**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure a comprehensive, person-centered care plan was developed, accurate, and revised to assure assessed care needs were implemented for 1 of 2 residents (R6) reviewed for urinary tract infections (UTI). Findings include: R6's significant change Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment and required assistance with all activities of daily living (ADL)'s. R6's diagnoses included hypertension, renal insufficiency, thyroid disorder, arthritis, non-Alzheimer's dementia, depression, respiratory failure, chronic respiratory failure with hypoxia, mononeuritis multiplex, morbid obesity and dependence on supplemental oxygen. R6's face sheet, print date of 4/9/25, included a diagnosis of urinary tract infection (UTI). R6's electronic health record indicated the following UTI history: 10/30/24 - was diagnosed with a UTI and was started on Cephalexin (antibiotic) 500 mg every 12 hours for seven days. 11/15/24 - was diagnosed with a UTI and was started on Bactrim (antibiotic) 800-160 mg twice daily for ten days. 12/10/24 - was started on methanamine hippirate (antibacterial medication)- one gram twice daily for recurrent UTI's. 1/9/25 - diagnosed with a UTI and was started on Cephalexin 500 mg every 12 hours for seven days 2/11/25 - was started on a cranberry supplement 500 mg twice daily for recurrent UTI's 3/20/25 - diagnosed with a UTI and was started on Cephalexin 500 mg every 12 hours for seven days. R6's physician orders, print date of 4/9/25, indicated an order for methenamine Hippurate (antibacterial medication used primarily to prevent and treat urinary tract infections) - one gram by mouth twice daily for recurrent UTI's. R6's care plan, print date of 4/9/25, did not include R6's urinary tract infection, R6's history of urinary tract infections, goals of treatment, and interventions allowing the nurse to assess the intervention's outcome and potentially revise care based on the resident's status. During interview on 4/10/25 at 9:58 a.m., registered nurse (RN)-A clinical coordinator stated the clinical coordinators are responsible for updating the resident's care plans. RN-A stated if a resident had an history of UTI's it should be included in the care plan so staff are watching for signs and symptoms and could recognize them earlier to treat the UTI sooner. RN-A stated it was important to include history of UTI's on the care plan to help with implementation of interventions or staff being aware so symptoms could be recognized and acted on. RN-A confirmed R6's care plan did not include that R6 had a history of UTI's or goals/interventions to prevent and treat UTI's. During interview on 4/10/25 at 10:06 a.m., director of nursing (DON) stated each discipline of practice completes their section on the resident's care plan. DON stated medical or nursing related issues were completed by the clinical coordinators. DON stated she would expect staff to update the RN clinical coordinator with any changes with the resident. DON stated if a resident had a history of UTI's, she would expect that to be included in their care plan. DON stated it was important so staff can know that R6 is susceptible to UTI's and that all steps are taken such as, thorough cares, increasing fluids and noticing the symptoms that R6 displays with UTI's so we can respond quickly with treatment. The facility Care Plans, Comprehensive Person-Centered policy, dated 2/25, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practical able physical, mental, and psychosocial well-being. c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. d. Incorporate identified problem area. e. Incorporate risk factors associated with identified problems f. Reflect the resident's expressed wishes regarding care and treatment goals. g. Reflect treatment goals, timetable and objectives in measurable outcomes. h. Identify the professional services that are responsible for each element of care: i. Aid in preventing or reducing decline in the resident's functional status and/or functional levels. j. Reflect currently recognized standards of practice for problem areas and conditions. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure medication regimens were free of unnecessary psychotropic drugs for 3 of 6 (R20, R43 and R6) residents reviewed who had orders for antianxiety medications beyond 14 days without documented rational. Findings include: R20's significant change Minimum Data Set, dated [DATE], identified severely impaired cognition with diagnosis of Alzheimer's dementia. R20's order listing report dated 4/10/25, identified an order for prn (per requested need) for Ativan (an antianxiety medication) oral tablet 0.5 mg (milligrams) to be given by mouth every 4 hours as needed for terminal agitation with a start date of 2/28/25 and an end date of 2/21/26. R20's care plan dated 2/5/25, identified the potential for adverse drug interactions related to the use of multiple medications including an antianxiety medication and directed staff to ensure minimum effective therapeutic dosing. R20's February 2025 medication administration record (MAR) indicated she had not used prn Ativan. R20's March 2025 MAR indicated she had used prn Ativan one time. R20's April 2025 MAR indicated she had not used prn Ativan. When reviewed on 4/10/25, R20's medical record lacked evidence of any provider rationale for continuation of the prn ativan beyond 14 days. R43's quarterly MDS dated [DATE], identified intact cognition and a diagnosis of anxiety. R43's order listing report dated 4/10/25, identified an order for prn Ativan oral tablet 0.5 mg by mouth one time a day for anxiety and give 0.5 mg by mouth as needed for anxiety with a start date of 4/7/25 and an end date of 10/3/2025. R43's care plan dated 8/27/24, identified the potential for adverse drug interactions related to the use of multiple medications including an antianxiety and directed staff to ensure minimum effective therapeutic dosing. R43's April 2025 MAR indicated she had used prn Ativan two times. When reviewed on 4/10/25, R43's medical record lacked evidence of any provider rationale for continuation of the prn ativan beyond 14 days. R6's significant change Minimum Data Set, dated , 1/31/25 identified severely impaired cognition, diagnoses of Alzheimer's dementia. R6's order listing report dated 4/9/25, identified an order for prn (per requested need) for Ativan (an antianxiety medication) oral tablet 0.5 mg (milligrams) to be given by mouth every 4 hours as needed for terminal agitation with a start date of 2/13/25 and an end date of 1/12/26. R6's care plan print date of 4/9/25, identified the potential for adverse drug interactions related to the use of multiple medications including an antianxiety medication and directed staff to ensure minimum effective therapeutic dosing. R6's February medication administration record (MAR) indicated she had not used any prn Ativan. R6's March 2025 MAR indicated she had not used any prn Ativan. R6's April 2025 MAR indicated she had not used any prn Ativan. When reviewed on 4/10/25, R6's medical record lacked evidence of any provider rationale for continuation of the prn ativan beyond 14 days. When interviewed on 4/9/25 at 4:47 p.m., the pharmacy consultant (Pharm D) stated a review of resident medications was completed monthly including any psychotropic (drugs that affect thoughts, behaviors, mood and perception) medications. The Pharm D stated any prn psychotropic medication including antianxiety medications such as Ativan were to be ordered only for a 14-day period and any continuation beyond that timeframe required review by and a statement of clinical rationale by the resident's provider. The Pharm D confirmed there was no documented clinical rationale for the extended prn Ativan orders for R20, R43 and R6 and she should have made this recommendation to their providers. When interviewed on 4/10/25 at 9:29 a.m., the director of nursing (DON) stated the facility process for review of psychotropic medications was done by the facility interdisciplinary team (IDT) monthly. The DON stated her expectation for R20's, R43's and R6 prn antianxiety medication orders would have been to have had a 14-day end date or review and provider clinical rationale for continued use and acknowledged this had been missed for R20, R43 and R6. The facility policy Psychotropic Medication Management-Long Term Care dated 10/2023, identified As needed orders for psychotropic drugs (with the exception of anti-psychotics) are limited to 14 days. Unless, the attending physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days in which case he/she should document their rationale in the resident's medical record and indicate the duration for the as needed order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and document review, the facility failed to ensure the required nurse staffing information was posted daily for 3 of 3 days reviewed. This had the potential to affect all 48 residents residing in the facility, visitors and staff who may wish to view the information. Findings include: During observation on 4/7/25 at 11:32 a.m., the nurse staffing information was posted on wall inside the entrance of the facility. However, the posted nurse staffing information was dated for 4/7/25 and 4/8/25. Posting did not include the facility name, current census and had inaccurate information posted. Posting included trained medication aides (TMA)'s posted on specific units of the facility labeled Team Leader LPN [licensed practical nurse] [NAME] Oaks and Charge Team Lead LPN Whispering Pines During observation on 4/8/25 at 8:00 a.m., same nurse staffing information remained posted on wall from 4/7/25. Posting did not include the facility name, current census and had inaccurate information posted. Posting included trained medication aides (TMA)'s posted under the section labeled Team Leader LPN [NAME] Oaks and Charge Team Lead LPN Whispering Pines During observation on 4/9/25 at 8:15 a.m., the nurse staffing information dated for 4/9/25 and 4/10/25 was posted. Posting did not include the facility name, current census and had inaccurate information posted. Posting included trained medication aides (TMA)'s posted under the section labeled Team Leader LPN [NAME] Oaks and Charge Team Lead LPN Whispering Pines During interview on 4/10/25 at 8:52 a.m., business office manager (BOM) confirmed she completed the daily staff postings and posts them to let staff know where they are working and she tried to keep it updated as much as possible. BOM stated she posts two days at a time. BOM confirmed there were TMA's listed under the Team leader LPN section, the facility name was not included on posting and the current census was not reflected on posting. BOM stated it was important to have the correct information so families and resident know the numbers of staffing the facility was running with, ensures we had the correct number of staff on so if something happened, we would have proof that we were properly staffed. BOM stated it was important to have staff listed under the correct titles because it could be false information and give off the wrong information as there are many things an LPN could do that a TMA could not legally do. During interview on 4/10/25 at 10:11 a.m., director of nursing (DON) stated the daily staff posting was for compliance. DON stated TMA's should not be listed under the LPN section as that was false documentation and families could think the TMA was able to do things that an LPN should do. DON confirmed posting did not contain the facility name or the current census. The facility's Posting of Nursing Hours policy, dated 4/25, indicated the facility posted nursing staffing data was to make staffing information readily available for resident and visitors at any given time. Staffing personnel and/or their designee will post the following daily information in a prominent area of the facility: 1. Facility name 2. Current date 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to provide timely results of x-rays services for 3 of 3 residents (R1, R2, R3) reviewed for timely diagnostic services. Findings include: R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnosis of Alzheimer's disease. R1's MDS indicated R1 had severe cognitive impairment with memory loss and a history of falls. R1's care plan dated 12/10/24, indicated R1 had a history of falls. On 1/7/25 at 4:46 a.m., a progress note indicated R1 had an unwitnessed fall with a 1.5 centimeter (cm) x 1.5 cm laceration noted to the left side of her head. On 1/8/25 at 9:41 a.m., a progress note indicated R1 had swelling to her left forearm. R1 was observed to use her left hand less than usual. On 1/9/25 at 5:23 p.m., a progress note indicated R1 had a bruise on her left arm around the elbow measuring 5.5 x 9.7cm x 9.7cm. R1 denied pain, and was able to complete range of motion (ROM). On 1/9/25 at 6:05 p.m., a progress note indicated the on-call provider was contacted, and an x-ray was ordered to be completed 1/10/25. On 1/9/25, a Physician's Order directed R1 to have an elbow x-ray. On 1/10/25 at 3:55 p.m., a progress note indicated R1's x-ray was completed at 1:30 p.m., with her daughter present. On 1/15/25 at 4:10 p.m., a progress note indicated R1 had increased swelling over the past two days. The clinic was called requesting the provider to review x-ray results. The clinic nurse informed registered nurse (RN)-A it might take up to two weeks to get the x-ray results. On 1/15/25 at 4:33 p.m., a progress note indicated R1's medical doctor (MD)-A personally reviewed R1's x-ray and recommended evaluation in the emergency room (ER). On 1/15/25 an After Visit Summary indicated R1 had diagnoses of closed fracture dislocation of left elbow, and closed displaced fracture of medial epicondyle of left humerus (bony prominence located on inner side of the elbow joint). On 1/29/25 at 9:20 a.m., registered nurse (RN)-A stated it took the facility five days to receive R1's x-ray results. R1 had increased swelling on 1/14/25 and 1/15/25. She called the clinic on 1/13/25, 1/14/25 and 1/15/25 requesting x-ray results. R1's physician looked at the x-ray himself on 1/15/25 and sent her to the ER due to a fracture to the left elbow, indicated by the x-ray. R2's significant change MDS dated [DATE] indicated R2 had a diagnosis of non-traumatic brain dysfunction and dementia. On 1/16/25 at 5:42 p.m., a progress note indicated MD-A ordered an x-ray of R2's right foot, and the x-ray was completed. On 1/21/25 at 1:55 p.m., a progress note indicated MD-A reviewed R2's foot x-ray and did not see any fracture. On 1/22/25, a Final Result Report indicated R2's x-ray of the foot indicated no definitive findings to explain symptoms. R3's significant change MDS dated [DATE] indicated R3 had diagnoses of debility, heart failure and respiratory failure. On 11/21/24 at 11:49 a.m., a progress note indicated MD-A ordered a chest x-ray for R3 following a clinic visit. On 12/2/24, a Final Result Report for R3's chest x-ray indicated R3 had cardiomegaly (enlarged heart), central vascular congestion, a large left pleural effusion (buildup of fluid between the tissues that line the chest), negative for pneumothorax (a condition where air leaks into the space between the lungs and chest wall), and calcified arteries. On 1/29/25 at 1:35 p.m., the assistant director of nursing (ADON) stated she did not find it acceptable to wait five days for x-ray results. On 1/29/25 at 2:00 p.m., the director of nursing (DON) stated she was told x-ray readings were delayed due to a shortage of radiologists. She expected to have x-rays read within 24 hours. On 1/29/25 at 2:33 p.m., the administrator stated the facility should have been made aware of R1's fracture within a couple of hours. The timeframe for x-ray results should be communicated to the facility. On 1/29/25 at 3:27 p.m., MD-A stated R1's x-ray was ordered by another provider in his absence on 1/9/25. He looked at the x-ray himself on 1/15/25 and observed a fracture. R1's x-ray from 1/10/25 was not formally read by radiology until 1/19/25. R2's foot x-ray was not read in a timely fashion. R2's x-ray was ordered on 1/16/25 and formal results were not available until 1/23/25. R3's chest x-ray was ordered on 11/21/25 and formal results were not available until 11/30/24. MD-A stated it is not unusual to wait 7-10 days for x-ray reports, which is not ideal. On 1/30/25 at 9:19 a.m., the director of regional hospital imaging department (DOR) stated he did not think there was formal process for the expectation of time for providing x-ray results. The delay was due to staffing shortages. General x-ray results were taking 5-7 days to review, unless they were marked STAT (immediate). The ordering provider should be looking at the images after they were completed, and they should not be waiting for the radiologist to provide their findings. On 1/30/25 at 1:50 p.m., via email, the DON stated the facility did not have a diagnostic testing policy via email. A facility document Contract for Radiology Services dated 1/18 directed to complete medical records in a timely and legible fashion.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to document assessments that occur during pressure ulcer dressing changes to include measurements and visual data and have a system to ensure appropriate reporting with findings and follow up occurred when the need for a more thorough assessment was identified for 1 of 1 resident (R1). Findings include: R1's admission Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses of osteomyelitis of vertebra (infection in a bone), extradural and subdural abscess (area of pus located in brain), severe protein-calorie malnutrition, acute infarction of spinal cord (stroke within the spinal cord), and a pressure ulcer. R1's care plan dated 9/5/24, indicated R1 had a deep tissue pressure ulcer to coccyx. Staff were to administer pain medications as directed, observe for signs and symptoms of pain with treatments, ensure an air mattress was on his on bed, assist/encourage R1 to float his heels while in bed, ensure a foot cradle was in place to offload pressure, provide nutritional supplements as ordered, observe for signs or symptoms of infection, and reposition side to side every 2 hours. There was no mention staff were to document findings when providing ordered dressing changes. R1's Weekly Complex Wound assessment dated [DATE], identified R1 had an unstable pressure wound located on coccyx measuring 11 centimeters (cm) long, 2.7 cm wide, and depth was 0.3 cm. Further assessment identified moderate amount of serous (thin, watery, clear drainage) exudate, slight odor present, 10% granulation tissue (pink or red tissue with shiny, moist, granular appearance), 40% slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or mucinous), and 50% necrotic tissue (black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges). R1's wound was noted to have 0.3 millimeters (mm) tunneling at 6 o'clock. R1 was scheduled to have a wound consult on 8/22/24. R1's physician was notified. R1's Medication Administration Record (MAR) for August 2024, revealed R1 had a wound treatment order which was Mepilex 6x6 to coccyx ulcer three times a week and as needed if soiled. R1's Treatment Administration Record (TAR) identified dressing changes and wound treatments were completed on 8/16/24, 8/19/24, and 8/21/24. R1's progress notes identified no corresponding treatment note, originating for the TAR was made on 8/16/24, 8/19/24, or 8/21/24 that would identify characteristics of the pressure ulcer, changes that were identified by licensed staff, or notification for the need for a formal assessment due to changes in the wound. R1's medical record lacked evidence of a any wound assessment on 8/16/24, 8/19/24, or 8/21/24, when R1's wound treatment was completed. On 9/17/24 at 1:08 p.m., licensed practical nurse (LPN)-A stated as a licensed nurse if she was made aware there was a change with a resident's wound, she would complete an assessment and notify the director of nursing (DON) with the information as well as informing the resident's physician. LPN-A stated upon notifying management, they would complete a comprehensive assessment on the wound and assess the wound more thoroughly. LPN-A stated R1 was admitted to the facility with a sacral wound. LPN-A stated she observed R1's wound on Friday 8/16/24, and again on Sunday 8/18/24, and LPN-A stated the wound looked worse and notified registered nurse (RN)-A and DON via email. LPN-A was unsure what happened after that but assumed RN-A re-assessed R1's wound on Monday 8/19/24. In addition, LPN-A could not recall if she documented the wound in R1's medical record regarding identified changes she made during her observations while providing wound care. RN-A was no longer employed by the facility at the time of survey and was unavailable for interview. On 9/17/24 at 4:25 p.m., DON stated R1 was admitted to the facility with the wound on his coccyx. The DON was made aware the need for a formal assessment via email from LPN-A regarding a concern of R1's wound potentially worsening but could not recall what the email said specifically. It was addressed to RN-A and the DON had been cc' d on the email. DON stated there was no evidence in R1's record of R1's wound being re-assessed after the change was identified by LPN-A, nor was there documentation to support her visual assessments at the time dressing changes were performed had been documented. Staff were expected to re-assess a change in a wound, document the assessment, and add progress notes identifying changes or current status of wounds. Further interview on 9/17/24 at 5:07 p.m., with LPN-A identified she sent the email to RN-A and the DON on 8/18/24 at 4:34 p.m On 8/16/24, when she saw R1's wound the wound bed appeared to be red in color but on 8/18/24, the wound bed now appeared to have white slough in the wound bed and an area that appeared to be brown in color, and another area at the 5 p.m. mark (like on a clock) that appeared to show muscle involvement in the wound. In her opinion, the wound had appeared worse as she recalled that was a change from 8/16/24, when she observed it and provided the dressing change. LPN-A had not documented her finding from wound care or dressing changes to identify characteristics of the wound, in order for staff to determine if changes were occurring that would warrant a more formal assessment or the need to update the physician. On 8/18/24 at 10:04 a.m., family member (FM)-A stated R1 was admitted to the facility with the wound on his tailbone area. FM-A stated R1 was sent to the hospital on 8/21/24 for another concern, and the non-visible wound was debrided surgically, and a wound VAC (vacuum) was placed. On 8/18/24 at 12:26 p.m., the medical director (MD) stated he would expect the facility to follow policy and procedures and if needed, notify him if a wound had deteriorated or showed signs and symptoms of infection. On 8/18/24 at 1:00 p.m., DON confirmed there was no documentation to support that assessments were documented, or a more thorough assessment had been performed. Review of facility policy titled Pressure Injury Management, dated April 2024, indicated a resident who had a pressure injury received necessary treatment and services to promote healing, prevent infection, and prevent the development of new pressure injuries. Upon performing dressing changes, staff were to have necessary supplies, practice goof infection control technique, inspect the wound, noting location and color, amount, and odor of any drainage or necrotic (dead tissue) debris. Staff were to note these characteristics, measure the wound, notify the physician for signs of infection or wound deterioration, and document the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure resident's physician and responsible parties were notified in a timely manner for 1 of 1 resident (R1) reviewed for notification of change, who had increasing depression and had attempted to harm self. Findings include: A Vulnerable Adult Maltreatment Report dated 8/15/24, identified a report had been submitted for R1 which alleged resident's increasing depression, anxiety and attempt to strangle self with resident's nasal cannula (tubing attached to an oxygen source to deliver oxygen). These included increased comments voiced by R1 of telling family members she would rather die than stay here, and on 8/13/24 that she was going to kill herself. On 8/13/24 at 9:55 p.m., licensed practical nurse (LPN)-A, documented in R1's medical record, Resident stated she was going to kill herself and had her oxygen cannula wrapped around her neck. Staff removed the cannula around the neck. [Daughter] [family member (FM)-B], is currently visiting with her to help her sleep. Resident states she sees people outside her window as well. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was moderately cognitively impaired, fed self after set up, but required extensive assistance for transfers, dressing, grooming and toileting. Further, the MDS documented diagnoses of chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, hypertension, cirrhosis, insulin dependent diabetes, major depression, and arthritis. R1's Care Area Assessment (CAA) for Cognitive Loss / Dementia, (from the admission MDS - dated 6/27/24), the facility documented the following: Resident does have a diagnosis of cognitive decline as well as delirium. She also has mild recurrent major depressive disorder. In regard to respiratory, she has a diagnosis of chronic respiratory failure with hypoxia, chronic interstitial lung disease and a [history] of pneumonia. Resident also has liver cirrhosis and fatty liver disease. In regards to possible incontinence she has a diagnosis of bladder cancer . R1's Preadmission Screening and Resident Review (PASARR) dated 6/18/24, indicated R1 did not have any developmental disability, mental illness, suicidal ideation nor civil confinement for mental illness. R1's Clinical Resident Profile from her electronic medical records (print date of 8/21/24), listed R1's primary physician's name and contact number, as well as the contact information for three family members. The family members were listed in order of who was to be contacted first. R1's electronic medical record (EMR) from the time of LPN-A's entry on 8/13/24 at 9:55 p.m., lacked what interventions and safety measures the facility staff implemented, until 8/14/24 at 8:48 a.m., when social services assessed R1 and contacted resident's primary physician and daughter. In a telephone interview on 8/20/24 at 11:35 a.m., LPN-A stated one of the nursing assistant (NA)-A came up to her and stated R1 voiced she wanted to die. LPN-A suggested to the NA-A to bring R1 out of her room to the day room and offer her coffee and a snack (the dayroom was across from the nurse station) to be more easily observed. At approximately 9:00 p.m., LPN-A stated the NA's (NA-A and NA-B) offered to get R1 ready for bed and R1 agreed. At approximately 9:30 p.m., LPN-A stated NA-A came to get her and said R1 was wrapping her nasal cannula around her neck. LPN-A entered the room noting NA-B holding R1's hands. LPN-A and NA's removed the cannula. While LPN-A was settling R1, she sent one of the NA's to call R1's daughter to see if she would come in and sit with R1 until she fell asleep. LPN-A stated family member (FAM)-B came in and sat with R1 until she fell asleep, leaving at 2:00 a.m. LPN-A verified neither she nor the NA informed family (FAM-A and FAM-B) of R1 wrapping the nasal cannula around her neck. Nor did the facility contact R1's primary physician or any on-call physicians. LPN-A stated the only conversation she had with FAM-B was FAM-B wanting the nurse to give R1 something to knock her out. LPN-A stated they did not have any orders for that type of intervention. LPN-A was asked if during that conversation, had she mentioned to FAM-B about R1's incident. LPN-A stated: no I didn't, she was kind a stand-off-ish. LPN-A stated from the time FAM-B left until morning staff came on (2:00 a.m. - 6:30 a.m.), she and the two NAs checked on R1 every 30 minutes, finding her sleeping until 6:30 a.m., when R1 requested to be toileted. During telephone interview on 8/20/24 at 11:51 a.m., the reporter (Report) stated the facility did not do enough to monitor R1's safety after finding R1 with the nasal cannula around her neck. Report stated the staff should have called the primary MD, on-call physician or brought her to the adjoining emergency room. An interview on 8/20/24 at 12:22 p.m., director of nursing (DON) stated after review of R1's EMR documentation during and after the incident, LPN-A lacked appropriate documentation to fully understand what occurred. DON verified the record lacked evidence that R1's primary physician / on call physician and family were contacted. During telephone interview on 8/20/24 at 2:05 p.m., FAM-A verified someone from the facility had called her around 9:30 p.m. on 8/13/24. However, she was only told that R1 was upset and wanted family to come in to visit. FAM-A stated she called FAM-B and requested FAM-B to go in and sit with R1. When asked if R1 would have the ability to follow through on harming herself, FAM-A only stated, R1's actions were not purposeful. An interview on 8/21/24 at 8:11 a.m., social work designee (SWD) stated she had not been informed of R1's attempt to harm self until the next morning during stand-up meeting with the interdisciplinary team. SWD performed a PHQ-9 (a depression assessment) and found R1's score greatly increased from admission over a month ago. SWD then performed a Columbia Suicide Assessment and found R1's score high. The facility then contacted R1's primary physician and FAM-A and transferred R1 to the adjoining emergency room for further assessment. During a telephone interview on 8/21/24 at 9:48 a.m., R1's primary physician (PP) verified neither he nor the on-call physician had been contacted about R1's incident of wrapping the nasal cannula around her neck until the morning of 8/14/24. PP stated he has known R1 for about 24 years and did not feel she was capable of mentally or physical strength to following through on the act. PP stated the facility staff should have contacted him or the on-call physician immediately for orders and further assessment. PP mentioned labs and CT scans were completed the day prior and found R1's liver function and ammonia levels were elevated. PP stated this could be root cause for the change in mental disturbance and her actions. When asked about facility staff monitoring R1 only every 30 minutes from 2:00 a.m. until 6:30 a.m., PP responded at least they did that. On 8/21/24, between 10:07 a.m. and 10:18 a.m., attempted to make contact with the two NAs (NA-A and NA-B) on the relief shift of 8/13/24, and the two NAs (NA-C and NA-D) on the night shift (scheduled from 8/13/24 until the morning of 8/14/24), receiving no return calls or messages. During an interview on 8/21/24 at 11:03 a.m., the facility administrator stated during general orientation all staff were educated in Vulnerable Adult regulations. In that education suicide was briefly discussed. Since this incident, all staff were provided copies of the facility's policy on Suicide Prevention. Furthermore, all staff have been assigned an online course in EDUCARE on Vulnerable Adult with a section on suicide prevention. Staff are to have it completed by Wednesday August 28, 2024. In review of the facility's policy, entitled: Suicide Prevention (effective date 01/2024) indicated in the following sections: A. Staff will notify Social Services of a resident making suicidal comments. If Social Services is not available, will notify the charge nurse. D. Social Services and/or the nurse will document investigation with the resident in the progress notes section of the medical record. E. If a resident is found to be actively suicidal, with the intent to harm self and meaningful plan the resident will not be left unattended. G. The resident's provider or provider [on-call] will be notified of situation, provider orders obtained as to what staff should do for resident. Orders will be followed. I. Responsible party of resident will be updated on resident's situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the completed quarterly Minimum Data Set (MDS) was accurately coded to reflect hospice services for 1 of 1 resident (R10) reviewed for MDS' accuracy. Findings include: The CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/2023, identified each section of the MDS along with various instructions how to code and/or complete them. The section labeled, Section O: Special Treatments, Procedures, and Programs, listed directions to record any special treatments or programs the resident received during the specified time period (i.e., assessment reference date; ARD). This included, . Hospice Care, and outlined, Code residents identified as being in a hospice program . where any array of services is provided for the palliation and management of terminal illness . R10's quarterly MDS dated [DATE], identified diagnoses included non-Alzheimer's Dementia, diabetes mellitus, end stage renal disease and hypertension (elevated blood pressure). The MDS failed to identify R10 received hospice care in section O- Special Treatments and Programs. Face sheet printed 2/14/24, identified R10 was admitted to hospice services on 8/8/23. During an interview on 2/14/24 at 9:45 a.m., registered nurse (RN)-A verified he had reviewed R10's MDS (dated 11/17/23) and stated hospice care should have been coded adding, That was a mistake. During an interview on 2/14/24 at 12:10 p.m. the director of nursing (DON) stated R10 was on hospice for some time. The DON stated MDS assessment accuracy was important because it drove reimbursement rates, staffing needs and was basis for everything long term care related. The facility policy Minimum Data Set, Management of, Long Term Care policy, revised 3/2023, identified the purpose to ensure the Minimum Data Set (MDS) is accurately and comprehensively completed. All MDS assessments and records will be completed and electronically encoded into the facility's electronic medical record and transmitted to the state database in accordance with current regulations. OBRA tracking records and assessments will be completed as defined per the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure resident choices were honored for storage and access to personal property brought in to meet the residents' fluid intake preferences for 1 of 1 resident (R3) reviewed for choices. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment with a diagnosis of heart failure. R3 required extensive assistance for most activities of daily living (ADL's) and R3 was usually understood. R3's MDS identified a life expectancy of less than six month. R3's Hospice admission Visit note dated 3/1/22, indicated discontinuation of fluid restriction to promote comfort and quality of life. R3's care plan dated 12/12/22, identified, Hospice: I am diabetic, I can make my own food decisions, Exercise the right to not always follow my diet. R3's care plan dated 9/3/21, included to provide with a choice of snacks, like diet coke. R3's Behavior Note dated 1/22/23, included, Resident was upset after supper because he noticed his 24 pack and 12 pack of pop was taken out of his room. Staff labeled pop with residents name and put in the fridge. Resident stated that it belonged in his room and that he was going to call the cops if we didn't bring it back. Resident was yelling at staff and wouldn't let them explain that we shouldn't keep that much in his room so staff let resident calm down and came back later. Last time resident had 2- 12 packs in his room he drank both of them within 2 days. Resident did not drink water during that time and was always incontinent through his (overnight) brief and pants even though he was toileted every two hours. Resident is also a diabetic and was previously on fluid restrictions. For the residents well being staff decided his pop should be put away and resident can then ask for one. When writer visited with resident after he was calm, he then understood that his pop has his name on it and is only for him, he just has to ask and staff can get it for him. No further behaviors. R3's Behavior Note dated 1/23/23, Resident was upset that his pop was not in his room. Writer tried to talk with resident and let him know that we have it with his name on it and that he just needs to let us know when he would like one. Resident continued to be upset and said 'If I want my pop in my room I can have my pop in my room.' Staff did bring pop back into residents room. R3's Nurses Note dated 1/24/23, In an unpleasant mood this morning. Not being very cooperative with NA [nursing assistant] as they reported. Pushing back on staff when trying to hook him up in the lift then wouldn't stand and when staff trying to adjust his leg so Hes standing properly on lift pad. Then getting angry at NA for assisting him with his positioning. Also reported that housekeeping staff asking resident if ok to mop the floors in his room. Resident stating that is ok so housekeeper starts to mop the floor and while she is doing these [sic] resident proceeds to run into her on purpose with his wheelchair multiple times. When interviewed on 1/24/23, at 11:15 a.m. nursing assistant (NA)-A stated, R3's pop had not been returned to his room at this time. R3 was to request from staff. When interviewed on 1/24/23, at 2:05 p.m. registered nurse (RN)-A. stated, R3 had a case of pop and drank it in two days. R3 Now usually gets about one a day. He is not able to keep in room due to lack of water consumption. RN-A was unsure if he prefers it to be cold. R3 does not have a refrigerator in his room. RN-A stated R3's pop is probably brought in by his power of attorney (POA) that is his good friend. It is R3's right to do so. However, RN-A identified that R3's is currently in the refrigerator down the hall. When interviewed 1/24/23, at 3:45 p.m. director of nursing (DON) stated she was aware likes to drink Diet Coke but does not drink water. In a recent interdisciplinary team (IDT) meeting it was noted that he went through a case in a few days. He is on hospice, and it was discussed to let him have his Diet Coke if he wants was the consensus with dietary staff present. DON stated it is noted that it helps his moods which can be major at times. The DON stated, unless the doctor ordered it to be taken away it should not be taken from him. DON indicated that she was not aware that it had been removed from R3's room. DON stated it should not have been removed. DON stated that if a resident is not cognitively intact we would need to discuss with the POA and physician prior to limiting his access or consumption. When reading R3's behavior notes DON stated, that's awful. R3's Behavior Note dated 1/24/23, included, Writer followed up with resident regarding his pop. Asked if he approved where his pop currently is at in his room, He stated 'yep, I like it right where it is.' Verified he was ok with having it at room temp, he stated 'yep.' Encouraged resident to ask for ice if he wanted it cold. Resident was smiling ear to ear with no further concerns. Care plan updated. When interviewed on 1/25/23, 03:53 p.m. R3'S POA stated, she brings pop in for him when she visits ever since he was taken off of the fluid restriction in March 2022. She brings in enough to allow him two cans a day but states he does not have any self-control when it comes to his pop. So there are times that he will run out. The POA stated R3, likes things his way or he gets mad. The POA was not aware that his pop had been removed from his room and stated it would, upset him greatly. When discussing the recent behaviors reported the POA stated, I'm sure it is about the pop. A resident choice policy was requested, but not provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to maintain a lift chair in good repair for 1 of 1 residents (R13) reviewed who utilized an electronic lift chair. Findings include: R13's face sheet printed 1/26/23, indicated R13's diagnoses included Parkinson's, anxiety, osteoarthritis, dorsalgia (low back pain) and weakness. R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 was able to communicate her needs. R13's cognition was intact. On 1/23/23, at 1:26 p.m. R13 was observed seated in the electronic lift chair in her room with the footrest elevated. The plastic covered wires for the remote were seen coming out of the remote. On 1/24/23, at 9:36 a.m. R13 demonstrated use of the remote for the electronic lift chair by lowering her legs. R13 stated she had no concerns with use of the remote, it worked each time she has tried it. R13 owned the chair. On 1/26/23, at 10:31 a.m. head of maintenance (HOM) stated all requests for repair of either resident owned items or facility owned items are submitted through the same process. HOM was not aware of R13's electronic lift chair needed repair. HOM confirmed the coated wires for R13's electronic lift chair were pulling out of the remote. HOM considered exposed, coated wires to be a high priority and should be repaired immediately. R13 was at risk for injury if the coating on the wires cracked or pulled off the wires. Facility policy, Electric Lift Recliners- Long Term Care revised 12/2021 indicated repair of privately owned lift chair is the responsibility of the resident but failed to provide direction regarding responsibility or a process to check the lift chair for need to be repaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to assess an increase in behaviors, failed to implement nonpharmacological interventions to ensure adequate medical justification prior to increasing an antipsychotic medication for 1 of 5 residents (R3) reviewed for unnecessary medication use. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment with a diagnoses of heart failure and schizophrenia. R3 required extensive assistance for most activities of daily living (ADL's) and R3 is usually understood. R3's MDS identified a life expectancy of less than six month. R3 took antipsychotic medication for seven of the seven-day assessment period. Gradual Dose Reduction (GDR) has been documented as clinically contraindicated. R3's Mood State Care Area Assessment (CAA) for assessment reference date 3/11/22, identified a psychiatric disorder and was on antipsychotic medication. The CAA was not signed and there was no indication that this care area would be care planned. R3's Behavioral Symptoms CAA for assessment reference date 3/11/22, identified long standing mental health problems but this area would not be care planned. The CAA was not signed. R3's Psychotropic Drug Use CAA for dated 3/18/22, resident admitted to Hospice 3/3/22 due to decline in overall health condition. Other diagnosis includes Schizophrenia. He is on a scheduled antipsychotic for this diagnosis. Proceed to care plan. Nurses give psychotropic medication per order. Monitor for effectiveness and for any adverse effects. Staff to monitor behaviors/mood, interventions and outcomes per Care Center protocol. Allow resident to vent/provide reassurance. DISCUS [ screening for antipsychotic side effects] as warranted. Titrate medication as warranted and per M.D. order. Update primary M.D., Hospice and [power of attorney (POA)] with changes. Care planning to be completed for this area. R3's care plan dated 9/3/22 included psychotropic drug use: potential for an alteration in cognition function/thought process r/t diagnosis of Schizophrenia. Resident has a history of delusions and hallucination. Zyprexa is given per order scheduled. Staff were directed to monitor mood and to titrate with physician as needed. R3's care plan failed to identify any behaviors toward others and failed to direct staff on how to prevent them from happening, or how to manage them when they occur. R3's Hospice admission Note dated 3/1/22, lists, [AGE] year-old patient with history of Chronic Diastolic Congestive Heart Failure (CHF), type II diabetes and coronary artery disease (CAD). Hospice admission completed today with R3 in his room at the facility. His POA was updated following the admission who was in full agreement with comfort focused cares and the hospice admission as well. R3 was not very verbal, which is his baseline per the facility, but was quite clear in expressing his wishes to be comfortable and being ready to die. The staff reported to me, that he has also been giving away some of his most precious items to the POA over the course of the last weeks. R3 has been experiencing a slow decline over the past month per documentation. R3's DISCUS assessment dated [DATE] indicated no facial tics or grimaces. No eye blinking. No lip smacking or chewing, nor puckering, sucking, or thrusting of the lower lip. No tongue thrusting or tongue in cheek, nor tonic tongue, tremor, nor lateral movements noted. No head, neck or trunk abnormalities/movements. No upper or lower limb movements of concern noted. Antipsychotic Medication Evaluation Follow Up completed 12/6/22 indicated two episodes of behaviors of R3 yelling out at staff, hitting at staff, kicking at staff and one episode of pushing against the straps for the lift making it had for staff to unhook device. Review also indicated R3 has been on the current dose of 15 mg of Zyprexa (antipsychotic medication) once a day in the evening since 6/17/21. Also noted was Olanzapine (antipsychotic medication) has been trialed. R3's Care Conference Note dated 12/16/22, identified care plan reviewed and remained the same. R3's Orders Administration Note dated 1/21/23, Zyprexa tablet Resident had a hard time getting medication down and stated that he did not want to take it. R3's Behavior Note dated 1/22/23, included, Resident was upset after supper because he noticed his 24 pack and 12 pack of pop was taken out of his room. Staff labeled pop with residents name and put in the fridge. Resident stated that it belonged in his room and that he was going to call the cops if we didn't bring it back. Resident was yelling at staff and wouldn't let them explain that we shouldn't keep that much in his room so staff let resident calm down and came back later. Last time resident had 2- 12 packs in his room he drank both of them within 2 days. Resident did not drink water during that time and was always incontinent through his (overnight) brief and pants even though he was toileted every two hours. Resident is also a diabetic and was previously on fluid restrictions. For the residents well being staff decided his pop should be put away and resident can then ask for one. When writer visited with resident after he was calm, he then understood that his pop has his name on it and is only for him, he just has to ask and staff can get it for him. No further behaviors. R3's Behavior Monitoring dated 1/23/23, Behavior Exhibited Initially refused to toilet and was upset with staff although he did toilet and had voided, upset that staff had taken pop out of his room but then had calmed down once staff explained his name was on it and he just needed to ask for it and then this evening resident continued on about his pop not being in his room so staff did put his pop back in his room this evening. Frequency and impact to self or others indicated no risk at physical injury to self or others interfered with cares x1, Non-pharmacological Approaches/Effectiveness states, Educated resident on importance of letting staff do cares. Pharmacological Interventions/Effectiveness lists Zyprexa 15 mg daily for Schizophrenia. R3's Behavior Note dated 1/23/23, Resident was upset that his pop was not in his room. Writer tried to talk with resident and let him know that we have it with his name on it and that he just needs to let us know when he would like one. Resident continued to be upset and said 'If I want my pop in my room I can have my pop in my room.' Staff did bring pop back into residents room. R3's Nurses Note dated 1/24/23, In an unpleasant mood this morning. Not being very cooperative with NA [nursing assistant] as they reported. Pushing back on staff when trying to hook him up in the lift then wouldn't stand and when staff trying to adjust his leg so Hes standing properly on lift pad. Then getting angry at NA for assisting him with his positioning. Also reported that housekeeping staff asking resident if ok to mop the floors in his room. Resident stating that is ok so housekeeper starts to mop the floor and while she is doing these [sic] resident proceeds to run into her on purpose with his wheelchair multiple times. R3's Orders Note dated 1/25/23, lists new orders per Hospice, start Zyprexa 7.5 mg once daily in the morning. R3's Behavior Note dated 1/25/23, resident was resistive with toileting this afternoon yelling at aid when she had to change his pants and socks due to being soaking wet aid finally got him changed and tried to hook him back up to the EzStand (lift) resident shoved it toward her and told her she was being mean. R3's Hospice Note dated 1/25/23, It is also reported that patient is having more behaviors. He has been resistive with cares. It is documented that he is trying to push the lift machine away when staff trying to hook him up also it is documented yesterday that housekeeping staff asked him if they could come and mop his floor which he agreed but then was purposefully running his wheelchair into the housekeeper multiple times. Last month on 12/14/22 we tried increasing his morphine thinking behaviors were possibly related to pain as he does have ongoing foot wound however his behaviors seem to be getting worse and his foot wound is looking better. I did update [primary physician] on behaviors and requested to possibly start a morning Zyprexa 7.5 mg and continue with the Zyprexa 15 mg at night awaiting response. R3's Behavior Note dated 1/26/23, Writer followed up with resident regarding his pop. Asked if he approved where his pop currently is at in his room, He stated yep, I like it right where it is. Verified he was ok with having it at room temp, he stated yep. Encouraged resident to ask for ice if he wanted it cold. Resident was smiling ear to ear with no further concerns. Care plan updated. When interviewed on 1/25/23, at 1:45 p.m. hospice registered nurse (RN)-B stated she was in to see R3 yesterday and reviewed the notes regarding recent mood/behavior of resident as well as the recent upset regarding his pop. RN-B stated they previously increased pain medication due to his behaviors and difficulty with communication. RN-B stated she requested an increase in Zyprexa due to recent increase in behavior frequency. She reported she has communication with R3's POA and they are ordering diabetic shoes as resident insists on wearing his shoes and they are ill-fitting due to foot wound. Stated she does speak with the nurses and nursing assistance when she is on site but all provider orders are requested by hospice nurses from the physician. She had reached out to the physician to request an increase in Zyprexa. Discussed possibility that behaviors were due to patient care rather than need for medication dose change and RN-B stated she will review R3's information. When interviewed on 1/25/23, at 3:53 p.m. R3's POA stated there is good communication with the care center staff as well as the hospice nurses in which she receives calls or texts with any information or updates. POA stated R3, likes things his way or he gets mad. When asked about the recent removal of patients personal supply of soda, she was not aware of this and stated this would, upset him greatly. When discussing the recent behaviors reported POA stated, I'm sure it is about the pop. She stated she has seen him in one of his manic moods and he usually becomes very quiet and sullen. POA stated she is consulted regarding medication changes usually after the fact and has not had any discussions about a medication change at this time. When interviewed on 1/26/23, at 9:04 a.m. nursing assistant (NA)-B stated, resident behavioral education is provided for all staff in upon hire and in general. She stated NA's pass on behavioral incidents to the nurses, who document in the resident record. NA-B states every resident has rights and they all should be kind to one another. NA-B stated she learned how to work with R3 with experience. NA-B stated she knows R3 doesn't mean what he says. She stated R3 loves his pop, and she can offer that to help diffuse a situation. NA-B stated R3 likes music and listening to the radio as well as crossword puzzles. NA-B stated this is all in the computer along with toileting and repositioning. When interviewed on 1/26/23, at 9:48 a.m. DON stated staff is to Monitor mood and behavior per facility policy. DON stated they do not have target behavior monitoring or interventions. DON stated she is trying to implement this. DON informs that she has started monthly behavior meetings with the nurses a couple of months ago this review not documented in the resident chart. The nurses verbally discussion their resident concerns to collaborate. DON reviewed R3's medical record and was unable to find a comprehensive behavioral assessment or care planned interventions. DON also confirmed there was no interdisciplinary team (IDT) meeting completed to determine increased frequency or change in severity and no new nonpharmacological interventions were attempted prior to new hospice order for increase in antipsychotic medication. When interviewed on 1/26/23, at 11:07 a.m. RN-C stated, there is a verbal update with hospice staff while in the facility which is usually daily, or facility staff will call the hospice nurse if they feel it is urgent. Facility staff does not call the physician directly, but hospice staff does take concerns to the physician and report back to the facility. Additionally, a verbal report is completed daily with the hall staff during walking rounds as well as the recently implemented monthly meetings with the DON. Monitoring for mood and behavior triggers on the [NAME] (system of communication and organization used in nursing to relay important patient information and needs) if order is entered in the chart. This allows the staff to check off boxes accordingly while interacting with the residents. RN-C states they are working on transitioning to resident specific targeted behaviors with the specific patient needs and prevention as well as interventions. Hoping to change system wide to be more patient specific rather than broad as it currently is. When interviewed on 1/26/23, at 11:22 a.m. NA-A states she was not really trained on behavior management and this was overwhelming at first. NA-A states that training upon hire was very broad addressing behaviors and how to respond. NA-A states that she feels more comfortable now as she knows the residents more. NA-A states she has not had issues with R3 on being physically aggressive toward her and he is usually only grumpy or verbally upset at times. NA-A states R3 has specific staff that he seems to not like and be more physically aggressive with. NA-A states she usually gets a verbal pass on during walking rounds updating on resident condition, mood, and behaviors. NA-A states that if there were an issue with any resident, she passes this on to the nurse right away and the nurses makes a note in the chart, as she can only click the appropriate boxes. NA-A states if a resident is visibly or verbally escalating, she speaks calmly with the resident to try to calm them down. A policy for psychotropic medication requested but not provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure proper gloving and hand hygiene was implemented during incontinent cares for 1 of 8 residents (R1) observed for personal cares. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was fully dependent on another person for physical assistance with toileting and personal hygiene. R1 was always incontinent of bowel and bladder and had a diagnosis of dementia. R1's care plan with last review date 12/5/22, indicated R1 required assist of one to two staff with peri cares and changing incontinent products. On 1/24/23, at 10:12 a.m. during observation of incontinent cares, nursing assistant (NA)-C clean bowel movement from R1's buttocks with her right hand and removed the soiled brief from under R1 with her left hand. Without changing her gloves, NA-C reached into R1's bedside table for a clean brief and placed it under R1. NA-C reached into the top drawer of R1's bedside table for a tube of barrier cream, then applied the barrier cream to R1's buttocks with her right hand. NA-C with assistance from NA-D rolled R1 side-to-side to adjust the brief, then assisted R1 with dressing upper and lower extremities. NA-C brought the wash basin to the bathroom and dumped the water into the sink. NA-C then assisted to straighten R1's sheet over him. NA-C removed the garbage with the soiled brief in it and placed it into a larger garbage can in R1's room. NA-C continued touching various items in R1's room including his tray table and bed controls. NA-C removed gloves when removing other personal protective equipment (PPE), the used hand sanitizer when leaving R1's room. On 1/24/23, at 10:30 a.m. NA-C confirmed she did not change her gloves or clean her hands after assisting R1 with peri care following bowel incontinence. NA-C stated she knew she was expected to change her gloves after cleaning bowel, before touching clean items and to clean her hands each time she changed her gloves. On 1/26/23, at 11:50 a.m. director of nursing (DON) stated she expected gloves were changed after removing a soiled brief, especially after bowel incontinence. Hands should be cleaned anytime gloves are changed and when visibly soiled. Education has been provided to staff so they do not touch items in the resident's room after cleaning a resident up after incontinence, but especially bowel incontinence. DON stated it was important for staff to change their gloves and wash their hands to prevent possible spread of infection and to prevent contamination of other items in the resident's room. A facility policy for hand hygiene was requested but not received.