**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and Ombudsman interviews, the facility failed to notify the Ombudsman in writing of a resident transfer for 2 of 5 residents reviewed for hospitalization (Resident #2 and Resident #42). The findings included: 1a. Resident #2 was admitted to the facility on [DATE]. The nursing progress note dated 7/02/24 at 3:00 pm revealed Resident #2 was transferred to the hospital for evaluation of change in mental status. Resident #2 was discharged from the facility on 7/02/24 and returned to the facility on 7/08/24. Record review of the Ombudsman Discharge and Transfer report provided by the facility revealed the Ombudsman was notified of Resident #2's 7/02/24 transfer to the hospital on [DATE]. b. The nursing progress note dated 8/12/24 at 3:38 pm revealed Resident #2 was transferred to the hospital for evaluation of altered mental status. Resident #2 was discharged from the facility on 8/12/24 and returned to the facility on 8/23/24. Record review of the Ombudsman Discharge and Transfer report provided by the facility revealed the Ombudsman was notified of Resident #2's 8/12/24 transfer to the hospital on [DATE]. 2a. Resident #42 was admitted to the facility on [DATE]. The nursing progress note dated 7/21/24 at 9:00 am revealed Resident #42 was transferred to the hospital for evaluation. Resident #42 was discharged from the facility on 7/21/24 and returned to the facility on 7/25/24. Record review of the Ombudsman Discharge and Transfer report provided by the facility revealed the Ombudsman was notified of Resident #42's 7/21/24 transfer to the hospital on [DATE]. b. The physician progress note dated 8/20/24 revealed Resident #42 was transferred to the hospital for further evaluation. Resident #42 was discharged from the facility on 8/20/24 and returned to the facility on 8/23/24. Record review of the Ombudsman Discharge and Transfer report provided by the facility revealed the Ombudsman was notified of Resident #42's 8/20/24 transfer to the hospital on [DATE]. A telephone interview was conducted on 10/23/24 at 03:29 pm with the Ombudsman who revealed she had not received written notification of hospitalization discharges for the last 6 months. An interview was conducted with Social Worker #1 on 10/23/24 at 3:49 pm who revealed she started working at the facility in April 2024 and she was educated at that time to send the transfers and discharges to the Ombudsman. Social Worker #1 stated she had not sent any discharge and transfer information to the Ombudsman since she started at the facility because she forgot the information was to be sent monthly. Social Worker #1 reported it was her fault that she had not sent the information to the Ombudsman prior to today (10/23/24). During an interview on 10/24/23 at 10:24 am with the Interim Administrator she revealed she was not sure why Social Worker #1 had not sent any information to the Ombudsman. The Interim Administrator stated Social Worker #1 was educated upon hire, but she felt Social Worker #1 just forgot to send the lists to the Ombudsman monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, staff interviews, the facility failed to ensure there was a physician's order in place for the size of an indwelling urinary catheter and frequency to change the indwelling urinary catheter for 1 of 1 resident reviewed for catheters (Resident #49). The findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses that included disorder of kidney and ureter. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident had severe cognitive impairment with no behaviors present. He was coded as dependent on staff for toileting and had an indwelling urinary catheter. A review of a care plan dated 10/5/24 revealed Resident #49 was care planned for an indwelling urinary catheter. The goal was for Resident #49 to be/remain free from catheter-related trauma and have no signs and symptoms of urinary tract infection through review date. The interventions included monitor and document sign and symptoms of infection. Review of a physician's order revealed an order dated 10/7/24 for a size 20 French (FR) urinary indwelling catheter. Review of a physician progress note dated 10/8/24 revealed Resident #49 had a chronic catheter and was admitted to the hospital for possible infection. Review of a health status note dated 10/17/24 revealed Resident #49 was out to a urology appointment and returned with no new orders. A review of the consultation progress notes for urology dated 10/17/24 revealed an order to change 16 FR indwelling urinary catheter every month and call office with issues. A review of the electronic health record revealed no order in place for 16 FR indwelling urinary catheter change every month. An observation was conducted of Resident #49 with Nurse Aide #4 on 10/23/24 at 09:45 AM. Resident #49 had a 16 French indwelling urinary catheter that was connected to a urinary drainage bag. An interview was conducted with Unit Manager #2 on 10/23/24 at 03:39 PM. She stated Medical Records was out during the week of October 17th. The Unit Manager stated she was responsible for taking off the orders. She reported that Medical Records Clerk normally scanned in the information from consults and would either call on the phone to let her know to review or she would bring her a stack of consults for her to review. An interview was conducted with the Medical Records Clerk on 10/23/24 at 3: 48 PM. She stated she reviewed the information from consults when a resident returned for an appointment. The Medical Record Clerk stated she scanned the consults into the electronic medical records then gave the hard copy of the consult to the unit manager. An interview was conducted on 10/23/24 at 3:59 PM. The Interim Administrator verified the medical records clerk scanned the consults into the system. The Administrator stated the unit managers were responsible for entering the orders into the electronic medical record when the residents returned from appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, resident, Respiratory Therapist, and Nurse Practitioner interviews, the facility failed to obtain a physician order for liters of oxygen and the fraction of inspired oxygen (FiO2) for a resident with a tracheostomy for 1 of 1 resident reviewed for respiratory care (Resident #112). The findings included: Review of the hospital speech therapy consultation provided by the facility dated 9/05/24 revealed Resident #112 had a tracheostomy (a surgical opening through the front of the neck into the windpipe for an air passage to help breathe) and was on a trach collar (a soft plastic mask that fits over the tracheostomy) with 5 liters of oxygen with 28% FiO2 (percentage of oxygen in the air that a person inhales). Review of the hospital Discharge summary dated [DATE] revealed no orders were noted for Resident #112's oxygen or FiO2 settings. Resident #112 was readmitted to the facility on [DATE] with diagnoses which included acute respiratory failure with hypercapnia (carbon dioxide retention), pneumonia, and tracheostomy. Review of the nursing progress note dated 9/08/24 at 11:08 am by Nurse #3 revealed Resident #112 was scheduled to return to the facility from the hospital in the afternoon. Nurse #3 further noted that Resident #112 had a tracheostomy and would be returning to the facility on 5 liters of oxygen at 28% FiO2. An attempt to interview Nurse #3 on 10/24/24 at 12:30 pm was unsuccessful. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #112 had clear speech and was cognitively intact. Resident #112 was coded for oxygen therapy, suctioning, and tracheostomy. The care plan dated 9/21/23 and last reviewed on 10/03/24 revealed Resident #112 had a care plan in place for tracheostomy related to impaired breathing mechanics with an intervention of oxygen settings via trach at 5 liters continuous with 28% humidity. A record review conducted on 10/21/24 of the physician orders revealed no orders for oxygen or FiO2 settings for Resident #112's tracheostomy. An observation and interview conducted with Resident #112 on 10/21/24 at 10:45 am revealed Resident #112's oxygen concentrator (a machine that gives extra oxygen) was set to 5 liters and the compressor's (machine that pushes air through a bottle of water to pick up moisture) FiO2 was set to 35%. The oxygen tubing was noted to be connected to the concentrator water humidification bottle which was connected to the tracheostomy tubing and Resident#112's trach collar. Resident #112 was observed in bed with no respiratory distress noted. Resident #112 stated she had the tracheostomy for about one year and had just been in the hospital. During an interview on 10/22/24 at 2:01 pm with Medication Aide #1 she revealed she was assigned to Resident #112's hall but she was not able to do the respiratory care since she was not a nurse. Medication Aide #1 stated Unit Manager #2 was responsible for Resident #112's care due to the tracheostomy. An observation of Resident #112's room with Unit Manager #2 was conducted on 10/22/24 at 2:07 pm. Resident #112 was noted to be in bed with the trach collar in place. Unit Manager #2 confirmed Resident #112's oxygen was set to 5 liters and the FiO2 was set to 35%. An interview with Unit Manager #2 was conducted on 10/22/24 at 2:18 pm. Unit Manager #2 revealed Resident #112's settings for the oxygen at 5 liters and 35% FiO2 were her normal settings since returning from the hospital, and the physician order should be in the computer. Unit Manager #2 confirmed no physician orders were in place for Resident #112's 5 liters of oxygen or 35% FiO2 for the tracheostomy. She stated she recalled being told in report from the hospital that Resident #112 was coming back to the facility with 5 liters of oxygen and the FiO2 was at 35% but she would have to look for the discharge information to review and confirm. Unit Manager #2 stated she was responsible for entering Resident #112's physician orders and was unable to state why the oxygen and FiO2 orders were not put back in place when Resident #112 returned to the facility from the hospital. An interview was conducted on 10/24/24 at 9:27 am with the Nurse Practitioner (NP) who revealed the provider did not determine the settings required for Resident #112's tracheostomy. The NP stated it was the facility's standard practice to obtain Resident #112's tracheostomy oxygen and FiO2 settings when she returned to the facility and once obtained the provider would confirm and sign the order. A telephone interview was conducted on 10/24/24 at 9:52 am with the Respiratory Therapist (RT) who revealed she last saw Resident #112 on 10/09/24 for a tracheostomy change only and she did not review any orders at that time. The RT stated Resident #112's settings would normally come from the hospital discharge record or if needed she could provide. The RT stated she was fine with the setting of 35% for the FiO2 for Resident #112 because the FiO2 setting was for humidification purpose only. The RT stated when a trach collar was used for Resident #112's tracheostomy, the oxygen order and FiO2 settings were needed. An interview was conducted with the previous Director of Nursing (DON) on 10/24/24 at 9:06 am who revealed Resident #112's oxygen and FiO2 settings would have been received by the hospital or given in report from the hospital. The previous DON stated Unit Manager #2 was responsible to obtain Resident #112's orders and confirm the orders with the NP. The previous DON stated admission orders were reviewed during the clinical meetings, and she stated the missed orders for Resident #112's oxygen and FiO2 settings should have been identified when reviewed during the clinical meeting. The previous DON was unable to state how the orders for Resident #112 were missed for so long.

Based on observation, staff interviews, the facility failed to dispose/discard expired medications in 2 of 4 medication carts (200 Hall, 700 Hall medication cart) observed for medication storage. The findings included: 1a. An observation was conducted of the 700 Hall medication cart on 10/22/24 at 11:43 AM. One opened bottle of Simethicone 80 milligrams (mg) had an expiration date of July 2024. An interview was conducted with Medication Aide #2. Mediation Aide #2 stated the medication should have been discarded. Medication Aide #2 stated the medication aide/nurse assigned to the cart was responsible for checking for expired medications each shift. 1b. An observation of the 200 Hall medication cart on 10/22/24 at 11:43 AM revealed an open bottle of Moxifloxacin 0.5% eye drops with a prescription filled date of 9/20/24 and had an open date of 9/20/24. The bottle was labeled by the pharmacy: Administer 3 drops to right eye 3 times a day for 3 days. The manufacturer's package insert indicated any unused ophthalmic moxifloxacin should be discarded 30 days after you first opened the bottle to avoid getting another eye infection. The moxifloxacin medication was outdated and not discarded from the medication cart. An interview was conducted with Medication Aide # 3. Medication Aide #3 stated the medication should have been discarded once the resident completed the doses. Medication Aide #3 stated the medication aide/nurse assigned to the cart was responsible for checking for expired medications each shift An interview was conducted with the Interim Director of Nursing and Interim Administrator on 10/22/24 at 3:28 PM. The interim Administrator stated the medication aides and nurses assigned to the medication cart were responsible for checking carts for expired medication. The Administrator stated expired medications were to be removed from the cart immediately.

Based on record review and staff interviews, the facility failed to sign off documentation for physician orders of cleansing area to right ankle and applying Calcium Alginate and Cleanse left lateral ankle and apply Santyl ointment daily, in the Treatment Administration Records (TAR) for 1 of 2 reviewed residents for treatment (Resident #94). Resident #94's TAR had blanks where staff were to indicate if treatment was administered or an indication that the treatment was not administered with an explanation on the reverse side of the TAR for 1 of 2 residents reviewed for documentation (Resident #94). The findings included: Physician orders for Resident #94 dated 9/20/24 revealed orders for cleansing area to right lateral ankle and applying of calcium alginate with silver cover with superabsorbent gelling fiber with silicone border to promote wound healing daily. Physician orders for Resident #94 dated 9/27/24 revealed an order for cleansing left lateral ankle and apply Santyl ointment to plain calcium alginate daily. During a telephone interview with Nurse #1 on 10/24/24 at 8:10 A.M. she revealed she provided care to Resident #94 regularly but was not aware she did not sign off on the TAR on 10/3/24, 10/5/24, 10/6/24, 10/10/24, 10/13/2024, 10/19/24, and10/20/24. During an interview with Nurse #2 on 10/24/2024 at 8:17 A.M. She revealed she provided Resident #94's wound care on 10/19/24 at 10 P.M. but could not remember why she did not document the treatment on the TAR. A telephone interview with Unit Manager #1 on 10/24/24 at 8:30 A.M. revealed she was not sure why nursing staff failed to document wound care provided to Resident #94 on the TAR on 10/3/24, 10/5/24, 10/6/24, 10/10/24, 10/13/2024, 10/19/24, and10/20/24. She further stated nursing staff are required to document whether Resident #94 agreed to or declined care. In an interview with the Director of Nursing (DON) on 10/24/24 at 9:11 A.M. she revealed nursing staff were required to document medication administration even when there is a refusal. During an interview with the Administrator on 10/24/24 at 9:15 A.M. she stated that nursing staff are required to document the care provided to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident and staff interviews the facility failed to provide written advance directive information and/or an opportunity to formulate an advance directive for 10 of 33 residents reviewed for advance directives (Residents #2, #14, #22, #42, #45, #49, #72, #80, #109, and #427). The findings included: a. Review of Resident #2's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart failure, chronic obstructive pulmonary disease, and a history of a stroke. The review revealed a full code Physician order dated 8/23/24. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. b. Review of Resident #14's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included diabetes, heart failure, and kidney failure. The review revealed a full code Physician order dated 10/18/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. c. Review of Resident #22's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and chronic obstructive pulmonary disease. The review revealed a do not resuscitate Physician order dated 7/10/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. d. Review of Resident #42's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included a history of a stroke and diabetes. The review revealed a do not resuscitate Physician order dated 8/24/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. e. Review of Resident #45's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included a history of a stroke, heart failure, and diabetes. The review revealed a full code Physician order dated 7/26/24. There was no documentation in the record for education regarding a formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. f. Review of Resident #49's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included high blood pressure and seizure disorder. The review revealed a do not resuscitate Physician order dated 10/4/24. The was no documentation in the record for education regarding a formulation of an advance directive and/or the opportunity to formulate an advance directive was offered. g. Review of Resident #72's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and diabetes. The review revealed a do not resuscitate Physician order dated 1/17/22. There was no documentation in the record for education regarding the formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. h. Review of Resident #80's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease, diabetes, and a history of a stroke. The review revealed a full code Physician order dated 4/12/23. There was no documentation in the record for education regarding the formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. i. Review of Resident #109's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and diabetes. The review revealed a do not resuscitate Physician order dated 7/1/24. There was no documentation in the record for education regarding the formulation of an advance directive and/or an opportunity to formulate an advance directive was offered. j. Review of Resident #427's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included heart disease and kidney failure. The review revealed a do not resuscitate Physician order dated 10/9/24. There was no documentation in the record for education regarding the formulation of an advance directive and/or the opportunity to formulate an advance directive was offered. An interview was completed on 10/22/24 at 1:30pm with the facility's Administrator. She revealed at this time the facility only discussed the resident's code status with the resident and/or their responsible party. An interview was completed on 10/23/24 at 11:37am with the facility's Admission's Director. The Admission's Director stated she only discussed code status with the resident and/or their responsible party. An interview was completed on 10/23/24 at 12:07pm with the facility's Social Worker. The Social Worker stated she only reviewed the resident's code status with the resident and/or responsible party. A follow-up interview was completed on 10/24/24 at 11:41am with the facility's Administrator. The Administrator stated the Social Worker was new to the position. She stated the Social Worker was unaware of the requirement for providing education regarding the formulation of an advance directive, not just regarding a resident's code status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when 1) Unit Manager #2 failed to wear a gown and did not perform hand hygiene between glove changes while performing tracheostomy care for a resident on Enhanced Barrier Protection (EBP) (Resident #112), 2) when the Wound Treatment Nurse failed to perform hand hygiene between glove changes during the observation of wound treatment (Resident #115), and 3) when Nurse Aide #1 was observed carrying uncontained dirty linen in the hallway. The facility also failed to implement its hand hygiene policy when Nurse Aide #1 failed to perform hand hygiene and remove gloves before entering and exiting 2 of 2 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER]) observed for infection control practices. The findings included: The facility's Infection Prevention and Control Program policy last updated 10/01/23 indicated all staff should assume that all residents were potentially infected or colonized with an organism that could be transmitted while providing resident care services. The policy stated hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. The policy further noted all staff shall use personal protective equipment (PPE) according to the established policy governing the use of PPE. Further review of the Infection Prevention and Control Program policy revealed in part soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled linen room. The facility's Enhanced Barrier Precautions (EBP) policy dated 4/01/24 revealed EBP was an infection control intervention designed to reduce transmission of multidrug-resistant organisms that used targeted gown and glove use during high contact resident care. The policy further stated EBP would be initiated for any resident with indwelling medical devices (such as tracheostomy tubes and feeding tubes) and wounds (such as pressure ulcers). The policy noted that personal protective equipment (PPE) for EBP was only necessary when performing high-contact care activities which included wound care and device care such as tracheostomy care. Review of the facility's Hand Hygiene policy last updated 10/01/22 indicated hand hygiene was to be conducted before resident care procedures, before and after handling clean or soiled linens, before applying and after removing personal protective equipment (PPE), including gloves. 1a. Resident #112 had signage posted on the door that alerted staff that the resident was on EBP. The signage noted that providers and staff must wear gloves and gown for the following high-contact resident care activities which included device care or use including tracheostomy. A large double door cabinet was observed in the hall stocked with PPE, which included disposable gowns. A continuous observation was conducted on 10/23/24 from 9:48 am through 10:35 am of tracheostomy care for Resident #112. Unit Manager #2 was observed to enter Resident #112's room, perform hand hygiene with hand sanitizer, and prepare supplies for tracheostomy care. Unit Manager #2 was observed to perform hand hygiene, don sterile gloves and began tracheostomy care for Resident #112 without a disposable gown in place. Unit Manager #2 was observed to touch the sterile supplies with her dirty glove and stopped tracheostomy care, removed supplies, removed gloves, completed hand hygiene, and left Resident #112's room to obtain more supplies. At 10:02 am Unit Manager #2 returned to Resident #112's room with additional supplies, performed hand hygiene, donned gloves, and prepared supplies. Unit Manager #2 was observed to perform hand hygiene, donned sterile gloves, and began tracheostomy care for Resident #112 without a disposable gown in place. #2 Unit Manager #2 completed Resident #112's tracheostomy care at 10:35 am, which included suctioning, without a disposable gown in place throughout the observation. An interview was conducted with Unit Manager #2 on 10/23/24 at 3:05 pm. Unit Manager #2 confirmed Resident #112 was on EBP for the tracheostomy, and staff were required to wear a disposable gown when tracheostomy care and suctioning were performed for Resident #112. She stated she did not realize she did not wear one until she was asked by this surveyor if Resident #112 was on EBP. Unit Manager #2 stated disposable gowns were readily available for use and it should have been used during the tracheostomy care observation. An interview was conducted with the Infection Preventionist (IP) on 10/24/23 at 8:55 am who revealed all staff, which included Unit Manager #2, had been educated on the use of proper PPE for residents on EBP. The IP stated PPE supplies including disposable gowns were available outside of Resident #112's room and the gown should have been on when Unit Manager #2 performed tracheostomy care. b. A continuous observation was conducted on 10/23/24 from 9:48 am through 10:35 am of tracheostomy care for Resident #112. At 10:23 am Unit Manager #2 was observed to place a sterile suction kit on Resident 112's overbed table, perform hand hygiene, open the sterile kit and attempt to don the sterile gloves. Unit Manager #2 was unable to don the sterile gloves fully and removed the sterile gloves and placed the gloves in the trash. Unit Manager #2 then opened Resident #112's bottom dresser drawer and obtained a new sterile suction kit and placed the kit on the overbed table. Unit Manager #2 was observed to open the sterile suction kit and place the sterile gloves from inside the kit onto her hands without performing hand hygiene after obtaining supplies from Resident #112's drawer. Unit Manager #2 was observed to complete Resident #112's tracheostomy care and suctioning, removed gloves and performed hand hygiene. During an interview on 10/23/24 at 3:05 pm with Unit Manager #2 she revealed she was required to perform hand hygiene between glove changes when she performed Resident #112's tracheostomy care. Unit Manager #2 stated she changed the gloves so often during the observation that she just forgot to do hand hygiene after getting more supplies from the drawer and before she put on the sterile gloves to suction Resident #112's tracheostomy. An interview was conducted with the Infection Preventionist (IP) on 10/24/23 at 8:55 am who revealed all staff, which included Unit Manager #2, had received education on hand hygiene and the education was completed yearly and as needed. She stated hand hygiene was to be completed before gloves were donned and again when gloves were removed. The IP stated Unit Manager #2 was required to perform hand hygiene before donning the sterile gloves from the suction kit when tracheostomy care was provided to Resident #112. During an interview on 10/24/24 at 10:48 am with the Interim Administrator she revealed all staff were required to follow the facility's infection prevention and control program policies. 2. During a continuous observation of a pressure ulcer treatment on 10/23/24 at 3:39 pm through 3:54 pm the Wound Treatment Nurse was observed to perform hand hygiene, don clean gloves, and remove Resident #115's soiled dressing from the right hip. The Wound Treatment Nurse then removed the soiled gloves, and donned clean gloves without performing hand hygiene. The Wound Treatment Nurse then cleansed the right hip wound bed with gauze and normal saline and prepared and placed the wound dressing on Resident #115's right hip wound. The Wound Treatment Nurse did not remove the dirty gloves or perform hand hygiene after cleansing the wound bed or before preparing and placing the wound treatment dressing on Resident #115's right hip wound. Resident #115 then turned onto the right side and the Wound Treatment Nurse removed the soiled dressing from the left hip. The Wound Treatment Nurse then removed the soiled gloves and without performing hand hygiene, donned clean gloves and cleansed the left hip wound with gauze and normal saline. The Wound Treatment Nurse prepared the new dressing and placed the dressing on Resident #115's left hip without removing the dirty gloves or performing hand hygiene after cleansing the wound bed and before placing the new wound dressing on Resident #115's left hip. The Wound Treatment Nurse then removed the soiled gloves and performed hand hygiene. An interview was conducted on 10/23/24 at 3:55 pm with the Wound Treatment Nurse who revealed the dirty gloves should have been removed after the wound bed was cleansed and hand hygiene should have been completed between the glove changes. The Wound Treatment Nurse stated she just realized that she did not change gloves and perform hand hygiene in between glove changes during the observation. The Wound Treatment Nurse was unable to say why she did not change her gloves when moving from dirty to clean or perform hand hygiene between glove changes, but she confirmed she had received education on proper PPE use and handwashing. During an interview on 10/24/24 at 9:03 am with the Infection Preventionist (IP) she stated hand hygiene education was completed for all staff annually and as needed. The IP stated the Wound Treatment Nurse was educated to complete hand hygiene between glove changes and to change gloves when moving from dirty to clean tasks. During an interview on 10/24/24 at 10:48 am with the Interim Administrator she revealed all staff were required to follow the facility's infection prevention and control program policies. 3. A continuous observation was conducted on 10/24/24 at 9:01 AM. Nurse Aide #1 was observed to exit room [ROOM NUMBER] with gloved hands. Nurse Aide #1 removed the gloves and walked across the hall to room [ROOM NUMBER] without performing hand hygiene. Nurse Aide #1 returned to room [ROOM NUMBER] without performing hand hygiene. Nurse Aide #1 was observed exiting room [ROOM NUMBER] with gloved hands and carrying dirty linen that was not contained in a plastic bag. Nurse Aide #1 was observed to walk down the 700 hall and turn the doorknob to the dirty laundry room door. An interview was conducted with Nurse Aide #1 on 10/24/24 at 9:07 AM. Nurse Aide #1 stated she was aware that she was supposed to carry dirty linen in a plastic bag and remove her gloves when exiting a resident's room. Nurse Aide #1 stated she did not have any plastic bags, so she carried the linen to the dirty laundry room with her gloves on. Nurse Aide #1 stated she was unaware that she had not performed hand hygiene after removing her gloves and before entering room [ROOM NUMBER]. An interview was conducted with the Director of Nursing (DON) on 10/24/24 at 9:32 AM. The DON stated Nurse Aide #1 should have had plastic bags available, taken off her gloves and immediately washed her hands before leaving the room. The DON further stated Nurse Aide #1 should have performed hand hygiene between resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to assess a resident for self-administration of medication for 1 of 1 resident (Resident #47) reviewed for self-administration of medication. The findings included: Resident #47 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease. The resident ' s care plan dated 1/16/23 did not include the self-administration of medication. There was not an assessment for Resident #47 in the medical record to determine if it was safe for the resident to self -administer medication. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact. On 3/26/23 at 11:13 AM Resident #47 was observed lying on the bed with a cup containing 7 tablets sitting on the bedside table. Resident #47 was resting on the bed with his eyes closed. An interview was conducted with Medication Aide #1 on 3/26/23 at 11:15 AM. Medication Aide #1 stated she had left Resident #47 ' s medication at the bedside because he was not awake. The Medication Aide stated she had been told by other staff she could leave Resident #47 ' s medication at the bedside and he would take it when he woke up. Further interview with Medication Aide #1 revealed that she had been educated not to leave resident ' s medication at the bedside. During an interview with the Director of Nursing on 3/28/23 at 3:44 PM. The DON stated the Medication Aide should have made sure Resident #47 took his medication or attempted to offer the medication at a later time. The DON stated medication should never be left at a resident ' s bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and Nurse Practitioner interview, the facility failed to obtain physician orders for supplemental oxygen (Resident #74) and tracheostomy care and suctioning (Resident #82) for 2 of 5 residents reviewed for respiratory care. Findings included: 1. Resident #74 was re-admitted to the facility on [DATE] and had cumulative diagnoses which included asthma, low blood oxygen, and stroke. Record review of the hospital discharge record dated 2/13/23 revealed Resident #74 was diagnosed with COVID-19, acute hypoxic (low blood oxygen) failure, and he did not have an order for supplemental oxygen upon discharge. The care plan dated 2/15/23 revealed Resident #74 had a care plan for oxygen therapy related to respiratory illness with intervention to provide oxygen 2 L via nasal canula (NC) continuous humidified. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #74 had severe cognitive impairment and was coded for oxygen use. Observations on 3/26/23 at 10:51 am and 3/27/23 at 1:51 pm revealed Resident #74 had oxygen at 3 L via NC in use. A record review conducted on 3/27/23 of the physician orders revealed no order for supplemental oxygen use for Resident #74. During an interview on 3/27/23 at 2:50 pm Nurse #2 confirmed Resident #74 had oxygen at 3 LNC in place. She stated a physician order was required for Resident #74's oxygen but she was unable to find the order. Nurse #2 was unable to state why the order for Resident #74's supplemental oxygen was not in place. An interview was conducted on 3/29/23 at 9:20 am with Nurse #3, who was assigned to Resident #74 upon return from hospital, revealed she completed Resident #74's readmission and was given in report from the transportation staff that Resident #74 was on oxygen at 2L via NC. She stated she was unable to state why the order for supplemental oxygen for Resident #74 was not entered but stated the oxygen did require a physician order. During an interview on 3/28/23 at 12:30 pm the Nurse Practitioner (NP) revealed she was not aware Resident #74 was on supplemental oxygen, but she stated a physician order was required. An interview was conducted on 3/29/23 at 11:29 am with the Director of Nursing (DON) who revealed the supplemental oxygen for Resident #74 required a physician order. The DON stated Resident #74's supplemental oxygen order was just missed. 2. Resident #82 was readmitted on [DATE] with diagnoses that included chronic respiratory failure, coronary artery disease, and tracheostomy status. Review of the quarterly Minimum Data Set completed on 12/5/22 revealed Resident # 82 was severely cognitively impaired. The MDS coded the resident as receiving oxygen use, suctioning and tracheostomy care. The care plan dated 5/27/20 and updated on 10/8/22 revealed Resident #82 had a care plan for tracheostomy care related to respiratory illness with intervention to provide suctioning and change tracheostomy inner cannula every day. Record review of the physician orders dated 6/22/22 revealed Resident #82 had an order to suction the tracheostomy every shift for respiratory distress/ increased secretion. The order was discontinued on 11/25/22. Record review of the physician orders revealed an order dated 8/24/22. Review of the order revealed Resident #82 had an order to change tracheostomy inner cannula every day every evening shift. The order was discontinued on 11/25/22. A record review conducted on 3/28/23 of the physician orders revealed no order for suctioning tracheostomy for Resident #82. A record review conducted on 3/28/23 of the physician orders revealed no order for provide trach care for Resident #82. An interview was conducted on 3/29/23 at 11:02 AM with the Director of Nursing (DON) who revealed the Nurse managers would read over the physician orders and treatments from the Discharge Summary orders and put the orders into the record. She revealed if there were no physician orders the nurse manager should call the physician or hospital to get their discharge orders. She indicated Resident #82 should have orders for tracheostomy care and suctioning.

Based on observations, staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions the committee put into place following the 1/14/22 complaint and recertification survey. This was for a recited deficiency on the current recertification survey in the area of respiratory/tracheostomy care and suctioning and dispose garbage and refuse properly. The continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F814 Based on observations and staff interviews, the facility failed to maintain the area surrounding the grease bin free of grease buildup and debris. This included 1 of 1 grease bin observed. During the recertification and complaint survey on 1/14/22 the facility was cited for failure to maintain the area around the dumpster free of debris. F695 Based on observations, record review, staff interviews, and Nurse Practitioner interview, the facility failed to obtain physician orders for supplemental oxygen (Resident #74) and tracheostomy care and suctioning (Resident #82) for 2 of 5 residents reviewed for respiratory care. During the recertification and complaint survey on 1/14/22 the facility was cited for failure to obtain a Physician's order for use of supplemental oxygen. An interview was completed on 3/29/23 at 1:45pm with the Director of Nursing (DON) and Administrator. The DON indicated the QAA committee meets monthly to discuss the facility's ongoing performance improvement plans. The DON revealed there were no ongoing performance improvement plans regarding respiratory care or maintaining the cleanliness of the area surrounding the dumpster. The DON and Administrator stated it was their expectation that the facility identify deficient practice and create performance improvement plans to correct the deficient practice.

Based on observations and staff interviews, the facility failed to maintain the area surrounding the grease bin free of grease buildup and debris. This included 1 of 1 grease bin observed. The findings included. During an observation of the dumpster area on 3/27/23 at 9:45 AM the grease bin was observed. The 4 foot lip of the grease bin was observed with grease dripping down and the ground was soiled with thick black layers of grease buildup. On 3/28/23 at 3:37 PM an observation was conducted with the Dietary Manager and the grease bin was observed to be in the same condition. An interview was conducted with the District Dietary Manger on 3/28/23 at 4:11 PM. She revealed the maintenance director had removed the grease and would pressure wash the area. In an interview on 3/29/23 at 9:08 AM, the Maintenance Director indicated he had noticed the grease bin and planned to contact the company to replace it. He revealed he had shoveled up the grease, power washing was unable to clean the stain off the cement pad and he would find a compatible chemical to clean the area. An interview was conducted with the Interim Administrator on 3/28/23 at 4:24 PM. He revealed they would get the area cleaned up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to clarify code status orders for 1 of 2 residents reviewed for advanced directives. (Resident #21). Findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses which included dementia. Record review of the advanced directive care plan dated 10/6/21 and revised on 10/25/21 revealed Resident #21 was a full code. Record review of hard copy code status book revealed Resident #21 had a full code order dated 10/6/21. Resident #21 ' s Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitively impairment. Record review of MDS Discharge Return Anticipated assessment dated [DATE] revealed Resident #21 was discharged from the facility to an acute hospital. Record review of MDS Entry Tracking assessment dated [DATE] revealed Resident #21 returned to the facility from an acute hospital. A physician order dated 12/23/21 for full code was entered in the electronic medical record by Nurse #2. A physician order dated 12/28/21 for Do Not Resuscitate (DNR) entered in electronic medical record by the Social Worker. During an interview on 1/13/22 at 8:33 AM Nurse #1 revealed that the Social Worker was responsible to obtain and enter Resident #21 ' s code status in the electronic record and place a paper copy in code status book located at the nursing station. Nurse #1 stated that if a discrepancy of code status orders were found the resident would be a full code until the order was clarified. During an interview on 1/13/22 at 9:26 AM the Social Worker revealed she confirmed code status with the resident or responsible party (RP) if resident was cognitively impaired upon admission to the facility or when a code status change was requested while a resident. She stated she entered the code status order in the electronic medical record and placed a written copy in the code status book at the nurse station. The Social Worker reported she reviewed the physician orders in the electronic record before she entered the code status order, but she did not remember seeing the full code order when she entered the DNR order on 12/28/21. The Social Worker was unable to state how she missed the full code order for Resident #21. During an interview on 1/13/22 at 9:59 AM the Director of Nursing (DON) revealed the Social Worker was responsible for confirmation and electronic order entry of code status. She stated Resident #21 ' s RP had considered hospice care and a DNR order was discussed but RP decided not to pursue hospice care and the code status was not changed. The DON was unable to state how Resident #21 ' s conflicting code status orders were missed. During an interview on 1/14/22 at 11:19 AM the Administrator revealed the Social Worker was responsible to obtain the code status order and enter in electronic medical record. She stated the Social Worker was expected to ensure the code status was correct and if discrepancy to clarify before entering a new code status order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interviews, the facility failed to obtain a physician order for the use of supplemental oxygen for 1 of 4 residents reviewed for oxygen. (Resident #38). Findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea and chronic respiratory failure. Resident #38 ' s Annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and was on oxygen. Record review of care plan dated 10/23/18 with revisions on 3/4/19, 8/23/19, and 2/6/20, revealed care plan for ineffective breathing pattern related to chronic respiratory failure and obstructive sleep apnea. Record review of physician orders revealed Resident #38 did not have a physician order for oxygen. During an observation on 1/11/22 at 3:10 PM Resident #38 with oxygen via nasal cannula at 2 Liters and oxygen in use sign on resident door. Record review of Oxygen Saturation Summary Report for the month of January revealed resident had oxygen saturation levels between 96%-99% with oxygen via nasal cannula. During an interview on 1/13/22 at 8:33 AM Nurse #1 revealed that Resident #38 was on oxygen and that a physician order was required for the oxygen. Nurse #1 reported that orders were entered by floor nurse or the unit nurse. She was unable to state why the physician order for oxygen was not entered for Resident #38. During an interview on 1/13/21 at 8:36 AM Nurse Aide (NA) #2 revealed that Resident #38 was on oxygen. During an interview on 1/13/22 at 1:39 PM NA #1 revealed that Resident #38 was on oxygen, and he would put on and take off as he wanted. During an interview on 1/13/22 at 9:56 AM the Director of Nursing (DON) revealed that Resident #38 required a physician order for oxygen. She stated that the orders were entered by the floor or unit nurse. She stated physician orders were reviewed in the clinical meeting but was unable to state how the oxygen order was missed for Resident #38. During an interview on 1/14/22 at 11:15 AM the Administrator revealed the DON or unit nurse were responsible to confirm orders were entered. She stated physician orders were reviewed in clinical meeting and was unable to state why the order was missed for Resident #38.

Based on observations and staff interviews the facility failed to maintain the area surrounding the dumpster free of debris for 2 of 2 dumpsters observed. The findings included: During an observation of the dumpster area on 1/11/22 at 10:46 AM, 2 disposable gloves were observed behind dumpster # 1, assorted papers, and a jelly cup were between dumpster #1 and dumpster # 2. Broken glass from a fluorescent light bulb was observed between dumpster #2 and the grease disposal container. During a second observation on 1/13/22 at 9:54 AM 2 disposable gloves were behind dumpster # 2, a jelly cup and clear broken glass were between dumpster #1 and dumpster # 2. Broken glass from a fluorescent light bulb was observed between dumpster #2 and the grease disposal container. A third observation of the dumpster area on 1/14/22 at 9:26 AM 4 disposable gloves and assorted papers were observed on the ground behind dumpster # 2. a jelly cup and clear broken glass were between dumpster #1 and dumpster # 2. Broken fluorescent light bulb was observed between dumpster #2 and the grease disposal container. An observation of the dumpster area was conducted with the regional dietary manager on 1/14/22 at 10:17 AM revealed the dumpster area to be in the same condition. During an interview 1/14/22 at 10:19 AM the regional dietary manager stated all departments, including dietary used the dumpster every day and the kitchen staff did their part to keep the area clean. She indicated she would get the area cleaned up. In an interview on 1/14/22 at 10:22 AM the housekeeping manager stated the garbage truck driver should have cleaned up the area. He indicated they would no longer rely on the garbage truck driver and his staff would sweep and clean the area daily. In an interview on 1/14/22 at 12:01 PM the administrator indicated staff would begin making daily rounds to check and clean the dumpster area.