Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1), in a review of three sampled residents, did not leave the facility without staff knowledge. Further review showed the facility had not addressed the resident's history of exit seeking and had not ensured effective interventions were put in place that all staff were aware of both before and after the resident's elopement. The census was 51. Review of the facility policy, Elopement Prevention and Response Policy, dated 04/07/25, showed the following: -The facility is committed to ensuring resident safety through vigilant prevention, monitoring and timely intervention related to elopement and exit-seeking behaviors. Elopement is defined by Center for Medicare Services as a resident leaving the premises or a safe area without authorization and/or necessary supervision, placing themselves at risk. Our policy treats all observed exit-seeking behavior as a near-miss and responds with immediate action, documentation, and systemic review; -Elopement is defined as a resident leaving the premises or a safe area without authorization and/or necessary supervision or within line of site; -Near-Miss: Any exit-seeking behavior where the resident does not leave the safe area due to timely staff intervention; -All staff will monitor for residents with known cognitive impairment, dementia, or exit-seeking behavior; -Residents identified as high-risk for elopement will have care plans reviewed and updated if deemed appropriate due to change; -All staff are responsible for maintaining secured doors and ensuring supervision in high-traffic and visitor areas; -If a resident attempts to leave the building, staff must: -a. Immediately intervene and redirect the resident; -b. Notify the charge nurse and the Director of Nursing (DON); -c. Assess the resident for injury or distress; -d. Document the incident in the Electronic Medical Record (EMR); -e. Notify the resident's responsible party or family; -f. Treat the event as a near miss, unless the resident exits the safe area un-detected; -The administrator and or DON will perform a review of any incident or near-miss; -The incident will be reviewed by QAPI and followed up with an audit, in-service and care plan adjustment if applicable. Review of the undated facility policy, Wandering/Elopement, showed the following: -It is our standard that the safety and well being of all residents with a potential for wandering is ensured at all times; -Wandering will be assessed on admission and a wander guard will be placed on the resident per wanderguard policy. A wander guard will be placed on the resident and the placement of this wanderguard will be checked every shift and as needed. The nursing staff will initial on the medication administration record that the wanderguard is intact and placement checked shiftly; -If a confused resident, unable to determine boundaries of facility and oblivious of physical and safety needs, is seen leaving the building exit doors, the resident should be redirected and charted as an attempt to exit the facility and alert the interdisciplinary team; -If a confused resident, unable to determine boundaries of facility and oblivious of physical and safety needs is outside alone, still on facility property, chart as attempt to elope. 1. Observation on 04/24/25 at 8:30 A.M. and 10:00 A.M., showed when exiting the front entrance doors of the facility, there was a sloped incline to the paved facility parking lot. The front entrance doors of the facility were sliding glass doors which opened automatically when a person stepped in front of the doors. Upon entering the facility, there was an open office/foyer area and then a set of two double doors which led from this area to the facility dining room. 2. Review of Resident #1's admission risk assessment, dated 11/21/24, showed the following: -No history of elopement; -Self propels in wheelchair; -Change in the resident's living arrangement within the last 30 days; -Cognitively impaired with poor decision making skills; -Visual and auditory deficits; -Indications of dementia or delirium or diagnosis; -Score of zero for elopement risk (not at risk for elopement). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by the facility and dated 03/12/25, showed the following: -Moderately impaired cognition; -Highly impaired hearing; -Moderate vision impairment/wore glasses; -Substantial to maximum assist for transfers; -Set up/ manual wheelchair for locomotion; -No wandering. Review of the resident's Physician Order Sheet (POS), dated April 2025 showed his/her diagnoses included dementia (group of thinking and social symptoms which interfere with daily functioning) with mood disturbance, depression and anxiety. There was no order for a wanderguard (a device that is integrated with a security system to alert caregivers when residents have wandered past a protected area), . Review of the resident's progress notes showed facility staff documented the following: -On 04/11/25 at 9:05 P.M., resident out and about halls via wheelchair, had been sitting in the front lobby and brought back to TV area; -On 04/12/25 at 1:47 P.M., resident followed family member out of the front door, resident redirected to his/her room, family notified; -On 04/18/25 at 3:45 A.M., resident attempted to enter locked unit; thinks his/her room was down that hall. Resident upset he/she cannot go down that hall; -On 04/22/25 at 1:39 A.M., resident wandered about halls earlier in the evening looking lost, not sure what he/she wanted or was looking for, assisted back to room. Review of the resident's care plan on 04/24/25 at 9:30 A.M., showed the care plan did not address the resident's behaviors of wandering, following the family to the door or exit seeking. Review of the resident's medical record showed no documentation of the following: -The care plan had not been updated or an adjustment made, after the 04/12/25 incident, as the facility policy directed; -The care plan had not been updated with the 04/12/25 incident; -The care plan had not been updated with the addition of the wanderguard; -There was no additional elopement risk assessment completed after the incident of 04/12/25. During an interview on 04/24/25 11:10 A.M., Family Member I said the resident attempts to follow them out of the facility (when they leave) after a visit. During an interview on 04/24/25 at 11:47 A.M., Family Member J said the following: -He/She had visited the resident around 11:00 A.M. on 04/12/25 and sat with him/her while he/she ate lunch; -After lunch, he/she and the resident went back to the resident's room where he/she visited a bit longer; -When he/she left, the resident was not following him/her. When the resident tried to follow him/her in the past, he/she would let staff know so they could watch the resident; -He/She was notified via text from Family Member I) that the resident had gotten outside and one of the nursing staff had gone outside and found the resident. During an interview on 04/24/25 at 2:15 P.M., Certified Nurse Aide (CNA) E said the following: -He/She only worked part time, (day shift/weekends) and had worked on 04/12/25; -He/She had reported to Registered Nurse (RN) A he/she had to go to his/her car located outside of the facility; -When he/she was in his/her car, he/she looked up and saw the resident at the front entrance door; -He/She looked down and then back up again and the resident was out of the door, in his/her wheelchair, rolling down the sloped area of the pavement in the parking lot; -He/She ran up and grabbed the resident; -The resident said, I am going home. They are waiting on me.; -He/She assisted the resident back into the facility. There were no staff waiting at the facility front door. He/She pushed the resident to the nurse's desk and reported the incident to Registered Nurse (RN) A. During an interview on 04/24/25 at 1:15 P.M., Registered Nurse (RN) A said the following: -He/She worked day shift on 04/12/25; -On 04/12/25, he/she had observed the resident around 12:30 to 1:00 P.M. in the dining room with his/her family visiting; -The resident followed the family member out the front door into the parking lot when the family member left, sometime after lunch (around 1:00 or 1:30 P.M.); -He/She and a CNA were right behind the resident and the CNA (could not recall who this was) stood at the door as CNA E (who had gone to his/her car about the same time) brought the resident back into the building; -He/She had not seen the resident go out of the building; -The unidentified CNA did not have to go outside as CNA E brought the resident back inside; -He/She notified the DON and the resident's family member; -He/She documented the resident followed his/her family out of the front door in the progress notes, but did not create an event in the progress notes as he/she did not consider the incident an actual elopement; -He/She conducted a quick inservice at the desk with staff on duty at the time, explaining what would have needed to be done if it were an actual elopement; -He/She thought the resident had a wanderguard on his/her wheelchair after the incident; -The care plan should probably say something about the resident attempting to follow family out of the building. During an interview on 04/24/25 at 9:27 A.M., CNA H said the following: -He/She worked day shift 7:00 A.M. to 3:00 P.M.; -He/She knew of one resident who wandered but was easily redirected; this resident was not identified as Resident #1; -He/She was not aware of any resident who had eloped recently and had not attended any inservices specific to elopement. During an interview on 04/24/25 at 9:35 A.M., CNA B said the following: -He/She worked day shift 7:00 A.M. to 3:00 P.M.; -He/She worked with CNA E a couple of weeks ago on a Saturday. CNA E told him/her that he/she was in the parking lot when Resident #1 followed his/her family member out of the front door and into the parking lot. The family member brought the resident back into the building; -Staff are to be with the resident when his/her family leave the building. During an interview on 05/09/25 at 11:44 A.M. the Social Services Director (SSD) said the following: -The resident would sit up front (in the foyer area) every once in a while; -He was aware of the resident watching his/her family leave at times; -He had been instructed to redirect the resident back to his/her room, the nurse's station, or maybe to activities if the resident tried to follow family when they left. During an interview on 05/09/25 at 11:37 A.M., the Care Plan Coordinator said the following: -She was responsible for care plans, including updating, but any licensed nurse could update them; -Staff will notify him/her with issues they feel need to be included on the care plan; -She was informed of the resident's elopement by a charge nurse after the incident; -The resident's care plan should have been updated when the incident occurred. During an interview on 04/24/25 at 9:38 A.M., Licensed Practical Nurse (LPN) C said the following: -He/She worked day shift 7:00 A.M. to 3:00 P.M.; -He/She was not aware of any resident getting out of the building: -He/She knew that Resident #1 liked to sit up front and socialize with others and staff had to re-direct him/her when family left as the resident wanted to leave with them; -There was no elopement binder for residents at risk for elopement; -If residents were deemed an elopement risk, they were placed on the secure unit; -Elopement assessments were completed by him/herself or any nurse. Some are completed monthly and some quarterly; -If a resident did elope, it should be documented in the progress notes and an incident report would be created under events in the electronic record; -He/She was unsure if there were any residents with wanderguards, but there may be one resident on the A hall that had one (not identified as Resident #1). A wanderguard would be placed on a resident's equipment and not on the resident. During an interview on 04/24/25 at 4:00 P.M. the central supply supervisor said the following: -He/She was responsible for handing out the wanderguard devices; -He/She recalled receiving a call on 04/12/25 from staff (he/she believed RN A), requesting a wanderguard alarm for a resident. He/She told them where to retrieve the alarm and to check to ensure it worked by passing it through the door, prior to placement. Review of the resident's Treatment Administration Record dated April 2025 showed staff should check placement of the wanderguard every shift (7:00 A.M.-7:00 P.M. and 7:00 P.M. to 7:00 A.M.), date initiated 4/28/25. Review of the resident's medical record showed no documentation staff placed a wanderguard or that it was checked to ensure it worked by passing it through the door prior to, or after, placement. During an interview on 04/24/25 at 3:50 P.M. the Administrator and Director of Nurses (DON) said the following: -They thought the resident had a wanderguard alarm on his/her wheelchair; -They did not know who placed the alarm or when it was placed; -There was no documentation of staff placing the alarm, when it was placed or who placed it. During an interview on 4/24/25 at 1:50 P.M. and 5/13/25 at 3:34 P.M , the DON said the following: -RN A notified her the resident had followed his/her family member out of the building on 04/12/24. She was told that CNA E, who was returning from lunch and in the parking lot, brought the resident back inside; -The resident liked to watch family leave after they visited. The front office personal (the Receptionist and SSD) usually monitored the resident, but since the incident happened on a weekend, there was no receptionist or SSD in the area at that time; -She did not know if the resident had a wanderguard alarm; -The front doors were alarmed for residents who have a wanderguard device; -Documentation of monitoring of a wanderguard should begin with the placement of the device; -She did not know if the care plan had been updated but would have expected it to be updated; -She was not sure of inservicing completed, but the facility has stand up meetings daily at 9:30 A.M., 3:30 P.M. and 11:30 P.M., and she believed the Administrator had mentioned the incident in stand up meetings; -She had not performed a review of the incident or near-miss as the policy instructed. Observation on 04/24/25 at 3:55 P.M. showed the following: -The Administrator pushed the resident's empty wheelchair to the front entrance doors; -A wanderguard alarm hung from the underside of the chair and an alarm detector hung from the left, lower wall just inside the front entrance doorway; -The administrator pushed the wheelchair near and then through the front door exiting the building and then back inside. The alarm did not activate; -The Administrator turned the chair sideways in the doorway, pointed the front of it directly at the detector on the wall at which time the alarm did activate; -The Administrator repeated the act again, pushing the chair through and out the front door. The alarm on the chair did not activate when the chair went through the doorway; -Staff moved the alarm to the arm rest of the chair (and on the third attempt), the alarm activated when the chair was pushed through the door way. During an interview on 4/24/25 at 2:20 P.M the Administrator said the following: -There was no video surveillance for 04/12/25; -RN A told her that he/she had interviewed CNA E about the incident and had completed a quick stand up inservice with staff about elopements on 4/12/25; -There was no documentation or written statements about the incident; she had not performed a review of the incident or near-miss as the policy instructed; -It was her understanding that the resident did not get outside of the door as this is what RN A reported. During an interview on 4/24/25 at 2:45 P.M. the DON and the Administrator said the facility had no documentation of facility inservices, as the policy directed, related to the resident leaving the facility as of 04/24/25 at 2:45 P.M. MO#252686

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to implement interventions to promote healing for one resident (Resident #32), of two sampled closed records, at risk for pressure ulcer development after the resident returned to the facility from an acute hospital stay with pressure ulcers. Staff also failed to complete timely skin assessments as directed to monitor for improvement or decline of the pressure ulcers for two residents (Resident #32 and #35) and complete accurate documentation regarding Resident #35's skin. The facility census was 34. Based on interview and record review facility staff failed to complete timely skin assessments as directed to monitor for improvement or decline of pressure ulcers for two closed record residents (Resident #32 and #35) and complete accurate documentation regarding one resident's (Resident #35) skin. The facility census was 35. Review of the undated facility policy Pressure Ulcers showed the following: -The purpose of this procedure is to provide guidelines for the assessment and identification of at risk for developing pressure ulcers, to assure that residents admitted without pressure ulcers do not develop pressure ulcers unless the individual resident's clinical condition demonstrates that the pressure ulcer was unavoidable, and to ensure that residents with pressure ulcers receive the necessary treatment and services to promote healing and prevent infection and prevent new pressure ulcers from developing; -Once a pressure ulcer develops, it can be extremely difficult to heal; -Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs of a developing pressure ulcer to the supervisor; -The care process should include efforts to stabilize, reduce, or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate; -Skin assessments are completed on shower days; -Skin assessments are completed each time CNA gives care; -Skin assessments are completed weekly by the Licensed Practical Nurse (LPN)/Registered Nurse (RN); Assessment: -A pressure ulcer risk assessment will be completed upon admission, with each additional assessment; quarterly assessment, annually and with significant changes; -Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated; -Staff will maintain a skin alert, performing routine skin inspections daily or every other day as needed, nurses are to be notified to inspect the skin if skin changes are identified, and/or nurses will conduct skin assessments at least weekly to identify changes; -The admission evaluation will help identify initial care approaches. 1. Review of Resident #35's face sheet, showed the following: -admission to facility on 01/03/23; -Diagnosis included fracture of unspecified party of neck of left femur (a broken left hip), Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister) of right buttock, Stage II pressure ulcer of the left buttock, Stage II pressure ulcer of the right heel, Stage II pressure ulcer of the left heel. Review of the resident's admission observation report, dated 01/03/23 at 5:34 P.M., showed skin temperature was warm, skin moisture was dry, skin color was normal, skin turgor (skin elasticity) was normal and no alterations in skin. Review of the resident's admission progress note, dated 01/03/23 at 6:46 P.M., showed the resident was admitted with a surgical site that was well approximated with no signs of infection, two spots on his/her buttocks that are Stage II, and left heel soft and purple. The resident came with pressure relieving boots which need to be worn while in bed. Review of the resident's diagramed admission skin assessment, dated 01/03/23 and untimed, showed a Stage II pressure ulcer on the resident's left and right buttock, and a purple left heel. Review of the resident's baseline care plan, dated 01/03/23, showed the following: -Wound/pressure injury diagram was blank; -Activities of daily living with areas of help needed was blank; -Admitting diagnosis was fracture of left hip; -Up with assistance. Review of the resident's January 2023 physician order sheet (POS) showed an order for monthly Braden (a scale for prediction of pressure ulcer risk) and weekly skin assessments. Review of the resident's Braden Scale for Pressure Ulcer Risks, dated 01/03/23, showed the following: -Very limited sensory perception; -Occasionally moist skin; -Chairfast activity level; -Very limited mobility; -Probably inadequate nutrition; -Problem related to friction and shearing with movement; -Resident is at high risk for pressure ulcer development; -Interventions included pressure reducing device for bed and turning/repositioning program. Review of the resident's January 2023 licensed nurse administration history showed the administration box for the resident's weekly skin assessment, due on 01/04/23, said not administered/other, indicating the skin assessment had not been completed as ordered. Review of the resident's daily skilled nursing notes from 01/05/23 - 01/06/23, showed staff documented the resident's skin was warm and dry with no issues. There was no information to show the status of the resident's pressure ulcers or heel. Review of the resident's January 2023 POS showed an order for Triad wound dressing paste (a wound treatment indicated for the management of pressure ulcers) to be applied three times a day, unspecified place to apply, with a start dated of 01/06/23. Review of the resident's daily skilled nursing notes from 01/07/23 - 01/10/23, showed staff documented the resident's skin was warm and dry with no issues. There was no information to show the status of the resident's pressure ulcers or heel. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/10/23, showed the following: -Extensive assistance of two staff members for bed mobility, transfers, toileting, and personal hygiene; -At risk for pressure ulcers; -Four, Stage II pressure ulcers present on admission. Review of the resident's daily skilled nursing note on 01/11/23 showed staff documented the resident's skin was warm and dry with no issues. There was no information to show the status of the resident's pressure ulcers or heel. Review of the resident's January 2023 licensed nurse administration history showed the administration box for the resident's weekly skin assessments, due on 01/11/23 said not administered/other, indicating the skin assessment had not been completed as ordered. Review of the resident's daily skilled nursing notes from 01/12/23 - 01/16/23 showed staff documented the resident's skin was warm and dry with no issues. There was no information to show the status of the resident's pressure ulcers or heel. Review of the resident's comprehensive care plan, dated 01/16/23, showed the following: -Limited ability to perform self-care, assist of one to two staff with all of his/her cares; -Actual impaired skin integrity related to pressure ulcer, admitted with multiple Stage II pressure injuries; -Observe ulcer area daily/between dressing changes for dressing intact, signs and symptoms of complications/infections, evidence of pain, effectiveness of pain management; -Skin and wound assessments weekly. Review of the resident's daily skilled nursing note from 01/17/23 - 01/18/23 showed staff documented the resident's skin was warm and dry with no issues. There was no information to show the status of the resident's pressure ulcers or heel. Review of the resident's January 2023 licensed nurse administration history showed the administration box for the resident's weekly skin assessments, due on 01/18/23, said not administered/other, indicating the skin assessment had not been completed as ordered. Record review of daily skilled nursing notes from 01/18/23 - 01/24/23 showed staff documented the resident's skin was warm and dry with no issues. Record review of medical record showed no weekly skin assessment or documentation of progress/measurements of the resident's wounds. During an interview on 08/08/23, at 1:53 P.M., Licensed Practical Nurse (LPN) H said the following: -He/She did not recall specifics about Resident #35's wounds other than he/she had pressure wounds; -Weekly skin assessments are supposed to be completed on each resident, usually on a Wednesday; -If a skin assessment is not done on the assigned day it has to be done in that week; -If he/she documented the skin assessment's for Resident #35 was not done on 01/04/23, 01/11/23, and 01/18/23, he/she probably did them another day; -He/She was unable to find in the resident record any completed skin assessments; -He/She must not have completed the assessments; -If the assessments were not completed, he/she must have gotten busy and missed them; -The facility does not have a wound nurse; -The nursing staff measures wounds weekly and the Director of Nursing (DON) would be responsible for tracking wounds and changes. During an interview on 08/02/23, at 2:44 P.M., Registered Nurse (RN) K said the following: -He/She vaguely remembered Resident #35, nothing specific; -If his/her signature was charted on the baseline care plan, admission observation and skin assessment would have been completed on those forms; -He/She was unsure why there was no skin issues addressed on the baseline care plan or admission observation; he/she must have missed it; -The baseline care plan, admission observation and skin assessment should all indicate the same skin status; -When doing a skilled nursing note the resident's skin condition should be addressed and documented accurately. 2. Review of Resident #32's POS, dated 07/03/23, showed an order for weekly skin assessment. Review of the resident's base line care plan, dated 07/03/23, showed the following: -admitted for skilled services due to weakness post-surgery; -Presence of wounds left blank; -Admitting diagnosis, fractured right hip; -Wound care not checked by staff. Review of the resident's Braden Scale for Pressure Ulcer Risk, dated 07/03/23, showed the following: -Score of 15 and at risk for pressure ulcers; -Pressure reducing device for chair and bed, turning and repositioning program; -Initiate plan of care. Review of the resident's admission MDS, dated [DATE] showed the following: -Required extensive assist of two or more staff for bed mobility and transfers; -Lower extremity functional limitation in range of motion on one side; -Frequently incontinent of bowel and bladder; -Diagnoses of hip fracture; -At risk for developing pressure ulcers; -Resident does not have one or more unhealed pressure ulcers; -Pressure reducing device for chair; -Pressure reducing device for bed. Review of the resident's care plan, dated 07/18/23, showed the following: -At risk for impaired skin integrity related to Braden score of 15; -Use moisture barrier cream after incontinent episodes; -Wound care as ordered. Review of the resident's POS, dated 07/19/23, showed an order for Triad Wound Dressing mix with Nystatin (antifungal) powder apply topically three times a day (nothing to specify where to apply the cream/powder mixture. Review of the resident's July 2023 MAR showed the following: -Staff documented the weekly skin assessment as not completed on 07/12/23-not administered: other comment; -Staff documented the weekly skin assessment as not completed on 07/19/23-not administered: other comment. Review of the resident's electronic health record dated 07/12/23 and 07/19/23 showed no wound or skin assessments. During an interview on 07/24/23 at 12:50 P.M., the resident's family member said the following: -The resident was admitted to the facility with pressure ulcers that developed at the hospital; -While at the facility, the wounds on the resident's bottom had been open and bleeding at times. During an interview on 07/27/23 at 1:50 P.M., LPN E said the following: -He/She has been the charge nurse for Resident #32; -He/She is in charge of weekly skin assessments; -He/She usually assesses the skin on the resident's legs; -The charge nurse is responsible for treatments; -He/She had seen the resident's bottom once and it was red with shearing. During an interview on 7/27/23 at 3:20 P.M., RN M said the following: -The resident's bottom was red on admission; he/she did not remember any blisters or open areas; -He/She wrote the order for Triad cream then notified the physician; -Prior to 07/17/23, the resident had at least one open area on his/her buttock. During an interview on 07/27/23 at 4:27 P.M. and 07/27/23 at 6:40 P.M., and on 08/09/23 at 2:06 P.M., the Director of Nurses (DON) said the following: -Resident #32 is at risk for pressure ulcers; -She knew the resident had a Stage II pressure area because staff documented the resident had blisters on his/her buttocks on admission on the skin assessment; -She would expect staff to complete skin assessments as ordered; -Staff should document wound measurements and assessments on the wound management screen in the electronic health record; -The charge nurse that does the admission completes the baseline care plan; -All known information about a resident is expected to be put on the baseline care plan; -She would expect the current skin condition to be reflected on the baseline care plan; -She would expect weekly skin assessments to be completed on all residents; -A skilled nursing note should reflect the condition of the skin and does not take the place of a weekly skin assessment; -The LPN's assigned to each hall monitor's the healing of pressure ulcers for their residents; -The facility does not have a wound care nurse; -The LPN's stage the wounds and do measurements for all of the pressure ulcers; -Pressure ulcers are tracked by completing weekly skin assessments: -She was aware Resident #35 had pressure ulcers that were documented on the admission skin assessment; -Resident #35 did not have any weekly skin assessments documented. MO#00213138 MO#00220808

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure interventions added by the Registered Dietitian (RD) were acted upon for one resident (Resident #22) in a sample of 13 residents, who had a 10.63 percent (%) weight loss the month prior. The facility census was 34. Review of the facility's Protocols related to Nutrition Interventions, dated February 2023, showed the following: -The Nutrition Intervention Program (NIP) as set forth by the NHC Clinical Resource/Best Practice Guidelines for Dietary Services is available to allow residents the highest practicable level of nutritional care through aggressive intervention. NIP Fortified Foods, oral nutrition supplements, house supplement and house protein supplement are four types of nutritional interventions; -NIP Fortified Foods: After appropriate assessment of a resident, the RD will be able to implement NIP Fortified Foods (or NIP) to begin providing additional calories and protein to the daily diet. Individualization will be used as appropriate to meet resident needs. The RD will discontinue the program when it is no longer needed or no longer desired by the resident. Please refer to NIP Policy for the determining factors for residents to receive NIP; -House Supplement: House Supplement program is also a nutritional intervention program available for appropriate residents. A high calorie, high protein commercial supplement. RD may initiate or discontinue their use for House Supplement as appropriate. The standard amount to be used is 120 milliliters (ml), unless otherwise specified. House Supplement is provided at meals by the dietary staff. It will be noted on the appropriate resident's meal tickets. No physician order is required. The frequency of the supplement will be determined based on the resident and need (example: Once daily, twice daily (BID), three times daily (TID); -Regular and Therapeutic Diets Food and Nutrition Services will promote optimal nutritional status for each patient by providing diets in accordance with the physician's diet orders and consistent with the patient's individual physical, psychological, and social needs; -Medications, treatments and diets are given as ordered and are documented in the electronic health record. 1. Review of Resident #22's face sheet, showed the resident's diagnosis include Alzheimer's Disease, abnormal posture, and depression. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment, dated 07/12/22, showed the following: -Severe cognitive impairment; -147 lbs; -Independent with eating. Review of the resident's quarterly MDS, dated [DATE], showed the following: -141 lbs; -Supervision with eating. Review of the resident's Registered Dietitian Note, dated 04/06/2023, showed the following: -Diet: Regular; -Weight: 141.2 lbs, 0.86% weight gain in 1 month (March Weight); -Resident is alert to self and able to make most needs and preferences known and are provided as available; -Tolerating diet and meeting estimated needs; -No nutritional concerns at this time.; -Mini Nutritional Assessment indicates he/she is at risk for malnutrition; -Recommend continuing with current plan of care; -Provide a divided plate at meals; -RD will continue to follow and is available as needed. Review of the resident's Registered Dietitian Note, dated 05/30/2023, showed the following: -Significant Weight Loss Nutritional Note; -Diet: Regular ; -Weight: 127.8 lbs, -10.63% weight loss in one month; -Resident is alert to self and can make some needs and preferences known and are provided as available; -Resident is currently tolerating diet, however is not meeting estimated needs at this time as evidenced by significant weight loss in one month; -His/Her weight had been stable around 140-143 lbs since November; -April weight was 143 lbs; -He/She has not been eating in the recent weeks; -Interventions in place: - Divided Plate; - Foam Handled Utensils; - House Supplement 120 ml three times a day; - Fortified Cereal; - Honor food preferences ; -RD will continue to follow and is available as needed. Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Mild depression; -134 lbs, significant weight loss not on a physician prescribed plan; -Requires extensive physical assistance with eating. Review of the resident's Care Plan, last updated 06/20/23, showed the following: -At nutritional risk related to not meeting estimated needs as evidenced by significant weight loss; -Will maintain adequate nutritional status through next review; -Eating meals at bedside table in Reflections dining room; -Provide house supplement 120 ml three times a day; -Provided fortified cereal at breakfast; -Provided divided Plate, foam handled utensils and a special cup with lid; -Diet: Regular; -Encourage good intake and honor food preferences; -Likes: whole milk at breakfast and tea at lunch and dinner. Review of the resident's Physician's Orders, dated July 2023, did not include a diet order. Observation on 07/24/23, at 12:00-12:45 P.M., showed the following: -The resident sat at a bedside table in the Reflections Unit; -Staff served the resident chicken cordon blue, scalloped potatoes, tomato slices, a roll, a dessert with chocolate topping and a cup with a lid; -Staff did not serve the resident a house supplement; -Staff served the meal on a divided plate and the resident had foam handled utensils; -At 12:08 P.M. the resident attempted to cut his/her chicken cordon blue, but could not; -At 12:15 P.M. certified nurse assistant (CNA) E cut the resident's chicken, and cued the resident; -The resident was able to consume his/her food. Review of the resident's Morning Meal ticket, dated 07/25/23, showed the following: French toast with maple syrup; -Egg of choice; -Bacon, -Toast; -Orange juice, whole milk, and coffee; -Divided plate with foam handled utensils; -Special cup with lid; -Fortified hot cereal; -120 ml house supplement. Observation on 07/25/23, at 07:29-08:05 A.M., showed the following: -The resident sat at the dining room table, not at his/her bedside table; -At 07:29 A.M., Licensed Practical Nurse (LPN) Q served the resident another resident's tray; -Staff served the resident eggs, bacon, toast, rice krispie cold cereal and a cup with a lid with whole milk; -Staff did not provide the resident with his/her bedside table (as the care plan instructed), divided plate, foam handled utensils, fortified hot cereal or a house supplement; -The resident struggled to reach his/her food that was at the level of his/her shoulders (the bedside table is lower than the dining room table and assists the resident to reach his/her food); -The resident dropped his/her fork four times while eating; -At 7:55 A.M., staff gave the resident his/her foam handled utensils; -The resident consumed 75% of his/her meal; -At 8:05 A.M., the resident completed eating; -The staff did not provide a divided plate, fortified hot cereal or a house supplement for the duration of the meal. Observation on 07/26/23, at 12:00 P.M., showed the following: -The resident sat at the dining room table with his/her lunch tray; -The resident was not sitting at his/her bedside table and the resident did not have a house supplement. During an interview on 07/26/23, at 12:08 P.M., CNA N said the following: -There was only one resident with concerns about weight loss (resident was not Resident #22); -No residents on the Reflections unit gets house supplements; -If house supplements were ordered, they would be sent from the kitchen on the resident's tray. During an interview on 07/26/23, at 12:16 P.M., Dietary Partner C said the following: -There are no resident's on the Reflections Unit with supplements; -If there were, they would be on the supplement list (referred to list on the wall; Resident #22 was not on the list); -They can send supplements to the nursing staff to keep in the refrigerator, but they have to call and ask for them. During an interview on 07/26/23, at 12:22 P.M., the Dietary Manager, said the following: -She was new and not sure what the process was for providing supplements; -She would have to ask the RD. During an interview on 07/26/23, at 12:27 P.M., the RD said the following: -If an intervention or supplement is on the diet ticket, then dietary staff are expected to send it with the resident's tray; -Nursing staff are expected to double check the ticket when they serve the tray and call the kitchen for anything that is missing; -The resident lost a significant amount of weight in June; -The resident's interventions are important to ensure he/she is getting the proper nutrition; -If he/she thinks interventions are being done and they are not, the resident could lose more weight and he/she (the RD) may not figure out what to do right away; -It is important to serve the residents the correct diet, with the correct accommodations. During an interview on 07/27/23 at 6:40 P.M., the Director of Nursing said the following: -House supplements are put on the meal trays by dietary; -When reading a dietary ticket, it is expected to list the house supplement if one has been suggested for the resident; -Nursing staff is expected to double check the tray with the dietary ticket and obtain anything from the kitchen that is missing; -Interventions for weight loss include fortified cereals, extra butter, extra cereals and supplements; -IDT goes over weight loss every Wednesday; -The RD makes recommendations; -RD reviews residents once a month; -When the RD makes a recommendation, nursing request the order from the physician, transcribes the order, sends the communication to dietary, dietary staff adds them to diet ticket and the RD adds them to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for two sampled residents (Resident #22 and #185) in a review of 13 sampled residents and one additional resident (Resident #32). The facility census was 34. Review of the Resident Assessment Instrument Manual, dated October 2019, showed the following: -Code question N0410B, Antianxiety: Record the number of days an anxiolytic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). -Code question N0410D, Hypnotic: Record the number of days a hypnotic medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). -Code medications in Item N0410 according to the medication's therapeutic category and/or pharmacological classification, not how it is used. For example, although oxazepam may be prescribed for use as a hypnotic, it is categorized as an antianxiety medication. Therefore, in this section, it would be coded as an antianxiety medication and not as a hypnotic. -Medications that have more than one therapeutic category and/or pharmacological classification should be coded in all categories/classifications assigned to the medication, regardless of how it is being used. For example, prochlorperazine is dually classified as an antipsychotic and an antiemetic. Therefore, in this section, it would be coded as an antipsychotic, regardless of how it is used. -Pressure ulcer/injury: A pressure ulcer/injury is localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful; -Pressure ulcers/injuries occur when tissue is compressed between a bony prominence and an external surface. In addition to pressure, shear force, and friction are important contributors to pressure ulcer/injury development. The underlying health of a resident's soft tissue affects how much pressure, shear force, or friction is needed to damage tissue. -Stage 1 pressure ulcer: An observable, pressure related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body,may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues. Non-blanchable: Reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device; -Stage 2 pressure ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. May also present as an intact or open/ ruptured blister. -Examine the area adjacent to or surrounding an intact blister for evidence of tissue damage. If other conditions are ruled out and the tissue adjacent to or surrounding the blister demonstrates signs of tissue damage (e.g., color change, tenderness, bogginess or firmness, warmth or coolness), these characteristics suggest a deep tissue injury (DTI) rather than a Stage 2 pressure ulcer. Review of drugs.com showed the following: -Buspirone drug class is anxiolytics, sedatives and hypnotics, it is used for treatment of anxiety; -Ramelteon drug class is anxiolytics, sedatives and hypnotics, it is a sedative, also called a hypnotic. Ramelteon is used to treat insomnia that is associated with having trouble falling asleep. 1. Review of Resident #22's face sheet showed the resident's diagnoses include anxiety. Review of the resident's Physician Orders (POS), dated 09/16/20, showed Buspirone (medication for anxiety) 10 mg three times a day. Review of the resident's annual MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Antianxiety use daily; -No hypnotic medication used; -No Gradual Dose Reduction (GDR) attempt. The MDS did not include the use of hypnotic medication, the resident continues on Buspirone. Review of the resident's Pharmacist to Physician Report, dated 01/27/23, showed please assess risk versus benefit and if your patient would benefit from a reduction of the Buspirone 10 mg three times a day. Review of the resident's physician note, dated 01/31/23, showed the following: -Pharmacist request review of medications Buspirone; -Diagnosis of anxiety; -No changes at this time. Review of the resident's POS, dated April 2023, showed the resident continued on Buspirone. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Last physician documented GDR as clinically contraindicated, was on 01/31/23. -No antianxiety or hypnotic medication. The MDS did not include the use of antianxiety and hypnotic medication; the resident continues on Buspirone for anxiety. 2. Review of Resident #185's face sheet showed the resident's diagnosis includes unspecified dementia with agitation. Review of the resident's POS, dated 07/17/23, showed Ramelteon (a medication to assist with sleep) eight mg, two tablets at bedtime; the medication order did not include an indication for use. Review of the resident's Medication Administration Record (MAR), dated July 2023, showed the resident's Ramelteon medication administered as ordered. Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Diagnosis of hip fracture, other fracture, dementia, and anxiety, -Mild depression symptoms; -Verbal behaviors directed towards others four to six days but not daily. The MDS did not include the use of antianxiety and hypnotic medication, the resident continues on Ramelteon. 3. Review of Resident #32's base line care plan, dated 07/03/23, showed the following: -admitted for skilled services due to weakness post-surgery; -Presence of wounds left blank; -Admitting diagnosis, fractured right hip; -Wound care not checked by staff. Review of the resident's Braden Scale for Pressure Ulcer Risk, dated 07/03/23, showed the following: -Score of 15 and at risk for pressure ulcers; -Pressure reducing device for chair and bed, turning and repositioning program; -Initiate plan of care. Review of the resident's admission skin assessment dated [DATE] showed three blisters (no measurements documented) on the resident's buttocks. Review of the resident's admission MDS, dated [DATE] showed the following: -Required extensive assist of two or more staff for bed mobility and transfers; -Lower extremity functional limitation in range of motion on one side; -Frequently incontinent of bowel and bladder; -Diagnoses of hip fracture; -At risk for developing pressure ulcers; -Resident does not have one or more unhealed pressure ulcers; -Resident does not have other wounds or dressings. The MDS did not include wounds found on the admission assessment. Review of the resident's care plan, dated 07/18/23, showed the following: -At risk for impaired skin integrity related to Braden score of 15; -Use moisture barrier cream after incontinent episodes; -Wound care as ordered. Review of the resident's POS, dated 07/19/23, showed an order for Triad Wound Dressing mix with Nystatin (antifungal) powder apply topically three times a day (nothing to specify where to apply the cream/powder mixture. During an interview on 07/24/23 at 12:50 P.M., the resident's family member said the following: -The resident was admitted to the facility with pressure ulcers that developed at the hospital; -While at the facility, the wounds on the resident's bottom had been open and bleeding at times. During an interview on 07/27/23 at 1:50 P.M., Licensed Practical Nurse (LPN) E said he/she had seen the resident's bottom once and it was red with shearing. During an interview on 07/27/23 at 3:20 P.M., Registered Nurse (RN) M said the following: -The resident's bottom was red on admission; -He/She wrote the order for Triad cream then notified the physician; -Prior to 07/17/23, the resident had at least one open area on his/her buttock. During an interview on 07/27/23 at 4:27 P.M., 07/27/23 at 6:40 P.M. and 08/09/23 at 2:06 P.M., the Director of Nurses (DON) said the following: -Resident #32 is at risk for pressure ulcers; -She knew the resident had a Stage II pressure area because staff documented the resident had blisters on his/her buttocks on admission on the skin assessment; -She would expect staff to complete skin assessments as ordered; -Staff should document wound measurements and assessments on the wound management screen in the electronic health record; -She was aware Resident #35 had pressure ulcers that were documented on the admission skin assessment. During an interview on 8/3/23 at 12:59 P.M., the MDS Coordinator said the following: -Pressure ulcers and psychotropic medication are expected to be coded on the MDS; -Wounds caused by shear are not coded as pressure - they are coded somewhere else; -She is not sure without looking at the MDS, she thinks sheer would only be included as a treatment; -She is expected to use the RAI manual as the reference to ensure accurate coding of the MDS is completed; -If a resident takes a psychotropic medication or has a pressure ulcer, it should be coded on the MDS as such; -She looks at resident's skin prior to coding the MDS; -When she looked at Resident #32, his/her buttock was only red and not blistered; -She also looks at the admission paperwork to see what skin conditions were present on admission. -If she was unable to assess the residents skin, she would interview staff and look at their skin assessments; -She is not sure how blisters are coded; she will have to look that up, but believes a blister is coded as an unstagable pressure ulcer; -She does not know why it was not coded on the resident's MDS. During an interview on 7/27/23, at 6:40 P.M., the Director of Nursing said the following: -The MDS Coordinator is expected to review the resident's medical record, go to resident room, interview staff and interview family members to ensure accuracy on the MDS; -The MDS Coordinator is expected to follow the rules of RAI manual for coding of items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs and risks to provide effective person centered care that met professional standards of quality care within 48 hours of admission to the facility for one resident (Resident #185), in a review of 13 sampled residents and two closed record residents (Resident #32 and #35). The facility census was 34. Review of the facility's undated policy for Baseline Care Plans showed the following: -Baseline care plans will be completed on all residents upon admission within 48 hours of admission; -All problems, goals, and interventions will be reviewed and replaced by a comprehensive care plan within 21 days of admission. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. 1. Review of Resident #185's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of unspecified dementia with agitation. Review of the resident's Physician's Orders (POS), dated 07/17/23, showed the following: -Quetiapine (an antipsychotic medication for hallucinations and delusions) 25 milligram (mg) at bedtime; -Ramelteon (a medication to assist with sleep) eight mg, two tablets at bedtime; -Sertraline (medication for depression) 50 mg daily; -Trazodone (medication for depression) 50 mg at bedtime. Review of the resident's baseline care plan, dated 07/17/23, showed the psychosocial well-being care section was blank. The baseline care plan did not include the use of psychoactive medications or monitoring for side effects from psychoactive medication. Review of the resident's care plan, dated 07/21/23, did not include include the use of psychoactive medications or monitoring for side effects from psychoactive medication. 2. Review of Resident #32's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnosis of right femur fracture. Review of the resident's admission skin assessment dated [DATE] showed three blisters (no measurements documented) on the resident's buttocks. Review of the resident's baseline care plan, dated 07/03/23, showed the following: -admitted for skilled services due to weakness post-surgery; -Wound/pressure injury diagram was blank; -Wound care: blank. 3. Review of Resident #35's face sheet showed the following: -admission to facility on 01/3/23; -Diagnosis included fracture of unspecified party of neck of left femur (a broken left hip), Stage II pressure ulcer of right buttock (a partial thickness skin loss involving the epidermis 'the surface of the skin' and/or dermis 'the thick layer of living tissue below the dermis' caused by pressure), Stage II pressure ulcer of the left buttock, Stage II pressure ulcer of the right heel, Stage II pressure ulcer of the left heel. Review of the resident's January 2023 POS showed an order for Triad wound dressing paste (a wound treatment indicated for the management of pressure ulcers) to be applied three times a day, unspecified place to apply. Review of the resident's baseline care plan, dated 01/03/23, showed the following: -Admitting diagnosis was fracture of left hip; -Up with assistance; -Wound/pressure injury diagram was blank; -Activities of daily living with areas of help needed was blank. Review of the resident's admission skin assessment, dated 01/03/23, showed a Stage II pressure ulcer on his/her left and right buttock, and a purple left heel. Review of the resident's admission observation report, dated 01/03/23, showed skin temperature was warm, skin moisture was dry, skin color was normal, skin turgor was normal and no alterations in skin. Review of the resident's admission progress note, dated 01/03/23, showed the resident was admitted with a surgical site that was well approximated with no signs of infection, two spots on his/her buttocks that are Stage II, and left heel soft and purple. He/She came with pressure relieving boots which need to be worn while in bed. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/10/23, showed the following: -Extensive assistance of two staff members for bed mobility, transfers, toileting, and personal hygiene; -At risk for pressure ulcers -Four, Stage II pressure ulcers present on admission. Record review of daily skilled nursing note from 01/04/23 through 01/24/23 skin section showed no skin issues, skin was warm and dry. During an interview on 08/02/23, at 2:44 P.M., Registered Nurse K said the following: -If a resident has any skin issues they should be included on the baseline care plan; -He/She was unsure why he/she noted the presence of pressure ulcers for the resident on the admission skin assessment and not on the baseline care plan; -He/She must have missed noting the pressure ulcers on the baseline care plan. During interview on 07/27/23, at 6:40 P.M., the Director of Nursing said the following: -The charge nurse that does the admission completes the baseline care plan; -All known information about the resident is expected to be put on the baseline care plan; -She would expect the current skin condition to be reflected on the baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update interventions in the resident's care plan to reflect current care needs for two residents (Resident #2 and #14) in a sample of 22 residents. The facility census was 34. Review of the facility's undated policy for Care Plans showed the following: -Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -Care Plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying sources of the problem areas, rather than addressing only symptoms or triggers; -Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change; -The care planning/interdisciplinary team is responsible for the review and updating of care plans when there has been a significant change in the residents condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly; -Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition, when the desired outcome has not been achieved, when the resident has been readmitted to the facility from a hospital/rehabilitation stay, and at least quarterly; -Care plans include the physicians orders, Medication Administration Record (MAR's), and Treatment Administration Record (TAR's); -Interim care plans are completed upon admission and updated by the interdisciplinary team. Review of the Centers for Medicare and Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, Chapter 4, revised October 2019, showed the following: -The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents; -A well developed and executed assessment and care plan: 1. Looks at each resident as a whole human being with unique characteristics and strengths; 2. Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident's functional status (MDS); 3. Gives the IDT a common understanding of the resident; 4. Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); 5. Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 6. Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow- up; 7. Reflects the resident's/resident representative's input, goals, and desired outcomes; 8. Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well- being (care planning); 9. Re-evaluates the resident's status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary; 10. Reviews and revises the current care plan. 1. Review of Resident #2's face sheet showed the following: -Chronic respiratory failure with hypoxia; (lack of oxygen) -Dependence on supplemental oxygen; -Chronic obstructive pulmonary disease (disease affecting the lungs making it difficult to breathe); -Unspecified dementia with agitation. Review of the resident's Physician's Orders (POS), dated 01/11/23, showed orders for oxygen at 4 liters (L)/minute (min) via nasal cannula (tube from oxygen to the residents nares) continuous. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 04/05/23, showed the following: -Moderate cognitive impairment; -Does not have a condition or chronic disease with a life expectancy less than six months; -Oxygen use. Review of the resident's quarterly MDS, dated [DATE], showed the resident has severe cognitive impairment and delusions. Review of the resident's POS, dated 07/11/23, showed consult with hospice. Review of the resident's medical record showed the resident began hospice services on 07/11/23. Review of the resident's Care Plan, last updated 07/18/23, showed the following: -Oxygen use and respiratory care was not addressed on the resident's care plan; -Hospice and/or end of life care was not addressed on the resident's care plan. Review of the resident's significant change MDS, dated [DATE], showed the resident was now receiving hospice care. Observation on 07/24/23 at 11:23 A.M., showed the resident in the dining room with oxygen at 4 L/min per nasal cannula. Review of the resident's Care Plan, on 07/27/23, showed the oxygen, respiratory care, and hospice care were not addressed on the resident's care plan. 2. Review of Resident #14's Continuity of Care Document showed diagnoses include dysphagia (difficulty swallowing) following cerebral infarction (stroke) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's February 2023 physician order sheets showed an order for Triad wound dressing (a sterile coating that can be used on broken skin) was discontinued on 2/20/23. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Extensive assist of two staff for transfers; -Set up help and supervision for meals; -No current pressure ulcers. Review of the resident's comprehensive care plan, revised on 07/21/23, showed the following: -The resident has moderately impaired cognition; -Pressure injury care as ordered; -He/She is assisted by one staff for transfers; -He/She requires supervision with meals, cut up foods/meats; -No straws to be used. Observation on 07/24/23, at 11:45 A.M. showed the resident sat up in his/her wheelchair in the dining room drinking fluids from cups with covers and straws. The resident was not attempting to feed himself/herself. No nursing staff were present in the dining room to assist or encourage the resident with eating. Observation on 07/25/23, at 7:10 A.M. showed the resident sat up in his/her wheelchair in the dining room drinking fluids from cups with covers and straws. Dietary Manager sat down to feed the resident. No nursing staff were present in the dining room to assist or encourage the resident with eating. Observation on 07/25/23, at 8:16 A.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -The resident was transferred from his/her wheelchair to recliner, recliner to wheelchair and then wheelchair to bed with assistance of two staff members. Observation on 07/26/23, at 11:16 A.M. showed the resident sat up in his/her wheelchair in the dining room drinking fluids from cups with covers and straws. The resident was not attempting to feed himself/herself. The Dietary Manager sat down to feed the resident. No nursing staff were present in the dining room to assist or encourage the resident with eating. During interview on 07/26/23, at 11:25 A.M., the resident said he/she was able to pick up his/her spoon and showed the surveyor how he/she could scoop food on the spoon to eat. He/She scooped a small spoon of vegetables onto the spoon but did not attempt to eat the food. He/She said he/she was full and did not feed himself/herself anything. The resident ate less than 5% of lunch. Observation on 07/26/23, at 1:15 P.M., showed the resident did not have any skin breakdown or pressure ulcers. Observation on 07/27/23, at 11:30 A.M. showed the resident sat up in his/her wheelchair in the dining room drinking fluids from cups with covers and straws. The resident did not attempt to feed himself/herself. No nursing staff were present in the dining room to assist or encourage resident to eat. Review of the resident's care plan showed the facility failed to update the interventions in the resident's care plan to reflect current care needs including: -Severely impaired cognition; -Use of straws with meals; -Extensive assistance of two staff for transfers; -No current pressure ulcers; -More than supervision at meals for adequate nutritional intake. During an interview on 08/03/23 at 12:59 P.M., the MDS coordinator said the following: -Any member of the Interdisciplinary Department Team (IDT) is responsible for updating the care plan if it pertains to their department; -Anyone in nursing can update the care plan if needed; -Items that would be updated in the care plan would be anything that would be a change in condition, such as falls, pain, nutrition concerns and feeding assistance; -The care plan is updated with any change and quarterly with the MDS; -MDS information should match the care plan and level of care/assistance being provided to the resident. During an interview on 07/27/23 at 6:40 P.M., the Director of Nursing (DON) said the following: -Everything needed to provide care for the resident should be included on the comprehensive care plan; -She would expect the care plan to be revised with any including hospice services, falls,and wound updates were to be completed within 24 hours; -Anyone can update a resident's care plan; -The MDS coordinator is responsible to update a resident's care plan; -She would expect the resident's care plan to include oxygen use; -Resident #14 drinks from a straw and needs assistance with feeding him/herself.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure facility staff provided one resident (Resident #2), the necessary care and services to maintain good personal hygiene and prevent body odor. Additionally, the facility failed to provide and one resident (Resident #14), in a sample of 13 residents, the necessary feeding assistance to ensure adequate consumption of meals. The facility census was 34. Review of the facility's undated policy, Peri care, showed the following: -Perineal care is provided to clean the perineum and provide comfort; -Wash and Rinse areas well, starting with the inner most area and moving to the outer most area. Wash legs if urine came into contact with any portion of them. Review of the facility's policy, Patient Care Policies, revised 02/2023, showed the following: -An active program of restorative nursing care will be directed toward assisting each patient to achieve and maintain his or her highest level of self-care and independence; -Restorative nursing services are available to all patients; -A comprehensive nutritional assessment will identify each patient's individual nutrition needs, based on identified nutritional deficits; -Preventive, curative, or palliative interventions will be instituted, monitored and evaluated to correspond with patient goals and plan of care, including, but not limited to, weight loss, pressure ulcers, dialysis, dehydration, and nutrition support. 1. Review of Resident #14's Continuity of Care Document showed his/her diagnoses include dysphagia following cerebral infarction (difficulty swallowing foods or liquids following a stroke), and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's speech therapy Discharge summary, dated [DATE], showed the following discharge recommendations: -To facilitate safety and efficiency, it is recommended the resident use the following strategies and/or maneuvers during oral intake: alternation of tastes, alternation of temperatures, alteration of liquids/solids, eating paired with automatic tasks, general swallowing techniques/precautions; -Close supervision; -To facilitate optimal cognitive-communicative performance, the following strategies are recommended: appropriate redirection with resident, one step directions by speaker to increase comprehension, consistent words/verbal direction, short, direct comments to facilitate follow-through and touch to achieve and maintain attention to tasks. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/17/23, showed the following: -Severely impaired cognition; -Supervision and set-up help for eating. Review of the resident's comprehensive care plan, revised on 07/21/23, showed the following: -The resident has moderately impaired cognition; -Encourage food by mouth intake at meals and snacks. Observation on 07/24/23 at 11:45 A.M., showed the resident sat up in his/her wheelchair in the dining room drinking fluids from cups with covers and straws. The resident did not attempt to feed himself/herself. No nursing staff were present in the dining room to assist or encourage the resident to eat. Observation on 07/25/23 at 7:10 A.M., showed the resident sat up in his/her wheelchair in the dining room drinking fluids from cups with covers and straws. The resident was not attempting to feed himself/herself. The Dietary Manager sat down to feed the resident. No nursing staff were present in the dining room to assist or encourage resident to eat. Observation on 07/26/23 at 11:16 A.M., showed the resident sat up in his/her wheelchair in the dining room drinking fluids from cups with covers and straws. The resident was not attempting to feed himself/herself. The Dietary Manager sat down to feed the resident. No nursing staff were present in the dining room to assist or encourage the resident to eat. Observation on 07/26/23 at 11:25 A.M., showed the resident ate less than 5% of his/her lunch. Observation on 07/27/23, at 11:30 A.M. showed the resident sat up in his/her wheelchair in the dining room drinking fluids from cups with covers and straws. The resident was not attempting to feed himself/herself. No nursing staff were present in the dining room to assist or encourage the resident to eat. During interview on 07/26/23, at 11:40 A.M., the Dietary Manager said the following: -She was not assigned to assist Resident #14 with eating; -She just sat down to encourage and help him/her with the meal; -She did not have any training related to feeding residents from the facility as this was her first week working at the facility. During an interview on 07/26/23, at 12:28 P.M., the Registered Dietician said the following: -The resident would benefit from a restorative feeding program to assist with meals due to being at risk for weight loss; -There was currently no restorative program and she was unsure how long there had been no restorative program. During an interview on 07/26/23, at 1:10 P.M., the Speech Therapist said the following: -She was unsure of current diet orders due to not having the resident on case load; -She had recommended the resident for restorative dining due to needing 1:1 assistance with cueing and helping to feed if necessary; -The resident had a short attention span and needed someone with him/her to cue him/her to eat and to slow down while eating; -She would expect someone in nursing to sit with the resident, not someone in dietary as they were not properly trained. 2. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Requires extensive physical assistance with bed mobility, transfer, locomotion off unit (dining activities), dressing, toilet use and bathing; -Frequently incontinent of bowel and bladder. Review of the resident's Care Plan, last revised 07/18/23, showed the following: -Activity of Daily Living (ADL'S)/Elimination/Skin: Resident needs assist of one to two certified nurse assistants (CNA's) with all of his/her cares; -Toilet use: Assist with toilet use by one to two Certified Nurse Aides (CNA's); -Resident is occasionally incontinent of bladder and bowel; -Use moisture barrier cream (protective skin barrier) after incontinent episode. Observation on 07/27/23, at 8:20 A.M., showed the following: -The resident was in his/her bathroom with CNA N and Certified Medication Technician (CMT) O; -The staff assisted the resident to a standing position; -CMT O removed the resident's incontinence brief and CMT O said the brief was saturated with urine; -The resident sat on the toilet; -When the resident was ready, CMT O and CNA N assisted the resident to a standing position; -CMT O cleansed the resident's perineum; the CMT did not clean the outer buttock and inner thigh areas where the wet brief was in contact with the resident's skin; -CMT O then placed a clean brief on the resident and dressed the resident; -When the resident was back in his/her room, he/she continued to smell of urine. During an interview on 07/27/23, at 10:45 A.M., CMT O said the following: -Staff are expected to use one wipe per swipe when cleaning a resident's perineum; -Staff are expected to clean all skin in contact with urine or feces. During an interview on 07/27/23, at 6:40 P.M. and 08/09/23 at 2:00 P.M., the Director of Nursing (DON) said the following: -During perineal care, staff are expected to cleanse the resident's skin in contact with urine or feces; -She would expect a resident that needs feeding assistance to have that assistance provided by nursing or therapy staff; -The facility had not had a restorative aide for feeding assistance in the past four years due to staffing issues; -With no restorative program for feeding assistance, nursing would need to provide assistance if recommended; -Resident #14 needed assistance with feeding; -She was not aware of the speech therapist recommendations for restorative dining or 1:1 assistance for eating for Resident #14. During an interview on 07/26/23, at 11:45 A.M., the administrator said the facility had not had a restorative program for feeding assistance for quite some time due to staffing. There was a restorative dining room but no restorative staff at present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], Konnie Based on observation, interview and record review, the facility failed to ensure staff transported residents in wheelchairs utilizing the foot rests for two residents (Resident #2 and #185), and failed to ensure a proper gait belt transfer for one resident (Resident #14), in a sample of 22 residents. The census was 34. Review of the facility's Wheelchair Transportation and Leg Rests Policy, dated 12/07/22, showed the following: -The primary objective of this policy is to ensure the safe and efficient transportation of residents in wheelchairs within the skilled nursing home premises; -Leg rests are provided to enhance resident comfort and provide proper support for their legs and feet and they should be adjusted to the resident's height and comfort level; -During wheelchair transportation, leg rests should be raised and secured to prevent the resident's feet from dragging on the ground, which can cause discomfort and injury; 3. Residents who can self propel themselves in wheel chairs do not need to have wheelchair leg rests on at all time; 4. It is the patients choice if they want to use them or not' IF transporting out of' the center, if the patient normally does not want leg rests, it is still advised to take them. Review of the facility's undated policy, Gait Belts for Transfer, showed the following: -Gait belts are provided to assist staff to safely transfer or ambulate residents; -Explain procedure to resident; -Apply belt around resident waist; -Pass the metal-tipped end through the buckle under the teeth; -Bring tip of the belt across the front of the buckle and slip it through to the other side; -Tuck any excess through the belt; -Ensure belt is snug, but allow enough room for your hand to comfortably grasp it; -Stand as close to the resident as possible, maintaining a broad base of support; -Assist resident to a standing position by grasping belt at the waist from underneath. Pivot resident into chair or bed; -Assist resident to standing position by grasping belt at the waist from underneath; -Standing on weaker side of resident, wrap your arm around waist of resident and grasp belt from underneath; -Maintain a firm grasp on belt and proceed to ambulate; -When transfer is completed, remove the belt and return to storage area. 1. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 07/05/23, showed the following: -Severe cognitive impairment; -Requires extensive physical assistance with locomotion off unit (dining activities); -Uses a wheelchair. Review of the resident's Care Plan, last revised 07/18/23, showed he/she used wheelchair as primary means of locomotion. Observation on 07/25/23, at 6:25 A.M., showed the following: -Certified Nurse Aide (CNA) P propelled the resident from the dining room to the resident's room; -The resident's feet slid on the floor. During an interview on 07/25/23, at 6:52 A.M., CNA P said the residents have foot rest for their wheelchairs if they don't hold up their feet when asked. Observation on 07/27/23, at 8:20 A.M., showed the following: -Certified Medication Technician (CMT) O propelled the resident from his/her table in the dining room to the resident's room without foot rests on the resident's wheelchair; -The resident lifted his/her legs, but his/her heels hit the floor three times between the dining room and his/her room; -When the resident's heels hit the floor, CMT O said, hold up your feet. During an interview on 07/27/23, at 10:45 A.M., CMT O said staff remind the residents to hold up their feet when propelling them in a wheelchair without foot rests. Most of the residents do not have foot rests on their wheelchairs. 2. Review of Resident #185's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses of unspecified dementia with agitation, displaced fracture of the right leg and history of falling. Review of the resident's baseline care plan, dated 07/17/23, showed the resident was a fall risk, used a manual wheelchair, and had right hip fracture with surgical repair prior to admission to the facility. Review of the resident's history and physical, dated 07/19/23, completed by the resident's physician, showed the following assessment: -Right hip fracture; -Right humerus (long bone in the arm) fracture; -Dementia with anxiety. Review of the resident's admission MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Moderate difficulty hearing with a hearing device; -Requires extensive physical assist of two or more staff members with locomotion on and off unit; -Impairment functional limitation in range of motion to one lower extremity; -Wheelchair use; -Frequent pain limited day to day activities; -Pain is severe. Observation on 07/25/23, at 10:50 A.M., showed the following: -CNA N propelled the resident to the dining room; -The resident's wheelchair did not have foot rests; -The resident attempted to hold his/her right leg up with his/her right foot; -His/Her right foot fell off the resident's left foot two times while staff propelled the resident down the hall; -When the resident's foot dropped, the resident winced in pain and held his/her right leg; -Each time the resident's foot dropped, the CNA stopped and told the resident to try to keep his/her feet up if possible. During an interview on 07/25/23, at 11:18 A.M., CNA N said the following: -The resident is a fall risk and had a hip fracture prior to admission; -He/She normally has foot rests on his/her wheelchair, but he/she did not see them. 3. Review Resident #14's Continuity of Care Document showed his/her diagnoses include heart failure (occurs when the heart muscle does not pump blood as well as it should), chronic kidney disease (a gradual loss of kidney function) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Extensive assist of one staff member for bed mobility; -Extensive assist of two staff for transfers; -No impairment of range of motion upper or lower extremities. Review of the resident's comprehensive care plan, revised on 07/21/23, showed the following: -He/She is at risk for falls; -He/She is assisted by one staff for bed mobility; -He/She ambulates with assist of two staff; -He/She transfers with the assist of two staff. Observation of the resident on 07/25/23 at 8:16 A.M., showed the following: -He/She sat in his/her wheelchair in his/her room; -CNA E applied a gait belt around the resident's waist; -CNA E and CNA J instructed the resident to stand to be transferred to his/her recliner; -CNA E held on to the gait belt at the back and lifted under the resident's left shoulder, while CNA J held on to the gait belt at the right side of the resident's waist and back to transfer the resident to the recliner; -The resident was bent over at the waist during the transfer, his/her knees were bent with only toe touch pressure on the floor during the transfer; -The resident requested to be put to bed; -CNA E lifted the resident by the gait belt at the back and under his/her left shoulder while CNA J lifted the resident with the gait belt at the right side of his/her waist and back and transferred the resident from the recliner to the wheelchair; -The resident was bent at the waist, his/her knees were bent with only toe touch pressure on the floor for the transfer; -CNA E lifted the resident by the gait belt at the back and under his/her left shoulder while CNA J lifted the resident with the gait belt at the right side of his/her waist and back and transferred the resident from his/her wheelchair to the resident's bed; -The resident was bent at the waist, his/her knees were bent with only toe touch pressure on the floor during the transfer. Observation on 07/26/23 at 1:11 P.M., in the resident's room, showed the following: -The resident sat in his/her wheelchair; -CNA E applied a gait belt around the resident's waist; -CNA E and CNA J attempted to assist the resident to stand; -The resident was bent at the waist and his/her knees were bent; -The resident did not fully bear weight; -CNA E and CNA J pivoted the resident to his/her bed. -His/Her feet slid across the floor during the transfer. During an interview on 07/27/23, at 1:53 P.M., CNA E said the following: -A gait belt should always be used when a resident is a manual transfer; -The resident should be able to bear weight with a manual transfer; -A resident should not be lifted under his/her arm as it could cause injury; -He/She was not sure why he/she lifted Resident #14 under his/her arm/shoulder; -Resident #14 did not bear much weight during a manual transfer and should probably have his/her transfers status re-evaluated. During an interview on 07/27/23 at 6:40 P.M., the Director of Nursing (DON) said the following: -She expected residents to have foot pedals on their wheelchairs if staff were pushing the wheelchair; -A resident needs to bear weight to transfer with a gait belt, this should be more than toe touch and pressure should not be placed on the resident's shoulders; -Propelling residents in a wheelchair without foot pedals could cause the resident to be thrown out of wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nursing staff performed acceptable infection control practices to prevent contamination of respiratory equipment according to facility policy, when staff failed to protect the mask of a continuous positive airway pressure (CPAP) (machine that uses a hose connected to a mask or nosepiece to deliver constant and steady air pressure to help you breathe while you sleep) device when not in use, and left the CPAP machine and mask on the floor for one resident (Resident #19) in a review of two residents with respiratory devices. The facility failed to change and document oxygen tubing and ensure proper infection control was utilized according to facility policy for three residents (Resident #2, #11 and #19) and one additional resident (Resident #10) in a sample of 13 residents. The facility census was 34. Review of the facility's undated Oxygen Tubing Policy, showed the following: -Oxygen tubing will be replaced weekly on Friday; -Oxygen tubing is to be dated when put into place; -Tubing is to be placed in a new zip lock bag and attached to the concentrator; -When oxygen tubing is not in use it is to be stored in the zip lock bag. Review of the facility's CPAP Cleaning and Storage Policy, dated 12/02/22, showed the following: -The objective of this policy is to maintain the cleanliness, functionality, and proper storage of CPAP machines used by patients in the skilled nursing facility, ensuring effective respiratory therapy and minimizing the risk of infections; -Each patient will have a designated, clean, and dust-free area to store their CPAP machine and accessories; -When not in use, patients will cover CPAP machines with a clean, breathable cloth or store them in a provided case to prevent dust accumulation; -CPAP machines will be placed on stable surfaces to prevent accidental falls or damage. 1. Review of Resident #2's undated face sheet showed the following: -Chronic respiratory failure with hypoxia (absence of enough oxygen in the tissue to sustain bodily function); -Dependence on supplemental oxygen; -Chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe); Review of the resident's July 2023 Physician's Orders (POS), showed orders for oxygen at 4 liters (L)/minute (min) via nasal cannula (tube from oxygen to the residents nares) continuous, there were no specific orders as to when to change the tubing. Review of the resident's July 2023 medication administration record (MAR) showed no documentation to show when staff were to change the resident's oxygen tubing or a place to document if the tubing was changed. Review of the resident's July 2023 treatment administration record (TAR) showed no documentation to show when staff were to change the resident's oxygen tubing or a place to document if the tubing was changed. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 07/5/23, showed the resident used oxygen. Review of the resident's Care Plan, last revised 07/18/23, showed oxygen use and respiratory care was not addressed on the resident's care plan. Observation on 07/24/23, at 11:43 A.M., showed the resident at the dining room table. The resident's oxygen was connected to a concentrator and set at 4L/min via nasal cannula. The resident's oxygen tubing did not contain a label with the date the tubing was changed. Observation on 07/27/23, at 9:43 A.M., showed the the resident at the dining room table. The resident's oxygen was connected to a concentrator and set at 4L/min via nasal cannula. The resident's oxygen tubing did not contain a label with the date the tubing was changed. 2. Review of Resident #11's face sheet, showed he/she had diagnoses that included COPD. Review of the resident's quarterly MDS dated [DATE], showed the following: -He/She had trouble breathing with exertion; -He/She required oxygen therapy. Review of the resident's July 2023 POS showed orders for oxygen at two liters by nasal cannula every shift, every day; there were no specific orders as to when to change the oxygen tubing. Review of the resident's July 2023 MAR showed no documentation to show when the resident's oxygen tubing was to be changed or was changed. Review of the resident's July 2023 TAR showed no documentation to show when the resident's oxygen tubing was to be changed or was changed. Observation on 07/24/23 at 9:09 A.M., showed the resident sat in his/her recliner, awake, oxygen delivered via a NC at two liters (2L) from an oxygen concentrator (a medical device that delivers almost pure oxygen through the nasal cannula tubing); the oxygen tubing was not labeled with a date of application. The baggie which was taped to the side of the oxygen concentrator was labeled 7/7 (17 days from the first date of application). Additional oxygen tubing was wrapped around an oxygen canister that sat on an empty wheelchair; the tubing was labeled with illegible writing on a piece of tape and was not in a plastic bag. Observation on 07/27/23 at 7:21 A.M., showed a NC at the foot of the resident's bed, uncovered and was not in a storage bag. The oxygen tubing was not labeled with the date of application. The storage bag taped to the side of the oxygen concentrator was labeled 7/7 (19 days from the date of first application). Review of the resident's medical record showed no documentation to show when staff changed the resident's oxygen tubing. 3. Review of Resident #19's face sheet showed the following: -Diagnoses included CHF, (congestive heart failure - the heart can't pump blood well enough to give the body a normal supply), COPD, chronic respiratory failure (a condition that makes it difficult to breathe), dependence on supplemental oxygen and obstructive sleep apnea (the throat muscles relax and block the airway while asleep). Review of the resident's quarterly MDS, dated [DATE], showed the following: -His/Her diagnoses also included asthma (a respiratory condition marked by spasms in the airways of the lungs, causing difficulty breathing), -CPAP use was blank; -Oxygen use was blank. Review of the resident's July 2023 POS showed the following: -Oxygen at four liters via nasal cannula, every shift, every day; there were no specific orders as to when to change the tubing; -Apply CPAP at bedtime and remove in the morning. Review of the resident's July 2023 MAR showed no documentation to show when the resident's oxygen tubing was to be changed or was changed. Review of the resident's July 2023 TAR showed no documentation to show when the resident's oxygen tubing was to be changed or was changed. Observation on 07/24/23 at 9:58 A.M., showed the following: -The resident sat in his/her wheelchair, awake, oxygen delivered via a NC at 4L from an oxygen concentrator; -The label on the resident's oxygen tubing was illegible; -The CPAP machine was uncovered and sat directly on the floor behind the resident's recliner; -The resident's CPAP mask was attached to the CPAP tubing and sat uncovered on top of the CPAP machine. Observation on 07/25/23 at 6:16 A.M., showed the following: -The resident sat in his/her wheelchair, awake, oxygen delivered via a NC at 4L from an oxygen concentrator; -The label on the resident's oxygen tubing was illegible; -Extra oxygen tubing that was stored in the resident's backpack on the back of his/her wheelchair. The connector end of the tubing stuck out of the backpack and touched the back of the resident's wheelchair with no label showing date of application; -Certified Nurse Aide (CNA) G took the resident to the shower room and removed the oxygen tubing from the resident's nostrils, set the tubing down on a small table in the shower room with the nasal cannula pointing down and touching a gait belt; -CNA G placed the contaminated nasal cannula back into the resident's nostrils while the resident received a shower; -Following the shower, CNA G took the nasal cannula out of the resident's nostrils and bundled the tubing in his/her hand; with the same hand, he/she grabbed onto the oxygen concentrator's handle, with the nasal cannula touching the oxygen concentrator, as he/she pushed the resident down the hall from the shower room; -Once back in the resident's room, CNA G put the contaminated nasal cannula back into the resident's nostrils; -CNA G and CNA E applied a gait belt and helped the resident stand using a grab bar on the back of the resident's bathroom door; -The resident was able to sit down on his/her toilet; While on the toilet, the resident tossed his/her nasal cannula into the floor; -CNA G picked the nasal cannula up off of the floor and cleaned it with [NAME] Stay Dry Washcloth and put the cannula back into the resident's nostrils; -The resident's CPAP machine remained uncovered and sat directly on the floor behind the resident's recliner; -The resident's CPAP mask was attached to the CPAP tubing and sat uncovered on top of the CPAP machine. Observation on 07/26/23 at 9:15 A.M., showed the following: -The resident sat in his/her wheelchair, awake, oxygen delivered via a NC at 4L from an oxygen concentrator; -The label on the resident's oxygen tubing was illegible; -The CPAP machine was uncovered and sat directly on the floor behind the resident's recliner; -The resident's CPAP mask was attached to the CPAP tubing and sat uncovered on the top of the CPAP machine. Observation on 07/27/23 at 7:26 A.M., showed the following: -The resident sat in his/her wheelchair, awake, oxygen delivered via a NC at 4L from an oxygen concentrator; -The label on the resident's oxygen tubing was illegible; -The CPAP machine was uncovered and sat directly on the floor behind the resident's recliner; -The resident's CPAP mask was attached to the CPAP tubing and sat uncovered on the floor behind the CPAP machine; -The oxygen tube connector for the CPAP machine touched the floor and was not placed in a baggie. During an interview on 07/25/23 at 10:39 A.M. and 10:59 A.M., CNA I said oxygen tubing was changed every week on Friday nights by the night CNA. The tubing was supposed to be labeled with the date and the staff initials. There should be a new baggie with a date written on it attached to the concentrator for the oxygen tubing to be placed when it was not in use. The CPAP mask and machine should not be on the resident's floor. During an interview on 07/27/23 at 10:50 A.M., Licensed Practical Nurse (LPN) H said the Friday night shift CNA is supposed to change out the oxygen tubing. The tubing should be labeled with a date. A clean baggie should be dated also and placed on the side of the concentrator. When oxygen tubing or a CPAP mask is not in use they are to be stored in a baggie. During an interview on 08/4/23 at 5:57 A,M,, Registered Nurse (RN) L said the following: -CNAs change oxygen tubing every Friday night and the nurse makes sure the task is completed; -There is no documentation of the oxygen tubing changes; -The oxygen tubing was changed for all resident's who use oxygen, about two weeks ago, by CNA staff; -There have to be more than two CNAs working in order for the oxygen tubing to be changed; -A CNA complained that the chores he/she was assigned, including the replacing/changing of the oxygen tubing could not all get completed, so the Director of Nursing (DON) said that chores would be completed if there were three CNAs working at night; -This was a verbal understanding between the DON and the staff, and was not a part of their policy. During an interview on 08/04/3 at 9:20 A.M., RN K said the following: -The resident's CPAP machine was supposed to be next to him/her because he/she sleeps in his/her recliner; -The CPAP machine should not be on the floor, it should be on a table; -When the CPAP machine is not in use it should have a towel underneath the machine; -When the CPAP mask is not is use it should be stored face down on a towel. 4. Review of Resident #10's Continuity of Care Document showed the resident had a diagnosis of COPD. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -No use of oxygen. Review of the resident's care plan, revised on 05/17/23, showed the resident needs assistance with activities of daily living and is on oxygen. Review of the resident's July 2023 physician order sheet showed an order for oxygen at 2-5 liters per minute as needed. Observation on 07/24/23, at 11:49 A.M., showed the resident awake in his/her recliner with oxygen in use. The oxygen tubing attached to an oxygen tank on the back of his/her wheelchair was rolled up and placed around the wheelchair handle, it was not stored in a baggie. The oxygen extension tubing was dated 05/12 (74 days from the date of first use to the date of observation). Observation on 07/25/23, at 06:15 A.M., showed oxygen tubing and a nasal cannula uncovered on the resident's bed comforter (the tubing was not being stored in a baggie when not in use). Observation on 07/25/23, at 6:38 A.M., showed the resident sat in his/her wheelchair in the dining room with oxygen in use via oxygen cylinder on the back of his/her wheelchair. Staff brought out the resident's oxygen concentrator, the resident stood up, took off his/her nasal cannula and sat it in his/her wheelchair seat and sat down on the tubing. Staff gave the resident his/her tubing from the oxygen concentrator and did not intervene when the resident sat down on his/her tubing attached to the cylinder. Observation on 07/25/23, at 7:14 A.M., showed the resident finished eating, stood up and took the nasal cannula and tubing attached to oxygen concentrator, rolled up the tubing and put it in the handle of the concentrator. The resident then took the contaminated nasal cannula that he/she had been sitting on, turned on his/her oxygen and placed the nasal cannula in his/her nose. During an interview on 07/27/23, at 1:10 P.M., the resident said he/she uses his/her oxygen daily. Sometimes staff put baggies to store his/her tubing in on his/her wheelchair and concentrator, but they don't last long and fall off in a day or so. During an interview on 07/27/23 at 6:40 P.M. and 8:30 P.M., also 08/08/23 at 10:17 A.M., the DON said the following: -Oxygen tubing and CPAP masks are expected to be stored in bag when not in use and changed weekly on Friday; -The oxygen tubing should be changed every Friday regardless of the number of CNAs working; -If oxygen tubing is contaminated, by touching the floor or not being stored properly, it should be changed; -Cleaning the nasal prongs would not be acceptable if contaminated; -The CPAP machine should sit on a bedside table, and should not be sitting on the floor; -When the CPAP machine is not in use, it should be unhooked from all of the attachments; -When the CPAP mask is not in use, staff should disconnected it from the CPAP machine and place it on a towel on the bedside table; -The CPAP mask should not be on the floor. MO#00220808

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physician's orders for as needed (PRN) psychotropic medications were limited to 14 days for three residents (Resident #2, #12 and #30), in a review of 13 sampled residents, and one additional sampled resident (Resident #10) unless otherwise indicated by the physician. The facility failed to identify use of psychotropic medications without an indication for use for one sampled resident (Resident #185), when one of his/her medications, quetiapine (an antipsychotic medication), was contraindicated for use in resident's with dementia. Additionally the facility failed to attempt Gradual Dose Reductions (GDR) in two quarters, at least one month apart, or document a clinical contraindication as directed by the facility policy, or have an appropriate indication for use of an antipsychotic medication for two residents (Resident #18 and #22) in a sample of five residents for unnecessary medications. The census was 34. Review of the facility's undated policy, Policy and Procedure for Addressing Consultant Pharmacist Medication Regimen Review Communication Letters to the Physician, showed the following: -Physician either accepts recommendation and writes the order OR, rejects the recommendation and provides a brief explanation, such as in a dated progress note; -Consultant Pharmacist's Medication Regimen Review Communication Letters will be addressed in a timely manner by the Physician, i.e. 30 days; -Any letters not addressed will be sent to the Medical Director to be addressed or to obtain physician cooperation. Review of the facility's undated policy, Policy and Procedure for Psychotropic Reductions, showed the following: -Tapering of any medication may be indicated when, for example: 1. The resident's clinical condition has improved/stabilized the underlying causes have resolved; 2. Non-pharmacological interventions have been effective; -Goal of GDR: 1. Evaluate the continued need for the medication, and; 2. Determine whether the resident is being maintained on the lowest effective dose; -What to evaluate: 1. Resident's target symptoms and the effect of the medication on symptoms (e.g., severity, frequency); 2. Changes in resident's function during previous quarter (e.g., MDS) Whether resident experienced any medication-related adverse consequences during previous quarter; 3. GDR and behavior monitoring now applies to antipsychotics no matter what the indication - behavioral symptoms related to dementia OR psychiatric disorder; -Antipsychotic: 1. Within first year after admission on antipsychotic or after initiation: a. GDR in 2 separate quarters, with at least one month between attempts After First year b. GDR annually 2. GDR is clinically contraindicated if: a. Resident's target symptoms returned or worsened after MOST RECENT GDR attempt WITHIN facility, AND; b. MD has documented clinical rationale; 3. With the appropriate diagnosis of Schizophrenia, and all forms, Huntington's Chorea, Turret's disorder, per CMS guidelines and standards of Practice no GDR is required; -Psychopharm defined as any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders; b. Classes might this include or impact: i. Anticonvulsants; ii. Antidepressants; iii. Anxiolytics - including buspirone, antidepressants; -Reduction (SAME AS ANTIPSYCHOTICS); -Within First year after admission on psychopharm or after initiation: 1. Taper in 2 separate quarters, with at least one month between attempts After First year; 2. Taper annually; -Tapering is clinically contraindicated if: 1. Resident's target symptoms returned or worsened after MOST RECENT tapering attempt WITHIN facility, AND; 2. MD has documented clinical rationale; a. The Resident's clinical condition has improved/stabilized; b. The underlying causes have resolved; c. Non-pharmacological interventions have been effective; -Goal of gradual dose reduction: 1. Evaluate the continued need for the medication; 2. Determine whether the resident is being maintained on the lowest effective dose; -To reduce the use of anti psychotropic medications with the elderly: 1. Evaluate the resident's target symptoms and the effect of the medication on symptoms (example severity, frequency); 2. Evaluate the changes in resident's function during previous quarter; 3. Evaluate whether resident experienced any medication-related adverse consequences during previous quarter; -GDR (gradual dose reduction) and behavior monitoring now applies to anti-psychotropic is no matter what the indication -behavior symptoms related to dementia psychiatric disorder: 1. Within the first year after admission on anti-psychotropic or after initiation; 2. GDR in 2 separate quarters, with at least one month between attempts; 3. After the 1st year: 4. GDR annually; -GDR is clinically contraindicated if: 1. Resident's target symptoms returned or worsened after most recent GDR attempt within facility, AND; 2. MD has documented clinical rationale. Review of drugs.com showed the following: -Abilify is an antipsychotic medication that is not approved for use in older adults with dementia-related psychosis. -Quetiapine is an antipsychotic medication that may increase the risk of death in older adults with mental health problems related to dementia. 1. Review of Resident #10's face sheet showed he/she had a diagnosis of dementia with anxiety (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's consultant pharmacist's medication regimen review, dated 04/26/23, showed the pharmacist asked the physician to review psychotropic lorazepam (Ativan) (a medication given for anxiety) PRN order for addition of a stop date (14 days) or have physician or psychiatry provide progress note for continued use. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/10/23, showed the following: -Cognitively intact; -Diagnosis of psychotic disorder other than schizophrenia; -Anti-anxiety medication administered three days during the observation period. Review of the resident's care plan, revised 05/17/23, showed a problem of psychiatric condition, agoraphobia (fear of places and situations that might cause panic, helplessness, or embarrassment) with panic disorder and anxiety state. Review of the resident's July 2023 physician order sheet (POS) shows an order for Ativan 0.5 milligrams (mg), one tablet every four hours as needed for anxiety/air hunger, with a start date of 02/06/23 and no end date. Review of the resident's medical record showed no evidence the 14 day stop date had been addressed by placing a stop date to the order or by a progress note from physician or psychiatry for continued use. 2. Review of Resident #12's face sheet showed he/she had diagnoses that included unspecified dementia, unspecified severity, with anxiety. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident had severe cognitive impairment; -His/Her diagnoses included dementia and anxiety disorder. -No documentation to show the resident had received anti-anxiety medication in the last seven days. Review of the resident's care plan, edited 05/17/23, showed the following: -Problem: psychotropic drug use; the medication is Ativan; -The resident is at risk for adverse reaction to medications; -Have the pharmacy review the resident's psychotropic medication. Review of the resident's July 2023 POS showed an order for Ativan 0.5 mg, three times a day, PRN, for anxiety; order date of 01/26/23 with not stop date noted. 3. Review of Resident #30's face sheet showed a diagnosis of anxiety disorder. Review of the resident's significant change MDS, dated [DATE], showed the following: -Cognitively intact; -Diagnosis of anxiety disorder; -No administration of anti-anxiety medication during the observation period. Review of the resident's care plan, revised on 05/05/23, showed no indication of use of anti-anxiety medication. Review of the resident's consultant pharmacist's medication regimen review, dated 05/25/23, showed the pharmacist asked the physician to review psychotropic lorazepam PRN order for addition of a stop date (14 days) or have physician or psychiatry provide progress note for continued use. Review of the resident's consultant pharmacist's medication regimen review, dated 06/26/23, showed the pharmacist asked the physician to review psychotropic lorazepam PRN order for addition of a stop date (14 days) or have physician or psychiatry provide a progress note for continued use. Review of the resident's July 2023 POS showed an order for lorazepam, 0.5 mg, one tablet every two hours as needed with a start date of 05/04/23 and no end date. Review of the resident's medical record on 07/27/23 showed no evidence the 14 day stop date had been addressed by placing a stop date to the order or by a progress note from the physician or psychiatry for continued use. 4. Review Resident #2's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Diagnosis dementia, and depression; -No symptoms of depression (PHQ9, a test for depression symptoms, score 00); -Hallucinations; -Antidepressant medication daily. Review of the resident's History and Physical, dated 01/11/23, showed the following diagnosis: -Congestive heart failure (CHF) (condition where the heart does not pump blood as well as it should); -Hypoxia (lack of oxygenation). -Diabetes (inability to regulate sugar). -Atrial fibrillation (abnormal heart rhythm. -Senile degeneration of the brain. -Buttocks ulcer by history. Review of the resident's POS, dated 03/02/23, showed duloxetine (medication for depression) 60 mg daily; the order did not include a diagnosis or indication for use. The POS also showed an order for Trazodone (medication for depression) 50 mg once daily; the order did not include a diagnosis or indication for use. Review of the resident's POS, dated 03/22/23, showed Trazodone 50 mg twice daily. The order did not include a diagnosis or indication for use. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Added diagnosis of anxiety, psychotic disorder, chronic mastoiditis left ear, visual and auditory hallucinations; -No symptoms of depression; -Hallucinations; -Antidepressant medication daily. Review of the resident's POS, dated 07/12/23, showed Ativan, 0.5 mg every four hours, PRN, for agitation/anxiety; the order did not contain a stop date. 5. Review of Resident #185's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnosis of unspecified dementia with agitation. Review of the resident's POS, dated 07/17/23, showed the following: -Quetiapine (an antipsychotic medication for hallucinations and delusions) 25 mg, half a tablet at bedtime; the medication order did not include an indications for use; -Ramelteon (a medication to assist with sleep) eight mg, two tablets at bedtime; the medication order did not include an indications for use; -Sertraline (medication for depression) 50 mg daily; the medication order did not include an indications for use; -Trazodone (medication for depression) 50 mg at bedtime; the medication order did not include an indications for use. Review of the resident's baseline care plan, dated 07/17/23, showed the psycho social well being care section was blank. The baseline care plan did not include the use of psychoactive medications or monitoring for side effects from psychoactive medication. Review of the resident's history and physical, dated 07/19/23, completed by the resident's physician showed the following: ASSESSMENT: -Right hip fracture; -Right humerus (long bone in the arm) fracture; -Right knee pain; -Right forehead contusion (bruise); -Dementia with anxiety; -Hypertension (high blood pressure); -Hyperlipidemia (high cholesterol); -Hypothyroidism (disorder of the thyroid). Review of the resident's medical record showed no documentation the resident had a diagnosis of a psychotic condition, depression, or insomnia. Review of the resident's care plan, dated 07/21/23, did not include include the use of psychoactive medications or monitoring for side effects from psychoactive medication. 5. Review of Resident #18's face sheet showed his/her diagnoses included dementia with mood disorder, anxiety, and delusional disorder. Review of the resident's Care Plan, dated 03/25/21, showed the following: -Behaviors: Resident wanders and refuses medications at times; -He/She is a very private person so he/she resists cares, showers and fights back when being assisted with cares; -He/She has a history of paranoia (delusional beliefs, suspicion and mistrust of others) and delusional (psychotic) disorder; -Administer psychotropic medications as ordered: Abilify (antipsychotic medication for mental illness such as schizophrenia, bipolar disorder or depression) and Zoloft (antidepressant); -Antipsychotic Side Effects from use of Abilify: Observe for side effects of abnormal movements (tremors, shuffling gait, etc.) anxiety, nervousness, compulsive behavior, confusion, drowsiness, fever, change in appetite, change in urination, seizures, Extrapyramidal symptoms (EPS) (are serious side effects that can develop after taking certain antipsychotic medications. They can affect your motor control and coordination); -Assess for stressors in their environment; -Calmly reassure resident; -Pharmacy review; -Zoloft: Observe for adverse reactions: nervousness, nausea, headache, changes in appetite, shakiness, drowsiness, seizures, constipation, blurred vision. Review of the Resident's POS, dated 01/26/22, showed an order for sertraline, 50 mg daily. Review of the resident's Nurses Notes, dated 07/13/22-07/28/22, showed no documentation the resident had hallucinations, delusions, or behaviors. Review of the Resident's POS, dated 07/28/22, showed Abilify, 10 mg daily; the order did not include a diagnosis or indication for use. Review of the resident's Pharmacist Note, dated 8/26/22, showed see nursing report. Review of the resident's Pharmacist Medication Regimen Review Communication to Nursing (nursing report), dated 08/26/22 showed, reviewed the resident for fall assessment, due to co-morbidity diagnosis and medications, the resident is at risk for falls. Review of the resident's records, dated 07/28/22-10/19/22, showed no documentation the resident had hallucinations, delusions, or behaviors. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -No delirium, hallucinations, delusions or behaviors; -New diagnosis of psychotic disorder; -Diagnosis of anxiety and depression; -New antipsychotic medication given on a routine basis; -No GDR attempted; -The physician did not document a clinical contraindication; -Antipsychotic and antidepressant medications daily; -One fall with injury. Review of the resident's Pharmacist Note, dated 10/25/22, showed see nursing report. (The facility did not have this report for the surveyor to review and the pharmacy did not provide upon request). Review of the resident's Dementia Query form, dated 10/26/22, completed by the physician, showed the resident with a diagnoses of dementia with psychotic disturbance, mood disturbance, and anxiety. The physician also wrote hallucinations are not due dementia. Review of the resident's Pharmacist Note, dated 11/27/22, showed see nursing report. (The facility did not have this report for the surveyor to review and the pharmacy did not provide upon request). Review of the resident's records, dated 10/20/22-01/11/23, showed no documentation the resident had hallucinations, delusions, or behaviors. Review of the resident's annual MDS, dated [DATE], showed the following: -No delirium, hallucinations, delusions or behaviors; -Two or more falls with no injury; -Antipsychotic medication given on a routine basis; -No GDR attempted; -The physician did not document a clinical contraindication. Review of the resident's Pharmacist Note, dated 01/27/23, showed see nursing report. Review of the resident's Pharmacist Medication Regimen Review Communication to Nursing, dated 01/27/23, showed, reviewed the resident for fall assessment, due to co-morbidity diagnosis and medications, the resident is at risk for falling. Please review medication regimen, please note falling is a geriatric syndrome that can be improved with deprescribing. Recommend review of regimen to assess if medication changes can be considered. Abilify use increases risk of falls. Review of the resident's Pharmacist Medication Regimen Review Communication to Nursing, dated 01/27/23, showed, reviewed the resident for fall assessment, due to co-morbidity diagnosis and medications, the resident is at risk for falls. Review of a fax communication between facility staff and the resident's physician, dated 01/30/23, showed the facility sent the physician the Pharmacist Medication Regimen Review for the resident, dated 01/27/23, asking the physician to please review the medication regimen. Review of the fax response from the physician, dated 01/31/23, responding to the facility fax of 01/30/23, showed the physician responded no changes at this time. Review of the resident's Pharmacist Note, dated 02/22/23, showed see nursing report. (The facility did not have this report for the surveyor to review and the pharmacy did not provide upon request). Review of the resident's medical records, dated 01/12/23- 04/12/23, showed no documentation the resident had hallucinations, delusions, or behaviors. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No delirium, hallucinations, or delusions; -Behaviors: rejection of care one to three days in the last seven days; -Antipsychotic medication given on a routine basis; -No GDR attempted; -The physician did not document a clinical contraindication. Review of the resident's Pharmacist Medication Regimen Review Communication to Nursing, dated 06/26/23, showed reviewed the resident for fall assessment, due to co-morbidity diagnosis and medications, the resident is at risk for falls. Review of the resident's Pharmacist Note, dated 06/27/23, showed see nursing report. Review of the resident's medical record showed no nursing report to review for the date of 06/27/23. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No delirium, hallucinations, delusions or behaviors; -One fall no injury. -Antipsychotic medication given on a routine basis; -No GDR attempted; -The physician did not document a clinical contraindication. The facility did not attempt a GDR in two separate quarters one month apart as directed by the policy, the physician did not document a clinical contraindication to a GDR, and the order for Abilify did not contain an appropriate diagnosis or indication for use. Abilify is not approved for use in elderly residents with a diagnosis of dementia with psychosis. 6. Review of Resident #22's face sheet showed diagnosis of Alzheimer's disease, dementia with depression, and anxiety. Review of the resident's Physician Orders, dated 09/16/20, showed buspirone (anti-anxiety medication) 10 mg three times a day, quetiapine 25 mg at bedtime, sertraline 100 mg daily, zonisamide (medication for seizures sometimes used for mood) 25 mg twice daily, the orders did not include a diagnosis or indication for use. Review of the resident's annual MDS 07/12/22, showed the following: -Severe cognitive impairment; -Minimal depression; -No symptoms of delirium, hallucinations, delusions, or behaviors; -Antipsychotic, antianxiety, and antidepressant use daily; -No GDR attempt. Review of the resident's Pharmacist Note, dated 07/27/22, showed see physician and nursing report. The facility did not have the Physician report or a response to the physician report. Review of the resident's Pharmacist Medication Regimen Review Communication to Nursing, dated 07/27/22, showed reviewed the resident for fall assessment, due to co-morbidity diagnosis and medications, the resident is at risk for falls. Review of the resident's Pharmacist Note, dated 01/27/23, showed see physician report. Review of the resident's Pharmacist to Physician Report, dated 01/27/23, showed the following: -Please assess risk versus benefit and if your patient would benefit from a reduction of the buspirone 10 mg three times a day, quetiapine 25 mg at bedtime, sertraline 100 mg daily orders; -Or address in your progress note that a change is clinically contraindicated. Review of the resident's physician note, dated 01/31/23, showed the following: -Depression/Dysthymia (long lasting depression): -On multi-drug regimen for his/her mood disorder; -Pharmacist request review of medications buspirone, sertraline and quetiapine; -Nursing staff indicates has episodic emotional events; -Two times in the last week he/she became agitated/tearful yelling for help or at another resident; -During one of those times he/she thought someone broke something of his/hers; -Diagnosis of dementia, anxiety, depression, and unspecified mood disorder (a severe disturbance in mood like depression, anxiety, elation, and excitement); The physician did not document a clinical contraindication for a GDR or an approved indication for use of quetiapine. Review of the resident's quarterly MDS, dated [DATE], showed the following: -No symptoms of delirium, hallucinations, delusions, or behaviors; -Last physician documented GDR as clinically contraindicated 01/31/23; -No antianxiety medication. (The resident continued on buspar which is an antianxiety medication.) Review of the resident's Nurse Practitioner Note, dated 05/30/23, showed the following: -Mood/affect pleasant, agitation absent, minimal short term deficits noted today, speech and eye contact normal; -Diagnosis include Alzheimer's disease, unspecified mood disorder, diabetes mellitus, and high blood pressure; -Alzheimer's disease ongoing progression; -Unspecified mood [affective] disorder no change today, overall is doing well. (The practitioner did not document any clinical contraindications.) Review of the resident's Pharmacist Note, dated 06/06/23, showed, reviewed per nursing request, related to decline in condition, see nursing report. Review of the resident's medical record showed no nursing report to review for the date of 06/06/23. (The facility could not provide a nursing report for this date). Review of the resident's significant change MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No symptoms of delirium, hallucinations, delusions, or behaviors; -Mild depression. The facility and the physician did not attempt a gradual dose reduction or document a clinical contraindication or indication/diagnosis for use of Quetiapine for the resident. During an interview on 07/27/23, at 6:30 P.M., the Director of Nursing said the following: -PRN psychotropic medications are expected to have a stop date of 14 days or less; -Antipsychotic medications should have an appropriate clinical diagnosis for use; -The facility has physicians that are non compliant; they will not give clinical contraindications as to why they want to continue the psychotropic beyond the 14 days and do not give an appropriate clinical diagnosis for use of antipsychotic medications; -The pharmacy consultant sends out letters to the physician's for GDR's every three or six months; -The pharmacist sends a spread sheet to the DON to show when he (the pharmacist) recommends a GDR; -Recommendations are then sent to the physicians; some review when here on rounds and some are faxed as the physician prefers; -The Medical Director always addresses his pharmacist recommendations, other physicians are hit and miss; -If a resident is having hallucinations, or any behaviors, she expects those to be documented in the nurses notes or on the medication administration record; -The pharmacist is responsible to make the GDR recommendations and to ask for PRN stop dates. During an interview on 07/24/23, at 10:00 A.M., the Administrator said the facility has issues with psychotropic medication use. The physicians are resistant to attempt the pharmacist recommendations. The facility started a process improvement plan, but it requires physician participation to make progress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure insulin pens were labeled when opened for two residents (Resident #28 and #31 ), in a review of 13 sampled residents and one additional resident (Resident #16 ). The facility census was 34. Review of the undated, facility Insulin Policy, showed it did not provide direction to staff regarding the labeling of insulin pens when opened. Review of the manufacturer's information for Humalog insulin suggests after opening a vial or pen of Humalog, throw away an opened vial or pen after 28 days of use, even if there is insulin left in the vial. 1. Review of Resident #16's [DATE] physician's orders (POS), showed an order for Humalog (fast acting insulin) KwikPen 100 units/milliliter (ml), give 12 units subcutaneously (SQ) four times a day. Hold if fasting blood sugar (a finger stick procedure to determine the amount of sugar in the blood) is less than 200. The resident had a diagnosis of diabetes. 2. Review of Resident #31's [DATE] POS showed the following: -Humalog KwikPen 100 units/ml, give 9 units SQ three times a daily with meals; -Humalog KwikPen 100 units/ml per sliding scale (an amount to be administered is based on a blood sugar check) three times a day. If blood sugar is 151-200 give 4 units. If blood sugar is 201 to 250 give 6 units. If blood sugar is 251 to 300, give 8 units. If blood sugar is greater than 300, give 10 units. The resident had a diagnosis of diabetes. 3. Review of Resident #28's [DATE] POS showed an order for Humalog KwikPen 100 units/ml give per sliding scale before meals. If blood sugar is 150 to 199, give 1 unit. If blood sugar is 200 to 249, give 2 units. If blood sugar is 250 to 299, give 3 units. If blood sugar is 300 to 349, give 4 units. If blood sugar is 350 to 399, give 5 units. If blood sugar is 400 to 449, give 6 units. If blood sugar is greater than 449, call physician. The resident had a diagnosis of diabetes. Observation on [DATE] at 8:50 A.M., of the C hall medication cart, showed the following: -One opened Humalog KwikPen 100 units/ml labeled with Resident #16's name-no open date; -One opened Humalog KwikPen 100 u/ml labeled with Resident #28's name-no open date; -One opened Humalog KwikPen 100 u/ml labeled with Resident #31's name-no open date; -With no open dates, staff could not determine if these open, in-use insulin vials had expired based on an open date and manufacturer's recommendation to discard 28 days after opening. During interview on [DATE] at 8:50 A.M. Certified Medication Technician (CMT) F said the following: -The residents' insulin pens were currently opened and in use; -Whoever opens the insulin pen should date the pen when opened. During interview on [DATE] at 6:40 P.M., the Director of Nursing (DON) said insulin pens should be dated when opened.

Based on interview and record review, the facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 34. Review of the facility's policy, Antibiotic Stewardship, showed the following: -The facility is committed to encouraging appropriate use of antibiotics; -Record all antibiotics used in the facility on a patient by patient basis. (dose, duration, indication); -Report the culture reports, antibiotic use to treat the infection, and outcome of treatment; -Obtain antibiogram for the region from the reference laboratory and provide it at the nurse's stations and provide a copy to each provider; -Use Interact tools (SBAR) to communicate resident change in condition to the provider; -Alert the attending when antibiotics have reached 14 days and obtain new orders; -Report all infections to the Health Department. For clusters of infections, ask the Health Department to test for the identity of the infecting agent; -Review proper culture collection techniques with staff; -Educate residents about potential adverse events associated with antibiotics (example: C. Diff); -Revisit antibiotic effectiveness after 48 hours. Record review of facility Antibiotic Medications Report, provided by the Director of Nursing, showed the following: -Review of the last 12 months of antibiotic use showed a printed list of resident antibiotic use from the electronic health record program; -For UTI's, no indication of culture and sensitivity or organism being treated was noted; -For wound infections, no indication of type of infection or signs and symptoms of infection was noted; -The facility did not use an infection control log ; -No trending or tracking of infections per wing completed; -No tracking of post antibiotic use was completed; -No indication of staff education provided if a rise of infections was noted; -No indication of resident education with infection noted. During an interview on 07/27/23, at 11:57 A.M., the Infection Preventionist (IP) said the following: -She had recently completed the (IP) program a month ago; -She does not get dedicated IP time and it was hard for her to complete what she feels like is necessary for the IP program; -She also serves as a charge nurse when she is working; -She thought there was a book in the Director of Nurses (DON) office that the antibiotic use was tracked in; -She knows she has seen tracking of infections on a facility map that used different colors to indicate different types of infections, but was not sure if that was in her training or at the facility; -She has not completed any tracking of infections since she took over as IP. During an interview on 07/27/23, at 12:30 P.M. and 6:40 P.M., the DON said the following: -The current IP was new and the facility had at least three IP's in the last year or so; -She has been printing the antibiotic use report monthly and writes what the antibiotic was being used for, but did not indicate what the specific infection was; -She has not filled out a log or a surveillance tracking for the infections due to Covid, less staffing, and changes with the IP; -Examples of tracking logs in the IP policy binder are just suggestions of ways to track infections; -The facility used to track infections on a facility map, but they had not done that in quite some time; -Infections should be tracked and trended; -The map would be beneficial for tracking trends; -The goal of the antibiotic stewardship program was to not have unnecessary antibiotic use for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pneumococcal (lung inflammation caused by bacterial or viral infection) vaccine for two residents (Resident #2, and #235), in a review of five sampled residents, or provide education for refusal of vaccine for one resident (Resident #30). The facility census was 34. Review of the facility's policy, Pneumococcal Vaccine, updated January 2023 showed the following: -The best way to prevent pneumococcal disease is by getting vaccinated; -Two pneumococcal vaccines are recommended for adults: -Pneumococcal conjugate vaccine (PCV15, PCV20); -Pneumococcal polysaccharide vaccine (PPSV23); -The Centers for Disease Control (CDC) recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 yeas or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown; -If PCV15 is used, this should be followed by a dose of PPSV23 one year later. The minimum interval is eight weeks and can be considered in adults with an immunocompromising condition, cochlear implants, or cerebrospinal fluid leak; -If PCV20 is used, a dose of PPSV23 is NOT indicated; -See pneumococcal vaccinations;summary of who and when to vaccinate for CDC guidance on vaccination options for adults who have previously received a pneumococcal conjugate vaccine; -New admissions will be offered pneumococcal vaccine if the resident meets outlined requirement for receiving; -The policy did not address providing education on vaccinations to residents or their representatives, did not address obtaining consents, or the documentation of refusal of vaccinations. Review of the Centers for Disease Control (CDC) recommendations for pneumococcal vaccine timing, dated 4/1/22, showed the following: -CDC recommends pneumococcal vaccination for adults [AGE] years old or older, and for adults 19 through [AGE] years old with certain underlying medical conditions including cigarette smoking; -For adults who have never received a pneumococcal vaccine, or those with unknown vaccination history, one dose of PCV15 (15-valent pneumococcal conjugate vaccine) or PCV20 (20-valent pneumococcal conjugate vaccine) should be administered; -If PCV 20 is used, their pneumococcal vaccinations are complete; -If PCV 15 is used, follow with one dose of PPSV23 (23-valent pneumococcal polysaccharide vaccine) with a recommended interval of at least one year; -For adults who have previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (PCV), one does of PCV15 or PCV20 may be administered with an interval of at least one year; -For adults 65 years or older without an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant, who have previously received PCV13 at any age, it is recommended to receive one dose of PPSV23 at or after [AGE] years of age (at least one year after PCV13 was received). Their pneumococcal vaccinations are complete; -For adults 19 years or older with an immunocompromising condition who have previously received a PCV13 at any age, CDC recommends two doses of PPSV 23 before age [AGE] years and one dose of PPSV23 at the age of 65 or older: -Administer a single dose of PPSV23 at least 8 weeks after the PCV13 was received; -If the patient was younger than [AGE] years old when the first dose of PPSV23 was given and has not turned [AGE] years old yet, administer a second dose of PPSV23 at least five years after the first dose of PPSV23. This is the last dose of PPSV23 that should be given prior to [AGE] years of age; -Once the patient turns [AGE] years old and at least five years have passed since PPSV23 was last given, administer a final dose of PPSV23 to complete their pneumococcal vaccinations. 1. Review of Resident #2's face sheet showed the following: -admission date 01/5/23; -Resident is over [AGE] years of age; -Diagnoses of congestive chart failure (inability to adequate pump blood through the heart); -Diabetes mellitus (inability to regulate blood sugar); -Chronic respiratory failure with hypoxia; (lack of oxygen) -Dependence on supplemental oxygen; -Chronic obstructive pulmonary disease (disease affecting the lungs making it difficult to breathe). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 04/05/23, showed the following: -Moderate cognitive impairment; -Oxygen use; -Pneumococcal up to date. Review of the resident's electronic Preventative Health record, showed one pneumococcal vaccine administered 11/01/22, type unknown, administered outside of the facility. Review of the resident's admission Tuberculosis Screen and Immunization review, dated 01/05/23, showed the following: -The resident is 65 years or older; -Pneumococcal vaccination is complete. -The form did not list the year and type of vaccinations received. During an interview on 06/27/23, at 2:32 P.M., the Director of Nursing said the following: -The admission nurse is expected to obtain vaccination data for residents; -If a vaccination is given prior to admission, the nurse is expected to get the date and the specific type of vaccination given; -There is no way to verify if the nurse had the specific immunization types and dates when he/she recorded them as complete and up to date; -She cannot see the dates or specific vaccinations administered for Resident #2 in the medical record; -She called the health department and they had a record the resident received the PPSV23 on 01/01/09; -She does not know if the resident has had PCV13, PCV15 or PCV20. 2. Resident of Resident #30's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included malignant neoplasm of the colon (colon cancer), atrial fibrillation (an irregular heart beat) and diabetes mellitus (too much sugar in the blood stream); -The resident was over [AGE] years of age, was his/her own person and had an emergency contact/significant other listed. Review of the resident's significant change MDS, dated [DATE], showed the resident was up-to-date on pneumococcal vaccination. Review of the resident's preventative health care report showed no vaccines found. Review of the resident's medical record showed no documentation of education provided related to refusal of pneumococcal vaccination as well as no consent form offering vaccination with refusal of vaccination by resident or responsible party. During an interview on 08/08/23, at 3:25 P.M., the resident's emergency contact/significant other said the following: -The resident refuses to take the influenza or pneumococcal vaccination; -He/She does not recall signing anything on admission related to vaccination status; -No education was provided to the resident by staff related to benefits/risk of the vaccination. 3. Review of Resident #235's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included atherosclerotic heart disease (high cholesterol), presence of a cardiac pace maker (an implanted device to regulate heart rate and rhythm), right left lung mass (potential cancer), and hemiplegia following cerebral infarction (paralysis of one side of the body following a stroke); -The resident was over [AGE] years of age. -The resident had a responsible party. Review of the resident's admission MDS, dated [DATE], showed the resident is up-to-date in pneumococcal immunizations. Review of the facility provided, immunization record, showed the following: -PPSV23 received on 10/01/2020 outside of the health care setting; -No indication of pneumococcal conjugate vaccine (PCV13, PCV15 or PCV20) being offered or education provided regarding the vaccine. Review of the resident's medical record showed no documentation of education provided related to refusal of pneumococcal vaccination as well as no consent form offering vaccination with refusal of vaccination by resident or responsible party. During an interview on 08/08/23, at 1:13 P.M., the resident's responsible party said he/she would like the resident to be up-to-date on his/her pneumococcal vaccinations. The resident had not been offered the immunization or education. During an interview on 08/08/23 at 1:53 P.M., Licensed Practical Nurse H said the following: -When a resident is admitted to the facility, staff ask if they are up-to-date on their vaccinations; -Vaccinations are documented in the preventative health record; -Staff ask the resident what type of pneumococcal vaccine they received; -He/She was unsure if there is a specific consent form but feels like there is; -The Director of Nursing (DON) or the MDS coordinator tracks the vaccinations. During an interview on 08/10/23, at 3:30 P.M., the MDS coordinator said the following: -The nurse doing an admission is responsible for asking about vaccinations and updating the preventative health record when the dates are provided; -Long term residents vaccination status is verified by the DON and herself yearly in November when preparing for the local health department to give the facility annual vaccinations; -Dates of vaccinations are verified by the admitting nurse or herself through the residents physician's office, local health department or medical records provided on admission; -The DON and MDS coordinator are responsible for making sure all of the residents are up-to-date on vaccinations and review the records yearly in November; -Consents for vaccinations are obtained by the local health department when they give vaccinations in November; -If a resident refuses a vaccination, the risks and benefits of vaccinations are discussed with the resident at that time by the nurse or health department; -She knows the resident is up-to-date for the purpose of MDS completion through the preventative health record in the eHr (electronic health record), the vaccine observation form, the medical record, the bottom of the Medicare verification form or by calling the health department or physician's office; -The facility follows the CDC recommendation for pneumococcal vaccinations. During an interview on 07/27/23, at 11:57 A.M., the Infection Preventionist said the following: -On admission, resident vaccinations are verified to see if they are up-to-date; -Usually a list accompanies the resident on admission with vaccination history; -She is not sure if there is a consent for vaccinations that is signed on admission or at any time; -She is unsure if education is provided to a resident if a resident refuses a vaccination; -If she is unable to verify what type of pneumococcal vaccination was given, she would ask the family or call where the immunization was received; -CDC recommendations for all vaccinations should be followed; she knows there are specific requirements but she is unsure what those are without looking at the recommendations. During an interview on 07/27/23, at 3:30 P.M. and 6:40 P.M., the DON said the following: -Vaccinations should be up-to-date for all residents; -A vaccination record is obtained on new admissions and recorded in preventative health record; -No one is tracking vaccination status for residents at this time; -She was unsure if education is provided to any resident that refuses vaccinations; -She was unsure if there is a vaccination consent form that is obtained on admission.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety. Staff failed to discard food that was expired or showed visible signs of deterioration and failed to label and date food items. Staff failed to shield lights located in food storage areas. The facility failed to ensure sanitary practices when staff failed to ensure tableware was protected from moisture, debris, and other contaminants and failed to ensure surfaces, such as ceiling vents and ice machines, were clean to prevent potential contamination. Staff failed to ensure hygienic practices when preparing and serving food and beverages to residents and employ proper hand hygiene, hair restraint usage, and surface sanitization practices. The facility census was 34. Review of the facility policy, Safety and Sanitation Best Practice Guidelines - Safe Food Storage, revised November 2017, showed the following: -All ready to eat food prepped in-house must be labeled with the following information - name of food item and the date by which it should be eaten or discarded; -Securely wrap or cover all food items; -Foods will be stored in their original container or a National Sanitation Foundation approved container or wrapped tightly in moisture-proof film, foil, etc. clearly labeled with the contents and the use by date; -Dry Storage: all non-potentially hazardous foods shall be stored in a clean and dry location, not exposed to splash, dust, or other contamination; -Discard food items that have passed the manufacturer's best by, use-by, or expiration date. Review of the facility policy, Safety and Sanitation Best Practice Guidelines - Handwashing, revised November 2017, showed the following: -All partners handling food products or contacting equipment used in food preparation should wash their hands and forearms with soap and warm water using proper procedures. The basic practice of hand washing is the single most important action that can be taken to prevent the spread of disease; -Hands should be washed after touching hair, face, or body; leaving and returning to a food preparation area; before putting on and after removing gloves; after cleaning or taking out the garbage; touching clothing or apron; or after touching anything that might contaminate hands, such as dirty equipment, work surfaces, or towels; -Method: thoroughly wet hands and exposed arms up to the elbow, apply soap and rub hands and forearms briskly for at least 10-15 seconds, rinse hands and exposed arms thoroughly under clean, warm running water to remove soap, dry hands and arms with disposable paper towel or air-drying device, turn off the faucet with a disposable paper towel and discard. Review of the facility policy, Safety and Sanitation Best Practice Guidelines - Chemical Sanitizing, revised November 2017, showed the following: -An ideal cleaning and sanitizing station will have two color-coded buckets: green for detergent/cleaning solution and red for sanitizing solution, after cleaning, the area will be sanitized with sanitizing solution, towels and cloths will be stored in the solution and be available to clean and sanitize work areas during food preparation; -At the end of the afternoon shift, the soiled towels and cloths are taken to the laundry and washed separately from other laundry; -Chemical sanitizing may be accomplished either by immersing a clean object in a specific concentration of sanitizing solution for a required period of contact time or by rinsing, swabbing, or pressure spraying the object with a specific concentration of sanitizing solution; -Quaternary ammonium compound solution: concentration as indicated on manufacturer's directions included in the labeling [concentration of 150-400 ppm (parts per million) mg/L (milligrams per liter) and minimum temperature of 75 degrees Fahrenheit (F)], with an exposure time of at least 30 seconds; -Iodine Solution: concentration between 12.5-25 ppm mg/L and minimum temperature of 68 degrees F with an exposure time of at least 30 seconds; -The immersion time of chlorine sanitizing solution is based on the concentration range (mg/L) and the temperature of the solution: -25 ppm mg/L at 120 degrees F, exposure time at least 10 seconds; -100 ppm mg/L at 55 degrees F, exposure time of 10 seconds; -50 ppm mg/L at 75 degrees F, exposure time of 7 seconds; -If another solution of a chemical sanitizer is used, the solution must achieve sanitization and must be approved, or if a chemical sanitizer other than chlorine, iodine, or a quaternary ammonium compound is used, it shall be applied in accordance with the manufacturer's use directions included in the labeling; -Strength of sanitizing solution should be evaluated using proper test strip. Solution will be discarded and fresh solution made when needed. 1. Observation on 07/24/23 at 9:04 A.M., of the walk-in cooler, located in the facility kitchen, showed the following: -One opened, half-full bag of shredded cheese, with the top corner cut off and the top of the bag loosely folded over and not securely sealed; -One opened, three quarters-full package of butter, loosely wrapped in the manufacturer's paper packaging, was not securely sealed. Observation on 07/24/23 at 11:12 A.M. of the upper cabinets, located in the B Hall dining room, showed the following: -An opened 80-ounce container of peanut butter, with a manufacturer's best by date of 02/05/22; -Approximately 15 individually-wrapped peppermint patties, with a manufacturer's best by date of 01/20/23; -One unopened 16-ounce container of peanut butter, with a manufacturer's best by date of 05/02/23; -Three 1-ounce packages of animal crackers, with no visible expiration date; -Seven clear zipper-top bags of chocolate chip bars, with no labeling or use-by date; -Approximately 15 clear zipper-top bags of rice crispy bars, with no labeling or use-by date. Observation on 07/24/23 at 1:21 P.M., in the dry storage room located adjacent to the kitchen, showed a box of approximately 30 potatoes sat on a metal cart. A foul odor came from the box of potatoes and two potatoes had brown-colored liquid and foam coming from the interior onto the exterior surfaces of the potatoes. During an interview on 07/25/23 at 1:03 P.M., Dietary Partner C said foods should be labeled, dated, and properly sealed. Expired or spoiled foods should be discarded. During an interview on 07/25/23 at 2:56 P.M., [NAME] B said the following: -Food items should be labeled and dated, and expired foods should be discarded; -He/She monitored food items in the refrigerator and upper cabinets in the B Hall dining room on a daily basis when he/she worked; -He/She had overlooked the expired containers of peanut butter in the upper cabinets; -He/She was unaware of the unlabeled and undated cookies and rice crispy bars. 2. Observation on 07/24/23 at 9:13 A.M., of the dry storage room located adjacent to the kitchen, showed the following: -Two of four ceiling light fixtures, that contained glass fluorescent light bulbs, did not have covers; -A large, uncovered pan of dessert bars sat cooling on top of the reach-in beverage cooler, located below the area of the uncovered bulbs, in preparation for the lunch meal. During an interview on 07/25/23 at 1:13 P.M., the Dietary Manager and Assistant Dietary Manager said glass light bulbs should be properly shielded in food storage, preparation, and service areas. During an interview on 07/23/23 at 12:43 P.M., the Maintenance Supervisor said the two lights in the dry storage room had been without covers for a couple of months. He wasn't able to order new covers due to them no longer being made. During an interview on 07/25/23 at 1:58 P.M., the Administrator said she was unaware of the unshielded lights in the dry storage room. 3. Observation on 07/24/23 at 1:00 P.M., of a two-tiered cart located inside the dishwashing room, showed the following: -Stacks of several small bowls and plates on the cart were not inverted; -One bowl, located at the top of a stack of bowls, contained small, dried pieces of debris; -The space between two stacked bowls contained a large clump of dust. Observation on 07/24/23 at 1:02 P.M., of a stack of clean trays located in the kitchen food serving area, showed two, approximate 0.25 inch pieces of moist, tan-colored food debris on the edge of two trays. During an interview on 07/25/23 at 1:13 P.M., the Dietary Manager and Assistant Dietary Manager said dishes and food trays should be clean, dry, and inverted or covered to protect them from contamination. 4. Observation on 07/24/23 at 12:55 P.M., of the approximate 2-foot by 2-foot ceiling vent cover, located near the walk-in cooler and above the food preparation counter in the kitchen, was covered with a moderate layer of dust. During an interview on 07/25/23 at 1:58 P.M., the Administrator said she expected ceiling vents in the kitchen to be clean. The Maintenance Supervisor was responsible for cleaning the ceiling vents in the kitchen. 5. Observation on 07/24/23 at 10:32 A.M., of the ice machine located in the clean utility room on C Hall, showed the following: -An approximate 6-inch by 0.25 inch area of moist, black-colored debris, located on the right interior metal piece above the ice storage area; -Several small chunks of moist, pink and brown colored debris, located on the right side of the interior metal piece above the ice storage area. During an interview on 07/25/23 at 12:41 P.M., the Director of Nursing said the Maintenance Supervisor was responsible for cleaning the ice machines, which were located in the kitchen and clean utility room on C Hall. During an interview on 07/25/23 at 12:43 P.M., the Maintenance Supervisor said he cleaned the ice machines monthly and a professional company cleaned and sanitized the machines every six months. The C Hall ice machine routinely had excess moisture on the interior metal piece located above the ice storage area which could contribute to debris buildup. 6. Observation on 07/24/23 at 9:32 A.M., in the food preparation area located in the kitchen, showed the following: -Dietary Partner C prepared desserts for the lunch meal service; -He/She dropped a measuring cup on the floor, picked up the measuring cup with his/her gloved hands, and brought the measuring cup to the dishwashing room to be washed; -He/She did not wash his/her hands or change his/her gloves; -He/She used his/her soiled gloved hand to carry the washed measuring cup from the dishwashing room to the food preparation area; -He/She placed the measuring cup on the preparation counter while he/she washed his/her hands and changed gloves; -He/She then used the measuring cup to continue preparing desserts. Observation on 07/24/23 from 11:42 A.M. to 12:02 P.M., in the food serving area located near the kitchen during the lunch meal service, showed the following: -Dietary Partner C used his/her bare hands to obtain clean meal trays and place drinks, condiments, placemats, meal tickets, and silverware onto the meal trays; -He/She dropped an individual container of butter onto the floor, used his/her bare hands to pick up the butter container, and placed the dirty butter container back into the container of other butter containers located on the service cart; -He/She did not discard the butter container that fell onto the floor and did not wash his/her hands; -He/She used his/her bare hands to hand a glass of lemonade to a staff member in the dining room to give to a resident; -While handing the glass of lemonade to the staff, he/she touched the upper drinking surface of the glass with his/her bare hands; -He/She rubbed his/her nose and adjusted his/her glasses multiple times throughout the meal service; -He/She did not wash his/her hands and continued assisting with the meal service. Observation on 07/24/23 at 12:52 P.M., in the food serving area located near the kitchen, showed the following: -Dietary Partner C used his/her bare hands to place new disposable lids into a container; -He/She rubbed his/her nose and adjusted his/her glasses with his/her bare hands; -He/She did not wash his/her hands and continued placing the lids into the container. Observation on 07/25/23 from 6:11 A.M. to 6:34 A.M., in the food preparation area located in the kitchen, showed the following: -Dietary Partner C used his/her bare hands to prepare beverages in pitchers for the breakfast meal service; -He/She adjusted his/her glasses and rubbed his/her nose; -He/She did not wash his/her hands and continued preparing the beverages; -He/She used his/her bare hands to hold a whisk to mix the beverage contents in a pitcher while two of his/her fingers made contact with and extended approximately 2 inches inside the pitcher; -He/She picked up the pitcher using his/her hand on the handle and his/her thumb on the inside portion of the pitcher; -He/She placed the pitcher on a cart by using his/her hand on the handle and his/her first two fingers touching the outside surface of the pouring spout of the pitcher; -He/She washed his/her hands, adjusted his/her glasses and pushed the cart of beverage pitchers to the walk-in cooler; -He/She adjusted his/her glasses, took a clean tray to the kitchen, obtained mugs, filled the mugs with coffee, put disposable lids on the mugs, and placed the mugs on the tray; -He/She placed silverware on a cart, rubbed his/her nose, did not wash his/her hands, moved clean trays to a cart in the serving area, adjusted his/her glasses, and put bowls of cereal on a cart; -He/She filled residents' mugs with coffee. When he/she picked up the mugs, he/she used his/her bare hands to touch the rims and drinking surfaces of the mugs. Observation on 07/25/23 from 6:42 A.M. to 7:28 A.M., in the food serving area located near the kitchen during the breakfast meal service, showed the following: -Dietary Partner C used his/her bare hands to obtain clean trays and placed drinks, condiments, bowls of cereal, meal tickets, and silverware onto the trays; -At multiple intervals, he/she scratched the side of his/her head, adjusted the inside of his/her clothing, adjusted his/her glasses, touched the side of his/her face, and rubbed his/her nose; -He/She did not wash his/her hands and continued assisting with the meal service. During an interview on 07/25/23 at 1:03 P.M., Dietary Partner C said staff should wash their hands every time they enter the kitchen, go to the bathroom, touch their face, change gloves, or drop something on the floor. During an interview on 07/25/23 at 2:56 P.M., [NAME] B said staff should not handle dishes by the eating or drinking surfaces and should handle them using the sides or handles of the dishes. During an interview on 07/25/23 at 1:13 P.M., the Dietary Manager and Assistant Dietary Manager said staff should properly wash their hands and change gloves as necessary, such as when picking up items from the floor, touching their face, moving from dirty to clean tasks, changing tasks, and going in and out of doors. 7. Observations on 07/25/23 at 6:19 A.M., 6:28 A.M., and 6:34 A.M., in the food preparation area located in the kitchen, showed the following: -Dietary Partner C prepared containers of beverages for the breakfast meal service; -He/She wore a hairnet on his/her head; -An approximate two-inch section of his/her hair, along the entire circumference of his/her hairline, was uncovered by the hairnet. Observation on 07/25/23 from 6:47 A.M. to 7:28 A.M., in the kitchen serving area during the breakfast meal service, showed the following: -Dietary Partner C prepared and served residents' drinks and food items onto trays; -He/She wore a hairnet on his/her head; -An approximate two-inch section of his/her hair, along the entire circumference of his/her hairline, was uncovered by the hairnet. During an interview on 07/25/23 at 1:13 P.M., the Dietary Manager and Assistant Dietary Manager said staff should properly wear hairnets while working in the kitchen. 8. During an interview on 07/24/23 at 6:39 A.M., [NAME] A said the red-colored buckets in the kitchen contained sanitizing solution and the green buckets contained a detergent solution. Observation on 07/24/23 of the red sanitizing buckets located in the kitchen showed the following: -At 1:10 P.M., the disposable cloths, located in the bucket in the three-compartment dish sink, were not fully submerged in the sanitizing solution and approximately 2 inches of cloth material was located above the surface of the solution; -At 3:24 P.M., the disposable cloths, located in the bucket in the two-compartment food preparation sink, were not fully submerged in the sanitizing solution and approximately 3 inches of cloth material was located above the surface of the solution. Observation and interview on 07/24/23 at 3:25 P.M. and 07/25/23 at 1:03 P.M., showed the following: -Kitchen staff used a commercial sanitizing solution diluted with water in red colored buckets and in spray bottles; -Dietary Partner C mixed the sanitizing solution in a spray bottle by filling it about halfway with sanitizer and the rest of the bottle with hot water. He/She sprayed the solution on surfaces and immediately wiped the surface; -During interview, Dietary Partner C said he/she was unaware of the manufacturer's directions for sanitizer mixing concentrations or surface contact times. He/She did not test the chemical concentration of the sanitizing solutions, such as with chemical test strips, nor was he/she trained on how to test the solutions; -Observation of the sanitizing spray bottle's label read: -EcoLab Smart Power Sink and Surface Cleaner Sanitizer; -Active ingredients: dodecylbenzenesulfonic acid and lactic acid; -The product in this container must be diluted at the use rate of 0.27 - 1.41 fluid ounces per gallon of water as directed on the concentrate product label; -Diluted product in this container is ____ fluid ounces per gallon water [no diluted product ounces were marked on the bottle]. Follow the directions for use on the concentrate label when applying this product. Observation on 07/25/23 from 6:11 A.M. to 6:34 A.M., in the food preparation area located in the kitchen, showed the following: -Dietary Partner C wiped the food preparation counter with a cloth from a green bucket of detergent solution, located in the food preparation sink; -He/She left the cloth on the counter, washed his/her hands, adjusted his/her glasses, and used the cloth to wipe tomato juice splatters from the counter and manual can opener; -While holding the cloth in his/her bare hand, he/she opened the trash can lid and discarded trash into the can; -He/She did not wash his/her hands; -He/She used his/her bare, dirty hands to wipe the preparation counter with the cloth (that touched the trash can lid); -He/She left the cloth on the preparation counter and took a container of tomato juice into the walk-in cooler; -He/She did not use sanitizing solution to sanitize the food preparation counter or can opener. During an interview on 07/25/23 at 2:56 P.M., [NAME] B said the following: -He/She did not test the chemical concentration of the sanitizing solution in the red buckets; -He/She was unaware of a log sheet to record sanitizer chemical levels; -The sanitizer buckets were already filled when he/she arrived to work in the afternoons and staff dumped the sanitizer buckets after the last meal service of the day. During an interview on 07/25/23 at 1:13 P.M., the Dietary Manager said the cooks were responsible for maintaining the sanitizing solutions in the kitchen, including testing for chemical levels of the solutions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review ,the facility failed to develop a policy to address Legionella Control that included specific control parameters based on Center for Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards and failed to complete a facility assessment to identify potential sources of Legionella growth (started but not completed). The facility's water management team had not had a meeting, and the facility's water flow map was not completed and did not implement the facility's Legionnaire Disease (severe pneumonia like infection caused by contaminated water) policy that instructed staff how to monitor residents for Legionnaire's disease. The facility also failed to ensure staff used gloves while giving a resident a shower or change a catheter bag when the catheter bag connector landed on the wet shower floor for one resident, (Resident #19), in a sample of 13 residents. Additionally, the facility failed to ensure staff changed gloves and washed hands as indicated during provision of care for one resident (Resident #2). The facility census was 34. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17, showed the following: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard (https://www.cdc.gov/Legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Review of the Centers for Disease Control and Prevention Legionella Environmental Assessment Form, undated, showed Legionella generally grow well between 77 degrees Fahrenheit (F) and 113 degrees F. The optimal growth range for Legionella is between 85 degrees F and 108 degrees F. Growth slows between 113 degrees F and 120 degrees F, and Legionella begin to die above 120 degrees F. Growth also slows between 68 degrees F and 77 degrees F, and Legionella become dormant below 68 degrees F. Review of the facility's Legionella Control policy, revised 07/27/23, showed the following: -Legionella risk management team consist of: Administrator (ADM), Maintenance Director, Director of Nursing (DON), Infection Preventionist (IP), and the Director of Housekeeping and Laundry Services; -The team will do risk analysis by: Gather information on the water supply system, gather information on the water uses and users within the facility, describe the system including treatment, discuss the quality of incoming water, identify hazards associated with the facility's water system; -Inventory of system components: a. The facility listed eight water heaters and their location; b. Water treatment-facility adds no chemicals to their water; c. Pipework was done in 1982; d. Water outlets: Hot water; 32 resident sinks, 2 public sinks, 2 shower/sink (therapy); Cold water; 22 showers (resident) and 4 showers (common). The numbers do not equal hot outlets to cold outlets. e. Ice Machines 2, did not give details of ice machines; -System description, there is a small diagram that does not give the complete water flow of the building (did not include all facility plumbing); -Incoming potable water is city water; -Uses of water is listed; -Emergency water supply is listed; -System details: Incoming water is supplied to a water heater set at the setting between medium or high. If the temperatures do not register between 105-120, the water heaters are adjusted by turning a screw, there is no temperature screen/panel (temperature range is not preferred range); -Summary of Actions: a. Utilize ASI Services to detect if Legionella is present bi-annually; b. Ensure hot water heaters function at or about 140 degrees Fahrenheit in order to kill the Legionella virus (bacteria can no longer grow above 140 degrees F); c. Monitor [NAME] Public water system quality reports for appropriate chloride levels (bacteria is eradicated between 0.5-2 parts per million (PPM)). -Responding to detections or cases, the team will: a. Identify measures for responding to Legionella detections and cases in various scenarios (plan not developed at this time); b. Identify key people and their responsibilities and authorities when responding to detections or cases; -Maintenance Director will be responsible for water sampling, system investigation and complete system flush; -Administrator will be responsible for media liaison; -Clinical (DON and IP roles not identified); c. Develop written procedures for required actions (policy not fully developed) The facility did not complete the policy, the temperature ranges were not within the ASHRAE recommendations to prevent Legionella growth, cold water temperatures were not addressed. Review of the facility's Water Management Program, undated, showed the following: -Water management team consist of Administrator (ADM)-facility administration, Maintenance Director-director of management, Director of Nursing (DON)-facility management, Infection Preventionist (IP)-infection preventionist, and the Director of Environmental Services-facility engineer/environmental; -Facility administration role: Communication of new construction, equipment changes, treatment changes, water usage change, municipal water supply change; Oversight of data review, case review, updates to regulations; Response to update process flows, update written description, disseminate information for training; -Facility Management role: Confirmation of program performance, risk management, and quality assurance; -Infection Preventionist role: Monitor and document program performance with environmental services, infection prevention, and infectious disease expertise; -Facility Engineer/Environmental services: Knowledge of water system, identify locations and control limits, take corrective action, monitor and document program performance with infection preventionist, works/communicates with outside specialist; -Ice machines (2) maintenance staff to clean monthly, filters changed by vendor every six months; -Monitor scaling, sediment and water temperatures of faucets. The water management program did not include how often or when the water management team would meet, acceptable temperature ranges for hot and cold water, how facility was going to monitor or test resident's for Legionella if resident's developed signs and symptoms, and how results would be documented. The policy did not include reporting any cases of Legionellosis to the health department and to the state agency. The water flow map was started but was not complete. The facility assessment was started but not complete. The facility was unable to provide minutes from the water management team because they had not met at the time of the survey. Review of the facility's undated Catheter Care Policy, showed the following: -Use standard precautions when handling or manipulating the drainage system; - Be sure the catheter tubing and drainage bag are kept off of the floor, catheter bag cover in place at all times. Review of the facility's undated policy, Catheter Care, showed the following: - Purpose: -Maintain indwelling catheter as ordered and prevent catheter-associated urinary tract infections; -Do not clean the peri-urethral area with antiseptics to prevent catheter associated UTI's while the catheter is in place. Routine hygiene is appropriate; -Be sure the catheter tubing and drainage bag are kept off of the floor; Review of the facility's undated Handwashing Policy, showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infections; -All personnel shall follow the hand washing procedures to help prevent the spread of infections to other personnel, residents, and visitors; -Employees must wash their hands for at least 15 seconds using soap and water under the following conditions: 1. When coming on duty; 2. When hands are visibly soiled; 3. Before and after direct resident contact; 4. Before and after performing an invasive procedure; 5. Before and after eating or handling food; 6. Before and after assisting residents with meals; 7. Before and after assisting a resident with personal cares; 8. Before and after changing a dressing; 9. Upon and after coming in contact with a resident's intact skin; 10. After personal use of the toilet; 11. Before and after assisting a resident with toileting; 12. Before and after handling soiled or used linens, dressings, bedpans, catheters, or urinals; 13. After handling soiled equipment or utensils; 14. After performing your personal hygiene; 15. After removing gloves or aprons; 16. After completing duty; 17. When changing cloves when going from dirty to clean. Review of the facility's undated Policy for Changing Gloves, showed the following: -Staff must change gloves when: 1. Between contact with different body sites of a resident; 2. While performing cares when go from clean task to dirty task or dirty task to a clean task; 3. When gloves come into contact with feces, urine, blood or other bodily fluids; 4. When gloves become visibly soiled after performing peri care. 1. During an interview on 7/24/23, at 3:30 P.M., the Administrator said the Legionella policy was not completed. Observation on 7/26/23 at 12:42 A.M., showed the following: -The surveyor measured water temperatures using a stem analog thermometer; -The dementia unit kitchenette hot water temperature was 108 degrees F, and the cold water 70 degrees F; -Room B1 hot water temperature 112 degrees F, cold water 70 degrees F; -Room C2 hot water temperature 114 degrees F, cold water 72 degrees F; -Room DSC hot water temperature 112 degrees F, cold water 72 degrees F; -Room D6 hot water temperature 106 degrees F, cold water 76 degrees F. The kitchenette and room D6 were not at optimal temperatures to slow Legionella growth. During an interview on 07/26/23 at 09:32 A.M., the Maintenance Director said the following: -The facility does not have a water management team that he knew of; -He ensures hot water temperatures are between 105-120 degrees F, the kitchen is usually 140 degrees F. -He does not check cold water temperatures; -He does not know what ASHRAE is; he does not check for sediment or biofilm in the water distribution system; -He currently does not flush empty rooms or water lines not being routinely used; -He has sent water samples to be tested for Legionella; -The facility has no other monitoring for Legionella that he knew of. During an interview on 07/26/23 at 1:04 P.M., the Director of Nursing said the following: -The Infection Preventionist (IP) was not available and was transitioning into the role; -She was also trained for the IP role, so she assisted as much as possible; -She and the IP were not on a water management team; -She did not know the symptoms of Legionnaire's Disease, Pontiac Fever, or Legionellosis (generic term describing the pneumonic and non-pneumonic forms of infection with Legionella); -She does not have a system to track residents with symptoms of Legionellosis; -She does not know how to test residents for Legionellosis; -She does not know who to report cases of Legionellosis to. 2. Review of Resident #19's face sheet showed the following: -Diagnoses included neuromuscular dysfunction of bladder (the nerves and muscles don't work together very well and the bladder may not fill or empty correctly) and retention of urine. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 07/05/23, showed the following: -The resident was cognitively intact; -He/She has an indwelling urinary catheter (tube inserted into bladder to drain urine into a bag). Observation on 07/25/23 at 6:16 A.M., showed the following: -The resident sat in his/her wheelchair with his/her night gown on and naked from the waist down; -Certified Nurse Aide (CNA) G did not wash his/her hands with soap and water or apply gloves before assisting the resident; -CNA G applied a gait belt around the resident's waist; -CNA G took the resident's catheter bag and tubing that hung on the wheelchair and placed it directly on the wet shower floor; -CNA G assisted the resident to a standing position by using his/her bare hands to lift up on the resident's bare bottom; -With contaminated, bare hands, CNA G removed the gait belt and set it on a small table; -CNA G moved the resident's wheelchair out of the way with his/her contaminated, bare hands and helped the resident sit down on the shower chair; -CNA G removed the oxygen tubing from the resident's nostrils and set it down on the same small table in the shower room, with the nasal cannula pointing down and touching the gait belt; -CNA G hooked the catheter bag and tubing that was on the wet floor to the shower chair; -CNA G placed the nasal cannula that had been sitting on top of the gait belt back into the residents's nostrils; -CNA G showered the resident using his/her bare hands; -CNA G unhooked the catheter bag tubing connector where the catheter and tubing connect, which had urine flowing through it to his/her catheter bag; -The catheter bag and connector fell off of the shower chair and landed on the wet shower floor; -CNA G hooked the catheter bag back onto the shower chair with the connector hanging freely next to the shower chair in the air; -He/She said he/she was going to empty and clean the catheter bag after the resident's shower was completed; -When the shower was completed, CNA G connected a leg bag to the resident's catheter; -CNA G took the nasal cannula out of the resident's nostrils and bundled the tubing in his/her hand and with the same hand he/she grabbed onto the oxygen concentrator's handle with the nasal cannula touching the oxygen concentrator as he/she pushed the resident down the hall from the shower room back to the resident's room; -CNA G put the nasal cannula back into the resident's nostrils. During an interview on 07/25/23 at 10:59 A.M., CNA I said staff should wear gloves while giving a shower. During an interview on 07/27/25 at 11:15 A.M., CNA G said when he/she gives a resident a shower, he/she does not use gloves because the dirty water runs into them. He/She cleaned the catheter connector with alcohol wipe. 3. Review of Resident #2's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Requires extensive physical assistance with toilet use; -Frequently incontinent of bowel and bladder. Review of the resident's Care Plan, last revised 7/18/23, showed the following: -Activity of Daily Living (ADL'S)/Elimination/Skin: Resident needs assist of one to two certified nurse assistants (CNA's) with all of his/her cares; -Assist with toilet use by one to two CNA's; -Resident is occasionally incontinent of bladder and bowel. Observation on 07/27/23 at 8:20 A.M., showed the following: -CNA N and Certified Medication Technician (CMT) O propelled the resident into his/her bathroom; -CNA N and CMT O did not wash their hands and donned gloves; -CNA N and CMT O assisted the resident to a standing position; -CMT O removed the resident's incontinence brief (absorbent disposable underwear), CMT O said the brief was saturated with urine; -CMT O placed the soiled brief in a trash bag; -CMT O removed his/her gloves, did not wash hands and donned new gloves; -The resident sat on the toilet; -When the resident was ready, CMT O and CNA N assisted the resident to a standing position; -CMT O cleaned the resident's perineum; -CMT O removed his/her gloves, did not wash his/her hands and donned new gloves; -CMT O placed a clean brief on the resident and dressed the resident; During an interview on 7/27/23, at 10:45 A.M., CMT O said the following: -Staff are expected to wash hands before and after care of a resident; -Staff are expected to wash hands any time they anticipate coming in contact with bodily fluids; -Staff are expected to wash hands after coming in contact with bodily fluids before touching clean surfaces; -Staff are expected to wash hands with gloves changes. During an interview on 07/27/23 at 6:40 P.M. , the Director of Nursing (DON) said the following: -If catheter bag and connector tubing drop onto floor during a shower, staff should get the Licensed Practical Nurse (LPN) to change the bag; -Staff are expected to wash hands when they enter a resident's room, and before performing resident cares, when hands are visibly soiled, every time change gloves and between dirty and clean tasks; -Staff are expected to use gloves while giving a shower a resident; -Staff should not use their bare hands while touching a resident's bare bottom; -Staff are expected to wear gloves during resident care and peri care and if they come in contact with bodily fluids; -Staff are expected to change gloves when they become soiled and should be changed between dirty to clean use. During an interview on 07/27/23 at 1:00 P.M., the Administrator said the following: -She had a basic policy for Legionella, but knew the policy needed work; the facility had not implemented the policy; -She was obtaining a copy of the ASHRAE standards to assist her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care plans for two residents (Residents #39 and #297), in a review of 16 sampled residents, included interventions and approaches to address the residents' care needs. The certified facility census was 48. 1. Review of facility's undated policy, Care Plans, showed the following: -Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change; -The care planning/interdisciplinary team is responsible for the review and updating of care plans. 2. Record review of Resident #297's admission skin assessment, dated 11/7/19 at 6:11 P.M., showed the following: -The resident was not at risk for developing pressure ulcers; -An open/red area on left buttock 2 centimeters (cm) by 2 cm; -Rash on right and left buttock and groin area; -Surgical wound on abdomen. Record review of the resident's skin assessment (body diagram), dated 11/07/19, showed Registered Nurse (RN) N documented a surgical site on the resident's abdomen 7 cm by 5.5 cm by 3 cm deep and a red area on the resident's coccyx (tailbone)/buttock no breakdown - yeast. Review of the resident's baseline care plan, dated 11/7/19, showed the following: -Potential for skin breakdown; -Pressure reducing mattress; -Nutritional assessment with interventions; -Repositioning every one to two hours and as needed for comfort. Observation on 11/19/19 at 11:10 A.M. showed six open areas on the resident's left hip, left buttock and coccyx. Two of these areas were approximately the size of a half dollar and the other four ranged from quarter size to dime size. All six areas had a layer of thick yellow tissue covering the wound. Observation on 11/20/19 at 02:41 P.M. showed the yellow tissue on the six open areas on the resident's left hip, left buttock and coccyx had started to thin and had a pink wound base along the edges. Review of the resident's care plan, edited 11/20/19, showed the following interventions for skin: -Monitor for skin issues; -Actual impaired skin integrity related to open surgical wound; -Ostomy bag (bag placed on the outside of the body) placed over draining area on his/her surgical abdominal wound. Wound dressing care as ordered; -Skin and wound assessments weekly; -Treatments as ordered; -Use moisture barrier after incontinent episodes; -Observe for signs/symptoms of skin irritation, breakdown; (The resident's care plan did not identify or include multiple open areas on the resident's buttock and left hip. The care plan did not have updated interventions in place for the continued breakdown.) During interview on 11/20/19 at 6:27 A.M., Registered Nurse (RN) E said he/she usually only worked one Saturday a month and the last time he/she worked he/she sent a fax to the physician about blisters on the resident's buttock and upper leg. The blisters have since popped and there was not a new treatment in place. During interview on 11/20/19 at 2:23 P.M., RN N said when the resident was admitted to the facility, he/she had a rash on his/her left hip, left buttock and coccyx. This area has gotten a little worse since his/her catheter was removed. During interview on 11/21/19 at 03:50 P.M., the director of nursing (DON) said she expected any licensed nurse to update the residents' care plans as needed. She expected the care plan to be updated after every event and when a skin issue was identified. 3. Review of Resident #39's nurse's notes, dated 8/25/19 at 6:29 P.M., showed the resident complained of pain in his/her bilateral knees and rated his/her pain a six out of ten on the pain scale. The resident's knees were red, warm to touch and swollen; the right knee more so than the left. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/30/19, showed the following: -Moderately impaired cognition; -Required extensive assistance from one staff for transfers and ambulation; -No scheduled pain medication; -Received as needed pain medications and non-medication interventions for pain. Review of the resident's physician order sheets, dated November 2019, showed the following: -Diagnoses included right knee replacement, infection of right knee prosthesis, back and knee pain, and history of falls; -Pain assessment shiftly (11/5/19); -Oxycodone (narcotic pain medication) 5 milligrams (mg) every four hours as needed for pain (8/10/19). Review of the resident's care plan, last updated on 11/5/19, showed the following: -At risk for falls related to his/her fall risk scale. Full weight bearing on right knee; -Barber pole at bedside to assist with transfers; -Encourage use of non-skid socks; -Transfer with assist of one staff; -Wheelchair as primary means of locomotion. (The resident's care plan did not address the resident's pain.) Observation on 11/18/19 at 10:07 A.M. showed the resident sat in his/her wheelchair in the hall. He/She said he/she had knee replacements and had an infection in his/her right knee. He/She said he/she was supposed to have surgery recently, however, the appointment was canceled due to the weather and he/she was awaiting new appointment. The resident said he/she had pain in both knees. During interview on 11/20/19 at 8:00 A.M., the resident said he/she fell on [DATE] after he/she took himself/herself to the bathroom. He/She said he/she was a few feet from the door, when his/her legs began shaking. As he/she tried to reach for his/her chair, he/she fell. Observation on 11/21/19 at 8:34 A.M. showed the resident was up in his/her chair. He/She said his/her pain was bad and medicine was not helping due to his/her recent fall. During interview on 12/6/19 at 3:05 P.M., Certified Medication Technician (CMT) S said the following: -The resident usually took a pain medication once on his/her shift for complaints of knee pain; -The resident usually rated the pain about a six out of ten on the pain scale; -When the resident fell on [DATE], he/she complained of knee pain. During interview on 11/21/19 at 1:50 P.M., the DON said the following: -She expected staff to update the resident's care plan with the fall (on 11/19/19) and interventions; -She did not see any documentation the resident's care plan had not been updated at this time. During interview on 11/21/19 at 3:07 P.M., RN N said the following: -Staff notified him/her the resident fell on [DATE] around supper time; -He/She had not updated the resident's care plan. During interview on 11/21/19 at 3:55 P.M., the DON said she expected a care plan to include pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary services to maintain personal and oral hygiene for two residents (Residents #14 and #21), who were unable to carry out their own activities of daily living (ADLs), in a review of 16 sampled residents. The facility certified census was 48. 1. Review of the facility's policy on mouth care, revised October 2010, showed the purpose of the procedure was to keep the resident's lips and oral tissues moist, to cleanse and freshen the resident's mouth, and to prevent infections of the mouth. 2. Review of the Nurse Assistant in a Long-Term Care Facility manual, revised 2001, showed the following: -Oral hygiene: A clean mouth and properly functioning teeth are essential for physical and mental well-being of the resident to prevent infections in mouth, remove food particles and plaque, stimulate circulation of gums, and eliminate bad taste in mouth thus food is more appetizing. Give oral care before breakfast, after meals, and also at bedtime; -Perineal care: Clean the peri area for the resident who is unable to or has difficulty with adequately cleaning self, prevents itching, burning, and odor, and prevents infections. Perineal care is very important in maintaining the resident's comfort. More frequent care is required for residents who were incontinent. -Perineal care for a male included: -Expose the perineal areas, wash the penis from the tip downward, rinse, and dry (specific instructions for uncircumcised); -Wash and rinse the scrotum; -Wash and rinse other skin areas between the legs (Perineum the area between the scrotum and rectum in a male); -Wash and rinse the anal area; and -Pat the area dry. -Perineal care for a female included: -Expose the peri area, wash the inner legs and outer peri area along the outside of the labia (Labia Majora); -Wash the outer skin folds from front to back; -Wash the inner labia (Labia Minora) from front to back; -Gently open all the skin folds and wash the inner area (urinary meatus and vaginal area) from front to back; -Rinse the area well, start from the innermost area and proceed outward; -Wash and rinse the anal area; and -Pat the peri area dry. 3. Review of Resident #21's Significant Change in Status Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/9/19, showed the following: -Diagnoses included stroke, dementia, anxiety, and chronic lung disease; -Required extensive assistance of two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Cognition was intact. Review of the resident's care plan, last reviewed 10/11/19, showed the following: -The resident had limited use of his/her hands and was weak; -Required assistance of one or two staff for all cares. Observation on 11/20/19 at 6:42 A.M. showed the following: -The resident lay in bed in his/her room; -Certified Nurse Assistant (CNA) B and CNA C provided perineal cleansing, dressed the resident and transferred him/her to the wheelchair; -CNA B and CNA C left the room; -The resident had a visible buildup of white colored debris at the gum line of both the upper and lower teeth; -CNA B returned to the resident's room with a pick and picked out the resident's hair; -CNA B pushed the resident to the dining room in the wheelchair. Staff did not offer or provide the resident with assistance to brush his/her teeth. During an interview on 11/20/19 at 6:50 A.M., the resident said he/she had his/her own teeth. The resident said he/she would like to brush them before he/she ate, but no one ever took the time to help him/her and he/she could not brush his/her teeth without assistance. The resident said his/her teeth had not been brushed in a long time. Observation and interview on 11/20/19 at 2:05 P.M. showed the following: -The resident sat in the main dining room playing Bingo; -There was a buildup white colored debris at the gum line on both the upper and lower teeth; -The resident said no one had offered to assist him/her to brush his/her teeth so far that day. During an interview on 11/21/19 at 8:05 A.M., the resident said he/she had finished breakfast. Staff did not assist him/her to brush his/her teeth that morning. Observation on 11/21/19 at 8:27 A.M. showed the resident lay in bed. There was a visible buildup of white debris on the resident's gum line. There were no oral care supplies observed in the resident's room or bathroom. During an interview on 11/21/19 at 8:30 A.M., the resident said he/she would like to have his/her teeth brushed because they had not been brushed in a long time. The resident was not sure if he/she had a toothbrush or where it would be located. He/She would like to have his/her teeth brushed every morning when he/she got up. Observation and interview on 11/21/19 at 9:53 A.M. showed the following: -The resident lay in bed; -CNA D entered the resident's room; -CNA D said he/she had assisted the resident to brush his/her teeth that day after breakfast; -The resident said CNA D did not assist him/her to brush his/her teeth; -CNA D said, I helped you with it after breakfast. Don't' you remember? -The resident said he/she did not remember; -The resident had a visible buildup of white colored debris at both gum lines; -CNA D said the resident's oral care supplies were kept in the resident's bed side drawer; -CNA D opened the resident's bedside drawer and found there were no oral care supplies in the bedside drawer; -CNA D could not locate any oral care supplies in the resident's room. During an interview on 11/21/19 at 4:00 P.M., the director of nursing (DON) said staff should offer assistance or provide oral care for residents when they got up in the morning, after meals, at bedtime, and any other time it was needed. 4. Review of Resident #14's annual MDS, dated [DATE], showed the following: -Required extensive assistance from two staff for transfers and toilet use; -Required extensive assistance from one staff for personal hygiene and dressing; -Always incontinent of bladder; -Frequently incontinent of bowel. Review of the resident's care plan, dated 5/30/19, showed the following: -Required assistance with activities of daily living; -Provide perineal care after incontinent episodes; -Stand-up lift (mechanical lift used to assist weak residents with standing) with assist of two staff for transfers. Observation on 11/20/19 at 1:40 P.M. showed the following: -The resident sat in his/her wheelchair in his/her room; -Certified Nurse Assistant (CNA) H and CNA O transferred the resident to the toilet with a stand-up lift; -CNA O removed the resident's feces soiled incontinence brief; -CNA H obtained smears of feces as he/she cleaned the resident's anal area with toilet paper. He/She did not use wipes or wet cloths to clean the resident. Staff did not provide front perineal care for the resident. During interview on 11/21/19 at 2:30 P.M., CNA H said the following: -Staff should complete front perineal care for an incontinent resident; -Toilet paper would not be sufficient in cleaning a resident of feces. Staff should use wipes or moistened wash cloths to clean feces from the resident's skin. During interview on 11/21/19 at 3:55 P.M., the director of nursing (DON) said the following: -She expected staff to cleanse all areas of an incontinent resident's skin that were contaminated with urine or feces when providing perineal care; -If staff did not provide front perineal care, the perineal care would be incomplete; -Staff cleansing a resident with toilet paper after the resident was incontinent or after toileting (with smears of feces noted) the resident would not be adequate; -She expected staff to use wipes or soap and water for perineal care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to notify the physician and obtain a treatment to treat a Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) identified on admission for one resident (Resident #249), in a review of 16 sampled residents. The facility failed to document the details of the pressure ulcer (type, stage, measurements, etc) according to facility policy, and to provide documentation of daily monitoring. An open area was also identified on 11/20/19. Nursing staff did not assess the resident's skin until 11/21/19. Staff identified the area as a pressure ulcer and applied treatment without obtaining a physician order. The facility identified one resident (Resident #249) with pressure ulcers. The facility certified census was 48. 1. Record review of the facility's policy Skin and Wound Management, dated October 2010, showed the following: -The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. -Verify there is a physician's order for this procedure. Record review of the facility's policy Assessment Guidelines for Skin Integrity Manual, dated May 2010, showed the following: -Weekly wound assessment includes documenting the type, stage, location, measurement of site (length, width, depth) -History of a healed pressure ulcer; -Type, odor, amount, and color of exudate (if present); -Describe wound bed; -Daily pressure ulcer monitoring includes evaluation of the pressure ulcer, the dressing (whether it is intact and whether drainage is present), the status of the area surrounding the pressure ulcer, if pain is present, and if there is a possibility of complications such as signs of increasing area of the ulceration or soft tissue infections. 2. Record review of Resident #249's skin assessment (human body illustration), dated 9/11/19 and signed by Licensed Practical Nurse (LPN) Q, showed a circle drawn around the buttock area. A line pointed to the intergluteal cleft (the area between the buttocks) with a description 1 inch long open area. Record review of the resident's weekly/admission skin assessment, dated 9/11/19 and completed by LPN Q, showed the resident's skin integrity was warm, dry, and thin. LPN Q identified the resident had no wounds, open or red areas. (There was no documentation to show the resident had 1 inch long open area as identified by LPN Q on the body diagram on 9/11/19.) During a telephone interview on 12/5/2019 at 1:15 P.M., LPN Q said he/she observed an open area on the resident's skin upon admission. The area had Triad cream (a zinc oxide-based hydrophilic (tending to dissolve in, mix with, or be wetted by water ) paste) on it when the resident came into the facility. The description and area of the wound was just like the illustration (dated 9/11/19) showed. He/She does not stage wounds and does not describe the wound bed. He/She reports open areas to the director of nursing (DON). Review of the resident's medical record showed no evidence staff notified the resident's physician of the open area identified on admission. Review of the resident's physician's orders, dated September 2019, showed the following: -The resident was admitted to the facility on [DATE]; -Diagnoses included generalized muscle weakness and Parkinson's disease (a progressive nervous system disorder that affects movement); -Weekly Braden Scale (tool for predicting pressure ulcer risk) and skin assessments; -No evidence of orders to treat the open area identified on admission. Review of the resident's Braden Scale, dated 9/11/19, showed the resident was at risk for developing pressure ulcers. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 9/18/19, showed the following: -Required extensive assistance from two or more staff for bed mobility, transfers, toilet use and personal hygiene; -Frequently incontinent of bowel and bladder; -The resident had one or more unhealed pressure ulcers; -The resident had one Stage II pressure ulcer present on admission; -Pressure reducing device for chair and bed; -Pressure ulcer/injury care. Review of the resident's Care Area Assessment (CAA), dated 9/18/19, showed the resident was admitted to the facility with a Stage II pressure ulcer to his/her buttock/coccyx (tailbone) area. He/She is incontinent of bowel and bladder. He/She needs assist of two certified nurse assistants (CNAs) with turning and positioning, wet checks, and peri care (perineal care, washing the genitals and anal area). Record review of the resident's weekly skin assessment, dated 9/18/19 and completed by LPN Q, showed the resident's skin was warm, dry, and thin. LPN Q noted the resident did not have any wounds, open or red areas. Record review on the resident's care plan for pressure ulcers, dated with a problem start date of 9/23/19, showed the following: -The resident had actual impaired skin integrity related to pressure ulcer; -Observe ulcer area daily/between dressing changes checking for dressing intact, signs and symptoms of complications/infection, evidence of pain, and effectiveness of pain medication; -Pressure redistribution cushion to chair; -Pressure redistribution mattress; -Skin and wound assessments weekly. Report worsening condition to the physician; -Treatments as ordered. During a telephone interview on 12/5/19 at 1:25 P.M., the MDS Coordinator said when completing the resident's MDS, he/she assessed the resident for pressure relieving devices for his/her bed and chair. He/She got the information about the resident having a Stage II pressure ulcer upon admission from the nurses and the resident's weekly skin assessments. Record review of the resident's weekly skin assessments, dated 9/25/19, 10/3/19, 10/9/19, 10/16/19, 10/23/19, 10/30/19, and 11/13/19, showed the resident's skin was warm, dry, and thin. LPN Q noted the resident did not have any wounds, open or red areas. There were no skin treatments or interventions. Observation on 11/18/19 at 10:54 A.M., showed the resident sat in his/her recliner. The resident said his/her bottom hurt. Observation showed there was no pressure relieving device in the resident's recliner or bed. During an interview on 11/19/19 at 9:30 A.M., the resident said he/she applied lotion on his/her bottom. The resident said staff did not apply anything on his/her bottom. The resident said he/she had pain in his/her buttocks area. Record review of the resident's skilled note, dated 11/20/19 at 9:22 A.M., showed Registered Nurse (RN) N noted the resident's skin was intact, warm and dry. There were no abnormalities in the resident's skin condition. Observation on 11/20/19 at 11:37 A.M., showed CNA O assisted the resident to the bathroom. The resident's skin on his/her buttocks and coccyx was red. There was a dark discoloration with shearing (top layer of skin was missing leaving an open area) on the resident's coccyx. During an interview on 11/20/19 at 11:37 A.M., CNA O said the resident has something in his/her room he/she puts on his/her bottom. The resident had poor skin integrity and was often incontinent. Record review of the resident's Wound Management Detail Report, dated 11/20/19 at 1:06 P.M., showed staff did not document an observation of a wound. During an interview on 11/20/19 at 2:15 P.M., Registered Nurse (RN) N said a CNA told her/him this morning there was an open area on the resident's buttock area. RN N was not aware the resident had an open area. The area could not be measured or assessed due to family members and friends in the resident's room this afternoon. Record review on 11/21/19 at 7:48 A.M., showed RN N had not updated the resident's progress notes to show CNA O's notification of a skin concern. Observation on 11/21/19 at 8:16 A.M., showed RN N located an open area in the resident's intergluteal cleft. RN N measured the open area at 1 centimeter (cm) x 0.5 cm. The open area had a pink wound bed with serous drainage (clear, thin, watery plasma. It's normal during the inflammatory stage of wound healing and smaller amounts is considered normal wound drainage). The wound edges were slightly macerated (softened). RN N did not stage or describe the open area. The area on the resident's coccyx was blanchable (after applying pressure, color returns to normal upon release of pressure) with dark discoloration and shearing. During interview on 11/21/2019 at 8:28 A.M., CNA H said she/he was not aware of the area between the resident's buttocks but did know about the open area to the resident's coccyx. CNA O said he/she wasn't sure but thought the resident had an open area on the coccyx area. Neither CNA H or CNA O remembered any treatments done to the resident's buttocks/coccyx area. During an interview on 11/21/2019 at 9:05 A.M., RN N said when staff identify an open area, it is standard protocol to call the physician to see if he/she wanted an order for cream. During interview on 11/21/19 at 9:10 A.M., the director of nursing (DON) said there were no past treatment orders for the resident. Staff did not notify the resident's physician of the Stage II pressure ulcer identified on admission. Observation on 11/21/19 at 9:10 A.M., showed the DON assessed the open area between the resident's buttocks. There was white, thick paste between the resident's buttocks and on the resident's coccyx area. During assessment, the resident said his/her bottom was sore. The DON observed the open area in the intergluteal cleft and said it was about 0.5 x .0.5 (no indication to type of measure) and the bed was pink. The DON attempted to wipe white paste aside during the assessment with his/her gloved finger and was unsuccessful. The wound size, bed, and edges could not be seen through the white paste. During an interview on 11/21/19 at 11:11 A.M., RN N said she/he put Triad cream on the resident and had not yet notified the physician of the open area. RN N said the coccyx area is the Stage II pressure ulcer the resident was admitted with, so the open area in his/her intergluteal cleft was a new open area. RN N said his/her skilled note on 11/20/19 which showed the resident did not skin issues was probably not correct. RN N said when staff noticed a pressure ulcer, they were to call the physician and ask what he/she wanted to do for the area. Review of a telephone encounter with the resident's physician, dated 11/21/19, showed the resident has a 1 cm open area on his/her bottom that he/she had when he/she came to the facility. He/She also has an open area on the top of his/her buttocks that is blanchable. Would like an order for Triad. Record review of the resident's Physician's Order Sheet showed a new treatment order started on 11/21/19 for Triad wound dressing. During interview on 11/21/19 at 4:00 P.M., the DON said the following: -The pressure ulcer the resident had on admission was the area located within the resident's intergluteal cleft, and not the area on the resident's coccyx; -The pressure area (in the resident's intergluteal cleft) measured 0.5 x 0.5 and has improved because it was 1 inch long at admission. He/She did not use measuring device and was just guessing. He/She could see the pink wound bed through the white paste, however, the edges were not visible; -When the staff find a wound, they start a treatment. Staff do not call the physician before starting treatment; -She was unaware there was no treatment in place for the pressure ulcer that had been present since the resident's admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to maintain urinary catheter (small tubular structure that drains urine from the bladder to the outside of the body) bags and tubing off the floor and below the level of the bladder for two residents (Residents #21 and #35), with indwelling urinary catheters, in a review of 16 sampled residents. The facility identified three residents with urinary catheters. The facility certified census was 48. 1. Review of the facility's policy on catheter care, undated, showed the following: -Maintain indwelling catheters as ordered and prevent catheter associated urinary tract infections; -The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder; -Be sure the catheter tubing and drainage bag are kept off the floor. 2. Review of Resident #21's hospital admission note, dated 9/2/19, showed the following: -The resident was previously hospitalized from [DATE] to 8/7/19 for a urinary tract infection and was treated with antibiotics; -The resident returned to the emergency room on 8/22/19 and was diagnosed with a urinary tract infection and bronchitis and again treated with antibiotics; -Staff reported the resident was slow to respond and required higher oxygen supplementation and also noted to have dark urine on 9/1/19; -Staff reported the resident had a urinary catheter placed approximately two months ago; -Assessment and plan: Urinary tract infection and altered mental status secondary to infection. Follow up with urine cultures and continue with antibiotics. Review of the resident's medical record showed the resident was readmitted to the facility from the hospital following treatment for a urinary tract infection on 9/5/19. Review of the resident's Significant Change in Status Assessment Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/9/19, showed the following: -Diagnoses included stroke and renal insufficiency; -Required extensive assistance of two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Urinary catheter; -Frequently incontinent of bowel. Review of the resident's care plan, last reviewed 10/11/19, showed the following: -The resident had limited use of his/her hands and was weak; -Required assistance of one or two staff for all cares; -Urinary catheter; -Maintain catheter tubing below the level of the bladder; -Catheter care every shift. Review of the resident's physician order sheet for November 2019 showed an order for an indwelling urinary catheter, size 24 French, 30 cubic centimeter (cc) bulb for a diagnosis of urinary retention. Change monthly. Observation on 11/19/19 at 5:09 P.M. showed the resident lay in bed. The resident's catheter bag was in a cloth privacy cover attached to the bed frame. The bottom of the bag lay on the floor. The catheter tubing also lay on the floor beside the bed. Observation on 11/20/19 at 5:26 A.M. showed the resident lay in bed. The resident's catheter bag was in a cloth privacy cover attached to the bed frame. The bottom of the bag lay on the floor. The catheter tubing also lay on the floor beside the bed. Observation on 11/20/19 at 6:42 A.M., showed the following: -The resident lay in bed. Certified Nurse Assistant (CNA) B and CNA C provided perineal care and catheter care for the resident; -After providing care to the resident, CNA B removed the urinary catheter bag from the bed frame and held it above the level of the resident's bladder. Urine back flowed in the catheter tubing toward the resident; -CNA B and CNA C transferred the resident from the bed to the wheelchair with the mechanical lift; -CNA C attached the catheter bag under the resident's wheelchair. The catheter tubing was in contact with the floor under the resident's wheelchair; -CNA B pushed the resident to the dining room. The resident's catheter tubing dragged along the floor under the wheelchair. Observations on 11/20/19 showed the following: -At 7:20 A.M., the resident remained at the dining room table. His/Her catheter tubing remained in contact with the floor under the wheelchair; -At 7:40 A.M., the resident remained at the dining room table. The catheter tubing remained in contact with the floor under the wheelchair; -At 8:30 A.M., the resident remained at the dining room table. The catheter tubing remained in contact with the floor under the wheelchair. During an interview on 11/20/19 at 11:10 A.M., CNA C said the resident's catheter bag and tubing should be kept below the level of the resident's bladder. Catheter bags and tubing should not touch the floor. Observation on 11/21/19 showed the following: -At 8:03 A.M., the resident sat in a wheelchair in the dining room. The resident's catheter bag was in a cloth privacy cover under the wheelchair which was in contact with the floor under the wheelchair; -At 8:07 A.M., CNA D wheeled the resident back to his/her room with the catheter bag in a cloth privacy bag dragging the floor under the wheelchair. -At 8:25 A.M., the resident lay in bed. The resident's catheter bag was in a cloth privacy cover. The bottom of the privacy bag was in contact with the floor next to the bed. 3. Record review of Resident #35's care plan, dated 8/26/19 and last revised 10/20/19, showed the following: -The resident had a urinary catheter and was at risk for complications; -Maintain catheter tubing below bladder level; -Maintain drainage bag in privacy cover. Review of the resident's nurses notes, dated 10/22/19 at 9:21 A.M., showed the resident continued on an antibiotic for a urinary tract infection. Review of the resident's annual MDS, dated [DATE], showed the following: -The resident had a urinary catheter; -Required extensive assistance from one staff for bed mobility, personal hygiene and toileting; -Required extensive assistance from two staff for transfers. Review of the resident's physician order sheets, dated November 2019, showed the following: -Diagnoses included urinary tract infection and hemiplegia (muscle weakness or partial paralysis on one side of the body); -Change indwelling/suprapubic urinary catheter every 30 days. Insert catheter size 20 French and bulb size 30 cc (11/19/19). Observations on 11/18/19 showed the following: -At 9:46 A.M., the resident lay in bed. The resident's catheter bag was in a privacy bag attached to the bed frame. The bottom of the bag touched the fall mat on the floor beside the resident's bed; -At 3:35 P.M., the resident lay in the low bed. The catheter tubing lay on the fall mat. The resident's catheter bag was in a privacy bag. The bag touched the fall mat. Observations on 11/19/19 showed the following: -At 8:13 A.M., CNA O and CNA H transferred the resident from his/her wheelchair to bed. CNA O moved the catheter bag from under the resident's wheelchair to the privacy bag on the resident's bed. The bottom of the bag touched the resident's fall mat on the floor beside the resident's bed; -At 10:58 A.M., the resident lay in the low bed. The resident's catheter bag was in a privacy bag attached to the side of the resident's bed frame. The bag sat on the fall mat beside the resident's bed; -At 2:22 P.M., the resident lay in the low bed. The resident's catheter bag, in a privacy bag, hung from the bed frame. The bag sat on the fall mat beside the resident's bed. During interview on 11/21/19 at 2:10 P.M., CNA H and CNA O said no part of a urinary drainage system should touch the floor. During an interview on 11/21/19 at 4:00 P.M., the Director of Nursing said staff should maintain catheter bags and tubing below the level of the bladder and should keep catheter bags and tubing, including the privacy covers, secured off the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for 14 residents (Residents #2, #7, #14, #17, #21, #26, #27, #29, #34, #39, #44, #45, #248, and #297), in a review of 16 sampled residents and five additional residents. The facility failed to obtain weights upon readmission per facility protocol for Resident #27 who presented with a significant weight loss; failed to obtain physician orders for oxygen and failed to confirm gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach) placement prior to administering his/her feeding for Resident #44; failed to follow the facility's protocol following a fall for Resident #39; failed to follow up on physician recommendations to discuss a reduction in psychotropic medication use with Resident #2; failed to identify settings for Resident #21's CPAP machine (continuous positive airway pressure, a machine that helps people with sleep apnea breath more easily while sleeping); failed to provide a safe and effective form of medication administration for Residents #248, #297, #29, #45, #26, #17, #7, #14, #34 and #27 when staff prepared multiple residents medications, placed them in a medication tray with the residents' first name written on the medication cup, and did not identify the medications; and failed to keep Resident #14's liquid narcotic schedule II controlled medication (a medication with high risk of addiction and dependence) secure in the locked narcotic box of the medication cart during the medication pass. The facility certified census was 48. 1. Review of the facility policy, titled, Confirming Placement of Feeding Tubes, dated March 2015, showed the following: -The purpose of this procedure is to ensure proper placement of the feeding tube to prevent aspiration during feedings; -To Confirm Placement of Tube: Confirm by a minimum of one method listed below: -Observe for a change in the external tube length marked at the time of the initial insertion X-ray or documented length from transferring location; -If feeding has been interrupted for a few hours, observe and check the pH of aspirate (nasogastric, gastric, jejunostomy tubes); -The policy did not address how staff was to administer feedings. Review of the undated facility policy, Oxygen Administration, showed the following: -The purpose of this procedure is to provide guidelines for safe oxygen administration; -Verify there is a physician's order for this procedure; -Review the physician's order or facility protocol for oxygen administration. Review of the facility's undated policy, Falls, showed the following: -Purpose: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. -If a fall occurs, the charge nurse will determine if it is appropriate to move the resident and shall be present during the transfer unless the charge nurse has appointed someone else to take over due to him/her needing to contact emergency contacts as well as the physician. -Fall interventions are placed on the care plan and adjusted as needed by the care plan coordinator, fall nurse and nursing staff. -Family and physician are notified of the fall and when and what occurred. The response is recorded on the post fall nursing assessment and or nursing notes at time of notification. Review of the undated facility policy, Policy and Procedure for Antipsychotic Use and the Dementia Patient, showed the following: -Tapering of any medication may be indicated when, for example, the resident's clinical condition has improved/stabilized or the underlying causes have resolved; -The goal of the gradual dose reduction (GDR) is to evaluate the continued need for the medication and determine whether the resident is being maintained on the lowest effective dose. Review of the facility's CPAP Support Policy, undated, showed the following: -Purpose: To provide the spontaneously breathing resident with continuous positive airway pressure and to improve resident comfort and safety; -Review the physician's order to determine the oxygen concentration and flow, and the pressure for the machine; -Review and follow manufacturer's instructions for CPAP machine setup and oxygen delivery; -Set mode and CPAP settings on the machine as prescribed; -Document the mode and settings for the CPAP and how the resident tolerated the procedure. Review of the facility policy, Storage of Medication, dated April 2007, showed the following: -The facility shall store all medications in a safe, secure and orderly manner; -The policy did not address how narcotic medications were to be stored. Review of the undated facility policy, Policy and Procedure for Documentation, showed the following: -Orders: Written and verbal orders constitute the attending physicians directions for the treatment of the resident in the facility; -Processing and noting orders: The statement noted, accompanied by the nurse's signature and the date and time indicates accountability for the accurate and timely processing of orders. All orders, including recapped orders should be noted. 2. Review of Resident #27's face sheet showed he/she was readmitted to the facility on [DATE]. Review of resident's vitals reports showed on 11/03/19, the resident weighed 162.6 pounds. Review of the resident's Observation Detail List Report, dated 11/05/19 and completed by the registered dietician, showed the following: -The resident's diagnoses included hypertensive heart and chronic kidney disease with heart failure and Stage 1 through Stage 4 chronic kidney disease; -The Mini Nutritional Assessment (MNA; detects risks of malnutrition before severe change in weight or serum protein occurs. It is used as a nutritional intervention tool.) was completed and the resident's screening score was 11 (a score between 8-11 indicates at risk for malnutrition); -Current weight is 162.6 pounds and there was no anticipated loss or gain; -The resident had a 9.42 percent weight change in 30 days; -The resident is alert with confusion and able to make some needs and preferences known and are provided as available. Resident is currently tolerating diet however has had a decline in condition. He/She was admitted to the hospital on [DATE] due to mental status changes and decrease in activities of daily living. He/She returned on 11/1/19. Noted increase weight times one month due to fluid retention. Review of facility vitals report showed on 11/06/19, the resident's weight was 163 pounds. Record review hospital emergency department notes, dated 11/07/19, showed the following: -The resident complained of difficulty breathing to nursing home staff. The resident said he/she has had some abdominal pain, and has had a poor appetite lately as he/she experienced pain after eating; -The review showed positive for appetite change; -The resident's lower extremities were evaluated at +1 non-pitting edema. Resident was given Lasix (diuretic which causes increased passing of urine) 80 milligrams (mg) intravenous (IV) 10 mg/ml at 5:01 P.M.; -The hospital records showed the resident's weight was 179 pounds; -Discharge instructions for medication change was to take Lasix 40 mg daily by mouth for the next seven days and continue taking Spironolactone (potassium-sparing diuretic) and to discontinue Sotalol (medication used to treat and prevent abnormal heart rhythms that is only recommended in those with significant abnormal heart rhythms due to potentially serious side effects). The resident was discharged back to nursing home. Review of the resident's physician orders showed an order dated 11/8/19 for Lasix 40 mg daily. Review of the resident's medical record on 11/19/19 showed no evidence staff obtained the resident's weight on any date after he/she returned from the hospital (11/7/19- 11/18/19). Observation on 11/19/19 at 5:05 P.M., showed staff weighed the resident (at the request of the surveyor). The resident weighed 130.4 pounds (a 32.6 pound weight loss since 11/6/19). During an interview on 11/20/19 at 11:05 A.M., the registered dietician (RD) said when a resident is readmitted , it is facility protocol to obtain weight daily for three days and then weekly for four weeks, and then monthly unless ordered differently. During interview on 11/21/2019 at 3:45 P.M., the director of nursing (DON) said staff weigh residents upon admission. Staff weigh the resident for three consecutive days and then weekly for four weeks. During a telephone interview on 11/27/19 at 8:40 A.M., the dietary manager said the following: -Nursing staff enter residents' weights in the computer system. The dietary manager can see the base weight, gain, or loss of each resident in the computer; -She would expect nursing to obtain weights per facility protocol. The facility protocol is weigh the residents every day for three days then once a week for four weeks. During a telephone interview on 11/27/19 at 10:15 A.M., the registered dietician said the following: -It is the facility's policy to weigh a resident daily for three days and then weekly for four consecutive weeks upon admission, re-admission, or return from hospital; -Staff should have weighed the resident on 11/13/19 (one week after weight obtained on 11/6/19). During a telephone interview on 11/27/19 at 1:15 P.M., the DON said the admission/re-admission protocol on obtaining the resident's weight is to weigh the resident daily for three days and then weekly for three weeks. This protocol is what is used to observe and maintain resident's nutritional needs. 3. Review of Resident #44's care plan, dated 5/30/19 and updated 8/15/19, showed the following: -Receives tube feedings; -Oxygen via nasal cannula as ordered. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 10/30/19, showed the following: -Diagnoses included chronic obstructive pulmonary disease (COPD; lung disorder); -The resident had coughing and choking during meals or when swallowing medications; -The resident had a tube feeding; -26-50% of the residents total calorie intake was through his/her tube feeding; -Oxygen therapy was not marked to indicate oxygen use. Review of the resident's November 2019 physician order sheets (POS) showed the following: -Check tube placement, from skin to bumper measurement is 3 cm, every shift, scheduled for day and night shift; -Jevity 1.5 calorie feeding, 240 milliliters (ml) four times per day per tube, scheduled for 6:00 A.M., 10:00 A.M., 2:00 P.M. and 8:00 P.M.; -Tube feeding flush of 120 ml four times daily, scheduled for 6:00 A.M., 10:00 A.M., 2:00 P.M. and 8:00 P.M.; -No documented order for oxygen. Observation on 11/18/19 at 9:00 A.M. showed the following: -The resident lay in bed with nasal cannula oxygen tubing in his/her nose; -The tubing was connected to an oxygen concentrator, set to 3 liters of oxygen per minute administered; -A hand-written, taped note on the oxygen concentrator showed 3 lpm PRN (three liters per minute as needed). Observation on 11/18/19 at 12:00 P.M. showed the following: -The resident sat in a wheelchair in the dining room with nasal cannula oxygen tubing in his/her nose; -The tubing was connected to a portable oxygen tank on the back of his/her wheelchair, set to 3 liters of oxygen per minute administered. Observation on 11/19/19 at 10:00 A.M. showed the following: -The resident sat in his/her bedside recliner with nasal cannula oxygen tubing in his/her nose; -The tubing was connected to an oxygen concentrator, set to 3 liters of oxygen per minute administered; -A hand-written, taped note on the oxygen concentrator showed 3 lpm PRN (three liters per minute as needed). Observation on 11/19/19 at 5:00 P.M. showed the following: -The resident sat in a wheelchair in the dining room with nasal cannula oxygen tubing in his/her nose; -The tubing was connected to a portable oxygen tank on the back of his/her wheelchair, set to three liters of oxygen per minute administered. Observation on 11/20/19 at 6:22 A.M. showed the following: -Registered Nurse (RN) E gathered the resident's Jevity feeding and a 60 ml syringe from the medication cart; -The resident sat in his/her bedside recliner with nasal cannula oxygen tubing in his/her nose; the tubing was connected to an oxygen concentrator which was set at 3 liters per minute; -RN E lifted the resident's shirt, exposing the resident's gastrostomy tube site, removed the plunger from the 60 ml syringe and attached the syringe to the gastrostomy tube; -RN E poured the Jevity feeding in the attached syringe, placed the plunger in the syringe and quickly pushed down on the syringe, administering the feeding; -RN E repeated this process four times; -RN E did not confirm tube placement before administering the resident's feeding. During interview on 11/20/19 at 6:28 A.M. and 7:02 A.M., RN E said the following: -The resident wore oxygen as needed whenever the resident wanted; -The resident's oxygen was to be set at 3 liters per minute; -The resident should have an order for the oxygen, directing staff as to how much he/she was to receive, but there was also a note on the concentrator to tell staff; -Placement of tubes couldn't really be checked without an x-ray and who was going to do that all of the time; -He/She did check for placement earlier in the evening at his/her 8:00 P.M. feeding, using a stethoscope, and knew it was fine, so he/she did not feel the need to check for placement again; -The resident was up in his/her bedside chair at the 8:00 P.M. feeding, had transferred to the bathroom several times and in and out of bed through the night and had also been assisted up in his/her bedside chair that morning prior to his/her morning feeding; -He/She had always pushed the resident's feeding; he/she had never let it run in via gravity. 4. Review of Resident #39's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance from one staff for transfers, ambulation and toileting; -Used a walker and wheelchair; -Balance was not steady but able to stabilize without staff assistance. Review of the resident's physician orders, dated November 2019, showed the resident's diagnoses included right knee replacement, infection of right knee prosthesis, back and knee pain, and history of falls. Review of the resident's care plan, last updated on 11/5/19, showed the following: -At risk for falls related to his/her fall risk scale. Full weight bearing on right knee; -Therapy as ordered; -Barber pole at bedside to assist with transfers; -Encourage use of non-skid socks; -Transfer with assist of one staff; -Wheelchair as primary means of locomotion. Review of the resident's fall risk assessment, dated 11/5/19, showed the resident was at moderate risk for falls. During interview on 11/20/19 at 8:00 A.M., the resident said he/she fell on [DATE] after he/she took himself/herself to the bathroom. He/She said he/she was a few feet from the door, when his/her legs began shaking. As he/she tried to reach for his/her chair, he/she fell. Two staff and the DON assisted him/her off the floor. During interview on 11/21/19 at 8:36 A.M., Licensed Practical Nurse (LPN) J said falls are noted in a binder at the desk and they are also on a board in the physician's lounge. He/She looked in the binder at the desk and the resident was not listed. He/She said he/she did not know the resident had fallen. Observation on 11/21/19 at 8:40 A.M. of the fall board in the physician's lounge showed the resident's name was not listed to show the resident had a fall. Record review of the resident's electronic medical record on 11/21/19 at 1:30 P.M. showed the record contained no documentation of a fall for the resident on 11/19/19. Observation on 11/21/19 at 1:30 P.M., showed the fall binder and board in the physician's lounge did not include the resident for falls. During interview on 11/21/19 at 1:50 P.M., the DON said the following: -She recalled the resident fell on [DATE] as he/she was summoned to help staff get the resident off the floor; -She, RN N and one other staff used a gait belt and assisted the resident to his/her chair; -The resident did not tell her what had happened; -She would have expected staff to complete an incident report, update the care plan with the fall and intervention, place the resident's fall in the fall binder at the desk, update the fall board in the break room, and notify family and physician as soon as possible after the fall; -She did not see any documentation of the fall or notifications of parties in the nurse's notes, there was no event report and the care plan had not been updated at this time. During interview on 11/21/19 at 3:07 P.M., RN N said the following: -Staff notified him/her the resident fell on [DATE] around supper time; -When he/she arrived in the resident's room, the resident was sitting on his/her bottom on the floor; -The DON, Certified Medication Technician (CMT) S, and RN N assisted the resident off of the floor; -He/She did not document the fall in the nurse's notes, on an event report, or any other place until a few minutes ago and had not updated the resident's care plan; -He/She had not notified the resident's representative or physician of the fall until today; -It was his/her responsibility (as the charge nurse) to document the incident, create an event report and make necessary notifications, but he/she did not get tasks done as he/she was trying to get blood glucometer checks done; -He/She had instructed the resident (after the fall) to use the call light when needing to get up. During interview on 11/21/19 at 3:50 P.M., the DON said the following: -The fall protocol included staff notifying the charge nurse of a fall and the nurse assessing the resident; -Staff would then assist the resident off the floor (if appropriate), take vital signs, call the physician and family, create an event report, document it in the nurse's notes, update the care plan at that time, and ensure the incident was placed in the fall binder at the desk (so the next shift would be aware and know to follow up and chart on ) as per protocol. 5. Review of Resident #2's Consultant Pharmacist Regimen Review Communication to the resident's physician, dated 6/26/19, showed the following: -Please assess risk versus benefit and if your patient would benefit from a reduction of the Zoloft (an antidepressant) 50 milligrams (mg) daily order or address in your progress note the necessity for continued use at current dosing and a change is clinically contraindicated; -The physician documented to decrease Zoloft to 25 mg if family/resident agree and dated the response 7/17/19; -There was no documentation to show a nurse had noted or responded to the physician's direction. Review of the resident's July 2019 POS showed an order for Zoloft 50 mg at bedtime. Review of the resident's July 2019 Medication Administration Record (MAR) showed staff administered the resident Zoloft 50 mg at 8:00 P.M. Review of the resident's August 2019 POS showed an order for Zoloft 50 mg at bedtime. Review of the resident's August 2019 MAR showed staff administered the resident Zoloft 50 mg at 8:00 P.M. Review of the resident's quarterly MDS, dated [DATE], and completed by staff showed the following: -Diagnoses included depression; -The resident took an antidepressant seven of the last seven days; -No documentation a GDR had been attempted. Review of the resident's care plan, dated 8/15/19 and 11/7/19, showed the following: -The resident was alert and orientated with moderately impaired cognition; -The care plan addressed the resident's Zoloft use. Review of the resident's September 2019 POS showed an order for Zoloft 50 mg at bedtime. Review of the resident's September 2019 MAR showed staff administered the resident Zoloft 50 mg at 8:00 P.M. Review of the resident's October 2019 POS showed an order for Zoloft 50 mg at bedtime. Review of the resident's October 2019 MAR showed staff administered the resident Zoloft 50 mg at 8:00 P.M. Review of the resident's November 2019 POS showed an order for Zoloft 50 mg at bedtime. Review of the resident's November 2019 MAR showed staff administered the resident Zoloft 50 mg at 8:00 P.M. Review of the resident's medical record showed no documentation staff had spoken with the resident or his/her family regarding a decrease in the resident's Zoloft medication. During interview on 11/21/19 at 4:40 P.M., the resident said the following: -He/She could not recall staff ever speaking to him/her about reducing his/her antidepressant medication; -If staff would have, he/she would have done what the physician suggested. During interview on 12/4/19 at 8:15 A.M., the resident's family member said the following: -He/She was the resident's power of attorney. He/She always let the resident make decisions for himself/herself. If he/she felt like the resident was not making a good decision, they would talk about it and decide together; -He/She could not recall the facility ever calling him/her about reducing the resident's anti-depressant; -He/She did not even know the resident was on an anti-depressant; -He/She did not think the resident needed an anti-depressant and would have agreed to the physician's suggestion to reduce the medication and even come off it completely. During an interview on 11/21/19 at 9:44 A.M., the resident's physician said the following: -He would expect staff to follow physician orders; -He expected staff to speak with the family/resident and if family/resident agreed, they were to change the order as he had documented on the GDR. 6. Review of Resident #21's Significant Change in Status MDS, dated [DATE], showed the following: -Diagnoses included stroke, dementia, anxiety, and chronic lung disease; -Required extensive assistance of two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Oxygen therapy; -CPAP. Review of the resident's care plan, last reviewed 10/11/19, showed the following: -The resident had limited use of his/her hands and was weak; -Received assistance of one or two staff for all cares; -CPAP at night and oxygen as ordered. Review of the resident's physician order sheet (POS) for November 2019, showed the following: -Apply CPAP at bedtime and remove in the morning. Settings: Left blank; -Oxygen at 2 liters per nasal cannula every shift. During an interview on 11/21/19 at 8:27 A.M., the resident said he/she used a CPAP machine at night. His/Her CPAP mask did not fit well last night and was leaking, and caused his/her face and gown to get wet. The night shift nurse applied the CPAP mask and later removed it per the resident's request because it was not working correctly. Interview and observation on 11/21/19 at 8:42 A.M. showed the following: -LPN A entered the resident's room; -LPN A said the resident reported to him/her that morning there was a problem with his/her CPAP machine during the night and the mask was leaking; -LPN A said he/she was not sure what the resident's CPAP machine settings were and would have to refer to the resident's POS; -LPN A turned on the CPAP machine and the screen showed settings for full face mask and a pressure of 4.0 to 12.0; -LPN A said the machine settings for the full face mask were incorrect because the resident wore a nasal mask; -LPN A changed the settings on the CPAP machine to nasal mask and applied the nasal mask on the resident to determine if it was leaking; -LPN A said if there were no settings listed for resident's CPAP machine in his/her orders, there would be no way to know the machine was programmed correctly. During an interview on 11/21/19 at 4:00 P.M., the DON said she would expect a resident's CPAP settings to be included in their physician orders so staff could refer to them to ensure the CPAP machine was set correctly when they applied. Staff should not mess with the settings on the CPAP machine but should call the company who provided the equipment if there were any problems. 7. Review of Resident #248's November 2019 POS showed an order for pantoprazole (decreases the amount of acid produced in the stomach) 40 milligrams (mg) twice daily, scheduled for 6:00 A.M. Review of Resident #297's November 2019 POS showed an order for pantoprazole 40 mg twice daily, scheduled for 6:00 A.M. Review of Resident #29's November 2019 POS showed an order for Synthroid (thyroid medication) 50 micrograms (mcg) daily, scheduled for 6:00 A.M. Review of Resident #45's November 2019 POS showed orders for the following: -Ferrous sulfate (iron supplement) 325 mg daily, scheduled for 6:00 A.M.; -Raloxifene (osteoporosis) 60 mg daily, scheduled for 6:00 A.M.; -Vitamin C 500 mg, daily, scheduled for 6:00 A.M. Review of Resident #26's November 2019 POS showed an order for levothyroxine (thyroid medication) 75 mcg daily, scheduled for 6:00 A.M. Review of Resident #17's November 2019 POS showed orders for the following: -Famotidine (medication to decrease stomach acid) 20 mg daily, scheduled for 6:30 A.M.; -Methylprednisolone (steroid) 4 mg four times daily, scheduled for 6:30 A.M. Review of Resident #7's November 2019 POS showed orders for the following: -Levothyroxine 25 mcg daily, scheduled for 6:00 A.M.; -Pepcid (treatment and prevention of stomach and intestine ulcers) 20 mg twice daily, scheduled for 6:00 A.M. Review of Resident #14's November 2019 POS showed orders for Pepcid 20 mg twice daily, scheduled for 6:00 A.M. Review of Resident #34's November 2019 POS showed an order for levothyroxine 125 mcg daily, scheduled for 6:30 A.M. Review of Resident #27's November 2019 POS showed an order for omeprazole (stomach ulcers) 40 mg daily, scheduled for 6:00 A.M. Observation on 11/20/19 at 6:10 A.M. of the morning medication pass showed the following: -RN E administered medications from a medication cart; -The top drawer of the medication cart contained a plastic medication tray that could hold 18 medication cups; -The plastic medication tray held ten plastic medication cups, all with a name written on the outside of the cup and the cups each contained unidentifiable medications; -One cup, labeled with Resident #248's first name, contained an oblong, white pill; -One cup, labeled with Resident #297's first name, contained an oblong, white pill; -One cup, labeled with Resident #29's first name, contained a round, white pill; -One cup, labeled with Resident #45's first name, contained a round red pill, a round white pill, and an oblong white pill; -One cup, labeled with Resident #26's first name, contained an oblong, blue pill; -One cup, labeled with Resident #17's first name, contained a round peach pill and an oval white pill; -One cup, labeled with Resident #7's first name, contained a round peach pill and a round yellow pill; -One cup, labeled with Resident #14's first name, contained a round, yellow pill; -One cup, labeled with Resident #34's first name, contained a round, beige pill; -One cup, labeled with Resident #27's first name, contained a purple and yellow capsule. During interview on 11/20/19 at 6:15 A.M., RN E said the following: -He/She had prepared the residents' 6:00 A.M. morning medication pass around 4:30 A.M.; -He/She always prepared the residents' medications by removing them from the pill packs or bottles and placing the medications in a plastic medication cup. He/She wrote the resident's name on the outside of the medication cup before placing the cup in the tray; -He/She probably could not identify every one of the resident's medications in the cups; -He/She documented on the MAR at the time of the administration and not the preparation; -He/She just knew the residents' medications and how many medications they were to take; -He/She had been taught to administer resident medications one at a time, but the morning routine was so busy, it was just easier the way he/she did it; -The medication cups of medications that were in the medication tray were for Residents #27, #248, #17, #34, #297, #26, #14, #29, #45 and #7. 14. Review of Resident #14's November 2019 POS showed orders for hydrocodone-acetaminophen (schedule II narcotic controlled substance) 7.5-325 mg/15 ml, administer 10 ml twice daily, scheduled for 6:00 A.M. Observation on 11/20/19 at 6:10 A.M. of the morning medication pass showed the following: -RN E administered medications from a medication cart; -The top drawer of the medication cart contained a bottle of liquid hydrocodone-acetaminophen 7.5-325 mg for the resident. (The medication was not secured under double lock). During interview on 11/20/19 at 6:15 A.M., RN E said he/she pulled the resident's bottle of narcotic medication out of the narcotic bin when he/she prepared the medication pass. 15. During interview on 11/14/19 at 3:55 P.M., the director of nursing said the following: -The charge nurses are to monitor the gradual dose reductions (GDR); -She expected staff to document any change to orders or responses from the GDR in the resident progress notes; -Residents who receive oxygen therapy should have a physician order for the oxygen; -She expected staff to check the placement of gastrostomy tubes before administering feedings; staff was to check for placement by measuring from the resident's skin to the bumper; -Tube feedings should be administered via gravity and not pushed through a syringe; -Staff should prepare and administer one resident's medication at a time; -Preparing a tray of multiple residents' medications and labeling the medications cups with just the resident's first name was not how she expected staff to administer medications; -Narcotics should always be kept locked up in the locked bin of the medication cart and only removed from the locked narcotic bin during preparation; -Narcotic medications should not be stored in the medication cart anywhere other than the locked narcotic bin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standards of practice during personal care for four residents (Residents #14, #21, #26, and #297), in a review of 16 sampled residents. The facility certified census was 48. 1. Review of the facility's undated policy Infection Control Guidelines for all Nursing Procedures showed the following: -Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions and excretions, regardless of whether or not they contain visible blood, no-intact skin, and/or mucous membranes. -Employees must wash their hands for 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct contact with resident, when hands are visibly dirty or soiled with blood or other body fluids, after contact with blood, body fluids, secretions, mucous membranes or non-intact skin, after removing gloves, after handling items potentially contaminated with blood, body fluids, or secretions, before eating or after using a restroom, when there is likely exposure to spores. Review of the facility's undated policy Handwashing showed the following: -This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly inserviced on the importance of hand hygiene in preventing the transmission of infections. All personnel shall follow the hand washing procedures to help prevent the spread of infections to other personnel, residents and visitors. Employees must wash their hands for at least 15 seconds using soap and water under the following conditions: when coming on duty, when hands are visibly soiled, before and after direct resident contact, before and after assisting a resident with personal cares, before and after changing a dressing, after contact with a resident's mucous membrane, bodily fluids or excretions, after handling soiled or used linens, dressings, bedpans, catheters or urinals, after performing personal hygiene, after removing gloves when changing gloves when going from dirty to clean. -The use of gloves does not replace hand washing. 2. Review of Resident #21's Significant Change in Status Assessment Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 10/9/19, showed the following: -Required extensive assistance from two or more staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Indwelling catheter; -Frequently incontinent of bowel. Review of the resident's care plan, last reviewed 10/11/19, showed the following: -The resident had limited use of his/her hands and was weak; -Required assistance of one or two staff for all cares; -Indwelling catheter. Observation on 11/20/19 at 6:42 A.M., showed the following: -The resident lay in bed. Certified Nurse Assistant (CNA) B and CNA C entered the room; -CNA B and CNA C washed their hands in the resident's sink and put on gloves; -CNA C prepared wash cloths with water and soap in the resident's sink; -CNA B wiped the resident's buttocks with a soapy wash cloth, then rinsed and dried the area; -CNA C rolled the resident to his/her back, removed his/her gloves, washed his/her hands, and left the room for more wash cloths; -CNA C returned to the resident's room with more supplies, washed his/her hands, and prepared wash cloths with soap and water in the resident's sink; -Without removing his/her soiled gloves, CNA B washed the resident's front perineal area, cleansing the catheter insertion site and down the catheter tubing, then rinsed and dried the area; -Without removing his/her soiled gloves, CNA B removed the catheter bag from the bed frame, handed the catheter bag to CNA C who pulled the catheter bag through the resident's pant leg; -CNA B and CNA C transferred the resident from the bed to the wheelchair with the mechanical lift; -CNA B then removed his/her gloves and without washing his/her hands left the resident's room; -CNA B returned to the resident's room with a comb. He/She did not wash his/her hands, and proceeded to comb the resident's hair. CNA B then pushed the resident to the dining room. 3. Review of Resident #26's quarterly MDS, dated [DATE], showed the following: -Modified independence for decision making; -Diagnosis of chronic obstructive pulmonary disease. Review of the resident's care plan, edited on 10/14/19, showed the following: -Assist of one staff for activities of daily living (ADL)s; -The resident had moderately impaired cognition; -The resident wore oxygen at all times. Review of the resident's Treatment Administration Record (TAR), dated October 2019, showed an order for oxygen at 2-5 liters per minute via nasal cannula continuous. Observation on 11/20/19 at 6:27 A.M. showed the following: -The resident lay in his/her bed; -RN E entered the resident's room with the resident's morning medication; -RN E did not wash his/her hands or use alcohol based hand sanitizer when he/she entered the room; -RN E placed medication in the resident's mouth by tipping the medication cup up and letting the tablet fall into the resident's mouth; -The resident spit out the medication and the tablet landed on the resident's shirt; -RN E picked the medication (tablet) up with his/her bare hand and placed it back into the resident's mouth; -The resident spit out the medication again, RN E picked up the medication and placed it in a cup of water and threw the cup in the trash on the medication cart; -The resident's oxygen tubing, including the nasal cannula, lay on the floor on the fall mat; -RN E stepped on the oxygen tubing, including the nasal cannula, two times; -RN E picked the oxygen tubing up and placed it in the resident's nose; -RN E exited the room without washing his/her hands; -RN E continued pushing the medication cart up the hall. 4. Review of Resident #297's Medication Administration Record, dated November 2019, showed the following: -Miconazole nitrate cream (medication to treat fungal infections) 2% apply topically twice a day; -Barrier cream to buttocks/leg rash every shift and as needed. Observation on 11/20/19 at 6:38 A.M. showed the following: -The resident lay in his/her bed; -RN E entered the resident's room, washed his/her hands and put on gloves; -RN E applied Miconazole cream to the open areas on the resident's left buttock and left hip; -Without removing his/her gloves, RN E touched the tip of the Miconazole tube, squeezed more cream into his/her glove, applied the cream to the resident's right and left groin, and then replaced the cap on the Miconazole tube. 4. Review of Resident #14's annual MDS, dated [DATE], showed the following: -Required extensive assistance from two staff for transfers and toilet use; -Required extensive assistance from one staff for personal hygiene and dressing; -Always incontinent of bladder; -Frequently incontinent of bowel. Review of the resident's care plan, dated 5/30/19, showed the following: -Required assistance with activities of daily living; -Provide perineal care after incontinent episodes. Observation on 11/20/19 at 1:40 P.M. showed the following: -CNA O and CNA H entered the resident's room, washed their hands and put on gloves; -CNA H and CNA O transferred the resident from his/her wheelchair to the toilet with a stand-up lift; -CNA O removed the resident's feces soiled incontinence brief, and without removing his/her gloves, put a clean incontinence brief through the resident's pants legs; -CNA H obtained smears of feces as he/she cleaned the resident's anal area with toilet paper, wiping multiple times with smears of feces noted. He/She pulled up the resident's pants and then removed his/her gloves; -Without washing his/her hands, CNA H touched the resident and the lift as staff transferred the resident to his/her wheelchair from the toilet; -CNA O removed his/her gloves; -Without washing his/her hands after providing incontinence care, CNA H and CNA O detached the resident's lift belt from the lift, and CNA H touched the resident's sweater and placed the foot rests on the resident's wheelchair. During interview on 11/21/19 at 2:30 P.M., CNA H said the following: -He/She should wash his/her hands upon entering a resident's room, when changing his/her gloves, and before exiting a room; -He/She should change his/her gloves when they become soiled and after providing perineal care; -He/She should not touch clean items/surfaces with soiled hands. 5. During an interview on 11/21/19 at 03:55 P.M and 4:00 P.M., the director of nursing said the following: -She expected staff to wash their hands and apply new gloves after cleansing a resident's buttocks and before cleansing a resident's front perineal area and catheter tubing; -She would not expect staff to touch medication with bare hands and place the medication back into the resident's mouth; -She would not expect oxygen tubing that had been on the floor and stepped on to be placed in a resident's nose; -She would not expect staff to touch the tip of a tube of cream with a soiled glove.