**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who required staff assistance with bathing received baths and/or showers to meet the needs of one sampled resident (Resident #68) out of 18 sampled residents. The facility census was 76 residents. Review of facility policy Bath, Shower/Tub revised 2/2018 showed: -The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. -Document date and time the bath or shower was preformed. -Document the name and title of the individual(s) who assisted the resident with the shower/tub bath. -Document all assessment data (e.g., any reddened areas, sores, etc., on the residents skin) obtained during shower/tub bath. -Document if the resident refused the shower/tub bath, reason(s) why and the interventions taken. 1. Review of Resident #68's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). Review of the resident's Care Plan dated 3/11/24 showed the resident required substantial assistance from staff for bathing. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/24/24 showed the resident: -Was cognitively intact. -Required substantial assistance/maximum assistance by staff for bathing. Review of the resident's Electronic Medical Record (EMR) on 12/9/24 showed baths for the previous 30 days were provided to the resident on 11/23/24, 12/7/24, and 12/8/24. Staff documented no on 11/14/24 and 11/15/24 with no documentation if the bath was offered and refused by the resident or was not offered to the resident. Review of the resident's paper bath sheets for the previous three months showed baths were offered and/or received: -The resident received five baths in September 2024. No baths were documented between 9/1/24 - 9/13/24. The resident was without a bath and/or shower for 13 consecutive days. -The resident received four baths in October 2024. No baths were documented after 10/12/24. -The resident received two baths in November 2024. No baths were documented between 10/12/24 - 11/8/24. No baths were documented between 11/10/24 - 11/22/24. The resident was without a bath and/or shower for 28 consecutive days. -The resident did not have any documented baths in December 2024. -NOTE: The resident was without a bath and/or shower 14 consecutive days when comparing the EMR and paper bath sheet record from 11/23/24 - 12/7/24. Observation on 12/6/24 at 11:59 A.M. the resident had a body odor and had greasy appearing hair. During an interview on 12/6/24 at 12:00 P.M., the resident said: -He/She did not get baths twice a week. -He/She thought it had been a couple of weeks since his/her last bath or shower. -He/She did not get any baths a couple of months ago when he/she had COVID (a new disease caused by a novel (new) coronavirus) sometime in October 2024. -He/She had asked for baths, but staff were not available to assist him/her. -He/She wished he/she could get baths at least twice a week. During an interview 12/13/24 at 10:41 A.M. Nursing Assistant (NA) A said: -The facility did have bath aides. -Charge nurse was responsible for daily bath schedules and would let him/her know what residents had needed baths for the day. -He/She was not aware the resident had missed multiple baths. -He/She would document baths on the bath sheet and in EMR. -Baths should be offered to residents twice a week. -He/She would report to the charge nurse if a resident refused a bath. During an interview on 12/13/24 at 10:53 A.M. Licensed Practical Nurse (LPN) B said: -The facility did not use bath aides and the charge nurses would be responsible for scheduling residents and making sure that they are completed. -Baths would be documented on bath sheets and the residents EMR. -He/She was not aware the resident had not gotten his/her baths for long periods of time and did not notice any odors. -Residents should be offered baths at least two times per week. During an interview on 12/13/24 at 10:57 the Assistant Director of Nursing (ADON) said: -Bathing should be offered to all residents two times a week unless care plan specifies otherwise. -Bathing would be documented on bath sheets and in the residents EMRs. -He/She had not notice any body odors or unkept residents. -He/she and the Director of Nursing (DON) would be responsible to make sure baths were completed as scheduled. During an interview on 12/13/24 at 12:26 the DON said: -He/She would expect baths to be completed as scheduled weekly. -He/She would expect the charge nurses would follow up with staff every day to make sure baths are completed. -The charge nurse, ADON, DON and administrator would help out to get daily baths completed. -He/She would expect baths to be documented on bath sheets and in EMR. -He/She would be responsible for bath audits along with the ADON. -He/She was not aware the resident was not getting his/her baths and did not notice any odors or resident not being groomed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #58's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses of Flaccid Hemiplegia (a condition characterized by paralysis and loss of muscle tone on one side of the body). Review of the resident's Significant Change of Condition MDS dated [DATE] showed the resident: -Had moderate cognitive impairment. -Had upper and lower extremity impairment. -Was dependent on staff for mobility. -Was always incontinent of bowel and bladder. -Was at risk for pressure ulcers. Review of the resident's Care Plan, initiated 12/4/24 showed: -Staff were to provide total assist with bed mobility. -Had history of pressure ulcers and immobility. -His/Her skin would remain intact. Observation on 12/6/24 at 9:26 A.M. showed: -The resident lying in bed on his/her back. -His/Her heels were resting directly on his/her mattress. Review of the resident's Braden Scale ( a risk assessment tool to identify residents at risk for developing pressure ulcers) dated 12/8/24 showed he/she was high risk for developing pressure ulcers. Observation 12/9/24 at 8:15 A.M. showed: -The resident lying in bed on his/her back. -His/Her heels were resting directly on his/her mattress. Observation on 12/10/24 at 8:47 A.M. showed: -The resident lying in bed on his/her back. -His/Her heels were resting directly on his/her mattress. Observation and interview on 12/10/24 at 9:17 A.M. Licensed Practical Nurse (LPN) A said: -The resident was lying in bed on his/her back. -His/Her heels were directly resting on his/her mattress. -His/heels were observed to be red. -LPN A had stated that he/she noticed redness on the heels 12/7/24 and had ordered heel protectors. -LPN A described the heels as feeling boggy (a feeling of sponginess in the tissue). -LPN A was not aware that heel protectors had not been on the resident. Observation on 12/11/24 at 8:28 A.M. showed. -The resident lying in bed on his/her back. -His/Her heels were resting directly on his/her mattress. Observation on 12/13/24 at 8:45 A.M. showed: -The resident sitting up in his/her wheelchair. -His/Her heels resting directly on his/her wheelchair foot rests. 3. During an Interview on 12/13/24 at 8:59 A.M. Certified Nursing Assistant (CNA) D said: -If a resident was at high risk for skin breakdown he/she would reposition resident every two hours. -He/She would get a daily report from the charge nurse if residents had a change in skin condition and needed new interventions. -He/She believed the resident care plans were at the nursing station. -He/She would report skin changes to the charge nurse. -He/She was not aware that Resident #58 was to have heel protectors. -The charge nurses were responsible for weekly skin assessments. During an interview on 12/13/24 at 9:08 A.M. Certified Medication Technician (CMT) B said: -He/She would get daily report from the charge nurse of any care need changes. -Charge nurses were responsible for weekly skin assessments. -He/She was not aware that Resident #58 needed heel protectors or heel pressure relief. During an interview on 12/13/24 at 9:20 A.M. LPN B said: -Residents who were at high risk for skin breakdown should be turned and checked for incontinence frequently, barrier cream after incontinence. -Charge nurses were responsible for weekly skin assessments, including detailed wound assessments, and documented the the resident electronic medical record. -The Care Plan Coordinator was responsible for updating the resident's care plan. During an interview on 12/13/24 at 9:30 A.M. the MDS Coordinator said: -There should be interventions in the resident's care plan if the resident was at high risk for pressure ulcers. -He/She was responsible for updating resident care plans. -He/She was not aware that Resident #58 did not have high risk for skin breakdown interventions in place related to his/her heels. -Charge nurses were responsible for completing weekly skin assessments, including detailed wound assessments. -The Assistant Director of Nursing (ADON) and Director of Nursing (DON) are responsible to make sure weekly skin assessments are completed. During an interview on 12/13/24 at 11:21 A.M. the ADON said: -All residents who were high risk for skin break down should have interventions in place including heel protectors. -He/She along with the DON were responsible to make sure weekly skin assessments, including detailed wound assessments, were done and interventions were in place in the residents care plan. During an interview on 12/13/24 at 12:26 P.M. the DON said: -He/She would expect weekly skin assessments to be completed by charge nurses. -He/She would be responsible to audit and make sure weekly skin assessments, including detailed wound assessments, were completed. -He/She would expect appropriate interventions be put in place for residents who were at high risk for skin breakdown. -He/She would expect Resident #58 to have heel protectors for prevention. Based on observation, interview, and record review, the facility failed to ensure weekly wound tracking for one sampled resident (Resident #2) with a history of a chronic Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) pressure ulcer pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); and failed to ensure services to prevent and heal pressure ulcers for one sampled resident (Resident #58) who was at high risk for skin breakdown out of 18 sampled residents. The facility census was 76 residents. Review of the facility Wound Care Policy, revised 10/2010 showed: -The following documentation should be recorded in the resident's medical record: --The type of wound care given. --The date and time the wound care was given. --All assessment data (i.e., wound bed color, size, drainage, ect.) obtained when inspecting the wound. Review of www.medline.com/strategies/skin-health/evidence-based-best-practices-heels-npiap-guidelines-help-prevent-pressure-injuries/ dated 7/2020 showed: -For residents at risk for heel pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow or foam cushion. -Be sure to offload (minimize or removing weight placed on the foot to help prevent and heal ulcers) the heel completely to distribute the weight of the leg along the calf. 1. Review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of a Stage IV pressure ulcer in the sacral area (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity). Review of the undated Physician's Order Sheet (POS) showed an order for skin assessments to be completed weekly on Friday by licensed nurse. Review of the resident's weekly wound reports showed no documentation of a detailed wound assessment on the following dates: -1/18/24. -2/1/24 and 2/8/24. -4/4/24. -5/22/24 and 5/29/24. -7/17/24. -8/8/24 and 8/29/24. -9/4/24 and 9/11/24. -10/28/24. -11/8/24 and 11/22/24. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/14/24 showed the resident: -Had a Stage IV pressure ulcer. -Was cognitively intact, During an interview with the resident on 12/6/24 at 1:13 P.M., he/she said: -He/She had a Stage IV pressure ulcer on his/her buttocks region. -He/She had the Stage IV pressure ulcer for years. It would heal and open back up frequently. Observation on 12/10/24 at 10:47 A.M. showed the resident's Stage IV pressure ulcer on his/her sacral area was healed with no open areas. During an interview on 12/10/24 at 11:00 A.M., Licensed Practical Nurse (LPN) A said: -The resident had a Stage IV pressure ulcer on his/her sacral area. -The resident's pressure ulcer would heal and open back up frequently. -The facility wound nurse documented the wound assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a thorough fall investigation to include interviews of staff and/or potential witnesses, failed to complete fall assessments after each fall, and failed to implement appropriate interventions for a significantly cognitively impaired resident (Resident #32) out of 18 sampled residents. The facility census was 76 residents. Review of the facility policy Assessing Falls and Their Causes Revised 3/2018 showed: -When a resident falls, the following information should be recorded in the resident's medical record: --The condition of which the resident was found. --Assessment data, including vital signs and any obvious injuries. --Interventions, first aid, or treatment administered. --Notification of physician and family, as indicated. --Completion of a falls risk assessment. --Appropriate interventions taken to prevent future falls. -Define details of falls. -Identify causes of falls. -Perform a post-fall evaluation. 1. Review of Resident #32's face sheet showed he/she was admitted to the facility 5/1/21 with the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Delusional disorder (delusions - fixed false beliefs). -History of repeated falls. Review of the resident's care plan dated 5/19/21 and revised on 9/14/24 showed: -The resident was at risk for falls. -Make sure call light is nearby and remind the resident to use the call light. -Educate resident and family safety reminders and what to do if a fall occurs. -Educate resident to wear non-skid shoes/socks when not in bed -The resident had non-injury falls on 12/16/23, 1/10/24, 2/17/24, 2/24/24. -The resident had injury falls on 5/11/23 and 5/29/24. --NOTE: No documentaion or care plan updates for the resident's falls on 8/27/24, 9/1/24, or 12/4/24. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 6/14/24 showed he/she: -Was severely cognitively impaired. -Had one injury fall since the prior assessment. Review of the resident's fall investigation dated 8/27/24 showed: -The resident was seen on the floor with his/her back against the bed. -The resident stated he/she was just sitting there waiting on the staff member. -The resident was not a good historian. -The resident was assessed with no apparent injuries. -The resident was wearing slide socks with no grips or shoes at the time. -The nurse educated the resident on using the call light, however the resident was not capable of retaining new information due to diagnosis. -NOTE: The investigation did not include interviews with staff or any other potential witnesses and it was noted the intervention was not appropriate for the resident due to the resident's impaired cognition. The investigation did not include a root cause analysis. Review of the resident's fall investigation dated 9/1/24 showed: -The nurse was called to the resident's room by a Certified Nursing Assistant (CNA). Upon entering the room, the resident was observed to be on the floor with his/her head slightly lifted off of the floor. The resident's feet were crossed over each other and his/her right shoe had fallen off. -The resident's walker was unlocked and call light was not being used at the time of the fall. -The resident said he/she was trying to get to out of the bathroom. -The resident was assessed with no apparent injury other than an abrasion to his/her right elbow. -The resident was educated on using the call light and waiting for assistance. -The resident had a prior fall on 8/27/24 when he/she attempted to get out of bed barefoot. The intervention for that fall was to educate on call light usage, however the resident was unable to retain information due to increased confusion. -NOTE: The investigation did not include interviews with staff or any other potential witnesses and it was noted the intervention was not appropriate for the resident due to the resident's impaired cognition. The investigation did not include a root cause analysis. Review of the resident's annual MDS dated [DATE] showed he/she: -Was severely cognitively impaired. -Had one injury fall and one non-injury fall since the prior assessment. Review of the resident's Fall Risk assessment dated [DATE] showed the resident: -Did not have any falls within the last three months. -Was disoriented times three (person, place, situation/time) at all times. -Was ambulatory and incontinent. -Required assistive devices such as a wheelchair or walker for ambulation. -Received 1-2 of a list of medications within the last seven days. The medications included psychotropic medication (mind altering medication used to treat mental illnesses). -The fall risk assessment did not include a total score to determine the resident's risk for falls, did not include any interventions or clinical suggestions as indicated on the form. --NOTE: A new fall risk assessment was not completed after the resident's fall on 8/27/24, 9/1/24, or 12/4/24. Review of the resident's quarterly MDS dated [DATE] showed he/she: -Was severely cognitively impaired. -Had one injury fall and one non-injury fall since the prior assessment. Review of the resident's fall investigation dated 12/4/24 showed: -The resident was found on the floor with a laceration (cut) to the back of his/her head. The resident was assessed and assisted back to bed. -The resident was alert, oriented to person only, was confused with impaired memory. -No staff interviews were included in the investigation. No further information describing the incident was included in the investigation. The investigation did not include a root cause analysis. During an interview 12/13/24 at 10:42 A.M. Nursing Assistant (NA) A said: -He/She would be informed by the charge nurses if any new fall interventions are added. -He/She would not think using the intervention Remind Resident To Use Call Light was appropriate for a resident with memory loss. During an interview 12/13/24 at 10:46 A.M. Licensed Practical Nurse (LPN) B said: -He/She would assess the resident after a fall for injuries. -He/She would start a fall risk management assessment, would include resident interview, staff interview and put an immediate intervention in place. -He/She would be made aware of new interventions for residents during shift report. -He/She would not use Remind Resident To Use Call Light as an intervention for a resident with memory loss. -The Assistant Director Of Nursing (ADON) and Director Of Nursing (DON) are responsible for reviewing fall investigations and appropriate interventions for falls. During an interview 12/13/24 at 10:59 A.M. the (Assistant Director of Nursing) ADON said: -If a resident fell a full assessment should be done to check for injuries. -A fall assessment and a fall risk assessment was completed. -An immediate intervention would be put in place and all falls would be reviewed as a team in the weekly risk meeting. -He/She would interview staff witnesses related to a fall. -The charge nurse would put in the immediate intervention after a fall. -He/She and the Director of Nursing (DON) were responsible to make sure all fall documentation was complete and the fall interventions were appropriate. -Remind to use call light for an intervention for a resident with memory loss would not be appropriate. During an interview 12/13/24 at 12:26 A.M. the DON said: -He/She would expect fall investigations to be complete and thorough with appropriate interventions. -He/She would be responsible to audit and review all fall investigations. -He/She was aware not all fall investigations were completed per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess a resident's Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat) for proper placement for one sampled resident (Resident #74) out of 18 sampled residents. The facility census was 76 residents. Record review of the facility's Confirming Placement of Feeding Tubes policy revised November 2018 showed: -The exit site of the feeding tune would be marked (by incremental marking on the tube or by documented tube length) at initial time of placement. -If a change in the incremental length was observed, use additional method(s) to test whether the tube was properly positioned: --Observed for symptoms of elevated gastric residual volume (GRV): ---A sharp increase in residual volume might have indicated that a small bowl tube has migrated into the stomach. ---Little to no residual might have suggested the tube has migrated from the stomach to the esophagus. --Observed and checked pH (scale measures how acidic or basic a substance) of the residual. ---Fasting stomach contents would have a clear and colorless or grassy green and brown appearance. ---Fluids from the lung space might have pale yellow clear appearance. ---Post-pyloric (after stomach)/small bowel contents might be bile stained, light to dark yellow or greenish-brown. ---Fasting stomach acid will have a pH of five or less. ---Fluid from the lung space will have a pH of seven or higher. ---A pH of five or less suggests that the tube is placed in the stomach. ---A pH of six or higher was not definitive of placement outside the stomach. 1. Review of Resident #74's admission Record showed he/she was admitted to the facility on [DATE] and had a PEG tube. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/24/24 showed he/she: -Had moderate cognitive impairment. -Received his/her over 51 percent (%) nutrition through tube feeding. Review of the resident's care plan revised on 11/29/24 showed he/she: -Was dependent on staff for all cares. -Had a PEG tube for nutrition. -Staff were to check for PEG tube placement and check for gastric residual. -The care plan did not show to check the PEG tube by measurement. Review of the resident's December 2024 Order Summary Report (OSR) showed: -Check for gastric residual each shift from the resident's PEG. -Every shift check and record tube feeding residual. If residual is greater than 150 ml, hold feeding and call doctor. -Every shift check tube placement prior to administration of medication and tube feeding. -Note: There were no orders of how to check placement or measure the tube feeding for placement. Observation on 12/10/24 at 9:39 A.M. of the resident showed: -Licensed Practical Nurse (LPN) A administered an air bolus through the resident's PEG tube and auscultated (listen) for sound through the resident's abdomen. -He/She then aspirated for gastric contents, then flushed the resident's PEG tube with water. -LPN C did not check for the external length/measurement of the PEG tube. During an interview on 12/10/24 at 9:58 A.M., LPN A said: -Staff were to verify PEG tube placement by auscultation and aspiration (to use a syringe to withdraw a small amount of stomach contents (the residual) from a feeding tube to assess how well the stomach is emptying, by checking the volume of fluid that remains after a feeding of gastric contents). -He/She has never measured a resident's external PEG tube length. -He/She followed facility policy on checking PEG tube placement. -He/She did not remember seeing anywhere in the residents' charts what the external length of tubing should be for their PEG tubes. During an interview on 12/13/24 at 12:25 P.M., the Director of Nursing (DON) said: -Staff should verify placement of a resident's PEG tube by aspiration of gastric contents and auscultation. -The facility policy was to verify placement by auscultation and residual of gastric contents. -He/she expected staff to follow the physician's order on how to assess a PEG tube. -He/she expected the care plan to include how to assess the resident's PEG tube to include auscultation and aspiration of gastric contents. -The orders did not include measuring the tube to check for placement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR- an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who was in cardiac arrest) staff were able to identify who was CPR certified staff on all shifts. The facility census was 76 residents. Review of the facility's Emergency Procedure-Cardiopulmonary Resuscitation policy revised February 2018 showed: -Personnel have completed training on initiation of cardiopulmonary resuscitation and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. -The chances of surviving sudden cardiac arrest may be increased if CPR was initiated immediately upon collapse. -Select and identified a CPR team for each shift in the case of an actual cardiac arrest. -To the extend possible, designated a team leader on each shift who was responsible for coordinating the rescue effort and directed other team members during the rescue effort. -The CPR Team in this facility would include at least one nurse and two Certified Nurse's Aides (CNA), all of whom had received training on CPR/BLS. 1. Review of facility staffing sheets dated [DATE] showed no designation for employees that were CPR certified, the CPR team, or CPR team leader. Review of facility staffing sheets dated [DATE] showed no designation for employees that were CPR certified, the CPR team, or CPR team leader. Review of facility staffing sheets dated [DATE] showed no designation for employees that were CPR certified, the CPR team, or CPR team leader. Review of facility staffing sheets dated [DATE] showed no designation for employees that were CPR certified, the CPR team, or CPR team leader. Review of facility staffing sheets dated [DATE] showed no designation for employees that were CPR certified, the CPR team, or CPR team leader. Review of facility staffing sheets dated [DATE] showed no designation for employees that were CPR certified, the CPR team, or CPR team leader. Review of facility staffing sheets dated [DATE] showed no designation for employees that were CPR certified, the CPR team, or CPR team leader. During an interview on [DATE] at 8:43 A.M., Nurse's Aide (NA) A said: -He/She thought all the nurses were CPR certified. -The staffing sheet did not designate who was on the CPR team or the CPR team leader. -The staffing sheets did not designate who was CPR certified. During an interview on [DATE] at 8:56 A.M., Housekeeping Supervisor said: -There was no documentation on the staffing schedule that showed who was CPR certified and there was no CPR team notated on the schedule. -The CPR team leader was not marked on the staffing schedule. During an interview on [DATE] at 8:59 A.M., the Staffing Coordinator said: -Not all the nurses or CNAs were CPR certified. -He/She did not have a list of all CPR certified staff. -He/She knew all the CPR certified staff. -There was no CPR team designated on the schedule. -He/She did not know that a CPR team was needed to be designated on the schedule. -He/She completed the staffing schedule and would post it. During an interview on [DATE] at 9:04 A.M., Certified Nurses Aide (CNA) C said: -The CPR team was not listed on the daily schedule. -The team leader of the CPR team was not listed on the schedule. -The schedule did not list who was CPR certified. During an interview on [DATE] at 9:10 A.M., Certified Medication Technician (CMT) A said: -He/She was CPR certified. -He/She did not know any other staff that were CPR certified. -He/She did not of any staff being listed as on the CPR team. -The CPR team was not listed on the schedule. During an interview on [DATE] at 9:14 A.M., Licensed Practical Nurse (LPN) A said: -The staffing sheet did not designate who was CPR certified. -The staffing sheet did not designate who was on the CPR team each shift nor who was the CPR team leader. During an interview on [DATE] at 12:25 P.M., Director of Nursing (DON) said: -The daily staffing schedule did not designate who was CPR certified. -The daily staffing sheet did not designate a CPR team with a nurse as the leader. -In the event that CPR was required the staff would have to ask who was CPR certified. -The fact staff were not designated on the staff schedule might cause a delay in starting CPR. -The DON or the Staffing Coordinator would be responsible for the list of CPR certified staff and having it placed at the nurse's station.

Based on interview and record review, the facility failed to develop and implement an antibiotic stewardship protocol/program and a system to monitor appropriate antibiotic use for residents. The facility census was 76 residents. Review of the facility Antibiotic Stewardship policy, revised December 2023 showed: -Antibiotics would be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. -Instruction that physician's orders for antibiotics would include the drug name, dose, frequency of administration, duration of treatment, start and stop date or number of days of therapy, route of administration and the indications for use. -If a laboratory test was ordered, the results and the resident's current clinical situation would be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. Review of the facility Infection Prevention and Control Program policy, revised December 2023 showed: -Culture reports, sensitivity data and antibiotic usage reviews were to be included in surveillance activities. -Medical criteria and standardized definitions of infections were to be used to help recognize and manage infections. -Antibiotic usage was to be evaluated and feedback was to be provided to practitioners. 1. Review of the facility Antibiotic Stewardship information for January 2024 through November 2024 showed no information was provided regarding antibiotic stewardship for September 2024 through November 2024. During an interview on 12/10/24 at 12:40 P.M. the Director of Nursing (DON) said: -Antibiotic stewardship information should be gathered, and data analyzed monthly. -He/she and the facility Infection Preventionist were both responsible for and worked together on monthly tracking and antibiotic stewardship. -He/she was responsible for ensuring antibiotic stewardship was completed monthly. -Antibiotic stewardship had not been completed for September through November 2024 due to management activities and system changes related to new ownership. -The facility corporation was currently developing a method for conducting antibiotic stewardship. -The Infection Preventionist joined the interview and said: --He/She and the DON worked together on antibiotic stewardship. --Antibiotic stewardship had not been completed September 2024 through November 2024. During an interview on 12/13/24 at 11:58 A.M. the Administrator said he/she was not aware that antibiotic stewardship was not being completed. The Infection Preventionist was responsible for completing antibiotic stewardship.

Based on interview and record review, the facility failed to ensure the Dietary Manager (DM) met one of the qualifications for a Certified Dietary Manager (CDM) by having an approved certification for food service management and safety from a certifying body, an associate's degree in food service management or hospitality, or had 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and had completed a course of study in food safety and management. This practice potentially affected all residents. The facility census was 76 residents. Review of the facility's Dietitian policy, revised November, 2022 showed if a Dietitian is not employed full time (35 or more hours per week) a Director of Food and Nutrition Services will be designated. This individual will: -Be a certified dietary manager, a certified food services manager, or be nationally certified in food service management and safety, or -Have an associate degree or higher in food service management or hospitality if the course includes food service or restaurant management from an accredited institution, or -Has two or more years' experience in the position of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management by no later than October 1, 2023 that includes topics integral to managing dietary operations, including, but not limited to foodborne illness, sanitation procedures, and food purchasing/receiving and meet any state requirements for food service or dietary managers, and -Receives frequent scheduled consultations from a qualified dietitian or nutrition professional. -For designations made before November 28, 2016 the director of food service management will meet the requirements no later than November 28, 2021. For designations made after November 28, 2016 the requirements will be met no later than November, 2017. 1. During an interview on 12/10/24 at 2:05 P.M., the DM said: -He/she had worked as a DM for the past two months since the previous DM manager left without notice. -He/She has no certification or education of any kind to qualify him/her for the DM position. -He/She had been a kitchen supervisor for the past 10 years, but had not worked as a DM. His/Her responsibilities involved scheduling and supervising kitchen staff. -There had been no training scheduled yet to meet the qualifications of a DM, so he/she didn't know when his/her classes would start. During an interview on 12/16/24 at 12:32 P.M., the Administrator said: -The previous DM abruptly quit one morning weeks ago, and they had been using someone with several years' experience cooking in the kitchen as the DM. - He/She realized the employee they were currently using as a DM needed the appropriate qualifications to be a DM, but the employee hadn't yet been enrolled in any dietary management training program.

Based on observation and interview, the facility failed to ensure condiments were stored properly, clean grease and food from condiment and spice containers, clean grease build up from kitchen surfaces including the stove and oven, remove build-up of soap or other substances from soap dispensers, a soap dish, and dish washing machine trays, and to ensure trays and food containers were not stored on surfaces that were chipped and therefore unable to be sanitized. This practice potentially affected all residents who ate food from the kitchen. The facility census was 76 residents. 1. Observation on 12/05/24 from 9:31 A.M. to 12:55 P.M. showed: -At 9:31 A.M. bits of debris were all over the kitchen floor, most of which were one-half inch and smaller, with a few bits larger. There were multiple spills on the floor. -The stove knobs, surface surrounding the knobs, and two oven handles of the stove (stove/griddle/oven appliance) had a build up grease. The six burners had a crusty charred built-up coating. The sides of the appliance had a light film of grease with adhering dust. The gas line including the gas valve behind the appliance had a thick build up of grease covered with dust. -The knobs, surface surrounding the knobs, and the handle of the baker's oven was greasy. The gas line behind the baker's oven was covered with grease and dust. -In the drink area (juice, coffee, ice machine room) a tray near the coffee pot contained: --A syrup bottle with syrup running down the sides and on the nozzle lid. The tip of the nozzle was open and uncapped. --An opened container of mustard, almost empty, and a red container with contents that looked and smelled like ketchup were both smeared on the sides with dried product. --Four spice containers had a film of grease and opened holes at the top. -In the kitchen, the microwave was greasy with multiple fingerprints on the door, handle, and buttons. -There were 24 spice containers in the kitchen with an oily film on the outside and adhering dust on the sides and lids. Four spice container lids were open approximately one-third to one-half inch exposing the contents to dust. -The eye wash bottle, soap and sanitizer dispensers at the hand-washing sink had a dried film coating on them. -The bottom shelves of the microwave table and three food prep tables each had several chips, some as big as a couple of inches, exposing a rusty-colored surface below which could not be effectively sanitized. All four bottom shelves had built-up greasy stains on the horizontal surface near the outside perimeters. Another food prep table with wheels had four trays with water cups sitting on the chipped surface and a tray with plastic cups with lids. -Below a stationary prep table four floor tiles were missing, exposing broken up concrete and/or gravel. -Twelve dish washer trays used for washing dishes were stacked near the dishwasher. Each tray was coated with a charcoal/mold-like color. The prongs where plates and glasses were stacked had a lighter grayish color. -The tiled wall behind the steam table was wet with steam and had built-up dust. Observation on 12/9/24 from 10:42 A.M. to 11:45 A.M. showed: -In the drink area the tray near the coffee maker contained the following: --The bottle of syrup with syrup on the sides and lid and no cap for the opened nozzle lid. --The red container had a sticky film and an opened nozzle lid with no cap. --The mostly empty mustard container had dried debris on the sides. The opened container was not labeled or dated. --A large plastic container of grape jelly had been opened and a little bit of the jelly had been used. The opened container was not dated or stored in a refrigerator. The container instructions were to Refrigerate after opening. --A grinder container of pink Himalayan salt had an oily film. The lid of the container was missing. --A jar of fennel spice had a greasy film. The lid was turned to where two holes were open. The top of the spice container was gritty with the spice or other debris. --A Creole seasoning container had greasy sides. The top was gritty with the spice or other debris and the lid was turned to where four holes were open. --A fourth jar had a piece of tape with someone's name on it and the word fennel handwritten on a piece of masking tape. A white substance resembling salt was in the see-through container. The lid was gritty and stained. All holes on the lid were open. -In the main kitchen area the bottom shelves below the microwave and the food prep tables had oily stains, chipped surfaces, and with containers, soup cans, and trays stored on them. -The microwave contained multiple greasy fingerprints on the handle, front door, and buttons. -A circle-shaped cereal piece was on the broken concrete where tile was missing under the stationary food prep table. -Spice containers in the kitchen had a greasy film to which dust adhered. -The baking oven door handle was smeared with oily fingerprints and the gas line was coated with built-up grease and dust. -The stove had built-up greasy oven handles, knobs, and knob panel. The six burners were black with crusty, oily build-up. The gas line behind the stove had built up grease and dust. -At 11:00 A.M. food was on the steam table. The wall behind the table was moist and dirty with dust. -Thirteen dish washer trays were stacked near the dishwasher, all with a charcoal/mold colored coating on the sides. The eye wash saline bottle and paper towel dispenser by the hand-washing sink were dirty with dust and the soap and sanitizer dispensers were soiled. -The floor was sticky in areas and had debris on the floor throughout the kitchen. -The mop bucket area floor was dirty with debris and the tray for soap or scouring pads was coated in a crusty dark substance. Observation on 12/10/24 from 1:00 P.M. to 2:20 P.M. showed: -In the drink area the mustard, ketchup, grape jelly, and spice containers sat on a tray near the coffee maker and were dirty and opened as they were the day before. The jelly was not refrigerated. -The kitchen floors were dirty with debris. -The mop bucket area soap/scour pad tray was crusted with a coating and the mop bucket area floor had built up dirt and debris. Review of the facility's monthly cleaning checklists for July, 2024 through 12/10/24 showed: -In July, 2024 cleaning tasks for the baker's oven and the stove (stove/griddle/oven appliance) had not been dated and initialed as having been completed. Cleaning for two refrigerators, sprinkler heads, vents, and the clock and dumpster inspections hadn't been dated and initialed as having been done. -In August, 2024 the following was not dated and initialed as having been cleaned: --Hood system and all vents. --Date and clean all spices. --Oven/grill/stove appliance. --Steam table and wall behind it and floor below it. --Four gray drawers and slides. --Hood system above dish machine. --Dish machine and chemical dollies and floor below the dish machine. --Garbage disposals and wall underneath. --Floor under baker's table and around tilt skillet. --Pot and pan shelves and floor below it. --Refrigerator number two and three shelves, wall, floors, and door. --Pot/pan sink and mop bucket sink. --Drink room machines, doors and walls and floor below machines. --Dry storage room. Check that all items are labeled and dated. Sweep and mop floor under shelves. --Sprinkler heads, vents, and clock. -In September, 2024, 16 of 20 monthly cleaning tasks were left blank. -In October, 2024, 16 of 20 monthly cleaning tasks were left blank. -There was no cleaning schedule completed for the month of November, 2024 and a cleaning schedule for December, 2024 had not been started. Review of the facility's daily cleaning checklist for 11/17/24 through 12/9/24 showed: -The same tasks were to be done daily on both the day and evening shifts, including: --Sweeping and mopping all floors (kitchen, drink room, and storage room). --Cleaning microwaves inside and out. --Removing outdated foods. --Cleaning the stovetop. --Refrigerating, labeling, and securing all food items. -The day shift left all tasks blank on 12/8/24 and the evening shift left all tasks blank on 11/21/24, 11/22/24, and 11/30/24. The bottom of the form showed spaces for the supervisor's daily initials. Supervisor initials were only marked on the day shift for November 18 and 19. During an interview on 12/10/24 at 1:00 P.M. Dietary Server B said: -They store ketchup in the red plastic bottle and keep mustard in the original mustard container. -They always kept the ketchup, mustard, jelly, and syrup out on the tray in the drink area during breakfast and lunch. They were left out on the tray near the coffee pot when he/she left for the day at 2:00 P.M. and were always out on the tray when he/she arrived in the mornings. They just leave the four condiments stored out on the tray. -Nobody cleaned the condiment containers that he/she knew of. He/She only cleaned the counter surfaces and the coffee maker and juice machine trays by running them through the dishwasher. -Floors were supposed to be swept and mopped daily after each meal. They sometimes cleaned after the breakfast or lunch meal if they had time. Nobody had swept or mopped yet today. -The lower shelves under the microwave and prep tables should all be kept clean. All dietary staff were responsible for cleaning all kitchen surfaces as well as the eye wash container and soap and sanitizer dispensers near the handwashing sink. They should be cleaned daily as needed. -He/She didn't know why the mop bucket area was so dirty. All dietary staff were responsible for cleaning it. -The grill and burners should be cleaned between each meal. -He/She didn't know if there was a cleaning schedule for kitchen surfaces. -It was fine to store trays and pans on the chipped bottom shelves below the microwave counter and the food prep tables. During an interview on 12/10/24 at 1:20 P.M. Dietary [NAME] A said: -There was a cleaning schedule for monthly and daily cleaning tasks and one for periodic cleaning that the Dietary Manager (DM) kept. -Whoever used the baking oven needed to clean it. The inside had to be cleaned monthly. -The monthly cleaning tasks were done any time during the month whenever dietary staff had time to do them, but each task should be done every month. If a task was not marked as having gotten done that meant it wasn't done or staff didn't mark it as having been done. -They had always stored pans and trays on the bottom chipped shelves under the microwave and food prep tables. The surfaces probably should be cleaned with a sanitizer every couple of weeks. -The cook was supposed to clean the stove burners. The charred burners have to be scraped off monthly. Anyone can clean the burner knobs with a degreaser or scouring pad. -The gas lines going to the baker's oven and stove should be cleaned on the special duty cleaning schedule which the DM has. -There used to be a spigot where the floor tiles were missing and the concrete was loose. Water used to go from the floor at that spot to the tilt skillet. The concrete kept breaking up and dietary staff just sweep around it. -Normally a dietary aide will sweep and mop the floor on the evening shift. -Whoever does the dishes should clean the dishwasher trays. They don't come clean in the dishwasher. He/She thought the darkened color was just soap build up. During an interview on 12/10/24 at 1:55 P.M. Dietary [NAME] B said floors should be cleaned at the end of each meal. During an interview on 12/10/24 at 2:05 P.M. the DM said: -Once the jelly, mustard and ketchup containers are opened they should be stored when not in use in a refrigerator that is not over 40 degrees Fahrenheit. The syrup and ketchup container nozzle lids should have a cap on them. -The spice and condiment containers should be wiped off with the sanitizer solution daily. The spice containers in the kitchen get greasy from the hood vent they are under. Lids on spice containers should all be closed. -When staff use the tilt skillet grease goes everywhere. -Dietary staff should try to clean floors three times daily after each meal. -The flat top griddle should be cleaned between breakfast and lunch. -An oven cleaner can be used to clean burners. They should be cleaned off at least every two weeks. -All dietary staff should be cleaning kitchen surfaces. Whoever uses a surface or an appliance should clean them. -The cook was responsible for cleaning knobs on the ovens and stove. -Oil on the back of the baker's oven and stove builds up fast. It should be cleaned at least weekly to make sure dust and debris doesn't build up on it. -He/She wasn't sure of the protocol for cleaning off the gas lines to the oven and stove. A company came out every six months to clean the hood. They should clean the gas lines then as well. They were just out in late November this year. -Staff should clean the wall behind the steam table monthly. -Dietary staff filled out maintenance logs several times related to the missing tiles and broken concrete in the kitchen. Several people put in a request at different times and the floor hasn't gotten fixed yet. He/She just kind of gave up on it getting fixed. -Whoever does a monthly task should date and initial beside the task they did. Every dietary staff member was responsible for the monthly and daily cleaning tasks. Staff have a whole month to complete each task on the monthly lists. He/She and the cook were responsible for checking to see that the cleaning tasks were being done as scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow appropriate infection control practices for three sampled residents (Resident #58, #27, and #74) who was on Enhanced Barrier Precautions (EBP - refer to an infection control intervention designed to reduce transmission of multi-resistant organisms that employs targeted gown and glove during high contact resident care activities) failed to use adequate hand hygiene during incontinence care for (Resident #58); failed to ensure infection control was maintained during wound care for one sampled resident(Resident #2); failed to perform proper hand hygiene during cares for one sampled resident (Resident #74); and failed to ensure yearly tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) test was completed for two sampled residents (Resident #32 and #2) out of 18 sampled residents. The Facility census was 76 residents. Review of the facility policy Handwashing/Hand Hygiene dated 2001 showed: -Hand hygiene is indicated: --Immediately before touching a resident, before performing an aseptic (aiming at the complete exclusion of harmful microorganisms) tasks, after contact with blood, body fluids, or contaminated surfaces, after touching residents, after touching residents environment, before moving from work on a soiled site to a clean body site on the same resident and immediately after glove removal. Review of the facility policy Wound Care revised 10/2010 showed: -Gather supplies (gauze, tape, scissors, etc.), personal protective equipment (gowns, gloves, masks etc.). -Wash and dry hands thoroughly. -Glove and remove dressing. -Pull glove over dressing and discard. Wash and dry hands thoroughly. -Glove. -Cleanse wound, pat dry. -Remove gloves and wash hands thoroughly. -Glove and apply treatment. Use no touch technique. -Remove gloves and wash hands thoroughly. Review of the facility policy Perineal Care revised 2/2018 showed: -The purpose of the procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irrigation, and observe the resident's skin condition. Review of facility policy Tuberculosis, Screening for Residents revised August 2019 showed: -The facility would screen all residents for tuberculosis infectious disease (TB). -The admitting nurse would screen referrals for admission and readmission for information regarding exposure to or symptoms of TB. -If a potential resident had been exposed to active TB or is at increased risk of TB infection, he or she would be screened for latent tuberculosis infection (LTBI residents do not feel sick, do not have any symptoms, but can potentially develop active TB disease) using a tuberculin skin test (can tell if you have TB germs in your body). -Screening of new admissions or readmissions for tuberculosis infection and disease was in compliance with Sate regulations. -The facility would have conducted an annual risk assessment to determine risk of exposure. -Risk factors for exposure to TB were: --those born in or who frequently traveled to countries where TB was common. --People who currently (or previously) lived in large group settings where TB was common (homeless shelters, prisons, etc.); or --Those who have spent time with a person who has had active TB disease. -Residents who had health conditions or have taken medications that predisposed them to developing active TB disease once infected are tested regularly according to their exposure risk assessment. Review of the facility policy EBPs dated 9/2024 showed: -EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. -Gloves and gown are applied prior to performing high contact resident care activities. -High-contact resident activities include: --Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube etc.) and wound care (any skin opening requiring a dressing). 1. Review of Resident #58's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: -Flaccid hemiplegia ( a condition characterized by paralysis and loss of muscle tone on one side of the body). -Feeding tube (a method of providing nutrition, fluids, and medication directly to the stomach or small intestine through a tube). Review of resident's significant change Minimum Data Set (MDS- a federally mandated assessment instrument completed by the facility staff for care planning) dated 11/24/24 showed the resident: -Had moderate cognitive impairment. -Had upper and lower extremity impairment. -Was dependent on staff for toileting. -Was always incontinent of bowel and bladder. -Had a feeding tube. Review of the resident's Electronic Medical Record (EMR) Physician's Order Summary (POS) dated 12/2024 showed he/she had feeding tube. Review of the resident's care plan dated 12/4/24 showed: -Staff was to provide total assist with toileting due to bowel and bladder incontinence. -Staff was to provide local care to feeding tube site and monitor for signs and symptoms of infection. Observation 12/9/24 at 11:03 A.M., of resident care showed: -The resident had EBP signage posted on the door. -Certified Nursing Assistant (CNA) A entered the resident's room and applied his/her gloves without washing his/her hands. CNA B was already in the room with his/her gloves on. CNA A and CNA B did not use Personal Protective Equipment (PPE) gown. -The resident was in bed on his/her back. CNA A and CNA B had pulled the resident's pants down to his/her ankles. -CNA A had released the residents incontinence brief and stuffed the brief between the resident's inner thighs. **NOTE: The residents brief was soiled with urine. -CNA A had used one wipe and had washed down the resident inner left thigh crease one time and had stuffed the wipe down into the brief between the resident legs and repeated that process on the right inner thigh crease. **NOTE: CNA A did not to wash the front genitalia of the resident. -CNA B assisted CNA A to roll the resident on his/her left side and CNA A completed the resident's peritoneal cares. -CNA A and CNA B had pulled the residents pants up then placed his/her blankets over him/her without removing their soiled gloves and handwashing. -CNA A had discarded his/her gloves into the trash, had exited the residents room to retrieve a mechanical lift and had not washed his/her hands. During an interview 12/9/24 at 11:22 A.M., CNA A said: -He/She would have used more wipes and washed his/her hands more. -He/She had not known the resident was on EBP and should have worn gown during the resident care. -He/She would be told by the charge nurse if a resident was on EBP. -He/She should also be looking for EBP signage on the resident door. -He/She should have provided cleansing to the front genitalia on the resident. -He/She had perineal care and EBP training recently. 2. Review of Resident #27's admission Record showed the resident was admitted to the facility on [DATE] with neuromuscular dysfunction of bladder (a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition). Record review of the resident's quarterly MDS dated [DATE] showed he/she had an indwelling catheter (drains urine from your bladder into a bag outside your body). Observation on 12/6/24 at 2:13 P.M. showed: -There was no PPE cart outside the resident's room. -There was no EBP sign on the door or the door frame to the room. -Staff entered room without putting on PPE and moved the resident's catheter bag. During an interview on 12/6/24 at 2:33 P.M., CNA A said that he/she should have used PPE when handling the resident's catheter bag. 3. Review of Resident #74's admission Record showed he/she was admitted to the facility on [DATE] and had a (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they are unable to eat). Review of the resident's admission MDS dated [DATE] showed he/she: -Had a moderate cognitive impairment. -Received his/her over 51 percent (%) nutrition through tube feeding. -Required extensive staff assistance for transfers, bed mobility, dressing, and eating. -Required total staff assistance for bathing and toileting. Review of the resident's care plan revised on 11/29/24 showed he/she: -Was dependent on staff for all cares. -Had a PEG tube for nutrition. Observation on 12/10/24 at 9:41 A.M., of LPN A showed: -He/she had prepared all the resident's medications and removed his/her gloves and did not sanitize/wash hands. -He/she used a swab to stir medications and put gloves back on without sanitizing/washing hands. -He/she removed his/her gloves did not sanitize/wash hands and grabbed the bed control and adjusted the bed. -He/she removed his/her gloves and did not sanitize/wash hands and grabbed more gloves to put on the bedside table. -Cleaned the resident's PEG tube then put his/her dirty gloved hand into a bag of clean gauze to grab more gauze out. -He/she removed gloves and did not sanitize/wash his/her hands. -He/she did not have a gown on while administering medication through the resident's PEG tube or providing cares. During an interview on 12/13/24 at 9:14 A.M., LPN A said: -All residents with wounds and indwelling devices like catheters and PEG tubes would be on EBP. -For a resident on EBP you would wear a gown and gloves at a minimum. -Residents on EBP would have a yellow triangle with the letters EBP on the triangle and this would be on the resident's door. -He/She said that he/she should have had the gown on when doing PEG tube medications and cares. -If a resident was on EBP, and there was no sign on the door he/she would put one on the door. 4. Review of Resident #2's annual MDS dated [DATE] showed the resident: -Had a Stage IV pressure ulcer. -Was cognitively intact. Review of the resident's undated POS showed: -Wound treatment: Sacrum (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity), cleanse with wound cleanser of facility choice, apply A&D Ointment (used to prevent, treat, and relieve rashes caused by incontinence) every shift for wound care. -Wound treatment: Stoma (surgical opening), cleanse with wound cleanser and apply collagen powder moistened with normal saline to open areas every day shift every Friday for wound care and as needed. Observation of wound care for the resident with LPN A on 12/10/24 at 10:41 A.M. showed: -LPN A sanitized his/her hands, donned a clean gown, entered the resident's room, applied a barrier on the resident's bedside table, placed the wound care and colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen) care supplied on the barrier, removed a pair of scissors from a lanyard on his/her uniform and placed the unsanitized pair of scissors on the clean barrier next to the wound care supplies. -Without sanitizing his/her hands, he/she donned clean gloves. -He/She cut the ostomy wafer (the piece of the pouching system that sticks to your body. It holds your pouch in place and should help protect the skin around your stoma from damage) to fit the stoma site without sanitizing the scissors. -After performing hand hygiene and changing gloves, he/she cleansed the resident's stoma site, removing stool as he/she was cleansing the site. Then with the same gloves, he/she reached into the gauze package, removed additional gauze. -After performing hand hygiene, he/she continued to cleanse the stoma site, then with the same gloves applied the collagen wound treatment, picked up the bottle of colostomy collagen powder and applied powder to the site. He/She then removed one glove and without sanitizing donned a new clean glove, applied the colostomy wafer and colostomy bag. -He/She removed his/her gloves and with ungloved hands, touched the resident's Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) tubing and bag, and placed it on the bed next to the resident. -Without washing or sanitizing his/her hands, he/she donned clean gloves and touched the resident as he/she assisted the resident to turn to his/her side, and with the same gloved hands, reached into the package of gauze to remove clean gauze, then cleansed the resident's healed sacral wound. With the same gloved hands, he/she applied ointment to the resident's sacral area. -He/She removed his/her gloves, then without washing or sanitizing his/her hands, with ungloved hands, he/she removed the Foley catheter from the resident's mattress, touched the resident's bedding, removed the remaining wound and ostomy supplies and scissors from the top of the bedside table and exited the room. -He/She placed the wound and ostomy supplies on top of the treatment cart, including the bottle of wound cleanser, the open package of gauze, and the scissors. -He/She opened the wound treatment cart and began to put the contaminated bottle of wound cleanser and opened package of gauze in the bottom drawer for later use. -He/She cleansed his/her scissors with an alcohol wipe. During an interview on 12/10/24 at 11:00 A.M., LPN A said: -He/She should have sanitized his/her hands with each glove change and before donning gloves. -He/She should not have removed just one glove, he/she should probably have removed both then sanitized his/her hands before putting on clean gloves. -He/She did not recall putting his/her gloved hands into the package of gauze to remove gauze after cleaning the resident's stoma and wound. He/She should not have done that. He/She should not put the contaminated package of gauze in the wound cart as he/she could not use the gauze for anyone else now. -He/She should have sanitized the wound cleanser bottle he/she brought into the resident's room before placing it in the wound treatment cart. -He/She used alcohol wipes to sanitize the scissors after using them. He/She did not sanitize them before using them on this resident. He/She should have used bleach wipes to sanitize the scissors. 5. During an interview on 12/13/24 at 8:34 A.M., Nurse Aide (NA) A said: -EBP meant PPE was required when doing cares on wounds and indwelling devices. -The minimum PPE wore is gown and gloves. -The residents that were on EBP would have a small triangle on the door frame with the letters EBP in the center of the triangle, and there would be a PPE cart near the room or right outside the door. -The PPE would be removed after cares, and hands were washed/sanitized before leaving the room. During an interview on 12/13/24 at 8:59 AM, LPN B said: -PPE had to be worn when providing cares on wounds or devices that were indwelling in residents such as catheters. -The minimum equipment would be gown and gloves. -The residents on EBP were designated by a yellow triangle outside the room and all residents with wounds and indwelling devices were on PPE. -If a resident had wounds or indwelling devices and the room did not have a triangle he/she would get one and place it on the door. During an interview on 12/13/24 at 9:04 A.M., CNA C said: -Enhanced barrier precautions were known as EBP. -This meant that gown and gloves had to be worn when working with a resident's catheter. -Resident's on EBP were marked by a yellow triangle on the door with EBP in the triangle. -If a resident was on EBP and there was no triangle on the door he/she would tell the nurse. During an interview 12/13/24 at 9:08 A.M., Certified Medication Technician (CMT) B said: -EBP was to be used on residents with urinary catheters (a thin flexible tube inserted into the urethra (the tube that carries urine from the bladder to the outside of the body) to drain urine from the bladder), wound infections and colostomy's (a surgical procedure that creates an opening in the abdominal wall was to bring one end of the colon to the surface). -He/She had been educated on EBP about a month ago. -The facility used to have EBP signs on the door but, does not think that was done anymore. -He/She would get report from the charge nurse on what residents would require EBP. -Hand washing should be done before and after gloving, before entering a resident room and before leaving a residents' room. During an interview 12/13/24 at 9:20 A.M., LPN B said: -EBP was posted outside resident doors. -Gowns and gloves should be worn when direct care was being provided. -The charge nurses would be responsible to make sure care givers are wearing PPE. -The Assistant Director of Nursing (ADON) would be responsible for posting EBP on the outside of resident doors. -He/She would be responsible to make sure peritoneal care was being provided appropriately. During an interview 12/13/24 at 12:24 A.M., the Director of Nursing (DON) said: -He/She would expect staff to wear gowns and gloves when giving direct care to resident on EBPs. -He/She would expect staff to wash hands and change gloves as per facility protocol when proving incontinence and wound care. -All resident's with wounds and indwelling devices would be on enhanced barrier precautions. -It was his/her expectation staff would use PPE gown and gloves at a minimum for these residents when doing cares on those things. -Residents on EBP would have the correct signage on the door, and if it was not there the nurse would it on the door. -Staff needed to wash/sanitize hands when staff removed gloves. -It was his/her expectation staff would have the EBP PPE on when doing medications through a PEG tube or cares on a PEG tube, and when handling a foley drainage bag. -He/She was responsible for auditing staff to ensure that staff were following the EBP precautions. 6. Review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's EMR showed the last TB testing and/or screening was completed May 2021. TB testing for 2023 and 2024 was requested from the facility but not received at the time of exit. 7. Review of Resident #2's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] . Review of the resident's EMR showed the last TB testing and/or screening was completed in 2019. TB testing for 2023 and 2024 was requested from the facility but not received at the time of exit. During an interview on 12/12/24 at 2:54 P.M. the DON said: -He/she could not locate any other TB testing for the residents. -He/she expected TB testing to be completed annually.

Based on observation, interview, and record review, the facility failed to ensure the correct dosage of Insulin(a hormone used to treat high blood sugar) was administered by not priming the insulin pen (an injection device with a needle that delivers insulin into the tissue) before administering insulin to one sampled resident (Resident #88) out of 19 sampled residents. The facility census was 87 residents. Record review of the facility's undated policy titled Procedure for Insulin Administration using Insulin Pen showed: -Once a new needle was attached, staff were to set the pen's dial to 2 units, hold the pen vertically with the tip facing the ceiling, and press the dose button. -Staff were to visualize a drop or stream of insulin at the tip of the needle to ensure all air had been removed. -If a drop or stream of insulin was not seen at the tip of the needle, staff were to repeat the process. 1. Record review of Resident #88's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 2/20/23, showed the resident: -Was cognitively intact. -Had Diabetes Mellitus (a group of diseases that result in too much sugar in the blood). Record review of the resident's Medication Review Report, dated 5/3/23, showed an order for Humalog (a fast acting insulin) to be given per sliding scale (dose dependent on blood sugar level at the time of testing). Observation on 5/1/23 at 11:17 A.M. showed the Director of Nursing (DON): -Tested the resident's blood sugar and the resident required one unit of Humalog based on the sliding scale set by the physician. -Removed the resident's Insulin pen from the medication cart, cleaned the tip of the pen with alcohol, attached a new needle, set the pen's dial to one unit, removed the cap, cleaned the resident's right upper abdomen with alcohol, inserted the needle into the resident's abdomen and pressed the dose button. -Removed the needle from the pen and returned the pen to the medication cart. During an interview on 5/1/23 at 11:17 A.M., the DON said he/she wouldn't have done anything differently. During an interview on 5/3/23 at 1:10 P.M., Certified Medication Technician (CMT) A said staff were to attach a new needle to the resident's Insulin pen, prime the needle with two units of Insulin, then set the dial for the resident's ordered dose before each administration. During an interview on 5/3/23 at 2:21 P.M., Licensed Practical Nurse (LPN) B said staff were to attach a new needle to the resident's Insulin pen, prime the needle with two units of Insulin, then set the dial for the resident's ordered dose before each administration. During an interview on 5/5/23 at 1:04 P.M., the Assistant Director of Nursing (ADON) said staff were to attach a new needle to the resident's Insulin pen, prime the needle with two units of Insulin, then set the dial for the resident's ordered dose before each administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #88's face sheet showed he/she was admitted with a diagnosis of retention of urine (an inability to fully empty the bladder). Record review of the resident's admission MDS dated [DATE], showed the resident: -Was cognitively intact. -Required one person to physically assist with toileting. -Required one person to physically assist with hygiene. -Was admitted with an indwelling urinary catheter. -Had not received antibiotics during the seven day lookback. Record review of the resident's undated care plan showed the resident: -Had an indwelling urinary catheter size 18 Fr with a 10 ml bulb (an inflatable balloon near the tip of the catheter that is inflated with sterile water to keep the catheter in the bladder). -Was to have catheter care done by staff once in the evening and as needed. Record review of the resident's admission summary, dated [DATE], showed: -The resident had returned from the hospital with a diagnosis of a UTI. -The resident had been started on an antibiotic for the UTI. -A new indwelling catheter had been placed during his/her hospitalization. Record review of the resident's Lab Results Report, dated 4/26/23, showed: -The resident's urinalysis (a test that examines a small sample of urine for abnormalities) was positive for an infection. -The resident's urine culture (a laboratory test to check for bacteria, yeast, or other microorganisms in the urine) and sensitivity (a laboratory test that determines what medication is most effective to treat what grew in the culture) grew Enterococcus faecium (bacteria normally present in human intestines). During an interview on 5/2/23 at 9:29 A.M., the resident said: -Staff only cleaned his/her catheter when he/she was showered twice a week. -Staff did not clean his/her catheter daily. -He/she did not clean his/her catheter. -He/she wore a brief because he/she had occasional bowel incontinence. Record review of the resident's Medication Review Report, dated 5/3/23, showed: -No order for an indwelling catheter or catheter care. -An order for Linezolid (an antibiotic) 600 milligrams (mg) to be given twice a day for a UTI. Observation on 5/3/23 at 10:24 A.M. of the resident showed he/she had an indwelling urinary catheter size 16 Fr with a 10 ml bulb. During an interview on 5/3/23 at 10:57 A.M., LPN D said: -An indwelling catheter required a physician's order. -The resident's catheter insertion site (the urethra-the tube through which urine leaves the body) was cleaned twice a week when he/she showered. -He/she would occasionally look at the resident to see if he/she appeared clean. -He/she believed the resident did his/her own cares. -He/she did not believe an order for a catheter was necessary as the resident was admitted with a catheter. During an interview on 5/3/23 at 12:48 P.M., CNA D said: -He/she was unsure how often a catheter should be cleaned. -He/she believed catheter care should be done once a week. During an interview on 5/3/23 at 1:02 P.M., CNA F said urinary catheters were to be cleaned each time peri-care was performed. During an interview on 5/3/23 at 2:21 P.M., LPN B said: -Indwelling catheters were to be cleaned daily. -All indwelling catheters required an order. -The resident's UTI could have most definitely been caused by inadequate cleaning of the catheter. During an interview on 5/4/23 at 10:08 A.M., the DON said he/she could not find any record of when the resident's catheter was placed, where, what size, or by whom. During an interview on 5/4/23 at 10:44 A.M., the resident said: -No one cleaned his/her catheter the day before. -He/she had emptied the urine collection bag but had not cleaned the catheter. -A unidentified CNA had assisted him/her throughout the night but did not touch his/her catheter. During an interview on 5/5/23 at 1:04 P.M., the ADON said: -Indwelling catheters were to be cleaned once per shift. -He/she expected staff to follow the facility's policies. -The catheter was to be cleaned each time peri-care was provided. -Staff were to visually inspect catheters to ensure it was cleaned, regardless of a resident's ability to perform the task themselves. -Since an order was not entered for the resident's catheter, staff would not have known to clean it and wouldn't have been able to document it. -He/she was not responsible for auditing physician's orders and did not know who, if anyone, was responsible for that. -The resident's UTI could have been caused by his/her catheter not being properly cleaned. -He/she trained all staff. -When the resident was diagnosed with a UTI, catheter care was not monitored. Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained by placing an indwelling catheter (a urinary bladder catheter inserted through urethra) drainage bag (catheter bag, a bag that held drained urine) at or above the level of the bladder during wound care for one sampled resident (Resident #2) and by not providing catheter care and not obtaining a physician's order for an indwelling catheter for one sampled resident (Resident #88), who were both at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system) out of 19 sampled residents. The facility census was 87 residents. Record review of the facility Catheter Care policy dated 6/13/22 showed: -The catheter and drainage bag should be kept as a closed system with the drainage bag kept at a level lower than the bladder to allow drainage by gravity. -The facility staff were required to provide catheter care for indwelling catheters at least twice a day and more often as needed when soiled with feces. -The facility was to have a physician's order for an indwelling catheter. 1. Record Review of Resident #2's admission Face Sheet showed he/she was readmitted on [DATE] and had diagnoses of: -Neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -History of UTI. Record review of the resident's catheter care plan revised on 11/24/22 showed: -Intervention updated on 4/29/22 included: --He/she had a Suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) as of 4/28/22. --Staff were to position the resident's catheter drainage bag and tubing below the level of his/her bladder. --He/she was taking medication daily to help prevent UTI's. Record review of the resident's medical record dated 2/2023 showed the resident had been on antibiotics for a UTI. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 2/16/23, showed he/she: -Was cognitively intact with no short term and long term memory problems. -Was able to understand others and make his/her needs known. -Required total assistance from staff for all cares and transfers. -Had an indwelling catheter. Record review of the resident's Physician Order Sheet (POS) dated 5/3/23 showed: -Supra Pubic (Indwelling Catheter 16 French (Fr) 10 milliliter (ml) balloon. Catheter Indication for Neurogenic bladder (order on 4/29/22). -May change catheter drainage bag as needed. -Staff were to provide catheter care on day shift and evening shift as needed. Observation on 5/1/23 at 1:30 P.M., of the resident's wound care showed: -Licensed Practical Nurse (LPN) C had turned the resident to his/her right side for wound/ skin care. -LPN C placed the resident's catheter drainage bag on the bed and level with the resident's bladder. -The resident said the staff had emptied the catheter drainage bag earlier that morning. -The resident had yellowish color urine in the catheter drainage bag and urine flowing into the catheter drainage tubing into the drainage bag, while laid on top of the bed. -After the resident's care was completed, LPN C placed the drainage bag below the resident's bladder and hooked it onto the bottom left side of the bed frame. During an interview on 5/4/23 at 10:09 A.M., Certified Nursing Assistant (CNA) E said: -The resident's catheter drainage bag could be placed on top of the bed at the level of the bladder or below the bladder as long as urine was flowing to the drainage bag during personal cares. -The resident's catheter drainage bag should be kept below the resident bladder at all times. During an interview on 5/4/23 at 11:10 A.M., CNA D said: -The resident's catheter drainage bag should be kept below bladder and hooked on the side bed-frame. -The resident's drainage bag should not be placed on top of the resident's bed during any cares. During an interview on 5/4/23 11:19 A.M., LPN A said: -The resident's catheter drainage bag should be kept below the bladder during care and never left on top of the bed at the level of the bladder during any care for the resident, including wound care. -The facility provided online training's and in-services once a month and included infection control and catheter care. During an interview on 5/5/23 at 10:10 A.M., LPN C said: -The resident's catheter bag should be kept below the resident's bladder. -He/she had placed the catheter drainage bag on top of bed so it would not pull while repositioning the resident. -Since he/she was performing a quick wound care treatment, the resident's catheter drainage bag could be on top of the bed and he/she would have ensured to have emptied the catheter drainage bag prior to placement on top of the bed. -The resident's catheter drainage bag should not be laid at the foot of the bed at the level of the bladder while performing longer resident's cares such as personal hygiene cares. -The resident's wound care only took him/her a few minutes and with that short period of time, the resident's catheter drainage bag being left on top of the bed at the level of the resident's bladder would not be harmful to the resident, nor would it place the resident at risk for urine back flow back into the bladder. During an interview on 5/7/23 at 1:04 P.M., the Assistant Director of Nursing (ADON) and Director of Nursing (DON) said: -Catheter drainage bag placement during wound care or personal cares, should be kept below the bladder and placed on the side of the bed the resident was turned toward. -Catheter drainage bags should never be laid on the bed during care for any extended period of time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #20's face sheet showed he/she was admitted with vascular dementia (the condition causes cognitive difficulty with reasoning and judgment). Record review of the resident's Quarterly MDS, dated [DATE], showed the resident: -Had severe cognitive impairment. -Required extensive assistance with toileting and hygiene. Observation on 5/1/23 at 8:56 A.M. during initial tour showed: -CNA A brought the resident into his/her room, where the resident's roommate was lying on their own bed watching television, closed the door, transferred the resident to his/her bed and removed the resident's shoes and pants. -CNA A did not close the privacy curtain between the roommates nor close the blinds on the outside window which faced a parking lot. -CNA A then removed the resident's brief and performed incontinence care and redressed the resident. During an interview on 5/1/23 at 8:56 A.M., CNA A said he/she couldn't think of anything they should have done differently. During an interview on 5/2/23 at 9:16 A.M., the resident said: -Staff normally do not close the privacy curtain between the two roommates. -He/she was upset that the roommate saw his/her entire body. -He/she didn't like that the outside blinds were open and anyone walking by could see his/her body. 3. Record review of Resident #66's face sheet showed he/she was admitted with quadriplegia (the loss of ability to move, and sometimes feel, all four limbs). Record review of the resident's Significant Change MDS, dated [DATE], showed the resident: -Was cognitively intact. -Was totally dependent on staff for toileting and hygiene. Observation on 5/3/23 at 7:46 A.M. showed: -CNA D was in the resident's room preparing to perform incontinence care. -CNA D had pulled the privacy curtain but had left the blinds to the outside window open. -CNA D removed the resident's brief, performed incontinence care, and began providing other hygiene related needs. During an interview on 5/3/23 at 8:07 A.M., the resident said he/she didn't like the blinds on the window being open. 4. During an interview on 5/3/23 at 8:12 A.M., CNA D said he/she had never thought about closing the blinds on the windows. During an interview on 5/3/23 at 1:02 P.M., CNA F said: -The privacy curtain between roommates were to be closed when providing cares. -Window blinds were to be closed before providing cares. During an interview on 5/3/23 at 1:10 P.M., Certified Medication Technician (CMT) A said: -When providing cares, staff were to close the door, pull the privacy curtain, cover any areas of the resident's body that did not need to be exposed, and the blinds on the windows were to be closed. -He/she would have a problem with being undressed in front of a window with the blinds open. During an interview on 5/3/23 at 2:21 P.M., Licensed Practical Nurse (LPN) B said when providing cares, staff were to close the door, pull the privacy curtain, close the blinds on the windows, and expose only what body parts were necessary for the care. During an interview on 5/5/23 at 1:04 P.M., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the ADON said: -The expectation was that nursing staff should pull the resident's privacy curtain between the residents when providing resident cares so the resident was not exposed. -Blinds on windows to the outside were to be closed during cares so no one could see inside. Based on observation, interview and record review, the facility failed to ensure privacy and dignity was preserved during incontinence care for two sampled residents (Resident #85, and #20) and one supplemental resident (Resident #66) out of 19 sampled residents and five supplemental residents. The facility census was 87 residents. Record review of the facility's undated Notice of Resident Privacy/Dignity Practices showed: -Dignity refers to treating residents with respect. Examples include respecting the resident's wishes, responding to their need and treating them as individuals. -Dignity also means respecting their rights, giving them freedom of choice .providing them privacy and their own personal space. -For those with cognitive impairments, it is important that the preferences they had are still acknowledged even though they may no longer be able to express their preferences. 1. Record review of Resident #85's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), heart failure (a chronic, progressive condition in which the heart muscle is unable to pump), Chronic Obstructive Pulmonary Disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), kidney disease, and muscle weakness. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/6/23, showed the resident: -Was alert with severe memory impairment. -Was totally dependent for mobility, transfers, bathing and toileting and was incontinent of bowel and bladder. Observation on 5/1/23 at 1:33 P.M., showed the resident sitting in his/her wheelchair with a sling underneath him/her. Certified Nursing Assistant (CNA) A was in the resident's room wearing gloves and was positioning the full body mechanical lift. CNA B was in the resident's room and put on gloves to assist with attaching the resident's sling to the mechanical lift. The resident's roommate was sitting in his/her wheelchair watching television and the privacy curtain between the residents was not pulled. The following occurred: -CNA A raised the resident's bed then began assisting CNA B with connecting the sling to the lift. Once the sling was connected, CNA A informed the resident they were getting ready to transfer him/her to his/her bed and then perform incontinence care. -CNA A lifted the resident while CNA B positioned the resident as he/she was lowered in to his/her bed. -Both CNA's began to assist the resident with removing the sling from underneath the resident and neither CNA pulled the resident's privacy curtain or moved the resident's roommate out of view of the resident before starting incontinence care. -CNA A removed the resident's pants and soiled brief. CNA A handed the sling and pants to CNA B and placed the soiled brief in the trash. -CNA A began providing incontinence care to the resident and never pulled the privacy curtain or provided any privacy to the resident, while his/her roommate was able to observe the resident's care. During an interview on 5/1/23 at 1:50 P.M. CNA A said: -He/she noticed that they did not close the resident's privacy curtain before providing care to the resident. -They should have closed the privacy curtain once the entered the resident's room because the resident's roommate was there and could observe the resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the ceiling vents in the shower rooms of 100 Hall, 200 Hall and the 500 Hall, free of a heavy buildup of dust; and to maintain the base of a standup lift (a medical device that assists individuals with limited mobility in standing up from a seated position. This type of lift is designed for individuals who find it difficult or impossible to stand up without assistance due to a variety of medical conditions or disabilities) without a two inch (in.) crack. This practice potentially affected at least 60 residents who may obtain their showers in the facility shower rooms and seven residents who needed the assistance of a stand-up lift. The facility census was 87 residents. 1. Observation with Maintenance Assistant A on 5/2/23, showed: -At 1:30 P.M., there was a buildup of dust in the restroom ceiling vent in resident room [ROOM NUMBER]. -At 1:44 P.M., there was a heavy buildup of dust in the ceiling vents in the 100 Hall shower room ceiling vent. -At 2:17 P.M., there was a heavy buildup of dust in the ceiling vent in the 200 Hall shower room ceiling vent. During an interview on 5/2/23 at 2:18 PM, Maintenance Assistant A said: -He/she had not cleaned the ceiling vents for 3-6 months. -Maybe one of the other Maintenance Personnel did the cleaning but he/she could not confirm that for sure. -He/she was not sure the last time the ceiling vents were cleaned. Observation with the Maintenance Director on 5/3/23 at 8:48 AM, showed a heavy buildup of dust inside the ceiling vents of the 500 Hall shower room. During an interview on 5/3/23 at 8:49 A.M., the Maintenance Director said the vents were supposed to be cleaned monthly, but the ones in that shower room had dust. 2. Observation with the Maintenance Director on 5/3/23 at 8:50 A.M., showed a standup lift which was stored in the 500 Hall, which had a two inch crack in its base. During an interview on 5/3/23 at 8:51 A.M., the Maintenance Director said no one told him/her about the crack in the lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident safety while on the toilet that resulted in a fall with injury for one sampled resident (Resident #27) out of 18 sampled residents. The facility also failed to maintain hot water temperatures in resident rooms 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 312, 313, 4101, 402, 403, 405, 406, 407, 408, 409, 502 and 504 below 120 ºF (degrees Fahrenheit) on 5/1/23. This practice potentially affected 33 residents who resided in resident rooms served by Nurse's Station 2. The facility census was 87 residents. Record review of the facility's undated Fall policy and procedure showed it is the policy of the facility to aggressively work to prevent resident falls by promoting a safe environment, by assessing possible causal factors which can lead to falls and to train staff, residents, and families on fall prevention. The policy showed: -Following any falls the staff will complete an occurrence report (fall report). Details of the fall will be reported and potential causal factors will be identified and investigated. Interventions will be immediately implemented following each fall and added to the resident's plan of care. Staff will review the resident's Fall Risk Assessment. An update or change to the assessment will only be made if the resident was previously at low risk. 1. Record review of Resident #27's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (abnormal heart rhythm), anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), high blood pressure, visual disturbance, history of fracture and history of falling. Record review of the resident's Care Plan dated 1/7/23 showed the resident was at risk for falls. It showed the resident had several falls while trying to transfer himself/herself from his/her wheelchair to/from bed (10/21/21, and most recently on 1/7/23). The care plan showed the resident required extensive assistance of one to two staff with transfers and toileting. Interventions showed staff was to: -Remind him/her to put his/her shoes on and to get into his/her wheelchair, and that he/she could not safely walk by himself/herself. -Educate him/her about safety reminders and what to do in case he/she fell. -Encourage him/her to wear non-skid shoes or socks when he/she get out of bed to help prevent him/her from sliding out of the wheelchair or slipping and falling when he/she was using the walker or walking behind his/her wheelchair. -He/she had an Anti-roll back device on his/her wheelchair. -He/she preferred his/her bed to be against the wall because it makes it easier to get in and out of the bed. -He/she would put himself/herself on the floor looking for things (example: Scorpions, lens from my glasses) He/she has not fallen. -If he/she were to fall a Licensed Nurse was to check him/her for injuries before at least two staff help him/her to get off the floor. -Maintenance tightened the anti-roll back device on his/her wheelchair. -Make sure that he/she can reach the call light when he/she was in his/her bed. He/she may need staff to remind him/her every time staff were in the room how and why to use the call light. -Make sure that he/she had non-skid strips in the bathroom and remind him/her to put on both shoes and use his/her wheelchair so that he/she had less chance of falling. -The nurse was to let his/her doctor know if he/she had any of the following within 72 hours from the fall: pain, bruises, change in mental status. New onset: confusion, sleepiness, inability to maintain posture, agitation. -Encourage him/her to wear non-skid socks at night. -Ensure that he/she had his/her shoe laces tied appropriately before transferring him/her. -He/she was moved to a room closer to the nursing station to help prevent falls. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/24/23, showed the resident: -Was alert with memory impairment. -Needed extensive assistance from staff for transfers, mobility, and toileting. -Was not steady moving from a seated to a standing position, performing surface to surface transfers, maintaining his/her balance on the toilet or performing transfers to and from the toilet without physical assistance. -Used a wheelchair for mobility and did not walk. -Had one non-injury fall prior to admission or during the prior assessment period. Record review of the resident's Fall Risk assessment dated [DATE], showed the resident had intermittent confusion, had no falls in the past three months, had a balance problem while standing, had decreased muscular coordination, was wheelchair bound, had three predisposing diseases and took medications that would predispose the resident for falls. His/Her fall risk assessment score was 14, which showed the resident was at risk for falls. Record review of the resident's Nursing Notes showed: -On 3/15/23 at 7:49 A.M., the (unidentified) Certified Nursing Assistant (CNA) called the nurse to the resident's room. -The nurse saw the resident laying on bathroom floor in front of his/her toilet. -The resident had an abrasion to the top of his/her head and no additional injuries were noted. -The resident's range of motion was at baseline. -Staff assisted the resident (three persons) from the floor to his/her wheelchair. -The resident stated that he/she was trying to transfer into his/her wheelchair from the toilet and slipped. -The nurse cleaned the abrasion with normal saline, and left it open to air. -The resident's vital signs (blood pressure, temperature, respirations and oxygen level) and neurological checks (level of consciousness, ability to move extremities, eye responses and change in pupils) were within normal limits and the nursing staff started monitoring the resident. -The note did not show what the resident's vital signs or neurological checks were and there was no documentation showing if or when the physician, responsible party and Hospice were notified. Record review of the resident's Fall Investigation dated 3/15/23, showed: -On 3/15/23 (no time documented) nursing staff called the nurse to the resident's room, where the resident was laying on the bathroom floor in front of the toilet. -The resident had an abrasion to the top of his/her head, his/her range of motion was at baseline with no further injury noted at that time. -Nursing staff assisted the resident to his/her wheelchair. -The resident said he/she was trying to get off of the toilet and slipped. -Immediate action taken showed the nurse assessed the resident for injury, documented there was an abrasion to the top of the resident's head and the nurse cleaned it with normal saline and left it open to air. -The resident denied pain and a note was placed in the physician's book. The physician was notified. -The note showed the resident was wheelchair bound, was oriented to person with confusion and had a gait imbalance. -Investigation Notes dated 3/22/23 showed staff observed the resident on the floor in the bathroom in front of the toilet. The resident said he/she was trying to transfer himself/herself off of the toilet and slipped, receiving an abrasion to his/her head. The nurse cleaned the abrasion and left it open to air. The resident was alert and oriented to self with moderate cognitive impairment. Prior to the fall, staff had assisted the resident to the toilet, then left the bathroom to assist another resident. When the nursing staff returned to the resident's room, the resident was on the floor. The resident was wearing gripped socks and his/her wheelchair was located near the bathroom. The floor was clean, dry and free from clutter. The resident had no recent medication changes, antibiotic use or hospitalizations. The resident had prior falls on 2/27/23 while attempting to transfer from his/her bed. -The summary showed due to the resident's moderate cognitive impairment, weakness and unsteady gait the resident attempted to transfer himself/herself and fell. Record review of the resident's nursing notes showed the facility documented fall follow up from 3/15/23 to 3/18/23. Documentation showed the resident had no further complaint of pain or discomfort to his/her left arm or wrist. Record review of the resident's Radiology Note dated 3/20/23, showed an x-ray of the resident's left wrist showed a non-displaced fracture (a break in which the bones stay in their original position) to the resident's distal (away from the center of the body) wrist. Record review of the resident's Nursing Notes showed: -On 3/20/23 the nurse notified the physician/ Nurse Practitioner with the results of the radiology report. Physician's orders were obtained to make an orthopedic appointment as soon as possible. The Assistant Director of Nursing (ADON) was notified and worked on that task. -On 3/24/23 the resident left for an Orthopedic appointment, facility staff transported and stayed with the resident. The resident returned to the facility with his/her left wrist in an immobilizer, and follow up appointment (5/19/23). Record review of the resident's Care Plan updated on 3/25/23 showed: -The resident had a fall with injury on 3/15/23: the resident fell off of the toilet after attempting to self -transfer. He/she complained of left wrist pain and guarding on 3/20/23. An x-ray obtained showed a non-displaced fracture to the resident's left wrist, a referral was made to the orthopedic physician. -On 3/25/23 the resident had a non-injury fall while attempting to transfer himself/herself from his/her wheelchair to the toilet. The resident was educated on using his/her call light and waiting for staff to assist him/her. Observation on 5/3/23 at 8:02 A.M. showed the resident was sitting up in his/her wheelchair in the dining room eating breakfast. The resident was wearing a brace on his/her left forearm and wrist. He/she did not seem to be in any pain or discomfort. There were three small scabs on his/her left knee that were clustered together (the largest was a nickel in size) they looked to be almost healed. After the resident finished eating, the nursing staff took him/her to his/her room. Observation on 5/3/23 at 9:05 A.M., showed the resident was in his/her room in his/her bed with the privacy curtain partially pulled. Nursing staff said they were providing incontinence care on the resident at that time. Observation on 5/3/23 at 10:37 A.M., showed the resident was in his/her bed with his/her eyes closed resting comfortably. His/her bed was in a low position with an anti-slip mat beside the bed on the floor. The resident's wheelchair was at the foot of the resident's bed but not within reach. His/her call light was within reach, pinned to the blanket. During an interview on 5/4/23 at 10:16 A.M., CNA C said: -Staff have to provide one person assistance with a gait belt to the resident for all transfers and toileting. -The resident could sit on the toilet without assistance, but staff moved his/her wheelchair out of reach because if his/her wheelchair was close to him/her, the resident would try to transfer himself/herself unassisted. -Usually staff would transfer the resident to the toilet and stand outside the door to provide him/her privacy and then wait until the resident was done and then transfer him/her back into his/her wheelchair. -Staff should never leave the resident sitting on the toilet and go to assist another resident because the resident will try to get up, so staff have to stay by the door and check on him/her frequently. -Usually the resident, while mobilizing in his/her wheelchair, would not try to get up independently, he/she usually wandered around in his/her wheelchair until staff would take him/her to the toilet or lay him/her down. -He/She was informed of the resident's fall on 3/15/23, but was not at work that day. -He/She heard the resident fell off of the toilet while trying to transfer himself/herself into his/her wheelchair. -He/She did not remember receiving an in-service on falls at that time, but he/she did know that the resident was still to be transferred with one person assistance and staff should not leave the resident on the toilet to go provide care to another resident because the resident would try to transfer himself/herself independently. During an interview on 5/4/23 at 10:27 A.M., Licensed Practical Nurse (LPN) A said: -The resident had days when he/she was stronger and was able to stand and pivot without assistance, but there were days when he/she was not as strong and needed assistance from staff for transfers. -They try to encourage the resident to ask for assistance whenever he/she wanted to get up because he/she was at risk for falling and has had falls in the facility. -He/She remembered the resident had falls recently, but did not remember whether they provided a fall in-service afterward. -Nurse Management has provided in-services to staff on fall prevention and staff continue to encourage the resident to wait for staff before trying to get up from his/her wheelchair. -When the nursing staff assist the resident to the toilet, they should never leave the resident on the toilet unattended. -The nursing staff try to provide the resident with privacy, but they should stay there to assist when the resident was done voiding so they could assist him/her off of the toilet. -The nursing staff should never place the resident on the toilet and leave to assist another resident if staff were trying to prevent the resident from trying to transfer himself/herself without staff assistance. -The resident's wrist fracture was probably a result of the resident's fall on 3/15/23, but there was no documentation that the resident had complained of pain in his/her left wrist until 3/20/23. -They received an order for an x-ray and completed it on 3/20/23 and the results revealed the resident had a non-displaced fracture of his/her left wrist. -It was possible that the resident fractured his/her wrist when he/she fell and at the time he/she did not have any immediate pain and swelling and that it came later. During an interview on 5/5/23 at 9:05 A.M., the Assistant Director of Nursing (ADON) said: -When the resident fell (on 3/15/23), an initial assessment was completed on the resident and he/she did not have any pain or discomfort to his/her left wrist. -About five days later, the resident complained of pain to his/her left wrist and was guarding it so they notified the physician and received orders to have an x-ray completed. -The x-ray results showed that the resident had a non-displaced left wrist fracture, so they sent him/her to the orthopedic specialist and he/she came back with an immobilizer. -When a resident falls, they normally have the nurse complete a fall packet which showed what occurred, the nursing response, fall investigation and they also look at the root cause during their post fall assessment. -At 1:04 P.M., he/she said for the residents at risk for falls he/she would expect the aide to stay in the room or nearby the resident when the resident was being toileted. -The nursing staff should not walk away from the resident, leaving the resident on the toilet to assist another resident. -He/she was aware of the resident's fall and that the staff left the resident on the toilet and walked away. -The nursing staff were educated not to leave the resident on the toilet unattended. -The resident's care plan should show all interventions and should be updated as the interventions change. 2. Record review of the facility's undated Hot water policy entitled: Monitoring Water temperatures, showed: -This facility will safeguard residents who cannot fully guard themselves from environmental hazards to which they are likely to be exposed, including conditions which would be hazardous to anyone and conditions which would be or are hazardous to a particular resident because of the resident's condition or handicap including being exposed to water that is too hot. -Hot water can cause scalding, i.e. second and third degree burns in which the skin blisters and swells. Skin does not return to normal but forms scar tissue on healing. Such burns may lead to permanent disability. Second and third-degree hot water burns can occur at the following rates at the following temperatures: --110 ºF 13 minutes --120 ºF 10 minutes --127 ºF 1 minute --130 ºF 30 seconds --140 ºF 6 seconds --158 ºF 1 second -This facility believes in the necessity for checking the temperature of the hot water at the sinks, tubs, and showers used by residents. The water temperature will be maintained between 110 ºF and 120 ºF. -Maintenance staff personnel will check random water temperatures bi-weekly (every 2 weeks) including a minimum of 33.3% of resident room sinks on every designated unit and 100% bath houses, common area toilet rooms, soiled and clean utility rooms, therapy room and beauty shop sinks. -Resident room monitoring will rotate to include all rooms every quarter. -All water temperatures will be documented on the Water Temperature Monitoring Log Sheet, which will be maintained in the office of the Environmental Services Manager for a period of not less than two (2) years. -Procedure for checking water temperatures from water faucets. -Thermometers will be calibrated in accordance with manufacturer recommendations. -Let hot water run from faucet for 2 minutes. -Insert stem of thermometer straight or at an angle, about 2 inches into the stream of running water. -Hold stem in full stream for 10-15 seconds. Observations on 5/1/23 showed the following rooms with the following hot water temperatures: ** Note: hot water temperatures were measured concurrently by a few different surveyors on 5/1/23, so the times of temperature observations in different rooms may be the same. -At 12:52 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 133.4 ºF. -At 12:56 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 130.0 ºF. -At 12:56 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 132.6 ºF. -At 12:58 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 126.1 ºF. -At 12:59 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 132.8 ºF. -At 1:01 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 133.8 ºF. -At 1:03 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 131.5 ºF. -At 1:03 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 132.8 ºF. -At 1:08 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 130.0 ºF. -At 1:09 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 129.8 ºF. -At 1:10 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 129.5 ºF. -At 1:12 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 130.6 ºF. -At 1:15 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 130.5 ºF. -At 1:18 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 131.2 ºF. -At 1:22 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 132.4 ºF. -At 1:28 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 127.8 ºF. -At 1:30 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 127.1 ºF. -At 1:32 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 126.0 ºF. -At 1:33 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 130.7 ºF. -At 1:38 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 129.7 ºF. -At 1:40 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 126.4 ºF. -At 1:42 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 125.9 ºF. -At 1:43 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 129.1 ºF. -At 1:47 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER] was 129.2 ºF. -At 1:49 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 130.6 ºF. -At 1:53 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 129.3 ºF. -At 2:48 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 133.6 ºF -At 2:51 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 130.0 ºF. -At 2:53 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 129.2 ºF. -At 2:56 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 125.6 ºF. -At 2:59 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 125.4 ºF. -At 3:02 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 124.3 ºF. -At 3:05 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER] was 122.4 ºF. -At 3:08 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 126.1 ºF. -At 3:11 P.M., the hot water temperature in occupied Resident room [ROOM NUMBER], was 128.4 ºF. Observation with the Maintenance Director of the hot water heater on 5/1/23 at 1:08 P.M., showed the thermometer which measured the hot water that was provided to the resident rooms on Station #2, showed a temperature between 135°F and 140 °F. 3. Record review of Resident #36's quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment indicated by a Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) score of 4. During an interview on 5/1/23 at 1:03 P.M., the resident said: -He/she had just come out of the bathroom. -He/she turned both hot and cold water on at the same time when he/she used the water. -The hot water did get pretty hot, but he/she did not use the hot water by itself. 4. Record review of Resident #16's admission MDS dated [DATE], showed he/she was cognitively intact with a BIMS score of 13. During an interview on 5/1/23 at 1:10 P.M., the resident said he/she usually used the water in the shower room, and he/she used the water in his/her room and the hot water was not excessively hot. 5. Record review of Resident #74's quarterly MDS dated [DATE], showed the resident was cognitively intact with a BIMS score of 15 out of 15. During an interview on 5/1/23 at 1:15 P.M., the resident said the water got hot, that's for sure. 6. Record review of Resident #25's annual MDS dated [DATE], showed the resident was cognitively intact with a BIMS score of 15. During an interview on 5/1/22 at 1:22 P.M., the resident said the water got really hot, but he/she mixed the hot water with the cold. 7. During an interview on 5/1/23 at 1:09 P.M., the Maintenance Director said: -The hot water temperature that was provided to the resident rooms on Station #2 was usually around 130 °F in the mechanical room, but would be under 120 °F, by the time it got to the rooms and in that case, the water was just too hot. -He/she would adjust the mixing valves (a device composed of a chamber with a sliding valve controlled often thermostatically by a handle and used to regulate water temperature in a shower or tub). -He/she checked the mixing valve every two weeks. During an interview on 5/1/23 at 2:28 P.M., LPN B said before that day (5/1/23), he/she had not heard of any residents complain about hot water temps. During an interview on 5/1/23 at 2:30 P.M., Certified Medication Technician (CMT) A said before 5/1/23, she had heard of no complaints from residents regarding hot water temperatures. During an interview on 5/1/23 at 2:35 P.M. the Maintenance Director said: -Before that day of 5/1/23, no one went into the mechanical room to make adjustments to the mixing valve. -If there are adjustments to be made, he/she was the one who made those adjustments. During an interview on 5/1/23 at 3:12 P.M., Maintenance Assistant B said he/she had not calibrated the facility's thermometer since he/she has had the thermometer for a few months. During an interview on 5/1/23 at 3:25 PM, the Maintenance Director said the problem which caused the water temperatures to exceed 120 ºF, was the actuator (a component of a machine that is responsible for moving and controlling a mechanism or system, for example by opening a valve. In simple terms, it is like a plunger that allows the hot and cold water to come together in the mixing valve).

2. Record review of Resident #12's face sheet showed he/she was admitted with a diagnosis of COPD. Record review of the resident's Treatment Administration Record (TAR), dated May 2023, showed the resident received five Ipratropium-Albuterol (a medication used to open the airways) treatments. Observation on 5/2/23 at 11:33 A.M. showed LPN E removed the resident's uncovered nebulizer mask from the machine, put the ordered medication into the chamber, placed the mask on the resident, and started the machine. During an interview on 5/2/23 at 11:33 A.M., LPN E said: -He/she was accustomed to nebulizer masks being stored in a bag but since the mask wasn't on the floor it was okay to use. -He/she expected any respiratory equipment to be bagged when not in use. -He/she didn't replace the mask because he/she was unsure of the facility's policy. Observation on 5/2/23 at 12:21 showed the resident's nebulizer mask was lying on the bedside table uncovered. Record review of the resident's Medication Review Report, dated 5/3/23, showed an order for: -Nebulizer mask and tubing to be changed weekly. -Oxygen tubing to be changed weekly. -Ipratropium-Albuterol 0.5 milligrams (mg)-2.5 milliliters (ml) to be inhaled four times a day. Observation on 5/3/23 at 7:51 A.M. showed the resident's nebulizer mask was on the floor uncovered. During an interview on 5/3/23 at 7:51 A.M., the resident said: -He/she took the nebulizer mask off after treatment. -Staff always come in after treatment to ensure he/she took all the medication. -He/she was bothered by his/her nebulizer mask touching his/her face after being left exposed. Observation on 5/4/23 at 9:03 A.M. showed the resident's nebulizer mask was on a hook on the side of the nightstand without a barrier and not in a bag. 3. Record review of Resident #49's face sheet showed he/she was admitted with a diagnosis of shortness of breath. Observation on 5/1/23 at 8:56 A.M. showed: -An oxygen concentrator, with an undated humidifier. -The prongs of the nasal cannula were resting on the floor without a barrier or date. Record review of the resident's Medication Review Report, dated 5/3/23, showed an order for Oxygen via nasal cannula as needed. Observation on 5/4/23 at 9:00 A.M. showed: -The resident's Oxygen tank, attached to his/her wheelchair, had a nasal cannula attached. -The nasal cannula prongs were in direct contact with the floor. 4. Record review of Resident #21's face sheet showed he/she was admitted with the following diagnoses: -Acute respiratory failure with hypoxia (a condition where you don't have enough Oxygen in the tissues in your body). -Need for assistance with personal care. Record review of the resident's TAR, dated May 2023, showed the resident received Ipratropium-Albuterol 0.5 mg-2.5 ml on six occasions during the month. Observation on 5/1/23 at 8:56 A.M. showed: -The resident's nebulizer mask was sat on the machine with no bag or barrier. -The nebulizer mask and tubing was not dated. Observation on 5/2/23 at 12:22 P.M. showed the nebulizer mask was laying on the resident's night stand with no barrier and not in a bag. Observation on 5/3/23 at 7:55 A.M. showed the resident's nebulizer mask was wrapped around the machine and touching the bedside table with no barrier and not in a bag. Observation on 5/3/23 at 12:46 P.M. showed the resident's nebulizer mask was wrapped around the machine and touching the bedside table with no barrier and not in a bag. Observation on 5/4/23 at 9:05 A.M. showed the resident's nebulizer mask was hanging from the machine with the mouth portion touching the resident's night stand with no barrier and not in a bag. 5. Record review of Resident #48's face sheet showed he/she was admitted with the following diagnoses: -COPD. -Obstructive Sleep Apnea (when the muscles in the back of your throat relax too much to allow normal breathing). -Need for assistance with personal care. Record review of the resident's Order Summary Report, dated 5/5/23, showed the resident had an order for: -Nebulizer mask and tubing were to be changed weekly. -Oxygen tubing was to be changed weekly. -No order regarding bi-pap. Observation on 5/1/23 at 8:56 A.M. showed the resident's bi-pap mask was on his/her bedside table uncovered. 6. During an interview on 5/3/23 at 12:48 P.M., CNA D said: -All reusable respiratory equipment was to be stored in a bag to keep it covered. -All care staff were responsible for checking rooms and making sure respiratory equipment was covered. -If staff found any respiratory equipment on the floor, they were to replace it immediately and ensure a bag was available to store it in. During an interview on 5/3/23 at 1:02 P.M., CNA F said: -All reusable respiratory equipment should be placed in a bag when not in use. -If he/she found respiratory equipment uncovered, he/she would throw it away and replace it with a new one. -CNA's were responsible for making sure all respiratory equipment was bagged each time they entered a resident room. During an interview on 5/3/23 at 1:10 P.M., Certified Medication Technician (CMT) A said: -Reusable respiratory equipment was to be stored in a dated bag. -It was the nurse's responsibility to ensure the nebulizer mask was bagged as the nurses were responsible for giving the medication. During an interview on 5/3/23 at 2:21 P.M., LPN B said: -Nasal cannulas, nebulizers, and bi-pap masks were all to be stored in a plastic bag when not in use. -Nurses were responsible for ensuring nebulizer masks were bagged. -All care staff were responsible for ensuring oxygen cannulas and bi-pap masks were covered. -Any staff that found respiratory equipment uncovered were to replace it immediately, especially if any of the items had touched the floor. During an interview on 5/5/23 at 1:04 P.M., the ADON said: -Nasal cannulas, nebulizer masks, and bi-pap masks were to be stored in a plastic bag when not in use. -All staff were responsible for ensuring equipment was stored properly. -All staff were responsible for replacing any equipment found uncovered. Based on observation, interview and record review, the facility failed to store oxygen face masks, tubing, nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils and from which a mixture of air and oxygen flows), in a plastic bag to prevent cross-contamination when not in use for one sampled resident (Resident #5) and one supplemental resident (Resident #49); to store a bi-level positive airway pressure (bi-pap a non-invasive ventilation with two pressures settings, one for inhalation and one for exhalation, to assist with breathing) mask in a plastic bag for one supplemental resident (Resident #48); to store a nebulizer (a device for producing a fine spray of liquid, used for inhaling a medicinal drug) mask in a plastic bag for two supplemental residents (Resident #12 and #21) out of 19 sampled residents and five supplemental residents. The facility census was 87 residents. Record review of the facility undated Oxygen storage Policy showed: -Oxygen tubing, nasal cannula and masks are to be changed weekly. The tubing must be labeled with the initial and dated. Document changing in the resident Treatment record. -Oxygen when not being used, the tubing, cannulas and masks are to be stored in a plastic bag. -When oxygen was no longer needed, all supplies were to be removed from the resident's room. 1. Record review of Resident #5's admission Face Sheet showed he/she had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Record review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 2/16/23, showed he/she: -Was cognitively intact. -Was able to understand others and make his/her needs known. -Required total assistance of staff for all cares and transfers. -Required the use of Oxygen. Record review of the resident's Physician Order Sheet (POS) dated 5/2023 showed he/she had a physician order for Oxygen (O2) at 2-3 Liter per minute via nasal cannula as needed, to keep Oxygen levels above 90%. (Ordered 2/17/23). Observation on 5/1/23 at 9:16 A.M. showed: -The resident was sitting in his/her recliner with his/her eyes closed. -The resident had the O2 set at 3 Liter per minute via nasal cannula. Observation on 5/2/23 showed: -At 9:30 A.M. the resident was not in his/her room. -His/her Oxygen concentrator was running and his/her O2 nasal cannula tubing was laying on the floor. -At 10:07 A.M. the resident's O2 nasal cannula and tubing remained on the floor with the concentrator running. -The resident's nasal cannula was not stored in a plastic bag. During an interview on 5/4/23 at 10:09 A.M., Certified Nursing Assistance (CNA) E said: -The resident required assistance by facility staff with all cares and transfers. -The resident required assistance with applying his/her O2 nasal cannula, but would remove the nasal cannula at times. -He/she would store O2 nasal cannula and tubing in plastic bag when not in use. During an interview on 5/4/23 at 10:33 A.M. Licensed Practical Nurse (LPN) B said: -The resident required assistance from staff to apply the Oxygen nasal cannula and to turn on and off the Oxygen concentrator. -CNA's and nursing staff would be responsible to ensure Oxygen supplies were stored in a plastic bag when not in use and the O2 concentrator machine was off when not in use. During an interview on 5/5/23 at 1:04 P.M., the Assistant Director of Nursing (ADON) and Director of Nursing (DON) said: -All staff would be responsible for ensuring proper storage of O2 supplies when not in use. -If staff found O2 supplies not stored properly he/she would expect the care staff to replace the O2 nasal cannula. -He/she would expect the O2 concentrator be turned off and Oxygen tubing and nasal cannula be stored in a plastic bag when not in use. -The resident required assistance from staff to apply the Oxygen nasal cannula and to turn on and off the Oxygen concentrator. -The resident would not be able to transfer himself/herself from his/her recliner to his/her wheelchair without staff assistance.

Based on observation and interview, the facility failed to remove a buildup of dust on the ceiling above the food preparation table; to remove a buildup of food debris and dust from under the six burner stove, the steam table and the food preparation table; to remove a heavy buildup of grease and burnt-on food from the metal grates that sit above the actual gas burners; and to maintain the gaskets (a material such as rubber or a part used to make the area between two pieces of a material resist the flow of fluid such as air or water) of the reach-in refrigerator in good repair. This practice potentially affected all residents. The facility census was 87 residents. 1. Observations on 5/1/23 from 9:15 AM through 12:50 PM, showed: -A torn gasket on reach-in Fridge identified as RI, was torn on both doors of the reach in refrigerator. -A buildup of dust on the ceiling tiles on and on the smoke detectors above the food preparation table. -A buildup of debris under reach-in refrigerators, under the steam table and under the six - burner stove, including a plastic cup. -A heavy buildup of grease and grime on grates of the six burner oven. During an interview on 5/1/23 at 12:08 P.M., Dietary [NAME] (DC) B said it has been at least a month or two since the stove top grates, were cleaned. During an interview on 5/1/23 at 12:35 PM, the Dietary Director (DD) said they needed to replace the tiles above the food preparation table, but they waited on a person to take down those tiles properly because the smoke detectors are installed on those tiles. During an interview on 5/1/23 at 12:31 PM, the DD said they are supposed to clean under the steam table weekly and the stove monthly but it looks like it has been longer than that span of time. Observation with the Assistant DD on 5/3/23 at 9:17 AM, showed the gaskets of the fridge identified as RI, had one rip that was 11 inches (in.) long and the other gasket had a rip that was 26 in. long. During an interview on 5/3/23 at 9:18 A.M., the Assistant DD said the gaskets for that fridge have been replaced in the past.

Based on interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) Plan pertaining to on-going systemic issues regarding infection control monitoring and tracking of infections in the facility which potentially affected all residents in the facility. There were 19 residents in the sample and the facility census was 87 residents. Record review of the Infection Surveillance-Overview from the facility's Infection Prevention and Control Manual dated 2020 showed, -Data Analysis will assist the facility in: --Determining the origin of infection. --Comparing current and past infection control surveillance. --Comparing the reported incidence of infections by type and location. --Determining need for additional education and staff competency. --This data is recorded at least quarterly and included in the QAA committee for review and inclusion of QAPI activities. 1. During an interview on 5/4/23 at 12:46 P.M. the Infection Preventionist said: -Whatever Point Click Care (PCC- a web based electronic health record (EHR) and practice management solution for long-term and post-acute care (LTPAC) organizations) did for tracking was the information that was pulled for trending of infections. -He/she was unable to pull up monthly reports on PCC during a demonstration of how he/she documented on infections. -He/she would write up any pertinent data for Quality Assurance (QA) meetings, but only kept them for personal record. -Urinary Tract Infections (UTIs) had been discussed in past QA meetings. During an interview on 5/5/23 at 11:02 A.M., the Administrator said: -The Quality Assurance met quarterly and was attended by the Administrator, Medical Director, Nurse Practitioner, Director of Nursing (DON), Assistant Director of Nursing (ADON), all department heads (Dietary Manager, Maintenance Director, Activity Director, Housekeeping/Laundry, Social Service Director, Minimum Data Set Coordinator, Director of Rehabilitation, Human Resource Director), and additional staff who monitored wounds and weights. -The facility mental health provider, laboratory and pharmacy providers didn't come physically to meetings but were sometimes on the telephone during the meetings. -They did not have sub committees, but they did discuss issues during their morning meeting daily. -Infection control was an area that the Quality Assurance Committee reviewed at every meeting. -Regarding Infection Control tracking, the former Infection Control Preventionist was completing the tracking monthly and was writing it by hand until August 2022, when he/she left abruptly due to health reasons. The ADON took over as the Infection Control Preventionist and at that time he/she primarily focused on COVID (a new disease caused by a novel (new) coronavirus) tracking. -He/she did not think the Infection Control Preventionist was tracking other infections after the former Infection Control Preventionist left. -The Quality Assurance Committee discussed the infections that were being treated over the past quarter during the meetings but he/she did not have a monthly report to compare their infections with tracking information monthly or quarterly. -Documentation on all of their infections was in their electronic records and was being entered but infections were probably not being tracked and recorded on a monthly basis. During an interview on 5/5/23 at 11:31 A.M., the Infection Control Preventionist said: -He/she was responsible for tracking all of the infections after the former Infection Control Preventionist left the facility. -He/she documented all of the infections in the electronic record system which included the resident, type of infection, date, duration, any antibiotics used for treatment, and when the infection was resolved. -He/she was able to pull the data from the electronic system, but he/she was not able to pull the information by month or by quarter because of the way the data is compiled. -He/She did not have a monthly or quarterly infection control summary for comparison for quality assurance purposes. -He/she received information from the pharmacy regarding antibiotic use, but he/she did not have documentation to show how he/she tracked antibiotics. -He/she reported to the Quality Assurance Committee quarterly on infections in the building, but he/she had not developed a comprehensive report that showed the monthly or quarterly infection and antibiotic data for comparison. -He/she was not able to provide information regarding increases/decreases in infections or antibiotic use month to month or for the current or prior quarter for comparison. -He/she had not been trained on how to track antibiotics or to compile the infection control data into a comprehensive report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of the facility's tracking and trending of infections from May 2022 through April 2023 showed: -The facility used Point Click Care (PCC- a web based electronic health record (EHR) and practice management solution for long-term and post-acute care (LTPAC) organizations). -The print out received was printed on 5/4/23 but dated for February 2023. -One of 19 infections had been confirmed and no tracking was completed for April 2023. -The print out received showed tracking for infections from February 2021 to present, and not a month to month report. -Of the 10 infections reported from November 2022 to March 2023 only one of them had data pertaining to the type of infection signs/symptoms of the infection. -No written infection tracking or trending, all documentation was placed in PCC by the Infection Preventionist. -No documentation of in-services or skills checks related to infection control was received. -No review on an ongoing basis of the signs and symptoms of each resident infection. -A Monthly Infection Control Log book was never received. During an interview on 5/3/23 at 1:45 P.M. the Infection Preventionist said he/she was not up to date on the tracking/trending of the April 2023 infections. During an interview on 5/4/23 at 9:41 A.M. the Infection Preventionist said: -He/she was unsure why there was no documentation for the infections showing in PCC from November on. -He/she did not have a reason why the documentation of the infections was not in PCC. -He/she knew that the tracking/trending documentation needed to be in PCC. -He/she did not have the infection mapping from 2022 and would need to find it in medical records. During an interview on 5/4/23 at 11:28 A.M. CMT A said the facility did online training and in-services for infection control training. During an interview on 5/4/23 at 12:17 LPN B said: -He/She would document signs/symptoms of an infection in a resident's chart and notify the doctor if indicated. -He/She would let the ADON, who was also the facility's Infection Preventionist, know if a resident had signs and/or symptoms of an infection as well. -He/She was unsure of any tracking system related to infection control in PCC. -He/She could not remember any Relias training he/she had recently completed. During an interview on 5/4/23 at 12:46 P.M. the Infection Preventionist said: -He/She was unsure if PCC had month to month reviews of infection tracking/trending. -He/She only documented the infections in PCC. -He/She was unsure of the policy related to infection control surveillance. -The nurses were responsible for starting the case in PCC and he/she would follow-up. -Whatever PCC did for tracking was what got pulled for trending of infections. -He/She was unable to pull up monthly reports on PCC during a demonstration of how he/she documented on infections. -He/She would write up any pertinent data for Quality Assurance (QA) meetings, but only kept them for personal record. -Urinary Tract Infections (UTIs) had been discussed in past QA meetings. -He/She was dependent on PCC for all tracking and trending of infections. -He/She would expect CNAs to report any change in vital signs or symptoms of an infection to the unit nurse. -He/She would expect the nurses to give any as needed medications for any signs and/or symptoms of infection and notify the doctor if needed. -He/She would also expect the nurses to put in a progress note once an infection was detected including: --When the doctor was notified. --What orders were received or if no orders were received. --Notification of family or guardian. --Vitals signs at the time the infection was detected. --Any sign or symptoms the resident had. -Staff were notified on infection control policies or updates through daily huddles. -Daily huddles were not signed by staff members to acknowledge what was presented in the huddles. -Staff who were not a part of the actual huddle meetings were expected to read the daily huddle sheet in the log book. -He/She had done in-services and skills check-offs in the past when issues pertaining to infection control were found. -He/She knew an in-service was needed based off what he/she would hear from staff and through the infection tracking. -No root cause analysis was completed for any infections in the building. -He/She was the only one responsible for infection control in the building. 5. Record review of Resident #75's undated face sheet showed he/she admitted to the facility on [DATE] with the diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery (the build-up of fats, cholesterol, and other substances in the coronary causing obstruction of blood flow) without Angina Pectoris (chest pain). Record review of the resident's Immunization Record dated May 2023 showed the resident refused the TB skin test. Record review of the resident's medical record showed there was no documentation indicating the resident had refused the Tb skin test or that staff had notified anyone or taken any steps to ensure the resident was tested for Tb. 6. Record review of Resident #73's undated face sheet showed he/she admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnosis of Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Documentation of the resident's TB records were not received at the time of exit. Record review of resident chest x-ray dated 8/25/22 did not show whether or not the resident had a presence of TB in his/her lungs. During an interview on 5/5/23 at 1:03 P.M. the Infection Preventionist said he/she thought the resident initially refused the TB test and there was no documentation of the refusal. 7. Record review of Resident #70's undated face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Stage IV Pressure Ulcer of the Sacral Region (full-thickness skin loss extending through the fascia with considerable tissue loss, which could include possible involvement of the muscle, bone, tendon, or joint). -Personal History of Sudden Cardiac Arrest (when the heart stops beating). Record review of the resident's Immunization Record dated May 2023 showed the resident refused the TB skin test. Record review of the resident's medical record showed there was no documentation indicating the resident had refused the Tb skin test or that staff had notified anyone or taken any steps to ensure the resident was tested for Tb. 8. Record review of Resident #27 undated face sheet showed the resident admitted to the facility on [DATE] with the diagnosis of Atrial Fibrillation (A-Fib- an irregular heart rhythm). Record review of the resident's Immunization Record dated May 2023 showed: -The first skin test for TB was completed on 9/4/21. -The second skin test for TB was completed on 9/11/21. -There was no record of a TB test or symptom questionaire having been completed in 2022. 9. During an interview on 5/4/23 at 12:17 P.M. LPN B said: -TB test orders were a part of the admission orders that automatically are placed in the resident's Physician Order Sheet (POS). -Nurses were capable of completed the TB skin test. -If a resident were to refuse a TB test he/she would educate the resident and inform the Infection Preventionist. -If a resident were to refuse a TB skin test a chest x-ray could be completed instead. During an interview on 5/4/23 at 2:24 P.M. LPN D said: -The TB test orders would show on the Medication Administration Record (MAR) after a resident was admitted . -Nurses were responsible for completing TB tests. -A chest x-ray could be completed instead of a TB skin test. -If a resident refused he/she would let the resident's family know. -If there were further issues of getting the TB skin test completed he/she would get the ADON or DON involved. -All residents were required to have a TB test completed to live in the facility. During an interview on 5/5/23 at 11:17 A.M. LPN A said: -Nurses were responsible for completing the TB skin tests. -The TB test orders were a part of the admission orders. -If a resident refused the TB skin test he/she would let the resident's family know. -A chest x-ray could be completed instead of the TB skin test. During an interview on 5/5/23 at 1:03 P.M. the ADON/Infection Preventionist said: -If a resident were to refuse a TB skin test he/she would expect nurses to chart the refusal in a progress note on PCC. -He/she would also expect nurses to place the refusal in the resident's Immunization Record. -A chest x-ray could be completed instead of the TB skin test. -TB tests were not required prior to admission to the facility. -He/she would not know if a resident did or did not have TB if the resident refused. -TB skin tests would show up in the admission orders. -If a resident refused the TB skin test and the chest x-ray he/she got a family history. -He/She had not run into the issue of residents refusing TB tests at the facility. -He/She was aware that Resident #73's chest x-ray did not indicate whether the resident had TB or not. 2a. Record review of Resident #88's Face Sheet showed he/she was admitted with the following diagnoses: -Retention of urine. -Type II Diabetes Mellitus (a disease that occurs when the body either doesn't make enough insulin or becomes resistant to insulin and blood sugar levels become too high). Record review of the resident's admission Minimum Data Set, dated [DATE], showed the resident was admitted with: -A Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. -A nephrostomy (an artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system). Observation on 5/1/23 at 11:17 A.M. showed the DON: -Placed the glucometer (a meter used for testing blood sugar levels) on top the medication cart without a barrier. -Placed a drop of the resident's blood on the test strip in the glucometer then placed the glucometer on top of the medication cart without a barrier. -Completed the blood sugar check, disposed of single use items appropriately, removed his/her gloves, did not perform hand hygiene, placed the glucometer back in the cart, and sat at the nurse's station to review orders. -He/she then returned to the medication cart and, without performing hand hygiene or putting on gloves, removed the resident's insulin pen, alcohol wipes, and a new needle from the medication cart, cleaned the tip of the pen with alcohol, and attached the needle. -Set the insulin pen to one unit, removed the cap, cleaned the resident's injection site with a new alcohol pad, and injected the resident with insulin without performing hand hygiene or wearing gloves. -Put on gloves, without performing hand hygiene, and removed the glucometer from the medication cart, cleaned it with disinfecting wipes, and placed the glucometer back in the drawer. During an interview on 5/1/23 at 11:17 A.M., the DON said he/she should have had the resident's insulin orders pulled up before starting process. Record review of the resident's Medication Review Report, dated 5/3/23, showed the resident had a physician's order for: -Blood glucose monitoring three times a day. -Humalog (a fast-acting insulin) based on a sliding scale (dose to be given dependent on blood glucose reading). Observation on 5/3/23 at 10:57 A.M. showed Licensed Practical Nurse (LPN) D: -Removed glucometer and supplies from the medication cart and placed on top with no barrier. -Performed blood glucose check appropriately, removed gloves, and threw away disposable items; did not perform hand hygiene. -Returned to the medication cart and removed the resident's insulin pen, cleaned the tip of the pen with an alcohol pad, inserted a new needle, primed the pen, set the pen for the correct dose, then put on gloves without performing hand hygiene. -Cleaned the resident's injection site with alcohol and injected the insulin. -Removed one glove, did not perform hand hygiene, removed a cough drop from his/her pocket with ungloved hand, removed the wrapper of the cough drop, and placed in his/her mouth. -Removed other glove and disposed of all supplies but did not perform hand hygiene. -Placed the glucometer back into the medication cart on top of cotton balls, closed the drawer, reopened the drawer, removed the glucometer and wiped with alcohol, then placed the glucometer back in the drawer. 2b. Record review of the resident's Medication Review Report, dated 5/3/23, showed the resident had a physician's order for Nephrostomy to be changed weekly on Tuesdays. Observation on 5/3/23 at 10:24 A.M. showed LPN D: -Performed hand hygiene, gloved, and prepared the resident for the procedure. -Removed gloves, sanitized hands, and put on new gloves. -Opened the sterile supplies in an appropriate manner using the packaging as a barrier, then removed his/her gloves and put on new gloves without performing hand hygiene. -Attempted to remove the resident's dressing unsuccessfully, removed gloves, sanitized hands, put on new gloves, used scissors to cut away the dressing from the nephrostomy tubing. -Removed his/her gloves, and without performing hand hygiene, opened the package of sterile gloves and put the sterile gloves on. -After cleaning the insertion site with Betadine, he/she used the gloves used to clean the wound to reach into the sterile field (now contaminated) and picked up gauze which he/she used to remove the excess Betadine and placed the dirty gauze onto the sterile field. -He/she then looked through the supplies, with dirty gloves, for the sterile split gauze (gauze with a precut split down one side to allow it to be fully wrapped around any tubing and provide a protective layer between the tubing and the skin) and found it was stuck to the gauze used to remove the excess Betadine and now had a 0.5 centimeter brown stain on it. -He/she removed the split gauze from the other gauze pad and placed it around the resident's nephrostomy tube. -He/she then touched the resident's exit site with his/her dirty gloves while he/she measured the length of the tubing. -He/she completed the procedure, removed his/her gloves, and performed hand hygiene. During an interview on 5/3/23 at 10:24 A.M., LPN D said: -The split gauze was clean enough. -He/she had seen the procedure performed one time and had not performed a return demonstration or ever attempted the procedure independently. -Nephrostomy care was a sterile procedure. -No items, including gloves and gauze, that had touched anything non-sterile could enter the sterile field. 3. During an interview on 5/3/23 at 12:48 P.M., CNA D said hand hygiene was to be performed between glove changes. During an interview on 5/3/23 at 1:02 P.M., CNA F said: -Hand hygiene was to be performed when entering and exiting a resident's room. -Hand hygiene was to be performed between glove changes. During an interview on 5/3/23 at 1:10 P.M., Certified Medication Technician (CMT) A said: -Hand hygiene was to be performed when entering a room, exiting a room, and between glove changes. -After cleaning a wound, gloves were to be changed before touching a clean dressing. During an interview on 5/3/23 at 2:21 P.M., LPN B said: -Hand hygiene was to be performed when entering and exiting a resident room and between glove changes. -After cleaning a wound, gloves were to be changed before touching clean supplies. -Nephrostomy care was a sterile procedure. -When a sterile procedure was performed, you could not use gloves that had touched a person or wound to touch any item in the sterile field. -He/she had read the procedure and policy for nephrostomy care but had not been asked to demonstrate the task to show competency. -Gloves were to be worn when injecting insulin. -The glucometer could not be sat on any surface without a barrier. -Reusable supplies were to be cleaned with a disinfecting wipe before they were placed back in the medication cart. During an interview on 5/5/23 at 1:04 P.M., the ADON said: -Staff were to perform hand hygiene when entering a room and between all glove changes. -After a wound was cleaned and before touching the new dressing, staff were to remove their gloves, perform hand hygiene, and put on new gloves. -Gloves used to clean a wound could not be used to touch any item in a sterile field. -Soiled gauze was not appropriate to put on a clean wound. -He/she expected all staff to follow the company's policy and procedures. -The Glucometer was to be cleaned before returning it to the medication cart. -The Glucometers were to be placed on a barrier and could not be placed directly on any surface. -Staff were expected to wear gloves when injecting insulin. Based on observation, interview and record review, the facility failed to ensure handwashing was completed to prevent cross contamination during incontinence care for one sampled resident (Resident #85); to ensure hand hygiene was completed during blood glucose monitoring, to ensure reusable devices were properly cleaned to prevent cross contamination, and to provide appropriate wound care for one sampled resident (Resident #88); to maintain an effective infection control program including tracking and trending of infections; and failed to ensure residents who admitted to the facility had Tuberculosis (TB- an infectious bacterial disease characterized by the growth of nodules in the tissues, especially the lungs) testing completed and up to date for four sampled residents (Residents #75, #73, #70, and #27) on admission out of 19 sampled residents. The facility census was 87 residents. Record review of the facility's Handwashing policy and procedure dated 4/09, showed: -Hand hygiene is a basic procedure that should be performed by all caregivers before and after contact with a resident. It is the most important and most basic technique in preventing and controlling the spread of infection. When hands are visibly soiled, handwashing will be done with soap and water. When hands are not visibly soiled, handwashing may be done with an alcohol based hand sanitizer or soap and water. Hand sanitizer should be at least 62 percent ethanol-alcohol based. The procedure showed -Not visibly soiled includes but is not limited to: ---Before direct contact with residents, donning sterile gloves, performing any non-surgical invasive procedures, preparing or handling medications, handling clean or soiled dressings/gauze pads, and moving from a contaminated body site to a clean body site during resident care. ---After contact with a resident's intact skin, handling used dressings, contaminated equipment, contact with objects in the immediate vicinity of the resident, and after removing gloves. -Visibly soiled includes but is not limited to: ---When hands are visibly soiled or dirty with blood or other bodily fluid; after contact with blood, bodily fluids, secretions, muscous membranes and non-intact skin; after handling items that are potentially contaminated with blood, bodily fluids and secretions; before eating and after using the bathroom. Record review of the facility's policy Glucometer Cleaning and Disinfecting dated August 2010 showed: -Staff were to clean the glucometer (a device that uses a drop of blood to measure the amount of glucose in the blood stream) with 10% bleach. -Staff were not to use alcohol to disinfect the meter. -Staff were to disinfect the meter, while wearing gloves, after each resident use. Record review of the facility's undated policy titled Infection Prevention and Control Manual showed: -Staff were to clean and disinfect all multi-use equipment after use. Record review of the facility's undated procedure titled Insulin Pen Administration showed: -Staff were to perform hand hygiene and put on gloves prior to giving insulin to a resident. Record review of the facility's undated policy titled Nephrostomy Tube Care showed staff were to: -Put on non-sterile gloves, remove the old dressing, measure the site, remove gloves and perform hand hygiene. -Put on sterile gloves without contaminating them, cleanse exit site, apply sterile gauze around tubing, and redress. -Remove gloves and perform hand hygiene. Record review of the facility's undated policy titled Tuberculosis Testing-Mantoux-PPD (a type of skin test to determine if a person has TB) showed: -All residents will be tested for TB upon admission and yearly thereafter. -For all newly admitted residents, the Unit Nurse will: --Review the resident's chart to determine whether a Mantoux test was administered during the past year. --If test status cannot be determined, administer the Mantoux test to the resident according to standards of clinical practice, unless contraindicated. -The Infection Control Nurse will monitor the TB logs and the unit practices to make sure the TB testing process meets clinical standards of care. 1. Record review of Resident #85's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including Dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), heart failure (a chronic, progressive condition in which the heart muscle is unable to pump), Chronic Obstructive Pulmonary Disease (COPD-a group of diseases that cause airflow blockage and breathing-related problems), kidney disease, and muscle weakness. Record review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/6/23, showed the resident: -Was alert with severe memory impairment. -Was totally dependent for mobility, transfers, bathing and toileting and was incontinent of bowel and bladder. Observation on 5/1/23 at 1:33 P.M., showed the resident was sitting in his/her wheelchair with a sling underneath him/her. Certified Nursing Assistant (CNA) A was in the resident's room wearing gloves and was positioning the full body mechanical lift. CNA B was in the resident's room and put on gloves to assist with attaching the resident's sling to the mechanical lift. The following occurred: -CNA A raised the resident's bed then began assisting CNA B with connecting the sling to the lift. Once the sling was connected, CNA A informed the resident they were getting ready to transfer him/her to his/her bed and then perform incontinence care. -CNA A lifted the resident while CNA B positioned the resident as he/she was lowered in to his/her bed. -Both CNA's rolled the resident to the right side and CNA A got a clean brief for the resident then he/she left the room without removing his/her gloves, washing or sanitizing his/her hands. -CNA A came back into the room carrying a clean bed pad and put the pad on the resident's bed. He/she then, without washing or sanitizing his/her hands, put on gloves and assisted CNA B to roll the resident to the opposite side and removed the sling from under the resident. -CNA A removed the resident's pants and soiled brief. CNA A handed the sling and pants to CNA B and placed the soiled brief in the trash. -CNA A began providing incontinence care to the resident (who had soiled himself/herself with bowel movement). -CNA A cleaned the resident's bottom using several wet wipes then rolled the resident on his/her back and used several wet wipes to clean the resident's groin. He/She did not change his/her gloves, wash or sanitize his/her hands during this care. -Once the resident was cleaned, CNA A, without removing his/her gloves washing or sanitizing his/her hands, put the clean brief on the resident. -CNA A then removed and discarded her gloves, and without washing or sanitizing his/her hands, removed the resident's socks, raised the head of the resident's bed, lowered the bed to the ground and placed a mat on the floor next to the bed. -Without washing or sanitizing his/her hands, CNA A then put on another pair of gloves then put the soiled sling and pants in a plastic bag and tied it, tied the trash bag, put a clean trash bag in the trash can and discarded his/her gloves. CNA A left the resident's room with the two bags without washing or sanitizing his/her hands. -CNA B placed the resident's soiled pants and sling on top of the trash can, and without removing his/her gloves and washing or sanitizing his/her hands, he/she removed the lift from the room. During an interview on 5/01/23 at 1:50 P.M. CNA A said: -When he/she completed incontinence care, he/she was supposed to wash his/her hands upon entering the resident's room, before gloving and upon leaving the resident's room. -He/she would not wash or sanitize his/her hands any more frequently when cleaning bowel movement from a resident. -He/she did not really know how often he/she should wash his/her hands during incontinence care, but he/she could find out. During an interview on 5/01/23 at 2:00 P.M. CNA B said: -They were supposed to wash or sanitize their hands before and after providing any resident care, whenever they change their gloves and between clean to dirty tasks. -He/She should have washed his/her hands before leaving the resident's room. During an interview on 5/05/23 at 1:04 P.M., with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the ADON said: -The expectation was that the nursing staff should use hand sanitizer or handwashing before they go into the resident's room. -The nursing staff was to then put on clean gloves and provide the resident's incontinence care. -During incontinence care, the nursing staff should change their gloves and wash or sanitize their hands anytime they are going from a dirty to clean task, then remove their gloves and wash or sanitize their hands before leaving the resident's room. -When handling bowel movement they should discard their gloves and wash their hands once they complete the care. -He/She would expect the nursing staff to wash or sanitize their hands before removing soiled linen or trash from the resident's room and wash their hands after discarding it.

Based on interview and record review, the facility failed to have a process to monitor antibiotic usage including prescribing and documentation of the indication, dosage, and duration of the use of antibiotics. This failure had the potential to affect all residents at the facility. The facility census was 87 residents. Record review of the facility policy titled Antibiotic Stewardship Program Policy dated 6/3/21 showed: -The facility was to maintain an Antibiotic Stewardship Program with the mission of promoting the appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. -Antibiotic stewardship actions were conducted to enable or to measure these key elements of care: --Knowing when to be concerned about an infection in a resident. --What clinical and historical information to gather for the provider. --When to submit diagnostic specimens to the laboratory. --How to quantify and assess appropriateness of antibiotics prescribed. --How to identify adverse outcomes that might be associated with antibiotics. -The actions involved in the Antibiotic Stewardship Program were: --Prescription record keeping. --Assessment of residents suspected of having an infection. --Provider communication. --Antibiotic time-out which indicated the facility would reassess for antibiotic need, duration, selection, and de-escalation point at the 72 hour mark of initiation of the antibiotic. --Following microbiologic specimen submission guidelines. --Following first-line treatment recommendations. --Apply interventions for Multi-Drug resistant infections. --Apply interventions for syndrome-specific antibiotic use and antibiotic prophylaxis. 1. Record review of the antibiotic tracking from May 2022 to April 2023 showed: -Only infection tracking was being monitored and not antibiotic usage. -Only a print out of the antibiotics used during the time frame and did not include the following: --Assessment of residents suspected of having an infection. --Antibiotic time-out after 72 hours of initiation of the antibiotic prescribed. --Specific provider communication related to the antibiotic usage. During an interview on 5/4/23 at 9:41 A.M. the facility's Infection Preventionist said the pharmacy would send monthly reports of the antibiotic usage in the facility. During an interview on 5/4/23 at 12:17 P.M. Licensed Practical Nurse (LPN) B said he/she was unsure of any antibiotic tracking in Point Click Care (PCC- a web based electronic health record (EHR) and practice management solution for long-term and post-acute care (LTPAC) organizations). and would write progress notes when a resident was on antibiotics. During an interview on 5/4/23 at 12:46 P.M. the Infection Preventionist said: -When a resident started on an antibiotic a case would be automatically populated in the PCC infection tracking. -He/she did not make a summary or report of the facility's antibiotic usage at the end of each month. -He/She did not know that he/she was supposed to track the antibiotic usage in the facility. -The previous Infection Preventionist would summarize and report everything at the end of each month. -He/she would be unable to provide any documentation of the use of the facility's Antibiotic Stewardship Program. -He/she was unsure of the Antibiotic Stewardship Program policy and would work with the Medical Director (MD) and Nurse Practitioners (NP's), and other members of the team regarding antibiotics. -Nurses were responsible for using McGeers criteria (certain symptoms a resident must show for a specific infection type before being placed on an antibiotic) and communicating the findings with the doctor. -Only some of the nurses knew they needed to use the McGeers criteria and provide the justification antibiotic usage to the doctor. -He/she would expect all nurses to complete the McGeers criteria and write a progress note if an infection was suspected in a resident.

Based on interview and record review, the facility failed to ensure the shift change narcotic count was completed and signed by the off-going and on-coming nursing staff per the facility policy. The facility census was 80 residents. Record review of the facility's undated Medications-Narcotics policy showed: -Narcotics should be counted at the beginning and end of every shift by the unit charge nurse or Certified Medication Technician(CMT). -Both nurses or CMTs should date and sign the count log in the cart's narcotic notebook. -The Director of Nursing (DON) should be notified immediately if there were any discrepancy in the narcotics count. -If the unit charge nurse or CMT had to leave before the end of a shift, he/she should count the narcotics with the oncoming charge nurse or CMT before he/she left the facility. The charge nurse/CMT would then count with the charge nurse or CMT from the oncoming shift. Record review of a facility Narcotic Shift Change Count Sheet showed staff were to document the date, shift, on-coming shift signature, off-going shift signature, number of medication cards, number of liquid medications, name of drugs added or removed (+/-) medication, and final total. 1. Record review of the Narcotic Count Sheet for the Station 2 CMT cart, dated 4/16/21 to 4/24/21 showed staff did not sign for off-going or on-coming shift count on 7 out of 44 opportunities. Record review of the Narcotic Count Sheet for the Station 2 CMT cart, dated 4/24/21 to 5/3/21 showed taff did not sign for off-going or on-coming shift count on 12 out of 46 opportunities Record review of the Narcotic Count Sheet for the Station 2 CMT cart, dated 5/3/21 to 5/11/21 showed staff did not sign for off-going or on-coming shift count on 9 out of 51 opportunities. Record review of the Narcotic Count Sheet for the Station 2 CMT cart, dated 5/12/21 to 5/18/21 showed staff did not sign for off-going or on-coming shift count on 11 out of 38 opportunities. Record review of the Narcotic Count Sheet for the Station 2 CMT cart, dated 5/19/21 to 5/26/21 showed staff did not sign for off-going or on-coming shift count on 21 out of 44 opportunities. Record review of the Narcotic Count Sheet for the Station 2 CMT cart, dated 5/27/21 to 6/3/21 showed staff did not sign for off-going or on-coming shift count on 14 out of 44 opportunities. No narcotic count sheet was made available from 6/3/21 to 6/15/21. Record review of the Narcotic Count Sheet for the Station 2 CMT cart, dated 6/15/21 to 6/16/21 showed staff did not sign for off-going or on-coming shift count on 4 out of 12 opportunities. During an interview on 6/17/21 at 10:58 A.M., Licensed Practical Nurse, (LPN) A said. -When narcotic counts were done, the charge nurse would do the cart counts with narcotics, the as needed (PRN) medications, and all morphine (a controlled substance medication used for treating moderate to severe pain) and hydrocodone (a controlled substance medication used to treat pain) based medications. -CMTs would do only scheduled narcotic medication counts. -On-coming and off-going staff would count together. -The counts were recorded in notebooks. -Each cart had a notebook. -The charge nurses were also responsible for the narcotic counts in the medication rooms. -The counts should be done at the beginning of each shift change. -On weekends, the shifts were 12 hours, so there would be fewer counts. -The expectation was that that the narcotic counts would be done each shift and signed off on. -If the count was not done, or there was a discrepancy or other issue, the staff would notify the DON, who would investigate to see if the staff had counted and forgotten to sign, or what the issue was. -If there was a discrepancy, they would call the DON, no matter what time of day. -He/she would do the investigation. During an interview on 06/17/21 at 11:29 A.M. CMT A said: -Narcotic counts were done when a nurse or CMT came on a shift and when they left. -If there were an empty space on the count sheet, he/she would take it to the charge nurse. -There were always two people counting the narcotics. -The expectation is that the count would be done on arrival for a shift, when the staff person receives the medication cart, and again before the person left. During an interview on 6/17/21 at 12:12 P.M., the Assistant Director of Nursing, (ADON) said: -The incoming and off-going nurses did the narcotic counts at each shift change. -The CMTs did the counts for their carts. -He/she was responsible for checking the narcotic books for any gaps in the documentation. -A Registered Nurse (RN) also checked the narcotic books. -If they found gaps in documentation, they would determine who needed to sign it. -They would see who gave medications that shift to determine who should sign, and flag it. -If documentation was missed when counting, it would be corrected at that time. -Some nurses would not take the carts if the narcotic sheets had not been signed off. -He/she would determine who should have signed and education would be provided for those people. -The expectation was that the narcotics would be counted at every shift change. During an interview on 6/17/21 at 1:03 P.M., the DON said: -The expectation was that narcotic counts should be done with each shift change or if someone left and someone else came on. -RN A was responsible for making sure the narcotic sheets were signed. -He/she worked Tuesdays, Thursdays and the weekends and he/she checked the count sheets on those mornings. -It was everyone's responsibility to make sure those were done. -If the count sheets were not signed, he/she would go back to the schedule and find out who was supposed to do it. -He/she would make sure they were signed as soon as possible. -Staff were educated to make sure to sign the narcotic count sheets.