Based on interview, record review, and review of the facility's policy, the Map 14 form, the facility failed to protect the resident's rights to privacy in communications, including the right to receive mail unopened for 1 of 13 residents who attended the Group Interview (Resident (R) 40). R40 received an opened letter addressed to him from the Kentucky Public Pensions Authority. The findings include: Review of the facility's policy, titled Resident Rights, revised 11/01/2024, revealed its purpose was to protect and promote the rights of each resident. Per policy, each resident has a right to personal privacy, including the right to privacy in oral, written, and electronic communications and the right to receive mail unopened. Review of the facility's policy, titled Breathitt Health and Rehab Clinical Standard and Guidance Postal Services/ Mail Guideline, revealed its purpose was to ensure the facility protected the resident's rights to communication with individuals within and externally to the facility. Per policy, each resident has the right to send and promptly receive unopened mail, letters, and packages delivered by the USPS (United States Postal Service) and other authorized delivery services/carriers. Only if directed by the resident or the resident's Power of Attorney would any mail or package be opened by staff. During a Group Interview Meeting, conducted by the State Survey Agency Representative, on 02/04/2025 at 2:49 PM, R40 complained he had received a letter addressed to him that had been opened by facility staff. Review of R40's Electronic Medical Record (EMR), revealed a Quarterly Minimum Data Set (MDS) Assessment, dated 09/16/2024. Per the MDS, the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Review of R40's EMR, revealed no documented evidence R40 was informed his mail would be opened nor was this documented in the resident's Care Plan. Review of the Map 14-Commonwealth of Kentucky Cabinet for Health and Family Services Department for Medicaid Services Authorized Representative, revised 10/2021, revealed R40 signed this consent form, allowing the Business Manager to apply, report changes, recertify, and receive a copy of notices for his Medicaid eligibility. During interview with R40, on 02/05/2025 at 11:40 AM, the resident stated the facility's Business Manager opened and read a letter from the Kentucky Public Pensions Authority which was addressed to him (R40). R40 stated the Business Manager stopped him outside her office and told him about the letter's contents. He further stated he had not given the Business Manager permission to open this letter. In continued interview, R40 stated he had been excited to receive this letter, and it upset him that he did not get to experience reading the content himself. R40 stated, staff reading his letter made him feel like he didn't exist. Review of R40's letter from the Kentucky Public Pensions Authority, revealed the letter was addressed to R40. During an interview with the Business Manager, on 02/05/2025 at 11:36 AM, she stated she had opened R40's letter which was addressed to R40 from the Kentucky Public Pensions Authority. She stated she thought R40 granted her permission to open his mail from the Kentucky Public Pensions Authority when he signed the Map 14 form. During an interview with the Administrator, on 02/06/2025 at 2:30 PM, she stated she expected all residents to receive unopened mail to protect their right to privacy in communication. The Administrator stated the Business Manager should only open the resident's mail if the letter was addressed to the business office or if the resident had given permission to open the mail.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) of 19 sampled residents (Resident (R)7, R28, and R50). 1. Observation on 02/02/2025 at 6:00 PM, revealed Certified Nursing Assistant (CNA)7 failed to don (put on) Personal Protective Equipment (PPE) prior to providing care for R7 who was on Enhanced Barrier Precautions (EBP). Additionally, CNA7 failed to wash or sanitize hands upon exiting R7's room after providing care. 2. Observations on 02/02/2025; 02/03/2025; 02/05/2025; and 02/06/2025, revealed R28's urinal was not labeled with the resident's name, nor was it dated or covered. R28's urinal was either lying on the floor or hanging from the rail in the bathroom. 3. Observation on 02/03/2025 at 9:47 AM, revealed R50's bathroom had two (2) unlabeled, undated, uncovered urinals on the back of the commode, and an uncovered bedpan. The findings include: Review of the facility's policy, titled Enhanced Barrier Precautions (EBP), dated 03/08/2024, revealed the EBP policy was implemented to reduce the transmission of multidrug-resistant organisms (MDROs) within the facility. EBP would be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities. Further review revealed high contact care activities included assisting with providing hands on care. 1. Review of R7's Face Sheet in the Electronic Medical Record (EMR), under the clinical information tab, revealed the facility admitted the resident on 09/12/2024 with diagnoses including lack of coordination and failure to thrive. Review of R7's Physician's Orders dated 10/10/2024, revealed orders for Enhanced Barrier Precautions (EBP- infection control intervention designed to reduce transmission of multidrug-resistant organisms) related to a history of Methicillin-resistant Staphylococcus aureus (MRSA) found in the wound. EBP included wearing the appropriate Personal Protective Equipment (PPE) which included a disposable gown and gloves. Observation on 02/02/2025 at 6:00 PM, revealed an orange dot at R7's door which meant the resident was on EBP. Additionally, there was a sign on the door that stated Enhanced Barrier Precautions. Further observation revealed there was a cart at the door which contained boxes of gloves and disposable gowns. During observation of dinner meal pass on 02/02/2025 at 6:00 PM, Certified Nursing Assistant (CNA)7 failed to don Personal Protective Equipment (PPE) prior to entering R7's room with a meal tray. CNA7 proceeded to lower the head of the bed and assist the resident up higher in the bed by holding the resident under her shoulder while the resident bent her knees and pushed herself up. After assisting R7 up higher in the bed, CNA7 failed to wash or sanitize her hands upon exiting the room. CNA7 then proceeded to the beverage cart outside of R7's room in the hallway to obtain water and orange juice for R7. CNA7 was observed going back into R7's room without donning PPE and proceeded to assist the resident with her dinner tray. During an interview with CNA7, on 02/05/2025 at 9:22 AM, she stated if PPE was not donned appropriately for Enhanced Barrier Precautions (EBP), it placed the resident, other residents and staff at risk for spread of infection. CNA 7 stated all residents on EBP should not be touched by staff unless staff was wearing gloves and a disposable gown. CNA7 stated, she always tried to don appropriate PPE prior to entering R7's room and she knew she should wash or sanitize her hands upon exiting the room. She stated, I must have been in a hurry. I would never put any of my residents at risk for getting an infection or bacteria. During interview with Registered Nurse (RN) 1, on 02/02/2025 at 6:18 PM, she stated all staff had been educated on infection control policies and an orange dot on the resident's room number indicated the resident was on EBP. RN 1 stated all staff should be aware they were to don the appropriate PPE before providing any type of care for residents on EBP. RN1 stated she monitored as she was going down the halls and if staff was identified not wearing appropriate PPE, she would immediately educate them. The RN stated the Director of Nursing (DON) completed daily rounds for infection control measures as well. During an interview, on 02/05/2025 at 1:46 PM, the Director of Nursing/Infection Preventionist (DON/IP), stated she expected nursing staff to follow the facility's policies regarding PPE and EBP. The DON/IP stated if she ever saw any staff not following proper infection control procedures, she would immediately provide them education on what they did wrong and the corrective actions needed. The DON/IP stated following infection control policies and procedures for a resident on EBP was important in order to prevent other residents or staff from being exposed. Further, she stated it was important to use good hand hygiene after providing care, and upon exiting a resident's room. The DON/IP further stated she had been the DON and IP for almost five (5) years. She stated she tried to make daily rounds and educate staff regarding infection control procedures as needed. 2. Review of the facility's policy, titled Bedpan/Urinal, Offering/Removing, undated, revealed per the general guidelines, bedpans and/or urinals were required to be labeled with the resident's name and would be stored in a clean and dignified manner. Continued review revealed bedpans or urinals would not be left in the bathroom or on the floor. During the initial tour of the facility, on 02/02/2025 at 2:40 PM, there was a urinal which was not labeled with R28's name, was not dated, and was uncovered. The urinal was sitting on the floor next to R28's bed, which was out of reach for the resident. Interview with R28 on 02/02/2025 at 2:40 PM, revealed staff assisted him with using the urinal so he would not have placed the urinal on the floor. Further interview revealed the resident required staff to check his brief as he was sometimes incontinent. Review of R28's Quarterly Minimum Data Set (MDS), dated 11/07/2024, located in the electronic medical record, revealed the facility assessed the resident as having a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. Continued review revealed the facility assessed R28 as being frequently incontinent of bladder. Observations on 02/02/2025 at 5:16 PM; 02/03/2025 at 10:15 AM; 02/05/2025 at 2:43 PM; and 02/06/2025 at 9:23 AM, revealed R28's urinal was unlabeled with the resident's name, undated, and uncovered on the floor or hanging from the rail in the bathroom. During interview with CNA5, on 02/02/2025 at 2:58 PM, she stated R28 was totally dependent on staff for toileting and was not able to place the urinal on the floor. CNA5 stated she was not sure who placed the urinal on the floor, but it had to be a staff member. CNA5 stated she had been trained on bedpans and urinals and both were to be labeled with the resident's name, dated and stored in a bag to prevent the spread of bacteria. The CNA stated urinals were not to be placed on the floor per the facility's policy. During interview with Registered Nurse (RN)1, on 02/02/2025 at 3:14 PM, she stated urinals were to be labeled with the resident's name, dated and placed in a bag and kept in the bathroom unless the resident had a preference of keeping it on a bedside table for easier reach. However, RN1 stated R28 was totally dependent for urinary needs and would not be able to use the urinal independently. She stated it was an infection control issue if the urinals weren't labeled with the resident's name, dated and bagged as it could spread bacteria to not only that resident but to another resident. 3. During observation on 02/03/2025 at 9:47 AM, R50's bathroom had two (2) urinals which were unlabeled with the resident's name, undated, and uncovered sitting on the back of the commode. Additionally, there was an uncovered bedpan on the back of the commode. During an interview on 02/05/2025 at 1:46 PM with the Director of Nursing/Infection Preventionist (DON/IP), she stated the urinals should be labeled with resident's name, dated, bagged, and stored per facility policy. She stated the urinals should be stored per the resident's preference. The DON/IP stated she made daily rounds. However, she did not go into residents' bathrooms during those rounds. She stated it was an infection control issue if urinals and bed pans were not labeled, dated and bagged as it could potentially cause the spread of bacteria which could lead to urinary tract infections. She stated all nursing staff was responsible for making sure the policy was followed. During an interview, on 02/06/2025 at 2:32 PM, with the Administrator, she stated general hand washing was number one, and donning PPE as indicated was expected of all staff. She stated she left it to her clinical management to make rounds to ensure there were no infection control concerns. She stated she expected all staff to follow the facility's infection control policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policies, the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Dietary staff failed to check six (6) of 12 food temperatures on the steam table during the dinner meal on 02/02/2025. Additionally, dietary staff failed to discard eight (8) expired food items. The findings include: 1. Review of the facility's policy titled, Food & Beverage Temperature Control, undated, revealed food and beverage temperatures were checked and recorded prior to meal service. Further review revealed all staff would ensure residents received safe food served at acceptable temperatures. Observation on 02/02/2025 at 5:07 PM, revealed Cook1 failed to check the food temperatures for the mashed potatoes, beef goulash, pureed green beans, pureed rice, pureed bread, and pureed beef goulash on the steam table prior to serving the dinner meal. During an interview with Cook1, on 02/02/2025 at 5:07 PM, she stated she only checked the temperature of the foods on the main steam table, not the pureed foods. 2. Review of the facility's policy titled,Food Safety, undated, revealed food or beverage items that had exceeded the manufacturer's expiration date would be discarded. Observation on 02/02/2025 at 2:02 PM, revealed seven (7) expired food items in the walk-in refrigerator and one (1) expired food item in the pantry. The expired food items in the walk-in refrigerator included Dill Pickle Chips with an expiration date of 12/24/2024; Less Sodium Soy Sauce with an expiration date of 12/20/2024; another Less Sodium Soy Sauce with no lid with an expiration date of 06/2021; Wishbone Zesty [NAME] Italian Dressing with an expiration date of 03/10/2024; Worcestershire Sauce with an expiration date of 12/24/2024; and two (2) bottles of Lemon Juice with expiration dates of 08/24/2024 and 12/12/2024. Observation of the pantry revealed one (1) pack of flour tortillas in saran wrap that was hardened with a date of 07/16/2024 and 07/19/2024 handwritten on the saran wrap. During interview with the Dietary Manager, on 02/04/2025 at 1:07 PM, she stated all food served to residents should have a temperature check prior to serving. The Dietary Manager further stated if the food was not the correct temperature it could cause the residents to become sick. Continued interview revealed it was all dietary staff's responsibility to check the pantry, freezers, and refrigerators for expired food. During an interview with the Administrator, on 02/06/2025 at 2:32 PM, she stated checking the temperature of all foods prior to serving should be part of the dietary staff's routine. She further stated it was important to check food temperatures at the steam table prior to serving because if the food temperatures were not the correct temperatures, this could lead to foodborne illnesses for the residents. The Administrator stated there should not be any expired food in the kitchen as expired food could possibly cause residents to become sick.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy it has been determined the facility failed to provide two (2) of thirty-one (31) sampled residents with reasonable accommodations to meet resident needs. Resident #64 was observed to have the call light on the floor on all observations made during the survey. Resident #37 was observed to have the call light placed out of reach and inaccessible. The findings include: The facility did not have a policy regarding call lights. Review of Resident #64's medical record revealed the facility admitted the resident on 08/14/17 with diagnoses of Hemiplegia, Contracture of the left hand, Muscle Weakness, and Abnormality of Gait. Review of Resident #64's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. The MDS also revealed the resident required extensive assistance of two (2) or more persons to transfer from bed to chair, and for toileting and bathing. Further review of the MDS revealed the resident required extensive assistance of one (1) or more persons for personal hygiene. Observation of Resident #64 on 06/05/18 at 3:12 PM revealed the resident's call light was on the floor and out of the resident's reach. The resident stated she could reach it with the hairbrush. Observation of Resident #64 on 06/06/18 at 9:33 AM revealed the resident was lying in bed and the resident's call light was observed on the floor. Observation of Resident #64 on 06/06/18 at 10:14 AM revealed the resident was awake and the resident's call light remained on the floor. An interview with the resident revealed if the resident needed help or assistance, I guess I would have to fall out of the bed. Further interview with the resident revealed he/she had heard the facility's announcement for a smoke break, but was not able to let them know that he/she wished to smoke. The surveyor asked staff to take the resident for a smoke break. Observation of Resident #64 on 06/07/18 at 8:34 AM and 9:27 AM revealed the resident was in bed and the resident's call light was on the floor, out of the resident's reach. Interview with State Registered Nurse Aide (SRNA) #4 on 06/07/18 at 9:55 AM revealed staff should monitor a resident's access to call lights every time they enter the room and during rounds. Interview with SRNA #5 on 06/07/18 at 10:02 AM revealed residents should be assessed to ensure they have access to their call light every time staff round on the residents. The surveyor asked staff to observe Resident #64's call light, and the SRNA picked up the resident's call light and clipped it to the resident's gown. 2. Review of Resident #37's medical record revealed the facility admitted the resident on 04/07/09, with diagnoses including Anemia, Congestive Heart Failure, Psychosis, Morbid Obesity, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of Resident #37's MDS assessment dated [DATE] revealed the resident had a BIMS score of 10, indicating the resident had moderately impaired cognition. Observation on 06/07/18 at 1:25 PM revealed Resident #37 was sitting in a Geri-Chair yelling, Help me! The resident's call light was observed clipped to the back of the resident's left shirt sleeve. An interview with the resident revealed the resident did not know where his/her call light was located. When the resident was shown where the call light was located, the resident could not reach the call light. Interview on 06/07/18 at 1:25 PM with SRNAs #4 and #5 revealed they were not aware the resident was unable to reach the call light when it was clipped to the back that of the resident's shirt. Interview with the Director of Nursing (DON) on 06/07/18 at 3:24 PM revealed it was her expectation that all residents would have access to a call light because it was the residents' avenue for communication to ensure residents' needs were met promptly and without delay. She stated when SRNAs/Nurses made rounds they should check to ensure residents were able to access their call light. According to the DON, the facility did not monitor to ensure call lights were accessible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to notify the physician for one (1) of thirty-one (31) sampled residents (Resident #37) when the resident had a need to alter treatment significantly. Resident #37 had a physician's order for lactulose (a laxative) to treat constipation. The facility failed to notify Resident #37's physician of a need to alter treatment when the resident began having two to three bowel movements per day in 2018. The findings include: Review of the facility policy and procedure titled Notification of Changes in A Resident's Condition, not dated, revealed that all changes in the resident's medical condition must be reported to the physician as soon as practical, but in no case should notification exceed twenty-four (24) hours. Review of Resident #37's medical record revealed the facility admitted the resident on 04/07/09 with diagnoses including Anemia, Congestive Heart Failure, Psychosis, Morbid Obesity, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderately impaired cognition. Interview on 06/06/18 at 9:48 AM with Resident #37 revealed the resident had been having diarrhea for over one month. Review of Resident #37's physician orders dated 02/19/18 revealed the resident had an order for Lactulose 30 ML by mouth once a day for constipation. Review of the intake/output summary from 04/30/18 through 06/06/18 for Resident #37 revealed the resident had two to three bowel movements per day. Continued review of Resident #37's physician orders revealed an order dated 05/31/18 to collect a stool specimen for Clostridium Difficile (C. diff) because the resident was pooping too much and to administer Loperamide HCL (used to treat diarrhea). However, review of laboratory results for the resident revealed the resident's stool specimen was negative for C. diff. Review of Resident #37's Medication Administration Record revealed the facility continued to administer Lactulose daily from 04/30/18 through 06/06/18, even though the resident was having two to three bowel movements each day. Interview on 06/06/18 at 2:37 PM with State Registered Nurse Aide (SRNA) #2 revealed Resident #37 had been having approximately three bowel movements each day for the past month and had three loose bowel movements since breakfast that morning. Interview on 06/06/18 at 2:44 PM with Licensed Practical Nurse (LPN) #3 revealed the night shift nurse was required to review all resident output records daily. She stated Resident #37's medical doctor should have been notified that the resident was having two to three bowel movements per day. She stated she was unaware the resident was having two to three bowel movements per day. Interview on 06/07/18 at 3:01 PM with the Director of Nursing (DON) also revealed the night shift nurse was responsible for reviewing all resident output records. The DON stated that Resident #37's physician should have been notified when the resident was having two to three bowel movements daily so the Lactulose dosage could have been decreased. Interview on 06/07/18 at 2:30 PM with Resident #37's physician revealed he prescribed Lactulose for the resident for constipation. He stated he had not been notified that the resident was having two to three bowel movements daily. The physician stated if he had been notified he would have decreased the medication to use as necessary (PRN).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation of Resident #10's bed on 06/06/18 at 9:34 AM revealed the resident had quarter bed rails that were padded with foam pipe insulation which was covered with black electrical tape that was loose and frayed. Interview with the Director of Nursing (DON) on 06/07/18 at 3:45 PM revealed the resident's rails were padded to prevent injuries because the resident had fragile skin. According to the DON, she was not aware the resident's bed rail padding was in need of repair or replacing. Further interview with the DON revealed managers were required to make rounds in the facility to identify concerns with resident equipment, and if concerns were identified they were required to notify Maintenance of the need to repair or replace the equipment. Interview with the Maintenance Director on 06/07/18 at 4:35 PM revealed he placed foam pipe insulation with electrical tape on Resident #10's bed rails. He further stated staff were required to report concerns to him; however, he had not been notified that the padding was loose/frayed. Based on observation, interview, and record review, it was determined the facility failed to provide a homelike environment for two (2) of thirty-one (31) sampled residents (Resident #10 and Resident #46). Observation of Resident #10 and Resident #46's bed rails revealed the foam pipe insulation/black electrical tape used to pad the residents' bed rails was loose and frayed. The findings include: Review of the facility policy and procedure titled Use of Side Rail Padding revealed side (bed) rail padding was used for safety interventions and as necessary for prevention of skin tears/bruises. The policy stated staff would monitor side rail padding on a daily basis. Further review of the policy revealed the padding would be cleaned as needed according to the housekeeping cleaning schedule, and Maintenance would be notified when any replacement was needed. Review of the facility policy and procedure titled Cleaning of beds and bed rails revealed housekeeping staff were assigned to clean resident rooms every day. The policy stated staff would wipe down immediate touch areas in the rooms, and if side rail padding was damaged, Maintenance would be informed. According to the policy, Maintenance staff was responsible for changing padding. 1. Review of Resident #46's medical record revealed the facility admitted the resident on 05/05/16, with diagnoses including Intellectual Disability, Anemia, Quadriplegia, Peptic Ulcer Disease, History of Encephalitis, and Aspiration. Review of Resident #46's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) could not be completed. Further review of the MDS revealed the resident was totally dependent on staff for activities of daily living. On 06/06/18 at 10:07 AM, an interview was attempted with Resident #46; however, the resident was unable to answer questions. Observation revealed the resident utilized two (2) upper bed rails that were covered with foam pipe insulation that was torn and frayed. Interview on 06/06/18 at 10:37 AM with State Registered Nurse Aide (SRNA) #2 revealed the facility placed foam pipe insulation on Resident #46's bed rails to protect [his/her] skin because the resident sometimes became agitated and moved his/her legs and arms wildly. SRNA #2 stated if she noticed a problem with the foam, she was required to notify a nurse or Maintenance staff. Interview on 06/07/18 at 2:00 PM with Housekeeper #5 revealed if she noticed a problem with the foam padding when she cleaned bed rails, she would have notified Maintenance staff. Interview on 06/07/18 at 3:01 PM with the Director of Nursing revealed foam padding was used to help protect residents from injury. She stated it was everyone's responsibility to let Maintenance staff know if the foam padding became torn so the padding could be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to provide respiratory care consistent with physician orders for one (1) of thirty-one (31) sampled residents. Resident #37 had a physician's order for oxygen at four (4) liters. The facility failed to ensure oxygen was provided to the resident. The findings include: Review of Resident #37's medical record revealed the facility admitted the resident on 04/07/09 with diagnoses including Anemia, Congestive Heart Failure, Psychosis, Morbid Obesity, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of Resident #37's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderately impaired cognition. Further review revealed Resident #37 had a physician's order for oxygen to be administered at 4 liters via nasal cannula. Observation on 06/05/18 at 10:30 AM revealed Resident #37 was in the activity room sitting at the head of the table. The resident was not utilizing oxygen. Interview with Resident #37 on 06/06/18 at 9:48 AM revealed the resident stated he/she was supposed to receive oxygen at 4 liters. The resident stated he was not able to reach the oxygen concentrator to turn his/her oxygen up or down. Observation on 06/06/18 at 3:03 PM revealed Resident #37 was lying in bed. The resident's oxygen concentrator was observed to be delivering no oxygen to the resident (set at zero). Further observation on 06/07/18 at 1:25 PM, revealed Resident #37 was sitting in a chair to the right side of his/her bed looking out the window. The resident's oxygen tubing was lying on the left side of the bed and not within reach of the resident. Interview with State Registered Nurse Aide (SRNA) #2 on 06/06/18 at 2:37 PM revealed the SRNAs could not operate oxygen concentrators; however, if they noted a concern, they would notify the resident's nurse. Interview on 06/07/18 at 3:30 PM with the Director of Nursing (DON) revealed Resident #37 should have received oxygen per the physician orders.

Based on observation, interview, and facility policy review, it was determined the facility failed to prepare and serve food under sanitary conditions. Observations on 06/05/18 and 06/07/18 revealed the hand washing sink in the kitchen was clogged and not draining water when staff washed their hands. The findings include: A review of the facility policy titled Sanitation, undated, revealed facility equipment would be maintained in a sanitary manner and dietary inspections would be performed on a routine basis. Observation of the hand washing sink during the initial kitchen tour on 06/05/18 at 10:00 AM, revealed the sink was not draining and had standing water in it while kitchen staff who were preparing the lunch meal were washing their hands. Observations of the hand washing sink during the kitchen sanitation tour conducted on 06/07/18 at 2:30 PM revealed the hand washing sink continued to have standing water in it and was not draining during hand washing. Interview with the Dietary Manager on 06/07/18 at 2:42 PM revealed she was responsible to monitor sanitary conditions in the kitchen daily and was aware the hand washing sink was not draining. The Dietary Manager stated she had informed Maintenance of the problem on the morning of 06/07/18, and Maintenance had observed the sink and placed drain cleaner in it; however, the sink continued to not drain. Interview with the Maintenance Director on 06/07/18 at 3:01 PM revealed he had placed drain cleaner in the sink earlier in the day, but stated the drain pipes were old and it may take a while to open the drain. However, there was no further evidence found to indicate the facility had taken further action to correct the problem.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure accuracy of the medical record for one (1) of thirty-one (31) sampled residents (Resident #37). Review of Resident #37's plan of care revealed the resident was to be administered oxygen at two (2) liters per minute. However, review of the physician's orders for Resident #37 revealed the resident was to be administered oxygen at four (4) liters per minute. The findings Include: Interview with the Director of Nursing on 06/07/18 at 4:15 PM revealed the facility did not have a policy related to ensuring the accuracy of documentation in resident records. Review of the facility's policy, CNA Careplan, undated, revealed when a new physician's order is obtained the nurse caring for the resident will update the Certified Nursing Assistant (CNA) careplan. In addition, at the end of the month the policy stated that Minimum Data Set (MDS) staff would ensure that all physician orders received during the month were accurately documented on each resident's plan of care. Review of Resident #37's medical record revealed the facility admitted the resident on 04/07/18 with diagnoses including Anemia, Congestive Heart Failure, Psychosis, Morbid Obesity, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. Review of a physician's order for Resident #37 dated 04/22/18 revealed the resident was to be administered oxygen at 4 liters per minute via nasal cannula. However, review of Resident #37's most recent CNA careplan instructed staff that the resident's oxygen was to be administered at 2 liters per minute. Interview on 06/07/18 at 3:10 PM with the Director of Nursing (DON) revealed when a new physician's order was received, the nurse caring for the resident was responsible to update the CNA careplan to reflect the the new orders. The DON further stated that at the end of each month the MDS Coordinator was responsible to ensure that current physician orders and each resident's careplan corresponded. Interview on 06/07/18 at 4:35 PM with the MDS Coordinator revealed she was responsible for reviewing resident care plans at the end of the month to ensure that they accurately reflected physician orders. However, the MDS Coordinator stated it had been overlooked that Resident #37's physician's order for oxygen was not correct on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure and maintain an infection prevention and control program for one (1) of thirty-one (31) sampled residents. Incontinence care observed for Resident #321 revealed the facility failed to utilize proper hand hygiene and infection control. The findings include: Review of the facility policy, Perineal Care to the Female Client, undated, revealed at completion of performing perineal care, staff should remove their gloves, wash their hands, and make the client comfortable. Review of the medical record revealed the facility admitted Resident #321 to the facility on [DATE] with diagnoses of Dementia, History of Urinary Tract Infection, and Retention of Urine. Review of Resident #321's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the resident utilized an indwelling urinary catheter, was incontinent of bowel, and dependent on staff for toileting. Observation of urinary catheter and incontinence care for Resident #321 on 06/06/18 at 10:28 AM revealed Certified Nursing Assistant (CNA) #1 completed catheter care for the resident, then proceeded to assist CNA #5 in performing bowel care for the resident. After completing the incontinence care, CNA #1 and CNA #5 were observed to put a clean incontinence brief on the resident without changing gloves and performing hand hygiene. Continued observation revealed CNA #5 also placed pants on the resident without changing gloves or performing hand hygiene. Interview with CNA #1 on 06/06/18 at 10:45 AM revealed she was aware that it is a requirement to remove soiled gloves and perform hand hygiene after care is completed. The CNA also stated that the facility routinely provided education/training for staff related to incontinence care. Interview with the Director of Nursing (DON) on 06/07/18 at 3:20 PM revealed when performing incontinence care, gloves should be changed and hand hygiene performed prior to applying a clean incontinence brief and clothing. The DON further stated that the failure of staff to perform appropriate hand hygiene was a break in infection control procedures.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice in two (2) of three (3) medication carts. Observation of medication carts revealed fifty (50) blue top laboratory collection tubes, one hundred (100) heparin flushes (treats or prevents blood clots), five (5) wound dressings, thirty-two (32) Metoprolol Tartate tablets (blood pressure medication), and one hundred twenty (120) Buspar (anxiolytic medication) tablets that were expired and available for use. In addition, the Heparin syringes were not labeled with a resident name or prescribing information and two (2) bottles of insulin were not dated when they were opened. The findings include: Review of the facility's policy, Storage and Expiration of Medications, Biologicals, Syringes and Needles, revised 10/31/16, revealed the facility should ensure that expired medications and biologicals were stored separately from other medications until destroyed or returned to the pharmacy or supplier. The policy also revealed once any medication or biological was opened, facility staff should record the date opened on the medication container and should follow manufacturer/supplier guidelines with respect to expiration dates. Observation of Team 1's medication storage on 06/07/18 at 1:16 PM revealed 50 anticoagulation serum collection vials that expired in April and May 2018, 100 5-milliliter syringes of Heparin that contained 10 units per milliliter that expired from March to May 2018, and five wound care dressings that expired in 2014. Observation revealed the Heparin syringes were also not labeled with a resident name or prescribing information. Observation of Team 2's medication storage on 06/07/18 at 2:50 PM revealed an opened vial of Humulin R insulin and Levemir insulin that were not dated when they were opened. Further observation of Team 2's medication cart on 06/07/18 at 4:55 PM revealed two Metoprolol Tartate 24-milligram tablets that expired on 05/31/18. Observation of Team 3's medication cart on 06/07/18 at 5:40 PM revealed 120 Buspirone HCL 15-milligram tablets and 30 Metoprolol Tartate 24-milligram tablets that expired on 05/31/18 and were available for use in the medication cart. Interview with the Pharmacist on 06/07/18 at 2:46 PM revealed the pharmacy did not label individual Heparin syringes, but labeled the medication box that contained the syringes with the resident's information. Interview with the Director of Nursing (DON) on 06/07/18 at 3:37 PM revealed staff were required to audit the medication room on Sunday night to remove medications before they expired. The DON further stated the auditing was not being done thoroughly and as required.