Based on observation, interview, and record review the facility failed to ensure urinary catheter equipment was consistently maintained in a secured and sanitary manner for 1 (Resident #36) of 2 residents reviewed for urinary catheter care, resulting in discomfort and pain at the urinary catheter insertion site and the potential for further catheter-associated urinary tract infections. Findings include: Review of Resident #36's most recent brief interview for mental status score, dated 2/6/25, was scored a 15 out of 15 suggesting Resident #36 was cognitively intact. Review of Resident #36's urology (branch of medicine focusing on the urinary system) consult note, dated 3/25/24, noted that Resident #36's primary diagnosis was Urinary retention and noted Resident #36 had an Atonic bladder (bladder (organ that holds urine) muscles don't fully contract) and an indwelling urethral catheter (tube inserted in the bladder through the penis to allow urine to flow). During observations and interview on 03/24/25 at 09:42 AM, upon entering Resident #36's (R36) room there was a sign on the door that indicated this resident was on enhanced barrier precautions (Enhanced barrier precautions are infection control interventions designed to reduce the spread of multidrug-resistant organisms). R36 was awake laying on his back in bed and a urinary catheter tube traveled down the side of the bed, from his right leg (catheter tubing was secured to the right leg by a white fabric strap), and down to the urinary catheter urine collection bag that was resting flat directly on the floor with the tube emptying spigot side up. R36 reported the catheter bag was often (R36 couldn't quantify exactly how many times) on the floor and it wasn't unusual to for the urinary catheter bag to be directly touching the floor. The urinary catheter bag was on the floor to the bottom left area of the bed which was closest to the entry door. R36 reported he had a recent urinary tract infection and received antibiotics to address it. R36 confirmed the catheter bag was directly on the facility floor; there was no barrier between the catheter bag and the floor. At 09:49 AM, Registered Nurse F entered R36's room, provided medication to the resident, and left the room. The urinary catheter bag remained on the floor unprotected with no barrier as the staff had not picked it up off the floor during the visit to R36's room. During observations and interview on 03/24/25 at 01:13 PM, Resident #36 (R36) and his urinary catheter tubing and bag were in nearly the same position they were at during the previous observation at 03/24/25 at 09:42 AM. The catheter bag was still laying directly on the facility floor with no barrier between the catheter bag and the floor. There was no device or bag affixed to the bed or near the bed to keep the catheter bag off the floor and to prevent potential tension in the urinary catheter tubing. As R36 turned himself independently from side to side in his bed the urinary catheter bag raised up off the floor and then back to resting on the floor flat again. During an interview on 03/25/25 at 12:38 PM, Certified Nurse Aide G reported urinary catheter bags should not be directly on the floor and there should be a barrier, such as a designated pad or the catheter bag be placed in the catheter holding bag that hangs from the bed frame, between the urinary catheter bag and the floor. During an interview on 03/25/25 at 03:41 PM, Director of Nursing (DON) B reported resident's urinary catheter bags, while laying in bed, should be placed in a privacy bag that hangs from the bed frame, in a plastic basin bin, or on a soaking pad that would create a barrier between the catheter bag and the floor. DON B confirmed Resident #36's urinary catheter bag should never be directly on the facility floor with no barrier. During an interview on 03/26/25 at 08:16 AM, Resident #36 (R36) showed his leg strap that held the urinary catheter tubing and reported when he moved in bed and the catheter bag was on the floor it would tug at his penis and stated it hurt. R36 reported the pain it caused was a 5 out of 10 (on a scale of zero being no pain and 10 being the highest level of pain). R36 confirmed this discomfort at times still occurred while the catheter tubing was secured to his leg with a leg strap and when the catheter bag was on the floor. R36 reported the leg strap often rides down his leg which would cause tension. R36 reported there were times staff placed his urinary catheter bag on a pad on the floor but the bag would end up directly on the floor as it moved as he moved in bed. R36 reported at times when the catheter was puling on his penis causing pain and the catheter bag was on the floor he would grab the tubing and pull it to give the tubing some slack to alleviate the discomfort. Review of R36's progress note, dated 3/12/25 at 9:24 PM, stated, CNA (certified nursing aide) mentioned to this writer around 21:30 (9:30 PM) that resident (Resident #36) has bloody urine in his bag when emptying it .resident (Resident #36) mentioned that when the tubing on the top is not positioned properly or the band that it tends to slide down and then ends up pulling . Review of Resident #36's Infection Report, dated 3/12/2025, indicated, Time of Onset 9:30 PM .Acquired Where? Facility .Infection Type CAUTI (Catheter-associated Urinary Tract Infection) .Observed with gross hematuria (blood in urine) in catheter collection bag and drainage around meatus (opening of the urethra where urine exits) with c/o (complaint of) doscomfort (discomfort) at site as well. UTI (urinary tract infection) monitor started, CBC (Complete Blood Count; lab) showed elevated WBCs (white blood cells). UA (urine analysis) collected which also demonstrated abnormal values. C&S (culture and sensitivity; lab test to identify bacteria and determine susceptibility to antibiotics) returned with e coli (escherichia coli; bacteria) and kleb. p (Klebsiella pneumoniae; bacteria), macrobid (antibiotic) started as both organisms sensitive .Symptoms - Urinary Tract .gross hematuria, Urinary Catheter specimen culture with at least 10^5 cfu/ml (colony-forming unit per milliliter) of any organism(s) .Purulent (pus) discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis (coiled tube inside the scrotum), or prostate (small gland below the bladder in men) .Comments ABX (antibiotics) completed. Review of the Physician orders indicated Macrobid (antibiotic) was given Twice a Day x (for) 7 days For UTI (urinary tract infection) started on 3/16/25 with the last dose on 3/23/25. Review of Resident #36's urinary care plan, start date of 3/4/24, stated, (Resident #36) utilizes an indwelling catheter use secondary to urinary retention during hospitalization, also has dx (diagnosis) of benign prostatic hyperplasia (condition that the prostate grows larger than usual). Trial voiding (urinating without the catheter) failed prior to discharge from hospital. He (R36) has the potential for urinary tract infection r/t (related to) catheterization .secure catheter on leg to avoid tension .Enhanced barrier precautions with ADLs (activities of daily living) and cath (catheter) care . Review of Resident #36's Care Area Assessment Summary, dated 2/6/25, stated, .He (Resident #36) does require one person assistance for catheter care. Review of the facility's Catheter -Usage and Care policy, date last reviewed 03/2018, stated, Catheter-Associated Urinary Tract Infection (CAUTI) .In order to prevent a catheter-associated urinary tract infection (CAUTI) .do not allow catheter tubing, bag or spigot to touch the floor .bag comes in different lengths and extension tubing can be added/cut to size to avoid tension at the catheter insertion site. Review of the Centers for Disease Control and Prevention's Summary of Recommendations Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated 2009 and viewable at https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html, stated, .Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Based on observation, interview, and record review the facility failed to develop a person-centered comprehensive care plan for 2 (Resident #31 and Resident #38) of 12 residents reviewed for comprehensive care plans, resulting in the potential for unmet care needs. Findings include: Resident # 31 Review of an admission Record revealed Resident #31 had pertinent diagnoses which included: Dementia, depression, and chronic obstructive pulmonary disease (COPD, a disease of the lungs that causes breathlessness and coughing). During an observation on 3/12/24 at 9:53 AM., Resident #31 was sitting in the recliner chair in her room sleeping wearing the oxygen nasal cannula (tubing connected to an oxygen machine and applied to the face with oxygen delivery into the nose) correctly with the oxygen concentrator running at 2 liters of oxygen per minute. During an observation on 3/12/24 at 12:19 PM., Resident #31 was sitting in her wheelchair in the dining room with an oxygen tank on the back of her wheelchair, nasal cannula tubing present in the bag on the back of the wheelchair. Resident #31 did not have oxygen tank turned on, nor was the nasal cannula applied to Resident #31's face. Review of Resident #31's physician orders revealed .Oxygen 1-2 liters/min Via nasal canula Q (every) shift. OK to Wean as able. - every shift ordered start date of 11/27/2023 . Lorazepam 0.5mg tablet oral by mouth Q week on bath/shower day for anxiety . Review of Resident #31's Care Plan revealed no care plan for oxygen use and no care plan related to anti-anxiety medication use prior to shower. During an observation on 3/13/24 at 9:45 AM., Resident #31 was sitting in her recliner chair in her room with her oxygen nasal cannula on her face and the oxygen concentrator running at 2 liters per minute. Resident #31 was sleeping. During an observation on 3/13/24 at 12:33 PM., Resident #31 was sitting in her wheelchair and was pushed down the hallway towards her room, Resident #31 had the oxygen nasal cannula in place on her face. The oxygen tank on the back of Resident #31's wheelchair was turned on and set to 2 liters/minute. During an interview on 3/13/24 at 12:56 PM, Licensed Practical Nurse (LPN) T reported that Resident #31 should wear her oxygen continuously at 1 to 2 liter/per minute. LPN T reported that Resident #31 can remove her nasal cannula herself. During an observation on 3/13/24 at 2:47 PM., Resident #31 was sitting in her wheelchair in her room. Resident #31 was not wearing her oxygen nasal cannula. Resident #31's oxygen nasal cannula was laying on her over the bed table beside her. The oxygen concentrator was running at 2 liters/minute. During an observation on 3/14/24 at 9:19 AM., Resident #31 was sitting in her recliner chair in her room with her oxygen nasal cannula on her face and the oxygen concentrator running at 2 liters per minute. Resident #31 was sleeping. During an interview on 3/14/24 at 9:34 AM., LPN U reported that Resident #31 has an order to wear her oxygen at 1-2 liters continuously. During an interview on 3/14/24 at 10:47 AM., Registered Nurse/Nurse Manager (RN/NM) M reported that care plans should be specific to each resident. RN/NM M reported that Resident #31 should have a care plan regarding oxygen use and the use of anti-anxiety medications prior to showers. During an interview on 3/14/24 at 11:12 AM., Director of Nursing (DON) B reported that his expectation was that a care plan be in place for any resident using oxygen. DON B reported he noticed yesterday Resident #31 did not have a care plan for oxygen use in place and created one. During an interview on 3/14/24 at 12:00 PM., LPN U reported that Resident #31 should have an anti-anxiety medication on the mornings her shower is scheduled to ease Resident #31's anxiety before her shower is given. LPN U reported that Resident #31's scheduled shower day was Tuesday. During an interview on 3/14/24 at 12:14 PM., Certified Nurse Assistant (CNA) L reported that Resident #31 had to have medicine for her anxiety before her shower is given. CNA L reported that Resident #31's scheduled shower day was Tuesday. Review of Medication Administration Record for Resident #31 revealed that administration of Lorazepam 0.5mg was done on Tuesday 3/12/24 at 06:00 AM. Resident #38 Review of an admission Record revealed Resident #38 had pertinent diagnoses which included: Dementia, diabetes mellitus (a disease that results in elevated blood sugar and low insulin production), and lymphedema (a disease that results in swelling of the legs and/or arms). Review of a Minimum Data Set (MDS) assessment for Resident #38, with a reference date of 12/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #38 was severely cognitively impaired. During an observation on 3/12/24 at 9:39 AM., Resident #38 was sitting in her wheelchair in her room, and it was noted that both legs appeared to be wrapped with dressing material. Review of Physician Orders for Resident #38 revealed . wound care Right lower extremity-1 area noted lower medial shin and 2nd area noted lateral upper shin near knee): cleanse with NS (normal saline) pat dry, apply hydro-cellular Foam Dressing; - every 72 hours (Q (every) 3 days) for wound . started on 3/1/24 .check dressing to (Right lower extremity) Q shift, change PRN if soiled or off,- Topical Every Shift . started 2/29/24 . Review of Care Plan for Resident #38 revealed no care plan related to wound care. During an interview on 3/13/24 at 12:59 PM., RN/NM M reported that Resident #38 does have wound care on her right leg, and it was scheduled to be changed on 3/14/24. RN/NM M reported that care plans were created by departments. RN/NM M reported that the nurse managers and the director of nursing were responsible for the nursing care plan creations for residents. RN/NM M reported that wound care should be a care plan created by nursing. During an interview on 3/14/24 at 11:12 AM., Director of Nursing (DON) B reported that his expectation was that a care plan be in place for any resident who needed wound care. DON B reported that Resident #38 did not have a care plan in place for wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that professional standards of nursing practice were followed during medication administration for 1 (Resident #249) of 16 sampled residents reviewed for professional standards of nursing care resulting in the potential for worsening of health conditions. Findings include: Resident #249 Review of an admission Record revealed Resident #249, was originally admitted to the facility on [DATE] with pertinent diagnoses which included unsteadiness on feet. During an observation and interview on 3/13/24 at 8:26 AM, Licensed Practical Nurse (LPN) U entered Resident #249's room to assess his vital signs. LPN U then exited Resident #249's room and walked over to her medication cart, opened the cart, and grabbed a cup of medications from a drawer. LPN U reported that she had prepared Resident #249's medications earlier in the morning, but when she went to his room to administer the medications, Resident #249 had other staff assisting him so she placed his medications in the cart and moved on to administer medications for someone else. LPN U reported that she thought she could prepare Resident #249's medications prior to administering them because Resident #249 was alert and oriented. LPN U reported that was not aware if the facility had a policy on if nurses were allowed to prepare medications prior to the time that the medications were to be administered. LPN U confirmed that it was not best practice to prepare medications prior to the time that they would be administered as this would be against the rights of medication administration, and could lead to medication errors. During an interview on 3/14/24 at 8:17 AM, Director of Nursing (DON) B reported that it was the facility expectation that nurses did not prepare medications prior to the time that they would be administering the medications. DON B reported that nurses should be checking to see if the resident is available for medication administration before preparing the medications. Review of the facility's Medication Administration policy, last revised 1/2020 revealed, Policy: Medications are administered safely as prescribed in accordance with state and federal guidelines . Administration . 4. Medications are administered at the time they are prepared and by the resident aide who prepared them .

Based on observations, interviews, and record review, the facility failed to ensure a positioning device was consistently used and applied accurately for 1 (Resident #22) of 2 residents reviewed for positioning, resulting in the potential for decreased range of motion and related complications, skin breakdown, contractures (hardening of the muscles, tendons, and other tissues) and pain. Findings include: Resident #22 Review of a Face Sheet revealed Resident #22 was a female, with pertinent diagnoses which included: hemiplegia following cerebral infarction (muscle weakness or partial paralysis following a stroke) affecting right dominant side. Review of Resident #22's current Care Plan revealed a focus of (Resident #22) has a self care deficit related to right sided weakness, secondary to Acute CVA (stroke). She requires assistance with all ADL's (activities of daily living) . with care planned interventions which included Arm rest (brand name omitted) cushion on armrest of wheelchair for right upper extremity (arm) when in the wheelchair with a start date of 11/11/22. During an observation on 3/12/24 at 1:49 PM, noted Resident #22 was seated in her room in her wheelchair. There was an arm rest cushion affixed to the right arm of the wheelchair. Resident #22's right arm was not placed in the cushion; rather, her right arm was bent at the elbow and resting across her abdomen with her right hand underneath her left elbow. During an observation and interview on 3/13/24 beginning at 1:30 PM, noted Resident #22 was seated in her room in her wheelchair. There was an arm rest cushion affixed to the right arm of the wheelchair with Resident #22's arm resting in the cushion. There was a velco strap that was part of the cushion that was applied across Resident #22's right forearm to keep her arm in place on the cushion. The arm rest cushion and Resident #22's right arm had slid around to the outer side of the arm rest of the wheelchair and Resident #22 was leaning slightly to the right. Licensed Practical Nurse (LPN) T, who was in the hallway outside Resident #22's room, was queried about Resident #22's positioning at that moment and about the purpose of the cushion. LPN T looked at Resident #22 in the wheelchair and reported Resident #22's arm rest cushion was on backwards, such that the longer lip of the cushion was on the inner side (next to Resident #22) instead of on the outer side of the armrest which was why the cushion and Resident #22's arm had slid outward. LPN T reported that therapy had worked with Resident #22 because the resident tended to pull her arm close to her body and never straighten it. LPN T reported that the arm rest cushion was supposed to be used every time Resident #22 was in her wheelchair to help keep her arm straight. In an interview on 3/14/24 at 10:46 AM, Therapy Manager (TM) GG reported Resident #22 had limited range of motion of her right arm following a stroke, and that she couldn't move the arm and it was tight. TM GG reported the purpose of the positioning cushion (referred to by TM GG as a lateral arm support cushion) for Resident #22 was to position her arm to prevent further contracture, assist with skin integrity, and reduce potential of pain when staff were performing ADLs (such as dressing the resident). TM GG demonstrated proper application of the cushion to the wheelchair arm and reported that the longer flap of the cushion needed to be on the outer side of the arm of the wheelchair to prevent the device from slipping away from the chair. TM GG reported if the longer flap of the cushion was on the inner side of the armrest of the wheelchair, it was applied improperly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #26 Review of a Face Sheet revealed Resident #26 was admitted to the facility on [DATE] with pertinent diagnoses which included: venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes) and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). During an observation on 1/24/23 at 11:14am, Resident #26 was seen sitting in a recliner with bilateral lower legs wrapped and protective sleeves in place. Review of Resident #26's Care Plan revealed no problems, goals or care approaches related to peripheral vascular disease, venous insufficiency or treatments in place for lower legs. In an interview on 1/25/23 at 11:31am, Registered Nurse (RN) J reported Resident #26 received dressing changes to bilateral lower legs every 3 days prior to 1/22/23, when the physician changed the order to dressing changes every other day. RN J reported the resident currently had no open areas on either lower leg but previously had wounds. Review of Resident #26's Physician Orders revealed four orders related to peripheral vascular disease to include: 1. R (right) moist/exudating (draining) areas of lower anterior (front) and posterior (back) ankle; cleanse with normal saline, apply xerofoam dressing (made up of a petrolatum blend on fine mesh gauze), ABD pad (used to absorb discharges from heavily draining wounds), secure with kling (gauze wrap) and tape, every other day for venous stasis ulcer (wound caused by vein and blood flow issues). Start date 1/22/23. 2. Tubagrip (a wrap that provides continuous support for the management of swelling) to bilateral legs knee to foot on during day off at night. Start date 1/16/23. 3. Furosemide (used to reduce extra fluid in the body) 20 mg tablet for HTN (high blood pressure)/Edema (swelling caused by too much fluid trapped in the body's tissues). Start date 11/23/22. 4. Elevate feet in bed. Start date 8/23/22. In an interview on 1/25/23 at 11:43am, Unit Manager Registered Nurse (RN) Y confirmed that Resident #26 did not have a care plan related to her diagnosis of peripheral vascular disease or venous insufficiency. Unit Manager RN Y reviewed current and past care plans and stated, There is not a care plan for those issues. Unit Manager RN Y reported the care plan should include Resident #26's diagnoses of venous insufficiency and peripheral vascular disease along with the prescribed treatments, to avoid a potential worsening of her skin condition, such as weeping of the skin and vascular ulcers. Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive, person-centered care plan for 2 of 2 residents (Residents #38 and #26) reviewed for care plans, resulting in Resident #38's fall mats not being implemented to prevent injury from falls and Resident #26 not having a care plan developed for the treatment of peripheral vascular disease. Findings include: Resident #38 Review of an admission Record revealed Resident #38 was a male with pertinent diagnoses which included pertinent diagnoses of dementia with severe anxiety, spinal stenosis, low back pain, lumbago with sciatica, right side, pain in right shoulder, pain in left shoulder, pain in right wrist, repeated falls, weakness, unsteadiness on feet, and glaucoma (nerve connecting the eye to the brain is damaged causing blindness). Review of a Minimum Data Set (MDS) assessment for Resident #38, with a reference date of 12/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated Resident #38 was cognitively moderately cognitively impaired. Review of current Care Plan for Resident #38, dated 7/13/22, revealed, .(Resident #38) is at risk for falls and injury r/t (related to) impaired mobility and symptoms of dementia . with the intervention .remain free of injury secondary to falls .Floor mats at bedside. Bilaterally . Review of Care Guide dated 1/25/23, revealed, .Falls, Safety, Alarms, SR .Fall Risk .Floor mats on both sides of bed when res (resident) in bed . During an observation on 1/25/23 08:38 AM, observed Resident #38 lying in his bed finishing his breakfast. Observed no bilateral fall mats at the bedside or side rails to assist with mobility. In an interview on 1/25/23 at 8:40 AM, Registered Nurse (RN) J reported when a resident had interventions the nurse was able to review the treatment care record as they were located there. Bilateral fall mats next to bed was not observed in the treatment care record. RN J reported the care plan would have the interventions. Reviewed the falls care plan and the intervention, bilateral fall mats next bed was there. Proceeded to Resident #38's room and RN J reported the bilateral fall mats were not in place next to Resident #38's bed. RN J' reported the fall intervention was important to be in place for the safety of the resident, in case he fell while attempting to get out of bed, to prevent injury. Review of 100 Hall Nurses Report dated 1/25/23, revealed, no intervention documented for bilateral fall mats next to Resident #38's bed. In an interview on 01/25/23 at 8:48 AM, Certified Nursing Assistant (CNA) K reported to find out what interventions or precautions were in place for a resident, the care guide, which is located at the central nurse's desk, would inform the nursing staff of what interventions were needed to care for the resident. CNA K reported when staff signed in for their shift, they received a printed care guide for the group of residents they were responsible for during the shift. In an interview on 01/25/23 at 12:23 PM, CNA E reported the staff would sign in on the schedule which shows you the group assignment for the day. The nurse has the care guide for your assigned group printed out already for you. Reviewing the care guide, you can see what the resident needs for diet, mobility, need for transfers, falls/safety and any special instructions. Review of ID Notes dated 12/15/22 at 5:55 PM, Resident #38 revealed, .Was Care Planned reviewed: Yes .Care plan revisions: Added floor mats to bilateral sides of bed, to prevent injury .Resident and wife agree with current plan of action, to add floor mats at the bedside . In an interview on 01/25/23 at 1:47 PM, Director of Nursing (DON) B reported the expectation would be staff would review the care guide and ensure the fall interventions were in place. DON B reported the care plan and care guide should be a mirror and the interventions implemented at the bedside. Review of policy, Fall Program: Prevention & Management revised 6/2020, revealed, .Following each fall, residents are assessed and care plans are reviewed and revised as needed .4. Initiate or revise the certified nurse aide (CAN) care guide to include all current fall risk prevention interventions . In an interview on 1/25/23 at 12:40 P.M., DON reported Resident #26 admitted several months ago with venous wounds, but that the resident currently had no open wounds. DON reported that Resident #25 had stasis dermatitis (inflammatory skin changes caused by chronic edema due to poor circulation and blood pooling) on her lower legs as a result of her peripheral vascular disease. During an observation and interview on 1/25/23 at 12:49 P.M. Resident #26 was sitting in her recliner in her room. Both of Resident #26's lower legs were observed with thick gauze bandaging and tubigrip extending from toes to the knees. DON removed the bandages, which included a stretch gauze wrap, multiple ABD pads, and Xeroform dressings. The skin on Resident #26's right lower leg and foot was observed red, shiny, and fragile, with clear fluid drainage. The skin on Resident #26's left lower leg was observed red and shiny. DON reported that Resident #26 should have a care plan that included her peripheral vascular disease, along with the stasis dermatitis and stated, .especially with her having the ongoing treatments in place . The care plan (see Chapter 18) is a map for nursing care and demonstrates your accountability for patient care. By making accurate nursing diagnoses, your subsequent care plan communicates a patient's health care problems to other professionals and ensures that you select relevant and appropriate nursing interventions. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 16159-16161). Elsevier Health Sciences. Kindle Edition. A well-planned, comprehensive nursing care plan reduces the risk for incomplete, incorrect, or inaccurate care. As a patient's problems and status change, so does the plan. A nursing care plan is a guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used later in evaluation (see Chapter 20). The plan of care communicates nursing care priorities to nurses and other health care providers. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 16878-16882). Elsevier Health Sciences. Kindle Edition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain air conditioners to be free from the accumulation of dust and debris in seven of eleven air conditioners assessed for cleanliness. This resulted in an increased risk of poor air quality and an increased risk of adding particulate matter to the air in the following rooms. Findings Include: During a tour of the facility, at 1:10 PM on 1/23/23, observation of resident room [ROOM NUMBER] found an air conditioner unit mounted on the far side wall. Observation of the unit found excessive accumulation of black spots and dusty debris. When asked how often these get cleaned, Housekeeping Manager Z stated that facilities would take care of that, and I am not sure of their schedule. During an interview with Facilities Manager AA, at 1:28 PM at 1/23/23, it was found that the wall mounted air conditioner units should have the filters cleaned and a vendor service the units twice a year. During a tour of the 200 hall, at 1:32 PM on 1/23/23, it was observed that both wall mounted units, in resident rooms [ROOM NUMBERS], were found with accumulation of debris inside the fan portion of the unit. During a tour of the facility, starting at 2:39 PM on 1/23/23, the following resident rooms were found with excessive accumulation of debris and black spotting on the inside of the wall mounted air conditioner units: 102, 111, 112, 113, 207, 214, and 215. An interview with Facilities BB, at 2:52 PM on 1/23/23, found that the wall mounted air conditioner units typically don't get deep cleaned until we do a deep clean of the room and the resident has moved out.