**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure a comprehensive care plan was developed to include a resident's diagnosis of Dementia, to provide information related to treatment and appropriate interventions for one (1) of 14 care plans reviewed. Resident #9 Findings Include: A review of the facility's policy titles, Comprehensive Care Plans, dated 10/23, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment . A record review of Resident #9's Comprehensive Care Plan reveled it does not have a focus, with goals and interventions related to a Dementia diagnosis. On 12/18/24 at 11:22 AM, during an interview with Registered Nurse (RN) #1/ Minimum Data Set (MDS) Nurse , she stated care plans are updated with new physician orders, new diagnoses, and falls. She stated Resident #9's diagnosis of Dementia should have been in the comprehensive care plan, if the resident is taking medication for the diagnosis. RN #1 stated the care plan is used by all staff to ensure residents received appropriate care. On 12/18/24 at 11:38 AM, in an interview with the Director of Nursing (DON), she confirmed a diagnosis of Dementia should have been included in Resident' #9's care plan, to ensure that staff know how to provide care. The DON stated the care plans are used by all staff providing direct care to residents and her expectations is that all care plans should be individualized and kept up to date. A record review of Resident #9 admission Record revealed Resident #9 was admitted to the facility on [DATE]. The resident's diagnoses included Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance or Anxiety, with an onset date of 6/1/23. A record review of Resident #9's Order Summary Report, with active orders as of 12/18/24, revealed an order to give 1 (one) tablet of Aricept 10 mg (milligrams) by mouth to be given at bedtime related to Unspecified Dementia. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/8/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure dietary staff supported and respected a resident's right to make choices about his or her meal preferences for one (1) of (14) sampled residents. Resident #46. Findings Include: A review of the facility policy titled, Residents Rights, (undated), revealed, . Freedom to Choose . We will accommodate as much as possible individuals needs and preferences in daily routines and activities. Self-determination and reasonable accommodations of individual choices are an important part of residents' rights . On 12/15/24 at 12:25 PM, during an interview with Resident #46, he mentioned that sometimes he likes the food, but he does not have alternative options available and would sometimes prefer to choose different foods instead of eating what is provided to him. He also noted that he is unaware of what is on the menu because there is not one in his room, and the staff do not inform him of the daily menu choices. On 12/16/24 at 10:19 AM, in a follow-up interview with Resident #46, he revealed that no one has come into his room to ask about his menu options today. He added that no one ever comes for that purpose and feels that he must eat what is brought to him. He stated that he would like to have different options available but has not been made aware that he has a choice. On 12/16/24 at 10:30 AM, in an interview with the Dietary Manager, she revealed that the menus are posted in the halls and the dining area. She stated that, at this point, no one from her team retrieves meal choices from residents who are unable to leave their rooms. From her understanding, it is the Certified Nurse Aides (CNA's) responsibility to do so. On 12/16/24 at 10:55 AM, in an interview with the Activities Director, she said she thinks it is the dietary aide who goes out to ask residents their food preferences if they are not able to leave the room to view menus. On 12/16/24 at 11:06 AM, in an interview with CNA #1, she revealed that she has worked in the facility for the last twenty years and has occasionally cared for Resident #46 during her shifts. She acknowledged that he is unable to leave his room to view the menu. While she indicated that it is not her assigned task to ask bed-bound residents about their lunch preferences, she said that if they ask her while she is in their room, she will check the menu for them and report back on their options. On 12/17/24 at 8:15 AM, in an interview with the Director of Nursing (DON), she revealed the facility does not currently have a way of ensuring that residents residents who are unable to walk out of their rooms are able to see the menu. She acknowledged that residents should have access to the menus to ensure they can make choices about their food preferences, as this aligns with resident rights and acknowledges that this is their home. A record review of the admission Record revealed the facility admitted the Resident #46 on 3/18/24, with diagnoses that included Weakness, Unsteadiness on feet, and Muscle Wasting and Atrophy, not Elsewhere Classified, Multiple Sites. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/25/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to ensure an enteral feeding pump was operated by licensed staff for one (1) of nine (9) residents observed with Percutaneous Endoscopic Gastrostomy (PEG) tube feedings. Resident #39 Findings include: A record review of facility's policy, Care and Treatment of Feeding Tubes, dated 04/2017, revealed, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . 6. In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location .: a. Tube placement will be verified before beginning a feeding . During an observation on 06/14/23 at 10:35 AM, Certified Nurse Aide (CNA) #1 was observed providing catheter care to Resident #39. Prior to exiting the resident's room, the CNA turned the resident's feeding pump back on, as the feeding pump was on hold prior to entering the room. On 06/14/23 at 11:48 AM, in an interview, CNA #1 stated that she should not have turned the resident's feeding pump on, as only the nurses are responsible for managing a resident's feeding pump. On 06/14/23 at 12:50 PM, in an interview, the Director of Nursing (DON) stated CNA #1 should not have turned the feeding pump on that was on hold, as the operation of feeding pumps are beyond the scope of practice of a CNA. A record review of the admission Record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses that included Dysphagia, Oropharyngeal Phase and Partial Intestinal Obstruction. A record review of the Order Summary Report, revealed a physician order dated 04/04/23, for Enteral Nutrition VIA PUMP-ISOSOURCE 1.5 at 60 ml (milliliters) PER HOUR CONTINOUSLY VIA PUMP PER PEG-TUBE (percutaneous endoscopic gastrostomy tube).

Based on observation, interviews, record review and facility policy review the facility failed to provide appropriate and sufficient care to prevent the possibility of Urinary Tract Infections (UTIs) for one (1) of four (4) incontinence care observations. Resident #15. Findings Include: Review of the facility's Perineal Care (peri-care) for Female policy, revised 4/2017, revealed, .The purpose of this procedure is to provide appropriate care according to current standards of practice . Procedure .8. Washes genital area, moving from front to back, while using a clean area of the washcloth or wipe for each stroke. 9. Using a clean washcloth or wipe, rinse soap from genital area, moving from front to back, while using a clean area of the washcloth or wipe for each stroke . On 06/14/23 at 11:35 AM, during an observation of incontinent care on Resident #15, with Certified Nurse Aide (CNA) #3 and Licensed Practical Nurse (LPN #1) revealed CNA #3 cleansed the genital area using a circular motion, instead of cleaning from front to back. In an interview on 06/14/23 at 11:38 AM, with CNA #3, she confirmed she cleaned the center of the genital area of Resident #15 using a circular motion. CNA #3 said she knew how to cleanse the resident's genital area, but she was nervous and could not think straight at that moment. CNA #3 also stated that not cleaning the resident properly could cause the resident to get an infection and she confirmed that she had been trained to wipe the center of the genital area from front to back. In an interview on 06/14/23 at 12:04 PM, with LPN #1, she confirmed that CNA #3 failed to cleanse the genital area from front to back, and instead had used a circular motion when cleaning the middle of the genital area. LPN #1 said that CNAs are trained to wipe one side of the genital area from front to back, wipe the other side of the genital area from front to back, and then wipe the center of the genital area from front to back. LPN #1 stated the resident could acquire an infection if the resident did not receive appropriate incontinence care. In an interview on 06/14/23 at 1:14 PM, with the Director of Nursing (DON), she confirmed CNA #3 could have caused the resident to develop an infection by not cleansing the genital area appropriately and that CNAs had received training on incontinence care. Record review of the admission Record revealed the facility admitted Resident #15 on 07/26/2021 with a diagnosis of Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/23, revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 03, which indicated she had severe cognitive impairment. Further review revealed Resident #15 required extensive assistance with personal hygiene and was frequently incontinent.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure infection control measures were consistently implemented to prevent the development and/or transmission of infection for two (2) of sixteen (16) sampled residents. Resident #15 and #39 Findings include: Review of the facility's policy, Infection Control Policy, dated 07/2017 revealed, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . 2. The objectives of our infection control policies and practices are to: .a. Prevent, detect, investigate, and control infections in the facility . Review of the facility's, Hand Hygiene Policy, dated May 2019 revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations with the facility .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached hand hygiene table Hand Hygiene Table .After handling contaminated objects .After handling items potentially contaminated with blood, body fluids, secretions, or excretions. When, during resident care, moving from a contaminated body site to a clean body site . Resident #15 An observation of incontinent care on 06/14/23 at 11:35 AM, revealed Certified Nursing Assistant (CNA) #3 and License Practical Nurse (LPN) #1 failed to perform hand hygiene prior to gloving and providing perineal care to Resident #15. CNA #3 also used gloves that had been contaminated with stool to apply a clean brief and incontinent pad under the resident. In an interview on 06/14/23 at 11:38 AM, with CNA #3 confirmed she failed to perform hand hygiene prior to providing care to Resident #15 and failed to remove her contaminated gloves and perform hand hygiene prior to applying a clean brief and incontinent pad. During an interview on 06/14/23, at 12:04 PM, with LPN #1, she confirmed she failed to perform hand hygiene prior to assisting with care of Resident #15. LPN #1 also confirmed CNA #3 failed to perform hand hygiene and apply clean gloves after contaminating her gloves with stool before applying a new brief and incontinent pad. LPN #1 confirmed that not performing hand hygiene could cause the resident to get an infection. .On 06/14/23 at 1:14 PM, in an interview with the Director of Nursing (DON), she also confirmed LPN #1 and CNA #3 should have performed hand hygiene prior to providing care. The DON also confirmed CNA #3 failed to follow infection control guidelines by not removing her gloves and performing hand hygiene after her gloves became contaminated with body excretions prior to applying a clean brief and incontinent pad. Record review of the admission Record for Resident #15 revealed, the facility admitted the resident on 08/24/2017, with diagnoses that included Urinary Tract infection, Alzheimer's Disease, Anxiety, and Kidney Failure. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 04/03/23 revealed Resident #15 had a Brief Interview of Mental Status (BIMS) score of 03, which indicated Resident #15 had severe cognitive impairment. Further review of the MDS revealed the resident required two (2) person extensive assistance with hygiene care and was frequently incontinent. Resident #39 On 06/14/23 at 10:35 AM, during an observation of catheter/perineal care with CNA #1 revealed as CNA #1 was performing foley catheter and perineal care Resident #39 had a bowel movement during the care. While performing care, CNA #1 wiped stool off her glove and applied hand sanitizer to her gloves and proceeded to apply a clean brief and pants on the resident. During an interview on 06/14/23 at 11:54 AM, CNA #1 stated she should have removed her gloves and performed hand hygiene when her gloves became contaminated with the resident's stool, prior to applying a clean brief and pants on the resident. She stated her actions could cause the resident to an infection. On 06/14/23 at 12:50 PM, in an interview with the Director of Nursing (DON), she stated CNA #1 should have removed gloves and not used hand sanitizer to clean gloves. She stated CNA #1 should have removed her soiled gloves, performed hand hygiene, and applied clean gloves before applying the resident's brief and pants. She stated the CNA's actions could cause the resident to get an infection. Review of the admission Record for Resident #39 revealed, the facility admitted the resident on 04/04/23 with diagnoses including Pressure Ulcer of Sacral Area, Stage 3, Dysphagia, Oropharyngeal Phase and Partial Intestinal Obstruction. Review of the Order Summary Report revealed a physician's order, dated 05/29/23, for FOLEY CATH CARE WITH SOAP AND WATER QDay (every day) and PRN (as needed) FOR PRESSURE ULCER.

Based on observation, staff interview, record review and facility policy review, the facility failed to provide privacy during wound care for one (1) of four (4) resident care observations, Resident #10. Findings include: Review of the facility's Resident Rights policy, not dated, revealed a resident is entitled to privacy in accommodations, personal care, visits and meetings of family and resident groups. A review of the facility's Clean Dressing Change policy, dated 4/2017, revealed to screen for privacy during the care. An observation, on 01/08/20 at 10:40 AM, revealed sacral wound care was provided for Resident #10 by Registered Nurse (RN) #2/Wound Care Nurse, and assisted by RN #1. RN #2 closed the door and pulled the curtain between the beds. Resident #10's bed was located next to the outside window. RN #2 did not close the blinds to the window. RN #1 did not close the blinds or say anything about the blinds being open during the care. Resident # 10 was in bed lying on her right side with her back facing the window with the open blinds. The window was located across from the front door of the facility. Resident #10's back and buttocks were facing the window during the whole wound care observation. An interview, on 01/08/20 at 10:55 AM, with RN #2/Wound Care Nurse, confirmed the window blinds were open, and she should have closed the blinds for privacy. She said any reasonable person would expect the blinds to be closed during care. An observation of Resident #10's room, on 01/08/20 at 2:05 PM, from the front door of the facility, one could see inside Resident #10's room and people was walking about in this area who could see into Resident #10's room at any time with the window blinds open. An interview, on 01/09/20 at 12:26 PM, revealed the Director of Nursing (DON) said the facility policy was to provide privacy during care and that would include closing the blinds.

Based on observations, staff interview, record review and facility policy review, the facility failed to revise the Comprehensive Care Plan related to the Focus for Resident #10's behaviors. This concern was identified for one (1) of 16 resident care plans reviewed. Findings include: Review of the facility's Reviewing and Revising the Care Plan policy, dated 2/2017, revealed the care plan would be updated with the new or modified interventions, and the care plan will be modified as needed by the Minimum Data Set (MDS) Coordinator or other designated staff member. A review of the Care Plan for Resident # 10 revealed a Focus related to Resident #10's behaviors for verbally aggressive, rummaging through other's belongings, refusing care and episodes of wandering into other rooms. A review of the Behavior Monitoring on Resident #10's Medication Administration Record (MAR) for the month of January 2020 revealed no issues with behaviors. A review of the Quarterly Minimum Data Set (MDS) Section E, with an Assessment Reference Dates (ARD) of 10/11/19 and 12/27/19, revealed no behaviors were exhibited. An observation, on 1/7/2020 at 10:30 AM, revealed Resident #10 was in a Geri-chair, quiet and her eyes were closed. An interview, on 1/8/2020 at 10:45 AM, revealed RN #1 said Resident # 10 no longer walked and needed a lift to get up to the wheel chair. An observation, on 1/08/20 at 11:13 AM, revealed Resident #10 was in her room lying in bed with her eyes closed. Resident #10 was not observed at anytime with behaviors toward staff or wandering. An interview, on 1/08/20 at 3:16 PM, revealed the Director of Nursing said Resident # 10 had a significant change after a hospital return, and the resident no longer wanders or had issues with behaviors towards staff. An interview, on 1/09/20 at 11:03 AM, revealed Licensed Practical Nurse (LPN) #1/MDS Nurse stated that he was notified through physician orders and daily stand up meetings for changes in resident status. He confirmed Resident # 10 no longer wandered or had behaviors towards staff, but the problem was still current on the care plan. LPN #1 said he usually waited with residents with a history of behaviors before he removed a problem. He said he could probably resolve Resident #10's behavior problems because she no longer wandered or acted out towards staff. LPN #1 said the importance to revise the care plan was to show the staff current resident status and current information for the resident on the care plan.