**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to ensure as needed psychotropic medication (a drug that affects behavior, mood, thoughts, or perception) orders were limited to 14 days unless specific duration and clinical rationale were provided for two of five sampled residents (Resident #14 and #45). The facility census was 59. 1. Review of the policies provided by the facility showed they did not contain a psychotropic medication policy. 2. Review of Resident #14's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had inattention and disorganized thinking, but no altered level of consciousness, delusions or behavioral symptoms; -Used antianxiety mediations; -Diagnosis of aphasia (the loss of ability to understand or express speech), Parkinson's Disease, anxiety, depression, bipolar disease, and schizophrenia; -Received hospice care. Review of the resident's POS, dated 12/2024, showed an order for Lorazepam (medication used to decrease anxiety), 0.5 milligrams (mg), one tablet every six hours as needed for anxiety disorder. The order had a start date of 08/27/24 and a stop date of 02/05/25. The order did not contain a 14 day stop date or a clinical rationale for the specified time frame. Review of the medical record showed it did not contain a clinical rationale for the specified time frame. Review of the resident's Medication Administration Record (MAR), dated 11/01/24 to 12/11/24, showed staff did not document the resident received the as needed Lorazepam. 3. Review of Resident #45's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/25/24, showed staff assessed the resident as: -Severely cognitively impaired; -Demonstrated inattention, disorganized thinking, delusions, physical and verbal behavioral symptoms, and rejection of care; -Used antianxiety medications; -Diagnoses of Alzheimer's disease, dementia, anxiety, depression, a psychotic disorder other than schizophrenia, and post-traumatic stress disorder (PTSD). Review of the resident's Physician Order Sheet (POS), dated 12/2024, showed and order for Xanax (medication used to decrease anxiety) 0.25 mg every eight hours as needed for anxiety disorder. The order had a start date of 08/01/24 and a stop date of 01/16/24. The order did not contain a 14 day stop date or a clinical rationale for the specified time frame. Review of the medical record showed it did not contain a clinical rationale for the specified time frame. Review of the resident's MAR, dated 11/01/24 to 12/11/24, showed staff documented the resident received Xanax on 11/12/24. During an interview on 12/11/24 at 1:11 P.M., Licensed Practical Nurse (LPN) A said when an order is received, the charge nurse is responsible to ensure as needed psychotropic medications are limited to 14 days and let the doctor know if it is not. LPN A said any PRN psychotropic medications must be limited to 14 days. If it is not used in 14 days, the order should be discontinued; if it is used regularly, it should be added as a scheduled medication; if it is used off and on, it would have to be stopped and reactivated after 14 days. LPN A said he/she did not know why psychotropic medication orders would be allowed for more than 14 days. LPN A said when the resident was admitted and the nurse was entering the orders into the facility's electronic orders, the PRN order greater than 14 days must have been overlooked. During an interview on 12/11/24 at 2:06 P.M., the Director of Nursing (DON) said the charge nurse who enters the orders is responsible to review for any questions or changes needed and verify with the physician. The DON said psychotropic drugs should not ordered as PRN for great than 14 days, unless the resident receives hospice services, then the medications can be ordered for 30 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to store and label creams and ointments in a safe and effective manner when staff did not document the open date on the creams and ointments in the treatment carts and failed to discard the expired creams and ointments. The facility census was 59. 1. Review of the facility's Medication Storage policy, undated, showed no discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines. Each resident must have a space assigned to them that prevents the possibility of a drug for one resident being administered to another. Review of the facility's Medication Destruction policy, undated, showed all medications not returned to the issuing pharmacy will be destroyed. Medications to be destroyed including pills, capsules, liquids, creams, etc., will be placed in a sealable container such as a plastic bag. The plastic bag will them be sealed and placed in the trash. 2. Observation on [DATE] at 10;29 A.M., of the East hall treatment cart showed: -One bottle of Nyamyc Nystatin powder (used to treat fungal or yeast infections) opened and undated, with an expiration date of [DATE]; -One tube of Lidocaine 4% topical cream (used for pain relief), opened and undated; -One tube of Nystatin cream, opened and undated; -One tube of Clotrimazole and Betamethasone cream (used to treat fungal infections), opened and undated; -One tube of Collagenase Santyl ointment, (used to remove damaged tissue from chronic skin ulcers), opened and undated; -One tube of Clobetasol Propironate topical solution (used to treat eczema and psoriasis, with no resident label. Resident could not be identified. 3. Observation on [DATE] at 12:46 A.M., of the [NAME] hall treatment cart showed: -One tube of Hydrogel (used to heal wounds), opened and undated, with an expiration date of 11/22; -One tube of Hydrogel, opened and undated with an expiration date of 7/23; -One box of chlorhexidine gluconate cloths (used to reduce bacteria on skin), unopened with an expiration date of [DATE]. 4. During an interview on [DATE] at 12:50 P.M., Licensed Practical Nurse (LPN) D said he/she is responsible for overseeing the treatment carts. The LPN said the facility does not have a process for checking the treatment carts for outdated ointments or creams. The LPN said he/she will sometimes go through the carts when a resident is discharged . The LPN said if an item is expired he/she would ask the Director of Nursing (DON) how to dispose of it. The LPN said he/she did know there were expired items in the carts. During an interview on [DATE] at 12:56 P.M., the DON said all the nurses are responsible for periodically checking the treatment carts for outdated or unlabeled ointments, and creams. The DON said he/she expects the nursing staff to remove outdated products and dispose of the products per the destruction policy. The DON said he/she did not know why there were expired unlabeled creams in the cart. During an interview on [DATE] at 1:10 P.M., the Administrator he/she and the DON are responsible for ensuring the treatment carts are checked for outdated or unlabelled products. The Administrator said he/she relies on the nurses and Certified Medication Technicians (CMT) to check dates and discard outdated products according to the medication destruction policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide an ongoing activity program designed to meet the resident's interest, mental, and psychosocial well-being for five dependent residents (Resident #11, #13, #20, #29, and #52) out 24 sampled residents. The facility census was 59. 1. Review of the facility's policy titled Resident Activities, dated 03/2012, showed staff were directed to: -The Activity Director (AD) plans and organizes a program of approved activities for residents on a group level and for individuals to meet the needs of the residents; -All staff is responsible for assisting residents to activities of their choice; -An activity program is planned for each resident as a part of their total resident care by the AD; -An individualized program will be implemented for residents unable to participate or attend activities; -The AD or designated person will make announcement of all activities; -The activity staff is responsible for encouraging resident participation. 2. Review of the facility's activity calendar, dated December 2024, showed: -Sunday, 12/08/24: 9:00 A.M. Watch Church on television (TV), 10:00 Church, 1:00 P.M. Go Outside, 6:00 P.M. Watch a Movie; -Monday, 12/09/24: 9:30 A.M. Exercise and Games, 10:00 A.M. Cooking Club, 2:30 P.M. Bingo, 4:00 P.M. Mail Pass, 6:00 P.M. Chit Chat; -Tuesday, 12/10/24: 9:30 A.M. Music, 10:30 A.M. Church, 1:30 P.M. Nails, 4:00 P.M. Mail Pass, 6:00 P.M. Visit A Friend; -Wednesday, 12/11/24: 9:30 A.M. Exercise and Games, 10:00 A.M. Shopping, 10:00 A.M. One on Ones (1:1's), 1:00 P.M. Church, 2:00 P.M. Bingo, 4:00 P.M. Mail Pass, 6:00 P.M. TV Time. 3. Review of Resident #11's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/20/24, showed staff assessed the resident as severely cognitively impaired, and unable to be interviewed for activity preferences. Review of the resident's care plan, dated 11/11/24, showed staff were directed to: -Inform of what activities are happening and when; -Provide activities that don't require much decision making; -Enjoys watching TV, listening to music, visiting with friends and family. Observation on 12/08/24 at 1:52 P.M., showed the resident in bed with eyes closed. Observation on 12/09/24 at 2:44 P.M., showed the resident sat in the common area with eyes closed and the TV on. Observation on 12/10/24 at 3:05 P.M., showed the resident in bed with his/her eyes closed. Observation on 12/11/24 at 9:27 A.M., showed the resident in his/her wheelchair in his/her room with eyes closed. 4. Review of Resident #13's Annual MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired, and not very important to have books, newspapers, and magazines to read, do favorite activities or go outside. Review of the resident's care plan, dated 10/13/24, showed staff were directed to: -Impaired hearing; -Allow activity options; -Encourage and invite to become involved in activities; -Provide verbal reminders of activities; -Provide 1:1 visits; -Radio or TV is preferred. Observation on 12/09/24 at 9:45 A.M., showed the resident in the common area with the TV on and his/her eyes closed. Observation on 12/10/24 at 8:40 A.M., showed the resident in the common area with the TV on and his/her eyes closed. Observation on 12/10/24 at 3:00 P.M., showed the resident in the common area with the TV on and his/her eyes closed. Observation on 12/11/24 at 9:26 A.M., showed the resident in the common area with the TV on and his/her eyes closed. 5. Review of Resident #20's Significant Change MDS, dated [DATE], showed staff assessed the resident as severely impaired cognition and unable to be interviewed for activity preferences. Review of the resident's care plan, dated 12/05/24, showed staff were directed to: -Impaired hearing; -Provide 1:1 visits; -Clergy visits; -Encourage participation and allow to decide what activity to attend. Observation on 12/09/24 at 8:43 A.M., showed the resident in the dining room with his/her eyes closed. Observation on 12/10/24 at 10:26 A.M., showed the resident in the common area with eyes closed and the TV on, while a church activity took place in another area of the facility. Observation on 12/11/24 at 9:26 A.M., showed the resident in the common area with his/her eyes closed and the TV on. 6. Review of Resident #29's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Very important to participate in religious activities; -Somewhat important to listen to music, do favorite activities; -Not very important to have books, newspapers, and magazines to read. Review of the resident's care plan, dated 11/05/24, showed staff were directed to: -Provide 1:1 visits; -Clergy visits; -Encourage participation and allow to decide what activity to attend. Observation on 12/08/24 at 1:23 P.M., showed the resident in the common area with eyes closed and the TV on. Observation on 12/09/24 at 2:47 P.M., showed the resident in bed with eyes closed. Observation on 12/10/24 at 10:00 A.M., showed the resident in the common area asleep where a church activity started. Observation showed staff did not attempt to wake or engage him/her. Observation on 12/11/24 at 9:26 A.M., showed the resident in the common area with his/her eyes closed and the TV on. 7. Review of Resident #52's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired. Review of the resident's care plan, revised 11/19/24, showed staff are instructed to: -Encourage to become involved with activities he/she may have an interest in; -Involve with those who have shared interests; -Provide verbal reminders and written calendar of upcoming activities; -Encourage the resident to participate in small group activities. Observation on 12/10/24 11:14 A.M., showed the resident in the front living area. Observation on 12/11/24 at 1:09 P.M., showed the resident in the front living area. 8. During an interview on 12/11/24 at 11:30 A.M., Licensed Practical Nurse (LPN) A said staff used to provide more activities for the cognitively impaired residents. LPN A said the nursing staff are responsible to remind and assist residents to activities if one is scheduled. LPN A said the facility has books and games available but he/she does not see them used. LPN A said staff should make sure the resident is awake and encourage them to engage in participation of activities. During an interview on 12/11/24 at 1:10 P.M., the AD said when it is time for an activity, he/she will make an announcement over the facility's intercom system. The AD said he/she tries to go to the rooms and invite the residents but he/she is not able to go to all the rooms himself/herself usually. The AD said it is his/her responsibility to ensure all residents receive activities appropriate for each individual, and social interaction. The AD said other staff are responsible to assist residents to and from activities and should ensure the resident is awake to be engaged in the activity and not asleep in their chair. The AD said if residents fall asleep staff should encourage them to wake up and engage. The AD said the residents should not be left sitting in a common area asleep in front of the TV for long periods of time, he/she said this is not an activity. The AD said he/she tries to do 1:1's with the residents who are unable to participate in most activities, but he/she said there are too many residents for him/her to do them often enough. The AD said each day every resident in the facility should have an activity to participate and engage in, including those who are cognitively or physically not able to participate in most activities. During an interview on 12/11/24 at 2:05 P.M., the Director of Nursing (DON) said he/she expects all staff to assist in taking residents to and from activities. The DON said residents should not be left in a common room asleep with the TV on for long periods of time and this is not considered an activity. The DON said all staff should ensure and encourage residents to be awake and engage in activities. During an interview on 12/11/24 at 2:05 P.M., the administrator said the AD is responsible to plan activities and adjust activities as needed. The administrator said he/she is responsible to oversee the activities department and ensure activities are being completed. The administrator said he/she expects staff to go room to room and invite each resident to the activities, he/she said all staff should help do this. The administrator said all staff should ensure and encourage residents to be awake and engage in activities and not bring them asleep in their chairs from one room to another. The administrator said residents should not be left in a common room asleep with the TV on for long periods of time, and this should not be considered an activity. The Administrator said residents who are cognitively impaired or physically not able to do certain activities should be asked if they want to attend activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to accurately code oxygen use for two residents (Resident #4 and #30), chemotherapy (drug treatment that uses powerful chemicals to kill fast-growing cells in the body) for one resident (Resident #20) and Continous Positive Airway Pressure (CPAP), a machine that uses mild air pressure to keep airways open while sleeping, use for one resident (Resident #40). The facility census was 67. 1. Review of the policies provided by the facility showed no Minimum Dat Set (MDS), a federally mandated assessment tool completed by facility staff, policy. 2. Review of Resident #4's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use oxygen. Review of the resident's Physician Order Summary (POS), dated 08/21/23 through 09/21/23, showed an order to administer three liters of oxygen continously via nasal cannula during waking hours. Review of the resident's care plan, dated 08/09/23, showed staff documented the resident received oxygen therapy related to potential for shortness of breath and breathing difficulty. Observation on 09/19/23 at 9:24 A.M., showed the resident wore oxygen. 3. Review of Resident #30's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use oxygen. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order to administer two liters of oxygen continously. Review of the resident's care plan, dated 08/10/23, showed staff documented the resident received oxygen therapy. Observation on 09/20/23 at 12:30 P.M., showed the resident's oxygen tubing and nasal cannula lay on the floor. Observation on 09/20/23 at 3:38 P.M., showed the resident's oxygen tubing and nasal cannula lay on the floor 4. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff documented the resident did not receive chemotherapy. Review of the resident's care plan, revised 04/18/23, showed staff documented the resident received chemotherapy due to a diagnosis of Malignant Neoplasm of Sigmoid Colon (colon cancer) and secondary Malignant Neoplasm of Liver and Bile Duct (liver cancer). During an interview on 09/19/23 at 10:39 A.M., LPN M said the resident was out of the facility today for his/her Chemotherapy. The LPN said the resident normally returned to the facility in the afternoon. During an interview on 09/21/23 at 10:56 A.M., Licensed Practical Nurse (LPN) A said the resident received Chemotherapy and it should be identified on the MDS, under treatments. 5. Review of Resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use a CPAP. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order for CPAP use in the evening or at bedtime (HS). Review of the resident's care plan, dated 08/09/23, showed staff were directed to change CPAP tubing weekly and as needed. Further review showed it did not direct staff in regard to use. Observation on 09/18/23 at 11:30 A.M., showed the resident's CPAP mask and tubing lay on his/her table. During an interview on 09/21/23 on 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said oxygen and CPAP use should be coded on the MDS Assessment, as well as infusion treatments. The ADON said he/she is responsible for completing the MDS assessments. During an interview on 09/21/23 at 12:02 P.M., the Administrator said chemotherapy, and oxygen and/or other respiratory equipment should be indicated on the MDS if the resident used or received the treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for two residents (Resident #29 and #58). The facility census was 67. 1. Review of the facility's policy, titled Care Plan, Temporary, undated, showed staff were directed to do the following: -A temporary care plan will be implemented to meet the new resident's immediate needs; -To assure that the resident's immediate care needs are met and maintained, a temporary care plan will be implemented within 24 hours of admission; -The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed according to the Resident Assessment Instrument (RAI) (assessment used to determine resident care needs) process. 2. Review of Resident #29's medical record showed staff documented the resident was admitted to the facility on [DATE]. The record did not contain a baseline care plan. 3. Review of Resident #58's medical record showed staff documented the resident was admitted to the facility on [DATE]. The record did not contain a baseline care plan. During an interview on 9/28/23 at 2:02 P.M., Licensed Practical Nurse (LPN) A said whoever is working when the resident is admitted is responsible for completing the baseline care plan. LPN A said if the baseline care plan was not completed on the admitting shift the next shift should complete it. LPN A said they give the aides an update on the resident so they will know how to care for them. During an interview on 9/28/23 at 2:10 P.M., the Administrator said the baseline care plans were completed upon admission. The administrator said the baseline care plan should be completed, if not staff will go by the report from the hospital. The administrator said he/she was responsible for making sure they were completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure three residents (Residents #4, #22 and #40), who were unable to complete their own activities of daily living (ADLs) (showering/bathing, dressing, and personal hygiene), received the necessary care and services to maintain good personal hygiene. The facility census was 67. 1. Review of the facility's policy titled, Activities of Daily Living, undated, showed it did not contain direction for staff in regards to how often to change resident's clothing, brush hair, or provide showers. Review of the facility's policy titled, Nails, Care of (Fingers and Toes), undated, showed staff were directed to do the following: -The purpose is to provide cleanliness, comfort, and prevent the spread of infection; -The nursing staff assistants may perform nail care on the residents who are not at risk for complications of infection. Review of the facility's policy titled, Shaving the Resident, undated, showed staff were directed to remove facial hair and improve the resident's appearance and morale. 2. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/15/23, showed staff assessed the resident as follows: -Cognitively intact; -Required limited assistance from one staff member for personal hygiene and dressing. Review of the resident's care plan, dated 08/09/23, showed staff were directed to assist the resident with ADLs per his/her needs. Further review showed no direction for staff in regard to the level of assistance the resident required for ADLs. Review of the resident's shower sheets showed staff documented the resident had a shower on 08/31/23, and staff did not trim the resident's nails. Further review showed no additional shower sheets had been completed. Observation on 09/18/23 at 11:37 A.M., showed the resident's nails were long and jagged. Observation on 09/19/23 at 9:20 A.M., showed the resident's nails were long and jagged. Observation on 09/20/23 at 3:31 P.M., showed the resident's nails were long and jagged. During an interview on 09/19/23 at 9:20 A.M., the resident said he/she had only received one shower in the past two weeks and he/she has asked for a shower but had not gotten one. The resident said he/she liked his/her nails cut short and staff did not always trim his/her nails when asked. The resident said he/she is unable to trim his/her nails without help. 3. Review of Resident #22's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not document having no natural permanent teeth in the mouth or complete tooth loss. Review of the resident's baseline care plan, dated 08/30/23, showed no direction for staff in regard to the resident's dentures. Observation on 09/18/23 at 2:49 P.M., showed the resident without his/her dentures. During an interview on 09/18/23 at 2:49 P.M., the resident said he/she wore dentures. The resident said he/she is visually impaired so staff are supposed to help him/her with his/her dentures. The resident said staff did not always help him/her put his/dentures in, and he/she had difficulty eating without them. During an interview on 09/20/23 at 11:24 A.M., the resident said staff had not put in his/her dentures or asked him/her if he/she wanted to wear dentures. Observation on 09/20/23 at 11:25 A.M., showed the resident's dentures on the bathroom sink. During an interview on 09/20/23 at 12:23 P.M., Certified Nurse Aide (CNA) B said he/she took the resident his/her meal tray this morning and did not ask the resident if he/she would like his/her dentures. The CNA did not know the resident had dentures. Additionally, the CNA said when he/she went back to ask the resident why he/she did not ask for the dentures, the resident said because it was embarrassing. 4. Review of Resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance from one staff member for personal hygiene; -Required limited assistance from one staff member for dressing. Review of the resident's care plan, dated 08/09/23, showed staff documented the resident would remain clean, dry, odor free and maintain hygiene/dignity with staff assistance. Further review showed no direction for staff in regard to the level of assistance required for ADLs. Review of the shower sheets showed staff documented the resident had a shower on 9/11/23. Further review showed it did not contain documentation the resident was shaved. Observation on 09/18/23 at 11:47 A.M., showed the resident with hair on his/her chin. Observation on 09/19/23 at 9:50 A.M., showed the resident wore the same hospital gown with a large orange stain on the front and had hair on his/her chin. Observation on 09/20/23 at 12:36 P.M., showed the resident had hair on his/her chin. Observation on 09/21/23 at 10:54 A.M., showed the resident had hair on his/her chin. During an interview on 09/18/23 at 11:47 A.M., the resident said he/she had not received a shower in two weeks. The resident said staff were told to shave his/her face on shower days, but they do not and it made his/her face itch. During an interview on 09/21/23 at 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said staff were directed to shower residents twice a week, but the facility was short staffed, so residents may not always receive showers. They said staff provided nail care and shaved residents on shower days and when needed. The LPN and ADON said they have noticed residents with unkempt facial hair and long nails and it was addressed with the CNAs and aides during an in-service. They said clothing should be changed daily or as needed and the resident's hair should be brushed daily and as needed. They said dentures should be given to the resident per their preference. During an interview on 09/21/23 at 12:02 P.M., the Administrator said the aides and other staff were responsible to provide showers. He/She said residents should be showered twice a week. He/She said nail care and shaving were done on shower days and as needed. He/She said clothing should be changed daily or as needed, as well as, brushing the resident's hair. He/She said the facility was understaffed, so resident's received one shower a week and some cares were not always completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff did not maintain a safe, clean, comfortable and homelike environment, when staff failed to properly maintain residents' rooms, bathroom vanities and furniture. Additionally, facility staff failed to clean and maintain oxygen concentrator filters for two residents (Resident #4 and #26). The facility census was 67. 1. Review of the policies provided by the facility showed no policy for reporting and/or reporting concerns with resident rooms, bathrooms or furniture. 2. Observation on 09/18/23 at 11:37 A.M., showed room [ROOM NUMBER] floor had black marks, stains and a buildup of debris between the tiles. The bathroom vanity had missing paint and a yellow substance on the front and the walls had gouges and black marks. 3. Observation on 09/18/23 at 2:59 P.M., showed room [ROOM NUMBER] floor had a buildup of debris between the tiles, scratches, black marks and stains. The walls had black marks, nail holes and exposed nails. 4. Observation on 09/19/23 at 10:16 A.M., showed room [ROOM NUMBER] floor had cracked, scratched and stained tiles. The bathroom vanity had black marks and the walls had gouges, black marks and nail holes. 5. Observation on 9/21/23 at 9:49 A.M., showed room [ROOM NUMBER] had paint chipping off of a green dresser, black marks on floor, and a crack in the wall next to the air conditioner. 6. Observation on 9/21/23 at 9:50 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser, carpet frayed by the door and a missing threshold strip. 7. Observation on 9/21/23 at 9:53 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser, and a missing rubber strip on the threshold by the door. 8. Observation on 9/21/23 at 9:54 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser. 9. Observation on 9/21/23 at 9:54 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser. 10. Observation on 9/21/23 at 9:54 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser. 11. Observation on 9/21/23 at 9:54 A.M., showed room [ROOM NUMBER] had paint chipping off of the dresser. 12. Observation on 9/21/23 at 9:56 A.M., showed room [ROOM NUMBER] had black marks on the floor in front of the dressers, black marks on the floor beside the bed and both dressers with chipped paint. 13. Observation on 9/21/23 at 9:58 A.M., showed room [ROOM NUMBER] had a dark black substance on the floor tiles next to the residents bed, food crumbs on the floor next to the bed, snack crumbs all over the top of the dresser and on the floor in front of the dresser and holes in the walls above the television and mini refrigerator. 14. Observation on 09/18/23 at 11:37 A.M., showed Resident #4's oxygen concentrator had a white substance covering the filter. 15. Observation on 09/18/23 at 11:37 A.M., showed Resident #26's oxygen concentrator had a white substance covering the filter. During an interview on 09/21/23 at 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said staff should document environmental concerns in the maintenance log. They said the logs are checked daily. They had not noticed environmental concerns. They said the nurses should clean the oxygen concentrator filters every Friday when the oxygen tubing is changed. During an interview on 09/21/23 at 10:44 A.M., Floor Technician K said staff should report environmental concerns to the maintenance staff and/or charge nurse. They should fill out a work order sheet to give to the maintenance department. Floor Technician K said the resident rooms are inspected monthly, and he/she had not noticed any issues with the floors on the 200 hall. He/She said the floors are buffed every couple of weeks, and he/she had completed repairs in some of the rooms. He/She said staff had not reported any environmental concerns to the maintenance department recently. During an interview on 09/21/23 at 11:31 A.M., Certified Nurse Aide (CNA) B said staff are directed to document maintenance issues in the maintenance log located at the nurses' station, which is checked daily. The CNA said he/she had not noticed any environmental concerns or reported any concerns. During an interview on 09/21/23 at 12:02 P.M., the Administrator said staff are directed to report environmental concerns including floors, walls, dressers and vanities to the supervisor or to him/her. He/She said there is a maintenance form on each hall and it is checked daily. The Administrator said the resident rooms are inspected daily and there had not been any reports of environmental concerns. Oxygen filters are cleaned every 14 days by the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the care needs for three residents (Residents #22, #29 and #58). The census was 67. 1. Review of the facility's policy, titled Care Planning - Interdisciplinary Team, undated, showed a comprehensive care plan for each resident is developed within seven days of completion of the resident assessment. 2. Review of Resident #22's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/02/23, showed staff assessed the resident as follows: -Cognitively intact; -No dental or oral status concerns. Review of the resident's baseline care plan, dated 08/30/23, showed it did not contain documentation the resident wore dentures. Observation on 09/18/23 at 2:49 P.M., showed the resident had no natural teeth and without dentures. Observation on 09/20/23 at 11:25 A.M., showed the resident's dentures were on the bathroom sink. During an interview on 09/18/23 at 2:49 P.M., the resident said he/she wore dentures. The resident said he/she was visually impaired, so staff had to help him/her put his/her dentures in. The resident said staff did not always help him/her with his/her dentures, and it was difficult for him/her to eat without them in. During an interview on 09/20/23 at 11:24 A.M., the resident said staff had not put in his/her dentures or asked him/her if he/she wanted to wear dentures. 3. Review of Resident #29's admission MDS, dated [DATE], showed staff assessed the resident as follows: -admission date of 7/18/23; -A Brief Interview for Mental Status (BIMS) (a screen for cognitive impairment) score of 12 out of 15, showed the resident as cognitively intact; -Diagnoses of coronary artery disease (heart disease), hypertension (high blood pressure), hyperlipidemia (high cholesterol), cerebrovascular accident (CVA, stroke), renal insufficiency (kidney failure), hyponatremia (low sodium), and malnutrition. Review of the resident's medical records showed no care plan for the resident. 4. Review of Resident #58's admission MDS, dated [DATE], showed staff assessed the resident as follows: -admission date of 8/04/23; -A BIMS score of 14 out of 15, showed the resident as cognitively intact; -Diagnoses of high blood pressure, depression, asthma, chronic obstructive pulmonary disease (COPD) (a group of lung disease that block airflow and make it difficult to breathe), arthritis, gastroesophageal reflux disease (GERD) and anxiety disorder. Review of the resident's medical record showed no care plan for the resident. During an interview on 09/21/23 at 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said care plans should be updated if the resident has a significant change and/or on a quarterly and yearly basis. The ADON said he/she is responsible for updating the care plans, and the care plan should include resident specific information. During an interview on 09/21/23 at 12:02 P.M., the Administrator said the care plans should be complete and updated with resident specific information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for six residents (Resident #4, #20, #30, #40, #52, and #53). The facility census was 67. 1. Review of the facility's policy, titled Care Planning - Interdisciplinary Team, undated, showed a comprehensive care plan for each resident is to be developed within seven days of completion of the resident assessment. Review of the policy showed no time frame for revisions of care plans. 2. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/15/23, showed staff assessed the resident as follows: -Cognitively intact; -Required limited assistance from one staff member for personal hygiene and dressing. Review of the resident's care plan, dated 08/09/23, showed staff were directed to assist the resident with ADLs per his/her needs. Further review showed no direction for staff in regard to the level of assistance the resident required for ADLs. Review of the resident's shower sheets showed staff documented the resident had a shower on 08/31/23, and staff did not trim the resident's nails. Further review showed no additional shower sheets had been completed. Observation on 09/18/23 at 11:37 A.M., showed the resident's nails were long and jagged. Observation on 09/19/23 at 9:20 A.M., showed the resident's nails were long and jagged. During an interview on 09/19/23 at 9:20 A.M., the resident said he/she had only received one shower in the past two weeks and he/she has asked for a shower but had not gotten one. The resident said he/she liked his/her nails cut short and staff did not always trim his/her nails when asked. The resident said he/she is unable to trim his/her nails without help. 3. Review of Resident #20's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Required extensive assistance from two staff members for bed mobility and transfers; -Required extensive assistance from one staff member for dressing, toilet use and personal hygiene; -Required total assistance from two staff members for bathing. Review of the resident's care plan, last reviewed 04/18/23, showed no direction for staff in regard to the resident's ADL needs. 4. Review of Resident #47's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Required total assistance from two staff member for bed mobility, transfers, dressing, toilet use, hygiene and bathing; -Independent with eating. Review of the resident's care plan, last reviewed 03/23/22, showed no direction for staff in regard to the resident's ADL needs. 5. Review of Resident #30's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use Continuous Positive Airway Pressure (CPAP) (a machine that uses mild air pressure to keep breathing airways open while you sleep); -Diagnosis of cancer; -Did not receive an infusion treatment. Review of the resident's medical record showed the resident had a diagnosis of lung cancer. Review of the resident's Physician Order Summary (POS), dated 08/21/23 through 09/21/23, showed an order for the use of CPAP administered during the evening or at bedtime (HS). Further showed the resident had a code status (type of resuscitation provided if found with no heartbeat or not breathing) of Do Not Resuscitate (DNR) (Do not provide treatment is found without a heartbeat or not not breathing). The POS did contain an order for infusion treatments. Review of the resident's care plan, dated 08/10/23, showed it directed staff to change CPAP tubing weekly and as needed (PRN). The care plan did not direct staff in regard to interventions, goals and monitoring of the use of the CPAP. Additional review showed the care plan showed a code status of Full Code, but updated with the correct advance directive status of DNR after the surveyor addressed the physician order did not match the information in the care plan. Additional review showed it did not contain direction for staff in regard to the resident's lung cancer diagnosis and infusion treatments. Observation on 09/18/23 at 11:30 A.M., showed the resident had a CPAP machine in his/her room. During an interview on 09/21/23 on 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said the resident receives a monthly infusion of Keytruda (cancer treatment) as a treatment for lung cancer. The LPN and ADON said CPAP use, infusion treatments, and code status information should all be included in the resident's care plan. 6. Review of Resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance from one staff member for personal hygiene; -Required limited assistance from one staff member for dressing. Review of the resident's care plan, dated 08/09/23, showed staff documented the resident will remain clean, dry, odor free and maintain hygiene/dignity with staff assistance. Further review showed no direction for staff in regard to the level of assistance required for ADLs. Review of the shower sheets showed staff documented the resident had a shower on 09/11/23. Further review showed it did not contain documentation the resident was shaved. Observation on 09/18/23 at 11:47 A.M., showed the resident with hair on his/her chin. During an interview on 09/18/23 at 11:47 A.M., the resident said he/she had not received a shower in two weeks. The resident said staff were told to shave his/her face on shower days, but they do not and it make his/her face itch. Observation on 09/19/23 at 9:50 A.M., showed the resident wore the same hospital gown as the day before with a large orange stain on the front and had hair on his/her chin. 7. Review of Resident #52's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), anxiety, Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Post Traumatic Stress Disorder (PTSD), a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. Review of the resident's face sheet showed staff documented the resident's code status as DNR. Review of the resident's POS showed an order for a DNR code status, dated 08/21/23. Review of the resident's care plan, last reviewed 06/24/23, showed no direction for staff in regard to the resident's code status. 8. Review of Resident #53's Annual MDS, dated [DATE], showed staff assessed the resident as: -admitted to the facility on [DATE]; -Cognitively intact; -Diagnoses of high blood pressure, other fracture, depression, peripheral vascular disease (PVD) (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes; Review of the resident's face sheet showed staff documented the resident's code status as DNR. Review of the POS showed an order for a Full Code status, dated 08/14/23. Review of the resident's care plan, last reviewed 08/14/23, showed staff documented the resident's code status as Full Code. Review of the resident's progress notes, dated 08/17/2023 at 07:35 A.M., showed staff documented the facility received the signed DNR paper work from the physician on 08/16/23. Observation on 09/18/23 at 2:25 P.M., showed the resident's name printed on red paper on the door to their room. During an interview on 09/18/23 at 11:11 A.M., Housekeeper G said if the resident's name was printed on red paper it indicated the resident was a DNR, and if the paper was green it indicated the resident was a full code. During an interview on 09/21/23 at 10:15 A.M., LPN A and the ADON said care plans should be updated whenever a resident had a significant change in status and on a quarterly and yearly basis. The ADON said he/she was responsible for updating the care plans. The LPN and ADON said respiratory treatments, code status, cancer diagnoses and treatments, and the level of assistance required for ADLs should be included in the residents' care plans. During an interview on 09/21/23 at 12:02 P.M., the Administrator said he/she expected respiratory treatments, code status, cancer diagnoses and treatment, and the level of assistance required for by residents included in the care plan. The Administrator said the resident's code status should be accurately reflected in the care plan, and staff should update the care plans with the resident's accurate code status after it was brought to the staff's attention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility staff failed to communicate pharmacy recommendations to the physicians of three residents (Resident #30, #34, and #56) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census is 67. 1. Review of the facility's policy, titled Drug Review, undated, showed staff were directed to do the following: -All medications given to each resident will be reviewed on a monthly basis in order to: - Review drug interactions; - Ensure adherence to stop orders; - Ensure accuracy in administration; - Evaluate medications are appropriate to diagnosis; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas; -Problems identified shall be addressed according to need in consultation with the physician. 2. Review of Resident #30's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/15/23, showed staff assessed the resident as: -Cognitively intact; -Diagnosis of cancer, peripheral vascular disease (PVD) (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), malnutrition (when the body does not get enough nutrients), anxiety (intense, excessive, and persistent worry or fear about everyday situations), and manic depression (a mental illness that causes ununusual shifts in a person's mood, energy, activity levels and concentration). Review of the Pharmacist's monthly Medication Regimen Review (MRR) note, dated 08/07/23, showed MRR- see report for gradual dose reduction (GDR) recommendation. Review of the resident's medical record showed no documentation of the pharmacist's report or the physician's response. 3. Review of Resident #34's admission MDS, dated [DATE], showed staff assessed the resident as: -Diagnoses of coronary artery disease (CAD) (damage or disease in the heart's major blood vessels), high blood pressure, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), anxiety, malnutrition, chronic kidney disease, dementia with behavioral disturbances, and major depressive disorder (MDD) (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life); -Received antipsychotic and antidepressant medications seven out of seven days in the look back period (period of time used to complete the assessment). Review of the Pharmacist's monthly MRR notes showed: -05/12/23 MRR - see report for recommendation; -08/07/23 MRR - see report for GDR recommendation. Review of the resident's medical record showed no documentation of the pharmacist's report or the physician's response. 4. Review of Resident #56's Annual MDS, dated [DATE], showed staff assessed the resident as: -Diagnoses of heart disease, high blood pressure, diabetes, anxiety, depression, and Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe); -Received antidepressants, insulin, anticoagulants (makes the blood thinner), and opioids seven out of seven days in the look back period. Review of pharmacist's monthly MMR, note dated 03/24/23, showed MRR- see report for GDR recommendation. Review of the resident's medical record showed no documenation of the pharmacist's report or physician's response. During an interview on 09/21/23 at 10:15 A.M., the Assistant to the Director of Nursing (ADON) said he/she and another staff member were responsible for ensuring the physician received a copy of the recommendations from the pharmacist. The ADON said the recommendations are placed in a folder for the physician to review when at the facility. The ADON said the physician should agree or disagree with the recommendation and the information is then update in the electronic health record (EHR). The ADON said he/she did not know why the residents did not have physician responses to the MRRs. During an interview on 09/21/23 at 12:01 P.M., the Administrator said the Director of Nursing (DON) was responsible for ensuring pharmacy recommendations are completed. The pharmacist gave the recommendations to the DON and then the DON sent the recommendations to the physician and waited for a response. The physician was in the building on Thursdays and staff should follow up with them. The Administrator said there was no system in place to ensure the recommendations were completed.

Based on observation, interview, and record review, facility staff failed to destroy discontinued and As Needed (PRN) medications in a timely manner for two residents (Resident #8 and #14). The facility census was 67. 1. Review of the facility's policy titled, Storage of Medications, dated 02/07/2013, showed staff were directed to do the following: -Discontinued medications will be place in a locked cabinet for destruction; -Medications will be destroyed at least weekly; -No discontinued medications may be retained for use. 2. Observation on 09/18/23 at 2:22 P.M., showed the following medications for resident #8 in the medication destruction cabinet of the [NAME] Side Medication Room: -14 capsules (caps.) of 100 milligram (mg) Gabapentin (anticonvulsant) with a discontinued date of 03/22/23; -10 caps. of 100 mg Gabapentin with a discontinued date of 03/22/23; -28 caps. of 100 mg Gabapentin with a discontinued date of 03/22/23; -28 caps. of 100 mg Gabapentin with a discontinued date of 03/22/23; -19 caps. of 100 mg Gabapentin with a discontinued date of 03/22/23; -8 tablets (tabs) of Potassium Chloride 20 milliequivalents (MEQ) with a discontinued date of 03/21/23. -29 tabs of Haloperidol (antipsychotic) 0.5 MG with a discontinued date of 03/08/23. 3. Observation on 09/18/23 at 2:22 P.M., showed the following medications for resident #14 in the medication destruction cabinet of the [NAME] Side Medication Room: -90 tablets of 10 mg Baclofen (muscle relaxant) with an order date of 09/16/22; -90 tablets of 10 mg Baclofen with an order date of 12/06/22; -79 tablets of 10 mg Baclofen with an order date of 01/02/23; -90 tablets of 10 mg Baclofen with an order date of 01/30/23; Review of the resident's Medication Administration Record (MAR), dated 09/16/22 through 09/18/23, showed the resident never requested and staff had never administered Baclofen 10 mg to the resident. During an interview on 09/18/23 at 2:50 P.M., Licensed Practical Nurse (LPN) M said staff should have destroyed the medications already. The LPN said Resident #14's PRN Baclofen was in the destruction cabinet because the resident doesn't ever ask for the medication. The LPN said the facility preferred Registered Nurses (RN)s destroy the medications, even if the medications were not controlled. The LPN said he/she did not know what was going on with the medications in the destruction cabinet. The LPN said he/she did not know if there was a set time for destroying medications after they have been discontinued. The LPN said there should not be medications in the cabinet that were discontinued six months ago. The LPN said if the resident had a PRN medication, but did not use it, staff should get rid of the medication. The LPN said he/she can not find where the resident ever requested the PRN Baclofen. During an interview on 09/20/23 at 4:31 P.M., the Director of Nursing (DON) said PRN medications should be discontinued after 30 days if the resident did not use it. The DON said staff should destroy medications as soon as there were two nurses available. The DON said he/she did not know why the medications weren't destroyed, but they should have been. During an interview on 09/21/23 at 10:56 A.M., LPN A said when a medication was discontinued staff was supposed to destroy the medication with two nurses and document the medications were destroyed. The LPN said he/she did not know what the facility's policy said about timeframe for destruction of medications. During an interview on 09/21/23 at 11:50 A.M., the Administrator said when medications were discontinued staff had five days to ensure the medications were destroyed. The Administrator said staff absolutely should have destroyed the medications and he/she did not know why it was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to to clean and store respiratory equipment and devices in a manner to prevent the spread of infection for four residents (Residents #22, #26, #30 and #40). The facility census was 67. 1. Review of the facility's policy titled, Continuous Pressure Airway Pressure (CPAP) (a machine that uses mild air pressure to keep breathing airways open while you sleep) Administration, dated March 2015, showed no direction for staff in regard to storing the mask in a sanitary manner when not in use. Review of the facility's policy titled, Oxygen Administration, undated, showed staff no direction for staff in regard to oxygen tubing storage when not in use. 2. Review of Resident #22's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/02/23, showed staff assessed the resident as follows: -Cognitively intact; -Used a BiPAP (Bilevel positive airway pressure) (a type of ventilator-a device that helps with breathing) or CPAP machine. Review of the resident's baseline care plan, dated 08/30/23, showed no direction for staff in regard to the resident's BiPAP machine. Review of the resident's Physician Order Summary (POS), dated 08/21/23 through 09/21/23, showed no order for BiPAP use. Observation on 09/18/23 02:43 PM., showed a BiPAP mask and tubing on the resident's nightstand. Further observation showed no bag in the room to store the BiPAP mask in a sanitary manner Observation on 09/20/23 at 9:09 A.M., showed the resident lay in his/her bed with the BiPAP mask and tubing above his/her head. Further observation showed no bag in the room to store the BiPAP mask in a sanitary manner. During an interview on 09/18/23 at 3:20 P.M., the resident said he/she used the BiPAP machine every night. The resident said he/she was visually impaired and staff set the machine up for him/her prior to use. 3. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Used oxygen. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order for oxygen to be administered at 2 liters per minutes (LPM) continuously per nasal cannula. Review of the resident's care plan, dated 08/23/23, showed staff documented the resident used oxygen. Observation on 09/19/23 at 9:24 A.M., showed the resident wore oxygen. Further observation showed no bag in the room to store the oxygen mask or tubing in a sanitary manner. Observation on 09/20/23 at 12:32 P.M., showed the resident's oxygen tubing on the resident's bedside table. Further observation showed no bag in the room to store the oxygen mask or tubing in a sanitary manner. 4. Review of Resident #30's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use oxygen. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order for the use of a nebulizer administered as needed and continuous oxygen administered at 2 LPM. Review of the resident's care plan, dated 08/10/23, showed staff documented the resident received oxygen. Observation on 09/19/23 at 10:16 A.M., showed the nebulizer mask lay on the resident's nightstand. Further observation showed no bag in the room to store the oxygen mask or tubing or nebulizer mask in a sanitary manner. Observation on 09/20/23 at 12:30 P.M., showed the resident's oxygen tubing and nasal cannula lay on the floor and the nebulizer mask lay on top of the nebulizer machine. Further observation showed no bag in the room to store the oxygen mask or tubing or nebulizer mask in a sanitary manner. 5. Review of Resident #40's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Did not use a BiPAP or CPAP. Review of the resident's POS, dated 08/21/23 through 09/21/23, showed an order for the use of CPAP administered during the evening or at bedtime (HS). Review of the resident's care plan, dated 08/09/23, showed it directed staff to change CPAP tubing weekly and as needed. Further review showed it did not direct staff in regard to tubing and mask storage when not in use. Observation on 09/18/23 at 11:30 A.M., showed the resident's CPAP mask and tubing on his/her table. Further observation showed no bag in the room to store the CPAP mask in a sanitary manner. Observation on 09/21/23 at 10:54 A.M., showed the resident's CPAP mask and tubing on his/her table. Further observation showed no bag in the room to store the CPAP mask in a sanitary manner. During an interview on 09/20/23 at 4:31 P.M., the Director of Nursing (DON) said CPAP masks, oxygen tubing, and nebulizer masks and tubing should be stored in a bag when not in use. The bag should be changed every week when the tubing or mask is changed. The DON said if a resident's nasal cannula touches the floor, bed or any contaminated area it should be thrown away and replaced with new tubing. The DON said he/she did not know why staff were not putting the masks and tubing in bags when not in use. He/She said staff had in-services in regard to this. The DON said he/she did not know why staff were not replacing tubing that touched contaminated surfaces. During an interview on 09/21/23 at 10:15 A.M., Licensed Practical Nurse (LPN) A and the Assistant to the Director of Nursing (ADON) said new plastic bags were placed on the oxygen concentrators on Fridays for storage of oxygen tubing and masks. They said they did not know why the residents who used respiratory equipment did not have bags to sanitarily store the equipment. The LPN and ADON said there was an infection control concern if the tubing and mask were not placed in the storage bag. The LPN and ADON said staff were directed to dispose of the tubing and/or mask if it touched the floor or the bed. During an interview on 09/21/23 at 11:24 A.M., Certified Nurse Aide (CNA) B said the residents' oxygen tubing and equipment should be placed in a plastic bag when not in use. The CNA said he/she thought there were a couple of rooms without plastic bags because it was just so busy. The CNA said the nebulizer and BiPAP masks were also supposed to be in plastic bags when not in use. The CNA said he/she should have stopped and gotten bags for the masks and oxygen tubing. The CNA said if the mask or nasal cannula touched contaminated surfaces, like a bed or floor, staff were supposed to throw it away and go to the nurse to get replacements. During an interview on 09/21/23 at 11:50 A.M., the Administrator said all tubing was supposed to be placed in plastic bags, when not in use. The administrator said if the tubing touched a contaminated surface the staff should discard it and replace it. Staff have been instructed to place masks and tubing in plastic bags.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide reasonable accommodations to meet the needs of dependent residents by failing to keep the call lights within reach for three residents (Resident #12, #24, and #29). The facility census was 56. 1. Review of facility Call light policy, undated, showed the staff were instructed as follows: - All facility personnel must be aware of call lights at all times; - When providing care to residents, be sure to position the call light conveniently for the resident's use; - Tell the resident where the call light is and show him/her how to use the light; - Be sure all call lights are placed on the bed at all times, never on the floor or bedside stand. 2. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/16/22, showed staff assessed resident as: - Severely cognitively impaired; - Active diagnoses of Downs Syndrome, Muscle weakness, visual loss, history of falling, and need for assistance with personal care; - Required extensive two person physical assistance for bed mobility, transfers, and toileting; - Required limited two person physical assistance for dressing and personal hygiene; - Wheelchair used as a mobility device with one person physical assist for locomotion on/off the unit. Review of the resident's care plan, last reviewed 02/22/22, showed an Activities of Daily Living (ADL's) deficit related to Down's Syndrome. Further review showed the resident at risk for falls related to diagnoses and assistance needed. Interventions directed staff to make sure the call light is within the resident's reach. Observation on 05/15/21, at 04:57 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the wall. Observation on 05/16/22, at 10:20 A.M., showed the resident's call light hung on the wall attached to itself and out of his/her reach. Observation on 05/17/22, at 01:36 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the wall. Observation on 05/18/22, at 05:40 A.M., showed the resident in his/her Broda chair (chair reducing skin breakdown). His/Her call light hung on the wall attached to itself and out of his/her reach. During an interview on 5/18/22 at 11:32 A.M., CNA A said he/she was not aware of Resident's call light hooked to the wall. During an interview on 05/18/22 at 12:48 P.M., the Director of Nursing (DON) said resident may not have the cognition to use their call lights but should still have them in reach at all times. During an interview on 5/18/22 at 1:04 P.M., the Administrator said he/she is not aware of the call light not being placed within reach for the resident. During an interview on 05/18/22, at 1:20 P.M., CMT B said he/she wasn't sure if the resident could use his/her call light, but it should still be within reach. During an interview on 05/18/22, at 02:15 P.M., LPN H said resident did not know how to use his/her call light. 3. Review of Resident #24's Annual MDS, dated [DATE], showed staff assessed resident as: - Cognitively intact; - Active diagnosis or Dementia, muscle weakness, lack of coordination; - Required extensive one person physical assistance for personal hygiene; - Required limited one person assistance for dressing, toileting, bed mobility, transfers, and locomotion on the unit; - Required two person physical assist for locomotion off the unit; - Wheelchair used as a mobility device with one person physical assist for locomotion on/off the unit. Review of the resident's care plan, undated, showed an ADL self-care performance deficit related to bilateral arm amputation just below the elbow, dementia, muscle weakness, and incontinence of bowl and bladder. Interventions directed staff to make sure the call light is within the resident's reach. Observation on 05/15/22, at 2:48 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand Observation on 05/16/22, at 8:11 A.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand Observation on 05/16/22, at 1:57 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand, Observation showed nursing aide (NA) E and NA G entered the room to provide care and did not place the resident's call light within reach before they exited the room. Observation on 05/17/22, 09:01 A.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand Observation on 05/17/22, at 01:12 P.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand. NA G and Licensed Practical Nurse (LPN) H did not place the resident's call light within reach before they exited the room. Observation on 05/18/22, at 07:32 A.M., showed the resident in his/her bed. Observation showed the call light out of his/her reach on the the nightstand During an interview on 05/16/22, at 01:57 P.M., the resident said his/her spouse helps with his/her needs when his/her call light is not within reach. During an interview on 05/16/22, at 01:59 P.M., the resident's spouse said he/she helps him/her and staff generally do not put the call light within his/her reach. During an interview on 5/18/22 at 11:32 A.M., CNA A said he/she placed the resident's call light on his/her chest. He/She said there were a lot of new staff, so he/she knows there were staff who have left his/her call light on the bedside table. He/She said the resident's spouse feeds him/her and will place the call light on the bedside table. He/She said the staff move the call light back within reach when they check on him/her. During an interview on 05/18/22 at 12:48 P.M., the DON said the resident not have the cognition to use his/her call light, but should still have it in reach at all times. During an interview on 5/18/22 at 1:04 P.M., the Administrator said he/she is not aware of the call light not being placed within reach for the resident. During an interview on 05/18/22, at 1:20 P.M., CMT B said the resident knew how to use his/her call light. During an interview on 05/18/22, at 02:15 P.M., LPN H said the resident could use his/her and his/her spouse could help utilize it. 4. Review of Resident #29's Annual MDS, dated [DATE], showed staff assessed resident as: - Severely cognitively impaired; - Active diagnosis of Alzheimer's, dementia, osteoarthritis, history of falls, and repeated falls; -Required limited two person physical assistance for toileting and personal hygiene; - Required extensive two person physical assistance for bed mobility and transfers; - Wheelchair used as a mobility device with one person physical assist for locomotion on/off the unit. Review of the residents care plan, undated, showed he/she had an ADL self-care performance deficit related to bowel and bladder incontinence, was at risk for falls due to a history of falls and repeated falls. Interventions directed staff to keep his/her call light within reach at all times and to keep call light within reach at all times (she may forget use call light due to diagnosis of dementia and Alzheimer. Observation on 05/15/22, at 2:40 P.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/16/22, at 8:17 A.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/16/22, at 1:54 P.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/16/22, at 3:00 P.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/17/22, at 9:00 A.M., showed the resident's call light on the floor, at the foot of the bed and out of the residents reach. Observation on 05/17/22, at 1:06 P.M., showed the resident in bed with his/her call light on the floor, at the foot of the bed and out of his/her reach. Observation on 05/18/22, at 05:48 A.M., showed the resident's call light on the floor, at the foot of the bed and out of his/her reach. During an interview on 5/18/22 at 11:32 A.M., CNA A said he/she clipped the resident's call light on the bed. He/She had not seen staff clip the call light to a string at the bottom of the bed and not sure how the resident would reach it if it was located there. During an interview on 05/18/22 at 12:48 P.M., the DON said the resident may not have the cognition to use his/her call light but should still have them in reach at all times. During an interview on 5/18/22 at 1:04 P.M., the Administrator said he/she is not aware of the call lights not being placed within reach for the resident. During an interview on 05/18/22, at 1:20 P.M., CMT B said the resident knew how to use his/her call light. 5. During an interview on 5/18/22 at 11:32 A.M., CNA A said the call light should be located within the resident's reach at all times. He/She had not seen staff clip call lights to a string at the bottom of the beds and not sure how the resident would reach it if it was located there. During an interview on 05/18/22 at 12:48 P.M., the Director of Nursing said all staff are responsible to ensure the call lights are in reach of residents at all times. During an interview on 5/18/22 at 1:04 P.M., the Administrator said call lights should be placed within reach of the resident and not wrapped around any items, such as a halo bar. During an interview on 05/18/22, at 1:20 P.M., CMT B said call lights are always supposed to be within reach of each resident when they are in their room. He/She was not aware of any call lights being out of reach and said all staff who enter and exit the room are responsible for making sure the call lights are within reach. During an interview on 05/18/22, at 02:15 P.M., LPN H said call lights should be within reach of the resident no matter where they are in their room and everyone is responsible for monitoring residents call lights. During an interview on 05/18/22 at 02:29 P.M., LPN C said the call light should be within reach of the resident and not hooked on things.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to revise care plans for three residents (Resident #20, #40, and #41) with interventions for facial hair and edema. Further review showed the facility staff failed to revise care plans for two residents (Resident #45) when staff failed to remove interventions in place for anticoagulant use. The facility census was 56. 1. Review of the facility's Care Planning-Interdisciplinary Team policy, undated, showed the Facility Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident is to be developed within seven (7) days of completion of the resident assessment (MDS). 2. Review of the facility's Care Plan Comprehensive policy, undated, showed: - An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; - The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; - The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the MDS; - Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; - A well-developed care plan will be oriented to using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities; assessing and planning for care to meet the resident's medical, nursing, mental and psychosocial needs; and addressing additional care planning areas that are relevant to meeting the resident's needs in the long-term care settings; - The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessment (MDS and CAAs); - The interdisciplinary care plan team is responsible for the periodic review and updating of care plan when a significant change in the resident's condition has occurred; at least quarterly; and when changes occur that impact the resident's care (i.e., change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 3. Review of Resident #20's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/12/22, showed staff assessed the resident with mild cognitive impairment and independent with personal hygiene. Review of the resident's care plan, dated 2/12/21, showed it did not contain direction for staff in regards to the resident's facial hair preference. Observations on 05/17/22 at 8:38 A.M., showed the resident had long facial hairs on his/her upper lip and chin. Observations on 5/18/22 at 11:27 A.M., showed the resident had long facial hairs on his/her upper lip and chin. 4. Review of Resident #40, annual MDS, dated [DATE], showed staff assessed the resident as with severe cognitive impairment and required extensive one person assistance with personal hygiene. Review of the resident's care plan, dated 4/2/21, showed it did not contain direction for staff in regards to the resident's facial hair preference. Observations on 5/15/22 at 2:30 P.M., showed the resident had long hairs on his/her upper lip and chin. Observations on 5/16/22 at 8:12 A.M., showed the resident had long facial hairs on his/her upper lip and chin. Observations on 5/17/22 at 8:02 A.M., showed the resident had long hairs on his/her upper lip and chin. Observations on 5/18/22 at 11:27 A.M., showed the resident had long hairs on his/her upper lip and chin. During an interview on 5/18/22 at 11:50 A.M., CNA/CMT B, said care plans are located at the nurse's desk, which included the type of care of the resident required. He/She said the MDS Coordinator updated the care plan. He/She said the staff reported resident changes to the charge nurse. He/She said he/she would expect the care plan to list the facial hair preference. He/She said he/she had noticed some residents with facial hair. During an interview on 5/18/22 at 12:08 A.M., the MDS Coordinator said he/she and the nursing staff are responsible for updating the care plan. He/She said the care plans are updated when there was a significant change in care, annually and quarterly. He/She said the baseline care plans are completed upon admission and the comprehensive care plan should be updated in seven days from the admission date. He/She said he/she would expect to see edema and facial hair preferences in the care plan. During an interview on 5/18/22 at 12:48 P.M., the Director of Nursing said, the MDS Coordinator is responsible for the care plans but can be updated at needed by the nurses. He/she said care plans should be updated daily with falls and any changes in care. In addition, he/she said shaves, nail care and facial hair preferences are expected to be in the care plan. During an interview on 5/18/22 at 1:04 P.M., the Administrator said the MDS coordinator updated the care plan when a resident had a change in condition (fall, hospice, etc.) quarterly, and annually. He/She said the care plan is reviewed and updated 7-14 days after admission. He/She said he/she would assume facial hair should be on the care plan. He/She said the care plan should list specific preferences for Activities of Daily Living (ADL's) for each resident, not broad. During an interview on 05/18/22, at 01:20 P.M., CMT B said staff have a care plan book to refer to for the residents care. He/She said the MDS coordinator is responsible for making and updating care plans. He/She said careplans are updated with a significant change but is not sure when else the care plan would be updated. He/She said he/she would expect guidance and preferences listed on the careplan for facial hair and edema. During and interview on 05/18/22, at 02:15 P.M, LPN H said careplans are updated by the MDS coordinator. He/She said if the staff know something has changed, they can update the paper care plan and let the MDS coordinator know if a change was made, so he/she can update the electronic care plan. He/She said he/she would expect edema to be addressed in the care plan with interventions and facial hair preferences to be listed on the care plan as well. During an interview on 5/18/22 at 2:29 P.M., Licensed Practical Nurse (LPN) C said the MDS Coordinator updated the care plans. He/She said he/she was not sure when the care plan are updated. He/She said the aides reported changes to the nurse who reported the changed to the DON. He/She said he/she is not sure if the facial hair preference should be listed on the care plan. 5. Review of Resident #41, quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required limited one person assistance with personal hygiene; -Diagnosis of anemia and hypertension. Review of the resident's care plan, revised on 10/15/2021, showed it did not contain direction regarding resident's edema (swelling). Review of the physician order summary, undated, did not contain an order for compression hose. Observations on 5/16/22 at 9:29 A.M., showed the resident had swelling in both feet and wore compression hose. Observations on 5/18/22 at 6:36 A.M., showed the resident wore compression hose. During an interview on 05/18/22 at 7:55 A.M., LPN O said the resident had edema from time to time, so he/she wore compression hose. He/She said there should be an order for compression hose and it should be listed on the care plan. He/She said the nursing staff updated the MDS Coordinator with changes in the resident, so he/she can update the care plan. During an interview on 5/18/22 at 11:50 A.M., CNA/CMT B, said care plans are located at the nurse's desk, which included the type of care of the resident required. He/She said the MDS Coordinator updated the care plan. He/She said the staff reported resident changes to the charge nurse. During an interview on 5/18/22 at 12:08 A.M., the MDS Coordinator said he/she and the nursing staff are responsible for updating the care plan. He/She said the care plans are updated when there was a significant change in care, annually and quarterly. He/She said the baseline care plans are completed upon admission and the comprehensive care plan should be updated in seven days from the admission date. He/She said he/she would expect to see edema and facial hair preferences in the care plan. During an interview on 5/18/22 at 12:48 P.M., the Director of Nursing said, the MDS Coordinator is responsible for the care plans but can be updated at needed by the nurses. He/she said care plans should be updated daily with falls and any changes in care. During an interview on 5/18/22 at 1:04 P.M., the Administrator said the MDS coordinator updated the care plan when a resident had a change in condition (fall, hospice, etc.) quarterly, and annually. He/She said the care plan is reviewed and updated 7-14 days after admission. He/She said edema and cellulitis should be listed on the care plan, especially when it is intermittent. He/She said the care plan should list specific preferences for Activities of Daily Living (ADL's) for each resident, not broad. During an interview on 05/18/22, at 01:20 P.M., CMT B said staff have a care plan book to refer to for the residents care. He/She said the MDS coordinator is responsible for making and updating care plans. He/She said careplans are updated with a significant change but is not sure when else the care plan would be updated. He/She said he/she would expect guidance and preferences listed on the careplan for facial hair and edema. During and interview on 05/18/22, at 02:15 P.M, LPN H said careplans are updated by the MDS coordinator. He/She said if the staff know something has changed, they can update the paper care plan and let the MDS coordinator know if a change was made, so he/she can update the electronic care plan. He/She said he/she would expect edema to be addressed in the care plan with interventions and facial hair preferences to be listed on the care plan as well. During an interview on 5/18/22 at 2:29 P.M., Licensed Practical Nurse (LPN) C said the MDS Coordinator updated the care plans. He/She said he/she was not sure when the care plan are updated. He/She said the aides reported changes to the nurse who reported the changed to the DON. 6. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed resident as: - Cognitively intact; - Diagnosis of Encepholopathy ( a disease in which the functioning of the brain is affected by some agent or condition), Altered mental status, and end stage renal disease; - Required extensive two person physical assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; - Wheelchair used for mobility with limited one person physical assistance for locomotion on/off the unit. Review of the resident's care plan, revised 02/23/22, showed the resident was prescribed an anticoagulant therapy. Interventions directed staff to administer anticoagulants to resident as ordered. Evaluate/record effectiveness. Evaluate/report adverse side effects. Review of the resident's POS, undated, showed the record did not contain an order for an anticoagulant. 7. During an interview on 5/18/22 at 11:50 A.M., CNA/CMT B, said care plans are located at the nurse's desk, which included the type of care of the resident required. He/She said the MDS Coordinator updated the care plan. He/She said the staff reported resident changes to the charge nurse. During an interview on 5/18/22 at 12:08 A.M., the MDS Coordinator said he/she and the nursing staff are responsible for updating the care plan. He/She said the care plans are updated when there was a significant change in care, annually and quarterly. He/She said the baseline care plans are completed upon admission and the comprehensive care plan should be updated in seven days from the admission date. During an interview on 5/18/22 at 12:48 P.M., the Director of Nursing said, the MDS Coordinator is responsible for the care plans but can be updated at needed by the nurses. He/she said care plans should be updated daily with falls and any changes in care. During an interview on 5/18/22 at 1:04 P.M., the Administrator said the MDS coordinator updated the care plan when a resident had a change in condition (fall, hospice, etc.) quarterly, and annually. He/She said the care plan is reviewed and updated 7-14 days after admission. He/She said the care plan should list specific preferences for Activities of Daily Living (ADL's) for each resident, not broad. During an interview on 05/18/22, at 01:20 P.M., CMT B said staff have a care plan book to refer to for the residents care. He/She said the MDS coordinator is responsible for making and updating care plans. He/She said careplans are updated with a significant change but is not sure when else the care plan would be updated. During and interview on 05/18/22, at 02:15 P.M, LPN H said careplans are updated by the MDS coordinator. He/She said if the staff know something has changed, they can update the paper care plan and let the MDS coordinator know if a change was made, so he/she can update the electronic care plan. During an interview on 5/18/22 at 2:29 P.M., Licensed Practical Nurse (LPN) C said the MDS Coordinator updated the care plans. He/She said he/she was not sure when the care plan are updated. He/She said the aides reported changes to the nurse who reported the changed to the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide care consistent with professional standards when they failed to follow a physician's order for weekly weights for one resident (Resident #41). Facility staff failed to identify the size of indwelling catheters (tube inserted into the bladder) for three residents (Resident #39, #55, and #257). Additionally, facility staff failed to obtain a physician's order for two resident's (Resident #45 and #55's) code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) and the facility failed to provide ongoing communication with the dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) center for one resident (Residents #45). The facility census was 56. 1. Review of the facility's Weight and Height Measurement policy, undated, showed residents are weighed on admission and monthly unless otherwise ordered by the attending physician to monitor the resident's condition. 2. Review of the facility's Weight Champion Program, undated, showed: -Each community should designate a weight champion to assist in the oversight and monitoring of residents that have or are at risk for weight loss; -The weight champion will be responsible for keeping the weight variance report from Matrix, as well as being custodian of the Daily, Weekly, and Monthly facility weight lists; -The following residents are to be weighed weekly: -New admissions and Re-admissions weekly times four weeks; -Residents that have a new feeding tube placed or has a change in tube feeding; -Residents that have displayed significant weight loss at the time of their monthly weight; -Residents with pressure ulcers that have displayed delayed healing or deterioration; -Residents weighing less than 100 pounds. -Weights will be documented in the medical record by the Weight Champion and/or Designee. 3. Review of Resident #41's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as with severe cognitive impairment and required limited one person assistance with personal hygiene. Review of the resident's Physician Order Sheet (POS), dated [DATE], showed an order for staff to get weekly weights. Review of the residents medical records, dated [DATE] through [DATE], did not contain weekly weights per the physician orders. During an interview on [DATE] at 11:32 A.M., CNA A said the nursing staff updated the POS. He/She said the CNA's were responsible for obtaining weights weekly weights on Wednesdays. He/She said he/she was not sure where they were documented. During an interview on [DATE] at 12:48 P.M., the Director of Nursing said he/she expects the shower aides to obtain weekly weights and the dietary supervisor or Minimum Data Set (MDS) nurse to record the weights in the computer. He/She was not aware it was not completed. During an interview on [DATE] at 1:04 P.M., the Administrator said the nursing staff oversees the weekly weight and the aides obtained the weights. He/She said the DON and MDS coordinator would document the weights to verify if there were any issues. During an interview on [DATE] at 2:29 P.M., LPN C said the shower aide gets weights on all residents. He/She said the dietary manager and the shower aide were responsible for documenting the weights. During an interview on [DATE], at 1:20 P.M, CMT B said the shower aides are responsible for obtaining residents weights. He/She said the weights are reported to the nurse, DON, and dietary. He/She is not sure who is responsible for entering the weights into their system. During an interview on [DATE], at 2:15 P.M., LPN H said the shower aide is supposed to do monthly weights on residents unless otherwise indicated. He/She said the dietary manager will adjust or request orders for weight management, and he/she enters the weights into the system. 4. Review of the facility's Physician Orders policy, undated, showed current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors. Additional review showed the content of orders for a foley catheter includes: -If as needed (PRN), specify why it is needed; -Irrigation - specific type, amount, frequency, and reason; -Specify the size and frequency of change; -Catheter care specifies what is to be used; 5. Review of Resident #39's annual MDS, dated [DATE], showed facility staff assessed the resident as follows: -Cognitively intact; -Always incontinent of bowel and bladder; -Requires physical assistance of one staff for toileting and bed mobility; -Functional limitations in Range of Motion to both lower extremities; -Did not contain catheter use; -Diagnosis of pressure ulcer to buttocks, encephalopathy (disease affecting the brain), paraplegia (inability to use lower body). Review of the resident's plan of care, revised [DATE], did not contain documentation for direction or presence of a catheter. Review of the resident's physician orders, dated [DATE], showed the physician ordered: -On [DATE] - Place a foley catheter due to wound vacuum, discontinue (D/C) foley catheter when vacuum is D/C'd -On [DATE] - Primary dressing hydrofera blue classic 4x4 (to left buttock). Do not change dressing unless needed. Please try to keep dressing in place. If necessary, change outer dressing only until returns to clinic. -It did not contain orders for catheter size or balloon size. Observation on [DATE] at 2:36 P.M., showed resident in bed with a foley catheter draining to gravity. Further observation showed he/she did not have a wound vacuum in place. Observation on [DATE] at 1:16 P.M., showed the resident in bed with a foley catheter draining to gravity. Further observation showed he/she did not have a wound vacuum in place. Observation on [DATE] at 8:08 A.M., showed the resident in bed with a foley catheter draining to gravity. Further observation showed he/she did not have a wound vacuum in place. Observation on [DATE] at 12:50 P.M., showed the resident with a foley catheter draining to gravity while in bed. Further observation showed he/she did not have a wound vacuum in place. During an interview on [DATE] at 2:36 P.M., the resident said he/she tried a wound vacuum but it would not stay due to moisture and incontinence. A foley catheter was put in to help keep him/her from getting urine in his/her wound. He/She said the wound is getting better and has a urology appointment in August. 6. Review of #55's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Mild Cognitive Impairment; -Catheter use; -Requires physical assistance of two staff for bed mobility, toileting and dressing; -Hospice; -Frequently in pain; -Diagnosed with heart failure, stroke, respiratory failure and pressure ulcer stage III to sacral region. Review of the resident's plan of care, dated, [DATE], directed facility staff to change the catheter per physician orders and provide catheter care every shift and as needed. Review of the physician orders, dated [DATE], showed: -On [DATE], catheter care every shift and as needed; -On [DATE], change catheter monthly on the 21st; -On [DATE], change catheter as needed. -It did not contain direction on catheter size, balloon size, or indication for use. Observation on [DATE] at 2:21 P.M., showed the resident in bed with a foley catheter hanging on the side of the bed draining to gravity. Observation on [DATE] at 8:04 A.M., showed the resident in bed with a foley catheter draining to gravity. Observation on [DATE] at 9:52 A.M., showed the resident with a foley catheter draining to gravity. During an interview on [DATE] at 2:21 P.M., the resident said he/she had a lot of pain in his/her hip and has a wound on his/her bottom. He/she said the catheter keeps him/her comfortable. 7. Review of Resident #257's medical record shows it did not contain MDS data. Review of the resident's Face sheet (a demographic profile of the resident), ran [DATE] showed: -admitted to facility [DATE]; -On hospice services; -Diagnosed with Metastatic Cancer of the uterus, lung, liver, and bone, Diabetes, Anemia, Chronic Embolism of Deep Veins, Wounds to right ankle, right leg, and abdominal wall. Review of the resident's care plan, dated [DATE], showed the presence of a catheter. It did not contain direction for changing or care of the catheter. Review of the resident's physician orders dated [DATE], showed: -On [DATE], catheter care every shift; -On [DATE], change catheter monthly on the 30th; -It did not contain direction for catheter size, balloon size, or indication for use. Observation on [DATE] at 3:30 P.M., showed the resident in bed on the isolation unit with a foley catheter draining to gravity. During an interview on [DATE] at 3:30 P.M., the resident said he/she is in a lot of pain, often all over and the catheter helps since he/she cannot get out of bed. 8. During an interview on [DATE] at 12:48 P.M., the Director of Nursing said the nurses are responsible for getting catheter orders. He/she expects the orders to include catheter size, bulb size, and indication for use. During an interview on [DATE] at 1:04 P.M., the Administrator said the physician orders were updated in the system by the nursing staff, which automatically updates the POS. He/She said the orders were updated as soon as the orders were received. He/She said the physician was able to update the system as well. He/She said the administrator and DON verified the POS was updated correctly by verifying the POS, physician orders and the MARS. He/She said the POS, physician orders and MARS were audited whenever a change occurred or at least monthly. Further, the Administrator said the orders should include the instructions of the catheter size, kind, and type (indwelling, etc), start date, and the reason for the diagnosis. He/She said another order is initiated for catheter care, which specified the shift to provide the care and another order for the date the catheter was placed in the resident and the date it should be changed. During an interview on [DATE], at 1:20 P.M., CMT B said he/she would expect catheter order's to contain instructions for the care, the output, and how often it's changed. He/She said from his/her experience the resident would have to have a diagnosis to have a catheter. During an interview on [DATE], at 02:15 P.M., LPN H said a resident should have a diagnosis for catheter use and would expect the orders to include the catheter size, how often and when it is changed, and the balloon size. During an interview on [DATE] at 2:29 P.M., LPN C said the physician comes to the facility on Thursday and the attending nurse entered the information, including the physician orders into the system. He/She said the nurse ensured the orders were accurate, but not sure if there was an audit in place. Further, he/she said the catheter orders included, size, toleration and how much is in the bowl, and how tolerated. He/She said there was another order when to change the bag, an order of how many times to flush and another order to direct catheter care every shift. 9. Review of the facility's Advanced Directives policy, undated, showed: -The facility will respect advanced directives in accordance with state law; -Upon admission to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive; -Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record under the advanced directives tab; 10. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's face sheet, undated, showed staff documented the resident was a Do Not Resuscitate (DNR), which indicated the resident did not want Cardio Pulmonary Resuscitation (CPR) performed if their heart stopped beating or they stopped breathing, code status. Review of the resident's POS, dated [DATE], showed the orders did not contain a code status for the resident. 11. Review of resident #55's Quarterly MDS, dated [DATE], showed facility staff assessed the resident with mild cognitive impairment. Review of the resident's plan of care, last reviewed [DATE], showed staff documented the resident was a DNR, indicated the resident would not want CPR performed if their heart stopped beating or they stopped breathing, code status. Review of the resident's POS, dated [DATE], showed they did not contain an order for the resident's code status. 12. During an interview on [DATE] at 12:48 P.M., the Director of Nursing said he/she expects there to be a physician's order for advanced directives. He/she said the nurses, the director of nursing, and the administrator are responsible for obtaining orders for advanced directives. During an interview on [DATE], at 01:20 P.M., CMT B said the admission pack has a sheet for code status the resident signs and the front office processes. He/She was unaware if a resident needed an order for a code status. During an interview on [DATE], at 02:15 P.M., LPN H said residents should have an order for their code status. He/She said this is taken care of upon admission and he/she does not know who is responsible for making sure it's put in the system. During an interview on [DATE] at 1:04 P.M., the Administrator said there should be a physician order for advanced directives status obtained upon admission. During an interview on [DATE] at 2:29 P.M., LPN C said a physician's order is required for advanced directives. 13. Review of the facility's Care of a Resident Receiving Dialysis Policy, undated, showed: - The dialysis communication record will be sent with the resident on each dialysis visit; - All care concerns in the last 24 hours will be addressed, including last medications given and facility contact person; - The dialysis unit will complete the lower portion of the report to include weight prior to and after dialysis, any labs completed, medication given, follow up information and any new physician orders; - The lower portion will be signed by the dialysis nurse and returned to the facility; - These records will be maintained in the medical record. 14. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed resident as: - Cognitively intact; - Diagnosis of acute kidney failure, end stage renal disease, and Hypertension (elevated blood pressure); - Received hemodialysis (a process of purifying the blood of a person who's kidneys are not working normally). Review of the resident's care plan, last reviewed [DATE], showed the resident received hemodialysis three time weekly (Monday, Wednesday, and Friday) and received a diuretic medication related to his/her diagnosis of hypertension. Interventions included: Monitor lab work as ordered, assess for signs of fluid and electrolyte disturbances. 15. During an interview on [DATE] at 12:48 P.M., the Director of Nursing said the facility does not have a formal communication tool between the facility and the dialysis center. He/she said they just communicate via phone as needed when there are changes in care. During an interview on [DATE] at 1:04 P.M., the Administrator said facility staff send the Dialysis Patient Communication form and POS with the resident to the dialysis clinic. He/She said the form included the resident's vital signs, medical problems, last meals, labs, and weights. He/She said the clinic does not send any paperwork back. He/She said the DON was responsible to ensure the dialysis clinic is returning paperwork, but the only thing the clinic would send back is lab results if requested. He/She said he/she is not sure if there is a log of communication. During an interview on [DATE], at 1:20 P.M., CMT B said he/she is not sure what paper work should be sent with a dialysis patient, has not sent any paper work out with a dialysis patient, and isn't aware of any paperwork or communication log which should be sent. He/She said the charge nurse would send paper work with the resident and if there was a change, the dialysis center would send paperwork back with the residents. He/She said the charge nurse would be responsible and would know where this paperwork was located. During an interview on [DATE], at 02:15 P.M., LPN H said he/she communicates with the dialysis center over the phone and does not send paperwork out with the resident. He/She said the dialysis doctor will call and verbally make changes when indicated. He/She said every now and then the dialysis center will send lab work back, but there is not any routine paperwork or communication log sent back and forth. He/She said the nurse would be responsible for making a progress note for any changes made by the dialysis doctor and the social services staff is responsible for scanning it into the residents Electronic Health Record (EHR). He/She said any hard copies could be found at the nurses station. During an interview on [DATE] at 2:29 P.M., LPN C said the dialysis clinic paperwork sent is the face sheet and a dialysis communication form, includes vital signs and other information. He/She said he/she does not believe the clinic sends anything back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure six residents (Residents #12, #27, #29, #41, #40, and #36), who were unable to complete their own activities of daily living (ADLs), received the necessary care and services to maintain good personal hygiene. The facility census was 56. 1. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/16/22, showed staff assessed resident as: - Severely cognitively impaired; - Active diagnoses of Downs Syndrome, Muscle weakness, visual loss, history of falling, and need for assistance with personal care; - Required limited two person physical assistance for personal hygiene; Review of the resident's care plan, reviewed 02/22/22, showed an (ADL's deficit related to Down's Syndrome. Interventions directed staff to assist with ADL's per his/her needs. Observation on 05/16/22, at 8:20 A.M., showed the resident in the common area, his/her nails were jagged and contained debris. Observation on 05/16/22, at 12:21 P.M., showed the resident in the dining room, his/her nails were jagged and contained debris. Observation on 05/17/22, at 1:36 P.M., showed the resident laid in bed, his/her nails were jagged and contained debris. Observation on 05/18/22, at 5:50 A.M., showed the resident sat in his/her wheelchair, his/her nails were jagged and contained debris. 2. Review of Resident #27's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: - Severe cognitive impairment; - Required total dependence with one person assistance with personal hygiene. Review of the resident's care plan, dated 9/8/21, showed the resident's needs will be provided by staff. Observations on 5/15/22 at 3:53 A.M., showed the resident's toenails were long with jagged edges. Observations on 05/18/22 at 6:33 A.M., showed NA G removed the resident's socks and his/her toe nails were long with jagged edges. During an interview on 5/18/22 at 6:33 A.M., NA G said the shower aides are responsible for trimming the toe nails during showers. He/She said he/she was not sure of the shower schedule. He/She said staff are assigned halls to check nails and facial hair daily and are to shave or trim nails when needed. He/She said it has not been done, since there was not enough staff until recently. 3. Review of Resident #29's Annual MDS, dated [DATE], showed staff assessed resident as: - Severely cognitively impaired; - Active diagnosis of Alzheimer's, dementia, and osteoarthritis; -Required limited two person physical assistance for personal hygiene. Review of the resident's care plan, undated, showed he/she had an ADL self-care performance deficit due to Alzheimer's and dementia. Interventions directed staff to assist with ADL's per his/her needs. Observation on 05/15/22, at 2:40 P.M., showed the resident laid in bed, his/her nails appeared long and contained debris. Observation on 05/16/22, at 8:17 A.M., showed the resident in the common area, his/her nails appeared long and contained debris. Observation on 05/16/22, 11:52 A.M., showed the resident in the dining room, his/her nails appeared long and contained debris. Observation on 05/16/22, 1:54 P.M., showed the resident laid in bed with his/her eyes closed, his/her nails appeared long and contained debris. Observation on 05/16/22, at 3:00 P.M., showed the resident laid in bed with his/her eyes closed, his/her nails appeared long and contained debris. Observation on 05/17/22, 9:00 A.M., showed the resident in the common area, his/her nails appeared long and contained debris. 4. Review of Resident #40, Annual MDS, dated [DATE], showed staff assessed the resident as follows: - Severe cognitive impairment; - Required extensive one person assistance with personal hygiene; Review of the resident's care plan, dated 4/2/21, showed it did not contain direction for staff in regards to the resident's facial hair preference. Further review showed, staff will assist the resident with his/her ADL's per his/her needs. Observations on 5/15/22 at 2:30 P.M., showed the resident had long hairs on his/her upper lip and chin. Observations on 5/16/22 at 8:12 A.M., showed the resident had long facial hairs on his/her upper lip and chin. Observations on 5/17/22 at 8:02 A.M., showed the resident had long hairs on his/her upper lip and chin. Observations on 5/18/22 at 11:27 A.M., showed the resident had long hairs on his/her upper lip and chin. 5. Review of Resident #41, Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: - Severe cognitive impairment; - Required limited one person assistance with personal hygiene. Review of the care plan, dated 7/2/2021, showed staff were to assist with ADL's per his/her needs. Observations on 5/16/22 at 9:29 A.M., showed the resident's toe nails were long, yellow and jagged. Observations on 5/18/22 at 6:36 A.M., showed CNA A removed the resident's socks and his/her toe nails were long, jagged and yellow. During an interview on 5/18/22 at 6:36 A.M., CNA A said the toe nails and facial hair are checked daily by the aides and the resident are shaved or nails trimmed if needed. He/She said the shower aides are responsible for cutting nails and shaving facial hair on shower days. 6. Review of Resident #36, Annual MDS, dated [DATE], showed staff assessed the resident as follows: - Severe cognitive impairment; - Required supervision with person assistance for personal hygiene. Review of the care plan, dated 3/24/2021, showed staff are to assist the resident with his/her ADL's and transfers. Observations on 5/16/22 at 3:11 P.M., showed the resident had long fingernails. Observations on 5/18/22 at 12:04 P.M., showed the resident had long fingernails. 7. During an interview on 5/18/22 at 12:48 P.M., the Director of Nursing said he/she expects CNA's to shave men daily and women at least weekly. Nail care should be performed at least weekly by the CNA's unless the resident is diabetic, then it is the responsibility of the nurse. During an interview on 518/22 at 1:04 P.M., the Administrator said resident's nails and facial hair are checked daily and on shower days. He/She said the the shower sheets specifically included the residents care that needed be done, including facial hair shaving and nail care. He/She said the DON and wound care nurse review the shower sheets to see if any concerns with skin. He/She said he/she was aware there are residents with facial hair. The CNA's are responsible for shaving and providing nail care when needed. During an interview on 05/18/22, at 1:20 P.M., CMT B said staff are supposed to check resident's nails everyday. The nurse checks and trims the nails of diabetics residents. All residents are to be shaved when they have stubble and any direct care staff who notices is responsible for providing the care. He/She said he/she would expect to see a resident's facial hair preference to be on their care plan. He/She said the charge nurse will help remind staff to check resident's nails and facial hair. During an interview on 05/18/22, at 02:15 P.M., LPN H said resident's nails and facial hair should be checked daily. He/She said staff should check them every morning because of not knowing what could be under a resident's nails. He/She said when a resident has a shower, their nails are checked and nurses are responsible for trimming the nails of diabetic residents. He/She said any staff can shave a resident, but it is the responsibility of the aides. He/She said it would be expected to see a resident's facial hair preference in their care plan. During an interview on 5/18/22 at 2:29 P.M. LPN C said the aides shaved the residents facial hair and trimmed the residents nails twice a week on shower days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when they failed to properly propel five residents (Resident's #40, #2, #32, #44 and #45) in wheelchairs in a manner to prevent accidents. The facility census was 56. Review of the facility's Wheelchair, Use Of policy, undated, showed the purpose is to provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living. Assist resident to the area of the facility desired. Encourage and instruct resident in proper guidelines for safely propelling the wheelchair. 1. Review of Resident #40's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/3/22, showed staff assessed the resident as follows: - Severe cognitive impairment; - Required extensive two person assistance with bed mobility and transfers; - Required extensive one person assistance with dressing, toileting and personal hygiene; - Uses a wheelchair for mobility. Observation on 5/16/22 at 12:49 P.M., showed Nurse Aide (NA) E propelled the resident from the dining room without the use of foot pedals. 2. Review of Resident #2, Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: - Moderate cognitive impairment; - Required extensive two person assistance with bed mobility, transfers, - Required limited one person assistance with dressing; - Required limited two person assistance with toileting and personal hygiene; -Uses a wheelchair for mobility. Observation on 5/16/22 at 8:18 A.M., showed NA E propelled the resident from the dining room without the use of foot pedals. Observation on 5/16/22 at 12:35 P.M., showed shower aide D propelled the resident from the dining room without the use of foot pedals. Observation on 05/16/22 at 3:01 P.M., showed NA J propelled the resident from his/her room, to shower room [ROOM NUMBER], without the use of foot pedals. Observation on 5/17/22 at 8:13 A.M., showed Certified Medical Technician (CMT) F propelled the resident from the dining room without the use of foot pedals. Observation on 05/18/22, at 5:35 A.M., showed NA I propelled the resident from his/her room, to the nurses station, without the use of foot pedals. 3. Review of Resident #32, Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: - Required supervision with one person assistance with transfer; -Required limited one person assistance with dressing, toileting and personal hygiene; -Uses a wheelchair for mobility. Observation on 5/16/22 at 11:34 A.M., showed NA E propelled the resident down the hall towards the dining room without the use of foot pedals. 4. Review of Resident #44, Annual MDS, dated [DATE], showed staff assessed the resident as follows: - Moderate cognitive impairment; - Required one person assistance with bed mobility; - Required limited one person assistance with transfers, dressing, toileting and personal hygiene; - Uses a wheelchair for mobility. Observations on 5/18/22 at 11:58 A.M., showed shower aide D propelled the resident down the hall towards the dining room without the use of foot pedals. 5. Review of Resident #45, Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: - Cognitively intact; - Required extensive two person physical assistance with bed mobility, transfers, dressing, toileting, and personal hygiene; - Used a wheelchair for mobility with one person assistance on/off the unit. Observation on 05/16/22, at 08:13 A.M., showed NA E propelled the resident from the 200 hall nurse's station to his room without the use of foot pedals. Observation on 05/16/22, at 08:15 A.M., showed NA E propelled the resident from his/her room, towards the dining room, without the use of foot pedals. Observation on 05/18/22, at 07:29 A.M., showed NA G propelled the resident form his/her room, to the dining room, without the use of foot pedals. (05/16/22 11:50 AM Staff pushed resident, without foot pedals from room to dining room) 6. During an interview on 5/18/22 at 11:32 A.M., CNA A said staff were required to use foot pedals when propelling a resident. He/She said staff were directed to report to the nursing staff any time a resident refused the use of foot pedals. During an interview on 5/18/22 at 11:50 A.M., CNA/CMT B, said staff are required to use foot pedals when propelling a resident in a wheelchair. He/She said there was an in-service regarding foot pedals, but can't recall the date. He/She said he/she would not push a resident without foot pedals because the resident could fall out of the chair and cause bodily injury. During an interview on 5/18/22 at 12:48 P.M., the Director of Nursing said any resident who needs pushed in wheelchairs should have his/her feet on foot pedals and not pushed unless those pedals are in place. In addition, he/she said that if a resident is able to propel themselves, a pedal bag is on the back of their wheelchair in case the need arises for staff to propel and has the pedals handy. During an interview on 5/18/22 at 1:04 P.M., the Administrator said the staff should always use foot pedals when propelling a resident. He/She said there should be a bag containing foot pedals placed on the back of the wheelchair. He/She said he/she witnessed a couple of staff propelling residents without pedals and completed an in-service with those staff members. He/She said staff received training during orientation on the correct procedure when propelling a resident in a wheelchair. He/She said he/she did not feel the residents were able to keep their feet up on long distances because they would get tired. During an interview on 05/18/22, at 01:20 P.M., CMT B said residents should not be propelled without using foot pedals. He/She said resident's are not to be pulled backwards in their wheelchairs. He/She said residents who can lift their feet and are cognitive still should not be pushed without foot pedals. During an interview on 05/18/22, at 02:15 P.M., Licensed Practical Nurse (LPN) H said residents are not to be propelled without foot pedals. He/She said not all residents are able to lift their feet to be pushed. During an interview on 5/18/22 at 2:29 P.M., LPN C said residents have to be upright position in the wheelchair. He/She said staff are directed to use foot pedals and only go in a forward direction when propelling a resident in a wheelchair. He/She said residents are not able to keep their feet up without the use of foot pedals.

Based on observation, interview, and record review, the facility staff failed to maintain the correct serving temperatures of 120 degrees (°) Fahrenheit (F) or higher for hot foods when it arrives to the resident on meal tray items served in resident rooms during meal services for one resident (Resident #34 ) with the potential to affect all residents who receive room trays. The facility census was 56. 1. Review of the facility's Food Temperatures Policy, dated April 2011, directed staff as follows: - Keep the temperature of hot food no less than 135°F during tray assembly; - Hot food should be at least 120°F when served to the resident. Review of the facility's food temperature log, dated 05/18/22, showed the breakfast temperatures as: - Meat= cooked 170°F , steam table 169°F; - Egg= cooked 173°F , steam table 170°F; - Hot Cereal= cooked 179°F , steam table 173°F. Review of the facility's food temperature log, dated 05/18/22, showed the lunch temperatures as: - Meat= cooked 177°F , steam table 170°F; - Vegetable= 171°F , steam table 169°F. 2. Observation on 05/18/22, at 7:50 A.M., showed Resident #34 received his/her room tray which contained biscuits, gravy, and a sausage patty. The plate was uncovered and sat on the resident's bedside table. The food temperatures measured as follows: - Biscuits 112°F - Gravy: 112°F - Sausage patty: 89°F. Observation on 05/18/22, at 12:15 P.M., showed Resident #34 received his/her room tray which contained a piece of bread and spaghetti with meat sauce. The plate was uncovered on the resident ' s beside table. The temperature of the spaghetti with meat sauce measured 120°F. During an interview on 05/18/22, at 12:15 P.M., the resident said his/her breakfast was barely warm, and the lunch was warm and he/she would have expected it to be warmer being served to him/her. He/She has told LPN H, but It has been a while ago. He/She has also told direct care staff and they've not done anything about it. He/She said he/she does not ask staff to warm his/her meal up because he/she feels like it's just better to eat the food as is, rather than prolonging him/her getting to eat due to waiting for the staff. During an interview on 05/18/22, at 01:20 P.M., Certified Medication Technician B said if a resident says their food is cold, he/she would take their plate back to the kitchen to get a fresh plate or would have them warm it up. He/She said if staff does reheat a resident's plate, it's warmed up in the area for resident's to heat their personal food and it should be heated to 160°F. He/She did not know how long the food should be reheated to that temperature. During an interview on 05/18/22, at 02:15 P.M., Licensed Practical Nurse (LPN) H said he/she would expect staff to warm the resident's food up or get them a new tray. He/She said food should be reheated to 160°F. He/She did not know how long the food should be reheated to that temperature. He/She said there's a sign and thermometer in the designated area where residents can heat their own personal foods as well. During an interview on 05/18/22, at 02:54 P.M., Dietary Manager (DM) said he/she is not aware of residents having cold food delivered to their rooms and the nursing staff should communicate back to him/her or kitchen staff. He/She said staff would verbally tell him/her if a resident had cold food and would make the resident a new plate or give an alternative meal. He/She said there's a sign hanging up in the area residents can use to heat personal foods. He/She would expect staff to heat to 165 for 15 seconds if reheating food for a resident. He/She said he/she expects staff to use the provided thermometer and refer to range. He/She said he/she would expect to hear about residents having consistently cold food. He/She said test trays are done weekly and only five rooms trays are served at one time. He/She said hot plates and lids are used to cover and keep the food warm. He/She said he/she would expect staff to serve straight from the steam table and deliver to the residents room. MO00200453

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, when staff failed to remove their gloves and/or perform hand hygiene during treatments for three (Resident #55, #34 and #39) Additionally, staff failed to perform hand hygiene, or change their gloves during incontinence care and provide appropriate incontinence care for three residents (Resident #41, #24, and #40). The facility census was 56. 1. Review of the facility's Handwashing policy, undated, showed the purpose is to reduce transmission of organisms from resident to resident, nursing staff to resident, and resident to nursing staff. The policy did not contain direction for staff in regards to when they should wash or sanitize their hands. Review of the facility's Gloves policy, undated, showed: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, and any moist body substances and/or persons with a rash; -Gloves must be changed between residents and between contact(s) with different body sites of the same resident; -Change gloves between contact with different residents or with different body sites of the same resident. -The policy did not contain direction for staff in regards to hand hygiene or when they should remove or change their gloves. 2. Review of the facility's Wound Care and Treatment policy, undated, showed: -Care must be taken to prevent contamination of the supplies and surfaces used in wound care; -Set up supplies on a clean surface at the bedside. Cover the surface with a clean, impervious barrier before putting the supplies down; -Handwashing must be done as outlined in the guidelines; -Put on gloves; -Remove soiled dressing and place in trash bag; -Remove gloves and discard in the trash; -Wash your hands and put on clean gloves; -Clean the wound according to the order; -Place soiled gauze in trash bag; -Remove gloves, place in trash bag, and put on a clean pair of gloves; -Apply clean dressing, position resident, and wash your hands. 3. Review of Resident #55's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 4/30/22, showed facility staff assessed the resident as: -Mild cognitive impairment; -Received pressure ulcer care; -Had one pressure injury present on admission. Observation on 5/16/22 at 9:52 A.M., showed Licensed Practical Nurse (LPN) I cleanse the resident's wound, remove his/her gloves, and reapply clean gloves. He/She did not perform hand hygiene. LPN I, then applied a clean dressing to the resident's wound. During an interview on 5/16/22 at 9:52 A.M., LPN I said he/she should have washed his/her hands between glove changes, but he/she didn't think about it. 4. Review of Resident #39's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Received pressure ulcer care; -Had two pressure injuries present on admission; -Diagnoses of pressure ulcer of buttocks. Observation on 5/17/22 at 12:50 P.M., showed LPN C place treatment supplies on the the resident's nightstand without a barrier. LPN C cleansed the resident's wound, and with the same gloves on, applied a clean dressing. During an interview on 5/17/22 at 12:50 P.M., LPN C said it makes sense to wash his/her hands between cleaning a wound and applying a new dressing, but he/she just didn't do it. 5. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of Neuromuscular dysfunction of bladder (lack of control to the bladder due to brain, spinal, or nerve problems); - Had a suprapubic (surgically created connection between the bladder and the skin used to drain urine from the bladder), indwelling urinary catheter; -Received care to catheter site. Observation on 5/16/22 at 2:20 P.M., showed LPN C placed treatment supplies on the bedside table without a barrier. LPN C cleansed the resident's catheter site and with the same gloves on, he/she applied a clean dressing. 6. Review of the facility's Hand Cleanser (Antiseptic) policy, undated, showed staff are to cleanse their hands between resident contacts during care and to prevent the spread of infection. Review showed staff are to wash and dry hands thoroughly in preparation for resident care. 7. Review of the facility's Perineal Care policy, undated, showed: -The purpose is to cleanse the perineum and prevent infection and odor; --For female perineal care: -Apply disposable gloves; -Wash from front to back. --For male perineal care: -Apply disposable gloves; -Wash from front to back; -Remove gloves and wash hands. 8. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required limited one person assistance with bed mobility, dressing, toileting, and personal hygiene; -Required extensive two person assistance with transfers. Observation on 5/16/22 at 9:29 A.M., showed Nurse Aide (NA) E and NA G enter the resident's room to provide care. NA E provided incontinence care, then touched the resident's clean brief, pulled up his/her pants, and put on the resident's slippers with the same gloves on. NA G then picked up the contaminated trash bag, touched the resident's wheelchair and made the bed with the same gloves on. NA E and NA G did not perform hand hygiene. During an interview on 5/16/22 at 9:43 A.M., NA E said staff are directed to change their gloves and use hand hygiene before and after providing perineal care and when they enter and exit a room. NA E said he/she realized he/she did not use hand hygiene after he/she provided perineal care and before he/she touched things. He/She forgot. During an interview on 5/16/22 at 9:46 A.M., NA G said he/she should have removed his/her gloves and performed hand hygiene after he/she touched the dirty trash bag and before he/she touched the resident's wheelchair and bedding. 9. Review of Resident #24's Annual Minimum Data Set (MDS), dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required extensive one person physical assistance for personal hygiene; -Required limited one person assistance for dressing, toileting, bed mobility, and transfers. Observation on 5/16/22 at 1:57 P.M., showed NA E and NA G enter the resident's room to provide incontinence care. NA G wiped the resident multiple times, with the same wipe, and same sides of the wipe. NA E and NA G removed their gloves. They did not perform hand hygiene. NA G then sat soiled bed linens on the resident's bed atop clean linens, and applied barrier cream to the resident with the same gloves on. NA E removed his/her gloves, did not perform hand hygiene, and applied a clean pillow case to the resident's pillow. NA E then gathered the trash, and with the same gloves on, he/she covered the resident with the blanket, and moved the soiled linens to the dirty linen bag. 10. Review of Resident #40's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive two person assistance with bed mobility and transfers; -Required extensive one person assistance with dressing, toileting and personal hygiene; -Uses a wheelchair for mobility. Observation on 5/16/22 at 3:03 P.M., showed Nurse Aide NA K and NA L enter the resident's room to provide care. NA K did not wash his/her hands before he/she applied gloves. NA L and NA K wiped the resident multiple times with a single wipe. NA K, with the same gloves on, applied a clean brief to the resident. Additional observation showed NA K and NA L adjusted the resident's clothes with the same gloves on. During an interview on 5/18/22 at 11:32 A.M., Certified Nurse Aide (CNA) A said staff are directed to wipe once in a downward direction, fold the wipe, wipe again, and then dispose of the wipe. During an interview on 5/18/22 at 11:50 A.M., CNA/Certified Medication Technician (CMT) B said staff are directed to wipe from front to back, fold the wipe, wipe with the clean portion, and then throw it away. Staff are not to use the same portion of the wipe more than once. 11. During an interview on 5/18/22 at 2:15 P.M., LPN H said staff are expected to wash their hands before and after they provide wound care and he/she expects staff to sanitize their hands between glove changes. Staff are expected to perform hand hygiene after they have removed a soiled dressing, and before they apply a clean one. Staff are expected to wash their hands before and after they provide perineal care and he/she expects them to sanitize their hands between glove changes. He/She said wipes should only be used once, and staff should wipe from to back. During an interview on 5/18/22 at 2:29 P.M., LPN C said staff are to perform hand hygiene when they enter or exit a residents room, after they change their gloves, and anytime they come in contact with any bodily fluid. Staff are to perform hand hygiene and apply new gloves before they remove a wound dressing, and before they apply a new dressing. LPN C said during perineal care staff are directed to perform hand hygiene and apply gloves, cleanse the residents front, remove their gloves, perform hand hygiene, and then cleanse the residents buttocks. Staff are directed remove their gloves and perform hand hygiene when they are done. He/She said staff are directed to wipe front to back. During an interview on 5/18/22 at 12:48 P.M., the Director of Nursing (DON) said he/she expects staff to wash their hands at a minimum between cleaning a wound and applying a new dressing. He/She expects staff to perform hand hygiene when they enter a room, and before they leave a room. He/She said staff should also perform hand hygiene when they remove their gloves, and before they apply a clean pair. He/She would expect staff to change their gloves during perineal care from dirty to clean areas. He/She said if staff use disposable wipes he/she expects them to wipe the resident one time with the wipe, dispose of the soiled wipe, and obtain a new wipe before they continue. During an interview on 5/18/22 at 1:04 PM., the Administrator said staff are directed to wash their hands and apply gloves before and after they perform wound care and/or perineal care, and before they move to another task. He/She said staff are to perform hand hygiene and change their gloves after they remove a soiled dressing, and before they apply a clean one. He/She said staff are to perform hand hygiene and change their gloves anytime they move from a dirty area to a clean area, and should wash their hands before and after glove application and removal. He/She said that would include before they touched a clean brief. He/She said staff are expected to use a single wipe one time, and wipe in a downward direction. He/She said staff are not to use the same wipe more than once.