**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)13 received care in a dignified manner during incontinent care when the window blind was left open. This deficient practice placed the resident at risk for decreased psychosocial well-being. Findings included: - Resident (R) 13's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying) and other idiopathic peripheral autonomic neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R13 required maximal to total assistance with ADL's (activities of daily living such as bed mobility, toileting, dressing, and bathing). R13 was always incontinent of bladder. The Quarterly MDS dated 04/23/24, documented a BIMS of 14. R13 required total assist with ADLs, except was independent with eating. R13 was incontinent of bowel and bladder. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/27/23, documented R13 was dependent on staff for bed mobility, dressing, toileting, and bathing. The Pressure Ulcer CAA dated 10/27/23, documented a Braden score of 14 (a tool for assessing the risk of developing a pressure ulcer), as was at risk for development of a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The Urinary Incontinence CAA dated 10/27/23, documents R13 was always incontinent of bowel and bladder. The Care Plan dated 05/15/24, revealed R13 required two staff for bed mobility. Staff were to check and change the resident and apply briefs for incontinent care. Staff were to provide barrier cream to buttocks after each incontinent care. Staff were to turn the resident every hour and a half to two hours. The Physician's Order dated 05/15/24, lacked orders for incontinent care or skin care. Review of the Progress Notes and Standard Assessments from 02/01/24 to 05/15/24 documented: On 04/17/24 through 04/23/24 Look Back MDS Assessment charting in EHR, documented R13 alert and oriented to person, place, time, and situation. Dependent of staff for ADL's, no behaviors. Incontinent of bowel and bladder. On 05/16/24 at 11:33 AM, observed certified nursing assistant (CNA) N and certified medication aide (CMA) U complete incontinent care for R13. CNA N and CMA U failed to close the window blinds when providing care to the resident. R13's bed was directly in front of the window. Staff were able to see across the yard to the therapy room window that measured approximately 46 feet away. R13's window faced ninth street that measured approximately 150 feet away from window. On 05/16/24 at 11:41 AM, CNA N and CMA U reported that the window blinds should have been closed completely during care provided. On 05/16/24 at 11:45 AM, R13 stated she did not like that the window blind was left open when she was having care provided to private area. Stated I don't want people to see me. On 05/16/24 at 11:49 AM, Administrative B and Consultant Nurse P stated that the window blind should been closed during care provided. On 5/20/24 facility failed to provide a policy on dignity. The facility failed to ensure Resident (R)13 received care in a dignified manner during incontinent care when the window blind was left open. This deficient practice placed the resident at risk for decreased psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 41 residents, with 12 residents sampled, including one resident sampled for advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed Resident (R)16 by having the guardian sign a completed Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire CPR in the event of cardiac arrest). Findings included: - Resident (R) 16's Electronic Health Record (EHR) revealed diagnoses of unspecified dementia (progressive mental disorder characterized by failing memory, confusion), unspecified intellectual disabilities and chronic atrial fibrillation (rapid, irregular heartbeat). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) not assessed, completed staff interview documented short and long term memory problem. R16 required partial to moderate assist with ADL's (activities of daily living such as bed mobility, toileting, dressing, and bathing). R16 independent with eating and wheelchair mobility. The Quarterly MDS dated [DATE], documented a BIMS of 03, indication of severely impaired cognition. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated [DATE], documented R16 declined to participate in a BIMs assessment. Staff assessment completed. R16 can locate his room and knows the current season. The Care Plan dated [DATE] documented, R16 had established an advance directive and had selected DNR. Check R16 each quarter to see if R16 changed anything related to advance directives wishes. The care plan lacked documentation that R16 had a guardian. The Physician's Order dated [DATE], documented a Do Not Resuscitate order. On [DATE] review of EHR an uploaded document dated [DATE], a signed DNR by R16's guardian, witnessed by Social Services Designee (SSD), and provider. On [DATE] review of EHR an uploaded document dated [DATE], a signed guardianship by <name of county> District Court, however lacked direction of advanced directives. Interview on [DATE] at 02:55 PM Consultant Nurse P stated that the guardian cannot sign a DNR form unless approved by the judicial system. Review of the facility's Advanced Directives policy dated [DATE], documented the facility will provide care and services in compliance with advanced directives, provided by the resident or resident representative according to state law. Policy lacked direction if resident had a guardian. The facility failed R16 by having the guardian sign a completed Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire CPR in the event of cardiac arrest).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 41 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for two sampled residents, Resident (R)19 related to oxygen use, and R9 related to completion of sections C and D of the Minimum Data Set (MDS). This placed the residents at risk for uncommunicated care needs. Findings include: - The 02/27/23 Electronic Health Records (EHR) documented R19 had the following diagnoses that included pulmonary fibrosis (a disease of the lung that causes scarring and stiffening of the tissues over time which causes increased work of breathing) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest). The 10/17/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R19 was independent for all cares except bathing which required supervision and setup. The assessment documented that R19 did not receive oxygen. The 09/28/23 Care Area Assessment (CAA) lacked documentation related to oxygen therapy. The 04/16/24 Quarterly MDS documented a BIMS score of 15 which indicated intact cognition. R19 was independent for all cares except bathing which required minimal assistance. The assessment documented R19 received oxygen. The 05/15/24 Care Plan documented the resident had been on oxygen but that the intervention documented as resolved on 06/17/22. The Physician Orders in the EHR lacked active orders related to oxygen therapy but contained an order for oxygen that had been discontinued by the physician on 03/16/22. The 09/27/23 to 10/31/23 Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation related to administration of oxygen. The Progress Notes reviewed from 01/14/24 to 05/16/24 lacked any documentation related to oxygen use. On 05/15/24 at 09:54 AM, an observation of R19's room revealed no oxygen equipment in his room. On 05/16/24 at 11:37 AM, R19 observed seated in the dining area with peers present, no oxygen observed in use. On 05/20/24 at 08:04 AM, an observation of R19's room revealed no oxygen equipment in his room. On 05/21/24 at 11:30 AM, Administrative Nurse D confirmed the above information and stated that a regional staff member completed that section of the MDS and that the entry on the MDS dated [DATE] was presumed to be a clerical error. On 05/21/24 at 11:32 AM, Administrative Nurse B confirmed the above information and stated that her expectation was for all MDS assessments to be accurate regardless of whether the section was completed in-house by Administrative Nurse D or if it was completed off-site by a corporate employee. On 05/21/24 at 11:34 AM, Consultant Nurse P confirmed the above information and confirmed that R19 did not receive oxygen during the look-back period for the 04/16/24 MDS assessment. The facility policy for Minimum Data Set (MDS), dated 11/28/17, documented that the facility would conduct the MDS according to federal regulations and that data gathering was completed by a licensed nurse or member of the interdisciplinary team and reviewed by a Registered Nurse for completion following the current RAI (resident assessment instrument) manual. The facility failed to accurately complete the MDS for R19 related to oxygen. This placed the resident at risk for uncommunicated care needs. - Resident (R) 9's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly MDS dated 01/02/24, documented a Brief interview for Mental Status (BIMS) score of 05, which was an indication of severely impaired cognition. Patient Health Questionnaire (PHQ-9 is a depressive symptom scale to assess the presence and severity of depressive symptoms) scored 00, which indicated no depression. R9 required maximal to total assistance with activity of daily living (ADLs). The Significant Change Minimum Data Set (MDS) dated [DATE], lacked documentation of Brief Interview for Mental Status (BIMS) and lacked documentation of the nine-item Patient Health Questionnaire. R9 required total assistance with activities of daily living, which included bed mobility, toileting, dressing, and bathing. R9 was always incontinent of bladder. R9 received hospice care. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 03/27/24 was not triggered. The Cognitive Loss/Dementia CAA dated 03/27/24, was not triggered. The Psychosocial Well-Being CAA dated 03/27/24, was not triggered. The Care Plan dated 03/26/24, revealed the resident received hospice services and R9 continued to be involved in her healthcare and life decisions for as long as she was able. R9 had as needed (PRN) Ativan to keep R9 comfortable at the end of life. The care plan lacked documentation of cognitive loss/dementia. The Physician's Order dated 03/21/24, documented admit to Hospice for diagnosis of senile degeneration. Review of the Progress Notes from 02/01/24 to 05/15/24 documented the following: On 02/27/24 at 04:50 PM, Social Service Designee (SSD) spoke with R9's son, stating he would set up an appointment to discuss hospice. On 03/20/24 at 02:14 PM, the Interdisciplinary Team met with the family, decided to enroll R9 with hospice. Lacked documentation if R9 was invited or attended the meeting. Interview on 05/21/24 at 08:25 AM, Administrative Nurse D and Nurse Consultant P both stated section C and D on MDS was not completed before Assessment Reference Date (ARD) and had to be not assessed per the Resident Assessment Instrument (RAI) manual. Both agreed that MDS was not a complete assessment of R9. Interview on 05/21/24 at 12:30 PM, social service staff E stated was not able to complete R9's MDS section C and D realized after the ARD they were not completed. The facility policy for Minimum Data Set (MDS)dated 11/28/17, documented that the facility would conduct the MDS according to federal regulations and that data gathering was completed by a licensed nurse or member of the interdisciplinary team and reviewed by a Registered Nurse for completion following the current RAI (resident assessment instrument) manual. The facility failed to accurately complete the MDS for R9 related to cognition and depression. This placed the resident at risk for uncommunicated care needs.

The facility reported a census of 41 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 one resident, Resident (R)30 related to use, care and maintenance of nebulizer equipment. This deficient practice had the potential to place the resident at risk for not receiving appropriate cares and treatments. Findings included: - The Electronic Health Records (EHR) documented R30 had the following diagnoses that included congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest) with hypoxia (inadequate supply of oxygen in the blood). The 09/19/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R30 was dependent on staff assistance for all cares except eating which was independent. The assessment documented that R30 received oxygen. The 09/19/23 Care Area Assessment (CAA) lacked documentation related to nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication therapy or oxygen therapy. The 03/12/24 Quarterly MDS documented a BIMS score of 14, which indicated intact cognition. R30 was dependent on staff for all cares except eating which was independent. The assessment documented that R30 received oxygen. The 05/15/24 Care Plan lacked documentation related to nebulized medication use or care and maintenance of nebulizer equipment. The Physician Orders in the EHR documented the following: Ipratropium (Atrovent - a medication used to dilate the medium and large airways of the lungs)-Albuterol (Ventolin - a medication used to relax the muscles of the lower airways) 0.5-2.5 (3) milligrams (mg)/3 milliliters (mL), one vial to be inhaled orally (PO) via nebulizer, four times each day, related to chronic respiratory failure with hypoxia, dated 10/24/23. The Physician's Orders lacked documentation related to care and maintenance of the nebulizer equipment. The Progress Notes reviewed from 01/18/24 to 05/16/24 lacked any documentation related to nebulized medication use. On 05/15/24 at 12:06 PM, an observation of R30's room revealed that a nebulizer with attached mask, labeled 5/13 sat intact inside the top drawer of a clear plastic bedside table with an unknown clear liquid in the atomizer chamber. On 05/16/24 at 07:54 AM, an observation of R30's room revealed that a nebulizer with attached mask, labeled 5/13 sat intact inside the top drawer of a clear plastic bedside table with an unknown clear liquid in the atomizer chamber. On 05/20/24 at 08:02 AM, R30 sat upright in bed with the nebulizer mask intact on the resident's face with no medication mist observed. On 05/20/24 at 08:08 AM, Certified Nurse Aide (CNA) K entered R30's room and assisted the resident in removing the nebulizer mask and placed the mask inside the top drawer of the bedside storage cabinet with an unknown clear liquid in the atomizer chamber. On 05/20/24 at 08:14 AM, CNA K revealed that she was unaware of any special handling/treatment/cleaning of nebulizer equipment. CNA K stated that sometimes at the end of a nebulizer treatment, CNA staff would assist the resident to remove the nebulizer equipment (mask or hand-held device) and place it on the nebulizer machine and stated that the Certified Medication Aides (CMA) or Licensed Nurses (LN) would come along later and take care of the nebulizer equipment. On 05/16/24 at 09:31 AM, Administrative Nurse C stated that Administrative Nurse D updated the care plans during morning clinical meeting with the interdisciplinary team. Further, Administrative Nurse C stated that she was unaware of how often care plans should be updated and stated there was no paper updates for care plans. On 05/20/24 at 12:30 PM, certified nursing assistant (CNA) M stated she was unaware of the care plan or how to view what interventions were to be performed for the residents. On 05/20/24 at 12:30 PM, CNA Q stated the care plan was viewable in the EHR and staff were able to have a Pocket Care Sheet paper that was available at the nurses' station that staff could carry in their pockets to refer to with the most recent revision dated 05/08/24. On 05/20/24 at 12:45 PM, Administrative Nurse D stated that she updated the Pocket Care Sheets whenever the care plan was changed and stated that she was not always able to update the care sheets in a timely manner. On 05/21/24 at 11:28 AM, Administrative Nurse B and Administrative Nurse D confirmed the care plans lacked documentation for care and maintenance of R30's nebulizer equipment. The facility's Care Plan policy, dated 03/21/24 documented the facility would develop a care plan for each resident that includes measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs consistent with the resident's desires and preferences. The facility failed to review and revise a comprehensive care plan for R30 to include nebulizer treatments. This deficient practice had the potential to lead to uncommunicated need for care and services to meet this resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)13 received care for removal of facial hair. This deficient practice placed the resident at risk for decreased psychosocial well-being. Findings included: - Resident (R) 13's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), and other idiopathic peripheral autonomic neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R13 required maximal to total assistance with ADL's (activities of daily living such as bed mobility, toileting, dressing, and bathing). The Quarterly MDS dated 04/23/24, documented a BIMS of 14. R13 required total assist with ADLs, except was independent with eating. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/27/23, documented R13 was dependent on staff for bed mobility, dressing, toileting, and bathing and required moderate assist with personal hygiene. The Care Plan dated 05/15/24, revealed R13 lacked direction for staff on bathing assistance and removal of facial hair. The Physician's Order dated 05/15/24, lacked orders for removal of facial hair. Review of the Progress Notes and Standard Assessments from 02/01/24 to 05/15/24, lacked notes or assessments regarded to care provided. Review of the Task Personal Hygiene (the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands) in EHR dated from 04/24/24 to 05/15/24, staff documented 54 times R13 dependent - helper does all of the effort. Resident does none of the effort to complete the activity. Observation on 05/15/24 at 11:33 AM, revealed R13 had facial hair above and both upper lips, several approximate length of 1/4 inch whiskers. R13 stated she cannot see them, and it bothered her that she had the facial hair. Observation on 05/16/24 at 11:33 AM, revealed facial hair remained above and below R13's lips, several approximate length of 1/4 inch whiskers. Interview on 05/16/24 at 11:41 AM, Certified Nurse Aide (CNA) N stated that facial hair should be removed on shower days and Res 13's shower day scheduled on Thursday and Sunday evening. CNA N stated she had not planned to remove R13's facial hair. On 05/20/24 at 10:31 AM, interview with Administrative Nurse B reported it was expected of staff to offer the residents facial hair be removed on bath/shower days or if resident requested to have the facial hair removed on any other day. On 5/20/24 facility failed to provide a policy on ADLs. The facility failed to ensure Resident (R)13 received care for removal of facial hair. This deficient practice placed the resident at risk for decreased psychosocial well-being.

The facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to maintain a clean, comfortable and homelike environment to the residents that resided in the facility. Findings included: - On 05/21/24 at 09:19 AM, physical environmental tour with Maintenance Director F revealed the following areas of concerns: 1. On the floor transition from the main area to the 200 hall, an area of frayed carpeting. 2. On the floor transition from the main area to the 300 hall, an area of frayed carpeting. 3. On the floor in the 200 hall, one floor sewer cleanout cap was loose and was able to be lifted easily. 4. On the divider wall inside the 400 hall shower, two tiles along the base and corner were broken with jagged exposed edges. 5. On the transition between the floor to the wall in the 200 hall shower, an unknown black substance was between the tiles. On 05/21/24 at 09:40 AM, Maintenance Director F confirmed the above findings. On 05/21/24 at 09:50 AM, Administrative Staff A confirmed the above findings and stated they would be immediately addressed by the facility. The facility's Housekeeping and Maintenance Services policy, dated 04/27/18 documented that the facility would provide housekeeping and maintenance services to maintain a safe, clean, comfortable and homelike environment. The facility failed to maintain a clean, comfortable and homelike environment to the residents that resided in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for Resident (R)13's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The facility further failed to develop a care plan for R19's care and maintenance of respiratory equipment. The facility further failed to develop a care plan for R42's dysphagia (swallowing difficulty). The facility further failed to develop a care plans' for R26's monitoring of behaviors for psychotropic (alters mood or thought) medications. This deficient practice placed the residents at risk for inadequate care and services. Findings included: - Resident (R)42's Electronic Health Record (EHR) revealed diagnoses of dysphagia (swallowing difficulty), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and epilepsy (brain disorder characterized by repeated seizures). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R42 was independent with ADLs (activities of daily living such as walking, grooming, toileting, dressing and eating) and required a mechanically altered, regular diet with regular thin liquids. The 03/14/24 Nutritional Status Care Area Assessment (CAA) documented R42 was able to choose his own meals and eat without assistance. R42 received a pureed diet with mechanical soft foods for pleasure. R42 reported choking episodes prior to admission to the facility. Speech Therapist worked with R42 for dysphagia and safe swallowing. The Nutrition Care Plan dated 05/16/24, guided staff to provide diet as ordered and R42 was able to choose the foods he wanted to consume. The care plan lacked the dysphagia, pureed diet, and recommended speech therapy interventions. The Physician's Order dated 03/07/24, included the resident to have a regular diet, pureed texture, regular thin liquids. The physician orders lacked mechanical soft foods for pleasure. On 05/08/24, the provider ordered the staff could crush medications or change to liquids. Review of the Progress Notes from 03/07/24 to 05/15/24 documented the following: On 03/08/24 at 04:07 PM, R42 requested rice krispies and a [NAME] buddy bar snack the nurse educated the resident on the risks of choking. R42 stated he could eat them. On 03/22/24 at 09:36 AM, Speech Therapist evaluated R42, and the swallowing recommendations received as follows: R42 needs to sit up at 90 degrees to eat and remain upright for 30 minutes after meals. Foods to be pureed with option of certain foods to be ground per R42's preference. Reminded to alternate the food with the liquids. Oral care twice a day especially before bed. On 05/07/24 at 10:28 AM, documented R42 choked on Colace pill at breakfast. Colace capsule changed to liquid. Interview on 05/20/24 09:39 AM, R42 stated he could eat what he wanted to, that the meat needed to be ground up. Stated he does get choked on foods sometimes. Interview on 05/20/24 at 09:44 AM, Certified Medication Aide (CMA) R stated R42's medications could be crushed, but CMA R does not crush the medications, instead would administer medications in applesauce per R42's requested the medications administered that way. CMA R stated that R42 had choked on medications prior to 05/07/24 at times and on 05/07/24 CMA R administered morning medications to R42. R42 coughed and placed his face over a garbage can in the dining room, then hurried himself to his room as the nurse followed behind him. CMA R stated that R42 requested snacks that are not pureed like [NAME] bars. Interview on 05/20/24 at 10:00 AM, Dietary Staff I stated R42 never requested food that was not purred. Stated that R42 received pancakes instead of his poached eggs that was ordered and would not eat them, R42 alerted dietary staff of the mistake. Interview on 05/20/24 at 10:15 AM, Licensed Nurse (LN) L stated R42 requested snack cakes often and knew that R42's diet was pureed. LN L stated she followed R42 down to his room on 05/07/24 when he had difficulty with the Colace capsule, stated R42 vomited the capsule into garbage can and Colace capsule was changed to liquid form. Interview on 05/20/24 at 02:50 PM, Administrative Nurse B and Administrative Nurse D reviewed current diet ordered in EHR and revealed that no mention of mechanical soft if requested was on order. They both reviewed the care plan and stated the care plan lacked the Speech Therapist recommended interventions and should have been added to the care plan. Administrative Nurse B stated that R42 requested snack cakes especially the [NAME] bars, and stated the [NAME] bar was soft enough to be consumed. The facility Care Plan policy dated 03/21/24, documented the facility would develop a care plan for each resident that included measurable objectives to meet the residents medical, nursing, mental and psychosocial needs consistent with the resident's desires and preferences. The facility failed to develop a care plan for R42's dysphagia (swallowing difficulty). This deficient practice placed the residents at risk for inadequate care and services. - Resident (R) 13's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus type two (DM2-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), neuromuscular dysfunction of bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying) and other idiopathic peripheral autonomic neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. R13 required maximal to total assistance with activities of daily living (ADLs), which included bed mobility, toileting, dressing, and bathing. R13 was always incontinent of bladder. The Quarterly MDS dated 04/23/24, documented a BIMS of 14. R13 required total assistance of staff with ADLs. R13 was independent with eating. R13 was incontinent of bowel and bladder. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 10/27/23, documented R13 was dependent on staff for bed mobility, dressing, toileting, and bathing. The Pressure Ulcer CAA dated 10/27/23, documented a Braden Score of 14 (a tool for assessing the risk of developing a pressure ulcer), which identified the resident as at risk for development of a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). The Urinary Incontinence CAA dated 10/27/23, documented R13 was always incontinent of bowel and bladder. The Care Plan dated 05/15/24, revealed R13 required two staff for bed mobility. Staff were to check and change the resident and apply briefs for incontinent care. Staff were to provide barrier cream to her buttocks after each incontinent care and turn the resident every hour and a half to two hours. The care plan lacked guidance to staff related to pressure ulcers. Review of the Progress Notes from 02/01/24 to 05/15/24 documented the following: On 05/08/24 at 03:05 PM, R13 had two intact blisters on her right (later identified as the left) coccyx, noted by an unidentified Certified Nurse Aide (CNA). Staff treated the blisters with a thick barrier cream and would notify a wound and skin nurse. Further review of the resident's record lacked any evidence staff notified a wound and skin nurse of R13's wound to her coccyx on 05/08/24. Review of the Skin Wound Assessments from 02/01/24 to 05/15/24 documented the following: On 05/14/24 at 03:00 PM (six days later) the Skin Wound Assessment documentation revealed R13 had a 0.2 centimeter (cm) by 0.2 cm stage two pressure ulcer to the left coccyx. Staff notified Physician Extender S and received an order for Triad cream (a hydrophilic wound, for difficult-to-dress wounds on wet or irregular surfaces). The Physician's Order dated 05/15/24, lacked orders for R13's two opened, stage two pressure ulcers. Observation on 05/16/24 at 11:33 AM, while staff provided incontinent care to R13, revealed two open areas on the left upper buttock near the coccyx, approximately 0.5 cm by 0.3 cm and a small area below area that measured approximately 0.2 cm by 0.2 cm. Both areas were superficial in depth, with a moist pink wound base with white granulation (new tissue formed during wound healing) of skin surrounding both open areas. The coccyx had redness. No old barrier cream residue was on the buttocks/coccyx area when staff provided the incontinence care and staff did not apply any cream after the incontinent care provided. Interview on 05/16/24 at 09:31 AM, Administrative Nurse C revealed that she did not update the care plan, stated that the MDS Nurse updated all the care plans. Administrative Nurse C did not know a time frame of when concerns such as a pressure ulcer should be added to the care plan. Interview on 05/16/24 at 09:42 AM, Administrative Nurse B, Administrative Nurse D, and Consultant Nurse P, stated the care plan should be updated immediately if a significant change of residents' care occurred and agreed that a new pressure ulcer was a significant change. The facility Care Plan policy dated 03/21/24, documented the facility would develop a care plan for each resident that included measurable objectives to meet the residents medical, nursing, mental and psychosocial needs consistent with the resident's desires and preferences. The facility failed to develop a comprehensive care plan for Resident (R)13's pressure ulcer. This deficient practice placed the residents at risk for inadequate care and services. - The Electronic Health Records (EHR) documented R19 had the following diagnoses that included pulmonary fibrosis (a disease of the lung that causes scarring and stiffening of the tissues over time which causes increased work of breathing) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest). The 10/17/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R19 was independent for all cares except bathing which required supervision and setup. The 09/28/23 Care Area Assessment (CAA) lacked documentation related to nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication therapy. The 04/16/24 Quarterly MDS documented a BIMS score of 15 which indicated intact cognition. R19 was independent for all cares except bathing which required minimal assistance. The 05/15/24 Care Plan lacked documentation related to nebulized medication use or care and maintenance of nebulizer equipment. The Physician Orders in the EHR documented the following: Budesonide (Pulmicort - an orally inhaled steroid used to decrease inflammation in the lungs) suspension 0.25 milligrams (mg)/2 milliliter (mL), one vial to be inhaled orally (PO) via nebulizer, one time per day, related to pulmonary fibrosis, resident may set up and self-administer, dated 01/10/24. Ipratropium (Atrovent - a medication used to dilate the medium and large airways of the lungs)-Albuterol (Ventolin - a medication used to relax the muscles of the lower airways), 0.5-2.5 (3) mg/3 mL, one vial to be inhaled PO via nebulizer, every four hours as needed for cough/shortness of breath, resident may self-administer after nurse setup, dated 11/17/21. Perforomist (formoterol - a long-lasting medication used to relax the muscles of the airways), 20 micrograms (mcg)/2 mL, one vial to be inhaled PO via nebulizer, one time per day related to pulmonary fibrosis, dated 12/06/24. The Physician's Orders lacked documentation related to care and maintenance of the nebulizer equipment. The Progress Notes reviewed from 01/14/24 to 05/16/24 lacked any documentation related to nebulized medication use. The EHR Assessments revealed on 01/09/24, staff assessed that R19 was capable to properly self-administer inhaled medications without assistance from staff. On 05/15/24 at 09:54 AM, an observation of R19's room revealed that a nebulizer, labeled 5/13 sat intact on the nebulizer machine on R19's over-the-bed table with an unknown clear residue noted in the atomizer chamber. On 05/16/24 at 08:03 AM, an observation of R19's room revealed that a nebulizer sat intact on the nebulizer machine on R19's over-the-bed table with an unknown clear residue and unknown clear liquid droplets in the atomizer chamber. On 05/20/24 at 08:04 AM, an observation of R19's room revealed that a nebulizer sat intact on the nebulizer machine on R19's over-the-bed table with an unknown clear residue and unknown clear liquid droplets in the atomizer chamber. On 05/16/24 at 09:31 AM, Administrative Nurse C stated that Administrative Nurse D updated the care plans during morning clinical meeting with the interdisciplinary team. Further, Administrative Nurse C stated that she was unaware of how often care plans should be updated and stated there was no paper updates for care plans. On 05/20/24 at 12:30 PM, certified nursing assistant (CNA) M stated she was unaware of the care plan or how to view what interventions were to be performed for the residents. On 05/20/24 at 12:30 PM, CNA Q stated the care plan was viewable in the EHR and staff were able to have a Pocket Care Sheet paper that was available at the nurses' station that staff could carry in their pockets to refer to with the most recent revision dated 05/08/24. On 05/20/24 at 12:45 PM, Administrative Nurse D stated that she updated the Pocket Care Sheets whenever the care plan was changed and stated that she was not always able to update the care sheets in a timely manner. On 05/21/24 at 11:28 AM, Administrative Nurse B and Administrative Nurse D confirmed the care plans lacked documentation for care and maintenance of R19's nebulizer equipment. The facility's Care Plan policy, dated 03/21/24 documented the facility would develop a care plan for each resident that includes measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs consistent with the resident's desires and preferences. The facility failed to accurately complete a comprehensive care plan for R19 related to nebulizer treatments. This deficient practice have the potential to lead to uncommunicated need for care and services to meet this residents' needs. - R26's signed physician orders dated 05/15/24 revealed the following diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R26's Significant Change in Status Minimum Data Set (MDS) dated 10/21/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The PHQ-9 (depression assessment) score of 10, indicating moderate depression. R 26 received as needed (PRN) pain medication for occasional complaints of pain. Medications included antianxiety (class of medication that calm and relax people), antidepressant (class of medications used to treat mood disorders), and opioid (pain medication) daily. The Mood State Care Area Assessment (CAA) dated 10/24/23 revealed the resident had depression and received Cymbalta 30 mg daily and Remeron 30 mg daily. During the assessment period, the resident stated he felt down and depressed daily and felt bad about himself. The resident was agreeable to weekly social service visits to ensure psychosocial needs were met. The Quarterly MDS dated 01/30/24 revealed a PHQ-9 score of one, indicating no depression. R26 received scheduled pain medication, antianxiety and antidepressant medications daily. The Care Plan dated 05/15/24 revealed no interventions planned to monitor for behaviors/mood related to the use of antidepressant and antianxiety medications. The physician orders included: Ativan, (Lorazepam), (antianxiety medication), 1 milligram (mg), two times a day, related to anxiety disorder. Give one mg, by mouth, every six hours, as needed for anxiety related to malignant neoplasm of nasopharynx, and for stressful events or thoughts, ordered on 05/14/2024. Remeron Tablet 30 mg, (Mirtazapine), (antidepressant medication), 30 mg by mouth, one time a day, related to major depressive disorder, ordered on 05/09/2024. Cymbalta, 30 mg, (Duloxetine), (antidepressant), 30 mg, by mouth at bedtime, related to anxiety disorder, ordered on 5/9/2024. On 05/16/24 at 10:41 AM, Licensed Nurse (LN) L provided tracheostomy care (care around the opening through the neck into the trachea through which an indwelling tube may be inserted). The resident was relaxed during the procedure. On 05/15/24 at 09:30 AM, Certified Nursing Assistant M reported she had not seen any real bad behaviors from the resident. He was usually cooperative with all care. On occasion he is kind of down and wants to be left alone. On 05/16/24 at 11:00 AM, LN L reported the facility does not document the resident's behavior in the on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). LN L reported the R26 receives medication for his mood state. On 05/21/24 at 11:28 AM, Administrative Nurse B and Administrative Nurse D confirmed that the physician's orders and care plan lacked documentation for monitoring of behaviors related to psychotropic medications for R26. Administrative Nurse B stated that her expectation was for monitoring of behaviors to be included in the care plan. The facility's policy for Care Plan dated 03/21/24 revealed a care plan will be developed for each resident that includes measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs and are consistent with the resident's desires and preferences. The facility failed to develop a comprehensive care plan to include interventions to monitor behaviors related to the use of psychotropic medications for this resident that required medication for depression and anxiety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R)42's Electronic Health Record (EHR) revealed diagnoses of obstructive sleep apnea (disorder of sleep characterized by periods without respirations), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and epilepsy (brain disorder characterized by repeated seizures). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R42 was independent with ADLs (activities of daily living such as walking, grooming, toileting, dressing and eating). The 03/14/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R42 was independent in ADLs, except required set-up to complete showers. The Physician's Order dated 04/11/24, included the resident to have CPAP (continuous positive airway pressure - a ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep) applied nightly in PM and removed in the AM daily. Staff instructed to clean the CPAP weekly on Thursdays. The physician's order lacked direction on how to clean the CPAP and store the mask when not used. Review of the Progress Notes from 03/07/24 to 05/15/24 lacked documentation regarded to the CPAP. Observation on 05/15/24 at 12:31 PM, a CPAP mask laid on R42's nightstand over other personal items. Observation on 05/16/24 at 08:13 AM, a CPAP mask laid on R42's nightstand over other personal items. Observation on 05/20/24 at 09:39 AM, a CPAP mask laid on the nightstand over the CPAP machine and came in direct contact with other items on the nightstand. R42 stated was not sure when staff would clean the mask. Interview on 05/21/24 at 11:30 AM, Administrative Nurse B and Administrative Nurse D confirmed a CPAP mask should be placed on the machine or in a bag, but not on the bed or nightstand. The facility policy Respiratory Care dated 04/24/18, documented that the facility would provide necessary respiratory care services in accordance with professional standards of practice, the resident's care plan and the resident's choice. The facility failed to properly store this resident's CPAP in accordance with professional standards of care, to prevent possible respiratory illness. The facility reported a census of 41 residents with 12 residents selected for review which included four residents reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to properly clean and store the nebulizer (a device for administering inhaled medications) for Resident (R)19 and R30. Additionally, the facility failed to properly store the CPAP (continuous positive airway pressure - a ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep) for R42. Furthermore, the facility failed to provide tracheostomy (an opening though the neck into the trachea through which an indwelling tube is inserted) care for R26 in accordance with professional standards of practice. These deficient practices had the potential to have a negative impact on the residents' physical and psychosocial well-being. Findings included: - The 02/27/23 Electronic Health Records (EHR) documented R19 had the following diagnoses that included pulmonary fibrosis (a disease of the lung that causes scarring and stiffening of the tissues over time which causes increased work of breathing) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest). The 10/17/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R19 was independent for all cares except bathing which required supervision and setup. The 09/28/23 Care Area Assessment (CAA) lacked documentation related to nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication therapy. The 04/16/24 Quarterly MDS documented a BIMS score of 15 which indicated intact cognition. R19 was independent for all cares except bathing which required minimal assistance. The 05/15/24 Care Plan lacked documentation related to nebulized medication use or care and maintenance of nebulizer equipment. The Physician Orders in the EHR documented the following: Budesonide (Pulmicort - an orally inhaled steroid used to decrease inflammation in the lungs) suspension 0.25 milligrams (mg)/2 milliliter (mL), one vial to be inhaled orally (PO) via nebulizer, one time per day, related to pulmonary fibrosis, resident may set up and self-administer, dated 01/10/24. Ipratropium (Atrovent - a medication used to dilate the medium and large airways of the lungs)-Albuterol (Ventolin - a medication used to relax the muscles of the lower airways) 0.5-2.5 (3) mg/3 mL one vial to be inhaled PO via nebulizer every four hours as needed for cough/shortness of breath, resident may self-administer after nurse setup, dated 11/17/21. Perforomist (formoterol - a long-lasting medication used to relax the muscles of the airways) 20 micrograms (mcg)/2 mL, one vial to be inhaled PO via nebulizer one time per day related to pulmonary fibrosis, 12/06/22. The Physician's Orders lacked documentation related to care and maintenance of the nebulizer equipment. The Progress Notes reviewed from 01/14/24 to 05/16/24 lacked any documentation related to nebulized medication use. The EHR Assessments revealed on 01/09/24 R19 was assessed to be capable to properly self-administer inhaled medications without assistance from staff. On 05/15/24 at 09:54 AM, an observation of R19's room revealed that a nebulizer, labeled 5/13 sat intact on the nebulizer machine on R19's over-the-bed table with an unknown clear residue noted in the atomizer chamber. On 05/16/24 at 08:03 AM, an observation of R19's room revealed that a nebulizer sat intact on the nebulizer machine on R19's over-the-bed table with an unknown clear residue and unknown clear liquid droplets in the atomizer chamber. On 05/20/24 at 08:04 AM, an observation of R19's room revealed that a nebulizer sat intact on the nebulizer machine on R19's over-the-bed table with an unknown clear residue and unknown clear liquid droplets in the atomizer chamber. On 05/15/24 at 09:54 AM, R19 stated staff do not clean or disassemble the nebulizer but change it every 6 weeks. Stated that he was able to self-administer the medications but was not aware if the nebulizer needed to be cleaned between uses. Additionally, R19 stated that he had not been trained on cleaning procedures related to the nebulizer. On 05/20/24 at 08:14 AM, Certified Nurse Aide (CNA) K revealed that she was unaware of any special handling/treatment/cleaning of nebulizer equipment. CNA K stated that sometimes at the end of a nebulizer treatment, CNA staff would assist the resident to remove the nebulizer equipment (mask or hand-held device) and place it on the nebulizer machine and stated that the Certified Medication Aides (CMA) or Licensed Nurses (LN) would come along later and take care of the nebulizer equipment. On 05/20/24 at 08:23 AM, LN L stated that LN staff perform all nebulizer medication administrations and stated CNA staff can assist the residents to turn off the machines and assist the resident to remove the nebulizer equipment, then the LN should clean the nebulizer after every treatment. LN L stated that the process for cleaning the nebulizer equipment was to disassemble the nebulizer and rinse all parts with tap water, then leave the nebulizer disassembled on a paper towel to air dry. LN L further stated that there are a couple of residents who self-administer their own nebulizer treatments, but ultimately the LN on duty is responsible for cleaning the nebulizer after each treatment. On 05/21/24 at 11:28 AM, Administrative Nurse B stated the facility staff were expected to follow the professional standards of care for cleaning a nebulizer after a breathing treatment. This included after the administration of nebulized medication, the LN who performed the medication administration should assess the resident's pulse rate, then disassemble the nebulizer and rinse the components off with tap water, then place the disassembled nebulizer on a paper towel to dry between uses. Administrative Nurse B confirmed that if staff are not performing this task, then a deficient practice existed. The facility's Respiratory Care policy, dated 04/24/18 documented that the facility would provide necessary respiratory care services in accordance with professional standards of practice, the resident's care plan and the resident's choice. The facility failed to properly clean and store the nebulizer for R19 in accordance with professional standards of care. - The Electronic Health Records (EHR) documented R30 had the following diagnoses that included congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest) with hypoxia (inadequate supply of oxygen in the blood). The 09/19/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R30 was dependent on staff assistance for all cares except eating which was independent. The assessment documented that R30 received oxygen. The 09/19/23 Care Area Assessment (CAA) lacked documentation related to nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication therapy or oxygen therapy. The 03/12/24 Quarterly MDS documented a BIMS score of 14, which indicated intact cognition. R30 was dependent on staff for all cares except eating which was independent. The assessment documented that R30 received oxygen. The 05/15/24 Care Plan lacked documentation related to nebulized medication use or care and maintenance of nebulizer equipment. The Physician Orders in the EHR documented the following: Ipratropium (Atrovent - a medication used to dilate the medium and large airways of the lungs)-Albuterol (Ventolin - a medication used to relax the muscles of the lower airways) 0.5-2.5 (3) milligrams (mg)/3 milliliters (mL), one vial to be inhaled orally (PO) via nebulizer, four times each day, related to chronic respiratory failure with hypoxia, dated 10/24/23. The Physician's Orders lacked documentation related to care and maintenance of the nebulizer equipment. The Progress Notes reviewed from 01/18/24 to 05/16/24 lacked any documentation related to nebulized medication use. On 05/15/24 at 12:06 PM, an observation of R30's room revealed that a nebulizer with attached mask, labeled 5/13 sat intact inside the top drawer of a clear plastic bedside table with an unknown clear liquid in the atomizer chamber. On 05/16/24 at 07:54 AM, an observation of R30's room revealed that a nebulizer with attached mask, labeled 5/13 sat intact inside the top drawer of a clear plastic bedside table with an unknown clear liquid in the atomizer chamber. On 05/20/24 at 08:02 AM, R30 sat upright in bed with the nebulizer mask intact on the resident's face with no medication mist observed. On 05/20/24 at 08:08 AM, Certified Nurse Aide (CNA) K entered R30's room and assisted the resident in removing the nebulizer mask and placed the mask inside the top drawer of the bedside storage cabinet with an unknown clear liquid in the atomizer chamber. On 05/20/24 at 08:14 AM, CNA K revealed that she was unaware of any special handling/treatment/cleaning of nebulizer equipment. CNA K stated that sometimes at the end of a nebulizer treatment, CNA staff would assist the resident to remove the nebulizer equipment (mask or hand-held device) and place it on the nebulizer machine and stated that the Certified Medication Aides (CMA) or Licensed Nurses (LN) would come along later and take care of the nebulizer equipment. On 05/20/24 at 08:23 AM, LN L stated LN staff perform all nebulizer medication administrations and stated that CNA staff can assist the residents to turn off the machines and assist residents to remove the nebulizer equipment, then the LN should clean the nebulizer after every treatment. LN L stated that the process for cleaning the nebulizer equipment was to disassemble the nebulizer and rinse all parts with tap water then leave the nebulizer disassembled on a paper towel to air dry. LN L further stated that there are a couple of residents who self-administer their own nebulizer treatments, but ultimately the LN on duty was responsible for cleaning the nebulizer after each treatment. On 05/21/24 at 11:28 AM, Administrative Nurse B stated the facility staff were expected to follow the professional standards of care for cleaning a nebulizer after a breathing treatment. This included that after the administration of nebulized medication, the LN who performed the medication administration should assess the resident's pulse rate, then disassemble the nebulizer and rinse the components off with tap water then place the disassembled nebulizer on a paper towel to dry between uses. Administrative Nurse B confirmed that if staff are not performing this task, then a deficient practice existed. The facility's Respiratory Care policy, dated 04/24/18 documented that the facility would provide necessary respiratory care services in accordance with professional standards of practice, the resident's care plan and the resident's choice. The facility failed to properly clean and store the nebulizer for R30 in accordance with professional standards of care. - R26's signed physician orders dated 05/15/24 revealed the following diagnoses that included ,anxiety disorder, type 2 diabetes mellitus with diabetic chronic kidney disease (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), sleep apnea (disorder of sleep characterized by periods without respirations), encounter for attention to tracheostomy (opening though the neck into the trachea through which an indwelling tube may be inserted), dysphagia (swallowing difficulty), malignant neoplasm of nasopharynx (a rare type of cancer that occurs in the nasopharynx, behind your nose and above your throat.), and chronic respiratory failure with hypoxia (inadequate supply of oxygen). R26's Significant Change in Status Minimum Data Set (MDS) dated 10/21/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident was dependent on staff for all cares except eating which required setup and supervision. R 26 received as needed (PRN) pain medication for occasional complaints of pain Medications included antianxiety (class of medication that calm and relax people), antidepressant (class of medications used to treat mood disorders), opioid (pain medication), hypoglycemic (medications used to control blood sugar levels) medications daily. The resident received oxygen and tracheostomy care. The Care Area Assessment (CAA) dated 10/24/23 revealed: Functional Abilities CAA revealed the resident was dependent on staff for all cares except eating which required setup and supervision. He was admitted to the hospital for an upper respiratory infection and hyperkalemia (greater than normal amount of potassium in the blood). He does not come out of his room and does not get out of bed. He is oxygen dependent with a tracheostomy. He was dependent on nurses for tracheostomy care. The Pain CAA revealed the resident reported occasional pain with the worst pain being 08/10. Resident has diagnosis of malignant neoplasm of nasopharynx. Resident receiving Morphine 0.25 milliliters (ml) every hour PRN and Oxycodone 7.5 milligrams (mg) every 4 hours PRN. The Quarterly MDS dated 01/30/24 revealed a BIMS score of 15. He continued to be dependent on staff for all cares except eating/oral care which was setup/supervision, R26 received scheduled pain medication. The required oxygen therapy and tracheostomy (trach) care. The tracheostomy care plan dated 10/05/21 revealed direction to clean the cannula insertion site, face plate, and peristomal area, and cleanse or replace the inner cannula using a clean technique. Staff were to contact the doctor immediately if the resident began to have trouble breathing through his stoma. Staff were to provide R26 with oxygen via the trach mask, dated 10/05/21. Staff were to provide suctioning whenever indicated, dated 10/07/21. The size of the inner cannula (of the tracheostomy tube) - 6.0 mm XLT, dated 10/26/23. If the entire trach comes out, call 911 per my physician's order, ordered 05/20/2024. On 04/24/2024 at 08:20 AM, the nurses' note revealed the resident reported feeling short of air (SOA), and the night nurse reported he had started complaining of the same last night. Lung bases were very diminished to absent. On 04/25/24 At 01:20 AM, the nurse notes documented R26 required transportation to the emergency room due to being short of air and slumped over onto his side, and delayed response to questions. R26 had started antibiotic for an upper respiratory infection prior to the transport to the emergency department. On 5/15/2024 at 12:15 PM, the nurses' note revealed staff updated orders on tracheostomy care. Tracheostomy care done with no issues, the resident tolerated it well. The trach ties were changed yesterday (05/14/24). Review of the physician orders dated 05/15/24 revealed: Lanolin External Cream (Lanolin (Topical), apply to tracheostomy site topically, everyday on day shift, for trach care. Oxygen per trach mask related to chronic respiratory failure with hypoxia. Tracheostomy site care to include a clean technique. Remove the dressing. Cleanse the stoma site, dry and apply nipple cream. Place a new fenestrated (having one or more opening) dressing. Change the securement ties as needed if soiled. Cleanse the #6 Shiley (name of the trachestomy tube) and replace, and lock into place. Re-apply [NAME] Valve (oxygen mask) and oxygen every day for tracheostomy routine care. Change #6 tracheostomy Shiley every Monday. On 05/16/24 at 02:00 PM, the resident reported he had not seen a Pulmonologist since he received the trach in 2021. He reported that the trach he has is the original trach and has never been changed. He reported staff do not routinely suction the trach. On 05/16/24 at 10:41 AM, Licensed Nurse (LN) L entered the resident room to perform tracheostomy care. The nurse donned gloves and the resident removed his oxygen (O2) hood from the stoma and LN L cleaned the site with a wound cleaner. She applied lanolin ointment around the opening and withdrew the inner tube and replaced it with a new clean sterile tube. The resident then put his O2 back in place. There was no extra tracheostomy in the room and the room lacked a suction machine. On 05/16/24 02:30 PM, LN L stated that she does not suction the resident's trach. Staff perform trach care daily and as needed by cleaning the inner cannula, stoma, and application of a new dressing. Stated staff replace the inner cannula every week. LN L stated that the resident has no back up trach in his room if the entire trach was to come out She stated, I only do what I was taught to do here for his trach LN L reported the facility did not keep a back up inner cannula or a suction machine in the resident's room. On 05/21/24 at 11:28 AM, LN W stated that she would call the residents physician if the resident's entire trach came out, and reported would not know what else to do as there was no back up if the entire trach were to come out. LN W stated she thought maybe the trach was sutured in. LN W reported she has never suctioned R26's trach area, but if needed, would take out the inner cannula and clean it. LN W stated she thought the facility should have suction materials in the room. On 05/20/24 at 11:55 AM, Consultant Nurse P reported the facility lacked a policy for tracheostomy care. Consultant Nurse P verified the facility lacked The facility failed to ensure tracheostomy care and equipment was available for emergency care for this resident with a tracheostomy, to prevent respiratory emergencies if the trachea was dislodged or the resident had copious secretions, consistent with professional standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to reply in a timely manner and act upon the Consultant Pharmacist of Medication Regimen Review (MMR) and Gradual Dose Reduction (GDR) recommendations for Residents (R) 8, R24, R26, R33 and R 35 medication regimen review. This deficient practice placed these residents at risk for receiving unnecessary medications. Findings included: - Resident (R)33's Electronic Health Record (EHR) revealed diagnoses of mixed hyperlipemia (condition of elevated blood lipid levels), chronic kidney disease and benign paroxysmal vertigo (sensation of spinning, dizziness). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R33 had no depression. R33 ADL's documented independent (activities of daily living such as walking, grooming, toileting, dressing and eating). R33 required supervision for shower. The Quarterly MDS dated 03/15/24, documented a BIMS of 12, which indicated cognition moderately impaired. The Patient Health Questionnaire (PHQ-9) total score of 02, showed minimal depression. R33 required minimal to moderate assistance with ADLs of transfers and dressing. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 11/18/23, documented R13 required set up with showering, used a front wheel walker. The Psychotropic Drug Use CAA dated 11/18/23, documented R13 diagnosis of depression and R13 received Zoloft (antidepressant) 25 mg daily. The resident's mood was pleasant and happy. The Activities of Daily living (ADL) Care Plan dated 05/16/24, guided staff to Provide with set up and assistance with showering, and ensured the walker is beside resident within reach. Allowed me time to grieve, I lost my daughter suddenly. Monitored for signs and symptoms of depression such as isolation or decreased appetite. Monitored for side effects of antidepressant. The Physician's Order dated 05/16/24, revealed Cholestyramine Powder give 2 grams by mouth in the afternoon for hyperlipidemia unspecified, mix with 8 oz of orange juice. Preparation H Cream 1-0.25-14.4-15 % (Pramox-PE-Glycerin-Petrolatum) insert 1 application rectally every 12 hours as needed for hemorrhoids unsupervised self-administration. Dated 11/11/23, Bactroban Ointment 2 % (Mupirocin) apply to forehead and neck topically two times a day for infection. Review of the Consultant Pharmacist MRR, from 12/01/24 thru 05/16/24, revealed on 12/03/23, the consultant pharmacist requested time of medication administered to coincide with one medication Cholestyramine Powder, that cannot be given with one hour of other medications. The facility did not respond until 01/08/24, a total of 36 days later. On 01/10/24, a consultant pharmacist noted Bactroban ointment, was started on 11-11-23. To ensure compliance with Centers for Medicare and Medicaid Services (CMS) regulations surrounding appropriate antimicrobial use: please ensure there is a duration of treatment notice on this order. The facility had a blank form of MRR and lacked a provider signature or a nurse signature. The form had three post it notes taped on it. One post it stated MD, second post it stated DC'd, third post it stated done 02/16/24. On 03/07/24, a recommendation that R33 have a current self-medications assessment in the EHR for preparation H (medication to temporarily relieve swelling, burning, pain and itching caused by hemorrhoids) at bedside. The facility documented done and lacked a date. On 04/05/24, requested R33 have a current self-medications assessment in EHR for preparation H to be left at bedside. Facility dated done and lacked a date. On 05/16/24 at 02:40 PM, Administrative Nurse B verified the above information. Stated the MRR process is that Consultant Pharmacist hand-delivered the reports on the second Thursday of each month when she attended the QAPI (quality assurance performance improvement - a quality management program that consists of an interdisciplinary team that takes a systematic comprehensive and data-driven approach to maintaining and improving safety and quality to all the residents in the facility) meeting and then the Administrative Nurse B tried to get them completed within a week. Stated that providers round on Tuesdays, so they address any of the recommendations from pharmacy when they perform rounds. Additionally, stated that response times to the pharmacy as documented of greater than 30 days is unacceptable. Further stated that some of the missing information may be found in other areas of the EHR, or it could be that she failed to document the facility's response, or it could be that the task was left incomplete. The facility's Drug Regimen Review policy, dated 11/28/17, documented that the pharmacist would complete a MRR of the EHR at least once per month and report any irregularities to the attending physician, the facility's medical director and the Director of Nursing (DON). The DON or designee would provide the pharmacist's report to the attending physician(s) and the facility's medical director the next working day and the physician would respond to the pharmacist's recommendations within seven days. Irregularities that did not require physician intervention would be acted upon by the DON or designee within three days. The facility failed to prevent the use of unnecessary medications for R33 when the facility failed to respond to pharmacist recommendations in a timely manner consistent with facility policy. This deficient practice placed R33 at risk for receiving unnecessary medications. - Resident (R)8's Electronic Health Record (EHR) revealed diagnoses of chronic kidney disease (CKD - a condition that damages the kidneys over time and increased the risk of other health problems), dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type 2 (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), atrial fibrillation (a rapid, irregular heart beat that can lead to blood clots and other medical conditions) and heart failure (a condition in which the heart muscle does not pump as well as it should which causes difficulty breathing). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R8 received an antidepressant (a class of medications used to treat mood disorders), a diuretic (medication to promote the formation and excretion of urine), a hypoglycemic (medication to lower the amount of sugar in the blood) and an anticoagulant (medication that prevents or slows the clotting of blood). The Psychotropic (classes of medications that affect the mind, mood or mental processes) Drug Use Care Area Assessment (CAA) dated 02/13/24, documented R8 received an antidepressant medication daily for depression. The Psychosocial Well-Being CAA did not trigger. The Mood State CAA dated 02/13/24 did not trigger. The Behavioral Symptoms CAA dated 02/13/24 did not trigger. The Quarterly MDS dated 11/14/23, documented R8 had a BIMS of 14, which indicated intact cognition and received antidepressant, diuretic and anticoagulant medications. The Physician Orders revealed the following: Dulcolax Tablet Delayed Release, (Bisacodyl - a stimulant laxative that stimulates bowel movements), five milligrams (mg), to be given by mouth (PO) once daily as needed (PRN) for constipation, dated 06/12/23. MiraLax Powder (Polyethylene Glycol 3350 - an osmotic diuretic that stimulates bowel movements by pulling fluid into the bowels to soften bowel movements), 17 grams (gm) mixed with 4-8 ounces (oz) of preferred drink, to be given PO once daily PRN for bowel management, dated 06/12/23. Metformin (a medication that lowers the level of sugar in the blood) HCl ER (extended release), 500 mg, to be given PO once daily in the evening related to DM2, dated 04/03/24. Eliquis Tablet (Apixaban - an anticoagulant), 2.5 mg, to be given PO two times a day related to atrial fibrillation, dated 03/21/24. Donepezil (Aricept - a medication used to treat dementia) HCl Tablet, 10 mg, to be given PO in the evening related to dementia, dated 03/19/24. Cymbalta (Duloxetine HCl - an antidepressant), 30 mg, to be given PO once daily related to depression, dated 02/24/24. Lasix (furosemide - a diuretic), 40 mg, to be given PO each morning, related to heart failure and CKD. The Physician's Orders lacked documentation for behavior monitoring related to antidepressant use. Review of pharmacist medication regimen review (MRR) reports revealed the following: 1. On 10/11/23, Consultant Pharmacist V documented a reminder to the facility for staff to document bowel movements (BM) in the log and not to document N/A (not applicable). The facility responded and documented that reeducation was provided to staff on an unknown date at an unknown time. 2. On 11/08/23, Consultant Pharmacist V documented a reminder to the facility for staff to document BMs in the log and not to document N/A. The facility responded that reeducation was provided to staff on an unknown date at an unknown time. 3. On 12/03/23, Consultant Pharmacist V documented a reminder to the facility for staff to document BMs in the log and not to document N/A. The facility responded that reeducation was provided to staff on 01/08/24. 4. On 04/05/24, Consultant Pharmacist V requested the most recent hemoglobin A1C (a laboratory test that measures the average blood sugar level in a 90-day look-back period). The facility responded on 05/08/24 with the laboratory results dated [DATE]. On 05/16/24 at 02:40 PM, Administrative Nurse B verified the above information and stated that the MRR process was the Consultant Pharmacist hand-delivered the reports on the second Thursday of each month when she attended the QAPI (quality assurance performance improvement - a quality management program that consists of an interdisciplinary team that takes a systematic comprehensive and data-driven approach to maintaining and improving safety and quality to all the residents in the facility) meeting and then the Administrative Nurse B tried to get them completed within a week. Stated that providers round on Tuesdays, so facility staff address any of the recommendations from the pharmacy when the providers perform rounds. Additionally, stated that response times to the pharmacy as documented of greater than 30 days is unacceptable. Further stated that some of the missing information may be found in other areas of the EHR, or it could be that she failed to document the facility's response, or it could be that the task was left incomplete. The facility's Drug Regimen Review policy, dated 11/28/17, documented that the pharmacist would complete a MRR of the EHR at least once per month and report any irregularities to the attending physician, the facility's medical director and the Director of Nursing (DON). The DON or designee would provide the pharmacist's report to the attending physician(s) and the facility's medical director the next working day and the physician would respond to the pharmacist's recommendations within seven days. Irregularities that did not require physician intervention would be acted upon by the DON or designee within three days. The facility failed to prevent the use of unnecessary medications for R8 when the facility failed to respond to pharmacist recommendations in a timely manner consistent with facility policy. This deficient practice placed R8 at risk for receiving unnecessary medications. - Resident (R)24's Electronic Health Record (EHR) revealed diagnoses of chronic kidney disease (CKD - a condition that damages the kidneys over time and increased the risk of other health problems), Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure), dementia (a progressive mental disorder characterized by failing memory and confusion), atrial fibrillation (a rapid, irregular heart beat that can lead to blood clots and other medical conditions), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. The MDS documented R24 received an antidepressant (a class of medications used to treat mood disorders) and an anticoagulant (medication that prevents or slows the clotting of blood). The Cognitive Loss / Dementia Care Area Assessment (CAA), dated 01/16/24 documented that R24 had a diagnosis that included dementia. The Psychotropic Drug Use CAA dated 01/16/24 documented that R24 received an antidepressant in the evenings and had no behaviors in the look-back period. The Quarterly MDS dated 04/16/24, documented R24 had a BIMS of six, which indicated severely impaired cognition. R24 received antidepressant and anticoagulant medications. The Care Plan dated 05/15/24, lacked interventions for staff to monitor behaviors related to antidepressant use. The Physician Orders revealed the following: Eliquis Tablet (Apixaban - an anticoagulant) 2.5 milligrams (mg), to be given by mouth (PO), two times a day, related to atrial fibrillation, dated 05/01/24. Cardizem (diltiazem HCl - a medication used to control heart rate and blood pressure), 120 mg, to be given PO once daily, related to atrial fibrillation, dated 07/11/23. Mirtazapine (Remeron - an antidepressant medication), 7.5 mg, to be given PO every evening, related to depression, dated 07/10/23. The Physician's Orders lacked documentation for behavior monitoring related to antidepressant use. Review of pharmacist medication regimen review (MRR) reports revealed the following: 1. On 10/11/23, Consultant Pharmacist V documented that a MRR had been completed. The facility failed to provide documentation of the MRR or facility or physician response. 2. On 12/03/23, Consultant Pharmacist V requested a reminder to the staff to report blood pressure measurements outside of established parameters to the provider. The facility responded on 01/08/24 that staff reeducation had been provided. 3. On 04/05/24, Consultant Pharmacist V documented that a MRR had been completed. The facility failed to provide documentation of the MRR or facility or physician response. On 05/16/24 at 02:40 PM, Administrative Nurse B verified the above information. Stated that the MRR process is that Consultant Pharmacist hand-delivered the reports on the second Thursday of each month when she attended the QAPI (quality assurance performance improvement - a quality management program that consists of an interdisciplinary team that takes a systematic comprehensive and data-driven approach to maintaining and improving safety and quality to all the residents in the facility) meeting and then the Administrative Nurse B tried to get them completed within a week. Stated that providers round on Tuesdays, so they address any of the recommendations from pharmacy when they perform rounds. Additionally, stated that response times to the pharmacy as documented of greater than 30 days is unacceptable. Further stated that some of the missing information may be found in other areas of the EHR, or it could be that she failed to document the facility's response, or it could be that the task was left incomplete. The facility's Drug Regimen Review policy, dated 11/28/17, documented that the pharmacist would complete a MRR of the EHR at least once per month and report any irregularities to the attending physician, the facility's medical director and the Director of Nursing (DON). The DON or designee would provide the pharmacist's report to the attending physician(s) and the facility's medical director the next working day and the physician would respond to the pharmacist's recommendations within seven days. Irregularities that did not require physician intervention would be acted upon by the DON or designee within three days. The facility failed to prevent the use of unnecessary medications for R 24 when the facility failed to respond to pharmacist recommendations in a timely manner consistent with facility policy. This deficient practice placed R24 at risk for receiving unnecessary medications. - R26's signed physician orders dated 05/15/24 revealed the following diagnoses that included anxiety disorder, type 2 diabetes mellitus with diabetic chronic kidney disease (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), sleep apnea (disorder of sleep characterized by periods without respirations), encounter for attention to tracheostomy (opening though the neck into the trachea through which an indwelling tube may be inserted), dysphagia (swallowing difficulty), malignant neoplasm of nasopharynx (a rare type of cancer that occurs in the nasopharynx, behind your nose and above your throat.), and chronic respiratory failure with hypoxia (inadequate supply of oxygen). R26's Significant Change in Status Minimum Data Set (MDS) dated 10/21/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R 26 received as needed (PRN) pain medication for occasional complaints of pain. Medications included antianxiety (class of medication that calm and relax people), antidepressant (class of medications used to treat mood disorders), opioid (pain medication), and hypoglycemic (medications used to control blood sugar levels) medications daily. R26's Quarterly MDS dated 01/30/24 revealed a BIMS of 15, indicating intact cognition. The resident received scheduled pain medication, and PRN pain medication for frequent pain. Medications included antianxiety, antidepressant, opioid, and hypoglycemic medications daily. The physician orders included: Insulin Glargine, inject 35 unit subcutaneously (SQ), at bedtime, related to diabetes mellitus with diabetic chronic kidney disease, ordered 05/09/2024. Insulin Lispro Injection Solution (Insulin Lispro), inject 20-unit, SQ with meals, related to diabetes mellitus with diabetic chronic kidney disease, ordered 05/09/2024. Blood Glucose Monitoring before meals and at bedtime, related to diabetes mellitus with diabetic chronic kidney disease. Notify the physician if blood glucose above 450 or below 70, ordered 05/09/24. Synthroid, 25 micrograms (mcg), (Levothyroxine Sodium), in the morning with 200 mcg tablet to equal 225 mcg daily, related to hypothyroidism (condition characterized by decreased activity of the thyroid gland). Give on an empty stomach, ordered 05/09/2024. The consulting pharmacist monthly medication regimen revealed: On 03/07/24, Consultant V requested clarification of the fasting blood sugar (FSBS) due to conflicting orders to notify provider if above 300 or 450. An undated reply from the facility documented fixed with no documentation of what the order should be or whether the physician was notified for the clarification. On 04/05/24, Consultant V reported FSBS out of parameters with no documentation found the physician had been notified. The facility responded to the recommendation on 05/07/24, greater than 30 days. On 05/16/24 at 02:40 PM, Administrative Nurse B verified the above information and stated that the MRR process was the Consultant Pharmacist hand-delivered the reports on the second Thursday of each month when she attended the QAPI (quality assurance performance improvement - a quality management program that consists of an interdisciplinary team that takes a systematic comprehensive and data-driven approach to maintaining and improving safety and quality to all the residents in the facility) meeting and then the Administrative Nurse B tried to get them completed within a week. Stated that providers round on Tuesdays, so facility staff address any of the recommendations from the pharmacy when the providers perform rounds. Additionally, stated that response times to the pharmacy as documented of greater than 30 days is unacceptable. Further stated that some of the missing information may be found in other areas of the resident record, or it could be that she failed to document the facility's response, or it could be that the task was left incomplete. The facility's Drug Regimen Review policy, dated 11/28/17, documented that the pharmacist would complete a medication regimen review (MRR) of the electronic health records (EHR) at least once per month and report any irregularities to the attending physician, the facility's medical director and the Director of Nursing (DON). The DON or designee would provide the pharmacist's report to the attending physician(s) and the facility's medical director the next working day and the physician would respond to the pharmacist's recommendations within seven days. Irregularities that did not require physician intervention would be acted upon by the DON or designee within three days. The facility failed to follow up with the pharmacist recommendations for R26 in a timely manner. - R35's Electronic Medical Record (EMR) revealed the following diagnoses included Alzheimer's disease with early onset (progressive mental deterioration characterized by confusion and memory failure), vascular dementia (progressive mental disorder characterized by failing memory, confusion) with psychosis (any major mental disorder characterized by a gross impairment in reality perception), agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition), and obsessive-compulsive disorder (OCD- anxiety disorder characterized by recurrent and persistent thoughts, ideas and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social or interpersonal functioning). R35's admission Minimum Data Set (MDS) dated [DATE] revealed the staff assessment of his cognition indicated severe cognitive impairment. Medications included antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), and antidepressant medications (class of medications used to treat mood disorders). R35's physician orders revealed: Trazadone, 50 milligrams (mg), 1.5 tablet by mouth at bedtime, related to insomnia, dated 03/18/2024. The Consulting Pharmacist Monthly Medication Review (MMR) dated 03/07/24 revealed an MMR was completed though the facility was unable to produce documentation of the recommendations. On 04/05/24, the Consulting Pharmacist requested the current sleep assessment due to the use of Trazadone for insomnia as the assessment was not located in the resident record. The facility produced a sleep study dated 04/02/24 that was signed but was unanswered with documentation of unable to answer. On 05/16/24 at 02:40 PM, Administrative Nurse B verified the above information and stated that the MRR process was the Consultant Pharmacist hand-delivered the reports on the second Thursday of each month when she attended the QAPI (quality assurance performance improvement - a quality management program that consists of an interdisciplinary team that takes a systematic comprehensive and data-driven approach to maintaining and improving safety and quality to all the residents in the facility) meeting and then the Administrative Nurse B tried to get them completed within a week. Stated that providers round on Tuesdays, so facility staff address any of the recommendations from the pharmacy when the providers perform rounds. Additionally, stated that response times to the pharmacy as documented of greater than 30 days is unacceptable. Further stated that some of the missing information may be found in other areas of the resident record, or it could be that she failed to document the facility's response, or it could be that the task was left incomplete. The facility's Drug Regimen Review policy, dated 11/28/17, documented that the pharmacist would complete a MRR of the resident record at least once per month and report any irregularities to the attending physician, the facility's medical director and the Director of Nursing (DON). The DON or designee would provide the pharmacist's report to the attending physician(s) and the facility's medical director the next working day and the physician would respond to the pharmacist's recommendations within seven days. Irregularities that did not require physician intervention would be acted upon by the DON or designee within three days. The facility failed to follow up with the pharmacist recommendations in a timely manner for this resident.

The facility reported a census of 41 residents with one main kitchen. Based on observation, interview, and record review, the facility failed to store foods safely and under sanitary conditions to the residents of the facility to prevent the potential for food borne bacteria by the staff's failure to date and reseal open food items in the refrigerators and freezer, and the failure to clean the thermometer between food items while taking food temperatures prior to serving. This had the potential to affect all 41 of the residents' receiving meals from the main kitchen. Findings included: - On 05/15/24 at 08:30 AM, initial tour with dietary staff H, the kitchen revealed the following areas of concern: In the reach-in refrigerator revealed two bags containing onions that had been partially used and neither were dated. A large block of cheese slices that was opened and lacked a date. A large package of opened, lunch meat and lacked a date. In addition, the freezer contained an an open tub of ice cream, undated and without a lid. The walk-in freezer had a large bag of hamburger patties (20 patties) in an open bag, open to air and a large bag of mozzarella cheese with the bag open to air and lacked an opened date. On 05/16/24 at 11:35 AM, prior to serving the noon meal, dietary staff J took a thermometer out of its sheath and turned the thermometer on. She then cleaned the thermometer with an alcohol prep pad. She placed the thermometer into the chicken, pasta, vegetables, and sauce without cleaning the thermometer between food items, and when she was done with the last food item, she wiped the thermometer with an alcohol pad and replaced the sheath. On 05/16/24 at approximately 12:30 PM, an unidentified resident requested a bowl of soup for lunch. Dietary staff J opened the can of soup, poured it into a bowl and placed it in the microwave. When the microwave oven shut off, dietary staff J removed the bowl and covered the bowl with plastic wrap and placed the soup on a tray for the resident. Dietary staff J failed to measure the temperature of the soup. Dietary staff J reported she did not measure the temperatures of food when she heats foods in the microwave before serving the residents. On 05/16/24 a 01:00 PM dietary staff H reported staff should cover and date all food items after opened. Dietary staff should know the proper procedure of food temperature measurements when preparing to serve foods. Review of the facility policy for Food Storage, revised 04/06/20 revealed staff was to wrap food properly. Never leave any food item uncovered and not labeled. No policy was provided for the serving temperatures of food at time of service. The facility failed to store foods safely and under sanitary conditions to the residents of the facility to prevent the potential for food borne bacteria by the staff's failure to date and reseal open food items in the refrigerators and freezer and the failure to clean the thermometer between food items while taking food temperatures prior to serving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R)42's Electronic Health Record (EHR) revealed diagnoses of obstructive sleep apnea (disorder of sleep characterized by periods without respirations), schizophrenia (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), and epilepsy (brain disorder characterized by repeated seizures). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. R42 was independent with ADLs (activities of daily living such as walking, grooming, toileting, dressing and eating). The 03/14/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R42 was independent in ADLs, except required set-up to complete showers. The Physician's Order dated 04/11/24, included the resident to have CPAP (continuous positive airway pressure - a ventilation device that blows a gentle stream of air into the nose to keep airway open during sleep) applied nightly in PM and removed in the AM daily. Staff instructed to clean the CPAP weekly on Thursdays. The physician's order lacked direction on how to clean the CPAP and store the mask when not used. Review of the Progress Notes from 03/07/24 to 05/15/24 lacked documentation regarded to the CPAP. Observation on 05/15/24 at 12:31 PM, a CPAP mask laid on R42's nightstand over other personal items. Observation on 05/16/24 at 08:13 AM, a CPAP mask laid on R42's nightstand over other personal items. Observation on 05/20/24 at 09:39 AM, a CPAP mask laid on the nightstand over the CPAP machine and came in direct contact with other items on the nightstand. R42 stated was not sure when staff would clean the mask. Interview on 05/21/24 at 11:30 AM, Administrative Nurse B and Administrative Nurse D confirmed a CPAP mask should be placed on the machine or in a bag, but not on the bed or nightstand. The facility policy Respiratory Care dated 04/24/18, documented that the facility would provide necessary respiratory care services in accordance with professional standards of practice, the resident's care plan and the resident's choice. The facility failed to maintain an effective infection control program related to improper cleaning of respiratory equipment, of this resident's CPAP in accordance with professional standards of care, to prevent possible respiratory illness. - The 02/27/23 Electronic Health Records (EHR) documented R19 had the following diagnoses that included pulmonary fibrosis (a disease of the lung that causes scarring and stiffening of the tissues over time which causes increased work of breathing) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest). The 10/17/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R19 was independent for all cares except bathing which required supervision and setup. The 09/28/23 Care Area Assessment (CAA) lacked documentation related to nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication therapy. The 04/16/24 Quarterly MDS documented a BIMS score of 15 which indicated intact cognition. R19 was independent for all cares except bathing which required minimal assistance. The 05/15/24 Care Plan lacked documentation related to nebulized medication use or care and maintenance of nebulizer equipment. The Physician Orders in the EHR documented the following: Budesonide (Pulmicort - an orally inhaled steroid used to decrease inflammation in the lungs) suspension, 0.25 milligrams (mg)/2 milliliter (mL), one vial to be inhaled orally (PO) via nebulizer, one time per day, related to pulmonary fibrosis, resident may set up and self-administer, dated 01/10/24. Ipratropium (Atrovent - a medication used to dilate the medium and large airways of the lungs)-Albuterol (Ventolin - a medication used to relax the muscles of the lower airways) 0.5-2.5 (3) mg/3mL one vial to be inhaled PO via nebulizer every four hours as needed for cough/shortness of breath, resident may self-administer after nurse setup, dated 11/17/21. Perforomist (formoterol - a long-lasting medication used to relax the muscles of the airways) 20 micrograms (mcg)/2mL, one vial to be inhaled PO via nebulizer one time per day related to pulmonary fibrosis, 12/06/22. The Physician's Orders lacked documentation related to care and maintenance of the nebulizer equipment. The Progress Notes reviewed from 01/14/24 to 05/16/24 lacked any documentation related to nebulized medication use. The EHR Assessments revealed on 01/09/24, R19 was assessed to be capable to properly self-administer inhaled medications without assistance from staff. On 05/15/24 at 09:54 AM, an observation of R19's room revealed that a nebulizer, labeled 5/13 sat intact on the nebulizer machine on R19's over-the-bed table with an unknown clear residue noted in the atomizer chamber. On 05/16/24 at 08:03 AM, an observation of R19's room revealed that a nebulizer sat intact on the nebulizer machine on R19's over-the-bed table with an unknown clear residue and unknown clear liquid droplets in the atomizer chamber. On 05/20/24 at 08:04 AM, an observation of R19's room revealed that a nebulizer sat intact on the nebulizer machine on R19's over-the-bed table with an unknown clear residue and unknown clear liquid droplets in the atomizer chamber. On 05/15/24 at 09:54 AM, R19 stated staff do not clean or disassemble the nebulizer but change it every 6 weeks. Stated that he was able to self-administer the medications but was not aware if the nebulizer needed to be cleaned between uses. Additionally, R19 stated that he had not been trained on cleaning procedures related to the nebulizer. On 05/20/24 at 08:14 AM, Certified Nurse Aide (CNA) K revealed that she was unaware of any special handling/treatment/cleaning of nebulizer equipment. CNA K stated that sometimes at the end of a nebulizer treatment, CNA staff would assist the resident to remove the nebulizer equipment (mask or hand-held device) and place it on the nebulizer machine and stated that the Certified Medication Aides (CMA) or Licensed Nurses (LN) would come along later and take care of the nebulizer equipment. On 05/20/24 at 08:23 AM, LN L stated that LN staff perform all nebulizer medication administrations and stated CNA staff can assist the residents to turn off the machines and assist the resident to remove the nebulizer equipment, then the LN should clean the nebulizer after every treatment. LN L stated that the process for cleaning the nebulizer equipment was to disassemble the nebulizer and rinse all parts with tap water, then leave the nebulizer disassembled on a paper towel to air dry. LN L further stated that there are a couple of residents who self-administer their own nebulizer treatments, but ultimately the LN on duty is responsible for cleaning the nebulizer after each treatment. On 05/21/24 at 11:28 AM, Administrative Nurse B stated the facility staff were expected to follow the professional standards of care for cleaning a nebulizer after a breathing treatment. This included after the administration of nebulized medication, the LN who performed the medication administration should assess the resident's pulse rate, then disassemble the nebulizer and rinse the components off with tap water, then place the disassembled nebulizer on a paper towel to dry between uses. Administrative Nurse B confirmed that if staff are not performing this task, then a deficient practice existed. The facility policy Respiratory Care dated 04/24/18, documented that the facility would provide necessary respiratory care services in accordance with professional standards of practice, the resident's care plan and the resident's choice. The facility failed to maintain an effective infection control program related to improper cleaning of respiratory equipment, of this resident's nebulizer in accordance with professional standards of care, to prevent possible respiratory illness. - The Electronic Health Records (EHR) documented R30 had the following diagnoses that included congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid) and chronic respiratory failure (a condition in which respiratory function is inadequate to maintain the body's need for oxygen supply and/or carbon dioxide removal while at rest) with hypoxia (inadequate supply of oxygen in the blood). The 09/19/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R30 was dependent on staff assistance for all cares except eating which was independent. The assessment documented that R30 received oxygen. The 09/19/23 Care Area Assessment (CAA) lacked documentation related to nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication therapy or oxygen therapy. The 03/12/24 Quarterly MDS documented a BIMS score of 14, which indicated intact cognition. R30 was dependent on staff for all cares except eating which was independent. The assessment documented that R30 received oxygen. The 05/15/24 Care Plan lacked documentation related to nebulized medication use or care and maintenance of nebulizer equipment. The Physician Orders in the EHR documented the following: Ipratropium (Atrovent - a medication used to dilate the medium and large airways of the lungs)-Albuterol (Ventolin - a medication used to relax the muscles of the lower airways) 0.5-2.5 (3) milligrams (mg)/3 milliliters (mL), one vial to be inhaled orally (PO) via nebulizer, four times each day, related to chronic respiratory failure with hypoxia, dated 10/24/23. The Physician's Orders lacked documentation related to care and maintenance of the nebulizer equipment. The Progress Notes reviewed from 01/18/24 to 05/16/24 lacked any documentation related to nebulized medication use. On 05/15/24 at 12:06 PM, an observation of R30's room revealed that a nebulizer with attached mask, labeled 5/13 sat intact inside the top drawer of a clear plastic bedside table with an unknown clear liquid in the atomizer chamber. On 05/16/24 at 07:54 AM, an observation of R30's room revealed that a nebulizer with attached mask, labeled 5/13 sat intact inside the top drawer of a clear plastic bedside table with an unknown clear liquid in the atomizer chamber. On 05/20/24 at 08:02 AM, R30 sat upright in bed with the nebulizer mask intact on the resident's face with no medication mist observed. On 05/20/24 at 08:08 AM, Certified Nurse Aide (CNA) K entered R30's room and assisted the resident in removing the nebulizer mask and placed the mask inside the top drawer of the bedside storage cabinet with an unknown clear liquid in the atomizer chamber. On 05/20/24 at 08:14 AM, CNA K revealed that she was unaware of any special handling/treatment/cleaning of nebulizer equipment. CNA K stated that sometimes at the end of a nebulizer treatment, CNA staff would assist the resident to remove the nebulizer equipment (mask or hand-held device) and place it on the nebulizer machine and stated that the Certified Medication Aides (CMA) or Licensed Nurses (LN) would come along later and take care of the nebulizer equipment. On 05/20/24 at 08:23 AM, LN L stated LN staff perform all nebulizer medication administrations and stated that CNA staff can assist the residents to turn off the machines and assist residents to remove the nebulizer equipment, then the LN should clean the nebulizer after every treatment. LN L stated that the process for cleaning the nebulizer equipment was to disassemble the nebulizer and rinse all parts with tap water then leave the nebulizer disassembled on a paper towel to air dry. LN L further stated that there are a couple of residents who self-administer their own nebulizer treatments, but ultimately the LN on duty was responsible for cleaning the nebulizer after each treatment. On 05/21/24 at 11:28 AM, Administrative Nurse B stated the facility staff were expected to follow the professional standards of care for cleaning a nebulizer after a breathing treatment. This included that after the administration of nebulized medication, the LN who performed the medication administration should assess the resident's pulse rate, then disassemble the nebulizer and rinse the components off with tap water then place the disassembled nebulizer on a paper towel to dry between uses. Administrative Nurse B confirmed that if staff are not performing this task, then a deficient practice existed. The facility policy Respiratory Care dated 04/24/18, documented that the facility would provide necessary respiratory care services in accordance with professional standards of practice, the resident's care plan and the resident's choice. The facility failed to maintain an effective infection control program related to improper cleaning of respiratory equipment, of this resident's nebulizer in accordance with professional standards of care, to prevent possible respiratory illness. The facility reported a census of 42 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 the facility to implement and staff to follow enhanced barrier precautions as required for three residents in the facility, Resident (R) 13 related to pressure ulcer treatment, R24 related to care of a urinary catheter (a hollow flexible tube that collects urine and leads to a drainage bag) and R26 related to tracheostomy (an opening though the neck into the trachea through which an indwelling tube may be inserted). Additionally, the facility failed to appropriately clean and store nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) for R19 and R30. Furthermore, the facility failed appropriately store the mask for R42's continuous positive airway pressure (CPAP - a non-invasive mechanical ventilator that provides respiratory support to decrease the work of breathing) machine. These deficient practices have the potential to the spread of potentially infectious organisms to vulnerable residents. Findings included: - On 05/16/24 at 10:41 AM, Licensed Nurse (LN) L performed tracheostomy care on Resident (R) 26 and the only personal protective equipment (PPE) utilized during the procedure was a disposable mask and disposable gloves. On 05/16/24 at 11:33 AM, Certified Nurse Aide (CNA) N and Certified Medication Aide (CMA) U performed incontinence care on R13, who had two pressure wounds, and the only PPE utilized during the procedure were disposable gloves. On 05/20/24 at 08:23 AM, CNA K and CNA Q entered R24's room to perform catheter care and the only PPE utilized during the procedure was disposable gloves. On 05/20/24 at 08:37 AM, CNA K stated that she did not know what had enhanced barrier precautions (EBP) was and had not received any training on the topic. On 05/20/24 at 08:41 AM, CNA Q stated that she did not know what had enhanced barrier precautions (EBP) was and had not received any training on the topic. On 05/20/24 at 08:44 AM, LN L stated that she did not know what had enhanced barrier precautions (EBP) was and had not received any training on the topic. On 05/20/24 at 09:13 AM, Administrative Nurse C stated that the facility had not implemented EBP and was aware that the implementation date was 04/01/24 and stated that the facility did not have a policy for EBP. On 05/20/24 at 09:17 AM, Consultant Nurse P and Administrative Nurse B stated that they were aware that implementation date for EBP was 04/01/24 and stated that they were waiting for guidance from the corporate team before implementation. Consultant Nurse P reported that the policy had not been developed by corporate offices or implemented at any of the buildings owned by the company. On 05/24/24, the facility provided the facility's Enhanced Barrier Precautions (EBP) policy dated 04/01/24 that documented that EBP was an infection control intervention designed to reduce the transmission of multi-drug resistant organisms (MDRO - a common bacteria that have developed resistance to multiple types of antibiotics) that employs targeted gown and glove use during high contact resident care activities. EBP was to be used in conjunction with standard precautions for residents with wounds even if the wound was not colonized with an MDRO, residents with indwelling medical devices such as central lines, urinary catheters, feeding tubes or tracheostomies. The facility failed to maintain an effective infection control program with the failure of the facility to implement and staff to follow enhanced barrier precautions as required for three residents in the facility. This deficient practice has the potential to the spread of potentially infectious organisms to vulnerable residents.

The facility census totaled 41 residents. Based on observation, interview, and record review the facility failed to provide a sanitary environment by the failure to have lids on the linen cans in the shower rooms, failure to have a lid on the biohazard container in the soiled utility room and failure to maintain appropriate flooring in the laundry area. These deficient practices had the potential to be an unsanitary environment which would affect all residents in the facility. Findings included: - On 05/21/24 at 11:55 AM, Maintenance Director F, identified one soiled utility room in the facility during environmental tour and four shower rooms: 1. On the 100-hall, the soiled linen can in the shower room lacked a lid or cover. 2. On the 200-hall, the soiled linen can in the shower room lacked a lid or cover. 3. On the 300-hall, the soiled linen can in the shower room lacked a lid or cover. 4. On the 400-hall, the soiled linen can in the shower room lacked a lid or cover. 5. In the soiled utility room, the biohazard box lacked a lid or cover. 6. In the laundry room, a large crack on the floor with broken/missing tile with exposed cement and with a large crack in the cement that created an uneven walking surface with unknown debris inside the crack in the cement. On 05/21/24 at 11:55 AM, Maintenance Director F revealed that all soiled linen cans in the shower rooms should be always covered with a lid, and the biohazard box in the soiled utility room should be have a lid or cover. On 05/21/24 at 09:50 AM, Administrative Staff A revealed that all soiled linen cans in the shower rooms and the biohazard container in the soiled utility room should be always covered with a lid. The facility failed to provide a policy related to lids or the covering on trash cans in the soiled utility rooms as requested on 05/21/24. The facility failed to provide a sanitary environment by the failure to have lids or covers on the soiled linen cans in the soiled utility rooms, failure to have a lid on the biohazard container in the soiled utility room and failure to maintain appropriate flooring in the laundry area. These deficient practices had the potential to be an unsanitary environment which would affect all residents in the facility.

The facility reported a census of 36 residents. The 15 residents selected for review included three residents reviewed for quality of care including one resident for non-pressure wounds. Based on observation, interview and record review, the facility failed to provide adequate non-pressure wound care to resident (R)188 to prevent possible infection. Findings included: - Review of Resident (R)188's Electronic Health Record (EHR) Physician Orders, dated 09/30/22, revealed the resident admitted to the facility on (09/30/22). The resident had a diagnosis that included heart failure. The admission Minimum Data Set (MDS) was incomplete but in progress. The Baseline Care Plan dated 09/30/22 indicated the resident had current and a history of skin integrity issues, however, the baseline care plan lacked guidance for skin integrity concerns. The admission Assessment dated 09/30/22 indicated seven areas of concern that included areas on the resident's coccyx (small triangular bone at the base of the spine), and right and left gluteal fold (pertaining to the buttocks or buttocks muscles). The Braden Scale (an assessment tool used to determine the risk of development of skin integrity problems) dated 09/30/22, indicated a score of 14 that determined the resident was at moderate risk of the development of impaired skin integrity. The EMR lacked a physician's order for wound care. A Skin/Wound Note dated 10/04/22, documented the presence of four distinct areas of concern of impaired skin integrity. Observation, on 10/05/22 at 09:00 AM, revealed Licensed Nurse (LN) H entered the resident's room to perform wound/skin care to resident's left buttock, coccyx, right flank (side) and left popliteal fold (space behind the knee. Staff performed hand hygiene, applied her gloves, cleaned the wounds with skin wipes, and applied a zinc-based ointment directly on three of the four wounds and covered the wounds with a dressing. LN H marked the dressing with the date/time/initials, and then removed the soiled gloves, and performed hand hygiene. Interview on 10/05/22 at 10:15 AM with LN H revealed that professional standards of wound care were established with a verbal discussion between herself and the Wound Care Consultant. LN H stated that the Wound Care Consultant visited the facility once per week to stage wounds and write orders for wound care. LN H stated that the use of wound cleanser is consistent with the professional standards and no physician order is required to use wound cleanser when cleaning wounds. LN H stated that the standard practice is to clean wounds with wound cleanser which she verified she failed to cleanse the wound properly. The facility policy for Wound Assessment, Prevention and Treatment, dated 11/29/17, included: Orders for treatment will be obtained and initiated immediately by the facility. Weekly assessments of skin issues will be completed at least every seven days by the wound nurse and will include location of the wound, measurements of the wound, description of the wound bed and surrounding tissue and description of any drainage. The facility failed to provide sanitary wound care to this resident's wounds consistent with professional standards to promote healing and prevent the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 36 residents with 15 selected for review which included three residents reviewed for bowel and bladder/urinary tract infection. Based on observation, interview and record review the facility failed to provide sanitary peri-care for one resident (R) 5, of the three residents reviewed for bowel and bladder/urinary tract infections. Findings included: - Review of Resident (R)5's Physician Order Sheet, undated, revealed diagnoses included Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease with dementia(progressive mental disorder characterized by failing memory, confusion), incontinence (inability to control urination and bowel movements), and hemiplegia (paralysis of one side of the body). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with severely impaired mental status and required extensive assistance of two staff for bed mobility and toileting. The resident was frequently incontinent of bowel and bladder. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 12/21/21, assessed the resident was incontinent of bowel and bladder most of the time. The Quarterly MDS, dated 06/21/22, assessed the resident with severely impaired mental status, required extensive assistance of two staff for bed mobility and toileting, and was always incontinent of bowel and bladder. The Care Plan, reviewed 07/05/22, instructed staff the resident was incontinent, used briefs for dignity and sanitation, and was no longer able to sit on the toilet. Staff should check and change the resident every one to three hours and as needed. Staff were to provide peri ( the exterior skin area in the genital and anal region) care after each incontinent episode to keep his skin clean and dry. Observation, on 10/03/22 at 12:45 PM, revealed Certified Nurse Aide (CNA) MM and Certified Medication Aide (CMA) R, transferred the resident into his bed with a mechanical full body lift. The resident was incontinent of urine. CMA R used a peri wipe to cleanse the resident's skin by repeated folding it over upon itself for the cleansing and then staff turned the resident and found him incontinent of stool. CMA R obtained several peri wipes and cleansed the resident skin of the stool. CMA R then applied barrier cream to the residents' anal and buttock area. Staff failed to change gloves after cleansing the resident. Interview, on 10/03/22 at 01:00 PM, with CMA R, revealed staff should change gloves prior to applying barrier cream after cleansing the skin. Interview, on 10/06/22 at 08:19 AM, with Administrative Nurse D, revealed she would expect staff to use one wipe per cleansing pass and to remove gloves when finished with incontinence care, sanitize hands and don a new pair of gloves prior to applying barrier cream. The facility utilized the Competency Checklist Hand Hygiene and Glove Use, undated, as the policy. This checklist instructed staff to remove gloves upon completing a task. The facility failed to provide peri care and application of barrier cream in a sanitary manner to prevent the spread of infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 36 residents with 15 residents sampled, including one resident reviewed for respiratory needs. Based on interview, record review, and observation, the facility failed to obtain a physician order to appropriately administer oxygen to the one sampled Resident (R)27, who used oxygen. Findings included: - Review of Resident (R)27's electronic medical record (EMR), included a diagnosis of acute and chronic respiratory failure (a long-term lung disease in which oxygen is not absorbed correctly) and dependence on supplemental oxygen (a long-term condition requiring the use of a supplemental oxygen supply). The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. He received oxygen. The Cognitive Loss/Dementia Care Area Assessment' (CAA), dated 03/01/22, documented the resident was able to make his own needs and wants known and was able to make daily decisions. The quarterly MDS, dated 08/30/22, documented the resident had a BIMS score of 14, indicating intact cognition. He received oxygen. The care plan, dated 02/11/22, lacked staff instruction on respiratory cares or oxygen usage for this resident. Review of the resident's electronic medical record (EMR), revealed the resident admitted to the hospital on [DATE] and returned to the facility on [DATE]. The orders lacked an oxygen order and staff failed to obtain a physician order for the resident's oxygen usage The MAR (medication administration record) lacked oxygen saturation levels to determine if the resident had levels of oxygen below 90 percent. On 10/04/22 at 01:40 PM, the resident rested in his recliner in his room with oxygen on via nasal canula. On 10/05/22 at 10:33 AM, the resident rested in his recliner in his room with oxygen on via nasal canula. On 10/06/22 at 08:45 AM, the resident rested in his recliner in his room with oxygen on via nasal canula. On 10/05/22 at 07:40 AM, Certified Nurse Aide (CNA) O stated that every morning the resident was switched from his CPAP machine (Continuous Positive Airway Pressure - used to treat Sleep apnea [disorder of sleep characterized by periods without respirations]) to an oxygen canula when he woke up for the day. On 10/05/22 at 09:24 AM, Consultant HH stated the facility lacked a policy for following physician orders. On 10/05/22 at 01:40 PM, Licensed Nurse (LN) H stated order for oxygen administration had been discontinued on 02/16/22 due to hospitalization and had not been restarted upon his readmission to the facility. On 10/05/22 at 02:30 PM, Administrative Nurse D and Consultant HH stated the facility had a standing order for the use of oxygen but expected staff to obtain the order for a resident that required oxygen as soon as possible after initiating standing order. Staff failed to obtain oxygen orders for the resident. On 10/05/22 at 02:30 PM, Administrative Nurse D stated staff should initiate standing orders when a resident required oxygen. Oxygen cannot be used without an order. Staff failed to get a physician order for the oxygen. The facility's standing orders, undated, included: Apply oxygen (O2), as needed (PRN), when saturations (a measure of how much hemoglobin is currently bound to oxygen) drop below 90%. Please call the provider when a condition change, such as hypoxia (deficiency in the amount of oxygen reaching the tissues), occurs. The facility lacked a policy for following physician orders. The facility failed to obtain a physician order for the use of oxygen for this resident, to ensure appropriate oxygen usage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 36 residents with 15 selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to obtain a physician's order for the discontinuation of insulin for one Resident (R)4 of the five residents reviewed for unnecessary medications. Findings included: - Review of Resident (R)4's Physician Order Sheet, dated 08/19/22, revealed diagnoses included diabetes (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, and chronic (persisting for a long period, often for the remainder of a person's lifetime) kidney disease. The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident received seven days of insulin. The Care Plan, reviewed 09/13/22, instructed staff to administer insulin as ordered by the physician and monitor blood glucose as ordered by the physician and as needed. This Care Plan also instructed staff to monitor blood sugars and treat. The Discharge Orders, dated 06/27/22 from acute care, instructed staff to discontinue the resident's Novolog, Victoza and Basaglar insulin and to monitor blood sugars closely for need to restart. The Physician Note, dated 06/29/22 instructed staff to resume insulin as before and hold insulin if the resident did not eat a meal. The Physician's Order, dated 06/29/22 instructed staff to administer the following insulin and blood glucose monitoring: 1.) Novolog 15 units, subcutaneously (into the tissue below the skin) with meals for diabetes. 2.) Victoza solution 1.2 ml (milliliters), subcutaneously, in the morning, for diabetes. 3.) Basaglar KwikPen Solution, 50 units, subcutaneously, at bedtime for diabetes. 4.) Blood glucose monitoring before meals and at bedtime. Staff instructed to notify the physician if the blood glucose was greater than 300 mg/dl (milligrams per deciliter) or less than 70 mg/dl. 5.) Blood glucose monitoring as needed for elevated blood sugar or low blood sugar. Staff instructed to notify the physician if the blood glucose was greater than 300 mg/dl (milligrams per deciliter) or less than 70 mg/dl. Review of the blood glucose levels as recorded on the Medication Administration Record, from 07/01/22 through 07/12/22 revealed a range of 43-372 mg/dl. Review of the July 2022 Medication Administration Record revealed staff discontinued these medications on 07/12/22. Review of the Medical Record lacked a physician's order for discontinuation. Observation, on 10/04/22 at 08:00 AM, revealed the resident seated at the dining room table, feeding himself breakfast. The resident stated the breakfast was good and he consumed approximately 80 percent. Observation, on 10/05/22 at 12:00 PM, revealed the resident feeding himself a chief's salad for his noon meal. Interview, on 10/06/22 at 09:44 AM, with Administrative Nurse D, revealed when the resident readmitted from acute care on 06/27/22, he received hospice services as he was nearly comatose and was expected to expire, however, the resident recovered and was able to feed himself, get up out of bed with assistance and converse. Administrative Nurse D stated the hospice nurse visited the resident on 07/12/22 and verbally gave an order to the licensed charge nurse to discontinue the insulin (the resident was not eating at that time). The charge nurse did not document the order but did discontinue the insulin and order for glucose monitoring before meals and bedtime. Administrative Nurse D stated staff the resident still had the As needed order for monitoring the resident's blood glucose when he displayed signs of hyper (elevated) or hypoglycemia (less than normal amount of sugar in the blood). Administrative Nurse D stated she would expect the licensed nurse to obtain a signed order from the physician to discontinue the insulin. Administrative Nurse D stated since the resident improved and was regularly eating, she would discuss with the physician and hospice the need for blood glucose monitoring/insulin. Interview, on 10/06/22 at 10:30 AM, with Consulting Nurse HH, revealed the facility did not have a policy for following physician orders and would expect staff to follow the standard of practice. The facility lacked a policy for following physician orders. The facility failed to obtain a physician's order to discontinue this resident's insulin and failed to notify the physician of the resident's improved status to clarify the need for blood glucose monitoring/insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 36 residents, with 15 residents sampled, including five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to administer as needed (PRN) medications to one Resident (R)6 for lack of bowel movements (BM) and failed to obtain ordered labs for one Resident (R)17. Findings included: - The Physician Order Sheet (POS), dated 08/19/22, documented Resident (R)17 had diagnoses of hypertension (HTN-elevated blood pressure), type II diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), major depressive disorder (MDD-major mood disorder) and heart failure (inability for the heart to function appropriately). The resident's annual Minimum Data Set (MDS), dated [DATE], documented she had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. She had antipsychotic (medication used to treat psychosis) seven days of the look back period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 07/26/22, documented the resident took Abilify (an antipsychotic medication) for major depressive disorder MDD. The Nutritional Status CAA, dated 07/26/22, did not trigger. The quarterly MDS, dated 04/26/22, documented the resident had a BIMS score of 10, indicating moderate cognitive impairment. She received no psychotropic medications during the look back period of the assessment. The care plan for behavioral symptoms, revised 07/25/22, instructed staff the resident had behaviors of refusing cares at times. Staff were to monitor for side effects of the antipsychotic medication the resident received. The nutrition/diabetes care plan, revised 07/25/22, instructed staff to monitor the resident's A1C (measures your average blood glucose, or blood sugar, level over the past 3 months), as ordered by the physician. Review of the resident's POS dated, 08/19/22, included the following orders: Basic metabolic panel (BMP-a group of 8 tests that measures several substances in your blood), no diagnosis given, every (Q) six months, ordered 06/21/19. Complete Blood Count (CBC-a blood test used to evaluate your overall health and detect a wide range of disorders), Q six months, for medication usage, ordered 09/15/20. Brain natriuretic peptide (BNP-a blood test that measures levels of a protein called BNP that is made by heart and blood vessels), Q year, for heart failure, ordered 11/14/20. Review of the resident's EMR, the record lacked any up-to-date labs. On 10/05/22 at 10:38 AM, Licensed Nurse (LN) H stated the scheduled labs were ordered by the nurses. LN H was unaware the resident lacked up-to-date labs. On 10/05/22 at 10:44 AM, LN G stated the routine labs were to be ordered by the floor nurse. The electronic system will give the nurses a notice when labs are due, and the nurse should fill out a lab requisition form for the lab person to obtain the lab on the next scheduled lab day. On 10/06/22 at 07:47 AM, Administrative Nurse D stated, the nurse was generally responsible for ensuring scheduled labs were drawn. The resident's labs were not drawn as ordered. The facility lacked a policy for obtaining ordered labs. The facility failed to obtain ordered labs for this dependent resident. - The Physician Order Sheet (POS), dated 08/19/22, documented Resident (R)6 had a diagnosis of hemiplegia (paralysis of one side of the body). The annual Minimum Data Set (MDS), dated [DATE], documented staff assessment for cognition revealed the resident was independent for daily decision making. He required total assistance of two staff for toileting and was always incontinent of bowel. Constipation was not present. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/20/22, documented the resident was dependent on staff for toileting. The quarterly MDS, dated 06/21/22, documented staff assessment for cognition revealed the resident was independent for daily decision making. He required extensive assistance of two staff for toileting and was always incontinent of bowel. The care plan for incontinence, revised 07/26/22, instructed staff to ensure briefs and wipes supplied. Review of the resident's electronic medical record (EMR), from 09/05/22 through 10/03/22, revealed the resident went from 09/28/22 through 10/01/22, for a total of four days, without having a bowel movement (BM). Review of R 6's EMR, revealed the following order: Milk of Magnesia (MOM), 400 milligrams (mg)/5 milliliters (ml), by mouth (po), every (Q) 24 hours, as needed (PRN), for constipation, ordered 10/03/21. Review of the resident's medication administration record (MAR), revealed staff failed to administer the MOM after the resident had gone three days without a BM. On 10/05/22 at 09:26 AM, Certified Nurse Aide (CNA) M stated, when a resident has a BM, staff will document it on the electronic documentation device. This way, the nurses can monitor who has had a BM and who has not. On 10/05/22 at 09:28 AM, CNA N stated, when a resident had a BM, it will be documented on the computer. On 10/05/22 at 10:38 AM, Licensed Nurse (LN) H stated, the night shift nurse should print out a list of residents who had not had a BM in 72 hours. The day nurse should administer a PRN laxative (a medication to stimulate or facilitate evacuation of the bowels) to all residents on the list. On 10/05/22 at 10:44 AM, LN G stated, the nurses run a BM report daily. The report shows all residents who have not had a BM for three days. LN G stated a PRN medication should be given to the residents on the list, according to their orders. On 10/06/22 at 07:47 AM, Administrative Nurse D stated, the expectation was for the bowel protocol to be started when a resident did not have a BM for three days. The facility policy for Bowel Elimination, revised 04/27/18, included: The facility will provide care and services to ensure adequate resident bowel elimination. Interventions to aid in elimination will be implemented according to doctor's orders if constipation is identified. The facility failed to administer PRN laxatives to this dependent resident who had not had a BM for over three days.

The facility reported a census of 36 residents. Based on observation and interview, the facility failed to maintain food preparation equipment in a clean manner and failed to ensure a two-inch air gap between the ice machine drainage pipes and floor drain to prevent the spread of food borne illness. Findings included: - Observation on 10/05/22 at 02:25 PM, during the environmental tour of the kitchen revealed the stand-alone oven contained six baking racks covered with a black hard substance and the interior of the oven, that included the doors, contained splatters of black baked on substances over the entire surfaces. Interview, on 10/05/22 at 02:30 PM, with Dietary Staff BB, revealed she would expect staff to clean the oven at least monthly and as needed, but she did not have a schedule for the cleaning and it had not been cleaned for approximately three months. The facility policy Cleaning Instructions: Oven, undated, instructed staff to regularly clean the ovens according to the cleaning schedule. The facility failed to ensure staff cleaned this oven used in food preparation regularly to prevent the spread of food-borne illness. - Observation, on 10/05/22 at 03:00 PM, revealed two ice machine drain pipes positioned directly on the floor drain lacked a two-inch air gap space as required. Interview, on 10/05/22 at 03:00 PM, with Maintenance Staff U, confirmed the observation and did not know how long the drainage pipes lacked a two-inch air gap. The facility policy Ice Handling and Cleaning, dated 04/27/20, instructed staff the ice storage shall be drained through an air gap of one to two inches from the floor drain or two times the diameter of the floor drain, whichever is greater. The facility failed to ensure a two-inch air gap between the ice machine drainage pipes and the floor drain to prevent the spread of food borne illness.

The facility reported a census of 36 residents. Based on observation and interview, the facility failed to ensure that staff contained trash in the dumpster and the lids to the dumpster were closed to prevent the spread of infection. Findings included: - Observation, on 10/05/22 at 03:15 PM, revealed the trash dumpster contained in a closed wooden gated enclosure. The dumpster lids were in an open position. Several broken open bags of trash which contained soiled incontinence briefs, peri-wipes and other used items lay directly on the ground that surrounded the dumpster. Interview, on 10/05/22 at 03:30 PM, with Maintenance Staff U, confirmed the open trash dumpster and open bags of trash. Maintenance Staff U stated staff should close the lids to the dumpster and ensure trash lands inside the dumpster. The facility policy Garbage and Rubbish Disposal, dated 04/06/22, instructed staff to ensure outside dumpsters are maintained in a clean and sanitary condition. The facility failed to contain trash in the dumpster with lids in a closed position to prevent the spread of infection.

The facility reported a census of 36 residents. Based on observation, record review and interview, the facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly environment in the storage closets that contained supplies for the residents of the facility. Findings included: - During an environmental tour on 10/06/22 at 11:30 AM with Housekeeping/Maintenance staff U, the following concerns were identified: A storage room on the 100- hall had two boxes of COVID rapid tests, two boxes of paper gowns, one box of five ounce (oz) plastic cups, with 2,500 cups per box, 1 box of 200 facial shields, a box with 20 graduates (containers to hold liquid), one box of 150 denture cups, one box of 48 urinals, one box with 20 rolls of toilet paper, ten boxes of briefs and pull-ups in varying sizes, and two boxes of 1,152 wipes. The nursing supply room on the 200- hall had one box of 3,000 facial tissues and one box of germicidal wipes, with 12 containers with 75 wipes in each container. On 10/06/22 at 11:30 AM, Housekeeping/maintenance staff U stated he was unaware supplies should not be stored directly on the floor. On 10/06/22 at 12:11 PM, Administrative Nurse D stated, staff should put supplies away in the storage rooms. Supplies should not be placed directly on the floor. The facility did not have a policy regarding storing items in the storage rooms. The facility lacked a policy for the storing of supplies. The facility failed to provide housekeeping and maintenance services to maintain a sanitary, orderly environment in the storage closets that contained supplies for the residents of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 27 residents with 12 selected for review, including two residents reviewed for dignity. Based on observation, interview, and record review, the facility failed to provide privacy for one of the two residents, Resident (R)28, while providing cares in his room. Findings included: - The Order Review History Report, dated 02/18/21, for Resident (R)28, included diagnoses of acquired absence of right leg below knee, recurrent depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness), anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder, morbid obesity, and pain in unspecified joint. The Annual Minimum Data Set (MDS), dated [DATE], revealed R28 had a Brief Interview of Mental Status (BIMS) score of 15, indicating he was cognitively intact. He required extensive assistance of two or more staff for dressing, was totally dependent on two or more staff for transfer, and required staff assistance of two or more for help in part of his bathing activity. The ADL [activities of daily living] Care Area Assessment (CAA), dated 12/16/20, revealed R28's ADL abilities were severely impaired related to his morbid obesity, right leg amputation and pain. He could raise his arms to assist with upper body dressing but was unable to do anything else regarding the dressing task, and he required a lift for transfers. The Quarterly MDS, dated 02/22/21, revealed R28 had a BIMS score of 13, indicating he was cognitively intact. He required extensive assistance of two or more staff for dressing, was totally dependent on two or more staff for transfer, and was totally dependent on two or more staff for his bathing activity. On 03/31/21 at 04:18 PM, Certified Nurse Aide (CNA) M, assisted R28 back to his room in the shower chair and positioned the shower chair near the foot of the bed facing the door to the room. CNA N was in the room to assist with cares of R28. CNA M removed the towels that were covering R28, opened the door to the room, went out to the hallway to get the mechanical lift, and returned to the room with the lift. The door to R28's room was left open and R28 was without any clothing or linens covering him while the door was left open. On 04/05/21 at 05:24 PM, Administrative Nurse D revealed that the staff should not leave a resident uncovered with the door open to the room. On 04/05/21 at 05:50 PM, Administrative Staff A confirmed that staff should cover the resident when the room door was open. The facility acknowledgement Resident Rights Under Kansas Law, undated, indicated that each resident shall have privacy provided during medical and nursing treatment and personal care. The facility failed to provide privacy for R28 while staff provided cares.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 27 residents with 12 selected for review including one resident reviewed for activities of daily living (ADL's). Based on observation, interview, and record review the facility failed to ensure the one sampled Resident (R)19 received appropriate personal hygiene assistance needed for trimming and cleaning of her fingernails. Findings included: - The Order Review Report, dated 02/18/21, for Resident (R)19, included diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed R19 with a Brief Interview of Mental Status (BIMS) score of nine, indicating moderate cognitive impairment, no rejection of care occurred, fed herself with setup, and required extensive assistance for personal hygiene. The ADL [activities of daily living] Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 09/09/20, indicated R19 required assistance with ADL's including showering as she was unable to wash her hair or her body. She required set-up assist only for meals. The Quarterly MDS, dated 02/15/21, assessed R19 with a BIMS score of six, indicating severe cognitive impairment. She rejected care one to three days, required supervision/setup for eating, extensive assistance for personal hygiene, and needed help with bathing. The Care Plan, dated 06/05/19, indicated that R19 liked to keep her nails well-trimmed, the staff was to help her with nail care, and since she was diabetic the care of her nails needed to be done by a nurse or a podiatrist. R19 wanted a whirlpool bath twice weekly. Review of the electronic medical record (EMR), revealed she had no orders in regards to nail care and that she was totally dependent for bathing on 03/24/21, refused bathing on 03/28/21 and 03/31/21, and needed help with bathing on 04/04/21. On 03/30/21 at 08:45 AM, R19 was resting in her bed with the head of the bed up, her breakfast plate was clean, and her fingernails were long with a brown substance underneath the nails. On 04/01/21 at 08:56 AM, R19 was resting in bed with the head of the bed up, feeding herself breakfast, fingernails were long with a brown substance under them and a few of the nails had uneven edges. On 04/01/21 at 01:53 PM, R19 was resting in bed and had no changes to the condition of her fingernails. On 04/05/21 at 11:47 AM, R19's fingernails remained long, a dark substance was present under some of the nails to the right hand, fingernails to her left hand were clean, and she continued with several nails that had an uneven surface. On 04/05/21 at 02:01 PM, Certified Nurse Aide (CNA) O stated that R19 gets a bath two to three times a week and yesterday was her bath day. CNA O stated that if a resident is diabetic then the nurse has to clip the fingernails and that the CNA's let the nurse know when they need trimmed. On 04/05/21 at 04:54 PM, Licensed Nurse (LN) G, stated that nail care is done by anybody, was not aware that R19 had diabetes, and she had not been alerted that she needed nail care. LN G confirmed that R19's fingernails needed trimmed and cleaned. On 04/06/21 at 09:18 AM, R19's fingernails continued to need cleaned and trimmed. She was resting in her bed with breakfast tray in front of her and had consumed her toast. On 04/06/21 at 11:56 AM, Administrative Nurse D stated that nail care was to be done every time a resident was bathed, the nails should be cleaned and trimmed if needed. If a resident has diabetes then the CNA's are to tell the nurse so the nurse can trim them. On 04/06/21 at 02:47 PM, Administrative Nurse D stated that there was not a facility policy that addressed nail care. The facility failed to provide appropriate personal hygiene assistance needed for trimming and cleaning of R19's fingernails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 27 residents with 12 residents selected for review including two residents reviewed for skin conditions. Based on observation, record review, and interview, the facility failed to provide a thorough skin assessment for adequate monitoring of one of the two residents, Resident (R)28, with red, broken skin to both posterior thigh areas. Findings included: - The Order Review History Report, dated 02/18/21, included diagnoses of acquired absence of the right leg below the knee, recurrent depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness), anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder, morbid obesity, pain in unspecified joint, and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], revealed R28 had a Brief Interview of Mental Status (BIMS) score of 15, indicating he was cognitively intact. He required extensive assistance of two or more staff for bed mobility and was totally dependent on two or more staff for transfers. He was at risk for developing pressure ulcers, did not have any skin problems, and received application of ointments/medications other than to his feet. The ADL [activities of daily living] Care Area Assessment (CAA), dated 12/16/20, revealed R28's ADL abilities were severely impaired related to his morbid obesity, right leg amputation and pain. He required a lift for transfers. The Pressure Ulcer/Injury CAA, dated 12/16/20, revealed R28 was a high risk for pressure ulcers and other skin irritations associated with moisture in body folds due to his size, lack [NAME] mobility, and incontinence/skin moisture. He is not able to turn from side to side well without staff assistance and had multiple medical conditions which can contribute to skin risk. The Quarterly MDS, dated 02/22/21, revealed R28 had a BIMS score of 13, indicating he was cognitively intact. He required extensive assistance of two or more staff for bed mobility and was totally dependent on two or more staff for transfers. He was at risk for developing pressure ulcers, did not have any skin problems, and received application of ointments/medications and nonsurgical dressings other than to his feet. The Care Plan, dated 01/22/20, included a problem for R28's skin, and that the staff were to look over his skin every time they provided a bath or cares and let the nurse know if there were any new issues so they could be taken care of right away. A licensed nurse was to assess R28's skin weekly. The electronic medical record (EMR) lacked any weekly wound notes but revealed these skin/wound notes under the progress notes: 1. On 11/22/2020 at 03:46 AM, R28's skin was clean and dry with zero redness noted at this time. 2. On 11/27/2020 at 04:52 AM, R28 had a skin abrasion to his right upper thigh near is bottom that measured 1.5 centimeters (CM) by 1.0 cm. The staff cleaned the area with normal saline, patted dry, applied zinc ointment, and covered with skin prep spray. 3. On 11/29/2020 at 05:13 PM, R28 had no new skin issues noted at this time. The note failed to address the abrasion noted on the 11/27/20 skin note. 4. On 12/3/2020 at 11:57 PM, R28 refused a shower this date. 5. On 1/1/2021 at 04:49 AM R28 had a skin fold that was red on his right side and the staff applied zinc. The note failed to include where this red area was and a further description. This skin/wound note was 29 days after the last note on 12/03/20. 6. On 1/14/2021 at 08:40 PM, R28 had no new skin issues noted at that time. The note failed to address a skin fold on his right side that was red that the staff noted in his previous note on 01/01/21. 7. On 1/16/2021 at 10:45 PM, R28 had superficial breakdown/shearing noted to his right upper posterior side under his gluteal fold. The staff applied barrier cream per his physician orders. The area showed improvement, more superficial. 8. On 1/24/2021 at 06:04 PM, R28 had no new skin issues noted. The note failed to address any breakdown/shearing to his right upper posterior side under his gluteal fold. 9. On 1/27/2021 at 09:23 PM, R28's calloused area remains to his posterior thigh/glute crease. The staff applied barrier cream and offloaded area with a pillow. 10. On 2/2/2021 at 09:34 PM, R28's skin assessed, no new skin issues observed or reported. The staff applied zinc ointment to his buttocks per physician orders. 11. On 2/7/2021 at 07:36 PM, R28 had no new skin issues or concerns. The note lacked what current skin issues were present. 12. On 2/11/2021 at 09:18 PM, R28 had no new skin issues noted. The note lacked what current skin issues were present. 13. On 2/18/2021 at 10:45 PM, R28 had no new skin issues noted. The note lacked what current skin issues were present. 14. On 2/25/2021 at 09:53 PM, R28 refused his shower. The note lacked if he refused a skin assessment. 15. On 2/27/2021 at 10:35 PM, R28 had no new skin issues, his redness to posterior thigh remains, blanches, and barrier cream applied. 16. On 3/7/2021 at 09:16 PM, R28 had no new skin issues, area to right posterior thigh improving with current treatment. 17. On 3/14/2021 at 01:08 AM, R28 had no new skin concerns noted at present time. The note lacked what current skin issues were present. 18. On 3/21/2021 at 09:25 PM, R28 had no new skin issues observed or reported. The note lacked what current skin issues were present. 19. On 3/30/2021 at 09:11 PM, R28 had no new skin concerns noted. The note lacked what current skin issues were present. 20. On 4/4/2021 at 07:43 PM, R28 refused shower or bed bath. The note lacked if R28 refused a skin assessment. The Order Review History Report, dated 02/18/21, included and order dated 12/16/20, for A&D zinc oxide cream, apply to bottom topically, three times a day, for rash/reddened area. On 03/31/21 at 08:56 AM, R28 reported that he had complained before about the lift sling being too small and cutting into the back of his legs which caused wounds last summer and the staff located his sling after a month or so. He revealed that the back of his legs were still not healed, they were bleeding yesterday when the staff assisted him to bed. The staff apply a lotion to the wound on each leg and covering with an absorbent padded cover, as other dressings did not work, they protect the back of my legs from the sling. They clean the wounds in the morning and apply the baby diaper before they get me up in the chair. On 03/31/21 at 03:48 PM, Certified Nurse Aide (CNA) M and CNA N were connecting the lift sling to the mechanical lift, R28 had an absorbent padded cover in place to the back of both legs, some blood was noted to each diaper that they removed. On 03/31/21 at 03:55 PM, CNA N reported that R28 has ointment that the CNA's put on, he had some zinc ointment that worked well, he will have some applied to him when he is done with his shower. On 03/31/21 at 04:18 PM, R28 returned to his room from his shower, and CNA M and CNA N transferred him to bed. The back of his right leg below his buttocks had a large reddened area with an area of shearing within it, and the back of his left leg below his buttocks had a red area with three areas where the skin was split open within the red area. CNA M wiped both areas with a cleansing cloth, applied the zinc oxide 20% ointment, then covered each area with an absorbent padded cover. On 03/31/21 at 04:38 PM, Licensed Nurse (LN) G revealed she does not do any treatments to the back of R28's legs, they are monitored weekly by skin observations that the night nurses do, they document on the Treatment Administration Record (TAR) that it was done and if there are any issues then they document those issues in the progress notes. LN G was not sure if he had any treatment orders, and after checking the record she confirmed he had an order for zinc. On 04/05/21 at 02:21 PM, Certified Medication Aide (CMA)/CNA O revealed that R28 gets zinc ointment applied to the back of his legs under his bottom area in the morning, then the nurse is informed of how the area is and if it is starting to open up again and bleed then we get the nurse and heave her look at it. He did not have any open areas this morning when I assisted to get him up. CNA O stated that they use an absorbent padded cover to cover the areas. Furthermore, she revealed that they will use a large sling if the extra-large sling is in the laundry to be washed or was drying still. R28 does not complain now if we use the large sling when the absorbent padded covers are used to the back of his legs. On 04/05/21 at 05:31 PM, Administrative Nurse D revealed that the facility should have more than one extra-large sling for the staff to use when transferring R28. On 04/06/21 at 01:26 PM, Administrative Nurse D confirmed that the expectations for weekly skin assessments was for any type of wound the nurse was to report it and then a weekly wound report would be filled out. The nurse should describe any skin conditions a resident has in the skin notes located in the progress notes. If a resident has any kind of open area to the skin it should be measured at the time of the assessment and entered on the weekly wound assessment in the EMR. The facility lacked a policy to address weekly skin and wound assessment guidelines. The facility failed to provide a thorough skin assessment for adequate monitoring of R28's skin conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 27 residents with 12 selected for review including five residents reviewed for unnecessary medications. Based on record review and interview, the facility failed to notify the physician for further instruction when blood sugar levels were out of parameters for one of the five residents, Resident (R)28. Findings included: - The Order Review History Report, dated 02/18/21, for Resident (R)28, included a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS), dated [DATE], revealed R28 had a Brief Interview of Mental Status (BIMS) score of 15, indicating he was cognitively intact, a diagnosis of DM, and received insulin injections seven days of the assessment period. The Quarterly MDS, dated 02/22/21, revealed R28 had a BIMS score of 13, indicating he was cognitively intact, a diagnosis of DM, and received insulin injections seven days of the assessment period. The Care Plan, dated 01/22/20, included R28 had a diagnosis of DM, administer his insulin and oral medication per physician orders, monitor his blood sugars as ordered by his physician, and update his physician with any concerns. The Order Review History Report, dated 02/18/21, included these orders: 1. On 12/16/20, Jardiance (medication used to lower blood sugar levels), 10 milligrams (mg), every day for DM. 2. On 12/17/20, Novolog (type of insulin used to control high blood sugar) flex pen, 100 unit/milliliter (mL), inject 39 units, subcutaneously, with meals, for DM. 3. On 12/17/20, monitor blood glucose four times daily and notify the physician if blood glucose is greater than 300 or less than 70, and as needed. 4. On 02/10/21, Basaglar (type of insulin used to control high blood sugar) flex pen, 100 unit/mL, inject 70 units, subcutaneously, twice daily, for DM. A physician order, dated 02/11/21, indicated to repeat his hemoglobin A1c (lab test that measure blood glucose levels over the past three months) since his insulin was just increased as R28's results were high on the lab report 02/11/21. The Consultant Pharmacist's Medication Regimen Review, dated 08/06/20, included a recommendation to ensure the staff notify the physician for blood sugar levels out of the parameters and document this in the electronic medical record (EMR). The Consultant Pharmacist's Medication Regimen Review, dated for recommendations created between 10/05/20 and 10/07/20, included a recommendation to ensure staff are notifying the physician for blood sugar reading outside of the parameters (greater than 300) and documenting this in the EMR. The Nursing Medication Administration Record (MAR), dated 03/2021, included these blood glucose levels that were out of parameters: 1. On 3/4/21, at hour of sleep (HS), R28's blood glucose level was 345. 2. On 3/22/21, at HS, R28's blood glucose level was 390. 3. On 3/25/21, at HS, R28's blood glucose level was 320. 4. On 3/28/20, in the morning, between 6:00 AM and 10:00 AM, R28's blood glucose level was 335. The progress notes, for the dates referenced above, lacked physician notification by the staff, due to the blood glucose levels being greater than 300. The nursing MAR, dated 03/22/21 at 08:05 AM, did indicate R28 received a one-time dose of Novolog, 10 units, for high blood sugar. There was no follow up blood sugar on that MAR, following the one-time dose, or any other time during the month of March. There were no other one-time doses administered for the month of March. On 04/06/21 at 02:31 PM, Licensed Nurse (LN) H, stated that when a resident's blood sugar was out of parameters, the physician is notified by the staff sending a fax or calling, and that notification should be documented in the nurses notes. On 04/06/21 at 02:34 PM, Administrative Nurse D stated that the nurses are to call the physician for notification when blood sugar levels are out of parameters, faxes are not an acceptable form of notification, and that the in-service last month on 03/18/21, included discussion about physician notification and documenting the notification in the progress notes. The facility lacked a policy regarding blood sugar notification to the physician when out of parameters and documentation of such notification in the progress notes of the EMR. The facility failed to notify the physician for further instruction when R28's blood sugar levels were out of parameters three times during March of 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 27 residents with one resident sampled for edema (swelling) of the lower extremities. Based on interview and record review the facility failed to provide resident (R)12 with prompt/timely results of his radiology diagnostic test results. Findings included: - Review of Resident (R) 12's undated Physician Orders, included diagnoses of edema (swelling), chronic pain syndrome, and polyneuropathy (a condition that affects the peripheral nerves throughout the body). and peripheral artery disease (a circulatory condition in which narrowed blood vessels and reduced blood flow to the limbs can result in pain and swelling). The annual Minimum Data Set (MDS), dated [DATE], documentation included the resident with the Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. The resident understands and makes himself understood. He was independent with his ADLs. His balance during transition was not steady but he was able to stabilize without staff assistance. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 02/01/2021 documentation included his balance during transition as unsteady, however ambulates independently in and out of his room with the use of his walker. The care plan (CP), dated 02/20/2021, directed staff the resident walks independently and used a walker sometimes when his feet hurt. Review of R 12's Resident Care Orders, dated 02/15/2021, documentation revealed a physician's order for a bilateral lower extremity arterial doppler (radiology test used to estimate the blood flow through the blood vessels) due to peripheral artery disease, swelling, and pain. Review of the R12's Nurses Progress Notes, dated 2/17/2021, documentation revealed the facility received the results of the bilateral lower extremity arterial doppler and lacked documentation of review of the results with the resident. On 03/30/2021 at 08:35 AM, R 12 reported he had a test on his feet and legs due to the edema and pain in his right knee and legs over a month ago and still had not been given the results. He stated he asked several staff including upper management, but no one let him know the test results. On 03/30/2021 at 10:08 AM, R12 asked Licensed Nurse (LN) G about the radiology test results for his legs. LN G stated she would follow-up on his test and get back to him with the results. On 03/31/2021 at 0303PM, on inquiry, the resident reported no one had gotten back to him about his test results. On 04/01/2021 at 10:27 AM, LN H stated that the nurse that received the residents x-ray results should notify the resident of the results and document the notification in the progress notes. She confirmed the lack of documentation of the review of the radiology report results with the resident. On 04/01/2021 at 01:23 PM, Administrative Nurse D confirmed the lack of evidence the facility notified the resident of his radiology results in a prompt or timely manner. She stated the nurse that received the test results on 02/17/2021 should provide the residents with the test results when received. The facility policy for Notification of Changes, dated 04/27/2021, lacked address of notification of residents of their test results. The facility failed to provide the resident with prompt/timely results of his radiology diagnostic test.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 27 residents with 12 selected for review including four residents reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to clean the oxygen concentrator filters for Resident (R)8, R19, R16, and R21. The facility failed to store the oxygen nasal cannula appropriately for R8, failed to clean a nebulizer kit after administration of a treatment and store appropriately for R16, and failed to store an oxygen nasal cannula appropriately and change the nasal cannula as ordered for R21. Findings included: - The Physician Visit, notes, dated 03/13/21, for Resident (R)8 included diagnoses of pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the heart), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and chronic respiratory failure. The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R8 with a Brief Interview of Mental Status Score (BIMS) of 8, indicating moderate cognitive impairment, and a diagnosis of respiratory failure. She required oxygen and had no shortness of breath or trouble breathing with exertion, while sitting at rest, or when lying flat. The Annual MDS, dated 03/17/21, assessed R8 with a BIMS score of 10, indicating moderate cognitive impairment and a diagnosis of respiratory failure. She required oxygen and had shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. The Care Plan, dated 04/22/20, indicated that R8 required oxygen and the staff were to change the oxygen tubing and clean the filter on her concentrator each Monday on night shift. The Physician Order, dated 03/12/21, included an order for oxygen per nasal cannula as needed and to change the tubing weekly. The Treatment Administration Record (TAR), dated 03/29/21, indicated the staff changed the nasal cannula oxygen tubing on 03/29/21. The TAR lacked instructions to clean the filter weekly. On 03/30/21 at 08:52 AM, R8's nasal cannula was not stored in a bag, the bag for storage was on the floor, and the oxygen concentrator filter had lint present. On 03/30/21 at 04:11 PM, R8's nasal cannula was on the floor in her room. On 03/31/21 at 02:17 PM, R8 was sitting up in the recliner in her room, oxygen was not in place, the tubing had a date of 03/30/21. On 04/01/21 at 03:33 PM, Certified Nurse Aide (CNA) P stated that the Certified Medication Aides (CMA's) change out the oxygen nasal cannulas and the cannulas should be stored in a bag that is tied to the oxygen concentrator when not in use. On 04/05/21 at 10:34 AM, the oxygen concentrator continued to have a lint build-up. On 04/05/21 at 05:10 PM, Licensed Nurse (LN) G confirmed the oxygen concentrator filter should be cleaned weekly with the oxygen tubing change and the filter needed to be cleaned. LN G stated the nasal cannula should be in a bag when not in use. On 04/05/20 at 05:20 PM, Administrative Nurse D confirmed the oxygen concentrator filters should be cleaned when the oxygen tubing is changed weekly. When the staff sign the TAR that they changed the tubing, the date of the tubing should match what is on the TAR. The nasal cannulas should be stored in a bag when not in use. The facility policy, Oxygen Safety and Management, undated, indicated the equipment used for oxygen administration (nasal cannulas, mask, tubing), would be replaced every two weeks. The oxygen cannulas and masks should not be allowed to come in contact with the floor or other potentially dirty surfaces, and if it occurred, they should be replaced. The cannulas or masks should be stored in plastic bags to prevent contamination. The concentrator filters should be cleaned at least every two weeks with running water, allowed to air dry, and placed back in the concentrator. The facility failed to clean the oxygen concentrator filter weekly with tubing changes, failed to store the nasal cannula appropriately when not in use to avoid contamination, and failed to change the tubing tubing timely and as designated in the TAR. - The Order Review Report, dated 02/18/21, for Resident (R)19, included diagnoses of obstructive sleep apnea (disorder of sleep characterized by periods without respirations) and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed R19 with a Brief Interview of Mental Status score of nine, indicating moderate cognitive impairment and a diagnosis of COPD. She required oxygen and had no shortness of breath or trouble breathing with exertion, while sitting at rest, or when lying flat. The Quarterly MDS, dated 02/15/21, assessed R19 with a BIMS score of six, indicating severe cognitive impairment and had a diagnosis of COPD. She required oxygen and had shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. The Care Plan, dated 06/05/19, included that R19 had a problem with respiratory function and she had a diagnosis of COPD. She required oxygen use all of the time and would become short of breath when she tried to do things that required very little exertion. The staff were to change her oxygen tubing on Monday nights and as needed. The care plan lacked instructions on cleaning the oxygen concentrator filter. The Order Review History Report, dated 02/18/21, included an order dated on 01/25/21 for oxygen per nasal cannula, change tubing every Monday related to her diagnosis of COPD. The order lacked instruction on when to clean the oxygen concentrator filter. The Nursing Treatment Administration Record, (TAR) dated 03/01/21 through 03/31/21 revealed the staff last changed the oxygen nasal cannula tubing on 3/29/21. On 03/30/21 at 08:45 AM, R19's oxygen concentrator filter had lint build-up. On 03/31/21 at 02:07 PM, R19's oxygen concentrator continued with lint build-up. On 04/01/21 at 08:56 AM, R19's oxygen concentrator filter had a heavy lint build-up. On 04/05/21 at 11:45 AM, R19's oxygen concentrator filter continue with a heavy lint build-up. On 04/05/21 at 05:10 PM, Licensed Nurse (LN) G confirmed the oxygen concentrator filter should be cleaned weekly with the oxygen tubing changes. On 04/05/20 at 05:20 PM, Administrative Nurse D confirmed the oxygen concentrator filters should be cleaned when the oxygen tubing is changed weekly. The facility policy, Oxygen Safety and Management, undated, indicated the concentrator filters should be cleaned at least every two weeks with running water, allowed to air dry, and placed back in the concentrator. The facility failed to clean R19's oxygen concentrator filter weekly with tubing changes. - The Order Summary Report, dated 01/22/21, for Resident (R)16, included diagnoses of a history of a malignant (cells that have the ability to spread to other sites in the body) neoplasm (new abnormal growth of tissue in part of the body, a characteristic of cancer) of the bronchus (airway in the respiratory system that conducts air into the lungs) and lung, dependence on supplemental oxygen, anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) disorder, chronic obstructive respiratory disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and chronic respiratory failure with hypoxia (inadequate supply of oxygen). The admission Minimum Data Set (MDS), dated [DATE], assessed R16 with a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact and included diagnoses of respiratory failure, COPD, and a personal history of a malignant neoplasm of the bronchus and lung. She required oxygen and had shortness of breath or trouble breathing with exertion and when lying flat. She received respiratory therapy for six days for a total of 240 minutes. The Care Plan, dated 01/25/21, included that R16 required oxygen continuously via a nasal cannula, the tubing should be changed, and the filter cleaned, every Monday night. The Order Review History Report, dated 01/22/21, included these orders: 1. On 01/21/21, for Ipratroprium-Albuterol (a bronchodilator medication-used to relax and open the air passages to the lungs to make breathing easier) solution 0.5-2.5 milligrams (mg)/3milliliers (mL), one vial, inhale orally, via nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs), every two hours, as needed, for shortness of air/wheezing. 2. On 01/21/21, Budesonide (a corticosteroid medication-used to decrease the swelling and irritation in the airways to allow for easier breathing) suspension, 0.5 mg/2 mL, one vial, inhale orally, via nebulizer, two times a day, for shortness of air. 3. On 01/21/21, Brovana (a long-acting beta agonist medication-used to relax and open air passages in the lungs to make breathing easier) nebulization solution, 15 micrograms (mcg) /2 mL, one vial, inhale orally, via nebulizer, two times a day, for shortness of air. The Order Review History Report, dated 01/22/21, lacked instruction on when to change the nebulizer tubing. The electronic medical record (EMR), revealed an order dated 02/23/21 for oxygen per nasal cannula, change the tubing every Thursday night. The order lacked instructions to clean the oxygen concentrator filter. The Nursing Treatment Administration Record, (TAR) dated 03/01/21 through 03/31/21, revealed the staff last changed the oxygen tubing on 3/29/21. On 03/30/21 at 09:06 AM, R16's oxygen concentrator filter had lint build-up, her nebulizer tubing was stored uncovered. On 03/30/21 at 09:07 AM, R16 reported that she takes a breathing treatment twice daily. On 03/31/21 at 02:21 PM, R16's oxygen concentrator filter had lint buildup On 04/01/21 at 08:15 AM, R16's nebulizer tubing was connected to the kit, which was also connected, and laying on the bedside table, without a barrier between the kit and the table. On 04/01 21 at 08:16 AM, R16 revealed that the staff did not clean the nebulizer kit after her last treatment. The staff will usually clean the kit and place it on the back of the toilet on a washrag and cover it with paper towels. On 04/01/21 at 08:38 AM, Licensed Nurse (LN) H went in to administer the breathing treatment and the kit was laying on the bedside table. On 04/01/21 at 09:00 AM, LN H placed the nebulizer kit on the bedside table following the breathing treatment. LN H failed to clean the nebulizer kit following the treatment. On 04/05/21 at 05:11 PM, LN G stated that the nebulizer kit is kept on the shelf above the toilet after cleaning and is put back together when it is time to give the next treatment. It was to bed covered with a paper towel when on the shelf. The oxygen concentrator filter should be cleaned weekly with the oxygen tubing changes. 04/05/20 at 05:20 PM, Administrative Nurse D stated the oxygen concentrator filters should be cleaned when we change the oxygen tubing every week. Nebulizer kits should not be left connected after the treatment. The facility has two policies for nebulizer kit cleaning, one says to clean and keep separated until dry and another says we can dry them. Administrative Nurse D stated she would find out which policy the facility should follow. The facility policy Hand-Held Nebulizer Cleaning, dated 11/28/17, revealed the storage bag and all nebulizer items except the machine will be replaced weekly. In between each use the plastic cups, lids, mouth pieces should be cleaned with warm soapy water, rinsed thoroughly, and placed on paper towels to air dry. After cleaning and air-drying, place all pieces in a plastic bag that has been labeled with the resident's name. The facility policy, Oxygen Safety and Management, undated, indicated the concentrator filters should be cleaned at least every two weeks with running water, allowed to air dry, and placed back on the concentrator. The facility failed to clean the oxygen concentrator filter weekly and failed to clean and store the nebulizer kit appropriately to prevent contamination for R16. - The Order Summary Report, dated 03/12/21, for Resident (R)21, included diagnoses of dependence on supplemental oxygen, chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), chronic pulmonary edema (accumulation of extravascular fluid in the lung tissues), and chronic respiratory failure with hypercapnia (abnormally elevated carbon dioxide levels in the blood). The admission Minimum Data Set (MDS), dated [DATE], assessed R21 with a Brief Interview of Mental Status score of 15, indicating cognitively intact and with diagnoses of COPD and respiratory failure. She required oxygen and had shortness of breath or trouble breathing with exertion, sitting at rest, and when lying flat. The Quarterly MDS, dated 03/01/21, included the same assessment findings except R21 did not have shortness of breath or trouble breathing when lying flat. The Care Plan, dated 11/19/20, included that R21 required oxygen, and the staff were to change her oxygen tubing and clean the filter on her oxygen concentrator every Monday night. The electronic medical record (EMR), revealed on 03/23/21, R21 had an order for oxygen per nasal cannula as needed, change the tubing weekly every Monday. The order lacked when to clean the oxygen concentrator filter. On 03/30/21 at 03:01 PM, R21's oxygen concentrator filter had lint build-up present, her oxygen tubing had a date of 03/22/21 and was laying on top of the nightstand. There was not a storage bag for the cannula on the concentrator. R21 was resting on her bed. The staff were to change the nasal cannula on Monday, 03/29/21. On 03/30/21 at 03:02 PM, R21 stated that her cannula is usually placed on the bed, on the nightstand, or over the concentrator. She stated that she usually uses oxygen when she is in bed. On 03/31/21 at 02:14 PM, R21's oxygen concentrator filter continued to have lint buildup, and her nasal cannula continued to be dated 03/22/21. On 04/01/21 at 08:52 AM, R21 was resting in bed with the head of the bed slightly elevated and eyes closed with her oxygen in place. The oxygen tubing continued to be dated 03/22/21 and the oxygen concentrator filter continued to have lint build-up. On 4/01/21 at 11:59 AM, R21 was in the dining room for lunch, her nasal cannula was resting on the floor behind the oxygen concentrator in her room. On 04/01/21 at 12:57 PM, Certified Nurse Aide (CNA) O was placing a nasal cannula dated 03/30/21 on R21. On 04/01/21 at 12:58 PM, CNA O stated that she used the nasal cannula that was on top of her nightstand in the bag that it comes in and the date was already on the tubing. On 04/01/21 at 03:33 PM, CNA P stated that the Certified Medication Aides (CMA's) usually change out the oxygen cannulas on the night shift and the cannulas should be stored in a bag tied to the oxygen concentrator when not in use. On 04/05/21 at 11:42 AM, R21's oxygen concentrator filter continued to have lint build-up. On 04/05/21 at 05:04 PM, Licensed Nurse (LN) G stated the oxygen concentrator filter needs to be cleaned weekly with the oxygen tubing change, and the nasal cannula should be in a bag when not in use. On 04/05/20 at 05:20 PM, Administrative Nurse D stated the filters should be cleaned when the oxygen tubing is changed every week. The nasal cannulas should be stored in a bag when not in use. The facility policy, Oxygen Safety and Management, undated, indicated the equipment used for oxygen administration (nasal cannulas, mask, tubing), would be replaced every two weeks. The oxygen cannulas and masks should not be allowed to come in contact with the floor or other potentially dirty surfaces, and if it occurred, they should be replaced. The cannulas or masks should be stored in plastic bags to prevent contamination. The concentrator filters should be cleaned at least every two weeks with running water, allowed to air dry, and placed back in the concentrator. The facility failed to clean R21's oxygen concentrator filter, change the oxygen tubing per orders, and store the nasal cannula appropriately to prevent contamination.