**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R)4's diagnosis included chronic obstructive pulmonary disease ([COPD] is a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing.) The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating interview not able to be conducted due to severely impaired cognition. The physician's order included Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligrams /3 milliliter per nebulizer (device that changes liquid medication into a mist easily inhaled into the lungs), four times a day, for wheezing, ordered 11/23/23. The care plan, updated 07/10/23 lacked guidance related to R4's nebulizer. The physician's order included to change the nebulizer tubing on the 15th of the month on night shift, dated 11/23/23. On 12/14/23 at 09:45 AM (LN) C reported she did not write the residents' care plans. If there was just a simple update, she would do those but Administrative Nurse B or the MDS person wrote the care plans. LN C verified the resident required O2. On 12/13/23 at 03:00 PM, Administrative nurse B reported the facility was able to find an MDS Coordinator to do the assessments and care plans and would be able to review the care plans. A policy regarding Comprehensive Care Plans requested on 12/14/23 with no policy provided. The facility failed to develop a comprehensive care plan for R4 for the use of a nebulizer treatment. The facility reported a census of 23 residents with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 10 related to the use of oxygen (O2) therapy, R 4 related to nebulizer treatments, and for R 16, related to no diabetic interventions on the care plan. Findings included: - R10's signed Physician Orders revealed the following diagnosis of vascular dementia (progressive mental disorder characterized by failing memory, confusion) and heart failure (heart not functioning properly). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The resident had delusions and verbal behaviors on one to three days of the look back period. The quarterly MDS dated [DATE] revealed no significant changes other than the addition of oxygen (O2) use. R10's Care Plan dated 06/10/22 revealed the resident required assistance with all daily cares. The care plan lacked use and care of oxygen therapy. Review of the physician's order dated 12/04/22 revealed Oxygen at two liters per minute per nasal cannula (NC), every shift. Observation on 12/13/23 at 08:54 AM revealed R10 reclined in her recliner chair. The resident had O2 applied. On 12/13/23 at 01:52 PM, Certified Nursing Assistant (CNA) D reported the resident was extensive assistance of two staff with most of her care and required O2. On 12/14/23 at 09:45 AM (LN) C reported she did not write the residents' care plans. If there was just a simple update, she would do those but Administrative Nurse B or the MDS person wrote the care plans. LN C verified the resident required O2. On 12/13/23 at 03:00 PM, Administrative nurse B reported the facility was able to find an MDS Coordinator to do the assessments and care plans and would be able to review the care plans. A policy regarding Comprehensive Care Plans requested on 12/14/23 with no policy provided. The facility failed to develop a comprehensive care plan for R10 for the use of continuous O2 therapy. - Resident (R) 16's signed physician orders revealed a diagnosis that included diabetes mellitus type two ( when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She received insulin injections daily. The annual MDS dated [DATE] revealed a BIMS of 15. No changes in medications. The care plan dated 03/17/21 lacked guidance related to R16's diabetes. The Physician Orders included the following orders: Accuchecks after meals and at bedtime, every Monday and Thursday, related to diabetes mellitus with hyperglycemia (greater than normal amount of glucose in the blood), ordered 07/26/21. Basaglar Kwik Pen Pen-injector 100 UNIT/Milliliters (ML) (Insulin Glargine), Inject 30 units, subcutaneously (beneath the skin) at bedtime, for type two diabetes mellitus, ordered 11/22/23. Novolog FlexPen injector 100 UNIT/ML (Insulin Aspart), Inject 23 units, subcutaneously, one time a day, in the morning, for diabetes, ordered 11/22/23. Novolog FlexPen injector 100 UNIT/ML (Insulin Aspart), Inject 30 units, subcutaneously, in the evening, for diabetes, ordered 11/22/23. Novolog FlexPen injector 100 UNIT/ML (Insulin Aspart), Inject 14 units, subcutaneously, every 24 hours, for diabetes, ordered 11/23/23. Give daily after noon meal. Observation on 12/13/23 at 12:30 PM, R16 ambulated with LN C out of the dining area for her insulin. On 12/13/23 at 12:30 PM Licensed Nurse (LN) C reported the resident was an insulin dependent diabetic with routine blood sugar monitoring. She was unaware if staff guidance related to R16's diabetes was care planned. On 12/13/23 at 03:00 PM, Administrative Nurse B reported the facility was able to find an MDS Coordinator to do the assessments and care plans and would be able to review the care plans. A policy regarding Comprehensive Care Plans requested on 12/14/23, with no policy provided. The facility failed to develop a comprehensive care plan for the care and treatment of R16's diabetes mellitus.

The facility reported a census of 23 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to review and revise the person-centered care plan for three residents, Resident (R) 21 regarding ambulating (walking) independently without a gait belt (a belt used to help transfer a person from one place to another, also used as an ambulation safety aid) and R13 and R24 regarding interventions related to oxygen use and nebulized (a device which changes liquid medication into a mist that is easily inhaled into the lungs) breathing treatment use. This placed the residents at risk to not receive appropriate cares and treatments. Findings included: - The Electronic Health Records (EHR) documented Resident (R)21 had the following diagnoses that included osteoarthritis (degenerative changes to one or many joints characterized by swelling, pain and stiffness), fracture of right pubis (a portion of the pelvic bone [a large basin-shaped complex of bones that connects the trunk of the body to the legs]), fracture of unspecified thoracic (chest and upper back) vertebra, broken internal left hip prosthesis (fracture of the bone surrounding an artificial joint replacement) and generalized anxiety. The 02/14/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R21 required the limited assistance of one staff for all cares and used a walker for mobility. The 08/08/23 Quarterly MDS documented a BIMS of three, which indicated severe cognitive impairment. R21 required limited or extensive assistance of one staff for all cares and used a wheelchair for mobility. The 02/14/23 Falls Care Area Assessment (CAA) documented that R21 took a diuretic (a class of medication to promote the formation and excretion of urine) and a benzodiazepine (a class of depressant medications that act on the central nervous system [brain]). The 02/14/23 ADL (activities of daily living such as walking, grooming, toileting, dressing and eating) Functional / Rehabilitation Potential CAA documented that R21 needed stand-by assist for all cares and had a history of falls. The 02/14/23 Care Plan documented R21 was at risk for falls related to impaired balance and instructed staff as follows: 1. Stand-by assist of one staff for all ADLs. 2. Use of gait belt and rolling walker for ambulation. The EHR Physician Orders lacked orders related to fall prevention. Review of EHR Physical Therapy (PT) notes, dated 05/09/23 documented that PT had assessed R21 with ambulation and determined that R21 was safe to ambulate independently without staff assistance or gait belt use. Review of EHR Fall Risk Assessments documented the following: 1. On 02/01/23, R21 scored a 13, which indicated high risk for falls. 2. On 03/15/23, R21 scored a 16, which indicated a high risk for falls. 3. On 04/15/23, R21 scored a 16, which indicated a high risk for falls. 4. On 05/15/23, R21 scored a 16, which indicated a high risk for falls. 5. On 06/15/23, R21 scored a 12, which indicated a high risk for falls. 6. On 07/15/23, R21 scored a 12, which indicated a high risk for falls. 7. On 08/15/23, R21 scored a 10, which indicated a high risk for falls. 8. On 09/15/23, R21 scored a 10, which indicated a high risk for falls. Review of Progress Notes documented the following. 1. On 03/01/23, R21 ambulated with one staff assistance with gait belt and walker. 2. On 03/28/23, R21 had an off-campus physician visit and returned with orders to ambulate with staff assistance and gait belt use at all times. 3. On 05/02/23, R21 had an off-campus physician visit and returned with orders to continue staff assistance and gait belt use with ambulation until cleared by PT to ambulate without staff assistance. 4. On 06/26/23, 07/26/23, 08/23/23, 10/25/23, 11/23/23 and 11/24/23 documented R21 ambulating with walker but lacked mention of staff assistance or gait belt use. On 12/12/23 at 12:45 PM, R21 observed ambulating in the hallway with four wheeled walker, without gait belt or assistance from staff. On 12/13/23 at 02:30 PM, R21 observed ambulating in hallway with staff member with gait belt in place. On 12/14/23 at 07:40 AM, R21 observed ambulating in the hallway with four wheeled walker, without gait belt or assistance from staff. On 12/14/23 at 11:17 AM, Certified Nurse Aide (CNA) J revealed that R21 was independent with ambulation. Further stated that she did not know what instructions were on the care plan and that she usually looked at the resident's care plans once per week. CNA J revealed that she did not know if R21's care plan had been updated to show that the resident was independent with ambulation. On 12/14/23 at 11:24 AM, CNA K revealed that the care plan dictated the cares provided to the resident and stated that R21's care plan documented that she was independent with ambulation. On 12/14/23 at 10:25 AM, Licensed Nurse (LN) C revealed that she did not know what R21's care plan documented related to ambulation with or without gait belt use. Further revealed that staff nurses could not update the care plans as this task was performed by Administrative Nurse B. On 12/14/23 at 12:18 PM, Administrative Nurse B revealed that during the day R21 is independent but required additional staff assistance at night. Administrative Nurse B stated that her expectation was for care plans to be accurate and up to date with current interventions. The facility failed to provide a policy related to care plan revision as requested on 12/14/23. The facility failed to review and revise the comprehensive person-centered care plan for R21. This placed the resident at risk uncommunicated care needs. - The Electronic Health Records (EHR) documented Resident (R)13 had the following diagnoses that included history of pulmonary emboli (blood clots in the lungs) and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 06/05/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was independent with all cares and received oxygen. The 06/05/23 Care Area Assessment (CAA), lacked documentation related to oxygen or nebulized (a device which changes liquid medication into a mist that is easily inhaled into the lungs) medication use. The 11/13/23 Quarterly MDS, documented a BIMS score of 15, which indicated intact cognition. The resident was independent with all cares and received oxygen. The Care Plan documented the following instructions for staff: 1. On 11/15/23, R13 was on oxygen therapy and included administration instructions to keep away from sparks and other sources of ignition, but lacked information related to changing of supplies, filling of humidifier or documenting dates on supplies. 2. On 12/13/23, lacked information related to administration of inhaled (nebulized) medications. The EHR Physician Orders documented the following: 1. Oxygen, two to three liters per minute (2-3 LPM) per nasal cannula every shift related to COPD, dated 11/22/23. 2. Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) milligram (mg) per 3 milliters (mL), inhale (nebulize) one vial four times per day related to COPD, dated 12/05/23. 3. Nebulizer: tubing and mask change, every night shift on the 15th of every month, dated 11/20/23. 4. Oxygen: tubing and humidifier change, every night shift on the 15th of every month, dated 11/20/23. The 09/01/23 to 12/13/23 Progress Notes reviewed and lacked information related to oxygen delivery or nebulized medication. On 12/12/23 at 08:30 AM, observation of R13's room included an Oxygen concentrator with a humidifier attached in-line with cannula, nebulizer device stored intact on top of the bedside table, undated, with an unknown clear liquid inside the nebulizer chamber. On 12/12/23 at 09:40 AM, R13 observed ambulating from the hallway to R13's room while wearing oxygen with a portable oxygen concentrator. On 12/13/23 at 08:14 AM, observation of R13's room included an oxygen concentrator with a humidifier attached in-line with cannula, the nebulizer device stored intact on top of the bedside table, undated with an unknown clear liquid inside the nebulizer chamber. On 12/13/23 at 01:09 PM, R13 observed in the activity room at a table with other residents as they played cards, R13 wore her oxygen. On 12/14/23 at 11:17 AM, Certified Nurse Aide (CNA) J stated that the nurses were responsible for changing the oxygen tubing/nebulizers/humidifiers on night shift on the 15th of every month. Further stated that she did not know what instructions were on the care plan and that she usually looked at the resident's care plans once per week. CNA J revealed that she did not know if the care plan had instructions related to oxygen or nebulizer therapy as that is a nursing intervention. On 12/14/23 at 10:25 AM, Licensed Nurse (LN) C stated that the night shift nurses were responsible for changing the oxygen tubing/nebulizers/humidifiers on the 15th of every month. Further stated that instructions should be on the care plan related to oxygen delivery or nebulized medication use but did not know for certain. On 12/14/23 at 12:18 PM, Administrative Nurse B stated that the expectation is for care plans to be accurate and up to date with current interventions. The facility failed to provide a policy related to care plan revision as requested on 12/14/23. The facility failed to review and revise the comprehensive person-centered care plan for R13. This placed the resident at risk uncommunicated care needs. - Review of the Electronic Health Record (EHR) documented Resident (R)24 had the following diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition in which the heart muscle does not pump as well as it should which causes difficulty breathing), heart disease (disease of the vessels of the heart) and persistent asthma (disorder of narrowed airways that caused wheezing and shortness of breath). The 08/14/23 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 13 which indicated intact cognition. R24 was independent with all cares and received oxygen. The 08/14/23 Care Area Assessment CAA lacked documentation related to oxygen or nebulized (a device which changes liquid medication into a mist that is easily inhaled into the lungs) medication use. The 10/23/23 Quarterly MDS documented a BIMS of 14 which indicated intact cognition and was receiving oxygen. The Care Plan documented the following instructions to staff: 1. On 08/15/23, R24 was on oxygen at two liters per minute (2 LPM) continuously but lacked interventions related to nebulized medications, changing of oxygen tubing or humidifier preference. The EHR Physician orders documented the following: 1. Oxygen at 2 liters per minute continuous, every shift related to COPD, dated 11/24/23. 2. Ipratroprium-Albuterol inhalation solution 0.5-2.5 (3) milligram (mg) / 3 milliters (mL), inhale (nebulize) one vial orally four times a day related to COPD, dated 11/24/23. The physician's orders lacked guidance related to changing of oxygen or nebulizer tubing. The 09/01/23 to 12/13/23 Progress Notes reviewed and lacked documentation related to oxygen delivery or nebulized medication. On 12/12/23 at 11:24 AM, R24 sat in the recliner in the bedroom. R24 had on oxygen via oxygen concentrator, and the nebulizer mask stored intact on the bedside table with an unknown clear liquid in the nebulizer chamber. On 12/13/23 at 08:24 AM, R24 sat in the recliner in the bedroom. R24 had on oxygen via oxygen concentrator, and the nebulizer mask stored intact on the bedside table with an unknown clear liquid in the nebulizer chamber. On 12/14/23 at 11:17 AM, Certified Nurse Aide (CNA) J stated that the nurses were responsible for changing oxygen tubing/nebulizers/humidifiers on night shift on the 15th of every month. Further stated that she did not know what instructions were on the care plan and that she usually looked at the resident's care plans once per week. CNA J revealed that she did not know if the care plan had instructions related to oxygen or nebulizer therapy as that was a nursing intervention. On 12/14/23 at 10:25 AM, Licensed Nurse (LN) C stated that the night shift nurses were responsible for changing the oxygen tubing/nebulizers/humidifiers on the 15th of every month. Further stated that instructions should be on the care plan related to oxygen delivery or nebulized medication use but did not know for certain. On 12/14/23 at 12:18 PM, Administrative Nurse B stated that the expectation is for care plans to be accurate and up to date with current interventions. The facility failed to provide a policy related to care plan revision as requested on 12/14/23. The facility failed to review and revise the comprehensive person-centered care plan for R13. This placed the resident at risk uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 23 residents with 12 residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to administer R22's antidepressant medication as ordered by the physician. Findings included: - R22's Physician's Order dated 01/09/23 included the diagnosis of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of two, indicating severely impaired cognition. The Psychotropic Drug Use Care Area Assessment (CAA) dated 01/19/23 was triggered, however was incomplete. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of one, indicating severely impaired cognition. The mood interview score was zero. The Care Plan dated 01/09/23 revealed R22 had depression. The Physician Orders ordered 12/07/23 revealed the following: 1. Sertraline HCl (antidepressant medication), 25 milligrams (mg), one time a day for 14 days, then: 2. Sertraline HCl, 25 mg, one time, every other day, for five days then stop (the medication). Review of the Consulting Pharmacist reports, on 12/07/23 revealed Sertraline, 25 mg, one time a day, every other day, for five days, was outside of the recommended dose or frequency. The frequency of every two days is below the usual frequency of daily. Review of the Psychotropic Review and Evaluation dated 12/07/23, revealed a recommendation of Sertraline, 25 mg for 2 weeks, then every other day for 5 days, then stop. The nurse's note on 12/07/23 revealed the physician ordered Sertraline to be decreased to 25 mg, daily for 14 days, then 25 mg daily every other day for 5 doses, then stop (the medication). Review of the December 2023 Medication Administration Record (MAR) revealed staff administered R22 Sertraline 25 mg daily starting on 12/08/23 in addition to Sertraline 25 mg every other day Sertraline 50 mg given on 12/08/23, 12/10/23, 12/12/23 and 12/14/23. On 12/14/23 at 11:13 AM, R22 smiled and giggled, however was unable to conduct a conversation. On 12/13/23 at 01:06 PM, Administrative Nurse B verified R22 received the incorrect dose of Sertraline, and revealed the facility lacked a policy for verification of new orders. The expectation was nurses should review all new orders received during the day for accuracy. The facility lacked a policy related to transcriptions of medications. The facility failed to administer this resident's medication as ordered by the physician. The resident received double the prescribed amount on four occasions when the order was to decrease the medication and stop the antidepressant.

The facility reported a census of 23 residents. The facility identified one central kitchen with one dining area. Based on observation, interview, and record review, the facility failed to provide proper sanitary food storage to prevent the spread of food born illness to the residents of the facility. Findings included: - Initial tour of the kitchen on 12/12/23 at 08:10 AM with Dietary Staff G revealed the following concerns: In the upright freezer: 1. One bag of tator tots unsealed and opened to air. 2. One package of hash browns opened and stored in a plastic bag, which lacked an opened date. 3. Two packages of opened french fries, opened to air, with visible freezer burn to both packages of fries. 4. One package of breaded chicken patties stored in a plastic bag with no opened date. 5. One package of breaded shrimp was open and not dated. 6. One package of chicken strips opened to air with visible freezer burn on the meat. 7. One package of chicken cordon bleu opened and undated. 8. Two packages of hot dogs stored in a plastic bag with no opened date. On 12/12/23 at 08:30 AM, dietary staff G reported staff should write an opened date on all food items. On 12/13/23 at 09:50 AM, dietary staff E reported food bags should be closed, labeled and dated. The facility's policy for Safe Food Preparation and Handling, dated 01/13/2016 revealed the facility would maintain a safe, sanitary environment for food storage, food would be covered when stored, and food would not be served from broken packages, swollen or dented cans. The facility failed to provide proper storage of food to prevent the spread of food borne illness to the residents of the facility.

The facility reported a census of 23 residents. Based on interview and record review, the facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS), complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ), related to licensed nursing staff coverage 24 hours a day. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for the fiscal year (FY)- Quarter 4, 2022 (July 1- September 30) revealed the lack of Licensed Nursing (LN) coverage 24 hours/ seven days a week 07/10/22, Sunday (SU), 08/02/22, Tuesday (TU), 08/07/22 (SU), 08/11/22, Thursday (TH), 09/03/22 (SA), 09/04/22 (SU), 09/16/22, Friday (FR), 09/24/22, (SA) and 09/25/22, (SU). Review of the PBJ's FY Quarter 1, 2023 (October 1- December 31) revealed the lack of LN coverage 24 hour/ seven days a week for 10/02/22 (SU), 10/08/22 (SA), 10/12/22, Wednesday (WE), 10/16/22 (SU), 10/22/22 (SA), 10/30/22 (SU), 11/06/22 (SU), 11/13/22 (SU), 11/19/22 (SA), 11/24/22 (TH), 11/27/22 (SU), 11/30/22 (WE),12/04/22 (SU), 12/11/22 (SU), 12/25/22, (SU), 12/28/22 (WE), 12/29/22 (TH), and 12/31/22 (SA). Review of the PBJ's FY Quarter 2, 2023 (January 01 - March 31) revealed the lack of LN coverage 24 hour/seven days a week for 01/01/23 (SU), 01/08/23 (SU), 01/15/23 (SU), 01/22/23 (SU) 02/05/23 (SU), 02/12/23 (SU), 02/26/23 (SU), 02/27/23 (MO), 03/11/23 (SA), 03/26/23 (SU),03/27/23 (MO), and 03/30/23 (TH). Review of the PBJ's FY Quarter 3, 2023 (April 1- June 30) revealed the lack of LN coverage 24 hour/seven days a week for 05/16/23 (TU), 05/24/23 (WE), 05/25/23 (TH), 06/11/23 (SU), 06/25/23 (SU), 06/26/23 (MO), and 06/27/23 (TU). Review of the nursing schedule and time sheets for licensed nursing staff on the above dates revealed adequate hours to account for 24- hour nursing coverage, however the facility reported inaccurate staffing data for LN coverage 24 hour/seven days a week for the above quarters Interview on 12/14/23 at 2:00 PM with Administrative Nurse B, reported she always had nursing coverage. It was difficult to find Registered Nurses but with staff and agency Nurses, the facility had licensed staff on duty. Review of the facility's policy dated 02/22/22 for Mandatory Submission of Uniform Format Staffing Information (PBJ) revealed the facility would electronically submit to the Centers of Medicare and Medicaid Services complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility failed to electronically submit to CMS complete and accurate direct care staffing information based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS related to licensed nursing coverage 24 hour/ seven days as week, as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering laundry to resident rooms, failure to place distilled water jugs on a surface other than the floor and failure of staff to appropriately clean nebulizers (a device which changes liquid medication into a mist easily inhaled into the lungs) after use. This deficient practice has the potential to lead to cross contamination between residents, and to place the residents receiving oxygen and nebulized medications at increased for respiratory infections. Findings include: - On [DATE] at 07:76 AM, Laundry Staff L observed carrying clean resident bed linens against her body from the cart in the hallway to a linen closet and then into a resident room . On [DATE] at 07:50 AM, Laundry Staff L confirmed she carried clean resident bed linens against her body and stated that staff should carry clean resident bed linens away from her body. On [DATE] at 12:32 AM, Administrative Nurse B confirmed staff should not carry linens against their body as this was an infection control concern with the potential for cross contamination. The facility failed to provide a policy related to delivering of resident bed linens as requested on [DATE]. The facility failed to maintain an effective infection control program with the failure of staff to follow infection control standards when delivering laundry to resident rooms. This deficient practice has the potential to lead to cross contamination between residents and negatively affect every resident in the facility. - The Electronic Health Records (EHR) documented Resident (R)13 had the following diagnoses that included history of pulmonary emboli (blood clots in the lungs) and chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The [DATE] Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident was independent with all cares and received oxygen. The [DATE] Quarterly MDS, documented a BIMS score of 15, which indicated intact cognition. The resident was independent with all cares and received oxygen. The Care Plan documented the following instructions for staff: 1. On [DATE], that R13 was on oxygen therapy and included administration instructions to keep away from sparks and other sources of ignition, but lacked information related to changing of supplies, filling of humidifier or documenting dates on supplies. 2. On [DATE], lacked information related to administration of inhaled (nebulized) medications The EHR Physician Orders documented the following: 1. Oxygen, two to three liters per minute (2-3 LPM) per nasal cannula every shift related to COPD, dated [DATE]. 2. Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) milligram (mg) per 3 milliters (mL), inhale (nebulize) one vial four times per day related to COPD, dated [DATE]. 3. Nebulizer: tubing and mask change, every night shift on the 15th of every month, dated [DATE]. 4. Oxygen: tubing and humidifier change, every night shift on the 15th of every month, dated [DATE]. The [DATE] to [DATE] Progress Notes reviewed and lacked information related to oxygen delivery or nebulized medication. On [DATE] at 08:30 AM, observation of R13's room included an oxygen concentrator with humidifier, dated [DATE], attached in-line with cannula, nebulizer device stored intact on top of the bedside table, undated, with unknown clear liquid inside the nebulizer chamber. Between the resident's recliner and concentrator, stored on the floor, was an opened and undated jug of distilled water. On [DATE] at 09:40 AM, R13 observed ambulating from the hallway to the resident's room while wearing oxygen with a portable oxygen concentrator. R13 ambulated into her room and switched herself from the portable oxygen concentrator to an oxygen concentrator in her room. The nebulizer device stored intact on the bedside table with an unknown clear liquid in the nebulizer chamber. Between the resident's recliner and the concentrator, stored on the floor, the opened and undated jug of distilled water remained. On [DATE] at 08:14 AM, observation of R13's room included an oxygen concentrator with a humidifier, dated [DATE], attached in-line with cannula, the nebulizer device stored intact on top of bedside table, undated with an unknown clear liquid inside the nebulizer chamber. Between the resident's recliner and concentrator, stored directly on the floor, was an opened and undated jug of distilled water. On [DATE] at 01:18 PM, observation of R13's room included an oxygen concentrator with humidifier, dated [DATE], attached in-line with cannula, the nebulizer device stored intact on top of bedside table, undated, with an unknown clear liquid inside the nebulizer chamber. Between the resident's recliner and the concentrator, stored directly on the floor, was an opened and undated jug of distilled water. On [DATE] at 08:30 AM, observation of R13's room included an oxygen concentrator with humidifier, dated [DATE], attached in-line with cannula, the nebulizer device stored intact on top of bedside table, undated with unknown clear liquid inside the nebulizer chamber. Between the resident's recliner and the oxygen concentrator, stored directly on the floor, was an opened and undated jug of distilled water. On [DATE] at 10:25 AM, Licensed Nurse (LN) C stated that the night shift nurses were responsible for changing the oxygen tubing/nebulizers/humidifiers on the 15th of every month and filling of humidifiers as needed. Further stated that she washes out, dries with a paper towel and places the nebulizer tubing back into a zipper-style plastic bag after each use, but stated does not know what the policy is for nebulizer cleaning after use. On [DATE] at 12:18 PM, Administrative Nurse B stated that night shift nurses were responsible for changing oxygen tubing and humidifiers. Further stated that the date of [DATE] on R13's humidifier meant that it expired on [DATE] and should have been changed on [DATE]. Additionally stated that her expectation was for nurses to clean nebulizers after each use by being rinsed with water, towel dried , reassembled and immediately put back in a zipper-style bag. Further stated that all bottles of distilled water for the humidifier should be stored on a shelf in the room or in the resident's closet. The facility failed to provide a policy related to filling of humidifiers or care of oxygen delivery equipment. The facility's Nebulizer Treatment policy, dated [DATE] documented that nebulizers were to be cleaned after each use by disassembling mouthpiece (or mask) and t-piece from cup and washing mouthpiece (or mask) and t-piece with mild soap and warm water, then rinsing under strong stream of water for 30 seconds, shake off excess water, dry on a clean cloth or paper towel and store nebulizer in zipper-style plastic bag. Lacked instructions related to cleaning of nebulizer chamber. The facility failed to maintain an effective infection control program with the failure of staff to appropriately clean nebulizers after each use as evidenced by unknown clear liquid in nebulizer chamber between uses. This deficient practice had the potential to lead to respiratory infections and/or complications for R13. - Review of the Electronic Health Record (EHR) documented Resident (R)24 had the following diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), heart failure (a condition in which the heart muscle does not pump as well as it should which causes difficulty breathing), heart disease (disease of the vessels of the heart) and persistent asthma (disorder of narrowed airways that caused wheezing and shortness of breath). The [DATE] admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 13 which indicated intact cognition. R24 was independent with all cares and received oxygen. The [DATE] Quarterly MDS documented a BIMS of 14 which indicated intact cognition, and R25 received oxygen. The Care Plan documented the following instructions to staff: 1. On [DATE], R24 was on oxygen at two liters per minute (2 LPM) continuously but lacked interventions related to nebulized medications, changing of oxygen tubing or humidifier preference. The EHR Physician orders documented the following: 1. Oxygen at 2 liters per minute continuous, every shift related to COPD, dated [DATE]. 2. Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) milligram (mg) / 3 milliters (mL), inhale (nebulize) one vial orally four times a day related to COPD, dated [DATE]. On [DATE] at 11:24 AM, R24 sat in the recliner in the bedroom. R24 had on oxygen via oxygen concentrator, and the nebulizer mask stored intact on the bedside table with an unknown clear liquid in the nebulizer chamber. On [DATE] at 08:24 AM, R24 sat in the recliner in the bedroom. R24 had on oxygen via oxygen concentrator, and the nebulizer mask stored intact on the bedside table with an unknown clear liquid in the nebulizer chamber. On [DATE] at 10:25 AM, Licensed Nurse (LN) C stated that the night shift nurses were responsible for changing the oxygen tubing/nebulizers/humidifiers on the 15th of every month and filling of humidifiers as needed. Further stated and demonstrated that she washed the nebulizer chamber out, dried with a paper towel and placed the nebulizer back into a zipper-style plastic bag after each use, but stated did not know what the policy was for nebulizer cleaning after use. On [DATE] at 12:18 PM, Administrative Nurse B stated that her expectation was for nurses to clean nebulizers after each use by being rinsed with water, towel dried, reassembled and immediately put back in a zipper-style bag. The facility's Nebulizer Treatment policy, dated [DATE] documented that nebulizers were to be cleaned after each use by disassembling mouthpiece (or mask) and t-piece from cup and washing mouthpiece (or mask) and t-piece with mild soap and warm water, then rinsing under strong stream of water for 30 seconds, shake off excess water, dry on a clean cloth or paper towel and store nebulizer in zipper-style plastic bag. Lacked instructions related to cleaning of nebulizer chamber. The facility failed to maintain an effective infection control program with the failure of staff to appropriately clean nebulizers after each use as evidenced by unknown clear liquid in nebulizer chamber between uses. This deficient practice had the potential to lead to respiratory infections and/or complications for R24. - The Electronic Health Records (EHR) documented Resident (R)7 had the following diagnoses that included chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) and heart failure (a condition in which the heart muscle does not pump as well as it should which causes difficulty breathing). The [DATE] Annual Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) of 13, which indicated intact cognition. R7 required limited assistance or supervision with all cares and received oxygen. The [DATE] Quarterly MDS documented a BIMS of seven, which indicated severely impaired cognition. R7 was independent with all cares and received oxygen. The undated Care Plan documented that R7 required oxygen therapy and instructed staff to: 1. Change tubing per protocol. 2. Deliver oxygen at two liters per minute (LPM) via nasal cannula. 3. Give nebulizer treatment four times per day as ordered. The EHR Physician Orders documented the following: 1. Oxygen as needed via nasal cannula to maintain oxygen saturation between 89-93 per cent (%), every shift, related to COPD, dated [DATE]. 2. Oxygen: tubing and humidifier change, every night shift on the 15th of every month, related to COPD, dated [DATE]. 3. Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams (mg) /3 milliters (mL), inhale (nebulize) one vial orally four times per day related to COPD, dated [DATE]. On [DATE] at 10:25 AM, observation of R7's room included an oxygen concentrator with attached nasal cannula, nebulizer device stored intact inside a plastic bag that hung from a bookshelf with an unknown clear liquid in the nebulizer chamber. On [DATE] at 08:30 AM, observation of R7's room included an oxygen concentrator with attached nasal cannula, nebulizer device stored intact inside a plastic bag that hung from a bookshelf with an unknown clear liquid in the nebulizer chamber. On [DATE] at 01:14 PM, observation of R7's room included an oxygen concentrator with attached nasal cannula, nebulizer device stored intact inside a plastic bag that hung from a bookshelf with an unknown clear liquid in the nebulizer chamber. On [DATE] at 10:25 AM, Licensed Nurse (LN) C stated that the night shift nurses were responsible for changing the oxygen tubing/nebulizers/humidifiers on the 15th of every month and filling of humidifiers as needed. Further stated that staff should wash out the nebulizer chamber, dry the chamber and place the nebulizer back into a zipper-style plastic bag after each use, but stated did not know what the policy was for nebulizer cleaning after use. On [DATE] at 12:18 PM, Administrative Nurse B stated that her expectation was for nurses to clean nebulizers after each use by being rinsed with water, towel dried, reassembled and immediately put back in a zipper-style bag. The facility's Nebulizer Treatment policy, dated [DATE] documented that nebulizers were to be cleaned after each use by disassembling mouthpiece (or mask) and t-piece from cup and washing mouthpiece (or mask) and t-piece with mild soap and warm water, then rinsing under strong stream of water for 30 seconds, shake off excess water, dry on a clean cloth or paper towel and store nebulizer in zipper-style plastic bag. Lacked instructions related to cleaning of nebulizer chamber. The facility failed to maintain an effective infection control program with the failure of staff to appropriately clean nebulizers after each use as evidenced by unknown clear liquid in nebulizer chamber between uses. This deficient practice had the potential to lead to respiratory infections and/or complications for R7.

The facility census totaled 23 residents. Based on interview and record review, the facility failed to maintain an in-service training program for nurses' aides that was appropriate and effective to ensure the continuing competence of nurse aides. The facility identified three Certified Nurse Assistants (CNA's) had been employed over one year. Three of three CNAs lacked the required 12 hours of in-service training to include dementia and abuse training, to ensure the continuing competence of nurse aides and appropriate care and services to all the residents of the facility. Findings included: - Review of a list of Certified Nursing Assistants (CNA) employment dates revealed only three CNAs had been employed for at least 12 months. Of the three employees, only one completed training in abuse, neglect, and exploitation (ANE). None of the three employees had training dealing with dementia residents. On 12/13/23 the training log for CNA J revealed in the last 12 months the employee had 14.25 hours of training including ANE-The Elder Act. However, CNA J lacked training for working with residents with dementia. On 12/13/23 the training log for CNA K had a total of 4.25 hours of training and had no training for ANE or dementia training. On 12/13/23 the training log for CNA L had a total of 2.0 hours with no dementia or ANE training completed. On 12/14/23 at 12:30 PM, CNA J revealed the facility had a computer training for staff and occasionally would have a meeting. CNA J did not know if administrative staff monitored the training, but most of the time, the on-line training was inconvenient. On 12/14/23 at 01:20 PM, CNA D reported she worked on contract at the facility and did not know if she had to do the CNA on-line training. On 12/14/23 at 02:30 PM, Administrative Nurse B reported the facility had online training, but she did not have anyone to oversee to make sure staff watched what they needed/required. She was surprised when she pulled the sheets for the above employees at how little training had been completed. Review of the facility's policy for Required Training and In-Services of Staff dated 02/15/23, revealed the facility developed, implemented, and maintains an effective training program for all new and existing individuals providing services under a contractual arrangement. All direct care staff are required to attend 12 hours of continuing education and demonstrate competency annually including dementia and abuse training. The facility failed to provide three of three CNAs with the required 12 hours of in-service training to include dementia and abuse training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with 12 sampled, including one for hospitalization. Based on observation, interview, and record review the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long-Term Care Ombudsman for Resident (R) 5. Findings Include: - Review of R5's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of R5's Medical Record lacked evidence of written notification of the facility-initiated hospitalization transfer/discharge and bed hold to R5's Office of the State Long-Term Care Ombudsman. Observation on 01/25/22 at 08:20 AM revealed R5 sat in the dining room eating. On 01/27/22 at 10:05 AM Licensed Nurse (LN) C stated she did not send a bed-hold policy with the resident when they discharged to the hospital. On 01/27/22 at 11:30 AM Administrative Nurse A stated the facility notified the Office of the State Long Term Care Ombudsman for discharges but not for the hospitalizations. On 01/27/22 at 11:35 AM Administrative Staff B confirmed the facility must notify the Office of the State Long Term Care Ombudsman at the time of discharge to the hospital. The Bed-Hold Policy revised 12/16/21 documented in compliance with regulation, all facility-initiated discharges, for any reason will be reported to the State Long-Term Care Ombudsman Office. The facility failed to send a copy of the notice of facility-initiated hospitalization transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman when R5 transferred to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 23 residents with 12 sampled including one for hospitalization. Based on observation, interview, and record review the facility failed to provide a copy of the facility bed hold policy to Residents (R) 5 or his representative for his facility-initiated hospitalization. Findings Include: - Review of R5's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of R5's Medical Record lacked evidence of written notification of the facility-initiated hospitalization transfer and bed hold to R5 or his representative. Observation on 01/25/22 at 08:20 AM revealed R5 sat in the dining room eating. On 01/27/22 at 10:05 AM Licensed Nurse (LN) C stated she did not send a bed-hold policy with the resident when they discharged to the hospital. On 01/27/22 at 11:30 AM Administrative Nurse A stated the facility went over the bed-hold policy on admission, but she would not send a policy with a resident when they went to the hospital. On 01/27/22 at 11:35 AM Administrative Staff B confirmed the facility must provide a bed hold policy at the time of discharge to the hospital and said she spoke with the Social Services Director (SSD) who stated she had forgotten to send it. The Bed-Hold Policy revised 12/16/21 documented a written notice which specifies the duration, or the bed-hold policy will be provided at the time of transfer of a resident for hospitalization. The facility failed to provide a copy of the bed hold policy for R5 or his representative for his 12/06/21 hospitalization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census was 26 with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to verify Resident (R) 23's Advance Directives (a legal document in which a person specifies what actions should be taken for their health), the staff failed to know the code status, and the facility provided conflicting information regarding the residents code status to the staff responsible for R23's care. Findings included: - Review of the Physician Orders dated [DATE] revealed R23 with diagnoses of Non-Alzheimer's dementia (disorder of the mental processes marked by memory disorders, personality changes, and impaired reasoning) and schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior). Review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00 indicating Severe cognitive impairment. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 00 indicating severe cognitive impairment. Review of R23's current Care Plan revealed the resident was a DNR (Do Not Resuscitate) in the informational section at the top of each page along with the residents name. The body of the Care Plan did not address advance directives. Review of the medical chart revealed the residents Face Sheet under the section titled Additional Information listed R23's code status as DNR. Review of R23's medical chart revealed it did not contain a Do-Not-Resuscitate form. Review of the Physician's order sheet listed R23's code status as Start CPR (cardiopulmonary resuscitation). An observation on [DATE] at 08:56 AM revealed R23 with no sticker on the name plaque near his door, but R23's chart at the nurse's station had a red heart sticker. During an interview on [DATE] at 09:34 AM, Certified Nurse Aid (CNA) E stated she knew the stickers represented the residents wish to be a DNR or a full code (CPR performed). CNA E stated she did not know which sticker meant DNR or full code. During an interview on [DATE] at 09:59 AM, Certified Medication Aid (CMA) I stated she could not remember what the stickers on the resident name plaques meant. CMA I stated the facility kept a key at the nurse's station for the meaning of the stickers. An observation on [DATE] at 10:02 AM revealed the key for the stickers meaning located at the nurses' station. The key revealed a red heart indicated the resident's full code status, and a yellow star indicated the resident's DNR code status. During an interview on [DATE] at10:14 AM Licensed Nurse (LN) J stated a red heart sticker meant the resident was a full code, and a yellow star meant the resident was a DNR. LN J stated these stickers were placed on the residents' doors, and on the medical chart at the nurses' station. LN J stated she knew of the discrepancy concerning R23's code status. The face sheet showed the resident was a DNR, but the chart did not contain a DNR. The sticker on the chart was a red heart which meant R23 was a full code. During an interview on [DATE] at 10:16 AM Administrative Nurse B stated R23's chart had a red heart, and the physician order sheet gave direction to start CPR. Administrative Nurse B stated she expected the staff to initiate CPR in the case of an emergency. Administrative Nurse B stated on admission the social service director discussed code status with the residents and their family. Review of the facility's policy titled Advance Directives dated 08/2019 stated, .Every resident will be asked on admission if the resident has executed an advance directive .The resident's advance directive will be reviewed on admission, with any significant change in condition and at least quarterly during the care plan conference to ensure full understanding and continued wishes of the resident/representative . The facility failed to verify the code status, the staff did not know of the resident's code status, and the facility provided conflicting information to staff regarding code status for R23's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 26 residents with 12 included in the sample. Based on observation, record review, and interview, the facility failed to revise the care plan for Resident (R) 11 related to the use of oxygen. Findings included: - Review of Physician Orders dated 03/05/20 revealed R11 had the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD, a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), asthma (disorder of narrowed airways that caused wheezing and shortness of breath), and congestive heart failure (CHF, a condition with low heart output and the body becomes congested with fluid.) Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating mildly impaired cognition.R11 experienced shortness of breath or trouble breathing with exertion. Review of the Quarterly MDS dated 02/10/20 revealed a BIMS score of 11 indicating moderately impaired cognition. R11 experienced shortness of breath or trouble breathing with exertion. Review of the Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/01/19 revealed R11 had diagnoses of CHF and COPD. Review of the Care Plan revealed lack of interventions specific to R11's oxygen use. Review of the Physician Orders revealed R11 with an order dated 06/27/17 for oxygen at 2 liters per nasal cannula as needed when in bed for COPD. An observation on 03/11/20 at 08:03 AM revealed R11's oxygen tubing, and bubbler with no date indicating the last time staff changed them, and no plastic bag in which to store the oxygen tubing and nasal cannula when not in use. During an interview on 03/11/20 at 09:08 AM, Certified Nurse Aide (CNA) F stated R11 needed the use of oxygen when in bed. During an interview on 03/11/20 at 09:13 AM, Licensed Nurse (LN) G stated R11 required the use of oxygen mostly when she laid down in bed but did not use it when she came out for meals. During an interview on 03/11/20 at 11:08 AM, Administrative Nurse H stated anyone could add things to the care plan, but stated she mostly updated the care plan. Administrative Nurse H stated she thought the use of oxygen should be included in R11's care plan. Review of the Care Plan Revisions policy revised 11/2019 revealed, The care planning process includes .revision of care and treatment in order to meet the patient's needs .When changes in condition, medications, treatments or approaches occur, the plan of care will be updated immediately by hand and written on the plan of care. The facility failed to revise the care plan to include information related to the use of oxygen for R11.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 26 residents with 12 included in the sample with one resident reviewed for the use of oxygen. Based on observation, record review, and interview, the facility failed to provide necessary respiratory care and/or services consistent with professional standards of practice when they failed to change, and date disposable oxygen equipment for Resident (R) 11. Findings included: - Review of Physician Orders dated 03/05/20 revealed R11 had the following diagnoses: Chronic Obstructive Pulmonary Disease (COPD, a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), asthma (disorder of narrowed airways that caused wheezing and shortness of breath), and congestive heart failure (CHF, a condition with low heart output and the body becomes congested with fluid.) Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating mildly impaired cognition. R11 experienced shortness of breath or trouble breathing with exertion. Review of the Quarterly MDS dated 02/10/20 revealed a BIMS score of 11, indicating moderately impaired cognition. R11 experienced shortness of breath or trouble breathing with exertion. Review of the Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/01/19 revealed R11 with the diagnoses of CHF and COPD. Review of the Care Plan revealed lack of specific needs and interventions for oxygen use for R11. Review of the Physician Orders revealed R11 had an order dated 06/27/17 for oxygen at 2 liters per nasal cannula as needed when in bed for COPD. Review of the January 2020 Medication Record revealed O2 cannula and nebulizer set up every month on the 15th lacked documentation of completion. Review of the February 2020 Medication Record revealed O2 cannula and nebulizer set up every month on the 15th lacked documentation of completion. An observation on 03/11/20 at 08:03 AM revealed R11's oxygen tubing and bubbler were not dated to indicate the last time they were changed, and no plastic bag observed in which to store the oxygen tubing and nasal cannula when not in use. During an interview on 03/11/20 at 09:08 AM, Certified Nurse Aide (CNA) F stated R11 needed the use of oxygen when in bed. CNA F stated the night shift staff were responsible for changing the oxygen tubing, but CNA F did not know how often they did this. CNA F stated it was his understanding the oxygen tubing were to be labeled with the date staff changed it. During an interview on 03/11/20 at 09:13 AM, Licensed Nurse (LN) G stated R11 required the use of oxygen mostly when she laid down in bed but did not use it when she came out for meals. LN G stated she thought the oxygen tubing should be replaced weekly by night shift. LN G stated the oxygen tubing should be labeled with the date staff replaced it. During an interview on 03/11/20 at 01:22 PM, Administrative Nurse stated the oxygen tubing should be changed monthly and expected the tubing to be dated. Review of the Administration of Oxygen policy dated 05/2019 revealed, Store all cannulas, oxygen tubing and nebulizer masks in plastic bag when not in use .Oxygen tubing will not be draped across bedroom furniture or equipment .Disposable cannulas, nebulizer masks and tubing will be changed monthly on the night shift and plastic storage bag will be changed and dated monthly on the night shift . The facility failed to change and date disposable oxygen equipment for R11.

The facility reported a census of 26 residents. Based on observation and interview the facility failed to serve food in accordance with professional standards for food service safety, ensuring the residents remain free from infections, when observations revealed dietary staff did not hold, deliver, and transport resident food/cups in a sanitary manner Findings included: - On 03/09/20 at 11:35 AM Dietary Staff (DS) D observed passing out beverages and touched the tops/lips of glasses multiple times. On 03/09/20 at 11:59 AM Certified Nurse Aide (CNA) E observed handing a resident a cup of juice while holding on to the top of the cup. On 03/09/20 at 12:06 PM DS D observed delivering a resident their food using a tray. DS D placed the food items on the table appropriately but moved the glasses and cups out of the way by holding the tops of the glasses and cups for two residents, then DS D brought a large glass of tea and held the top of the glass. On 03/09/20 at 12:10 PM DS D observed cutting a baked potato for a resident and used his ungloved fingers to keep the potato from moving while he used a fork to cut up the potato. On 03/10/20 at 08:50 AM DS D stated he should hold cups by the base and not touch the tops. During an interview on 03/11/20 at 10:16 AM, Certified Dietary Manager (CDM) C stated she expected all of her staff to know how to move a glass or cup on the table and to know the correct way to carry them. CDM C stated she did the education for the dietary staff on their tasks. Review of the Safe Food Preparation and Handling Practices policy revised 01/13/2016 revealed, Utensils and drinkware shall be handled in such a way as to avoid touching any surface that food or drink will come in contact with. The facility failed to distribute and serve food in accordance with professional standards for food service safety to prevent the outbreak of foodborne illness when observations revealed dietary staff did not hold, deliver, and transport resident food/cups in a sanitary manner.