**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 35 residents. The sample included 13 residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to prevent an incident of resident-to-resident abuse of Resident (R) 14, when R29 grabbed her knee, would not let go, and caused her knee to become reddened. This placed R14 at risk for injury and ongoing abuse. Findings included: - The Electronic Medical Record (EMR) for R14 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had moderately impaired cognition. R14 required partial assistance from staff for transfers, ambulation, personal hygiene, showers, and oral hygiene. R14 was independent with mobility and used a wheelchair. The Annual MDS, dated 04/18/25, documented R14 had moderately impaired cognition. R14 required substantial assistance from staff for showers, dressing, personal hygiene, transfers, and ambulation. R14 was independent with mobility and used a wheelchair. R14's Care Plan, dated 04/25/25, initiated on 05/05/25, directed staff to observe and notify the nurse for unexplained changes in mood, psychosocial status, or behavior. Staff were further directed to observe for increased confusion, odd/uncharacteristic behaviors, and changes in the amount of time spent with facility friends. The care plan further directed staff to observe R14 for increased anxiety, eating and dietary changes, tearfulness and crying episodes, and sleep disturbances. The Nurse's Note dated 02/17/25 at 01:46 PM documented that R14 was grabbed by R29, who had severely impaired cognition. R14 had been grabbed above the right knee. R14 had redness above the right knee but had no bruising noted. The Nurse's Note dated 02/17/25 at 02:09 PM documented R14 was removed from the situation, taken to her room, and assisted into her recliner. R14 stated she was fine and denied any pain. The EMR lacked documentation, further assessment, or any follow-up after the altercation. The EMR lacked documentation the nursing administration, family, or physician was notified of the resident-to-resident altercation. On 06/03/25 at 09:09 AM, Administrative Nurse D stated she was unaware of the resident-to-resident altercation. Administrative Nurse D stated staff are to tell her immediately when there is any type of altercation between residents so she could start the investigation. Administrative Nurse D further stated she would notify the physician and families of both residents and start an investigation. On 06/03/25 at 02:30 PM, R14 sat in her recliner, stated she was not afraid of any residents in the facility, and stated she received good care. On 06/03/25 at 12:40 PM, Certified Nurse Aide (CNA) M stated that on the day of the incident, she took R14 down the hall to her room to rest, which was down the South Hall. R14's room was at the end of the hall, and R29 was by the exit door, which was right next to R14's room. CNA M further stated that R14 told R29 hello, and R29 turned around quickly and grabbed R14's knee. R29 would not let go of R14's knee, and R14 stated, Ow, you're hurting me. CNA M stated she had to put her fingers under R29's hand so he would let go. CNA M stated that R29 left and propelled himself down the hallway. CNA M went to get the nurse to assess R14 because R14's knee was red but had no bruising. CNA M stated she talked to R14, about 30 minutes later, and there was slight redness to her knee but no bruising. CNA M stated that R29 did not have any further interaction with R14 that day or since that event. CNA M stated staff received abuse and behavior training at least yearly, and as needed. CNA M further stated that when a resident-to-resident altercation occurred, staff were trained to separate the residents and let the nurse know so the residents could be assessed for injury. On 06/04/05 at 08:35 AM, Social Service X stated she was unaware of the resident-to-resident altercation up until yesterday when Administrative Nurse D talked to her about it. Social Service X stated that she would have spent time with R14 to follow up and to see if she had any fears or concerns. Social Service X stated that she had not seen any changes in R14's behavior around the time of the incident or since. On 06/04/25 at 09:35 AM, Licensed Nurse (LN) G stated the CNA told her that R29 had grabbed R14 by the knee, so she went to R14's room to assess her for injury. LN G stated that R14's knee was a little red, but there was no bruising or any other injury. LN G stated she should have filled out an incident report and notified the administration per protocol but did not. LN G further stated she had notified the family but failed to document the conversation. LN G stated that staff received training on behaviors, and if there were any incidents, they had team huddles. The team would talk about the incident and discuss ways to prevent future incidents. The facility always had ongoing training for abuse and dementia with behaviors. LN G stated she passed information regarding the incident to the next shift, and R14 did not act afraid or concerned about the incident. On 06/04/25 at 10:00 AM, Administrative Nurse D stated she had reported the incident to the state agency. Administrative Nurse D stated she had taken the Abuse and Neglect policy around to the staff to do education and reminders of the protocol when there was any type of resident-to-resident altercation. The facility's Abuse and Neglect policy, dated 05/05/25, documented that all residents had the right to be free from neglect and abuse. Any person, including but not limited to physicians, professionals, practical nurses, social workers, or any other personnel who know or have reasonable cause to suspect that a resident has been abused, neglected, or exploited, shall immediately report it to the supervisor. The policy further stated that all incidents were investigated and may be reported to the state agency. If there was any resident-to-resident abuse, the resident must be protected from each other to prevent any occurrence. The facility's Resident to Resident Altercations undated policy documented that the goal was to keep residents and staff safe. The facility would do whatever possible to prevent and control resident-to-resident altercations to prevent mental, physical, sexual, and verbal abuse or exploitation of personal property from occurring, The Director of Nursing (DON) or designee would be immediately notified when a resident-to-resident abuse incident had occurred, and the primary care physician would also be notified. The Assistant Director of Nursing (ADON) or DON would immediately begin an investigation of the incident and would report the incident to the state reporting agency as required within two hours if a significant injury occurred or within 24 hours of the incident if no injury was found. The families of both residents involved would be notified of the incident, the result of the investigation, and the outcomes. All staff would be in-service annually and as needed for abuse, neglect, exploitation, and how to spot the warning signs of the resident-to-resident altercation to prevent incidents from occurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 35 residents. The sample included 13 residents, with three reviewed for abuse. Based on observation, record review, and interview, the facility failed to report to administration a resident-to-resident altercation for one resident, Resident (R) 14, when R29 grabbed her knee, would not let go, and caused her knee to become reddened. This placed R14 at risk for further injury and unidentified abuse or mistreatment. Findings included: - The Electronic Medical Record (EMR) for R14 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had moderately impaired cognition. R14 required partial assistance from staff for transfers, ambulation, personal hygiene, showers, and oral hygiene. R14 was independent with mobility and used a wheelchair. The Annual MDS, dated 04/18/25, documented R14 had moderately impaired cognition. R14 required substantial assistance from staff for showers, dressing, personal hygiene, transfers, and ambulation. R14 was independent with mobility and used a wheelchair. R14's Care Plan, dated 04/25/25, initiated on 05/05/23, directed staff to observe and notify the nurse for unexplained changes in mood, psychosocial status, or behavior. Staff were further directed to observe for increased confusion, odd/uncharacteristic behaviors, and changes in the amount of time spent with facility friends. The care plan further directed staff to observe R14 for increased anxiety, eating and dietary changes, tearfulness and crying episodes, and sleep disturbances. The Nurse's Note dated 02/17/25 at 01:46 PM documented that R14 was grabbed by R29, who had severely impaired cognition. R14 had been grabbed above the right knee. R14 had redness above the right knee but had no bruising noted. The Nurse's Note dated 02/17/25 at 02:09 PM documented R14 was removed from the situation, taken to her room, and assisted into her recliner. R14 stated she was fine and denied any pain. The EMR lacked documentation, further assessment, or any follow-up after the altercation. The EMR lacked documentation the nursing administration, family, or physician was notified of the resident-to-resident altercation. On 06/03/25 at 09:09 AM, Administrative Nurse D stated she was unaware of the resident-to-resident altercation. Administrative Nurse D stated staff are to tell her immediately when there is any type of altercation between residents so she could start the investigation. Administrative Nurse D further stated she would notify the physician and families of both residents and start an investigation. On 06/03/25 at 02:30 PM, R14 sat in her recliner, stated she was not afraid of any residents in the facility, and stated she received good care. On 06/03/25 at 12:40 PM, Certified Nurse Aide (CNA) M stated that on the day of the incident, she took R14 down the hall to her room to rest, which was down the South Hall. R14's room was at the end of the hall, and R29 was by the exit door, which was right next to R14's room. CNA M further stated that R14 told R29 hello, and R29 turned around quickly and grabbed R14's knee. R29 would not let go of R14's knee, and R14 stated, Ow, you're hurting me. CNA M stated she had to put her fingers under R29's hand so he would let go. CNA M stated that R29 left and propelled himself down the hallway. CNA M went to get the nurse to assess R14 because R14's knee was red but had no bruising. CNA M stated she talked to R14, about 30 minutes later, and there was slight redness to her knee but no bruising. CNA M stated that R29 did not have any further interaction with R14 that day or since that event. CNA M stated staff received abuse and behavior training at least yearly, and as needed. CNA M further stated that when a resident-to-resident altercation occurred, staff were trained to separate the residents and let the nurse know so the residents could be assessed for injury. On 06/04/05 at 08:35 AM, Social Service X stated she was unaware of the resident-to-resident altercation up until yesterday when Administrative Nurse D talked to her about it. Social Service X stated that she would have spent time with R14 to follow up and to see if she had any fears or concerns. Social Service X stated that she had not seen any changes in R14's behavior around the time of the incident or since. On 06/04/25 at 09:35 AM, Licensed Nurse (LN) G stated the CNA told her that R29 had grabbed R14 by the knee, so she went to R14's room to assess her for injury. LN G stated that R14's knee was a little red, but there was no bruising or any other injury. LN G stated she should have filled out an incident report and notified the administration per protocol but did not. LN G further stated she had notified the family but failed to document the conversation. LN G stated that staff received training on behaviors, and if there are any incidents, they have team huddles. The team would talk about the incident and discuss ways to prevent future incidents. The facility always had ongoing training for abuse and dementia with behaviors. LN G stated she passed information regarding the incident to the next shift, and R14 did not act afraid or concerned about the incident. The facility's Abuse and Neglect policy, dated 05/05/25, documented that all residents had the right to be free from neglect and abuse. Any person, including but not limited to physicians, professionals, practical nurses, social workers, or any other personnel who know or have reasonable cause to suspect that a resident has been abused, neglected, or exploited, shall immediately report it to the supervisor. The policy further stated that all incidents were investigated and may be reported to the state agency. If there was any resident-to-resident abuse, the resident must be protected from each other to prevent any occurrence. The facility's Resident to Resident Altercations undated policy documented that the goal was to keep residents and staff safe. The facility would do whatever possible to prevent and control resident-to-resident altercations to prevent mental, physical, sexual, and verbal abuse or exploitation of personal property from occurring, The Director of Nursing (DON) or designee would be immediately notified when a resident-to-resident abuse incident had occurred, and the primary care physician would also be notified. The Assistant Director of Nursing (ADON) or DON would immediately begin an investigation of the incident and would report the incident to the state reporting agency as required within two hours if a significant injury occurred or within 24 hours of the incident if no injury was found. The families of both residents involved would be notified of the incident, the result of the investigation, and the outcomes. All staff would be in-service annually and as needed for abuse, neglect, exploitation, and how to spot the warning signs of the resident-to-resident altercation to prevent incidents from occurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to provide services consistent with the standards of care for one of four residents reviewed for a urinary catheter (a tube inserted into the bladder to drain urine) or urinary tract infection (UTI). This placed Resident (R) 20 at risk for catheter-related complications and future UTIs. Findings included: - R20's Electronic Medical Record (EMR) documented R20 had diagnoses of benign prostatic hyperplasia (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency, and urinary tract infections) and a history of UTIs. R20's Quarterly Minimum Data Set (MDS), dated [DATE], documented R20 had short and long-term memory problems and severe cognitive impairment. The MDS documented R20 had a urinary catheter and no UTI during the observation period. R20's Care Plan, revised 03/19/25, documented the resident had a urinary catheter and instructed staff to provide catheter care twice a day and as needed (PRN) which included cleansing urinary meatus (opening on the penis which leads into the body) around the proximal end of the catheter. The care plan documented R20 was on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care). The plan instructed staff to monitor and record any signs or symptoms of UTI. A review of R20's clinical record revealed that R20 had a positive UTI on 03/22/24, 08/28/24, and 05/19/25. The clinical record revealed on 05/28/25, R20 had penis discharge which was positive for infection. On 06/03/25 at 11:00 AM, Licensed Nurse (LN) I and Certified Nurse Aide (CNA) N applied gloves, gown, and goggles, propelled R20 into his bathroom, and then used a sit-to-stand lift to transfer R20 from his wheelchair to the toilet. Once over the toilet, CNA N pulled down R20's pants, removed and discarded his incontinent brief, and provided catheter care, including his meatus. CNA N, with the same soiled gloves on, left the bathroom, touched the resident's leg, sit to stand lift, went to the dresser, touched each drawer, retrieved a new incontinent brief, and then returned to the bathroom. CNA N (with the same soiled gloves) touched the lift, and the resident's leg, when she entered the bathroom, placed a new incontinent brief on R20, and fastened a lift jacket on the resident's waist. CNA N went outside the R20's bathroom door, (with the same soiled gloves) touched the control handles of the lift, and used the lift control to raise R20. CNA N assisted LN I in transferring the resident to a wheelchair and touched his wheelchair arms, and R20's feet to place them off the footstand onto the floor. Then CNA N removed and discarded her gloves and gown in a trash can. On 06/03/25 at 11:15 AM, CNA N verified she had not changed her gloves after providing catheter care and stated she should have. On 06/04/25 at 11:21 AM, Administrative Nurse D stated she would expect staff to change gloves during catheter care whenever they go from dirty to clean. Upon request, the facility failed to provide a policy regarding changing gloves during catheter cares.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 35 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for one resident, Resident (R) 29. This placed R29 at risk for physical decline and fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move). Findings included: - The Electronic Medical Record (EMR) documented R29 had diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) type two, hypertension (high blood pressure), and constipation (difficulty passing stool). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had severely impaired cognition. R29 required substantial assistance from staff for showers, dressing, personal hygiene, transfers, and ambulation. R29 required partial staff assistance with toilet hygiene. R29 was frequently incontinent of bladder but was always continent of bowel. R29 was not on a bowel toileting program and did not have constipation. The Bladder and Bowel Assessment, dated 04/22/25, documented R29 had a diagnosis of constipation, was always continent of bowel and required assistance from staff with toileting. R29's Care Plan, dated 05/16/25, initiated on 10/17/24, documented R29 had a history of constipation and directed staff to notify the nurse by day three of no bowel movement to implement protocol for bowel management. The update, dated 11/04/24, directed staff to encourage fluid intake as tolerated, administer medication as ordered for constipation The Physician's Order, dated 11/04/24, directed staff to administer a Bisacodyl (laxative) suppository 10 mg rectally (by way of the rectum), every 24 hours, as needed for constipation. The Physician's Order, dated 01/23/25, directed staff to administer Senexon (a laxative), 8.6-50 mg, two tablets by mouth, at bedtime for constipation. The Physician's Order, dated 02/05/25, directed staff to administer MiraLax (a laxative), 17 grams (gms) by mouth daily, for constipation and hold for loose stools. R29's Bowel Monitoring Record, dated May 2024, documented R29 did not have a bowel movement for the following days: 05/25/25 - 05/30/25 (six consecutive days) R29's Medication Administration for May 2025 lacked documentation the staff provided interventions during the lack of bowel elimination on the above dates. On 06/03/25 at 08:34 AM, observation revealed R29, in the sit-to-stand mechanical lift, and his pajama pants were saturated with feces. R29 was angry and combative with the staff. Licensed Nurse (LN) H informed R29 that staff needed to get him into the bathroom to assist R29 with getting cleaned up. Further observation revealed R29 was taken to the bathroom and lowered onto the toilet. On 06/03/25 at 08:45 AM, LN H stated that R29 could be combative with care and required a lot of patience. LN H further stated that R29 had a history of constipation. Staff used the facility's standing orders as needed if R29 did not have a bowel movement after three days. On 06/03/25 at 9:09 AM, Administrative Nurse D verified that she was unable to find any interventions for R29 after he had not had a bowel movement for six days, and staff were to use the standing orders as needed. On 06/03/25 at 12:50 PM, Certified Nurse Aide (CNA) M stated they documented in the computer when a resident had a bowel movement and notified the nurse if the resident did not have one for three days. The facility's Standing Orders protocol dated 07/31/24, directed staff to use the standing orders as verbal orders and send them to the physician for signature. The standing orders directed staff to initiate Milk of Magnesia (MOM -a laxative), 1 oz, by mouth, every day, as needed, if no bowel movement after three days, and if no results administer Bisacodyl suppository, 10 mg, rectally, and if no results, administer a tap water or soap suds enema (stimulates the colon to have a bowel movement), and if no results contact the physician.

The facility had a census of 35 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop and implement an antibiotic stewardship policy to ensure the appropriate and effective use of antibiotics, reducing antibiotic resistance and improving patient outcomes. This placed the 35 residents who resided in the facility at increased risk of receiving an infection and/or negative effects of antibiotic use. Findings included: - On 06/04/25 at 09:37 AM, Administrative Nurse D verified the facility lacked an antibiotic stewardship policy. Administrative Nurse D stated the facility had a cyberattack on its computer system, which erased all the facility's policies. Administrative Nurse D stated she had been typing out one policy at a time to get them back, but had not gotten around to the antibiotic stewardship policy. Upon request, the facility failed to provide an antibiotic stewardship policy.

The facility had a census of 35 residents. The sample included 13 residents. Based on record review, and interview, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all residents who reside at the facility at risk for decreased quality of care. Findings included: - The Payroll Based Journal (PBJ-a required detail of staffing information submitted by nursing homes, provided by the Centers for Medicare and Medicaid Services (CMS)) documented that the facility lacked RN eight-hour coverage for the following days: 07/14/24 08/25/24 10/12/24 10/26/24 11/30/24 12/07/24 On 06/02/25 at 02:30 PM, Administrative Nurse D verified the above dates that there was not an RN in the long-term care. Administrative Nurse D stated that since they were attached to the hospital she thought they were able to have the RN from the hospital serve as their RN coverage. On 06/04/25 at 10:15 AM, Administrative Staff B stated she pulled staffing information from the timecard system to upload the information for the PBJ report. Administrative Staff B further stated that if there were any agency staff, she would get all the information required for the PBJ off the invoices. Administrative Staff B stated she thought the long-term care facility was able to use the RN from the hospital as coverage when they did not have an RN on duty. Upon request, a policy for PBJ was not provided by the facility.

The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the 35 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 06/02/25, a review of the noon meal consisted of a grilled pork burger on a bun, onion rings, corn, and no-bake cookies. On 06/02/25 at 10:30 AM, observation revealed Dietary Staff (DS) BB in the kitchen overseeing the preparation of the noon meal. On 06/01/25 at 07:50 AM, DS BB verified she was not a Certified Dietary Manager (CDM). DS BB stated she had enrolled and started the dietary certification classes. On 06/04/25 at 11:44 AM, Administrative Nurse D verified DS BB had no dietary manager certification but had enrolled and started the dietary certification classes. Upon request, the facility failed to provide a policy regarding a certified dietary manager.

The facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for the Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella and other waterborne pathogens). This placed the residents in the facility at risk for infectious disease. Findings Included: - On 06/04/25 at 10:05 AM, Maintenance Staff U stated he had a log pointing out weekly flushing places, but was unaware of any routine facility water management checks. On 06/04/25 at 11:20 AM, Administrative Staff D verified the facility lacked a system to check regarding standing water and potential growth inside the facility and lacked a system to mitigate the risk of Legionella. The facility's Water Management Program Policy, revised 02/18/19 documented that the facility would provide and maintain safe and healthy working conditions, equipment, and systems of work for all staff, patients, and visitors. To prevent the growth of Legionella, water services shall operate at the following temperatures: 1. Cold water distribution and storage at 20 degrees centigrade (C) (68 degrees Fahrenheit (F) or below. 2. Hot water distribution at least 50 degrees C (122 degrees F) attainable at taps within two minutes of running. 3. Hot water storage at 60 degrees C (140 degrees F). The policy documented staff would monitor and record cold water outlet temperature measured after allowing the water to run at full flow for one minute. Hot water outlet temperatures should be measured after allowing the water to run at full flow for one minute. The policy documented all areas would be monitored and water temperature at hot and cold outlets should be measured and recorded at least twice per year. The results would be recorded on a log sheet by maintenance personnel and all failures and large variations would be investigated. Sporadically used outlets should be flushed weekly by maintenance personnel.

The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to treat Resident (R) 25 with respect and dignity and failed to promote quality of life when staff performed an accucheck (blood sugar test) in a non-private area. This placed the resident at risk for impaired dignity. Findings included: - R25's Electronic Medical Record (EMR) recorded a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). On 09/18/23 at 11:49AM, observation revealed R25 sat in a recliner chair with her feet elevated in the living room. Further observation revealed Licensed Nurse (LN) G performed an accucheck on the resident while she was seated in the living room with six other residents also in the living room. When LN G completed the accucheck, she stated out loud your blood sugar is 123. On 09/18/23 at 12:10PM, LN G verified she should have taken R25 to a private area to perform the accucheck. On 09/20/23 at 07:50AM, Administrative Nurse D verified R25's accucheck should have been performed in a private area and not in the living room. The facility's Dignity policy, dated 2023, stated care for residents should be done in a manner and in an environment that maintains or enhances each resident's dignity/privacy with respect in full recognition of his/her individuality. The facility failed to provide dignity for R25, placing the resident at risk for embarrassment and an undignified experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to develop a comprehensive care plan to include Resident (R) 25's diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). This deficient practice placed the resident at risk for inappropriate care due to uncommunicated care needs. Findings included: - R25's Electronic Medical Record (EMR) documented she had diagnoses of diabetes mellitus. R25's Annual Minimal Data Set (MDS), dated [DATE], documented the resident had a Brief Interview of Mental Status (BIMS) score of five, which indicated severely impaired cognition. The MDS documented the resident was independently ambulatory and used a front wheeled walker for ambulation. R25 received insulin injections (hormone that lowers the level of glucose in the blood) seven days in the look back period. R25's medical record lacked a comprehensive care plan which addressed the use of insulin, signs of symptoms of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) and direction for the nursing staff to care for the resident with diabetes mellitus. On 09/18/23 at 01:30PM, observation revealed R25 ambulated with her front wheeled walker to the sunroom. On 09/19/23 at 02:45PM, Administrative Nurse E verified the facility lacked a care plan for R25's diabetes mellitus and use of insulin. On 09/20/23 at 07:50AM, Administrative Nurse D verified the facility lacked a care plan for R25's diabetes mellitus and use of insulin. The facility's Care Planning policy, dated 2023, stated each resident is to have a comprehensive care plan regarding individual needs and care provided for each resident. The facility failed to develop a comprehensive care plan for R25, placing her at risk for inadequate care due to uncommunicated care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents with one reviewed for pressure ulcers (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). Based on observation, record review, and interview, the facility failed to implement pressure reducing or offloading interventions to promote healing for Resident (R) 34, had a stage three (full thickness pressure injury extending through the skin into the tissue below) heel pressure ulcer. This placed the resident at risk for delayed healing, worsening of the wound, or additional pressure injuries. Findings included: - R34's Electronic Medical Record (EMR) documented R34 admitted to the facility 05/09/23. R34's EMR documented R34 had diagnoses of fracture of parts of lumbar sacral spine (lower back region of your spinal column or backbone) and pelvis (bones that connects the trunk and the legs), and had an unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcer on his back. R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had a Brief Interview of Mental Status score of five, which indicated severe cognitive impairment. The MDS documented R34 required total staff assistance with transfer, locomotion off the unit, dressing, toilet use and personal hygiene. He required extensive staff assistance with bed mobility, locomotion on the unit, and limited staff assistance with eating. The MDS documented R34 was at risk for developing a pressure ulcer, was on a turning/repositioning program, had a pressure reducing device for bed, and received nutrition or hydration interventions to manage skin problems; he received pressure ulcer /injury care. R34's Skin Integrity Care Plan, dated 05/19/23, instructed staff to encourage good nutrition and hydration for R34 in order to promote healthier skin. The care plan documented the resident had a history of pressure ulcer to areas on his back and buttock and instructed staff to apply treatment/ointment as order, reposition R34 every two hours, and treat pain as per orders prior to treatment/turning to ensure R34's comfort. R34's Activity of Daily Living (ADLs) Care Plan, revised on 08/21/23, documented R34 did not ambulate. R34 required two staff assistance with transfers using a sit to stand lift and required extensive staff assistance by one to two staff to turn and reposition in bed. R34's Pressure Ulcer Care Plan, revised on 08/21/23, documented R34 had a history of pressure ulcer to his lower back, and he had a pressure ulcer on his heel. The care plan instructed staff to assist R34 with turning/repositioning in bed at least every two hours, more often as needed (PRN) or requested. The plan directed R34 was seen by the wound care nurse for treatment of the pressure ulcer on his heel and instructed staff to see the Treatment Administration Record (TAR) for current treatment and recommendations. The Braden Scale, (scale for predicating risk for developing a pressure ulcer) dated 05/09/23, documented R34's score 12, which indicated R34 was at high risk for developing a pressure ulcer. The Skin/Wound Note, dated 05/15/23, documented R34's skin was intact. The Physician Order, dated 05/17/23, instructed staff to provide R34 with a house supplement with one scoop of protein powder, three times a day. The Skin/Wound Note, dated 05/22/23 at 02:09 PM documented staff removed the dressing from R34's mid lower back and the wound had dried red drainage. It measured 3.0 centimeters (cm) x 3.0 cm and had an open area measuring 10 cm long x 1.0 wide x 0.1 cm deep. The note documented staff covered the wound area with a band aid (adhesive bandage) dressing. The Skin/Wound Note, dated 08/07/23, documented R34 had an open, round area to his inner aspect of his right heel which measured 0.8 cm. The surrounding tissue was white. The wound measured 0.2 cm deep, with a small amount of drainage and was dark towards the toe. The wound had no odor. R34 complained of pain to touch, and the wound nurse was consulted. The Wound Consult Note, dated 08/09/23 at 2:30 PM, documented R34 presented to the wound clinic for an ulcer to his right heel which was likely a prior deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) that evolved into a stage three pressure injury. The note documented the wound nurse performed debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) to remove the non-viable tissue around the wound margins; no bleeding was produced. R34 tolerated the procedure with no complaints. The note documented the pressure ulcer measured 1 cm long x 0.8 cm wide x 0.2 cm deep. The wound nurse applied Xeroform (sterile non-adhering fine mesh gauze treated with a bacteriostatic agent) to the wound bed, covered with a cloth strip dressing and reinforced with cloth medical tape. The note documented the dressing would be changed on Monday, Wednesday, and Friday and R34 should follow up with wound care nurse weekly until healed. The Physician Order, dated 08/16/23, instructed staff to provide R34 with four ounces (oz) of Arginaid (a nonprescription nutritional drink that supplies the amino acid L-arginine along with vitamin C and E) three times a day with meals. The Wound Consult Note, dated 08/16/23, documented R34's night medial heel pressure ulcer was yellow, had a small amount to serosanguineous (semi-thick blood-tinged drainage), and no odor. The surrounding tissue color had erythema (abnormal redness of skin): the surrounding tissue was dry, and the wound status was unchanged. The note documented the wound nurse debrided the wound and R34 had pain with the debridement The note documented the wound nurse wrapped the wound with petroleum gauze. The Wound Consult Note, dated 09/13/23, documented R34's right medial heel pressure ulcer had no drainage, and the wound nurse was unable to chart what the dressing looked like due to facility staff had removed it prior to her arrival to the facility. The note documented the same treatment was used. The Physician Order, dated 09/20/23 instructed staff to administer to R34 a multivitamin one time a day for wound healing. On 09/19/23 at 01:16 PM, observation revealed R34 sat in a wheelchair with gripper socks on, covered by sheep skin heel protector. Licensed Nurse (LN) I removed the protectors and sock revealing an area on R34's inner right heel, approximately 0.4 cm x 0.2cm with a black scab in the middle of the wound, The surrounding tissue was dry, peeling, and pink. Further observation revealed when LN I touched the black scab area, R34 pulled back his foot and stated, that hurts. LN I verified R34 developed the pressure ulcer in the facility. LN I stated it was a stage three pressure ulcer. LN I stated she was unaware why staff placed the sheep skin heel protector on R34's right medial heel pressure ulcer because it was not an effective pressure relieving device. LN I stated maybe staff were using it to make the resident more comfortable. Further observation revealed R34's family member entered the room and LN I stated she was worried about R34 having pain when she touched the scabbed area of the wound and would like to get an x-ray of the area. LN I did not provide pressure ulcer care to the area, and left the room at that time. On 9/19/23 at 02:12 PM, LN I stated she saw the resident in outpatient at hospital for wound care, and staff would bring him after his shower. She stated R34 never presented to with the sheep skin pressure ulcer protector. She said 09/19/23 was the first time she saw the sheep skin protector on R34's heel, and stated it was not an appropriate pressure relieving device. LN I stated she would tell Administrative Nurse D that it was not appropriate. LN I stated she would recommend heel protector boots for other residents but not for R34 due to the fact he was pretty well mobile and could reposition his legs himself. On 09/19/23 at 02:40PM, Administrative Nurse D verified when R34 was admitted , R34's interventions implemented to prevent him from developing pressure ulcers only included monitoring and repositioning every two hours and as needed. Administrative Nurse D acknowledged no pressure reducing or offloading was implemented once the pressure injury was identified on R34's heel and stated staff only put in additional interventions to prevent pressure ulcers if the physician ordered them or if LN I ordered an intervention. Administrative Nurse D stated she felt like the interventions were appropriate due to the resident could move his legs around in bed and propel his wheelchair. The facility's Pressure Ulcer Policy, revised 2022, documented the facility would identify at risk individuals needing prevention and specific factors placing them at risk. Upon admission from acute care, guidance would be followed according to admission orders for continued therapies. The interdisciplinary team would be notified so they may develop a relevant care plan to include prevention and management interventions' with measurable goals. The facility failed to implement interventions consistent with the standard of care, including offloading and/or pressure reducing boots to promote healing for R34's stage three medial heel pressure ulcer. This also placed R34 at risk for additional pressure ulcer injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The electronic medical record (EMR) for R19 documented diagnoses of hypertension (HTN- elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), and syncope (fainting or passing out). The admission Minimum Data Set (MDS) dated [DATE] documented R19 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. R19 walked with a walker in room but required extensive assistance of one staff for locomotion off the unit. R19 was independent with cares with assist. R19 received insulin (hormone that lowers the level of glucose in the blood), an antidepressant (class of medications used to treat mood disorders), an anticoagulant (class of medication used to thin the blood and prevent clotting), and a diuretic (medication to promote the formation and excretion of urine) seven of seven days during the look back period. The Quarterly MDS dated 09/04/23 for R19 documented a BIMS score of 12 which indicated moderately impaired cognition. R19 required limited assist of one staff with activities of daily living (ADLs). R19 received insulin, an antidepressant, an anticoagulant, and diuretic seven of seven days during the look back period. The ADL Care Area Assessment (CAA) dated 06/07/23 documented R19 required assist as needed with ADLs. The Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) Care Plan initiated for R19 directed to administer medications as ordered. Staff was to monitor and document for side effects and effectiveness. The Order Summary for R19 documented a physician's order dated 05/25/23 for metoprolol (beta-blocker medication used to treat lower blood pressure and pulse rate) 50 milligrams twice daily for hypertension. Review of R19's Medication Administration Record (MAR) and clinical record revealed that R19's pulse was not monitored prior to administration of the metoprolol. The CP Monthly Medication Review (MMR) from May 2023 to August 2023 revealed the pharmacist did not identify and report to the facility and physician the lack of pulse monitoring prior to metoprolol administration. On 09/19/23 at 08:15 AM R19 sat in his wheelchair and self-propelled himself back to his room. On 09/20/23 at 07:19 AM Administrative Nurse D stated the CP had access to all the resident's charts and reviewed the medical records monthly and would make the recommendations she identified and those would be sent to the physician for review. Administrative Nurse D stated that when an antihypertensive medication was entered into the MAR it should flag the individual entering the medication to enter the parameters for monitoring a pulse or blood pressure. Administrative Nurse D stated this must have been inadvertently omitted. On 09/21/23 at 09:29 AM Consultant GG stated that she did review the resident's medication orders, administration record, and labs monthly and would make recommendations on irregularities she had noted. Consultant GG stated she did make recommendations for medications that lacked a required pulse or blood pressure monitoring. Consultant GG stated she must have overlooked that for R19 and would make that recommendation during her next review. The Drug Regimen Review policy dated 2023 documented: a pharmacist contracted by the facility will review each resident medical record during each monthly or routine drug regimen review. The drug regimen review will identify medications used without adequate monitoring. The facility failed to ensure the CP identified and reported the lack of pulse monitoring prior to metoprolol administration for R19. This placed R19 at risk for unnecessary medication administration and possible adverse side effects. The facility had a census of 34. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the consultant pharmacist (CP) identified and reported the lack of a stop date for Resident (R) 34's as needed (PRN) psychotropic (altering mood or thoughts) medication. The facility further failed to ensure the CP identified and reported the lack of pulse monitoring prior to administration of R19's metoprolol (blood pressure medication). This placed the resident at risk for unnecessary medication side effects. Findings included: - R34's Electronic Medical Record (EMR) documented the resident had diagnoses psychotic disturbance (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mood disturbance and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had a Brief Interview of Mental Status score of five, which indicated severe cognitive impairment. The MDS documented R34 required total staff assistance with transfer, locomotion off the unit, dressing, toilet use and personal hygiene. He required extensive staff assistance with bed mobility, locomotion on the unit, and limited staff assistance with eating. The MDS documented R34 received an antianxiety (class of medications that calm and relax people) daily during the look back period. R34's Antianxiety Medication Care Plan, revised on 08/21/23, instructed staff to monitor, document, and report any adverse reactions R34 had to his antianxiety therapy. The Physician Order, dated 08/15/23, instructed staff to administer R34 Ativan, 0.25 milligram (mg), PRN every 12 hours for anxiety disorder. The order lacked a stop date. The Pharmacy Regimen Review, dated 08/23/23 documented no irregularities. On 09/18/23 at 03:46 PM, observation revealed R34 sat quietly in a wheelchair at music activity. On 09/19/23 at 02:40 PM. Administrative Nurse D verified the facility's CP failed to identify and report R34's physician order for Ativan PRN without a stop date. Administrative Nurse D stated it should have a stop date. The facility's Drug Regime Review Policy, revised 2023, documented the consultant pharmacist would perform a drug regimen review on each elder living in this facility and at least monthly. The pharmacist contracted by the facility would review each resident medical record during each monthly or routine drug regime review which included inappropriate use of as needed (prn) antipsychotic medications The facility failed to ensure the CP identified and reported the lack of a stop date for R34's PRN psychotropic medication. This placed the resident at risk for unnecessary medication side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 34 residents. The sample included 12 residents with five residents sampled for unnecessary medications. Based on observation, record review, interview, the facility failed to ensure nursing staff monitored a pulse prior to administering Resident (R) 19 metoprolol (a beta-blocker medication used to treat and lower blood pressure and pulse rate). This placed R19 at risk for unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R19 documented diagnoses of hypertension (HTN - elevated blood pressure), atrial fibrillation (rapid, irregular heartbeat), and syncope (fainting or passing out). The admission Minimum Data Set (MDS) dated [DATE] documented R19 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. R19 walked with a walker in room but required extensive assistance of one staff for locomotion off the unit. R19 was independent with cares with assist. R19 received insulin (hormone that lowers the level of glucose in the blood), an antidepressant (class of medications used to treat mood disorders), an anticoagulant (class of medication used to thin the blood and prevent clotting), and a diuretic (medication to promote the formation and excretion of urine) seven of seven days during the look back period. The Quarterly MDS dated 09/04/23 for R19 documented a BIMS score of 12 which indicated moderately impaired cognition. R19 required limited assist of one staff with activities of daily living (ADLs). R19 received insulin, an antidepressant, an anticoagulant, and diuretic seven of seven days during the look back period. The ADL Care Area Assessment (CAA) dated 06/07/23 documented R19 required assist as needed with ADLs. The Black Box Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) Care Plan initiated for R19 directed to administer medications as ordered. Staff was to monitor and document for side effects and effectiveness. The Order Summary for R19 documented a physician's order dated 05/25/23 for metoprolol 50 milligrams twice daily for hypertension. Review of R19's Medication Administration Record (MAR) and clinical record from May 2023 to September 2023 revealed that R19's pulse was not monitored and recorded prior to administration of metoprolol. On 09/19/23 at 08:15 AM R19 sat in his wheelchair and self-propelled himself back to his room. On 09/19/23 at 07:40 AM Licensed Nurse (LN) H stated that R19's stated that a pulse should be obtained prior to metoprolol administration. LN H stated it looked like pulse for R19 was not being monitored but it should be. On 09/20/23 at 07:19 AM Administrative Nurse D stated that when a blood pressure medication was entered into the MAR it should flag the individual entering the medication to enter the parameters for monitoring a pulse or blood pressure. Administrative Nurse D stated this must have been inadvertently omitted on R19's MAR. The Medication Administration & Documentation policy revised 2023 documented: for residents on pulse altering medications, pulses will be obtained before medication administration and charted on EMAR under the supplementary documentation medication. The medication will be held if pulse was below 50. The facility failed to ensure that staff monitored R19's pulse prior to administration of metoprolol. This placed R19 at risk for unnecessary medication administration and possible adverse side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 34 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to place a stop date on an as needed (prn) psychotropic (medication used to treat mental health disorders) medication for Resident (R) 34. This placed the resident at risk for unnecessary medications and related complications. Findings included: - R34's Electronic Medical Record, (EMR) documented the resident had diagnoses psychotic disturbance (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), mood disturbance and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). R34's Quarterly Minimum Data Set (MDS), dated [DATE], documented R34 had a Brief Interview of Mental Status score of five, which indicated severe cognitive impairment. The MDS documented R34 required total staff assistance with transfer, locomotion off the unit, dressing, toilet use and personal hygiene. He required extensive staff assistance with bed mobility, locomotion on the unit, and limited staff assistance with eating. The MDS documented R34 received an antianxiety (class of medications that calm and relax people) daily, during the look back period. R34's Antianxiety Medication Care Plan, revised on 08/21/23, instructed staff to monitor, document, and report any adverse reactions R34 had to his antianxiety therapy. The Physician Order, dated 08/15/23, instructed staff to administer R34 Ativan, 0.25 milligram (mg), PRN every 12 hours for anxiety disorder without a stop date. The Pharmacy Regimen Review, dated 08/23/23 documented no irregularities. On 09/18/23 at 03:46 PM, observation revealed R34 sat quietly in a wheelchair at music activity. On 09/19/23 at 02:40 PM. Administrative Nurse D verified R34's physician order for Ativan PRN without a stop date. Administrative Nurse D stated it should have a stop date, staff must have missed it. The facility's PRN Medication Administration Policy, revised 2023, documented review of controlled medications after 14 days of use if stop date is not indicated on the original order. The facility failed to obtain from the physician a stop date for R34's PRN psychotropic medication. This placed the resident at risk for unnecessary medication side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 34 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure communication and collaboration between the facility and hospice provider which included a description of the services, medication, and equipment provided to Resident (R)21. This deficient practice created a risk for missed opportunities for services and delayed treatment. Findings included: - The electronic medical record (EMR) for R21 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion), major depressive disorder (a major mood disorder which causes persistent feelings pf sadness), and convulsions (a sudden, violent, irregular movement of a limb or of the body). The Significant Change Minimum Data Set (MDS) dated [DATE] for R21 documented she had both short and long-term memory problems and had severely impaired cognitive skills for daily decision making. R21 required extensive to total assistance of one to two staff for activities of daily living (ADLs). R21 was on hospice services. The Quarterly MDS dated [DATE] documented R21 had both short and long-term memory problems and had severely impaired cognitive skills for daily decision making. R21 required total dependence from staff for ADLs. R21 required hospice services. The Cognitive Loss Care Area Assessment (CAA) dated 04/08/23 documented R21 was on hospice. The Hospice Care Plan initiated 04/14/23 for R21 directed staff that hospice will provide supplies to manage incontinence, and medications to manage her diagnosis. The care plan directed staff that a hand brace/wash cloth roll was used as needed to extend R21's hand per her comfort. The care plan directed staff that R21 would be seen by hospice and nursing staff would update hospice of all conditional changes. This care plan was resolved 09/17/23, yet R21 still remained on hospice services as of 09/19/21. The care plan lacked staff direction on who the hospice provider was and the contact information. The care plan lacked how often hospice personnel would provide services/visit R21 at the facility. The care plan lacked direction on medications, equipoment, and other suplpies and services provided by hospice. The Orders tab for R21 recorded a physician's order dated 03/29/23 to admit R21 to hospice. A Hospice Admission was completed by the physician on 03/29/23. A Hospice Plan of Care was initiated by the hospice provider. On 09/19/23 at 09:16 AM R21 sat reclined in her Geri-chair (a recliner on wheels that can be pushed around like a wheelchair, usually with a removable tray);she had splint on her right hand, and was propelled by staff from dining room to commons area to watch tv. On 09/19/23 at 02:25 PM Administrative Nurse E stated hospice provided a book available for the family and staff that listed in detail about the hospice services but was not resident specific. Administrative Nurse E stated the hospice plan of care and other documents related to hospice had been scanned into R21's EMR that listed the medications, supplies and hospice visits for R21 so she did not think that the facility needed to care plan that information on R21's facility care plan. On 09/19/23 at 03:12 PM Administrative Nurse D stated that upon admission to hospice the facility received the hospice records for R21 but did not go that in depth on what was provided by hospice in R21's individual care plan as staff was told upon admission to hospice what supplies were provided, and the hospice supplies were kept separate from the facilities supplies. Administrative Nurse D stated she was not aware that all the hospice provider information, supplies and when the hospice nurse needed to be in the facility maintained care plan but said that would make sense so new staff or agency staff would be aware of what was provided by the hospice service. The Hospice policy dated 2023 documented the facility will coordinate care planning with the hospice provider including all services and supplies provided by the hospice provider including: nursing services, nurse aide services, social services, chaplaincy services, durable medical equipment, medications, and grief support to family member. The facility failed to ensure communication and collaboration between the facility and the hospice provider which included a description of the services, medication, and equipment provided to R21 by hospice. This deficient practice created a risk for missed opportunities for services and delayed treatment.

The facility had a census of 32 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to cover clean linens and/or clothing when delivering to resident rooms and failed to review or update infection control policies annually. This deficient practice placed the residents at increased risk for infection. Findings included: - On 05/25/22 at 08:15 AM, observation revealed laundry staff wheeled an uncovered cart of residents' clean clothing to the west hall. On 05/25/22 at 08:15 AM, Administrative Nurse D stated laundry staff did not use covers for the clean clothes but did for towels. On 05/25/22 at 08:18 AM, Laundry Staff U verified staff were to cover laundry carts when transporting clothing through the facility. She stated prior to and during the Covid (contagious respiratory infection) emergency, staff covered the carts. Laundry Staff U stated she was told covering the carts of clean linens was no longer required The facilities policies related to infection control were dated and/or last revision date: Infection Prevention and Control Plan- 2020 Antibiotic Stewardship Program- 10/19/17 Influenza and Pneumococcal Vaccines- 01/18/18 Covid 19 Procedures 08/2020 On 05/24/22 at 03:40 PM, Administrative Nurse D verified the policies were not updated or reviewed annually and acknowledged they should have been. The facility's Infection Prevention and Control Plan, dated 2020, documented the written infection prevention and control plan would be reviewed at least annually and updated as needed. The policy documented all staff were responsible for being knowledgeable and compliant with infection control policies and procedures. The facility failed to cover clean resident laundry when delivering clothing to resident rooms and failed to review or update infection control policies annually. This placed the residents at increased risk for infections.