Based on record review and interview the facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) in a timely manner for 1 (Resident #55) reviewed for Beneficiary Notification. Findings: Review of Resident #55's Beneficiary Notification Review revealed in part .Resident #55's Medicare covered Part A services started on 07/05/2024 and her last Medicare Part A covered day was 07/18/2024. Review of Resident #55's NOMNC revealed in part .Resident #55's last covered day of Medicare Part A service was 07/18/2024. Resident #55's NOMNC revealed Resident #55's signed the NOMNC on 07/17/2024 to acknowledge she received and understood the notice. Review of the above mentioned NOMNC revealed the facility did not issue Resident #55's NOMNC at least two days prior to the end of Medicare Part A coverage to allow her the right to appeal the discharge. Interview on 08/28/2024 at 9:19 a.m. with S4 SSD revealed she was currently responsible for issuing NOMNC's to the resident/and or resident representative when the facility initiated a Medicare Part A discharge. S4 SSD confirmed she did not issue a NOMNC to Resident #55 at least two days prior to their Medicare Part A discharge as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (#81) of 1 sampled Resident with MDS record over 120 days old. Findings: Review of the clinical record for Resident #81 revealed the Resident was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Type 2 Diabetes, Essential Hypertension, and Hemiplegia and Hemiparesis following cerebral infarction affecting left dominant side. Review of Resident #81's Discharge MDS Assessment with ARD (Assessment Reference Date) of 04/26/2024 revealed the assessment had been transmitted. Review of the facility's MDS transmission reports revealed Resident #81's Discharge Assessment with ARD of 04/26/2024 had been transmitted on 08/28/2024. Interview on 08/28/2024 at 10:41 a.m. with S5 LPN/MDS Nurse confirmed Resident #81's 04/26/2024 Discharge MDS was completed but never transmitted. Interview on 08/28/2024 with S2 DON revealed Resident #81's Discharge MDS with ARD date of 04/26/2024 was not transmitted in a timely manner, but should have been.

Based on interview and record review the facility failed to develop/implement a person-centered care plan for 1 (Resident #53) of 2 (Resident #26 and Resident #53) sampled residents to include respiratory care for Resident #53. Total sample size was 27. Findings: Review of Resident #53's Clinical Record revealed an admit date of 07/22/2024 with diagnoses that included in part . Dysphagia Oropharyngeal Phase, Disturbance of Salivary Secretion, Gastrostomy status, and Cough Unspecified. Review of Resident #53's Annual MDS with an ARD of 06/18/2024 revealed Resident #53 had a BIMS score of 99 (which indicated a resident's interview was incomplete). The MDS revealed Resident #53 was coded as Dependent for oral hygiene, toileting hygiene, shower/bath, and personal hygiene Record review of Physician orders dated 08/2024 for Resident #53 read in part . change suction canister and tubing every 48 hours. If suction machine was used and as needed. Review of Resident #53's Care Plan revealed no documentation of suctioning or a suction machine maintenance. Interview on 08/28/2024 at 10:41 a.m. with S7 LPN MDS confirmed a care plan had not been developed for the use of Resident #53's suctioning or maintenance of respiratory equipment and it should have been.

Resident #10 Review of Resident #10's Clinical Record revealed an admit date of 07/25/2024 with diagnoses that included in part .Alzheimer's Disease with Late Onset, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Pneumonia Unspecified, Chronic Obstructive Pulmonary Disease, and Chronic Respiratory Failure. Review of Resident #10's Physician orders for August 2024 revealed in part .Budesonide Inhalation Suspension 0.5 MG/2ML (breathing treatment). 1 vial orally via nebulizer two times a day related to Chronic Obstructive Pulmonary Disease. Review of Resident #10's care plan with a Target date of 10/16/2024 revealed in part .I require oxygen therapy. I sometimes experience Shortness of Breath upon exertion or while lying flat, with interventions that included: Administer me oxygen if ordered. Change my oxygen tubing per protocol and as needed (such as if it falls or I do not store the tubing in the appropriate place/manner). I have Congestive Heart Failure administer my medication if ordered. Observation and interview on 08/26/2024 at 9:55 a.m. revealed Resident #10 was in bed. Nebulizer mask lying on top of a refrigerator uncovered. Resident #10 revealed she received breathing treatments every day. Observation on 08/28/2024 at 9:20 a.m. revealed Resident #10's nebulizer mask was lying uncovered on top of her refrigerator. Observation and interview on 08/28/2024 at 9:26 a.m. with S6 LPN revealed Resident #10 received nebulizer treatments every 6 hours. Observation of Resident #10's nebulizer mask with S6 LPN revealed it was lying uncovered on top her refrigerator. S6 LPN confirmed Resident #10's nebulizer mask was uncovered and it should not have been. Interview on 08/28/2024 at 9:37 a.m. with S2 DON revealed the floor nurses were responsible for maintaining and changing respiratory equipment. S2 DON confirmed Resident #10's nebulizer mask should not have been lying uncovered on top of her refrigerator. Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #10 and Resident #67) of 2 (Resident #10 and Resident #67) sampled residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored and labeled. Findings: Review of the facility's policy titled, Care of Respiratory Equipment read in part . Any resident receiving any type of respiratory treatment on a continuous or PRN basis is to have said treatment listed on his treatment sheet. All respiratory equipment is to be maintained by nursing. Oxygen nasal cannulas are to be changed at least every 72 hours, labeled and dated. Oxygen concentrator canisters are to be changed every 3 months, labeled and dated. Review of the facility's policy titled, Oxygen Concentrator read in part . Procedure: 4. Nasal cannula is to be checked daily and changed every 3 days (minimum) when in use and to be kept clean and functional. When not in use, cannula is to be stored in Zip lock bag. Resident #67 Review of Resident #67's medical record revealed an admission date of 07/03/2023 with diagnoses that included Alzheimer's disease with late onset, Chronic Diastolic Congestive Heart Failure, Atrial Fibrillation, Essential Primary Hypertension, Chronic Obstructive Pulmonary Disease (COPD) and other nonspecific abnormal findings of lung field. Review of Resident #67's Physician's Orders for 08/2024 revealed an order to administer oxygen at 3 liters for saturation 92% or less as needed. Review of Resident's Quarterly MDS with an ARD of 07/30/2024 revealed a BIMS score of 03, indicative of severe cognitive impairment. Review of MDS revealed Resident #67 received hospice services. Review of Resident #67's Care Plan with review date 10/30/2024 revealed in part . I have COPD, Pulmonary Nodules and Chronic Diastolic Congestive Heart Failure. Interventions included in part . to administer oxygen if ordered. Change my oxygen tubing (if oxygen is ordered) per protocol and as needed (such as if it falls on floor or I do not store tubing in appropriate place/ manner). Staff will educate/ encourage/ redirect me frequently and not to take my oxygen off without calling for staff assistance for and infection control. Observation on 08/26/2024 at 11:30 a.m. of Resident #67 awake lying in bed. Oxygen nasal cannula and tubing observed left open to air, not contained or labeled with date lying on oxygen concentrator at bedside. Humidifier water bottle and tubing observed to be attached to oxygen concentrator without a label with date. Observation on 08/27/2024 at 9:17 a.m. revealed Resident #67 awake lying in bed. He stated he had used oxygen a couple of days ago. Observation of oxygen nasal cannula and tubing noted left open to air, not stored or dated and lying on top of the oxygen concentrator. Oxygen water humidifier bottle not dated attached to concentrator. Observation and interview in Resident #67's room on 08/27/2024 at 11:28 a.m. with S3 LPN revealed Resident #67's oxygen tubing and nasal cannula not contained or labeled with a date and left open to air lying on top of his oxygen concentrator at bedside. S3 LPN revealed that his hospice nurse may have changed out humidifier and placed Resident #67 on oxygen when she came yesterday morning around 09:30 a.m. S3 LPN revealed it was overlooked on her part and she should have dated and placed Resident #67's oxygen nasal cannula and tubing in a Zip Lock bag and did not. Interview on 08/27/2024 at 11:57 a.m. with S2 DON confirmed the above findings. S2 DON revealed that the oxygen equipment storage policy is to have tubing placed in a sealed bag, dated with tape on tubing and change out tubing every three days by the nurse on duty and was not done.

Based on observation and interview the facility failed to ensure that residents requiring assistance with meals were treated with respect and dignity by failing to ensure residents were not labeled and their names displayed on a list according to their care needs on 1 (Hall #Z) of 3 (Hall #X, Hall #Y and Hall #Z) halls. Findings: Review of the facility's undated policy titled Policy 49 revealed the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Observations on 08/26/2024 at 1:30 p.m. and 08/27/2024 at 3:05 p.m., revealed a sheet of paper posted at the Kiosk station on Hall #Z with 4 resident names labeled as feeders. This was visible to anyone passing on the hall. An interview on 08/27/2024 at 3:15 p.m. with S8 LPN revealed that the 4 resident names that was labeled as feeders were viewable from anyone passing on the hall, and stated that there are a lot of family members down this hall. An interview on 08/28/2024 at 8:11 a.m. with S2 DON, revealed that S8 LPN made her aware yesterday (08/27/2024) of the sheet of paper hanging at the kiosk on Hall #Z. S2 DON stated resident information including labeling resident's as feeders was inappropriate and should not have been hanging at the kiosk station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide services with reasonable accommodation of needs for 1 Resident (#10) out of 34 sampled Residents. The facility failed to ensure the call light was within reach for Resident #10 to call for assistance when needed. Findings: Review of Resident #10's Face sheet revealed she was a [AGE] year old female admitted on [DATE] with the following diagnoses: COPD (Chronic Obstructive Pulmonary Disease, Insomnia, Muscle Spasm Unspecified, Alzheimer Disease, Gastro-Esophageal Reflux Disease, Hyperlipidemia, and Dizziness. Review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) 05/18/2022 revealed Resident #10 was interviewble with a BIMS (Brief Interview for Mental Status) of 13 (intact cognition). Resident #10 required limited assistance with 1 person assistance for transfer, walking in room. Resident was coded as being highly involved in activity with staff providing guidance. Resident is not steady to stand alone only able to stabilize with human assistance. On 08/08/2022 at 11:15 a.m., an observation was made of Resident #10 up in a recliner in her room with a padded call light draped over a wall mounted blood pressure manometer. When asked if resident was able to use a call light, she stated Yes, but I can't reach it. Resident stated she had no means to call for assistance if needed. Resident stated she needed staff assistance with transfer. On 08/09/2022 at 9:40 a.m., an observation was made of Resident #10 up in recliner with a padded call light positioned on her bed. The Resident's recliner was positioned approximately 4-5 feet away from the bed, out of her reach. When asked if she was able to reach the call light, she stated No I can't get it. On 08/09/2022 at 10:35 a.m., an interview was conducted with S2 DON. Observation at the time of interview revealed Resident #10 was seated in her recliner, and her padded call light was positioned on her bed. S2 DON confirmed that Resident #10's padded call light was not within her reach for assistance and should have been.

Based on record review and interview the Facility failed to formulate an advanced directive for 1 (Resident #46) of 1 sampled Resident records reviewed for Advanced Directives. Findings: Review of Resident #46's Medical Record revealed no documentation Resident #46 or Resident #46's Representative had signed an Advanced Directive. Further review revealed Resident #46's family had signed a LaPost Acknowledgment Form and had checked the statement which said I wish to complete a LaPost/Advance Directive at this time. Interview on 08/09/2022 at 12:15 p.m. with S16 SSD revealed during the admittance of a Resident, the family is ask if they would like to sign an Advanced Directive. If so, this information is passed on to the nursing department for completion of a LaPost form. S16 SSD confirmed at this time the LaPost Acknowledgment Form was checked that the resident wished to have an Advanced Directive completed and there was not one on the Resident's record. Interview on 08/09/2022 at 12:17 p.m. with S6 LPN/MDS confirmed that there was no Advanced Directive/LaPost form signed in Resident #46's record and it should be.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents' assistive devices were maintained in good working condition for 2 (#39, and #75) of 34 sampled Residents. Findings: Resident #39 Observation on 08/08/2022 at 11:40 a.m. revealed Resident #39 sitting in a wheelchair in the hallway. The wheelchair was noted to have multiple tears on the right and left armrests. Observation on 08/09/2022 at 9: 30 a.m. revealed Resident #39 lying in bed with a wheelchair positioned at the foot of her bed. The wheelchair was noted to have multiple tears on the right and left armrest. Interview with Resident #39 at the time of the observation revealed she was unable able to walk so she uses the wheelchair to move around her room and the facility. Interview conducted on 08/09/2022 at 10:25 a.m. with S2 DON confirmed that after inspecting the wheelchair for Resident #39, the wheelchair was in need of repairs and or needed to be replaced. Resident #75 Observation on 08/08/2022 at 11:35 a.m. revealed Resident #75 sitting in a recliner in his room eating lunch with a wheelchair positioned by his bed. The wheelchair was noted to have multiple tears on the seat cushion. Interview with Resident #75 at the time of observation revealed he uses the wheelchair to move around the facility. Observation on 08/09/2022 at 10:02 a.m. revealed Resident #75 ambulating in the hallway assisted by a Physical Therapist with a Certified Physical Therapist Assistant pushing a wheelchair behind the Resident. The wheelchair was noted to have multiple tears on the seat cushion. Interview conducted on 08/09/2022 at 10:31 a.m. with S2 DON confirmed that after inspecting the wheelchair for Resident #75, the wheelchair was in need of repairs and or needed to be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #18 Review of the clinical record revealed Resident #18 admitted to the facility on [DATE] with the following diagnoses: Essential HTN, Pain, Diaphragmatic Hernia, Dysarthria following Cerebral Infarction, Type II Diabetes Mellitus, unspecified Convulsions, Dysphagia; Oropharyngeal Phase, Hemiplegia and Hemiparesis following Cerebral Infarct, Hyperlipidemia, Cataracts, Constipation, Muscle Wasting and Atrophy, and Cognitive Communication Deficit. Observation on 08/08/22 at 12:23 p.m. revealed Resident #18 in bed yelling out for her mother, asking for help, and shouting profanities. Observation on 08/08/2022 at 12:34 p.m. revealed S9 LPN entering Resident #18's room and attempting to redirect Resident #18. Resident #18 began banging on a bedside table and yelling, where's my mother. Review of Resident #18's Physician's Progress Notes revealed a diagnosis of Dementia had been added to progress notes dated 05/05/2022 and 07/06/2022. Further review of the progress notes revealed they had been signed off by S8 LPN. Review of Resident #18's CPOC with a target date of 09/07/2022 revealed no diagnosis of Dementia or interventions related to the diagnosis of Dementia. Interview on 08/09/2022 at 3:00 p.m. with S8 LPN revealed she was responsible for reviewing progress notes and taking off any new orders. She stated that after signing off the progress notes she scans them to the MDS/coding office. Interview on 08/09/2022 at 3:10 p.m. with S9 LPN revealed he was responsible for updating plans of care and MDS's as needed. He stated Resident #18's diagnosis of Dementia had not been added to the CPOC after the diagnosis on 05/05/2022. He further stated the CPOC had not been updated after the diagnosis of Dementia was noted on Resident #18's progress note on 07/06/2022. Interview on 08/09/2022 at 3:21 p.m. with S2 DON confirmed Resident #18 had not been care planned for the diagnosis of Dementia and should have been. Based on observation, record review, and interview the facility failed to review and revise a Resident's Care Plan to include suctioning for 1 Resident (#54) and failed to ensure a Resident's Care Plan included a diagnosis of Dementia for 1 Resident (#18) of 29 Resident records reviewed for Care Plans. Findings: #54 Observation on 08/08/2022 at 11:18 a.m. revealed a suction machine at Resident #54's bedside. There was 50 cc's of yellow fluid noted in the collection canister Observation on 08/09/2022 at 8:42 a.m. revealed a suction machine on Resident #54's bedside table. There was 50 cc of yellow fluid noted in the collection canister. Review of Resident #54's EHR revealed an admit date of 09/01/2021. Resident #54 had the following diagnoses including Dysphagia, COPD and encounter for screening for respiratory disorder NEC. Review of Resident #54's Care Plan with an ongoing target date for COPD, Aspiration and Cough revealed no intervention noted pertaining to suctioning. Review of Resident #54's Yearly MDS with an ARD of 07/06/2022 revealed the following in part: Section C - Cognitive Pattern - The Resident's BIMS score was 8 (indicating Resident #54 had moderate cognitive impairment). Review of Resident #54's 08/2022 MD Orders revealed the following in part: 11/11/2021 - Head of bed elevated at 45 degrees at all times 11/18/2021 - Change nebulizer set up q week 01/23/2022 - Change oxygen tubing every 3 days if in use. 03/08/2022 - Oxygen 2L/min via NC prn for SOB 07/01/2022 - Iprat-Albut 0.5-3(2.5) mg/3 ml administer 1 vial per nebulizer for inhalation q 6 hours prn coughing/wheezing Review of the Resident #54's 05/2022 - 08/2022 Progress Notes revealed no documentation that Resident #54 had been suctioned. Interview on 08/09/2022 at 12:22 p.m. with S7 LPN/IP confirmed there was a suction machine at Resident #54's bedside with 50 ccs of yellow fluid in the suction canister. S7 LPN/IP further confirmed that the suction yankauer was opened, was connected to the suction machine, had been used, and was undated. Interview on 08/10/2022 at 10:44 a.m. with S6 LPN/MDS confirmed there was no information concerning suctioning in the Resident's Care Plan and there should have been.

Based on observation and interview the facility failed to ensure that food was stored in accordance with professional standards for food service. This deficient practice had the potential to affect the 73 residents that received meals prepared by the kitchen. Findings: Initial tour of the kitchen on 08/08/2022 at 9:00 a.m. accompanied by S4 DM revealed the following: 1 opened, undated loaf of wheat bread, 1 opened, undated pack of hamburger buns and 1 opened, undated 25lb bag of fish fry on a counter in the kitchen. Findings confirmed with S4 DM at the time of observation. Observation of the facility cooler on 08/08/2022 at 9:30 a.m. accompanied by S4 DM revealed it contained the following items on a shelf for use: 1 quart of tuna salad undated and uncovered, 1 quart of whipped topping opened and undated. Findings confirmed with S4 DM at the time of observations. S4 DM stated all food items should be dated after opening and stored items in the cooler should be covered and dated as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** #11 Review of the clinical record revealed Resident #11 admitted to the facility on [DATE] with diagnoses that included COPD, Generalized Anxiety Disorder, Dysphagia, CKD, and GERD. Review of the facility policy titled: Administering Nebulizer Treatments with Aerosol Mask or Mouthpiece revealed in part . 6. The aerosol mask/mouthpiece and tubing are then disconnected from nebulizer and cleaned. Once cleaned, place mask/mouthpiece in a storage bag at bedside. Observation on 08/08/2022 at 12:10 p.m. revealed Resident #11 awake in bed watching television. An Aerosol mask attached to a nebulizer machine was observed on Resident #11's nightstand OTA. Observation on 08/09/2022 at 9:13 a.m. revealed Resident #11 awake in bed wearing supplemental oxygen. An Aerosol mask attached to nebulizer machine was observed on Resident #11's nightstand OTA. Interview with Resident #11 at the time of observation revealed he used the nebulizer 2 -3 times a day. Resident #11 stated he last had a nebulizer treatment at around 7:30 a.m.-8:00 a.m. that morning. Interview on 08/09/2022 at 9:16 a.m. with S5 LPN confirmed the above findings. S5 LPN stated Resident #11's Nebulizer mask should be bagged after each use and was not. #54 Observation on 08/08/2022 at 11:18 a.m. revealed a suction machine at Resident #54's bedside with 50 cc yellow fluid in the suction canister. There was an opened wrapper with a suction yankauer connected to the suction machine tubing which was undated. Observation on 08/09/2022 at 8:42 a.m. revealed a suction machine on Resident #54's bedside table. There was 50 cc of yellow fluid in the collection canister. The suction yankauer had been opened, was connected to suction tubing, had been used and was not dated when opened. Review of Resident #54's EHR revealed an admit date of 09/01/2021. Resident #54 had the following diagnoses including Dysphagia, COPD and encounter for screening for respiratory disorder NEC. Review of Resident #54's Care Plan with an ongoing target date revealed no interventions pertaining to suctioning. Review of Resident #54's Yearly MDS with an ARD of 07/06/2022 revealed the following in part: Section C - Cognitive Pattern - The Resident's BIMS score was 8 (indicating Resident #54 had moderate cognitive impairments). Review of Resident #54's 08/2022 MD Orders revealed the following in part: 11/11/2021 - Head of bed elevated at 45 degrees at all times 11/18/2021 - Change nebulizer set up q week 01/23/2022 - Change oxygen tubing every 3 days if in use. 03/08/2022 - Oxygen 2L/min via NC prn for SOB 07/01/2022 - Iprat-Albut 0.5-3(2.5) mg/3 ml administer 1 vial per nebulizer for inhalation q 6 hours prn coughing/wheezing Review of Resident #54's 06/2022-08/2022 Progress Notes revealed no documentation that Resident #54 had been suctioned. Review of the Facility's Suction Machine Policy revealed the following in part .Note: Suction catheters should not be cleansed with germicidal solution' change catheter every use. Interview on 08/09/2022 at 12:22 p.m. with S7 LPN/IP confirmed that there was a suction machine at Resident #54's bedside with 50 ccs of yellow fluid in the suction canister. S7 LPN/IP further confirmed that the suction yankauer was opened, was connected to the suction machine, had been used, and was undated. S7 LPN/IP stated that if it had been her, she would have done away with the canister and replaced it with a new one. Based on observation, record review and interview, the Facility failed to provide respiratory care consistent with professional standards of practice for 4 (Resident #11, Resident #47, Resident #54, and Resident #75) of 6 (Resident #11, Resident #13, Resident #46, Resident #47, Resident #54 and Resident #75) sampled Residents reviewed for respiratory care. Findings: Resident # 47 Review of the Facility's Policy/Procedure titled Oxygen Concentrator revealed in part: 5. Nasal cannula is to be checked daily and changed every 3 days (minimum) and to be kept clean and functional. When not in use, cannula is to be stored in a zip lock bag. Observations on 08/09/2022 at 10:36 a.m. and 1:10 p.m. revealed Resident #47 lying in bed with supplemental Oxygen at 3Liters/minute per nasal cannula. There was a wheelchair positioned at her bedside with a nasal cannula noted to be opened to air connected to a portable Oxygen tank. An interview with Resident #47 at the time of the observation revealed she was placed on portable Oxygen whenever she left the facility (Dialysis, and Doctor's appointment). Resident #47 stated she used a different nasal cannula on the portable Oxygen and the cannula on the Oxygen concentrator stayed connected to it. Observation on 08/10/2022 at 8:35 a.m. revealed Resident #47 lying in bed with supplemental Oxygen at 3Liters/minute per nasal cannula. There was a wheelchair positioned at her bedside with a nasal cannula noted to be opened to air connected to a portable Oxygen tank. Observation on 08/10/2022 at 8:45 a.m. accompanied by S2 DON confirmed the nasal cannula was open to air and should have been stored in a zip lock bag and dated. Review of Resident #47's Medical Records revealed she was admitted to the facility on [DATE] with Diagnoses which included: Hypertensive Heart and Chronic Kidney Disease with Heart, Stage 1-4 Unspecified Chronic Kidney Disease, Type 2 DM (Diabetes Mellitus) with Diabetic Neuropathy Disease with Heart Failure, and Major Depressive Disorder. Review of Resident #47's Physician's orders for August 2022 revealed: Oxygen at 3Liters per nasal cannula continuous- Dx. (Diagnosis) COPD (Chronic Obstructive Pulmonary Disease) Change tubing every 3 days. Review of Resident #47's Significant Change in Status MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/03/2022 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 (which indicated intact cognition). Further review of the MDS revealed that Resident #47 was on Dialysis and Oxygen Therapy. Resident #75 Observation on 08/08/2022 at 11:35 a.m. revealed Resident #75 sitting in a recliner in his room, there was a wheelchair at the foot of the bed. The wheelchair was noted to have a nasal cannula open to air draped over the front of it. An interview with Resident #75 at the time of the observation revealed he used the Oxygen whenever he left his room and the facility. Observation on 08/09/2022 at 10:31 a.m., accompanied by S2 DON confirmed the nasal cannula was open to air and should have been stored in a zip lock bag and dated. Review of Resident #75's Medical Records revealed he was admitted to the facility on [DATE] with diagnoses which included: Hypertensive Heart Disease with Heart Failure, Major Depressive Disorder, COPD, Generalized Muscle Weakness, Secondary Malignant Neoplasm of Right/Left Lung, and Malignant Neoplasm of Right/Left Kidney. Review of Resident #75's Physician's orders for August 2022 revealed: Oxygen at 3 L per nasal cannula continuous during the day. Change tubing every 3 days. Review of Resident #75's Quarterly MDS with an ARD of 06/22/2022 revealed the resident had a BIMS score of 13 (which indicated intact cognition).

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for 4 (Resident #25, Resident #45, Resident #47, and Resident #65) of 4 (Resident #25, Resident #45, Resident #47, and Resident #65) residents reviewed for transmission based precautions. The facility failed to have an infection control policy for transmission based precautions which included the disposal of regulated medical waste and failed to properly dispose the regulated medical waste of Resident #25, Resident #45, Resident #47, and Resident #65. Findings: Review of the facility's policy titled Isolation Precautions revealed in part . Trash will be kept in a basket in the residents' room. Basket is lined with large trash bag. The basket will be checked by housekeeping personnel daily and staff as needed. Trash will be disposed of per facility protocol. Interview on 08/08/2022 at 8:58 a.m. with S7 LPN/IP revealed the facility had two COVID-19 positive residents, Resident #45 and Resident #65. Observation on 08/08/2022 at 10:16 a.m. of Resident #65's room revealed he was on droplet isolation and two silver trash cans were noted outside of the room with white trash bags. Further observation revealed one trash can was labeled linen and the other one was labeled trash and no biohazard bags were noted. Observation on 08/08/2022 at 10:16 a.m. of Resident #45's room revealed he was on droplet isolation and two silver trash cans were noted outside of the room with white trash bags. Further observation revealed no biohazard bags were in use. Interview on 08/08/2022 at 1:30 p.m. with S11 CNA revealed when residents are on isolation for COVID-19, any trash is bagged in the resident's room and taken directly outside and placed into the trash can by the resident's door. S11 CNA reported whenever the trash can outside the door is full, it was then taken directly outside by using the door on the COVID-19 area. Observation on 08/08/2022 at 1:50 p.m. revealed two red dumpsters on wheels outside of the door by the COVID-19 area. Interview on 08/08/2022 at 2:01 p.m. with S1 Administrator revealed the red dumpsters outside the COVID-19 area were emptied by the maintenance men every morning and every evening. S1 Administrator reported they hook up a golf cart and bring it around to the main dumpster. S1 Administrator stated they take out the trash bags from the red dumpster by hand and move it to the main dumpster. Interview on 08/08/2022 at 2:03 p.m. with S12 Maintenance revealed the aides and housekeepers place trash in the red dumpsters outside. S12 Maintenance reported when he comes to work every morning, he attaches a golf cart to the red dumpsters and pulls them over to the main dumpster. S12 Maintenance stated he puts on gloves and grabs the bags from the red dumpster and places them in the main dumpster. S12 Maintenance reported he did not wear a mask, face shield, or a gown. S12 Maintenance stated he moves the trash from the red dumpsters to the main dumpsters every morning and every evening. Interview on 08/08/2022 2:08 p.m. with S13 HSK revealed she took the trash from Resident #45's room and Resident #65's room and placed it in the red dumpsters outside. Interview on 08/08/2022 at 2:09 p.m. with S14 CNA revealed she took the trash from Resident #45's room and Resident #65's room and placed it in the red dumpsters outside. Observation 08/09/2022 at 12:28 p.m. of Resident #65's room revealed a trash can for trash outside the door with a white trash bag. Further observation revealed no biohazard bags were in use. Observation 08/09/2022 at 12:28 p.m. of Resident #45's room revealed a trash can for trash outside the door with a white trash bag. Further observation revealed no biohazard bags were in use. Interview on 08/09/2022 at 12:35 p.m. with S7 LPN/IP revealed Resident #45 tested positive for COVID-19 on 08/06/2022 and Resident #65 tested positive for COVID-19 on 08/07/2022. Interview on 08/09/2022 at 12:50 p.m. with S15 LPN revealed the COVID-19 positive residents' trash is placed outside the door in the silver trash can. S15 LPN stated when the trash can was full, the CNAs took the trash outside and placed it in the red dumpsters. S15 LPN reported she did not use biohazard bags for anything on her hall. Observation of the storage room located in the COVID-19 area with S15 LPN revealed two open cardboard boxes with red biohazard bags that were empty and never used. S15 LPN stated a while ago at the facility, they were using the red biohazard bags for the trash of COVID-19 positive residents. S15 LPN reported now they have just been using the trash cans with regular trash bags. 08/09/22 01:44 PM Interview with S7 LPN/IP confirmed the facility did not have a policy or protocol for trash as stated in their policy titled Isolation Precautions but they should have had one. S7 LPN/IP reported the waste from residents on isolation was supposed to go outside of their room in a regular trash bag and when it was full, staff was to put it in a biohazard bag in a cardboard box. S7 LPN/IP stated when biohazard bags are full, the cardboard box is closed and the maintenance man puts it in his shop until it is picked up by the company that picks up the facility's biohazardous waste. S7 LPN/IP confirmed the waste of the residents on isolation should not have gone in the red dumpster outside with the regular trash and should have been placed in biohazard bags to be contained. Observation on 08/09/2022 at 2:05 p.m. revealed Resident #47's room had two trash cans outside the door with white trash bags. Further observation revealed no biohazard bags were in use. Observation on 08/09/2022 at 2:05 p.m. revealed Resident #25's room had two trash cans outside the door with white trash bags. Further observation revealed no biohazard bags were in use. Interview on 08/09/2022 at 2:25 p.m. with S10 ADON revealed Resident #47 was placed on transmission based precautions when she returned from the hospital because she was not vaccinated for COVID-19. S10 ADON stated Resident #25 was on transmission based precautions because she had ESBL in her urine.