Based on interview and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends for two residents (#3 and #54) out of two sampled residents. The facility census was 61. 1. Review of the facilities policy titled, Resident acitvity policy, undated, states activities refer to an endeavor, other than routine Activities of Daily Living (ADLs) in which a resident participates that is intended to enhance his/her sense of well-being and to promote physical, cognitive, emotional health. The certified Activity Director (AD) completes an Activity Assessment within 72 hours of resident admission in order to implement an effective daily activity program meeting their physical, cognitive social, spiritual, educational, and recreational needs with options essential for preserving and enhancing resident's sense of well-being. 2. Review of the facilities Activity Calander, dated May 2024, showed: -Saturday, 05/04/2024, library, music room, pool table, streaming service in the activity oom and use gaming console; -Sunday, 05/05/2024, did not contain acitvities; -Saturday, 05/11/2024, library, music room, pool table, streaming service in the activity oom and use gaming console; -Sunday, 05/12/2024, National Nursing Home Week Radiant Memories- A Tribute to the Golden Ages of Radio; -Saturday, 05/18/2024, library, music room, pool table, streaming service in the activity oom and use gaming console; -Sunday, 05/19/2024, did not contain acitvities; -Saturday, 05/25/2024, library, music room, pool table, streaming service in the activity oom and use gaming console; -Sunday, 05/26/2024, did not contain acitvities. 3. During an interview on 05/29/24 at 3:39 P.M., Resident #3 said the facility does not have activities on the weekends. The resident said he/she would participate in activities on the weekends if they were offered. During an interview on 05/29/24 at 2:29 P.M., Resident #54 said the facility does not offer activities on Saturday and Sunday. The resident said he/she would attend activities on Saturday and Sunday if they were offered. During an interview on 05/30/24 at 3:45 P.M., Certified Medication Technician (CMT) D said he/she works every other weekend. The CMT said activities are not offered regularly on the weekends. The CMT said when nursing staff have time they will provide activities on their hall. The CMT said there are not scheduled activities on the weekends. During an interview on 05/30/24 at 3:55 P.M., Regisitered Nurse (RN) E said he/she works some weekends. The RN said he/she thinks there is church every now and then on Sundays but there are no scheduled activities on the weekends. During an interview on 05/30/24 at 4:02 P.M., Acounts Payable/Receptionist said he/she also assists with acitvities. He/She does not work weekends and rarely does the weekend have scheduled activities. He/She said the activities on the weekends are what the residents choose to do on their own. During an interview on 05/31/24 at 3:27 P.M., the Director of Nursing (DON) said weekend activities are resident choice, there are no scheduled activities. The DON said residents can do things such as color, play the gamin console, watch movies, play board games, or do puzzles. The DON said the nursing staff should be offering activities on the weekend. The DON said he/she is aware activities are not always getting done on the weekends, it is only being done when staff have the time. During an interview on 05/30/24 at 4:15 P.M., the administrator said activities are offered on the weekends by the nursing staff and usually involve going outside, games, or independent activities. The administrator said there is not a way for the residents to know what activities are offered on the weekend because they are not listed on the schedule.

Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5% out of 25 opportunities observed, two errors occurred, resulting in a 8% error rate, which affected one resident (Residents #2) of 11 sampled residents. The facility census was 61. 1. Review of the facility's, Insulin Administration Policy, not dated, showed if using an insulin pen, prime needle with two units prior to dialing to the amount of insulin. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/09/24, showed staff documented the resident diagnosis of Diabetes and received insulin injections seven days of the seven days in the look back period. Review of the resident's Physician Order Sheet (POS), dated 05/01/24, showed Humalog Kwik Pen (Insulin Lispro) 100 Units/milliliter (ml) per sliding scale three times a day. Review of the resident's Medication Administration Record (MAR), dated 05/01/24, showed staff documented the following medication administrations: -05/30/24, five units before lunch; -05/31/24, five units before breakfast. Observation on 05/30/24 at 11:37 A.M., showed Certified Medication Technician (CMT) C dialed the resident's Humalog Kwik Pen to five units and administered the insulin to the resident. The CMT did not prime the insulin pen prior to administration. Observation on 05/31/24 at 8:44 A.M., showed CMT A dialed the resident's Humalog Kwik Pen to five units and administered the insulin to the resident. The CMT did not prime the insulin pen prior to administration. During an interview on 05/31/24 at 11:44 A.M., CMT A said he/she should have primed the the insulin pen, that was his/her mistake. The CMT said he/she knows to prime the insulin pen, he/she just missed it. During an interview on 05/31/24 at 2:48 P.M., The Director of Nursing (DON) said staff should prime the insulin pen, he/she thinks two units. The DON said staff prime the needle to remove air. The DON said if staff did not prime the insulin pen, then the resident would not get the correct amount of insulin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Kitchen 05/28/24 Initial Kitchen 10:35 A.M. Dishwasher, Cycle of cups already ran sitting to left of dishwasher drying. Dietary Manager (DM) [NAME] ran cycle on dishwasher for cups, wash cycle reached 110 F and Rinse cycle reached 112 F. DM did not check temp during cycle and moved cups on to dry an ran another load. Dishwasher washed at 110F again and Rinsed at 112F again at 10:37 A.M. DM not aware running cold as it is a low temp but minimum should be 120 F for rinse and wash cycle. Test strip showed chemical at 50 PPM. 10:44 A.M. Open to air 32 oz pack and sliced ham in white frigidaire refrigerator, undated. DM seen the ham as inspector seen it and said threw it away, said when in doubt throw it out. DM said we should always date and sill the food. 10:48 A.M. walk-in freezer and fridge have internal thermometers and temped good. 10:50 A.M. open 10 pound tube of hamburger, missing half tube wrapped in silifain on bottom shelf of [NAME] cooler with three full 10Ib tubes of hamburger in metal container. Half tube loosely covered and without open date. 10:53 A.M. walk-in fridge five 32oz. packages of thawed, sliced roast beef stored on third shelf up on left directly above open box with uncovered raw green peppers. 10:56 A.M. floor of [NAME] cooler has a lot of food debris and dried spills. Dry Storage: 10:59 A.M., 50 pound bag of oats stored on bottom shelf, top of bag torn open, no date and oats open to air and not covered. Based on observation and interview, the facility staff failed to maintain the mechanical dishwasher in good repair to ensure dishes were effectively washed and sanitized to prevent cross-contamination. This failure has the potential to affect all residents. The facility census was 61. 1. Observation on 05/28/24 at 10:35 A.M., showed the Certified Dietary Manager (CDM) washed a rack of soiled cups in the chemical sanitizing mechanical dishwasher.Observation showed the CDM did not check the temperature of the dishwasher during the cycle. Observation showed the gauge of the dishwasher registered the water temperature during the wash cycle as 110 degrees Fahrenheit (dF) and the water temperature of the rinse cycle registered 112 dF. Observation showed when the dishwasher cycle finished, the CDM removed the rack of cups to the clean side of the station to dry and then loaded another rack of soiled dishes into the machine to wash. Observation showed the gauge of the dishwasher registered the temperature during the wash cycle as 110 dF and the rinse cycle as 112 dF. Observation of the manufacturer's instruction label on the dishwasher showed direction for the minimum water temperature to be 120 dF. During an interview on 05/28/24 at 10:37 A.M., the CDM said the temperature of the dishwasher should be at least 120 dF for the wash and rinse cycles and he/she did not know the machine did not reach 120 dF during the two cycles of dishes he/she washed in the machine. Observation on 05/29/24 at 7:20 A.M., showed dietary staff loaded a soiled sheet pan into the mechanical dishwasher, started the machine and walked away. Observation showed the dietary staff did not check the temperature of the water during the wash and rinse cycles of the machine. Observation showed the gauge on the dishwasher registered the water temperature of the wash cycle as 112 dF and the water temperature of the rinse cycle as 116 dF. Observations during a second run of the dishwasher, showed when tested with a calibrated metal stem-type thermometer, the water temperature of the wash cycle measured 112 dF and the gauge on the dishwasher registered the water temperature as 112 dF. Observation showed when tested with a calibrated metal stem-type thermometer, the water temperature of the subsequent rinse cycle measured 116 dF and the gauge on the dishwasher registered the water temperature as 116 dF. Observation showed the dietary staff returned to the kitchen, removed the sheet pan from the dishwasher and placed it on the clean side of the station to dry. Observation on 05/30/24 at 8:39 A.M., showed [NAME] F washed the soiled food processor in the mechanical dishwasher twice. Observations during a second run of the dishwasher, showed when tested with a calibrated metal stem-type thermometer, the water temperature of the wash cycle measured 112 dF and the gauge on the dishwasher registered the water temperature as 112 dF. Observation showed when tested with a calibrated metal stem-type thermometer, the water temperature of the subsequent rinse cycle measured 117 dF and the gauge on the dishwasher registered the water temperature as 117 dF. Observations showed the cook checked the water temperatures during the wash and rinse cycles of the machine when they measured less than 120 dF. Observation showed, when the dishwasher cycle finished, the cook removed the food processor from the machine to dry. During an interview on 05/30/24 at 8:40 A.M., [NAME] F said staff are supposed to check the water temperature first thing in the morning on the machine and the water temperature should be at least 120 dF. The cook said the water is always the hottest in the morning and it loses temperature throughout the day. Observation on 05/30/24 at 8:42 A.M., showed [NAME] F used the food processor to prepare pureed waffles for service to a resident at breakfast. During an interview on 05/30/24 at 8:53 A.M., the [NAME] F said if the dishwasher is not reaching the proper temperature then staff should not use it and wash the dishes another way. The cook said he/she knew the water temperature of the dishwasher did not reach 120 dF when he/she washed the food processor and he/she went ahead and used it anyway because he/she needed to get the pureed waffles out for breakfast. During an interview on 05/31/24 at 9:15 A.M., the CDM said the cooks are responsible to monitor the dishwasher water temperature on both shifts and the temperature should be at least 120 dF. The CDM said the water temperature of the dishwasher is not very hot first thing in the morning or after it sits for a while until it is used a few times and staff should check the temperature to make sure the machine is working appropriately before they use it to wash dishes. The CDM said if the dishwasher is not working correctly, staff should not use it and report the issue to him/her or the production manager for correction. The CDM said the facility did not have a policy for use and maintenance of the mechanical dishwasher, but staff are trained on proper use of the dishwasher upon hire. During an interview on 05/31/24 at 9:25 A.M., the administrator said the CDM and staff are responsible to monitor the condition of the dishwasher and check the water temperature of the machine before they use it to wash dishes to make sure it is right and they may need to run it a couple of times to get the temperature up properly. The administrator said the water temperature of the dishwasher should be close to 120 dF and staff have been trained on this requirement. The administrator said if staff have ran the dishwasher a few times and the water temperature is still not correct, then they should not use it and report it to the CDM or maintenance staff for repairs.

Based on record review and interview, the facility staff failed to follow their policy to ensure they completed the required Nurse Aide (NA) Registry (a registry that is a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property) check in accordance with their policy prior to start date for 10 employees (Maintenance Worker L, Dietary Aid (DA) M, Housekeeping Aid N, Licensed Practical Nurse (LPN) O, LPN P, Certified Medical Technician (CMT) E, CMT A, Environmental Aid Q, NA R and Human Resource Director) out of 10 sampled employees. The facility census was 60. 1. Review of the facility's Abuse/Neglect policy, undated, showed: - The facility will not hire or maintain in employment a person with a history of abuse and will report any employee known to be abusive to the appropriate authorities; -The nurse aid registry will be checked prior to employment for each state where a nurse aid has shown to have worked, or has listed certification. Nurse aides will not be hired whose name is on any state abuse registry; -Verification of background checks, nurse aid registry checks, and reference checks will be maintained in the personnel file of each employee; A notation by facility staff member of telephone contacts for registry check and previous employer check would constitute verification. 2. Review of Maintenance worker L's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 3. Review of DA M's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 4. Review of Housekeeping Aid N's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 5. Review of LPN O's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 6. Review of LPN P's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 7. Review of CMT E's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 8. Review of CMT A's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 9. Review of EA Q's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 10. Review of NA R's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 11. Review of the Human Resource Director's personnel record showed: -The file did not contain documentation staff completed the NA Registry check. 12. During an interview on 2/23/22 at 8:20 A.M., the Human Resource Director said he/she knows the NA registry search should be done with each new hire but could not account for why personnel records did not contain a copy. During an interview on 2/23/23 at 8:33 A.M., with the Director of Nursing said background checks should be done on each employee including NA registry checks. During an interview on 2/23/23 at 8:57 A.M., with the Assistant Administrator said criminal background checks should be done with each employee and it should contain NA registry searches.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide the necessary care and services to maintain good personal hygiene for three sampled residents (Residents #4, #15, and #39) that were unable to perform their own activities of daily living (ADL), and failed to answer call lights in a timely manner for one resident (Resident #28). The facility census was 60. 1. Review of the facility's Bath and Shower policy, dated 10/10/22 showed: -It is the policy of the facility to allow residents their choice with their bath/shower regimen and schedule; -Resident are allowed to choose their preferred time of their bath/shower; -Residents will be bathed/showered minimally twice per week; -Residents have the right to request more showers/baths as they feel needed. 2. Review of Resident #4's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/7/22, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from two staff for transfers; -Required limited assistance from one person for personal hygiene; -Required one person physical assistance with bathing. Review of the resident's shower documents, from 1/1/23 through 2/23/23 showed staff documented the following regarding bathing assistance: - No bathing assistance between 1/1/23 and 1/24/23; - No bathing assistance between 1/26/23 and 1/31/23; - No bathing assistance between 2/1/23 and 2/7/23; - No bathing assistance between 2/9/23 and 2/22/23. Observation on 2/21/23 at 8:21 A.M., showed the resident's hair was unkempt and their fingernails had a brown substance under the nails. 3. Review of #15's Quarterly MDS dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required extensive assistance of two staff members for dressing, transfers and personal hygiene; -Did not have a bath in the lookback period (7 day period required to look back to complete the assessment); -Had no behaviors or rejection of care; -Had limited range of motion to one lower extremity; -Had diagnosis of hemiplegia (unable to move one side of body), and urinary incontinence. Review of the residents' Care Plan, dated 2/20/23 showed the record did not contain direction or guidance for the resident's shower preferences. Review of the resident's bath schedule, undated, showed staff should provide showers twice a week on Tuesday and Friday. Review of the resident's Point of Care ADL report, dated 1/1/23 through 1/14/23, showed staff documented they provided the resident one bath on 1/3/23 during the 14 day period. Review of the resident's Point of Care ADL report, dated 1/15/23 through 1/31/23, showed staff documented they provided the resident one bath on 1/10/23 during the 14 day period. Review of the resident's Point of Care ADL report, dated 2/1/23 through 2/22/23, showed staff documented they provided the resident one bath on 2/8/23 during the 22 day period. Observation on 2/20/23 at 10:41 A.M., showed the resident asked Certified Nurse Aide (CNA) K for a shower. CNA K told the resident, he/she could not have a shower because he/she was on isolation. Additionally, CNA K did not offer alternative ways to clean the resident. Observation on 2/20/23 at 3:00 P.M., showed the resident on isolation in his/her room. He/She had greasy hair, long dirty fingernails and long facial hair. During an interview on 2/20/23 at 3:00 P.M., the resident said he/she would like a shower but cannot have one because he/she is stuck in the room because of COVID. 4. Review of Resident #39's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance from two staff for transfers; -Required extensive assistance from one person for personal hygiene; -Required one person physical assistance with bathing. Review of the resident's shower documents, from 1/1/23 through 2/23/23 showed staff documented the following regarding bathing assistance; - No bathing assistance between 1/2/23 and 1/5/23; - No bathing assistance between 1/6/23 and 1/8/23; - No bathing assistance between 1/9/23 and 1/12/23; - No bathing assistance between 1/13/23 and 1/16/23; - No bathing assistance between 1/17/23 and 1/19/23; - No bathing assistance between 1/20/23 and 1/23/23; - No bathing assistance between 1/24/23 and 1/26/23; - No bathing assistance between 1/28/23 and 1/31/23; - No bathing assistance between 2/2/23 and 2/13/23; - No bathing assistance between 2/15/23 and 2/22/23. 5. During an interview on 2/23/23 at 9:11 A.M., CNA F said residents who do not leave their rooms, such as those with COVID-19 would get a bed bath in their rooms and should be documented at the nurses station. He/She said all residents are scheduled for twice weekly baths with refusals documented at the nurses station in an aide book. CNA F said showers should include changing of clothing, shaving and nail care of the resident. He/She feels there is enough staff to meet the needs of the residents. During an interview on 2/23/23 at 9:19 A.M., Nurse Aide (NA) G said resident are supposed to get a shower twice a week and clothing changed at least daily including COVID-19 positive residents. He/She said COVID-19 positive residents cannot leave their room so they receive a bed bath, but isn't sure if it is documented anywhere. During an interview on 2/23/23 at 10:26 A.M., CNA D said residents receive showers twice a week if they want. He/She said some residents prefer only one per week and will sometimes refuse that. He/She said showers and refusals should be documented in the aide book kept on the hallway. He/She said the aides do work from a shower schedule to make sure they are completed. CNA D feels there is enough staff to meet the needs of the residents including receiving the showers as scheduled. During an interview on 2/23/23 at 10: 27 A.M., Certified Medication Technician A said residents receive two showers a week that is recorded in a shower book at the nurse desk. He/She said sometimes the residents only wish one bath per week and should be documented they refused the second bath. During an interview on 2/23/23 at 11:18 A.M., the Director of Nursing (DON) said residents who must stay in their rooms during isolation will need to take a bed bath and remain in their rooms. He/She said residents are showered at least weekly and per the resident's preference. The DON said refusals should be reported to the charge nurse and resident preferences should be in the plan of care. 6. Review of the facility's policies showed staff did not provide a policy for call lights. 7. Review of Resident #28's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Had no behaviors or rejection of care; -Dependent on two staff for bed mobility, transfers, dressing and toileting; -Dependent on one staff for personal hygiene; -Had diagnosis of quadriplegia (inability to move all four limbs). Review of the facility's call light report dated 2/15/23 through 2/22/23 showed the following call light response times: -2/18/23 at 8:03 A.M., room [ROOM NUMBER], 20:36 minutes; -2/18/23 at 10:59 P.M., room [ROOM NUMBER], 21:49 minutes; -2/19/23 at 7:48 A.M., room [ROOM NUMBER], 29:15 minutes; -2/19/23 at 9:18 P.M., room [ROOM NUMBER], 26:36 minutes; -2/19/23 at 11:47 P.M., room [ROOM NUMBER], 20:28 minutes; During an interview on 2/21/23 at 10:00 A.M., the resident said he/she has to wait a long time to be assisted with transfers, being changed, and assisted to eat by staff due to the staff struggling to respond if a timely manner. During an interview on 3/1/23 at 8:58 A.M., the Assistant Administrator said all staff are expected to answer call lights. He/She said call lights should be answered timely to meet the resident needs.

Based on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections, when staff failed maintain a clean blood glucose meter (device used to obtain a blood sugar reading) between residents (Resident #15, #4, and #13). The facility census was 60. 1. Review of the facility's Blood Glucose Monitoring Device Care policy, undated, showed: -It is the mission of the facility to prevent transmission of pathogens through blood glucose monitoring devices; -Blood glucose monitoring devices must be disinfected by staff with hydrogen peroxide and/or Clorox wipes before and after each use; -Blood glucose monitoring devices are to be placed in a caddy and carried into the resident room; -The caddy is to be cleansed with hydrogen peroxide and/or Clorox wipes between resident's rooms; -If the caddy is placed on a hard surface, that area must be cleansed with hydrogen peroxide wipes after removal of caddy prior to leaving resident's room. Review of the CareSens N User Manual (the blood glucose monitoring device used by the facility), dated September 2015, showed: -Use a soft cloth or tissue to wipe the meter exterior. If necessary, dip the soft cloth or tissue in a small amount of alcohol; -Do not use any household and industrial cleansers that may cause irreparable damage to the meter. Review of the Centers for Disease Control (CDC)'s Infection Prevention during Blood Glucose Monitoring, dated March 2011, showed -Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleansed and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then is should not be shared; -Unsafe practices during assisted monitoring of blood glucose and insulin administration that have contributed to transmission of HBV or have put persons at risk for infection include using a blood glucose meter for more than one person without cleaning and disinfecting it in between uses and failing to change gloves and perform hand hygiene between finger stick procedures. 2. Observation on 2/22/23 at 11:00 A.M., showed CMT J entered Resident #15's room with a tote containing a vial of test strips, a sharps container, a medication cup filled with lancets (device used to poke the finger), a medication cup filled with pen needles (device used on an insulin pen), a medication cup holding the blood glucose meter and several alcohol pads. He/She sat the tote on the overbed table, removed the meter from the medication cup and placed the meter directly on the overbed table without a barrier. He/She obtained the blood sample and rested the meter back onto the overbed table and offered the resident some water. He/She removed the test strip with gloved hands and put it into the sharps container, removed his/her gloves, and washed his/her hands. He/She placed the blood glucose meter into the same medication cup on the tote, left the room and entered Resident #13's room without cleaning or disinfecting the blood glucose meter, tote or surface the tote sat on in Resident #15's room. 3. Observation and interview on 2/22/23 at 11:22 A.M., showed CMT J entered Resident #13's room sat the tote containing the blood glucose meter and supplies on the overbed table, and took the blood glucose meter from the medication cup used in Resident #15's room. When asked how often meters are cleansed, he/she stopped and said he/she better go clean it. He/she removed his/her gloves and washed his/her hands and went to the medication room after placing the meter back into the same medication cup. He/she did not cleanse the surface the tote sat on. Observation on 2/23/23 at 11:26 A.M., showed CMT J entered the medication room and sat the tote on the counter. He/she wiped the meter with a Clorox wipe and placed the meter back into the same medication cup. Observation on 2/23/23 at 11:28 A.M., showed CMT J entered Resident #13's room and sat the tote on the overbed table, placed the glucose meter on the overbed table after prepping it with a test strip without a barrier. He/She obtained the blood sample, removed the test strip with gloved hands, and placed the meter back into the same medication cup. Observation on 2/23/23 at 11:36 A.M., showed CMT J entered the medication room and sat the tote onto the counter. He/she wiped the blood glucose meter with a Clorox wipe and placed the meter back into the same dirty medication cup. 4. Observation on 2/23/23 at 11:40 A.M., showed CMT J entered Resident #4's room with the tote containing the glucose meter, lancet, alcohol pad and test strip and sat it on the overbed table. He/She took the meter from the medication cup, sat the meter on the resident's refrigerator, obtained a sample of blood, lay the meter on the resident's lap, removed his/her gloves and washed his/her hands, and placed the meter back into the medication cup on the tote. He/She left the room without disinfecting or cleaning the meter or surface the tote sat on. During an interview on 2/23/23 at 11:50 A.M., CMT J said normally blood glucose meters are cleaned between every 3-4 residents. He/She said, if he/she wasn't asked they would have checked Resident #13's blood sugar without cleaning the meter. He/She said staff just use Clorox wipes to clean the meters, but isn't sure if it's the right way or not. He/She said they should not put the meters back into a medication cup that had a used meter in it, and didn't think about it. CMT J said using a potentially dirty meter could spread germs. During an interview on 2/23/23 at 10:27 A.M., CMT A said staff are directed to clean the glucose meters with a bleach wipe after each resident so infection does not spread. During an interview on 2/23/23 at 10:38 A.M., LPN C said staff should clean the glucose meter with a bleach wipe after each resident. During an interview on 2/23/23 at 11:18 A.M., the DON said staff should take the glucose tote to the resident's room to obtain a glucose reading. He/She said staff should clean the meter and tote before leaving a resident's room. He/She said germs could spread if the equipment is not cleansed or disinfected between residents.

Based on interview and record review, the facility failed to ensure one or more individuals completed specialized training in infection prevention and control (IPC) prior to assuming the role of infection preventionist (IP) for the facility's infection prevention and control program. The census was 60. 1. Review of the Centers for Disease Control and Prevention (CDC) website showed: -The Nursing Home Infection Preventionist Training course is designed for individuals responsible for infection prevention and control (IPC) programs in nursing homes; -The course is made up of 23 modules and sub-modules that can be completed in any order and over multiple sessions. Review of the IP's CDC training transcript showed three modules were completed in January 2022 and seven modules in May 2022. Further review showed no additional modules had been completed since May 2022. During an interview on 2/22/23 at 12:57 P.M., the IP said he/she started as the IP in May of 2022 and had completed the CDC online course. During an interview on 2/23/23 at 8:31 A.M., the Director of Nursing (DON) said he/she expected the IP to have his/her required training done, but did not know it was required before assuming the IP role. During an interview on 2/23/23 at 11:22 A.M., the Assistant Administrator said the IP training should be done in a timely manner - within the first year. The Assistant Administrator said he/she was not aware of training requirement before assuming IP role. He/She also said the facility did not have a policy covering IP qualifications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for three (Residents #19, #40 and #47) of seven sampled residents. The facility also failed to ensure Resident #51 was offered the flu vaccine. The facility census was 61. 1. Review of the facility's Influenza/pneumococcal vaccination policy, last reviewed October 2022 showed: -All residents of the facility may receive an annual influenza vaccination and pneumococcal vaccination if needed, if not allergic to eggs and with resident or responsible party consent -Consent for vaccination(s) to be obtained on yearly basis and upon admission -Once resident has received either influenza or pneumococcal vaccination nursing staff will document regarding injection site and any adverse reactions for 24 hours. Review of the U.S. Department of Health and Human Services - Centers for Disease Control and Prevention (CDC), pneumococcal and influenza vaccine timing for adults, dated 4/01/2022, showed the following: -Four types of pneumonia vaccines are acceptable for adults 65 years or older. PCV13: 13-valent pneumococcal conjugate vaccine (Prevnar13), PCV15: 15-valent pneumococcal conjugate vaccine (Vaxneuvanc), PCV20: 20-valent pneumococcal conjugate vaccine (Prevnar20), and PPSV23: 23-valent pneumococcal polysaccharide vaccine (Pneumovax); -For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20) you may administer one dose of PCV15 or PCV20. -Regardless of which vaccine is used (PCV15 or PCV20): -The minimum interval is at least 1 year; -Their pneumococcal vaccinations are complete; -For those who have never received a pneumococcal vaccine or those with unknown vaccination history administer one dose of PCV15 or PCV20 2. Review of Resident #19's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument dated 2/20/23, showed facility staff assessed the resident as follows: -Cognitively intact; -The resident's pneumococcal vaccination is up to date. Review of the resident's medical record showed the resident received an unknown type of pneumonia vaccine on 9/01/21. The record did not contain documentation staff offered the second dose of the pneumonia vaccine. 3. Review of Resident #40's Quarterly MDS dated [DATE], showed facility staff assessed the resident as follows: -Severe cognitive impairment; -The resident's pneumococcal vaccination is up to date. Review of the resident's medical record showed the resident received the PPSV23 pneumonia vaccine on 10/01/2018. Further review showed a pneumonia consent form dated 9/15/21, annotated with the comment, not due received in 2018. 4. Review of Resident #47's admission MDS dated [DATE] showed facility staff assessed the resident as follows: -Cognitively intact; -The resident's pneumococcal vaccination is up to date. Review of the resident's medical record showed the resident received a PPSV23 pneumonia vaccine on 11/13/17. The record did not contain documentation staff offered the second dose of the pneumonia vaccine. 5. Review of Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP) United States, 2022-23. Summary of Recommendations, dated 8-25-2022, showed: -ACIP recommends that adults aged 65 years or older preferentially receive any one of the following higher dose or adjuvanted (ingredient used in some vaccines that helps create a stronger immune response) influenza vaccines: quadrivalent (A vaccine that works by stimulating an immune response against four different antigens, such as four different viruses or other microorganisms) high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4). If none of these three vaccines is available at an opportunity for vaccine administration, then any other age appropriate influenza vaccine should be used. 6. Review of Resident #51's Annual MDS dated [DATE] showed facility staff assessed the resident as follows: -Cognitively intact; -Resident received this year's influenza vaccine outside of the facility. Review of the resident's medical record showed the resident received the influenza vaccine on 10/26/21. The record did not contain documentation the resident received or was offered an influenza vaccine for the current influenza season. 7. During an interview on 02/22/23 12:57 P.M., the Infection Preventionist said the Director of Nursing (DON) is responsible for resident immunizations. During an interview on 2/22/23 at 2:52 P.M., the DON said facility staff administer the Prevnar 13 and PPSV-23 pneumonia vaccines. The DON also said he/she did not have a facility policy for administering vaccines. The DON said Resident #51 does not have documentation of the current influenza vaccine, but he/she should. The DON also said he/she is responsible for resident influenza and pneumococcal vaccinations. During an interview on 2/23/23 at 11:22 A.M., The Assistant Administrator said the DON and charge nurses are responsible for resident immunizations. He/She said facility staff reviewed the resident population every year in the fall to see who needed influenza or pneumococcal vaccinations. The Assistant Administrator also said he/she was not familiar with pneumonia vaccine guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to use food in a first in-first out method when facility staff opened multiple containers of the same food item for use. Facility staff also failed to wear hair restraints to protect food and food-contact surfaces from potential contamination. The facility census was 60. 1. Review of the facility's Food Storage policy, dated 11/01/17, showed the policy directed staff to store food obtained for use by the facility for consumption by the residents properly in the kitchens and the refrigerators and freezers are to be maintained by the dietary staff. Review of the facility's Label and Dating policy, dated 11/01/17, showed Any food prepared and stored for later use or partially opened food items must be clearly identified. If the original packaging is not still intact the label must include what the product is and dated with day item produced. Items containing eggs, mayonnaise containing eggs, or fish products must be disposed of same day produced. All other food items must be stored and disposed of properly in direction of the Food code. Observation on 02/20/23 at 10:26 A.M., showed the main kitchen service area counter contained an opened and undated four pound jar of peanut butter and an opened and undated 12 ounce (oz.) container of powdered coffee creamer. Observation on 02/20/23 at 10:28 A.M., showed the black refrigerator in the main kitchen service area contained: -an opened and undated one gallon container of milk; -two opened and undated bottles of chocolate syrup; -an opened and undated bottle of caramel syrup; -an opened and undated bottle of strawberry syrup; -an opened and undated bottle of pancake syrup; -an opened and undated bottle of mustard; -an opened and undated bottle of grape jelly; -an opened and undated jar of grape jam. Observation on 02/20/23 at 10:36 A.M., showed the white refrigerator in the main kitchen contained: -an opened, undated and unlabeled [NAME] jar which contained an unidentifiable brown applesauce textured substance; -two opened and undated bottles of mustard; -three undated and unlabeled clear plastic cups with lids which contained an unidentifiable white and brown substance; -two opened and undated bottles chocolate syrup; -an opened and undated container of vegetable oil whipped spread; -a metal container which contained a cut onion opened to the air; -a cut tomato open to the air and undated; -six boiled eggs in plastic wrap undated; -an opened and undated two pound package of smoked ham in a plastic food storage container; -an undated bag of four boiled eggs opened to the air; -an undated plastic food storage container of white cheese slices. Observation on 02/20/23 at 10:37 A.M., showed the rack next to white refrigerator in the main kitchen contained: -four opened and undated bags of potato chips; -an opened and undated box of stir-fry rice noodles, opened to the air; -an undated bag of blueberry muffin mix in an undated plastic bag, opened to the air. Further observation showed a use by date of 11/16/22 printed on the muffin mix bag; -an opened and undated bottle of white chocolate flavoring with a hardened substance on the top of the bottle; -an undated bottle chocolate sauce opened to the air; -an undated bag of gluten free chocolate chip cookies opened to the air. Observation on 02/20/23 at 10:50 A.M., showed an opened and undated box of farina cereal on top of the microwave. Observation on 02/20/23 at 10:51 A.M., showed the white cabinet above the hot box contained: -two opened and undated one gallon bottles of vanilla flavoring; -two opened, undated and unlabeled [NAME] jars which contained an unidentifiable brown applesauce textured substance; -two opened and undated bottles cream of tartar; -a bag of yellow cake mix dated 6-30 opened to the air; -an opened and undated bag of graham cracker crumbs; -an opened and undated bag of cake mix; -an opened and undated bag of powdered sugar. During an interview on 02/20/23 at 11:29 A.M., the Certified Dietary Manager (CDM) said he/she could not identify the brown applesauce textured substance in the [NAME] jars and the jars should be labeled. Observation on 02/20/23 at 10:57 A.M., showed a sign posted on the reach-in refrigerator door that read STOP Please date and label everything. Further observation showed the reach-in refrigerator contained: -an undated plastic food storage container of white cheese slices; -an undated and unlabeled metal container covered with plastic wrap with contained an unidentifiable white sauce textured substance; -an opened and undated one gallon container of mayonnaise; -an opened and undated one gallon container of Caesar dressing; -an opened and undated one gallon container of soy sauce opened and undated; -an opened and undated one gallon bottle of Worcestershire sauce; -an opened and undated 6.5 pound container of sliced strawberries. Observation on 02/20/23 at 11:03 A.M., showed the walk-in cooler contained: -a box of raw bacon opened to the air; -an undated plastic resealable bag of sliced onions; -an undated plastic resealable bag of cabbage. Observation on 2/20/23 at 11:11 A.M., showed the walk-in freezer contained: -an undated and unlabeled plastic resealable bag of hamburger patties removed from their original packaging; -an undated and unlabeled bag of a unidentifiable meat crumbles; -a box of frozen pizza crust opened to the air. Observation on 02/20/23 at 11:40 A.M., showed the reach-in refrigerator in the rehabilitation unit contained: -an undated plastic bag of shredded carrots and a purple item; -an undated bag of celery opened to the air; -an opened and undated five pound bag of shredded cheese; -an undated plastic resealable bag of of cooked sausage. Observation on 02/20/23 at 11:46 A.M., showed the rehabilitation kitchen dry goods pantry contained: -an undated and unlabeled bag of an unidentifiable grain-like substance; -an undated metal bowl of broken pasta covered with plastic wrap undated; -a bag of tortilla chips opened to the air. Observation on 02/20/23 at 11:51 A.M., showed the rehabilitation kitchen reach-in freezer contained: -three large unlabeled and unidentifiable chunks of meat removed from their original packaging and wrapped in plastic wrap; -a box of biscuit dough opened to the air; -an opened and undated bag of dinner roll dough. Observation on 02/20/23 at 11:53 A.M., showed the rehabilitation kitchen food preparation area contained opened and undated plastic containers of dill weed, garlic, Italian seasoning, paprika, cumin rotisserie seasoning, onion power, basil leaves, ground ginger and pumpkin pie spice. Observation on 02/20/23 at 11:56 A.M., showed the rehabilitation kitchen serving area contained: -an opened and undated bag of tortilla chips; -an opened and undated jar of peanut butter; -an opened and undated jar of grape jelly; -an opened and undated bottle of pancake syrup. Observation on 02/20/23 at 12:05 P.M., showed the white refrigerator in the rehabilitation kitchen contained: -an opened and undated one gallon bottle of milk; -an opened and undated jar of grape jelly; -an opened and undated bottle of chocolate syrup; -an undated plastic cup of applesauce; -an open and unlabeled [NAME] jar which contained an unidentifiable brownish applesauce textured substance dated 1-14-23. Observation on 02/20/23 at 12:22 P.M., showed the white refrigerator in the 300 hall dining room contained: -three opened and undated bottles of mayonnaise; -four opened and undated bottles of ketchup; -an opened and undated bottle of mustard; -an opened and undated one gallon bottle of milk; -one bottle chocolate syrup opened and undated; -an opened and undated bottle of grape jelly; -an opened and undated container of vegetable oil spread opened and undated. Observation on 02/22/23 at 7:20 A.M., showed the combination freezer/refrigerator unit in the main kitchen contained: -an opened, undated and unlabeled one quart [NAME] jar which contained an unidentifiable brown applesauce textured substance; -an opened and undated 14 oz. bottle of ketchup; -an opened and undated 24 oz. bottle of caramel syrup; -three opened and undated 13 oz. bottles of mustard; -an opened and undated 11.5 oz. bottle of mayonnaise; -two undated bags of commercially prepared boiled eggs opened to the air; -two opened and undated 3.5 pound container of vegetable oil whipped spread. Observation also showed brown specks in product inside the containers; -an opened and undated 24 oz. jar of sliced dill pickles; -a small metal pan labeled as Mayo 2/21/23 partially covered with a steamtable lid that contained a utensil hole which exposed the contents to the air; -an small undated and unlabeled plastic parfait cup of an unidentifiable white and brown substance. During an interview on 02/22/23 at 7:41 A.M., [NAME] L said he/she could not identify the substance in the [NAME] jar and it should have been dated and labeled before staff put it into the refrigerator. The cook said he/she does not look in that refrigerator since it is storage for the servers and the servers are supposed to maintain it. Observations on 02/22/23 at 7:42 A.M., showed a bulk container of sugar dated 02/21/23 and a bulk container of flour dated 12-21 stored beneath the coffee counter. Observation showed measuring cups stored in the bulk containers with their handles buried in the products. Observation on 02/22/23 at 7:51 A.M., showed the cabinet above the hot box contained: -an opened five pound bag of pound cake mix dated 6/10/21. Observation showed the exterior of bag covered with cocoa powder; -a five pound bag of yellow cake mix dated 6-30 opened to the air; -a five pound bag of yellow cake mix dated 11-11 opened to the air; -an opened and undated five pound bag of graham cracker crumbs; -an opened and undated bag of white cake mix; -an opened and undated five pound bag of southern yellow cornbread; -an undated one gallon plastic resealable bag which contained an opened and undated bag of cocoa powder; -pearled Italian [NAME] opened to the air and dated 2-12. -an opened and undated one gallon bottle of imitation vanilla flavor. Observation showed the delivery sticker on the bottle dated 08/26/20; -an opened and undated one gallon bottle of imitation vanilla flavor. Observation showed the delivery sticker on the bottle dated 08/18/21; -an opened and undated two pound bag of powdered sugar. During an interview 02/22/23 at 7:58 A.M., [NAME] L said the date of the Italian [NAME] would be 02/12/22 not 02/12/23 since they had not used it yet this year. The cook said everyone is responsible to monitor food storage and he/she had not looked in the cabinet for a while. Observation on 02/22/23 at 8:06 A.M., showed the reach-in refrigerator by the hot box contained: -an opened and undated one gallon bottle of soy sauce; -an opened an d undated one gallon bottle of Worcestershire sauce; -an opened and undated 6.5 gallon plastic container of commercially sliced strawberries. Observation showed the lid of the container bulged which abruptly deflated when opened and the strawberries smelled fermented and sour. -an opened and undated 17.25 oz. jar of grape fruit spread. Observation showed the grape fruit spread appeared brown in color and the container had a best if used by dated of 05/27/22 printed on the label; -an opened and undated one quart [NAME] jar which contained an unidentifiable brown applesauce textured substance; -an opened and undated 24 oz bottle of caramel syrup; -an undated and unlabeled round plastic food storage container which contained an unidentifiable white greasy substance; -an opened and undated one gallon bottle of barbeque sauce; -an opened and undated one gallon bottle of horseradish flavored french salad dressing. Observation showed the delivery sticker dated 09/14/22; -an opened and undated one gallon bottle of creamy Caesar dressing. During an interview 02/22/23 at 8:10 AM the cook said the strawberries had been in the refrigerator since 02/14/23. Observation on 02/22/23 at 8:28 A.M., showed the rack by the combination freezer/refrigerator unit contained: -an undated 14 oz. box of stir-fry rice noodles opened to the air; -an undated 24 oz. box of gluten-free all purpose baking mix opened to the air; -a 24 oz. bag of gluten-free pancake mix, dated 09/13/22; -a one gallon plastic resealable bag dated 11/16/22, opened to the air. Observation showed the bag contained an opened and undated 20 oz. bag of oat flour; -an undated 16 oz. bottle of chocolate sauce opened to the air. Further observation showed the product label included instructions to refrigerate the product after opening; -an opened and undated 16 oz. bottle of white chocolate flavored sauce. Further observation showed the product label included instructions to refrigerate the product after opening. During an interview on 02/22/23 at 8:35 A.M., [NAME] L said if a product says to refrigerate after opening then staff should refrigerate the item after it is opened. The cook said all opened food items should be dated, labeled and sealed. Observation on 02/22/23 at 8:59 A.M., showed the storage cart in the cook's station contained: -an opened and undated five pound five oz. container of instant mashed potatoes; -an opened and undated one gallon bottle of white vinegar; -an opened and undated 16 oz. bag of marshmallows; -an opened and undated five pound bag of yellow cake mix; -an opened and undated one gallon container of soybean salad oil; -an undated 28 oz. bag of chicken flavored stuffing mix opened to the air. During an interview on 02/22/23 at 9:09 A.M., the CDM said opened food items should be sealed, dated and labeled. If a container says to refrigerate after opening staff should refrigerate the item after it is opened. The CDM said when their are multiple packages of items, staff should use the oldest package first. The CDM said staff should return any unused portions of opened food items to where they got them from and use all of one package before they open another package of the same item. The CDM said all staff are responsible to ensure food is stored appropriately and he/she usually checks food storage on truck days. The CDM said staff should also not store scoops in the bulk food bins and staff have been trained on these requirements multiple times. Observation on 02/22/23 at 9:55 A.M., showed the refrigerator in the rehabilitation kitchen contained: -an opened and undated 24 oz. bottle of chocolate syrup; -an opened and undated 12.7 oz. bottle of dill relish; -an opened and undated 14 oz. bottle of ketchup; -an opened and undated five oz. bottle of Tabasco sauce. Observation on 02/23/23 at 11:13 A.M., showed the refrigerator in the 300 hall dining room contained: -three opened and undated 14 oz. bottles of ketchup; -three opened and undated 11.5 oz. bottles of mayonnaise; -an opened and undated 12.75 oz. jar of sugar free grape jam; -an opened and undated 24 oz. bottle of sugar free pancake syrup; -an opened and undated 24 oz. bottle of pancake syrup; -an opened and undated 13 oz. bottle of yellow mustard; -an opened and undated 20 oz bottle of strawberry fruit spread with a best by date of 01/28/23 printed on the label; -an opened and undated 20 oz. bottle of grape jelly; -an opened and undated 3.5 pound container of vegetable oil whipped spread. Observation at this time also showed the dining room cabinets contained: -an opened and undated 40 oz. bottle of honey; -undated plastic storage containers of cornflakes, fruit whirls, toasted oat O's and crisp rice cereal removed form their original packaging; -a bag of crisp rice cereal dated 12-21 opened to the air. During an interview on 02/23/23 at 11:55 A.M., the Assistant Administrator said staff should label, date and seal opened food items and staff are trained to do so upon hire. The Assistant Administrator said staff should dispose of any unused food items passed the best by or use by date and if a food item says to refrigerate after opening, then staff should refrigerate it after they open it. The Assistant Administrator said staff should use food items in a first in-first out manner and use all of one container before they open another. The Assistant Administrator said the CDM is responsible to monitor food storage weekly and if something is found not in compliance, the CDM should throw the item away and reeducate staff. 2. Review of the facility's Hair Restraint policy, dated 11/01/17, showed proper hair restraints are required while serving and/or preparing food as well in serving areas. Hair restraints will be provided to all dietary staff. Hair restraints are designed to effectively keep hair from contacting exposed food and/or serving areas. In the event that an employee has facial hair a beard net must be worn. Observations on 02/22/23 from 7:20 A.M. to 9:18 A.M., showed [NAME] L and the CDM prepared and served food to the residents without the use of hair restraints for their facial hair. During an interview on 02/22/23 at 9:24 A.M. the CDM said staff are trained to wear hair restraints, which included facial hair restraints. The CDM said staff use to wear the facial hair restraints, but they stopped since they had to wear facemasks as a result of the pandemic and he/she thought the masks helped with that. The CDM said all hair should be restrained and he/she did not think about the facemasks not covering all of the staff's facial hair. During an interview 02/23/23 12:08 P.M., the Assistant Administrator said dietary staff should wear hair restraints when they prepare or serve food and the facility policy includes the use of facial hair restraints. The Assistant Administrator said staff are trained on the hair restraint policy and the CDM is responsible to monitor for the use of hair restraints.

Based on observation, interview and record review, the facility failed to investigate an injury of unknown origin for one resident, (Resident #15) as well as failed to report the injury to the State Agency (SA). The facility census was 63. 1. Review of the facility's Zero tolerance Abuse/Neglect Policy, undated, showed staff is directed as follows: -Objective: To develop and implement a system for identifying, investigating, preventing, and reporting any incident, or suspected incident, of abuse, neglect, mistreatment, or misappropriation of resident property; -If an incident occurs, or there is any reason to suspect that an incident might have occurred, the administrator or designee will investigate; -The person doing the investigation will complete a Resident Abuse/Neglect Investigation Report; -If an alleged or suspected incident of abuse, neglect, mistreatment, or misappropriation of resident property occurs, the administrator or designee, will report the incident to the Elderly Abuse and Neglect Hotline within 2 hours of suspected incident; -The charge nurse is to complete a Resident Abuse/Neglect Report and forward the report to the Director of Nursing (DON) and administrator by the completion of the work period that the report occurred. Further review of the facility policy, showed it did not contain direction for the staff in regards to injuries of unknown origin, or when to report them to the SA. 2. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/10/2019, showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance of two staff members for bed mobility, transfers, dressing, and toilet use; -Had no functional limitation of range of motion (ROM) in his/her upper extremities; -And had no diagnosis related to chronic shoulder pain or discomfort. Review of resident's care plan, dated 12/11/19, showed staff was directed as follows: -Diagnoses: muscle weakness, age related osteoporosis (disease in which density and quality of bone are reduced), osteoarthritis (degeneration of joint cartilage and the underlying bone); -Used mechanical lift as needed with total dependence on two staff members; -Utilized bilateral half rails on bed for rolling, repositioning, and transfers; -And required extensive assistance of two staff members for dressing and toileting. Review of the resident's progress notes showed staff documented the following: -12/12/19 at 1:10 P.M., The resident had an irregularity of right shoulder placement. ROM of right arm was limited. The resident had slight discomfort with movement beyond ninety degrees. No bruising or swelling. The resident's primary care physician (PCP) was there to assess and attempted to manipulate (move) the right shoulder back in place. The PCP was unsuccessful and ordered the resident be sent to the emergency room for treatment. Family members were notified of need for transfer. The resident was transferred via mechanical lift to a gurney and transported via ambulance to the hospital. -12/12/19 at 3:10 P.M. (late entry on 12/13/19 at 8:36 A.M.), staff from the emergency room called. The family and physician had decided against a procedure to right the dislocated shoulder due to the dislocation not causing pain or discomfort and he/she had full ROM in the right shoulder. The family does not want sedation given to the resident. The resident's PCP was in the facility and stated he would like staff to talk to the resident's family about an orthopedic consult. The social service designee was notified. -12/12/19 at 8:44 P.M., the resident was sent to the emergency department on this date and returned. All departments were aware. Review of resident's after visit summary from the hospital, dated 12/12/19 showed the resident had a new diagnosis of anterior (front) dislocation of right shoulder, initial encounter (meaning the patient is receiving active treatment for the condition). Further review of the resident's medical record showed an emergency department physician documented the following on 12/12/19: -The resident presented with deformity to the right shoulder; -The family stated over the last month they noticed the resident's right shoulder appeared to stick out more; -Appears to be somewhat of a chronic issue that has occurred over the last month (November 2019 to December 2019); -Suspect that it is sublexed (partial dislocation) secondary to chronic rotator cuff (a capsule with fused tendons that supports the arm at the shoulder joint) degeneration. During an interview on 2/27/20 at 2:50 P.M., the Assistant Director of Nursing (ADON), said when injuries of unknown origin are found, the certified nursing assistant (CNA) reports it to the charge nurse immediately. The charge nurse investigates and then calls the doctor for orders. If there is going to be something to the injury, the charge nurse opens an event. If it looks like an old injury and doesn't require treatment, the charge nurse documents but doesn't need to open an event. Administration does an investigation if there is a complaint from the family or there is an accusation such as staff being rough with a resident. The grievance officer would then do an investigation. Furthermore, the ADON said he/she was the grievance officer, and if there had been bruising or something really noticeable the charge nurse would have come to him/her. He/she was not sure how cognitive the resident was or how well the resident could have answered questions anyway. The facility did not have a policy regarding injuries of unknown origin. He/she was not sure if anyone talked to the CNA's about the dislocated shoulder. He/she did not do an investigation regarding the dislocated shoulder. During an interview on 2/27/20 at 3:35 P.M., Licensed Practical Nurse (LPN) C said he/she checks injuries of unknown origin and tries to find out what happened but sometimes can't. He/she calls the doctor and family and probably tells the DON. The morning of 12/12/19 a CNA told him/her the resident's shoulder did not look right. It looked dislocated. The doctor had been there and tried to put the shoulder back in but could not without causing a lot of pain. The doctor wanted the resident sent to the hospital. During an interview on 2/27/20 at 4:08 P.M., the resident's family member said he/she noticed the resident's shoulder when the resident was in the rehab unit of the facility in March 2019. He/she did not want to place blame but thought it might have happened when staff were holding the resident under the arms when they were transferring him/her. He/she did not report it at the time. During an interview on 2/27/20 at 6:10 P.M., CNA D said if he/she found an injury on a person, such as a bruise, he/she would tell the charge nurse. He/she said he/she always reports injuries. During an interview on 3/3/20 at 10:20 A.M. the DON said the facility's policy for an injury of unknown origin says to start an internal investigation when the injury is discovered. The charge nurse reports the injury to the DON, and then the ADON and social service designee (SSD) completes an internal investigation. He/she was first made aware of the shoulder dislocation when the CNA reported it to the charge nurse. He/she said an investigation was not completed because the resident's dislocated shoulder was an old injury. Furthermore, he/she said the facility should have probably done an investigation just to have it in the paperwork and he/she said the documentation in the nurse's notes was not good. Review of the resident's record did not contain evidence of an investigation to determine the cause of the resident's right shoulder dislocation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to complete an accurate comprehensive Minimum Data Set (MDS), a federally mandated assessment tool, within the required timeframe's for one resident (Resident #20). Additionally, the facility failed to provide an accurate location and date of the documentation used to support care plan decisions for one resident (Resident #54). The facility census was 63. 1. Review of the Resident Assessment Instrument (RAI) Manual, October 2019, showed staff are directed as follows: -Comprehensive Assessments are required, and include the completion of both the Minimum Data Set, and the Care Area Assessment (CAA) process, as well as care plans. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required. -The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day one. -Assessment Completion refers to the date that all information needed has been collected and recorded for a particular assessment type and staff have signed and dated that the assessment is complete. -For required Comprehensive assessments, assessment completion is defined as completion of the CAA process in addition to the MDS items, meaning that the registered nurse (RN) assessment coordinator has signed and dated both the MDS (Item Z0500) and CAA(s) (Item V0200B) completion attestations. Since a Comprehensive assessment includes completion of both the MDS and the CAA process, the assessment timing requirements for a comprehensive assessment apply to both the completion of the MDS and the CAA process. 2. Review of Resident #20's admission MDS, a federally mandated assessment tool, dated 5/20/19 showed the staff assessed the resident as: -Cognitively impaired; -Did not exhibit behaviors of rejecting evaluation or care; -Experienced shortness of breath or trouble breathing with exertion; -And received oxygen therapy as a resident. Additional review of the resident's admission MDS showed the staff did not include the resident's use of Continuous Positive Airway Pressure (CPAP) (applies mild airway pressure on a continuous basis to keep the airways continuously open in people who need help keeping their airway unobstructed). Review of the resident's Physician Order Sheets (POS)'s, from May 2019 to February 2020, showed it did not contain an order for the resident's use of a CPAP. Review of the resident's care plan, dated 2/25/20, showed the resident has an active diagnosis of obstructive sleep apnea (breathing disorder that involves a decrease or complete halt in airflow), and staff was given direction to assist the resident with his/her CPAP at night per the doctor's orders. Review of the resident's progress notes showed staff documented the following: -5/13/19, the resident is ordered to use CPAP at night; -7/16/19, the staff received a note from the physician saying the resident absolutely has to wear his/her CPAP all night, every night; -7/17/19, the resident was resting with his/her CPAP in place; -11/20/19, the resident uses CPAP at night with education from the staff encouraging him/her to keep the mask on until he/she wakes in the morning; -12/14/19, the resident uses the CPAP at night to keep oxygen saturation (how much oxygen is being circulated in the resident's blood) within normal limits and the resident often removes his/her CPAP leading the staff to assist the resident with re-application of the mask; -12/16/19, the resident uses CPAP during hours of sleep with good compliance; -12/20/19, the resident utilizes CPAP at night; -2/20/20, the resident's CPAP was in place; -2/21/20, the resident was wearing his/her CPAP; -2/22/20, the resident's respirations were even and unlabored with CPAP in place; -And 2/22/20, the resident's CPAP was in place. During an interview on 2/27/20 at 11:47 A.M., the resident said he/she wears the CPAP at night to help him/her breathe, and he/she wears it most nights. During an interview on 2/27/20 at 12:14 P.M., CNA A said the resident uses a CPAP every night, and the resident has used it since he/she arrived to the facility. During an interview on 2/27/20 at 2:00 P.M., RN E said the resident has a CPAP in his/her room that he/she uses at night. The RN said he/she expects the resident's CPAP use to be included in the MDS. During an interview on 2/27/20 at 4:21 P.M., the MDS Coordinator said the resident utilizes a CPAP at night and since it is a scheduled intervention, it should be included on the resident's MDS. Additionally, he/she said the facility does not have a separate RAI policy and uses the RAI manual for direction to complete the MDS assessments. He/she could not tell me why the CPAP was not included on the admission MDS. He/she said he/she did not know why the resident's CPAP was not included on his/her MDS. 3. Review of Resident #54's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Having no speech or absence of spoken words; -Rarely/never understood; -Rarely/never understanding verbal content; -Short/long term memory problems; -Severely impaired decision making; -Having diagnoses of Dementia (diseases characterized by a decline in memory, language, problem-solving, and other thinking skills), Alzheimer's (a type of dementia), and anxiety disorder (mental disorders characterized by anxiety and fear). Review of the resident's Comprehensive CAA Summary, completed by facility staff, dated 11/6/19, showed staff documented See POC and progress notes 10/31/19-11/6/19, for all triggered care areas. Review of the resident's progress notes dated, 10/31/19-11/6/19, showed they did not contain information related to the resident's cognitive loss/dementia, communication, psychosocial well-being, or mood as directed in section V, even though the resident assessment identified these areas of concern. During an interview on 2/27/20 at 6:38 P.M., the MDS coordinator said he/she uses the seven day look-back period prior to the MDS Assessment Reference Date (ARD) to determine the dates and location of CAA documentation in section V of the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure staff reviewed and revised the care plan to include a newly diagnosed shoulder dislocation and interventions related to the shoulder dislocation for one resident (Resident #15), address the use of insulin for one resident (Resident #18), and reflect a change in code status for one resident (Resident #35). The facility census was 63. 1. Record review showed the facility does not have a care plan policy to provide direction to facility staff. 2. Review of Resident #15's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 12/10/2019 showed staff assessed the resident as follows: -Severely impaired cognition; -Requires extensive assistance of two staff members for bed mobility, transfers, dressing, and toileting; -And no functional limitation of range of motion (ROM) in his/her upper extremities. Review of resident's care plan dated 12/11/19 showed: -Diagnoses: muscle weakness, age related osteoporosis (disease in which density and quality of bone are reduced), osteoarthritis (degeneration of joint cartilage and the underlying bone); -Used mechanical lift as needed with total dependence of two staff members; -Utilized bilateral half rails on bed for rolling, repositioning, and transfers; -And required extensive assistance of two staff members for dressing and toileting. Review of the resident's progress notes showed staff documented the following: -12/12/19 at 1:10 P.M., the resident had an irregularity of right shoulder placement. ROM of right arm was limited. The resident had slight discomfort with movement beyond ninety degrees. No bruising or swelling. The resident's primary care physician (PCP) was there to assess and attempted to manipulate the right shoulder back in place. The PCP was unsuccessful and ordered the resident be sent to the emergency room for treatment. Family members were notified of need for transfer. The resident was transferred via mechanical lift to a gurney and transported via ambulance to the hospital. -12/12/19 at 8:44 P.M., the resident was sent to the emergency department on this date and returned. All departments were aware. Review of resident's after visit summary from the hospital, dated 12/12/19 showed diagnosis of anterior dislocation of right shoulder, initial encounter (meaning the patient is receiving active treatment for the condition). During an interview on 2/27/20 at 6:38 P.M., the MDS coordinator said after the resident's return from his/her trip to the emergency room related to a dislocated shoulder, he/she would add any new orders to the resident's care plan. Furthermore, he/she said precautions for the dislocated shoulder should be added to the care plan. He/She said he/she was not aware the resident had a dislocated shoulder. She said, and staff communicate changes to him/her by putting information in a folder at the nurse's station. During an interview on 3/3/20 at 10:20 A.M., the Director of Nursing (DON) said he/she would have expected the dislocation to be care planned so caregivers would be aware and know what precautions to take. The resident's care plan did not contain updates on the resident's condition, including direction for staff in regards to how to care for the resident's dislocated right shoulder. 3. Review of Resident #18's Quarterly MDS (Minimum Data Set) MDS, a federally mandated assessment tool, completed by facility staff to assessment a resident's care needs, dated 12/17/19, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Had an active diagnosis of diabetes mellitus (disease affecting how the body uses glucose (blood sugar); -And received insulin (medicine used to treat diabetes) injections, seven of seven days, in the look-back period (period of time used by facility staff to assess the resident and complete the MDS). Review of the resident's History and Physical, dated 11/21/17, showed the resident's physician assessed the resident as having a diagnosis of type two diabetes mellitus with other diabetic kidney complications and required the use of insulin. Review of the resident's Physician Order Sheets (POS's), dated 12/31/19, showed the resident had a physician order for Humalog insulin (rapid-acting medication used to lower blood glucose) three times a day before meals and an order for Lantus insulin (long-acting medication used to lower blood glucose) to be given at bedtime. Review of the resident's care plan, dated 2/17/20, showed staff did not document the resident's use of insulin to manage his/her diabetes. During an interview on 2/27/20 at 12:26 P.M., CMT B said the care plan should include glucose checks and dietary needs, such as if the family is bringing extra food. Additionally, he/she said the care plan should include medications such as insulin. During an interview on 2/27/20 at 2:00 P.M., RN E said for a resident who is diabetic, insulin should be included on the care plan. During an interview on 2/27/20 at 4:20 P.M., the MDS Coordinator said since the resident requires insulin for diabetes management, it should be included in the resident's care plan. 4. Review of Resident #35's Quarterly MDS, dated [DATE], showed staff assessed the resident as having moderate cognitive impairment. Review of the resident's POS, dated 2/22/20, showed the resident had a physician order for health care providers to not perform cardiopulmonary resuscitation (procedure involving compression of a person's chest in order to restore blood circulation and breathing) if a resident's heart stops or if he/she stops breathing. Review of the resident's care plan, dated 2/25/20, showed the staff are to perform all interventions to get the resident's heart restarted, including chest compressions. During an interview on 2/27/20 at 2:00 P.M., RN E said a resident's code status is included in the care plan which is updated with significant changes including a change in code status. During an interview on 2/27/20 at 4:19 P.M., the MDS Coordinator said the resident's care plan should include their code status. Additionally, he/she said when the code status is changed, the care plan should be updated. Facility staff failed to update the resident's care plan to represent his/her requested code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, facility staff failed to maintain professional standards of practice by not documenting neurological assessments after unwitnessed falls with signs of a head injury for two residents (Resident #38, and #42) and by not following restorative therapy orders for one resident (Resident # 14). Additionally facility staff failed to obtain a physicians' order for the use of a CPAP machine for one resident (Resident #20). The facility census was 63. 1. Review of the facility's Fall policy, dated 8/16/18, showed staff are directed as follows: -Staff are to document date of fall, time of fall, place of fall, if the fall was witnessed or not, the resident's cognitive status, any diagnosis that would put the resident at risk for fall, the resident's level of consciousness, neurological checks, and vital signs; -Staff are to note if there was a known or suspected head injury at the time of the fall; -Neurological checks are to be completed for falls resulting in a head injury including: -Changes in level of consciousness; -Obvious injuries to the scalp including, but not limited to, lacerations, bruising, contusions, or hematomas; -Assess for confusion, memory loss, difficulty speaking, slurred speech, abnormal gait, or balance difficulty; -Assess pupil size, headache, vomiting, visual disturbance, and/or periods of coherence alternating with periods of confusion and lethargy. -Neurological checks are to occur: -Every 15 minutes for two hours post fall (eight times in two hours after a fall); -Every 30 minutes for two hours post fall (four times in two hours); -Every 60 minutes for four hours post fall (four times in four hours); -Every eight hours for 16 hours post fall (two times in 16 hours); -Every eight hours until 72 hour charting is complete and the resident is stable. -The neurological assessment is to include: -Pulse; -Respirations; -Blood pressure; -Pupil size and reactivity; -Equality of hand grip strength; -Orientation (person, place, and time, noting baseline if not oriented to all three); -Any change to level of consciousness; -Head pain; -Speech; - And facial symmetry (both sides of the face are alike). 2. Review of Resident #38's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff to assess the resident's care needs, dated 1/14/20, showed staff assessed the resident as follows: -Cognitively impaired; -Utilized a walker and a wheelchair for mobility; -And active diagnoses of a cerebrovascular accident (CVA) (medical term for a stroke), transient ischemic attack (TIA) (brief episode of neurological dysfunction resulting from an interruption in the blood supply to the brain), or stroke (when blood flow to a part of the brain is stopped either by a blockage or the rupture of a blood vessel). Review of the resident's care plan, dated 2/17/20, showed the resident is at risk for falls related to poor safety awareness, confusion, and weakness. Further review of the care plan showed the resident had a fall on 1/31/20. Review of the resident's progress notes, dated 1/31/20, showed the resident fell sideways and hit his/her head on the door. Additional review showed the staff noted a small skin tear to the resident's head with pain present. Review showed staff did not follow their fall policy, including performing neurological checks as shown by: -On 2/1/20, 18 hours passed between the 3:00 A.M. assessment and the 9:20 P.M. assessment; -On 2/2/20, eight hours and forty minutes passed between the 9:20 P.M. assessment and the 6:00 A.M. assessment; -On 2/2/20, five hours passed between the 6:00 A.M. assessment and the 10:54 A.M. assessment; -On 2/3/20, five hours passed between the 2/2/20 7:00 P.M. assessment and the 12:12: A.M. assessment; -The staff did not continue to perform neurological checks which policy showed should have continued through 2/3/20 at 11:15 A.M. 3. Review of Resident #42's significant change, MDS dated [DATE], shows staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assistance of two or more staff members for bed mobility, transfers, dressing, and toileting; -Required extensive assistance of one staff member for locomotion on and off the unit, eating, and personal hygiene; -One fall with injury since admission or prior assessment; -Resident received hospice services; -Resident uses a wheelchair for mobility; -Diagnoses of cerebrovascular accident, dementia, and anxiety disorder. Review of the resident's nurses' notes showed the following entry dated 1/20/20 at 2:15 A.M., resident was observed sitting on the floor next to his/her bed, a moderate sized hematoma to the center of his/her forehead with abrasions and a one inch cute to his/her nose with swelling present. Review showed staff did not follow their fall policy, including performing neurological checks as shown by: -On 1/21/20, 12 hours and 19 minutes passed between the 2:00 A.M. assessment and the 2:19 P.M. assessment; -On 1/22/20, one hour and 14 minutes passed between the 4:22 A.M. assessment and the 1:36 P.M. assessment; -The staff did not continue to perform neurological checks which policy showed should have continued through 1/23/20 at 2:15 A.M. During an interview on 2/27/20 at 2:00 P.M., RN E said when a resident falls and has evidence of a head injury, the nurse evaluates the resident and then neurological checks and vital signs are completed. He/she said neurological checks include the assessment of consciousness, facial symmetry, hand grips and speech. He/she said he/she charts these checks per facility policy as well as the vital signs. Additionally, he/she said neurological checks are to be completed at the following intervals: -Every 15 minutes for two hours; -Every 30 minutes for two hours; -Every hour for four hours; -Every eight hours for 16 hours; and -Ever shift through the remaining 72 hours. 4. Review of Resident #14's Quarterly MDS, dated [DATE], shows staff assessed the resident as follows: -Cognitive; -Required extensive assistance of one staff member for bed mobility, transfers, locomotion on the unit, dressing, and toileting; -Required limited assistance of one staff member for locomotion off the unit and personal hygiene; -Required supervision and set up help only for eating; -Received restorative therapy (refers to nursing interventions suggest by licensed or certified therapists that promote the resident's ability to adapt and adjust to living as independently or as safely as possible), using passive range of motion three days during the seven day look back period; -Received restorative therapy using active range of motion three days during the seven day look back period; -Received restorative therapy assisting with splint or brace two days during the seven day look back period; -And diagnoses of hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), depression, cerebrovascular accident, and hemiplegia (paralysis of one side of the body) and hemiparesis (unilateral paresis, is weakness of one entire side of the body). Review of the resident's care plan, dated 1/28/20, showed the resident is to wear a carrot splint to his/her left hand. Review of the residents' physician's order sheet (POS), dated 01/27/20 - 02/27/20, showed the resident is to use a left hand carrot splint during daytime hours as tolerated, and the splint is to be removed for Range of Motion (ROM) (The measurement of the amount of movement around a specific joint or body part) and hygiene. Review of the residents' restorative care program, dated 2/3/20, showed the following: -Left hand carrot splint on during daytime hours as tolerated, and removed for ROM and hygiene; -Left hand ROM with warm washcloth hold for 5-10 seconds as tolerated repeating 10-15 times. Further review showed the restorative care program sheet did not contain documentation of staff providing restorative care to the resident. Observation on 2/24/20 at 11:30 A.M., showed the resident in his/her room. Further observation showed he/she did not have the carrot splint in his/her left hand. During an interview, the resident pointed to the carrot on his/her table and said that he/she has that (the carrot) to help his/her hand but he/she is not able to put it on without assistance from the staff. Observation on 2/24/20 at 2:30 P.M., showed the resident in his/her room. Further observation showed he/she did not have the carrot splint in his/her left hand. During an interview the resident said that he/she is unable to place the carrot in his/her hand by his/herself. Further observation showed the resident picked the carrot up from the table to show surveyor. Observation on 2/25/20 at 1:36 P.M., showed the resident in his/her room. Further observation showed he/she did not have the carrot splint in his/her left hand. Further observation showed the carrot laying on the table. Observation on 2/26/20 at 10:00 A.M., showed the resident in his/her room. Further observation showed he/she did not have the carrot splint in his/her left hand. Further observation showed the carrot laying on the table. Observation on 2/27/20 at 2:06 P.M., showed the resident in the activity room painting. Further observation showed he/she did not have the carrot splint in his/her left hand. Further observation showed the carrot laying on the table in the resident's room. During an interview on 2/27/20 at 4:04 P.M., Certified Nurse Aid (CNA) F said the resident can put the carrot in his/her hand independently. The CNA said that he/she is unsure how long the resident is to use the carrot. During an interview on 2/27/20 at 4:33 P.M., Restorative Aide (RA) G said that he/she does the follow up on Occupational Therapy (OT) and Physical Therapy (PT) orders. He/she said the CNA's are to put the resident's carrot in his/her hand in the mornings. Furthermore, he/she said he/she will put the carrot in the resident's hand if he/she does not see him/her with it. He/she said that the resident should wear it for two hours and remove it for two hours. He/she said that he/she did not see the resident using it today. Additionally, he/she said the CNA's are also responsible for making sure the washcloth exercises get done. RA G said he/she thinks the resident could possibly put the carrot in himself/herself but it would be difficult for him/her. During an interview on 2/27/20 at 6:14 P.M., the ADON said if a resident has a restorative device, staff should be attempting to put it on unless the resident refuses. He/she said that if a resident refuses treatment, staff are to notify the charge nurse for documentation. Furthermore, the ADON said that he/she would expect restorative therapy to make sure all therapy orders are followed, and staff should not assume a resident is able to put an adaptive device on without assistance. He/she said staff should be putting adaptive devices on residents and not expecting the residents to do it. Additionally, he/she said restorative therapy should be placing adaptive devices on residents unless staff are properly trained by the therapy department, and staff should be placing the carrot in the residents' hand as ordered by therapy, as well as documenting its usage. 5. Review of Resident #20's admission MDS, a federally mandated assessment tool, dated 5/20/19 showed the staff assessed the resident as: -Cognitively impaired; -Did not exhibit behaviors of rejecting evaluation or care; -Experienced shortness of breath or trouble breathing with exertion; -And received oxygen therapy as a resident. Review of the resident's care plan, dated 2/25/20, showed the resident has an active diagnosis of obstructive sleep apnea (breathing disorder that involves a decrease or complete halt in airflow). Additionally, the care plan showed the staff are directed as follows: -The resident and he/she is to wear his/her Continuous Positive Airway Pressure (CPAP) (applies mild airway pressure on a continuous basis to keep the airways continuously open in people who need help keeping their airway unobstructed) at night per the doctor's orders. Review of the resident's Physician Order Sheets (POS)'S, from May 2019 to February 2020, showed it did not contain an order for the resident's use of a CPAP. Review of the resident's progress notes showed staff documented the following: -5/13/19, the resident is ordered to use CPAP at night; -7/16/19, the staff received a note from the physician saying the resident absolutely has to wear his/her CPAP all night, every night; -7/17/19, the resident was resting with his/her CPAP in place; -11/20/19, the resident uses CPAP at night with education from the staff encouraging him/her to keep the mask on until he/she wakes in the morning; -12/14/19, the resident uses the CPAP at night to keep oxygen saturation (how much oxygen is being circulated in the resident's blood) within normal limits and the resident often removes his/her CPAP leading the staff to assist the resident with re-application of the mask; -12/16/19, the resident uses CPAP during hours of sleep with good compliance; -12/20/19, the resident utilizes CPAP at night; -2/20/20, the resident's CPAP was in place; -2/21/20, the resident was wearing his/her CPAP; -2/22/20, the resident's respirations were even and unlabored with CPAP in place; -And 2/22/20, the resident's CPAP was in place. During an interview on 2/27/20 at 11:47 A.M., the resident says he/she wears the CPAP at night to help him/her breathe, and he/she wears it most nights. During an interview on 2/27/20 at 12:14 P.M., CNA A said the resident uses a CPAP every night, and the resident has used it since he/she arrived to the facility. During an interview on 2/27/20 at 2:00 P.M., RN E said the resident has a CPAP in his/her room that he/she uses at night. During an interview on 2/27/20 at 4:21 P.M., the MDS Coordinator said the resident receives CPAP at night and it is a scheduled intervention. Facility staff failed to obtain an order or guidance from the physician in regards to the resident's CPAP.