, obtained a new cloth and cleansed R119's perirectal area several times, with different wipes, due to R119 was smearing stool. These areas were not patted dry and were left wet. V30 and V31 rolled R119 over onto her right side. V30 cleansed R119's left hip with a Personal Cleansing Cloth, obtained a new personal cleansing cloth, and cleansed R119's peri rectal area again. No areas were dried after care. R119's Braden Scale, dated 11/1/2022 documented that she was at moderate risk for skin breakdown and that her skin was very moist. R119's Care Plan, dated 7/30/2022, documented, Provide incontinent care after each incontinent episode. On 12/13/2022 at 11:30 AM, V29 (Customer Service Representative) from the makers of Personal Cleansing Cloths, stated that the company does not give recommendations for use and that it is left up to the facility to put something in their policy. On 12/14/2022 at 11:15 AM, a test of the time for drying after use of personal cleansing cloth was performed. Antecubital area was cleansed with personal cleansing cloth. The antecubital was closed for 1 minute to provide skin to skin contact. After 1 minute of skin to skin contact the antecubital area remained moist. The facility's Perineal Care policy, dated 11/18, documents Objective 1. To cleanse the perineum. 2. To prevent infection and odors. It continues, Procedure: 4. Wash perineal area with soap and water, perineal cleanser or wipes. Begin cleansing from the cleanest area in front to the most soiled area in back. Be sure that a clean surface of the washcloth is used for each wipe. On a female resident, clean the labia and its folds first. The facility's Catheter Care Policy, dated 6/05, documents Objective 1. To cleanse the perineum. 2. To prevent infection and odors. It continues, Procedure 4. Wash perineal area with soap and water or perineal cleanser. Begin cleansing from the cleanest area in front to the most soiled area in back. Be sure that a clean portion of the washcloth is used for each wiping motion. On a female resident, clean the labia; then spread the labia to wash the inner folds. 5. After cleansing is complete, rinse if necessary, and then dry the resident by patting skin gently with a clean bath towel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to adhere to infection control practices to prevent the spread of COVID 19 and other infectious organisms by failure to utilize appropriate PPE (Personal Protective Equipment), perform hand hygiene, and maintain clean oxygen equipment, for 5 of 7 residents (R12, R114, R119, R123, R281) reviewed for infection control in a sample of 57. Findings include: 1. On 12/14/22 at 7:55 AM, the door to R93's and R122's room, which is a Positive COVID (Coronavirus Disease) Isolation room, was left open and V19 (Housekeeper) was going in and out of the room, cleaning the floor in the room, placing the mop in the bucket outside the room and was only wearing a yellow surgical mask and no other PPE. V19 then left the unit with the housekeeping cart remaining in the unit. V19 was seen afterwards emptying trash in numerous rooms with the same yellow surgical mask on. On 12/15/22 at 9:28 AM, V24 (Licensed Practical Nurse/LPN) stated For any COVID/Isolation room, everyone who enters must wear full PPE, including N-95 mask, gown, and goggles, regardless, if you are doing resident care or not. On 12/15/22 at 9:35 AM, V25 (Housekeeper) stated Anytime I walk into a COVID or Isolation room, I wear a N-95 mask, gown, and goggles. I take the gown off before I leave the room and do hand hygiene. I don't want to take that home. The trash we tie up and put with the regular trash unless it is wet. The linen we put into a red bag, double bag, and take it to laundry. R122's Care Plan, dated 12/7/22, documents R122 has respiratory symptoms consistent with COVID 19 with the Approach Droplet isolation precautions with eye protection. 2. R12's Care Plan, dated 12/12/22, documents (R12) is at increased risk for skin breakdown related to decreased mobility, weakness, occasional bladder incontinence, low albumin, potential for friction and shearing with transfers and repositioning. Interventions: Open area to top of right second toe will heal/improve by the next review: Monitor for signs and symptoms of infection. Treat as ordered. See TAR (Treatment Administration Record). Notify MD (Medical Doctor)/NP (Nurse Practitioner) for changes. R12 will have minimized risk for skin breakdown during this quarter: Provide perineal care following each episode of incontinence, assist resident with turning and repositioning. It continues (R12) Resident Care Information. Interventions: Incontinent of urine and bowel at times. Assist Incontinence Products: Large pullups. R12's Minimum Data Set (MDS), dated [DATE], documents that R12 has a severe cognitive impairment. R12 requires limited assistance from one staff member for most of her ADL's (Activities of Daily Living). R12 requires extensive assistance from one staff member for toileting and personal hygiene. R12 is always incontinent of both bowel and bladder. On 12/13/22 at 9:55 AM, V14 (Registered Nurse/RN) went into R12's room to perform wound care to R12's right second toe. V14 carried in supplies on a clean folded towel, dumped the wound care supplies onto R12's bed, with comforter on top, and used the clean folded towel to put under R12's right foot. V14 donned a pair of gloves, without performing hand hygiene prior to donning gloves and removed the old dressing, dated 12/13/22, from R12's right second toe open wound, pink in color, and had no drainage. V14 used the same soiled gloves to spray wound cleanser onto R12's toe and used a 4X4 gauze to cleanse the wound. V14 used the same soiled gloves and cut a piece of Alginate dressing and applied it to the open wound, V14 then applied a 2X2 gauze dressing on top of the Alginate and taped it to her toe. V14 used the same soiled gloves to get a pen located in his shirt pocket and dated the dressing, then put his pen back in his pocket. V14 then gathered the remaining supplies and some trash using the same soiled gloves and exited the room. V14 put the wound cleaner spray, the pair of scissors, and other dressing supplies back in the wound supply cart, then removed his soiled gloves and did not perform hand hygiene as he took the cart away from the room. 3. R281's Care Plan, dated 12/7/22, documents (R281) is at increased risk for skin breakdown related to decreased mobility, generalized muscle weakness following recent illness and hospitalization. Interventions: (12/6/22) (specific type/brand of mattress) mattress to bed, monitor for signs and symptoms of infection. treatments as ordered. See TAR. Notify MD/NP for changes, provide incontinent care after each incontinent episode, pressure reducing device in wheelchair and bed, assist resident with turning and repositioning, side rails/enablers to assist with turning and repositioning. It continues (R281) Resident Care Information. Interventions: Turning and Repositioning: As needed. two quarter rails, Skin Care: Barrier cream as needed. Skin Checks each shift, Bowel and Bladder: Incontinent of both. Incontinence Products: Medium brief. R281's MDS, dated [DATE], is not completed. On 12/13/22 at 9:05 AM, V12 (Certified Nursing Assistant/CNA) and V11 (LPN) in R281's room for wound care. Supplies setting on clean towel on bedside table. Both V11 and V12 performed hand hygiene and donned clean gloves. The old dressing was removed from R281's coccyx which was dated 12/13/22. V11 doffed her gloves and performed hand hygiene. V11 donned clean gloves and used normal saline and gauze pads to cleanse R281's wound. Using the same soiled gloves, V11 applied Xeroform to the wound, then a padded dressing applied and dated. V11 then doffed her gloves and performed hand hygiene. R281's Nurses Note, dated 12/6/22 at 11:04 AM, documents Called and informed POA (Power of Attorney) of shearing area to the right buttock area that measures 1 cm (centimeters) x 0.7 cm and new treatment orders explained and understanding met. R281's Physician Note, dated 12/6/22, documents Cleanse open area to right buttock and apply Xeroform gauze and padded dressing daily and PRN (As Needed). On 12/15/22 at 10:53 AM, V1 (Administrator) stated, I would expect the staff to follow the infection control guidelines, including the wearing of appropriate PPE when necessary, especially going into COVID or isolation rooms, the changing of gloves when soiled, and proper hand hygiene when indicated. The Facility's Standard Precautions Policy, dated 8/2009, documents Standard precautions will be used in the care of all residents regardless of any suspected or confirmed presence of an infectious agent. Standard precautions are based on principle that all, blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. It continues Procedure: 1. Hand hygiene: a. Refers to washing hands with water and either plain soap or soap/detergent containing an antiseptic agent; or thoroughly applying an alcohol-based hand rub (ABHR). b. Wash hands when they are visibly soiled, before and after eating or handling food, before or after assisting a resident with meals, before and after assisting a resident with the toilet and after contact with a resident with infectious, whether or not gloves are worn. c. Hand hygiene should be performed immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer or microorganisms to other residents or environment. Utilize hand hygiene between tasks and procedure on the same resident to prevent cross-contamination of different body sites. d. Unless hand washing is specifically required, antimicrobial agents are appropriate for cleaning hands and can be used for direct resident care. 2. Gloves: a. Wear gloves (clean, non-sterile) when touching blood, body fluids, secretions, excretions, and contaminated items. b. Put on clean gloves just before touching mucous membranes and non-intact skin. c. Change gloves between tasks and procedures on the same resident after contact with material that may contain infectious agents. d. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of infectious agents to other residents or environments. The facility's COVID-19 Policy, dated 11/14/22, documents: The infection Control Program (ICP) at this facility recognizes Novel Coronavirus (COVID-19) as a highly contagious virus and has a focus to reduce the risk of unnecessary exposures among residents, staff, and visitors. Measures are based on guidance from the Centers for Disease Control (CDC), Center for Medicare and Medicaid Services (CMS) and state and local authorities. Interventions focus on prevention of exposure, early detection of symptoms, effective triage and isolation of potentially infectious residents. It continues Residents with confirmed COVID-19: 5. Resident with confirmed COVID-19 infection will be placed in a single-person room. The door should be kept closed (if safe to do so). Ideally, the resident should have a dedicated bathroom. It also documents, 8. Staff will wear N-95 respirators, eye protection, gowns and gloves when caring for residents with COVID-19. 4. 12/13/22 9:35 AM, V30 (Certified Nursing Assistant/CNA) and V31 (Certified Nursing Assistant/CNA) performed hand hygiene and donned gloves. V30 unfastened R119's soiled incontinent brief and rolled it down between R119's legs. Then V30 took a Personal Cleansing Cloth with left hand, and with right hand held open R119's abdominal fold and cleansed R119's abdominal fold with her left hand, threw cloth away, got another wipe, and then cleansed right groin area, with her left hand, and then retrieved another cleansing cloth and cleansed R119's left groin area. V30 continued to provide incontinent care without benefit of hand hygiene or glove changes. 5. On 12/12/2022 at 10:54 AM, R114's nasal cannula tubing was lying on the floor. R114's Resident Face Sheet, undated, documents, diagnoses of Congestive Heart Failure and Pneumonia. R114's Physician Order Report, dated 10/21/2022, documents an order for O2 at 2 (liters/min) nasal cannula (as needed) for (shortness of breath). R114's Care Plan, dated 07/08/2022, documented, Oxygen: 2 liters as needed. 6. On 12/12/2022 at 11:12 AM, R123's Oxygen nasal cannula tubing was lying on the floor under his bed. R123 stated that he wears oxygen when they put it on him. R123's Resident Face Sheet, undated, documents, diagnoses of Anemia, unspecified and Chronic diastolic (congestive) heart failure. R123's Physician Order Report, dated 12/14/2022, documented, that he was on Palliative Care. It does not document an order for Oxygen usage. R123's Care Plan, dated 10/09/2022, documented an approach of O2 at 2 (liters/nasal cannula) as needed. R123's MDS, dated [DATE], documented that his cognition was moderately impaired.

Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 5 of 5 residents (R26, R106, R303, R330, R331) reviewed for antibiotic stewardship in the sample of 57. Findings include: 1.The Facility's Monthly Infection Log for the month of December 2022 does not document an organism causing R26's infection. The log documents R26 was treated with the antibiotic Azithromycin. R26's Physician Order Report for 12/1/22-12/14/22 documents order for 250mg (milligram) Azithromycin tablet - 2 tabs day 1, then 1 tab, oral for chronic obstructive pulmonary disease, unspecified, with start date of 12/6/22 and end date of 12/10/22. R26's Medication Administration Record (MAR) for the month of December 2022 documents R26 received 4 of 6 prescribed doses of Azithromycin. On 12/14/22 at 1:00 PM, documentation to justify the use of Azithromycin was requested. On 12/15/22 at 2:44 PM, no documentation was received. 2. The Facility's Monthly Infection Log for the month of July 2022 does not document an organism causing R106's infection. The log documents prophylactic for laceration and the use of antibiotic Cephalexin. R106's Physician Order Report from 7/1/22 to 12/14/22 documents order for 500mg Cephalexin capsule - 1 capsule oral every 8 hours for encounter for prophylactic measures, unspecified, with start date of 7/13/22 and end date of 7/20/22. R106's MAR for the month of July 2022 documents R106 received 27 of 27 prescribed doses of Cephalexin. On 12/14/22 at 1:00 PM, documentation to justify the use of the antibiotic Cephalexin was requested. On 12/15/22 at 11:45 AM, V2 (Director of Nursing/DON) stated, There was no culture. They were treating him prophylactically. That is very common. 3. R303 was not listed on the Facility's Monthly Infection Log for any month in 2022. R303's Physician Order Report from 7/14/22 to 12/14/22 documents order for 250mg Keflex (cephalexin) capsule oral, once a day, for trigeminal neuralgia with start date of 10/23/21 and end date open ended. R303's MARs for July 1, 2022 through December 14, 2022 document R303 received 167 doses of Keflex. On 12/14/22 at 1:00 PM, documentation to justify the use of the antibiotic Keflex was requested. On 12/15/22 at 2:44 PM, no documentation was received from the Facility. 4. The Facility's Monthly Infection Log for the month of August 2022 does not document an organism causing R331's infection. The log documents prophylactic and use of the antibiotic Amoxicillin. R330's Physician Order Report from 8/1-22 to 9/30/22 documents order for 250mg Amoxicillin capsule - 1 capsule oral with special instructions to take for 90 days per (V6, physician). The diagnosis was documented as encounter for prophylactic measures, unspecified with start date of 8/29/22 and discharge date of 9/15/22. R330's MARs for the months of August and September 2022 document R330 received 17 doses of Amoxicillin. On 12/14/22 at 1:00 PM, documentation to justify the appropriate use of the antibiotic Amoxicillin was requested. On 12/15/22 at 2:44 PM, no documentation was received from the Facility. 5. The Facility's Monthly Infection Log for the month of July 2022 does not document an organism causing R331's infection. The log documents prophylactic and the use of antibiotic Bactrim. R331's Physician Order Report from 7/14/22 to 12/14/22 does not document order for Bactrim but does document order for 250mg Zithromax Z-Pak (Azithromycin) tablets - 2 oral for other specified diseases of upper respiratory tract with start date of 7/19/22 and end date of 7/19/22. There is also an order for 250mg Zithromax Z-Pak (azithromycin) tablet - 1 oral for other specified diseases of upper respiratory tract with start date of 7/20/22 and end date of 7/23/22. R331's MAR from 7/1/22 to 7/31/22 documents R331 received 5 doses of Zithromax Z-Pak. On 12/14/22 at 1:00 PM, documentation to justify appropriate use of Zithromax Z-Pack was requested. On 12/15/22 at 2:44 PM, no documentation was received from the Facility. On 12/14/22 at 9:40 AM, V23 (Infection Control Preventionist/ICP) stated, I read progress notes, run reports, look up antibiotic reports for new antibiotics, and fill out the monthly infection control log first thing in the morning before the morning meeting. Every time I get an antibiotic order I check to see if it is warranted. I look at the results first, and if it says 'no culture to follow' I put 'no' on the log. If not, I check with the doctor. Usually, they will say not to continue or to discontinue it. The Facility's Antibiotic Stewardship Policy revised 12/18/19 documents, It is the policy of the facility to follow an Antibiotic Stewardship program, including the core elements as outlined by the CDC (Centers for Disease Control). The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. The facility will track antibiotic use daily. The facility will communicate with the physician(s) prescribing antibiotics with a Utilization report on a monthly basis and as needed. The Facility's Infection Control Policy revised 12/17/19 documents, Nursing staff will develop weekly reports on antibiotics, including review to ensure appropriate use of antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to properly store and label medications. This has the potential to affect all 139 residents in the Facility. Findings include: On [DATE] at 3:20 PM, the medication storage room for the 400 and 500 halls was inspected. The medication room contained the following medication: 1-Bottle of Tubersol with no opened date. V10 (Licensed Practical Nurse/LPN) stated, I think that has been opened since the cap is off. On [DATE] at 1:48 PM, V21 (Licensed Practical Nurse/LPN) stated, We give the Tubersol on admission, then yearly, as needed. All the residents have standing orders to get it once a year. On [DATE] at 2:24 PM, V2 (Director of Nursing/DON), Tubersol has an expiration date on it, but it also has to have an opened date on it. The opened date is how we know when the product is expired. I would expect my nurses to put a date on it after opening. It is a multi-dose vial. Everyone receives it unless they have an allergy to it. On [DATE] at 3:10 PM, V1 (Administrator) and V2 (DON) stated that they were unsure whether the facility should follow manufacturer's instructions for Tubersol and would like to refer to their policy. The Facility's Pharmaceutical Procedures Policy revised [DATE] does not address multi-dose vials. Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated [DATE], documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. The Resident Census and Conditions of Residents, CMS 672, dated [DATE] documents the facility has 139 residents living in the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards. This has the potential to affect all 139 residents living in the facility. Findings include: On 12/13/22 at 11:45 AM, in the dry storage room, there was a large tub containing a white powdery substance labeled food thickener. There was no date on this container. On the shelf in the dry storage room, there was a plastic bag with macaroni that was wrapped up, but not labeled or dated. On 12/13/22 at 11:47 AM, in the walk-in freezer, there was a plastic bag full of biscuits that had been opened and tied up but was not labeled or dated. There was a bag containing pieces of oblong shaped meat that had been tied up but was not labeled or dated. V3 (Dietary Manager) stated, Those are pork riblets. On 12/13/22 at 11:48 AM, in the walk-in refrigerator, there was a container covered in aluminum foil with M/S chicken and 12/6-12/12 written in black marker. There was a container labeled coleslaw and 12/6/-12/12 on top. V3 (Dietary Manager) stated, These should have been thrown out on the twelfth. I'm going to get these out of here. On 12/13/22 at 11:55 AM, in the 100-hall satellite kitchen, temperatures were obtained from the steam table using metal calibrated thermometer. The mechanically altered beef measured 127 degrees Fahrenheit (F), and the pureed beef measured 127 degrees F. On 12/15/22 at 10:50 AM, V1 (Administrator) stated, I would expect my staff to follow our food service policies. The Facility's Purchasing, Receiving and Food Storage Policy revised 9/10 documents, It is the policy of the facility to provide quality and wholesome food by following assigned budget, and to receive and store food by following sanitation standards, which are in compliance with state and federal rules and regulations. Unless its identity is unmistakable, bulk food not stored in the original labeled container or package in which it was obtained shall be stored in a container labeled to identify the common name. The Facility's Food Temperatures-Measuring Procedure Policy adopted 8/19 documents, Hot foods should be held at least 135 degrees F or higher. 135 degrees F for hot holding-held in warming cabinet or on steam table. The Facility's Meal Service Procedure Policy, adopted 11/14/22, documents, Food items should be returned to the kitchen if hot food is below 135 degrees F. The Resident Census and Condition of Residents Form (CMS 672) dated 12/12/22 documents there are 139 residents living in the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R116's Physician Order Sheet dated 11/10/2021 documents diagnoses of contracture right hand and contracture left hand. R116's Physician Orders, dated 08/07/2021, documented, (Bilateral) hand splints to be worn (every) shift for minimum of 2 hours up to 6-8 hours. Replace splints with rolled washcloths to (bilateral) hands when splint therapy is complete. R116's Care Plan, dated 08/17/2021, documents, PROM Program: 1. Explain to (R116) what you are going to do. 2. Perform PROM to BUE (Bilateral Upper Extremities) and BLE (Bilateral Lower Extremities). 3. Monitor for any signs of pain/discomfort (i.e. facial grimacing, guarding of extremity, withdraw of extremity, etc.), if signs of pain stop performing PROM and notify the nurse. 4. Apply splint/brace to (Bilateral) hands for 2 hrs up to 6-8 hrs (she can sleep in them) with skin and splint fit checks. On 11/09/2021 from 01:00 PM to 2:30 PM, R116 was lying in bed without bilateral hand splints or rolled up wash cloths in hands. On 11/10/2021 at 9:50 AM, R116 was lying in bed without bilateral hand splints or rolled up wash cloths in hands. On 11/10/021 at 12:04 PM, R116 was sitting up to her high back reclining wheelchair; she did not have on her bilateral hand splints nor did she have rolled up wash clothes in her hands. On 11/10/2021 at 01:46 PM, V38 (CNA) stated that R116 doesn't like wearing her hand splints and that she (R116) takes them off. When was asked what about the rolled washcloths, V38 stated, Oh is that what that means? There was no documentation of R116 refusing bilateral splints. The facility policy Nursing Rehab Policies, revision date of 11/2006, documents, Purpose: To assist the resident to achieve and maintain the maximum level of function physically, mentally and socially. It continues, The nursing personnel shall receive special instruction, demonstrations and supervision in rehabilitation techniques. They include the following: It continues, 3. ROM technique. Residents shall be assisted in maintaining maximum range of motion. Based on observation, interview and record review, the facility failed to provide range of motion exercises and place splints for 3 of 5 residents (R50, R68, R116) reviewed for limited range of motion in the sample of 71. Findings include: 1. R50's Face Sheet, dated 11/16/21, documents R50 was admitted on [DATE] and has a diagnosis of left hand contracture. R50's Physician Orders document, Start date 7/28/21, Resident is to have rolled wash cloth in L (left) hand per therapy. Twice A Day 07:00 AM - 03:00 PM, 07:00 PM - 03:00 AM. R50's Minimum Data Set (MDS), dated [DATE], documents that R50 is severely cognitively impaired and has range of motion impairments on one side of the upper and lower extremity. R50's OT (Occupational Therapy) Progress and Discharge summary, dated [DATE], documents, Treatment diagnosis: Contracture left hand. Start of Goal Status as of 7/14/21. The patient has L (left) hand contractures and keeps hand in fist nearly all the time with increased risk of skin breakdown, deformity, worsening contractures, pain, and difficulty with hygiene care. End of Goal Status as of 10/10/21. The patient tolerates wearing the L resting hand splint for up to 6 - 7 hours intervals without signs and symptoms of skin breakdown with periodic splint fit and skin checks to prevent skin breakdown, improve joint posture, and prevent worsening of L hand contracture. Discharge Plan and Instructions: The patient is to be D/C (discharged ) from OT following Tx (treatment) this date due to reaching her goals of OT and highest functional level. RNP (Restorative Nursing Program) is in place for PROM (Passive Range of Motion) and splinting. R50's Therapy Recommendation/Communication, dated 8/9/21, documents, Resident's Current Status for each Suggested Program or Recommendation - Problem(s): The patient has decreased AROM (Active Range Of Motion) in B (both) hands to shoulders with decreased mobility and high risk of contractures and skin breakdown. Reason(s) of each Suggested Program or Recommendations - Goals: The patient will participate in PROM and gentle joint movement in B arms. The patient will wear the L resting hand splint each nursing shift for at least 2 hours to up to 6 - 8 hours (patient can sleep in it) with skin to splint fit checks. R50's Care Plan, revision date of 09/23/21, documents, PROBLEM: (R50) is at risk of decline in ROM (Range of Motion) to Left Upper/Lower extremities due to Hemiplegia secondary to past CVA (Cardiovascular Accident). GOAL: (R50) will have decreased risk of limitations in ROM to Left Upper/Lower extremities. APPROACH: PROM (Passive Range of Motion) Program: 1. Explain to (R50) what you are going to do. 2. Perform PROM to Left Upper/Lower extremities. 3. Monitor for any signs of pain/discomfort (i.e. (for example) facial grimacing, guarding of extremity, withdraw of extremity, etc.), if signs of pain stop performing PROM and notify the nurse. May participate in group AROMP (Active Range of Motion Program). On 11/08/21 at 09:01 AM, V26 (Certified Nurses Aide/CNA) stated, (R50) used to have a brace (for left hand), but I haven't seen it in a while. We don't do anything with restorative, no stretching or anything. I think therapy works with her. On 11/08/21 at 09:01 AM, R50 was lying in her bed. R50's left hand fingers were curled under into her palm. V26 (CNA) was able to stretch R50's fingers open to about 25%. 2. R68's Face Sheet, print date of 11/10/21, documents R68 was admitted on [DATE] and has a diagnosis of a contracture of the right hand. R68's MDS, dated [DATE], documents R68 is severely cognitively impaired. R68's Physician Orders dated 7/28/21, documents, Wash cloth is to be placed to R (right) hand per therapy. Twice A Day. 07:00 AM - 03:00 PM, 07:00 PM - 03:00 AM. R68's OT Therapist Progress and Discharge summary, dated [DATE], documents, Start of Goal Status as of 07/20/21. The patient has poor joint mobility and beginning contractures in the right hand with high risk of skin breakdown, deformity, pain, behaviors, and difficulty with hygiene care. She would benefit from a R resting hand splint to improve posture. End of Goal Status as of 10/22/21. The patient tolerates wearing the RUE (Right Upper Extremity) resting hand splint for 6 - 8 hours intervals with no signs or symptoms of skin breakdown with frequent skin checks and splint adjustments PRN (as needed) due to patient shifting in splint or trying to remove it at times. Analysis of Functional Outcome/Clinical Impression: The patient is being D/C from OT following tx this date due to reaching a plateau in progress at this time with goals partially met. The patient's caregivers are to follow through with the patients splint and PROM program for RNP (Restorative Nursing Program). R68's Therapy Recommendation/Communication, dated 8/9/21, documents, Resident's Current Status for each Suggested Program or Recommendation - Problem (s): The patient has decreased AROM in B hands to shoulders with very limited functional mobility and high risk of contractures and skin breakdown. Reason(s) of each Suggested Program or Recommendations - Goals: The patient will participate in PROM and gentle joint movement in Both arms and legs. The patient will wear the R resting hand splint each nursing shift for at least 2 hours to up to 6 - 8 hours (patient can sleep in it) with skin to splint fit checks. On 11/10/21 at 12:36 PM, R68 was sitting in dining room. R68's right hand fingers were contracted into the palm of her hand. On 11/10/21 at 12:38 PM, V27 (CNA) stated, We do stretching exercises with her but she does not like it. At this time, R68 did try to pull her hand away and grimace in pain when fingers were stretched. On 11/10/21 at 1:00 PM, V27 (CNA) stated, She (R68) used to have a splint. Therapy was working with her to find something different because it was very hard to get on her. On 11/10/21 at 01:40 PM, V2 (Director of Nursing/DON), stated, We do not have a restorative nurse. The therapy writes the programs that they suggest they need to have. The Care Plan Coordinator/MDS (V31) puts in what the CNAs should be doing. The shift coordinator will oversee the CNAs to ensure the CNAs are doing the restorative programming that therapy recommended. The therapy department also in-services the CNAs on the restorative program for the residents. The therapy department assesses all new admissions and decline in function. I have been trying to hire someone for 11 months and I haven't even got one application. On 11/16/21 at 12:46 PM, V36 (Certified Occupational Therapist Assistant/COTA) stated, The therapist will write up a program for the resident. The program is then given to the MDS Coordinator (V31) and she puts it into the computer. The CNAs are trained on how to apply the splints before the resident is discharged from therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the appropriate antibiotic was used for 1 of 5 residents (R9) reviewed for unnecessary medications in the sample of 71. Findings include: R9's Progress Note dated 10/27/21 at 1:11 PM documents Urine specimen taken to lab. Sent medi-procity (secure messaging for long term care providers) of Urinalysis (UA) results to Family Nurse Practitioner (FNP). Waiting orders. R9's Progress Note dated 10/27/21 at 3:00 PM documents FNP reviewed UA results and orders received. Macrobid 100 milligram (mg) 1 oral (PO) twice a day (BID) for seven days. R9's Physician Order Sheet dated 10/27/2021 to 11/03/2021 documented Macrobid (nitrofurantoin monohyd/mcryst) capsule 100 milligrams (mg) 1 oral, DX (diagnosis) urinary tract infection (UTI), site not specified twice a day; 6:30 am - 9:30 am, 3:30 pm - 5:45 pm. R9's UA culture dated 10/27/21, results on 10/30/21, documents (R9) had a UTI showing Extended Spectrum Beta-Lactamase (ESBL) with the organism of Escherichia Coli (E-Coli). It continues ESBL is resistant to Ceftriaxone (Rocephin) and Nitrofurantoin (Macrobid) antibiotics. R9 was already receiving the Macrobid, which was not stopped and R9 did not receive a medication change once results were obtained. R9 continued for another four days on Macrobid. R9's Progress Note dated 11/8/21 at 11:27 AM documents Resident continues to be monitored post antibiotic for treatment of UTI. Resident continues to display signs of altered mental status. Resident is refusing medications by pursing lips tightly shut. Staff continues to encourage caloric and fluid intake; however, resident is not receptive of the encouragement and is observed again, pursing lips tightly, refusing medications. Resident is also observed refusing activities of daily living (ADLs) and becoming easily agitated and combative. Resident is not easily comforted or redirected during ADLs. Orders have been received to send resident to the local hospital emergency room (ER) for further evaluation and treatment. Power of Attorney (POA) has been contacted via telephone and made aware. POA verbalized understanding. R9's Progress Note dated 11/8/21 at 4:07 PM documents Resident returned from local hospital per ambulance and two Emergency Medical Technician (EMT) assists with diagnosis of UTI. Attending Family Nurse Practitioner (FNP) is aware and provided orders to discontinue ER Physicians order for Levaquin 750mg; 1 tablet daily for seven days due to resident's unwillingness to take oral medications at this time due to altered mental state. FNP has opted to order Rocephin 1gram (g) Intramuscular (IM) for treatment of UTI. R9's Progress Note dated 11/8/21 at 4:11 PM documents A new prescription order was transcribed per the order of FNP. Ceftriaxone (Rocephin) recon solution; 1g; injection Once - One Time. 07:00 AM - 10:00 PM. The culture results on 10/30/21 document that the organism was resistant to Rocephin. R9's Progress Note dated 11/8/21 at 8:44 PM documents Antibiotic administered for treatment of UTI. Rocephin (Ceftriaxone) 1gm IM injection, reconstituted with 2.5 milliliters (ml) of Lidocaine 10mg/ml, was administered to the right dorsogluteal muscle. Resident tolerated well. Resident is resting per bed and continues to be monitored. R9's Progress Note dated 11/10/21 documents Lab called and stated resident has ESBL in urine. Orders received to insert urinary catheter until infection resolved. Urine catheter inserted per sterile procedure with a good return of yellow urine. (R9) tolerated procedure well. Fluids encouraged. On 11/15/21 at 10:50 AM, V25 (Licensed Practical Nurse/LPN) stated, (R9's) UA came back on 10/30/21 with ESBL (E-Coli) in urine. She (R9) was put on Macrobid 100mg for seven days at that time. I believe she (R9) finished that round of antibiotics. She (R9) began having behaviors and was sent to the ER on [DATE]. She (R9) was returned to the facility that day with a diagnosis of a UTI. Then the lab called me on 11/10/21 with her recent culture results from 11/8/21, which showed ESBL (E-Coli) in her urine. Because (R9) won't take pills, the physician changed it to the Rocephin 1gm IM. I see now that ESBL is resistant to both Macrobid and Rocephin and it wasn't addressed. We must have missed that. I will notify the physician and let her know. When asked about the urinary catheter inserted, V25 stated, We really can't have an isolation room in this unit because other residents can go into the rooms. We can't have a portable toilet next to their bed because other residents will go in and use it too. That is why a urinary catheter was put in her. When asked about moving the resident to another room to be isolated, V25 stated, That is up to our Administrator. On 11/15/21 at 12:50 PM V29 (FNP) stated, (R9's) UA from 10/27/21 documents that she (R9) had a colony count of greater than 100,000 and was considered to be colonized. Anything over 100,000 I would consider the person to be colonized. (R9) was treated with Macrobid first because we didn't know the culture results yet. The Macrobid was supposed to be discontinued and changed to something else. V3 (Assistant Director of Nursing/ADON) looked, and the order was not discontinued nor was anything else started. V29 then stated, (R9) continued with worsening symptoms and was sent to the ER on [DATE]. She was given Rocephin IM because if the ER physician thought she needed an antibiotic, who was I to think differently, so I gave her the Rocephin one time dose. When asked about giving meds that are resistant to ESBL, V29 stated, Sometimes it's like a 'Hail Mary' and we are hoping that it may treat something underlying. When asked about the urinary catheter insertion, V29 stated, That might be a facility policy to use a catheter instead of moving a resident to another room. On 11/15/21 at 1:15 PM V30 (Medical Doctor/MD) stated, I would consider a UA result with anything over 50,000 colonization as significant and treat with something that would work. I would not consider (R9) to be colonized. (R9) was probably given Macrobid first because that's what my FNP and I always use first. I see a note where my FNP was supposed to stop the Macrobid and change it to Cipro, but Cipro would not have been the correct drug either. (R9's) urinary catheter should not have been put in. The right thing would have been to move the resident to a room where they could have isolation, but that is the facility Administrator's decision. We really have not treated (R9) yet for her UTI, but I assure you it will be taken care of immediately. On 11/16/21 at 11:50 PM V2 (Director of Nursing/DON) stated, We asked (V29/FNP) about (R9's) UA results and if we could put a urinary catheter in her (R9), and (V29) stated to go ahead and do that. R9's progress note dated 11/15/21 at 1:46 PM documents (V30/MD) called and gave orders for Bactrim-DS twice a day for seven days. The UA is to be repeated on the eighth day. If (R9's) urine is negative for ESBL, remove the urinary catheter. The facility's Antibiotic Stewardship Policy, dated 12/18/19, documents The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events.

2. On 11/09/21 at 7:50 AM, a medication administration was observed with V9 (RN). V9 crushed two Acetaminophen 500mg tabs, a Levothyroxine 88mcg, a Losartan 100mg tab, a Methenamine hippurate 1 gm tablet, a MV1 with Minerals tablet, an Oscal + Vit (vitamin) D 250mg tablet, and a Quetiapine 50mg tablet in a plastic pouch. V9 then opened a hydrochlorothiaze 12.5mg capsule, a Memantine 28mg ER (extended release) capsule and the Potassium 10meq extended release and placed in the plastic pouch and crushed the medications. V9 then poured the crushed medications in a clear plastic medication cup of chocolate syrup. V6 then mixed the medication in the chocolate syrup and administered the medication to R102 orally. R102 received 250mg of Oyster Shell Calcium and not the 500mg per physician orders. R102's Physician Order Sheet (POS), not dated, documents Oyster Shell Calcium-Vit D3 tablet; 500mg (1,250mg) - 200 unit amt (amount) once a day. Drugs & Supplements (https://www.everydayhealth.com/drugs/), dated 12/10/20, documents, How to take Quetiapine (Seroquel)? Swallow the tablet whole and do not crush, chew or break it. 3. On 11/09/2021 at 8:18 AM, a medication pass was observed with V9 (RN). V9 administered a Chewable Aspirin 81 mg, a Fluoxitine 10mg tablet, a Metoprolol Succ 100mg tablet, a Vit B 12 500mcg tablet, and a Buproprion HCL 300mg tablet orally to R115. Prior to administration of the medication V9 obtained R115's blood pressure with results of 116/70. R115's POS, dated 11/1/2021 - 11/16/2021, documents Toprol XL (metoprolol succinate) tablet extended release 24hr; 100mg; 1 tablet daily. Special Instructions Hold if systolic is less than 120 or HR is less than 60. Lisinopril 10mg 1 tablet oral once a day. Special Instructions Hold if systolic is less than 120. R115's Medication Administration Record, dated 11/9/2021-11/16/2021, documents 11/9/2021 lisinopril 10mg tablet not given due to condition: systolic bp less than 120. It also documents Toprol XL (metoprolol succinate) tablet extended release 24hr; 100mg; 1 tablet daily as administered. On 11/17/2021 at 3:10 PM, V2 (DON) stated that when the nurses are passing medications she would expect the nurses to follow the physician orders and special instructions and parameters in place. The facility's Pharmaceutical Procedures, revised date 10/18/2019, documents Medication Errors and Adverse Reactions. A. Medication Errors Defined: Medication errors are defined as 2. Wrong dose administered. It continues, 4. Wrong dosage form. It further documents, 6. Not given per manufacturer's specification and with standards of practice. Based on observation, interview and record review, the facility failed to administer the prescribed medications in a form which is recommended according to the drug manufacturer. There were 60 opportunities with 4 errors resulting in a 6.67% medication error rate. The errors involved medications that could not be crushed that were crushed and not following physician orders for 3 of 12 residents (R84, R102, R115) observed during medication pass in the sample of 71. Findings include: 1. On 11/08/21 at 11:48 AM V15 (Registered Nurse/RN) prepared R84's noon medications. V15 opened two 300 milligram (mg) Gabapentin capsules and placed the contents in a medication cup and mixed it with pudding. V15 then administered it to R84. R84's Physician Order Report dated November 2021 documents, Neurontin (gabapentin). Capsule; 300 mg; amt: 2 tabs (tablets); Oral. Three Times A Day. 06:30 AM - 09:30 AM, 11:00 AM - 01:00 PM, 07:00 PM - 10:00 PM. The website https://www.mayoclinic.org/drugs-supplements/gabapentin-oral-route/proper-use/drg documents, for Gabapentin capsules, Swallow the capsule whole with plenty of water. Do not open, crush or chew it. On 11/16/21 at 3:45 PM V2 (Director of Nurses/DON) stated that she did not realize Gabapentin capsule could not be opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 11/16/21 at 11:50 PM V2 (Director of Nursing/DON) stated, We asked (V29/FNP) about (R9's) UA results and if we could put a urinary catheter in her (R9), and (V29) stated to go ahead and do that. ? Based on interview and record review, the facility failed to ensure the appropriate antibiotic was used for 1 of 5 residents (R9) review for antibiotic usage in the sample of 71. Findings include: R9's Progress Note dated 10/27/21 at 12:36 PM documents resident was confused, complained of burning when she urinated, and a urine sample was obtained. R9's Progress Note dated 10/27/21 at 1:11 PM documents Urine specimen taken to lab. Sent medi-procity (secure messaging for long term care providers) of Urinalysis (UA) results to Family Nurse Practitioner (FNP). Waiting orders. R9's Progress Note dated 10/27/21 at 3:00 PM documents FNP reviewed UA results and orders received. Macrobid 100 milligram (mg) 1 oral (PO) twice a day (BID) for seven days. R9's Physician Order Sheet dated 10/27/2021 to 11/03/2021 documented Macrobid (nitrofurantoin monohyd/mcryst) capsule 100 milligrams (mg) 1 oral, DX (diagnosis) urinary tract infection (UTI), site not specified twice a day; 6:30 am - 9:30 am, 3:30 pm - 5:45 pm. R9's UA culture dated 10/27/21, results on 10/30/21, documents (R9) had a UTI showing Extended Spectrum Beta-Lactamase (ESBL) with the organism of Escherichia Coli (E-Coli). It continues ESBL is resistant to Ceftriaxone (Rocephin) and Nitrofurantoin (Macrobid) antibiotics. R9 was already receiving the Macrobid, which was not stopped and R9 did not receive a medication change once results were obtained. R9 continued for another four days on Macrobid. R9's Progress Note dated 11/8/21 at 11:27 AM documents Resident continues to be monitored post antibiotic for treatment of UTI. Resident continues to display signs of altered mental status. Resident is refusing medications by pursing lips tightly shut. Staff continues to encourage caloric and fluid intake; however, resident is not receptive of the encouragement and is observed again, pursing lips tightly, refusing medications. Resident is also observed refusing activities of daily living (ADLs) and becoming easily agitated and combative. Resident is not easily comforted or redirected during ADLs. Orders have been received to send resident to the local hospital emergency room (ER) for further evaluation and treatment. Power of Attorney (POA) has been contacted via telephone and made aware. POA verbalized understanding. R9's Progress Note dated 11/8/21 at 4:07 PM documents Resident returned from local hospital per ambulance and two Emergency Medical Technician (EMT) assists with diagnosis of UTI. Attending Family Nurse Practitioner (FNP) is aware and provided orders to discontinue ER Physicians order for Levaquin 750mg; 1 tablet daily for seven days due to resident's unwillingness to take oral medications at this time due to altered mental state. FNP has opted to order Rocephin 1gram (g) Intramuscular (IM) for treatment of UTI. R9's Progress Note dated 11/8/21 at 4:11 PM documents A new prescription order was transcribed per the order of FNP. Ceftriaxone (Rocephin) recon solution; 1g; injection Once - One Time. 07:00 AM - 10:00 PM. The culture results on 10/30/21 document that the organism was resistant to Rocephin. R9's Progress Note dated 11/8/21 at 8:44 PM documents Antibiotic administered for treatment of UTI. Rocephin (Ceftriaxone) 1gm IM injection, reconstituted with 2.5 milliliters (ml) of Lidocaine 10mg/ml, was administered to the right dorsogluteal muscle. Resident tolerated well. Resident is resting per bed and continues to be monitored. R9's Progress Note dated 11/10/21 documents Lab called and stated resident has ESBL in urine. Orders received to insert urinary catheter until infection resolved. Urine catheter inserted per sterile procedure with a good return of yellow urine. (R9) tolerated procedure well. Fluids encouraged. On 11/15/21 at 10:50 AM, V25 (Licensed Practical Nurse/LPN) stated, (R9's) UA came back on 10/30/21 with ESBL (E-Coli) in urine. She (R9) was put on Macrobid 100mg for seven days at that time. I believe she (R9) finished that round of antibiotics. She (R9) began having behaviors and was sent to the ER on [DATE]. She (R9) was returned to the facility that day with a diagnosis of a UTI. Then the lab called me on 11/10/21 with her recent culture results from 11/8/21, which showed ESBL (E-Coli) in her urine. Because (R9) won't take pills, the physician changed it to the Rocephin 1gm IM. I see now that ESBL is resistant to both Macrobid and Rocephin and it wasn't addressed. We must have missed that. I will notify the physician and let her know. When asked about the urinary catheter inserted, V25 stated, We really can't have an isolation room in this unit because other residents can go into the rooms. We can't have a portable toilet next to their bed because other residents will go in and use it too. That is why a urinary catheter was put in her. When asked about moving the resident to another room to be isolated, V25 stated, That is up to our Administrator. On 11/15/21 at 12:50 PM V29 (FNP) stated, (R9's) UA from 10/27/21 documents that she (R9) had a colony count of greater than 100,000 and was considered to be colonized. Anything over 100,000 I would consider the person to be colonized. (R9) was treated with Macrobid first because we didn't know the culture results yet. The Macrobid was supposed to be discontinued and changed to something else. V3 (Assistant Director of Nursing/ADON) looked, and the order was not discontinued nor was anything else started. V29 then stated, (R9) continued with worsening symptoms and was sent to the ER on [DATE]. She was given Rocephin IM because if the ER physician thought she needed an antibiotic, who was I to think differently, so I gave her the Rocephin one time dose. When asked about giving meds that are resistant to ESBL, V29 stated, Sometimes it's like a 'Hail Mary' and we are hoping that it may treat something underlying. When asked about the urinary catheter insertion, V29 stated, That might be a facility policy to use a catheter instead of moving a resident to another room. On 11/15/21 at 1:15 PM V30 (Medical Doctor/MD) stated, I would consider a UA result with anything over 50,000 colonization as significant and treat with something that would work. I would not consider (R9) to be colonized. (R9) was probably given Macrobid first because that's what my FNP and I always use first. I see a note where my FNP was supposed to stop the Macrobid and change it to Cipro, but Cipro would not have been the correct drug either. (R9's) urinary catheter should not have been put in. The right thing would have been to move the resident to a room where they could have isolation, but that is the facility Administrator's decision. We really have not treated (R9) yet for her UTI, but I assure you it will be taken care of immediately. R9's progress note dated 11/15/21 at 1:46 PM documents (V30/MD) called and gave orders for Bactrim-DS twice a day for seven days. The UA is to be repeated on the eighth day. If (R9's) urine is negative for ESBL, remove the urinary catheter. The facility's Antibiotic Stewardship Policy, dated 12/18/19, documents The purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. It continues Antibiotic Stewardship is part of our Infection Control Program, including standardized tools such as UTI SBAR and McGreer Criteria. The facility will ensure the pharmacy reviews all antibiotic usage for appropriateness. The McGreer Criteria, 2021, documents that at least one of the following microbiologic criteria must be present for a voided urine sample to be considered a UTI: greater than 100,000/ml or no more than two species of microorganisms in a voided urine sample, or greater than 100/ml of any organism(s) in a specimen collected by an in-and-out catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice to the resident upon transfer to the hospital for 4 of 4 residents (R82, R118, R290, R294) reviewed for transfer in the sample of 71. Findings include: 1. Current Facility admission Records document R118 was admitted to the facility on [DATE] and transferred to the hospital for failing renal status on 10/19/2021 and readmitted back to the facility on [DATE]. R118's Nurses Notes, dated 10/19/2021 at 4:29 PM, document Ambulance arrived at this time. All appropriate information and paperwork given to EMS (Emergency Medical Services); including Renal Function Panel that was drawn this AM. Resident en route to (Regional) hospital. Report given to (Regional) hospital and notified of FNP-C (Family Nurse Practitioner) and POA's (power of attorney's) requests. On 11/16/2021, the Facility was not able to provide documentation to notify resident or representative of the reason for transfer or provide a Policy for providing written notice to the resident or representative reason for transfer. 2. Current facility admission records documents R290 was admitted to the facility on [DATE] and transferred to the hospital for a fall on 11/04/2021 and readmitted back to the facility on [DATE]. R290's Nurses Note, dated 11/4/2021 at 3:52 AM, documents CNA (Certified Nurse Assistant) heard a loud slam and responded immediately to room (R290's room). Resident noted to have fallen out of his bed. Resident laying on L (left) side of body on the floor. Bed in an elevated position. Resident states he was trying to go to the bathroom and forgot to ask for help. He stated he thought he could raise his bed up and do it on his own. Resident wearing a depend and no other clothing. Floor dry, clear of clutter. Denies hitting head. During assessment resident's L leg noted to be externally rotated with some shortening present, the rest of the leg noted to be swollen. Resident c/o (complained of) pain to L wrist, L knee and L hip. Due to the L leg being rotated outward with shortening and the amount of pain resident states he is in, 911 paged to transport resident to ED (Emergency Department) for evaluation. Emergency contact notified, expressed understanding and thanked writer for call and update. Mediprocity (secure messaging for long term care providers) sent to NP (Nurse Practitioner) to update on condition and transportation to hospital. On 11/16/2021, the Facility was not able to provide documentation to notify resident or representative of the reason for transfer or provide a Policy for providing written notice to the resident or representative reason for transfer. 3. Current facility admission records documents R294 was admitted to the facility on [DATE] and transferred to the hospital for numbness and weakness to left arm on 11/09/2021 and readmitted back to the facility on [DATE]. R294's Nurses Note, dated 11/09/2021 at 9:00 AM, documents Resident voiced complaints of numbness and weakness to L arm. Res (resident) pupils equal and reactive and foot strength was equal. L grip strength noticeably weaker than the Right. BP (blood pressure) noted to be 178/98. Writer notified NP of assessment and vitals and received order to send resident to (Local) ER (emergency room) for evaluation and tx (treatment). On 11/16/2021, the Facility was not able to provide documentation to notify resident or representative of the reason for transfer or provide a Policy for providing written notice to the resident or representative reason for transfer. On 11/15/2021 at 4:04 PM, V25 (Licensed Practical Nurse/LPN) stated that no paperwork is given to the resident. V25 stated that the physician order sheet, DNR (Do Not Resuscitate) are given to the EMTs (Emergency Medical Technicians). V25 stated that report and all documentation is given to the EMTs. V25 stated that she does not give any written documentation of why they are going to the hospital to the resident. V25 stated that the business office does the bed holds. On 11/15/2021 at 4:16 PM, V23 (Registered Nurse/RN) stated that he sends the physician order sheet, DNR sheet is given to the EMTs. V23 stated when sending a resident to the hospital all of the paperwork is given to the EMTs. V23 stated there is not any documentation stating why they are going to the hospital given to the resident by nursing. V23 stated that business office handles the bed hold. On 11/16/2021 at 11:43 AM, V2 (Director of Nursing/DON) stated that some nurses print off the sheet and some don't. V2 stated that it is not normal practice at this facility to give the resident written documentation of why they are being sent out or about the bed hold. The bed hold information is mailed out the next day.4. R82's Nurses note, dated 09/13/2021 at 01:43 PM, V18 (LPN) documented, Resident lethargic with poor nutrition and hydration for an extended period. Called (Power of Attorney) to send out to be evaluated. (Power of Attorney) okay with decision, resident physician notified. Resident was transported to hospital via ambulance at 12pm. On 11/16/2021, the facility was unable to provide documentation to notify residents or representative of the reason for transfer. On 11/16/2021 at 3:13 PM, V2 (DON) stated that the facility does not have a policy for notification of requirements before transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written information to the Responsible Party regarding the transfer, bed hold policy, and permitting the resident to return to the facility for 4 of 4 residents (R82, R118, R290, R294) reviewed for hospital transfer in the sample of 71. Findings include: 1. Current facility admission records document R118 was admitted to the facility on [DATE] and transferred to the hospital for failing renal status on 10/19/2021 and readmitted back to the facility on [DATE]. R118's Nurses Notes, dated 10/19/2021 at 4:29 PM, document Ambulance arrived at this time. All appropriate information and paperwork given to EMS; including Renal Function Panel that was drawn this AM. Resident en route to (regional) hospital. Report given to (regional) hospital and notified of FNP-C (Family Nurse Practitioner) and POA's (power of attorney's) requests. A review of R294's Health Record shows no documentation of bedhold given or sent with resident and given to power of attorney. On 11/16/2021, the facility could not provide verification of the Bedhold Policy Notification policy that was to be given upon admission and at the time one leaves for a hospitalization. 2. Current facility admission records documents R290 was admitted to the facility on [DATE] and transferred to the hospital for a fall on 11/04/2021 and readmitted back to the facility on [DATE]. R290's Nurses Note, dated 11/4/2021 at 3:52 AM, documents, CNA (Certified Nursing Assistant) heard a loud slam and responded immediately to room (R290's room). Resident noted to have fallen out of his bed. Resident laying on L (left) side of body on the floor. Bed in an elevated position. Resident states he was trying to go to the bathroom and forgot to ask for help. He stated he thought he could raise his bed up and do it on his own. Resident wearing a depend and no other clothing. Floor dry, clear of clutter. Denies hitting head. During assessment resident's L leg noted to be externally rotated with some shortening present, the rest of the leg noted to be swollen. Resident c/o (complained of) pain to L wrist, L knee and L hip. Due to the L leg being rotated outward with shortening and the amount of pain resident states he is in, 911 paged to transport resident to ED (Emergency Department) for evaluation. Emergency contact notified, expressed understanding and thanked writer for call and update. Mediprocity (secure messaging for long term care providers) sent to NP (Nurse Practitioner) to update on condition and transportation to hospital. A review of R290's Health Record shows no documentation of bedhold given or sent with resident and given to the Power of Attorney. On 11/16/2021 the facility could not provide verification of the Bedhold Policy Notification policy that was to be given upon admission and at the time one leaves for a hospitalization. 3. Current facility admission records document R294 was admitted to the facility on [DATE] and transferred to the hospital for numbness and weakness to his left arm on 11/09/2021 and readmitted back to the facility on [DATE]. R294's Nurses Note, dated 11/09/2021 at 9:00 AM, documents Resident voiced complaints of numbness and weakness to L arm. Res pupils equal and reactive and foot strength was equal. L grip strength noticeably weaker than the Right. BP noted to be 178/98. Writer notified NP of assessment and vitals and received order to send resident to (local) ER (Emergency Room) for evaluation and tx (treatment). A review of R294's Health Record shows no documentation of bedhold given or sent with resident and given to Power of Attorney. On 11/16/2021 the facility could not provide verification of the Bedhold Policy Notification policy that was to be given upon admission and at the time one leaves for a hospitalization. On 11/15/2021 at 4:04 PM, V25 (Licensed Practical Nurse/LPN) stated that no paperwork is given to the resident. V25 stated that report and all documentation is given to the EMTs (Emergency Medical Technicians). V25 stated that she does not give any written documentation of why they are going to the hospital to the resident. V25 stated that the business office does the bed holds. On 11/15/2021 at 4:16 PM, V23 (Registered Nurse/RN) stated that when sending a resident to the hospital all of the paperwork is given to the EMTs. V23 stated there is not any documentation stating why they are going to the hospital given to the resident by nursing. V23 stated that business office handles the bed hold. On 11/16/2021 at 11:43 AM, V2 (Director of Nursing/DON) stated that some nurses print off the sheet and some don't. V2 stated that it not normal practice at this facility to give the resident written documentation of why they are being sent out or about the bed hold. The bed hold information is mailed out the next day. 4. R82's Nurses note, dated 09/13/2021 at 01:43 PM, V18 (LPN) documented, Resident lethargic with poor nutrition and hydration for an extended period. Called (Power of Attorney) to send out to be evaluated. (Power of Attorney) okay with decision, resident physician notified. Resident was transported to hospital via ambulance at 12pm. On 11/16/2021, the facility was unable to provide documentation that they notified the resident or representative of the facility bed hold. The Facility's Bedhold and readmission Policy and Procedure, revised date 12/2011, documents Policy: The facility shall provide written information to the resident, family, or legal representative on the responsibility of the facility to hold a bed on admission and when a resident goes to the hospital or on therapeutic leave. It also documents Procedure: Hospital stay: Before a resident is transferred to a hospital, or within 24 hours in case of an emergency. It also documents, The bedhold policy shall accompany the resident to the hospital and, if needed, sent to the Power of Attorney or guardian. Social Services shall ensure that documentation has been made in the progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide complete and timely incontinence care, urinary catheter care, timely and appropriate treatment of a urinary tract infection, and failed to ensure that residents only receive a urinary catheter when clinically necessary for 6 of 8 residents (R9, R68, R90, R101, R116, R289) reviewed for incontinence care and urinary catheters in the sample of 71. Findings include: 1. R9's Progress Note dated 10/27/21 at 12:36 PM documents Resident observed walking in hallway with all of her clothing in both hands heading up the hall. Stating someone was stealing her clothes. Resident stated that she was taking them back to room (number) that she had been moved. Resident's room is (number). This writer and staff member validating her concerns when resident stated that she had to use bathroom, she also stated that it burned when she urinated. Staff member and writer assisted resident to bathroom and cleaned her and got a sample of urine for nurse. Resident remains confused and came into my office and was looking for a car over at the rest home and talking about her husband. Then she wanted to call her sister. This writer took her to dining room to speak with her sister. Nursing aware. R9's Progress Note dated 10/27/21 at 1:11 PM documents Urine specimen taken to lab. Sent medi-procity (secure messaging for long term care providers) of Urinalysis (UA) results to Family Nurse Practitioner (FNP). Waiting orders. R9's Progress Note dated 10/27/21 at 3:00 PM documents FNP reviewed UA results and orders received. Macrobid 100 milligram (mg) 1 oral (PO) twice a day (BID) for seven days. R9's Physician Order Sheet dated 10/27/2021 to 11/03/2021 documented Macrobid (nitrofurantoin monohyd/mcryst) capsule 100 mg 1 oral, DX (diagnosis) urinary tract infection (UTI), site not specified twice a day; 6:30 am - 9:30 am, 3:30 pm - 5:45 pm. R9's UA culture dated 10/27/21, results on 10/30/21, documents (R9) had a UTI showing Extended Spectrum Beta-Lactamase (ESBL) with the organism of Escherichia Coli (E-Coli). It continues with ESBL is resistant to Ceftriaxone (Rocephin) and Nitrofurantoin (Macrobid) antibiotics. R9 was already receiving Macrobid, which was not stopped and R9 did not have a medication change once results were obtained. R9 continued for another four days on Macrobid. On 11/8/21, at 9:00 AM, R9 was lying in bed, confused and not speaking or following commands from staff. R9's Progress Note dated 11/8/21 at 10:20 AM documents Went in to speak with resident this AM, resident laying in bed with eyes closed and did not acknowledge that I was in the room. Will continue to monitor. R9's Progress Note dated 11/8/21 at 11:27 AM documents Resident continues to be monitored post antibiotic for treatment of UTI. Resident continues to display signs of altered mental status. Resident is refusing medications by pursing lips tightly shut. Staff continues to encourage caloric and fluid intake; however, resident is not receptive of the encouragement and is observed again, pursing lips tightly, refusing medications. Resident is also observed refusing activities of daily living (ADLs) and becoming easily agitated and combative. Resident is not easily comforted or redirected during ADLs. Orders have been received to send resident to the local hospital emergency room (ER) for further evaluation and treatment. Power of Attorney (POA) has been contacted via telephone and made aware. POA verbalized understanding. On 11/8/21 at 11:30 R9 continued to display signs of altered mental status: confusion, refusing her ADLs and became easily agitated and combative with staff. R9's Progress Note dated 11/8/21 at 11:38 AM documents 911 has been telephoned for transport. R9's Progress Note dated 11/8/21 at 4:07 PM documents Resident returned from local hospital per ambulance and two Emergency Medical Technician (EMT) assists with diagnosis of UTI. Attending Family Nurse Practitioner (FNP) is aware and provided orders to discontinue ER Physicians order for Levaquin 750mg; 1 tablet daily for seven days due to resident's unwillingness to take oral medications at this time due to altered mental state. FNP has opted to order Rocephin 1gram (g) Intramuscular (IM) for treatment of UTI. The culture from 10/27/21 showed that the organism was resistant to Rocephin. R9's Progress Note dated 11/8/21 at 4:11 PM documents A new prescription order was transcribed per the order of FNP. Ceftriaxone (Rocephin) recon solution; 1g (gram); injection Once - One Time. 07:00 AM - 10:00 PM. R9's Progress Note dated 11/8/21 at 8:44 PM documents Antibiotic administered for treatment of UTI. Rocephin (Ceftriaxone) 1gm IM (intramuscular) injection, reconstituted with 2.5 milliliters (ml) of Lidocaine 10mg/ml, was administered to the right dorsogluteal muscle. Resident tolerated well. Resident is resting per bed and continues to be monitored. R9's Progress Note dated 11/10/21 documents Lab called and stated resident has ESBL in urine. Orders received to insert urinary catheter until infection resolved. Urine catheter inserted per sterile procedure with a good return of yellow urine. (R9) tolerated procedure well. Fluids encouraged. On 11/15/21, at 10:50 AM, V25 (Licensed Practical Nurse/LPN) stated, (R9's) UA came back on 10/30/21 with ESBL (E-Coli) in urine. She (R9) was put on Macrobid 100mg for seven days at that time. I believe she (R9) finished that round of antibiotics. She (R9) began having behaviors and was sent to the ER on [DATE]. She (R9) was returned to the facility that day with a diagnosis of a UTI. Then the lab called me on 11/10/21, with her recent culture results from 11/8/21, which showed ESBL (E-Coli) in her urine. Because (R9) won't take pills, the physician changed it to the Rocephin 1gm IM. I see now that ESBL is resistant to both Macrobid and Rocephin and it wasn't addressed. We must have missed that. I will notify the physician and let her know. When asked about the urinary catheter inserted, V25 stated We really can't have an isolation room in this unit because other residents can go into the rooms. We can't have a portable toilet next to their bed because other residents will go in and use it too. That is why a urinary catheter was put in her. When asked about moving the resident to another room to be isolated, V25 stated, That is up to our Administrator. On 11/15/21, at 12:50 PM, V29 (FNP) stated, (R9's) UA from 10/27/21 documents that she (R9) had a colony count of greater than 100,000 and was considered to be colonized. Anything over 100,000 I would consider the person to be colonized. (R9) was treated with Macrobid first because we didn't know the culture results yet. The Macrobid was supposed to be discontinued and changed to something else. V3 (Assistant Director of Nursing/ADON) looked and the order was not discontinued and was anything else started. V29 then stated, (R9) continued with worsening symptoms and was sent to the ER on [DATE]. She was given Rocephin IM because if the ER physician thought she needed an antibiotic, who was I to think differently, so I gave her the Rocephin one time dose. When asked about giving meds that are resistant to ESBL, V29 stated, Sometimes it's like a 'Hail Mary' and we are hoping that it may treat something underlying. When asked about the urinary catheter insertion, V29 stated, That might be a facility policy to use a catheter instead of moving a resident to another room. On 11/15/21, at 1:15 PM, V30 (Medical Doctor/MD) stated, I would consider a UA result with anything over 50,000 colonization as significant and treat with something that would work. I would not consider (R9) to be colonized. (R9) was probably given Macrobid first because that's what my FNP and I always use first. I see a note where my FNP was supposed to stop the Macrobid and change it to Cipro, but Cipro would not have been the correct drug either. (R9's) urinary catheter should not have been put in. The right thing would have been to move the resident to a room where they could have isolation, but that is the facility Administrator's decision. We really have not treated (R9) yet for her UTI, but I assure you it will be taken care of immediately. On 11/16/21, at 11:50 PM, V2 (Director of Nursing/DON) stated, We asked (V29/FNP) about (R9's) UA results and if we could put a urinary catheter in her (R9), and (V29) stated to go ahead and do that. R9's progress note dated 11/15/21 at 1:46 PM documents (V30/MD) called and gave orders for Bactrim-DS twice a day for seven days. The UA is to be repeated on the eighth day. If (R9's) urine is negative for ESBL, remove the urinary catheter. This was a delay of 16 days from the results of the culture to the treatment with the appropriate antibiotic for the UTI. On 11/17/21, at 11:50 AM, V2 (DON) stated, We don't have a policy on urinary catheter insertion or the criteria to insert a urinary catheter, we just follow the physician's order. We only have a policy on urinary catheter care. R9's Care Plan dated 11/4/21 documents that R9 is at risk for a decline in activity participation due to having a diagnosis of Dementia. It continues documenting (R9) is at risk for falling related to altered mental status, unsteady gait, requiring assistance with ADLs, and decreased safety awareness. It continues that (R9) requires assistance with washing face and hands related to diagnosis of Dementia. The Care Plan also documents (R9) has a UTI and ESBL. Administer antibiotic as ordered, assist (R9) with perineal care/incontinence care as needed. It continues that (R9) has a urinary catheter related to ESBL in urine, monitor for signs and symptoms of UTI. R9's Minimum Data Set (MDS) dated [DATE] documents (R9) has a severe cognitive impairment and requires extensive assistance from two staff members for bed mobility, transfers, and bathing. It continues that (R9) requires extensive assistance from one staff member for dressing, toileting, and personal hygiene, needs supervision with set up for eating, and (R9) is frequently incontinent of bladder and always continent of bowel. 6. R289's Care Plan, revision date 11/5/2021, documents Resident Care Information. It also documents Bowel and Bladder: Incontinent of both. Incontinence Products: Large brief. R289's MDS dated [DATE] documents that R289 is cognitively severely impaired, frequently incontinent of bowel and bladder and requires extensive assist of 2 people for toileting. R289's Physician Order Sheet dated 10/18/2021 documents Levofloxacin 750 mg (milligram) daily for urinary tract infection. On 11/8/2021 at 11:30 AM, V4 (CNA) and V14 (CNA) assisted R289 with incontinence care. V4 and V14 rolled R289 onto his right side and pulled pants down revealing a heavily urine soaked undergarment. V4 and V14 loosened the undergarment and V4 rolled undergarment beneath R289. V4 then using disposable wipes cleansed R289's groin area, shaft of penis and top of scrotum. V4 did not lift R289's scrotum and cleanse beneath. V4 did not cleanse R289's inner thighs. V14 and V4 assisted R289 over onto his side. V14 then, using the disposable wipes, cleansed R289's inner buttocks, applied and fastened R289's undergarment. V14 did not cleanse R289's right and left buttock. On 11/10/2021 at 2:06 PM, V4 stated that she usually pulls up the scrotum and doesn't know why she didn't do that when performing incontinence care on R289. V4 also stated that she is not sure why V14 didn't cleanse R289's buttocks during incontinence care. V4 stated that cleansing beneath the scrotum, outer buttocks and inner thighs is part of incontinence care. The Facility's Incontinent Care Policy, dated 2/04, documents Objective: 1. To keep skin clean, dry, free of irritation and odor. It also documents Procedure: 7. Wash all soiled skin areas and dry very well, especially between skin folds. The Facility's Catheter Care Policy, Revised date 6/05, documents Procedure: 4. On a female resident, clean the labia; then spread the labia to wash the inner folds. It also documents Gently clean catheter tubing nearest the body, wiping away from where it enters the meatus. 2. On 11/09/2021 at 01:25 PM V34 (Certified Nursing Assistant/CNA) used non rinse foam soap to cleanse R90 after an incontinence episode. V34 cleansed front to back of R90's perineal area but did not clean the inner labia nor did she dry area. V27 (CNA) rolled R90 on to her left side. V34 cleansed R90's right thigh and up to buttock but did not dry it afterwards. V27 rolled R90 over onto her right side and V34 cleansed R90's left thigh up to R90's buttock and did not dry area. R90 was repositioned on her left side. V34 did not cleanse R90's peri rectal area. R90's Care Plan dated 12/09/2018 documents Incontinent of urine and bowel. It continues use moisture barrier product to perineal area as needed. R90's MDS dated [DATE] documents that R90 is always incontinent of urine and feces and requires extensive assistance of 2 staff for toilet use. 3. On 11/10/2021 at 9:30 AM V32 (CNA) assisted V33 (CNA) in performing catheter care for R101. V33 cleansed R101 with no rinse cleanser, cleansed pubic area, cleansed bilateral groin area and cleansed the outer labia but did not dry these areas. V33 cleansed the urinary catheter from the outer labia outward. V33 did not spread the outer labia and cleanse the inner labia nor cleanse the catheter from the urethral opening to the outer labia. R101 was turned onto her right side; R101 had a bowel movement, V32 removed feces with dirty incontinent brief, cleansed left buttock and peri rectal area but did not dry the area. Neither V32 or V33 cleaned R101's left thigh, right thigh or right buttock. R101's Care Plan dated 06/29/2020 documented, Provide catheter care (every) shift and as needed. R101's MDS dated [DATE] documents that R101 has an indwelling urinary catheter and was always incontinent of feces. 4. On 11/10/2021 at 9:50 AM V39 (CNA) used no rinse foam, cleansed R116's front, bilateral groins and outer labia but did not spread outer labia to cleanse inner labia. V39 cleansed the indwelling catheter from the outer labia, outwards approximate 4 inches but did not cleanse from the urethral opening to the outer labia. V38 rolled R116 onto her left side, cleansed the right hip and buttock, cleansed and patted dry, then rolled onto right side and the left hip and buttock was cleansed and patted dry. V39 did not clean R116's peri rectal area. R116's MDS dated [DATE] documented that R116 has an indwelling urinary catheter and was always incontinent of feces. R116's Care Plan dated 01/30/2021 documented, Provide catheter care as needed. On 11/10/2021 at 10:38 AM V2 (DON) stated she would expect the CNAs to dry the no rinse cleanser, spread the outer labia apart to cleanse the inner labia and cleanse the catheter from the inner labia outward. 5. R68's Face Sheet, print date of 11/10/21, documents that R68 was admitted on [DATE] and has a diagnosis of Alzheimer's disease. R68's MDS dated [DATE] documents that R68 is severely cognitively impaired, requires extensive assistance of 2 staff members for toileting and personal hygiene and is always incontinent of bowel and bladder. R68's Care Plan dated 10/17/2019 documents (R68) is at increased risk for skin breakdown R/T (related to) age, incontinence, decreased mobility, potential for friction and shearing with repositioning and transfers, potential for poor appetite. Intervention: Provide incontinent care following each episode. On 11/10/21 at 1:00 PM, V27 (CNA) and V28 (CNA) transferred R68 to bed using the mechanical left. R68's wheelchair seat was noted to be wet. Once laid down, V27 removed R68's urine saturated pants and incontinence brief. V27 rolled R68 to her left side. R68 buttocks, inner thighs and back of her upper thighs were bright red and appeared wrinkled. V27 took two premoistened periwash cloths and wiped R68 right buttock and discarded them. V27 got one premoistened periwash cloth and cleansed the left buttock. V27 then placed a new incontinence brief under R68 and rolled R68 onto her back. V27 then pulled the incontinent brief up between R68's legs and fastened it. V27 failed to cleanse R68's rectal area, inner thighs, back of upper thighs, groin area and peri vaginal area. On 11/10/21 at 1:45 PM, V2 (DON) stated, I expect the staff to provide timely incontinent care. If someone is soiled, the staff should be performing complete incontinent care, which includes cleansing every part that was soiled and of course spread the labia of a female.

Based on observation, interview, and record review, the facility failed to properly store medication, label insulin and tuberculin vial, and discard expired medications. This has the potential to affect newly admitted residents and residents residing on the 400 Hall and the 200 Hall. Findings include: On 11/8/2021 at 10:00 AM the 400 Hall medication room was inspected. The refrigerator, located in the medication storage room on 400 Hall, contained the following: 1. One unlabeled with open date vial of Tuberculin (TB). V3 (Assistant Director of Nursing/ADON) verified that the medication did not have an open date and that the medication was being used. 2. One unlabeled plastic resealable medication bag with 8 pills of Vancomycin 125 milligran (mg) capsules in it was observed folded in a drawer in the medication room that contained tape, plastic trash bags and scissors. The pharmacy label had been partially removed. V3 verified that the Pharmacy label was removed. On 11/2/2021 at 10:10 AM, V3 (ADON) stated that the Vancomycin medication should be stored in the medication cart. V3 stated that it should not be in a drawer in the medication room with tape, bags, scissors and random non medical items. V3 also stated that the TB should be labeled with an open date and be kept in its original box. On 11/16/2021 at 9:40 AM, V37 (Licensed Practical Nurse/LPN) stated that the drawer label storage drawer is not for medication, it is a normal storage drawer with batteries and other things but no medication should be stored in this drawer. V37 also stated that the TB in the refrigerator is the medication that is used for all residents that are admitted . V37 stated that it is part of the admission process that residents receive a two step process and the medication is obtained from the refrigerator. On 11/16/2021 at 3:13 PM, V2 (Director of Nursing/DON) stated that it is not normal practice for the pharmacy label to be removed from the packaging and placed in a storage drawer. V2 stated that all medications are to be stored in the medication cart. V2 stated that the TB vial is to be labeled when use and not used past its expiration date. On 11/8/21 at 11:57 AM, the 200 Medication cart was inspected with V15 (Registered Nurse/RN). 3. R7's Levemir injection pen was open and did not have a date of when it was opened. R7's Humalog injection pen had an opened date of 10/7/21. R7's Medication Administration History, dated 11/1/21 - 11/10/21, documents, Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/ml (milliliter). Amount to Administer per sliding scale. This Medication Administration History documents that R7 received Humalog sliding scale injection 11/1/21 - 11/10/21. R7's Medication Administration History, dated 11/1/21 - 11/10/21, documents, Levemir FlexTouch U-100 Insulin, insulin pen; 100 unit/ml (3 ml); Amount to administer: 10 units; subcutaneous. This Medication Administration History documents that R7 received Levemir insulin injection 11/1/21- 11/10/21. 4. R77's Lantus injection pen and Humalog injection pen were both open and did not have a date of when they were opened. R77's Medication Administration History, dated 11/1/21 - 11/10/21, documents, Lantus Solostar U-100 Insulin. insulin pen;100 units/ml (3ml); Amount to administer: 12 units subcutaneous. This Medication Administration History documents that R77 received the Lantus injection 11/1/21 - 11/9/21. R77's Medication Administration History, dated 11/1/21 - 11/10/21, documents, Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/ml (milliliter). Amount to Administer per sliding scale. This Medication Administration History documents that R77 received Humalog sliding scale injection 11/1/21 - 11/3/21, 11/5/21 - 11/8/21. On 11/8/21 at 11: 35 AM, V15 (RN) prepared R77's medications. At this time, V15 was questioned about the date of opening of the Humalog injection pen. V15 stated, It doesn't have a date on it. Somebody didn't date it. V15 then entered R77's room and gave R77 2 units of the Humalog subcutaneous injection to R77's left lower abdomen. 5. R33's Humalog injection pen was open and did not have a date of when it was opened. R33's Medication Administration History, dated 11/1/21 - 11/10/21, documents, Humalog KwikPen Insulin (insulin lispro) insulin pen; 100 unit/ml (milliliter). Amount to Administer per sliding scale. This Medication Administration History documents that R33 received Humalog sliding scale injection 11/1/21 - 11/9/21. 6. There was also a Basaglar injection pen with no resident name or date of opening that had been used found in the cart. On 11/8/21 at 12:05 PM, V15 (RN) stated that he usually doesn't work this hall and that the insulin pens should be dated when they are opened. On 11//8/21 at 3:55 PM, V2 (DON) stated, The insulin pens all should have a label of the residents name and the date it was opened. The Lantus Full Prescribing Information, revision date of 5/2019, documents that Lantus 3 ml (milliliter) single use - patient - use Solostar prefilled pen if in use is good for 28 days after opening. The Humalog Full Prescribing Information, revision date of 6/2017, documents that Humalog 3 ml KwikPen if in use is good for 28 days after opening. The Levemir Full Prescribing Information, revision date of 3/2012, documents that the 3 ml Levemir KwikPen if in use is good for 42 days after opening. The Basaglar Full Prescribing Information, revision date of 12/2015, documents, 5.1. Never Share Basaglar KwikPen Between Patients. Basaglar KwikPens must never be shared between patients, even if the needle is changed. Sharing poses a risk for transmission of blood-borne pathogens. It continues, In use Pen. The pen you are using should be thrown away after 28 days, even if it has insulin left in it. Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. The Facility's Policy No: 3.17 Pharmaceutical Procedures, revised date, 10/18/19, documents IV. Procurement and Labeling of Drugs: Drug Labeling The label of each individual container filled by the pharmacist shall clearly indicate the resident's full name, physician's name, prescription number, name and strength of drug, directions for administration, date of issue, date of expiration of all time-dated drugs, the initials of the pharmacist filling the prescription, and amounts of medication contained in each prescription. In addition, the pharmacy's name, address, and telephone number shall be on all prescriptions. A. Only the pharmacist, or authorized personnel under the direct supervision of the pharmacist, prepares labels or makes changes in labels. It also documents, C. Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacist for relabeling or disposal. Medications in containers having no labels shall be destroyed in accordance with state and federal regulations. It continues, V. Care and Storage of Medications H. All discontinued, unlabeled, and expired medications shall be returned to the pharmacy for proper disposition and crediting considerations.

5. R289's Physician Order Sheet, dated 10/18/2021, documents Levofloxacin 750 mg (milligram) daily for urinary tract infection. On 11/8/2021 at 11:30 AM V4 (CNA) and V14 (CNA) assisted R289 with incontinence care. V4 and V14, wearing a cloth mask and no eye protection, applied gloves. No hand hygiene was performed. After completing incontinence care, V4 and V14 removed their gloves. V14 then left the room. No hand hygiene was performed. The Updated Interim Guidance for Nursing Homes and Other Long Term Care Facilities, updated 10/20/21, documents, For those residents not suspected to have COVID-19, HCP (Health Care Providers) should use community transmission levels to determine the appropriate PPE (Personal Protective Equipment) to wear. When community transmission levels are substantial or high HCP (Health Care Personnel) must wear a well fitted face mask and eye protection. The Facility's Standard Precautions Policy, revised date 08/2009, documents b. Wash hands when they are visibly soiled. It continues .before and after assisting a resident with the toilet. c. Hand hygiene should be performed immediately after gloves are removed. The Facility's Incontinence Care policy, revised date 02/04, documents Procedure: 2. Wash your hands and put on gloves. It continues, 12. Discard linen properly. 13. Wash your hands. Based on observation, interview and record review, the facility failed to ensure that staff wore appropriate eye protection, performed hand hygiene, properly disinfected shared resident equipment after use and ensure that vaccinated and unvaccinated residents were social distanced and were wearing masks while outside of their rooms to prevent the possible spread of COVID-19 and other infections for 14 of 27 residents (R7, R13, R14, R33, R35, R50, R51, R68, R77, R85, R94, R110, R135, R289) reviewed for infection control in the sample of 71. Findings include: 1. On 11/8/21 at 9:01 AM, V26 (Certified Nursing Assistant/CNA) performed a resident transfer and incontinence care for R50. V26 failed to wear eye protection. 2. On 11/8/21 at 11: 35 AM, V15 (Registered Nurse/RN) entered R77's room to perform a blood glucose check. V15 donned gloves with no hand hygiene and no eye protection and obtained R77's blood glucose by pricking R77's finger and placing the blood on the test strip. V15 stated that the R77's glucose level was 180; V15 removed his gloves and V15 left the room. V15 went to his medication cart. V15 donned gloves, wiped the blood glucose machine for 20 seconds with a MicroKill cloth and wrapped the machine up. The MicroKill cloth was touched after V15 placed the machine on top of his cart and it was dry. The MicroKill 1 minute container documents, To disinfect hard, non-porous surfaces, use one or more wipes, as necessary, to thoroughly wet the surface to be treated. Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on this label. The facility Glucose Monitoring policy, revised date of 11/2015, documents, The machine should be disinfected between uses, using a validated disinfecting agent. The facility supplied document of 200 hall blood glucose checks, undated, documents R7, R77, R51, R33, R14, R35 and R85 are the residents on the 200 hall that receive blood glucose monitoring. 3. On 11/10/21 at 11:34 AM, R135 (an unvaccinated resident) was sitting at a dining table that holds four people. R13, R110, R94 were sitting at the table with R135. No one was wearing a mask at this time and they were not socially distanced. 4. On 11/10/21 at 1:00 PM, V27 (CNA) and V28 (CNA) transferred R68 to bed using the mechanical lift and provided incontinence care. Neither wore eye protection while providing care. On 11/10/21 at 1:45 PM, V2 (Director of Nurses/DON) stated, The staff should be washing their hands before putting on gloves, changing gloves and after removing gloves. Gloves should be changed if they become soiled. On 11/10/21 at 02:06 PM, V2 (DON) stated, Unvaccinated residents wear an N95 when they are out of their rooms. They can do activities and communal dining. We try to maintain the 6 foot distance. We do allow them to set a table with another, but I would expect not a full table. On 11/16/21 at 9:30 AM, V1 (Administrator) stated, The staff should be wearing goggles while giving care. That was my fault when the regulations changed. I read it wrong. I don't believe we are spreading COVID through our building by not wearing goggles. That is for our staff protection.

Based on observation, interview and record review, the facility failed to prepare food according to safe food handling practices. This has the potential to affect all 136 residents living in the facility. Findings include: On 11/08/2021 at 10:45 am, V8 (Dietary Manager) was pureeing baked chicken and her face mask was below her nose during this task. On 11/08/2021 at 11:55 am, V7 (Dietary Cook) picked hard pieces of chicken out of pureed chicken with gloved hands, lifted up on the trash can lid and discarded it into the trash can. V7 then removed her gloves and put another pair on without performing hand hygiene. At 12:05 pm, V7 lifted up the trash can lid and threw something away and changed gloves without benefit of hand hygiene. At 12:20 pm, V7 changed her gloves without benefit of hand hygiene. On 11/16/2021 at 01:38 pm, V8 (Dietary Manager) stated that she would expect the staff to wash their hands after removing gloves and putting a new pair of gloves on and also she would expect the staff to keep their facemask above their noses. The facility policy, Standard Precautions, dated 08/2009 documents, C. Hand Hygiene should be performed immediately after gloves are removed . It continues, 3. Masks, Eye Protection, Face Shields. a. Wear a mask and eye protection or a face shield to protect mucous membranes of the eye, nose and mouth during procedures and resident-care activities . The Resident's Census and Conditions of Resident, CMS 672, dated 11/9/2021, documents that the facility has 136 residents living in the facility.