**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and Resident, staff and Nurse Practitioner (NP) interviews the facility failed to ensure a physician's order for the administration of supplemental oxygen was in place for 1of 2 residents (Resident #2) reviewed for respiratory care. Findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of asthma (a chronic lung condition which can cause shortness of breath). A review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She was not coded for receiving respiratory or oxygen therapy. A review of Resident #2's comprehensive care plan revealed a focus area last revised on 11/27/24 for risk of complications due to her asthma diagnosis. The goal was for Resident #2 not to exhibit signs of respiratory distress. An intervention was to administer oxygen as ordered. On 1/6/25 at 1:38 PM an observation of Resident #2 revealed she was receiving 2 liters of oxygen via nasal cannula. An interview with Resident #2 at that time indicated she used oxygen sometimes, especially at night if she had trouble breathing. On 1/6/25 a review of Resident #2's electronic medical record did not reveal any evidence of a physician's order for the administration of oxygen. On 1/6/25 at 1:54 PM an interview with Nurse #1 indicated she was caring for Resident #2 on the 7AM-3PM shift. She stated Resident #2 had been receiving 2 liters of oxygen via nasal cannula when she began her shift at 7:00 AM that day. Nurse #1 went on to say if oxygen was being administered to a resident, there should be a physician's order for this that would show up on the resident's medication administration record (MAR) letting the nurse know how much oxygen to administer. She stated she did not recall looking to see if Resident #2 had this order earlier, but she did not see a physician's order for oxygen now. On1/8/25 at 9:04 AM an interview with Nurse #3 indicated she cared for Resident #2 on 1/4/25 and 1/5/25 on the 3PM-11PM shift. She stated she did recall Resident #2 had been receiving oxygen at 2 liters via nasal cannula on her shifts on those days. She reported she did not check to see if Resident #2 had a physician's order for this oxygen. She went on to say if a resident experienced shortness of breath and needed supplemental oxygen, the facility had a standing order the nurse could activate. Nurse#3 stated once the nurse activated this order, it would appear on the resident's MAR. On1/8/24 at 9:08 AM an interview with Resident #2's Nurse Practitioner (NP) indicated he was familiar with Resident #2. He stated at times she experienced some anxiety that caused shortness of breath. He reported he would not want a nurse to wait to talk with him if a resident was experiencing a low oxygen saturation or shortness of breath. He stated there was some room for nursing judgement. He went on to say the facility had a standing order for oxygen therapy the nurse could initiate prior to speaking with a provider. The NP reported there should be an active physician's order in place if oxygen was being administered to a resident. On 1/9/25 at 8:39 AM an interview with the Director of Nursing (DON) indicated a resident should have an active physician's order in place if oxygen was being administered that included the amount of oxygen to be administered, and by what route. On 1/9/25 at 9:03 AM an interview with the Administrator indicated he would agree with the recommendation of Resident #2's NP and the DON regarding oxygen orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff and resident interviews the facility failed to clean blood from a floor surface for 1 of 1 room reviewed for environment (room [ROOM NUMBER]). Findings included: During observation of room [ROOM NUMBER] on 11/13/23 at 10:24 AM an approximately 3.0 inch by 0.5 inch area of dried blood was observed on the floor between the window and bed. During observation on 11/13/23 at 3:05 PM the dried blood was observed still on the floor in room [ROOM NUMBER]. Resident #12 stated the blood on floor was from his toenail which had bled that morning. During observation on 11/14/23 at 8:13 AM, the same dried dried blood was again observed on the floor of room [ROOM NUMBER]. During an interview on 11/14/23 at 8:14 AM Nurse Aide #1 stated she did not notice the dried blood on the floor in room [ROOM NUMBER] and did not know how she had missed seeing it. During an interview on 11/14/23 at 8:17 AM Nurse #5 stated she saw him in the morning when giving his medicine and did not note the blood. During an interview on 11/14/23 at 8:23 AM the Director of Nursing stated around 8:30 AM she entered room [ROOM NUMBER] and Resident #12 informed the Director of Nursing of the blood on his toe but did not mention any blood on the floor. Where his wheelchair was at the time blocked her view of that area of the floor. She concluded blood should be cleaned from surfaces for infection control concerns. During an interview on 11/14/23 at 8:31 AM the Contracted Housekeeping Account Manager stated Housekeeper #1 should visualize the entirety of the floor while cleaning and Housekeeper #1 was the staff member responsible for room [ROOM NUMBER]. If housekeepers noted any blood, which they should have noted in room [ROOM NUMBER], they should have reported the area to nursing who would clean the blood and then come back and sanitized the area after. Housekeeper #1 was unavailable for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interviews, the facility failed to develop an individualized person-centered comprehensive care plan related to tracheostomy care which included an intervention for suctioning for a resident who required suctioning daily and as needed. This occurred for 1 of 13 residents (Resident #73) reviewed for comprehensive care plans. Findings included: Resident #73 was admitted to the facility on [DATE] with multiple diagnoses that included encounter for tracheostomy and chronic respiratory failure. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was severely cognitively impaired. The MDS documented Resident #73's tracheostomy care but not suctioning. Resident #73's care plan dated 9-25-23 revealed goals and interventions for his tracheostomy but no goals and interventions related to as needed suctioning. Resident #73 was interviewed on 11-13-23 at 12:11pm. The resident used a communication board to state that he was suctioned at least once a day by nursing staff. Resident #73 communicated there were no issues with his suctioning. During an interview with Nurse #1 on 11-14-23 at 11:35am, Nurse #1 discussed Resident #73 having a tracheostomy. She explained the resident required to be suctioned at least once a shift but sometimes more. Nurse #1 stated she knew Resident #73 had a care plan for the care of his tracheostomy but said she did not recall ever seeing any goals or interventions for suctioning. The nurse explained when an order was written for trach care daily that it was understood by nursing staff that suctioning was part of daily trach care. Nurse #1 explained she would provide suctioning for Resident #73 when he had an increase in congestion. The MDS Nurse was interviewed on 11-14-23 at 11:41am. The MDS Nurse confirmed there were not any goals or interventions for Resident #73 to be suctioned. She explained the resident did not need a separate goal or intervention for suctioning because the task was part of his routine trach care. An interview with the Director of nursing (DON) occurred on 11-14-23 at 12:17pm. The DON discussed care plans for tracheostomy residents and stated she expected the residents to have goals and interventions for routine trach care and possibly suctioning. She explained not all their tracheostomy residents needed routine suctioning. The DON stated for Resident #73, she would expect to see interventions on his care plan for as needed suctioning. She said Resident #73 had not required routine suctioning but was aware he required suctioning at times. The DON stated she was not aware that there were not any goals or interventions for Resident #73's suctioning. The Administrator was interviewed on 11-16-23 at 11:18am. The Administrator discussed not knowing enough about tracheostomy care to say if Resident #73 should have goals and interventions on his care plan for suctioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff and family interviews, the facility failed to place a splint on 1 of 1 resident reviewed for range of motion (Resident #88). Findings included: Resident #88 was admitted to the facility on [DATE]. Her active diagnoses included cancer, hypertension, cerebrovascular accident [(CVA), TIA, or stroke], depression, and secondary malignant neoplasm of bone. She received hospice services. Resident #88's minimum data set assessment dated [DATE] revealed the resident was assessed as severely cognitively impaired. She had impairment to the upper and lower extremity of one side. She was dependent on staff for oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, and chair/bed-to-chair transfer. She was always incontinent of bowel and bladder. Resident #88's care plan dated 10/9/23 revealed she was care planned for impaired mobility related to diagnoses of history of cerebrovascular accident, cancer with metastasis to bones and is on hospice services. The interventions included placing her left hand splint as ordered by Hospice 4 to 6 hours daily. During observation on 11/13/23 at 9:47 AM Resident #88 was observed in her room and had no splint applied to her left hand. During an interview on 11/13/23 at 11:02 AM Nurse Aide #2 stated at one time, Resident #88 had a splint for one of her hands. She had not put Resident #88's splint on because she did not know where it was or if she still needed it. During observation on 11/13/23 at 11:34 AM Resident #88 was observed in her room and had no splint applied to her left hand. During observation on 11/14/23 at 11:32 AM Resident #88 was observed in her room and had no splint applied to her left hand. During a follow-up interview on 11/14/23 at 12:14 AM Nurse Aide #2 stated she was not putting splints on Resident #88 because she did not know where it was, and splints were not on the care guide in the closet, so she did not know the resident was to get splints. During observation on 11/14/23 at 12:14 AM the care guide in the closet was observed to not have splint use documented on the closet door care guide. During an interview on 11/13/23 at 12:22 Nurse #5 stated the daughter had splints on the resident prior to coming to the facility and the splint was placed on Resident #88 by staff including herself at times. She stated she believed it was to be put on daily and she had put the hand splint on Resident #88 in the mornings. She stated if she put the splint on, she would document it in the chart. Since she did not put the splint on yesterday or today, the MAR was blank. She concluded she did not put the splints on Resident #88 yesterday or today as she was busy and had forgotten. During an interview on 11/14/23 at 12:29 the Medical Director, after reviewing the order, stated that the order was for the splint to be placed for 4 to 6 hours each day. He stated he did not remember any discussion with the family about the splint but would expect the orders to be followed. As the Medication Administration Record (MAR) was blank, either it was not documented, or the splint was not put on. During an interview on 11/14/23 at 1:22 PM the Director of Nursing stated most of the time hospice would bathe the resident in the morning and put the hand splint on the resident and if not, their staff should place the splint on Resident #88. She concluded, based on the MAR, the splint was not placed on the resident 11/1/23 through 11/13/23 and it should have been placed per physician's orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and physician interviews, the facility failed to obtain a physician's order to suction a resident who was trach dependent. This occurred for 1 of 1 resident (Resident #73) reviewed for tracheostomy care. Findings included: Resident #73 was admitted to the facility on [DATE] with multiple diagnoses that included encounter for tracheostomy. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 was severely cognitively impaired. Review of the Physician's standing orders dated 11-7-23 read trach care every shift. During an interview with Nurse #1 on 11-14-23 at 11:35am, Nurse #1 explained when a resident received tracheostomy care, the care was documented on the resident's Medication Administration Record (MAR). She further explained if the resident required suctioning, that would also be documented on the resident's MAR. Nurse #1 discussed Resident #73 not having suctioning on his MAR and stated, that is because there is not an order to suction the resident. The nurse explained that suctioning was part of Resident #73's routine trach care and she was not aware there needed to be an order. An interview with the Director of Nursing (DON) occurred on 11-14-23 at 12:17pm. The DON discussed if a resident required routine suctioning, there was a physician order for suctioning but if a resident required suctioning on an as needed basis, then the order for routine daily trach care would include suctioning. She explained that Resident #73 required suctioning on an as needed basis and stated she was not aware a separate order should be written. The Medical Director was interviewed on 11-14-23 at 1:59pm. The Medical Director explained he did not write orders for trach care because there were standing orders for trach care. He further explained it was understood by nursing that the standing order for trach care would include suctioning when needed. The Medical Director discussed Resident #73 and stated there should be a physician's order for as needed suctioning for the resident. He said he was not aware that there was not an order in place for Resident #73's suctioning. The Administrator was interviewed on 11-16-23 at 11:18am. The Administrator stated he was not familiar enough about tracheostomy care and would defer to what the DON and Medical Director discussed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and Physician interviews, the facility failed to educate 3 of 3 nurses (Nurse #2, Nurse #3, and Nurse #4) to ensure competency and demonstrate skills in providing care to 1 of 1 resident (Resident #73) reviewed for tracheostomy care. Findings included: Resident #73 was admitted to the facility on [DATE] with multiple diagnoses that included encounter for tracheostomy. A telephone interview occurred with Nurse #2 on 11-15-23 at 9:41am. Nurse #2 explained she began working at the facility in May 2023 and had been assigned to Resident #73 sometimes. She stated when she had worked with Resident #73, she remembered having to provide trach care and having to suction Resident #73 once during her shift. The nurse discussed not receiving trach training or having to show competency in providing trach care and/or suctioning to Resident #73. An interview with Nurse #3 occurred by telephone on 11-15-23 at 10:21am. Nurse #3 explained she had begun working at the facility in the middle of October 2023 and stated she had provided trach care and suctioning to Resident #73. She discussed not receiving training or skills competency on trach care and/or suctioning since she was hired. During an interview with Nurse #4 on 11-15-23 at 4:11pm, Nurse #4 discussed working for an agency and often being assigned to Resident #73 where she stated she had performed trach care and suctioning. She said she had not been provided training and/or skills competency on trach care and/or suctioning to Resident #73. The Medical Director was interviewed on 11-14-23 at 1:59pm. The Medical Director discussed not being aware the nurses had not received competency education or demonstrated their competency to provide trach care to Resident #73. He stated all nursing staff should have competency training and be able to demonstrate their competency in providing trach care. The Staff Development Coordinator (SDC) was interviewed on 11-15-23 at 12:24pm. The SDC explained when there was a new nurse hired, the new nurse would be paired with a seasoned nurse who would be responsible for completing the competency skills check list with the new hire. He stated trach care and suctioning was part of the new hire competency check list, however when reviewing the document, the SDC realized trach care and suctioning was not part of the new hire competency check list. The SDC discussed not being aware that trach care and suctioning was not part of the new hire competency check list but stated all new nursing staff should be trained and show competency prior to performing trach care and/or suctioning. The Director of Nursing (DON) was interviewed on 11-14-23 at 12:17pm. The DON discussed not being aware that all the new nurses hired had not had trach care and/or suctioning training and competencies completed. She stated all nurses should be trained and show competency in trach care and/or suctioning prior to working with trach residents.

Based on record review and staff interviews the facility failed to review and annually update the Facility Assessment and to ensure the Facility Assessment identified and addressed the care required for the population of residents with a tracheostomy and to address the staff training necessary to competently provide tracheostomy care. Findings included: Review of the Facility Assessment revealed the assessment was last updated in November 2022. The document indicated the facility had completed education/training/competencies with staff specific to resident care needs, however, the facility lacked training/competencies to care for residents who required a trach. The Facility Assessment also indicated the facility had an Emergency Preparedness Plan that was up to date, however the Emergency Preparedness Plan that was present was not complete. The Administrator was interviewed on 11-16-23 at 11:18am. The Administrator confirmed that the facility had 2 residents that were trach dependent and discussed that the Facility Assessment was a collaboration effort with management. He indicated he was unaware that tracheostomy care and training was not addressed in the Facility Assessment. The Administrator also stated he was not aware that some of the staff had not received education/competencies in providing trach care/suctioning. He also stated he believed the Emergency Preparedness Plan was complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff, and resident interviews, the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation surveys of 10-13-22. This was for 4 recited deficiencies in the areas of Emergency Preparedness (E001), Safe/Clean/Comfortable/Homelike Environment (F584), Respiratory/Tracheostomy care and Suctioning (F695), and Facility Assessment (F838). The continued failure during 2 federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag was cross referenced to: E001: Based on record review and staff interviews, the facility failed to establish and maintain a comprehensive Emergency Preparedness (EP) plan. The facility failed to establish policies and procedures, provide subsistence needed for staff and residents, list staff and their responsibilities, provide an alternate means of communication, review and update the communication plan, share information with residents or family members, complete a tabletop or full-scale exercise and EP education. During the recertification and complaint investigation survey of 10-13-22 the facility was cited for failing to include/document facility based and community-based risk assessment, address persons at risk, establish policies and procedures, develop a system to track residents' and staff, maintain/ update current contacts, review and update the communication plan, update names and contact information, share information with residents or family members and to complete a tabletop or full-scale exercise and EP education. F584: Based on observations and staff and resident interviews the facility failed to clean blood from a floor surface for 1 of 1 room reviewed for environment (room [ROOM NUMBER]). During the recertification and complaint investigation survey of 10-13-22 the facility was cited for not maintaining resident walls and heating/air units in good repair and maintaining a clean-living environment. F695: Based on record review, staff, and physician interviews, the facility failed to obtain a physician's order to suction a resident who was trach dependent. This occurred for 1 of 1 resident (Resident #73) reviewed for tracheostomy care. During the recertification and complaint investigation survey of 10-13-22 the facility was cited for failing to provide tracheostomy care following sterile technique and set oxygen as ordered. F838: Based on record review and staff interviews the facility failed to review and annually update the Facility Assessment and to ensure the Facility Assessment identified and addressed the care required for the population of residents with a tracheostomy and to address the staff training necessary to competently provide tracheostomy care. During the recertification and complaint investigation survey of 10-13-22 the facility failed to review and annually update the Facility Assessment. The Administrator was interviewed on 11-16-23 at 11:18am. The Administrator discussed trying not to have repeat citations and stated, but it happens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to keep 2 of 2 residents (Resident #78 and Resident #77) covered while providing care and the facility failed to provide incontinent care for 1 of 7 residents (Resident #16) who stated he felt mad and ignored. Findings included: 1.Resident #78 was admitted to the facility on [DATE] with multiple diagnoses that included nontraumatic subarachnoid hemorrhage and hydrocephalus. The 5-day Minimum Data Set (MDS) revealed Resident #78 was severely cognitively impaired. An observation of Activities of Daily Living (ADL) care occurred on 10-13-22 at 10:48am with Nursing Assistant (NA) #13. The NA was observed providing Resident #78 a full bed bath. He was observed removing the resident's gown, not covering Resident #78's lower half, leaving the resident laying in the bed with a brief. NA #13 washed the upper half of the resident's body then removed the resident's brief without covering the upper half of the resident's body. The NA was observed to continue completing Resident #78's bath leaving the resident fully exposed with no cover or brief. Once the bath was completed, the NA left Resident #78 on his back fully exposed as the NA cleaned up the dirty linen. NA #13 was then observed to place a brief and gown on the resident. NA #13 was interviewed on 10-13-22 at 11:10am. The NA discussed his usual practice was to keep the resident covered during a bath but stated he did not think about covering Resident #78 because he was hurrying, and he was nervous. NA #13 said since the resident did not have a privacy curtain it would have been better to cover the resident in case someone walked into the room. The DON was interviewed on 10-13-22 at 1:00pm. The DON discussed being pleased NA #13 provided good care, but she expected staff to maintain resident dignity and privacy during care. 2. Resident #77 was admitted to the facility on [DATE] with multiple diagnoses that included pressure ulcer stage 4 of sacral region. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was cognitively intact. An observation of wound care occurred on 10-12-22 at 10:21am with the Treatment Nurse and Nurse Practitioner (NP) #1. Resident #77's window blind was open, and the window was observed to be facing the driveway and walkway. The Treatment Nurse was observed to turn the resident on her side and remove Resident #77's brief allowing the resident's buttocks to be exposed to the open window blind. The Treatment Nurse was interviewed on 10-12-22 at 10:33am. The Treatment Nurse stated she should have closed the blind because anyone walking by could have seen Resident #77's buttocks. She commented she did not think about closing the blind or the window being a breech of dignity and privacy. During an interview with the Director of Nursing (DON) on 10-12-22 at 3:08pm, the DON stated the Treatment Nurse should have closed the blind in Resident #77's room so the resident would not have been exposed to anyone walking by. She also said she expected staff to provide respect and dignity to all residents when providing care. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator stated all staff needed to provide privacy and dignity to all residents when receiving care. 3) Resident #16 was admitted to the facility on [DATE]. His diagnoses included hemiplegia of the right dominant side, speech deficit, diabetes, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was moderately cognitively impaired. He required extensive assistance with all activities of daily living including toileting, bathing, and personal hygiene. He was always incontinent of bowel and bladder. The care plan for Resident #16 indicated he had impaired mobility related to right sided hemiplegia. The approaches included assist with ADLs to completion and assist resident with toileting needs PRN (as needed). On 10/10/22 at 2:22 PM Resident #16 reported the last time he had received incontinent care was on the 11:00 PM to 7:00 AM shift. He acknowledged he was soiled and had been wet for a long time. On 10/10/22 at 2:55 PM an observation of incontinent care was completed with Nurse Aide (NA) #8 and revealed Resident #16's adult brief was saturated with a dark dry ring on the inside. The Resident's under pad was noted to be wet with a dark dry ring around the edges. The Resident's gown was noted to be wet. On 10/10/22 at 3:18 PM NA #8 said she and NA #9 worked together to meet the residents' needs but she was assigned to Resident #16. She said she provided incontinent care to Resident #16 between 8:00 and 9:00 AM that morning. She said the resident's pad was dirty when she provided care, but there were no clean pads available, so she used a folded sheet instead of a pad. When asked about the resident having a soiled pad, she stated there were no pads in the clean utility room. She said she was told by the 11:00 PM - 7:00 AM shift that Resident #16 received a partial bath that morning so she did not provide a bath for Resident #16. On 10/11/22 at 3:00 PM NA #10 reported she worked on the 11:00 PM to 7:00 AM shift on 10/10/22 and was assigned to Resident #16. She reported she provided incontinent care to him between 12:30 AM and 1:00 AM then again at 4:00 AM and around 6:00 AM. She said she did not provide a full bath. On 10/13/22 at 3:30 PM the Director of Nursing (DON) stated the NA should be checking the residents more frequently as least every 2-3 hours and a resident should not remain in wet briefs for an entire shift. On 10/13/22 at 4:00 PM Resident #16 stated being left wet during the 7:00 AM - 3:00 PM shift on 10/10/22 made him feel mad and ignored because he did not have a voice. He felt the staff did not provide care to him because he could only communicate with his communication board.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and family interviews the facility failed to notify the resident's representative (RP) of a new diagnosis and medication order and an outside physician consult appointment. This was for one of one resident (Resident #89) reviewed for notification of change. Findings included: Resident #89 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. A review of Resident #89's medical record revealed a new physician's order dated 9/27/21 for Tobrex (an antibiotic eye drop) 0.3 percent (%) 2 drops each eye every 4 hours for 3 days. The diagnosis was conjunctivitis (an eye infection). The order was signed as being reviewed by Nurse #1. A further review of Resident #89's medical record revealed no documentation that her RP was notified of this new diagnosis of conjunctivitis or the new antibiotic eye drop medication order. On 10/11/22 at 2:08 PM a telephone interview with Resident #89's RP indicated she was not notified of the new diagnosis of conjunctivitis or the new order for an antibiotic eye drop for her family member. She stated she found out at a visit after the medication was already started. She went on to say she expected the facility to notify her of any change in her family members condition or new medication order. She further indicated the facility was aware of her desire to be notified. On 10/13/22 at 8:21 AM an interview with Nurse #1 indicated she was the nurse who reviewed and signed off the new physician's order with the diagnosis of conjunctivitis and an antibiotic eye drop for Resident #89 on 9/27/2021. She stated which ever nurse reviewed and signed off a new order for a resident would be responsible for notifying the RP. She went on to say if there was no documentation in the progress notes she could not recall if she notified Resident #89's RP of this new order or not. She further indicated if she had notified Resident #89's RP, she would have documented this notification in Resident #89's progress notes. A further review of Resident #89's medical record revealed a physician's order dated 12/22/21 for an orthopedic (a branch of medicine concerned with disorders of the musculoskeletal system) consult due to left knee swelling. A facility physician's progress note dated 1/25/22 revealed Resident #89's RP was not present when Resident #89 saw the orthopedist. On 10/11/22 at 2:08 PM a telephone interview with Resident #89's RP indicated she was not made aware that Resident #89 had an orthopedic consult appointment on 1/14/2022 in Rocky Mount and so she had not been present at this appointment. She stated she would have gone if she had been notified of the appointment date and time. She stated Resident #89 had dementia and was not capable of making her needs known, understanding information given to her, or consenting to any treatments. The RP stated the facility was aware that she wanted to be notified of any outside consult appointments so she could be present with her family member. On 10/12/22 at 11:16 AM an interview with the Schedular indicated she scheduled the 1/14/22 orthopedic consult for Resident #89 to see the physician in Rocky Mount who originally did Resident #89's left knee surgery in response to the physician's order dated 12/22/21 for an orthopedic consult. She stated she would have been responsible for notifying Resident #89's RP of the appointment location, date, and time. She went on to say after Resident #89 went to this appointment, her RP called the facility upset because she had not been made aware of the appointment and had not been present. The Schedular stated she apologized to Resident #89's RP. She went on to say while she would have been responsible for notifying Resident #89's RP of the appointment when she arranged it, she thought Nurse #4 notified Resident #89's RP. On 10/12/22 at 12:37 PM an interview with Nurse #4 indicated Resident #89's RP had been upset that she was not notified of Resident #89's 1/14/22 orthopedic consult. She stated she had apologized to Resident #89's RP. Nurse #4 went on to say she did not think it had been her responsibility to make Resident #89's RP aware as she had not scheduled the appointment. She stated it was usually the person scheduling the appointment who made the RP aware. In a follow-up interview on 10/13/22 at 12:10 PM Nurse #4 indicated she did receive information about the location, date, and time of Resident #89's orthopedic consult from the Schedular via a text message prior to the 1/14/22 appointment when Resident #89's RP was in the facility, however, had not passed the information on to Resident #89's RP because she had gotten busy with an emergency. On 10/13/22 at 4:15 PM an interview with the Director of Nursing (DON) indicated while there may have been some miscommunication between Nurse #4 and the Schedular, Resident #89's RP should have been immediately made aware of any change in her condition, her new physician's order for eye drops and her consult appointment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to protect resident medical information for 1 of 1 resident (Resident #250) when a Nursing Assistant (NA) #11 left Resident #250's medical information up on a computer screen located on hall 200 east. Findings included: Resident #250 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) revealed Resident #250 was severely cognitively impaired. Observation of the computer on hall 200 east occurred on 10-10-22 at 12:23pm. The computer monitor was observed to have Resident #250's medical information on the screen. During an interview with NA #11 on 10-10-22 at 12:25pm, the NA said she had Resident #250 pulled up on the screen charting on him when the lunch trays arrived on the unit, and she did not log off. NA #11 stated I don't understand what the problem is. The NA logged off the computer and walked away. Nurse #7 was interviewed on 10-10-22 at 12:35pm. The nurse stated it was a privacy violation to leave resident information visible to the public. She said if she would have seen Resident #250's medical information on the computer screen when she would have logged NA #11 out of the system, so the resident information was no longer visible. An interview with the Director of Nursing (DON) occurred on 10-10-22 at 9:20am. The DON stated all staff had training on keeping resident information private on 5-4-22 and expected all staff to keep resident information private. She also stated she thought NA #1 was charting and when the lunch trays arrived, the NA forgot to log out. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator stated the computers had been set to power down after one minute but said somehow the computer NA #11 was using became programmed to never time out or power down. The Administrator stated he expected all resident information to remain confidential and for staff to log out of the system if they are leaving the area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and facility staff interviews and record review the facility failed to have a cognitively intact resident participate in the care plan meetings. This was for 1 of 2 residents reviewed for care plans (Resident #72). The findings included: Resident #72 was admitted to the facility on [DATE]. She had reentries on 8/2/22 and 8/30/22. Her diagnoses included diabetes, peripheral vascular disease, bilateral lower extremity amputations and a fracture of the right femur. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #72 was cognitively intact. The admission and significant change MDS dated [DATE] indicated Resident #72 was readmitted to the facility on [DATE] from an acute care hospital. Resident #72 was cognitively intact. Her quarterly MDS dated [DATE] indicated Resident #72 was cognitively intact. On 10/10/22 at 12:04 PM Resident #72 stated she was not aware of being invited and had not attended a meeting about her care. She said she had not participated in the development or review of her plan of care. On 10/12/22 at 1:15 PM Social Worker (SW) #1 said the residents who are capable of understanding are invited to the care plan meeting. SW #1 said she had spoken to Resident #72 in the past about attending the care plan meeting. She said Resident #72 told her in the past that she did not need to come to the meeting. She said she had verbally communicated with Resident #72 but had not provided written information to the resident about the care plan meetings. SW #1 said she did not remember when she had last spoken to Resident #72 about the care plan meetings. A review of the Care Plan Participation Record provided by SW #1 for Resident #72 revealed the interdisciplinary team members participated in the care plan development on 3/9/22, 6/8/22,7/6/22, 8/24/22 and 9/21/22. The area of these forms for documentation of resident/representative included 1) participated by telephone, 2) participated by videotelephony or 3) declined to participate. On each of the forms this area was not completed. On 10/13/22 at 2:15 PM SW #1 said she was not aware of the need to document if Resident #72 attended the meeting or chose not to attend the meeting. She said she had developed a new form since the previous conversation with the surveyor on 10/12/22 to make the cognitively intact residents a sign to remind the residents of their meetings. On 10/13/22 at 3:40 PM the Director of Nursing reported she was not aware Resident #72 was not participating in the care plan development meetings and that there should be documentation of her invitation and declination to participate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, and facility staff interviews the facility failed to provide incontinent care for 1 of 7 residents (Resident #16) reviewed for activities of daily living (ADLs). The findings included: Resident #16 was admitted to the facility on [DATE]. His diagnoses included hemiplegia of the right dominant side, speech deficit, diabetes, and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was moderately cognitively impaired. He required extensive assistance with all activities of daily living including toileting, bathing, and personal hygiene. He was always incontinent of bowel and bladder. The care plan for Resident #16 indicated he had impaired mobility related to right sided hemiplegia. The approaches included assist with ADLs to completion and assist resident with toileting needs PRN (as needed). On 10/10/22 at 2:22 PM Resident #16 reported the last time he had received incontinent care was on the 11:00 PM to 7:00 AM shift. He acknowledged he was soiled and had been wet for a long time. On 10/10/22 at 2:55 PM an observation of incontinent care was completed with Nurse Aide (NA) #8 and revealed his adult brief was saturated with a dark dry ring on the inside. The Resident's under pad was noted to be wet with a dark dry ring around the edges. The Resident's gown was noted to be wet. On 10/10/22 at 3:18 PM NA #8 said she and NA #9 worked together to meet the residents' needs but she was assigned to Resident #16. She said she provided incontinent care to Resident #16 between 8:00 and 9:00 AM that morning. She said the resident's pad was dirty when she provided care, but there were no clean pads available, so she used a folded sheet instead of a pad. When asked about the resident having a soiled pad, she stated there were no pads in the clean utility room. She said she was told by the 11:00 PM - 7:00 AM shift that Resident #16 received a partial bath that morning so she did not provide a bath for Resident #16. On 10/11/22 at 3:00 PM NA #10 reported she worked on the 11:00 PM to 7:00 AM shift on 10/10/22 and was assigned to Resident #16. She reported she provided incontinent care to him between 12:30 AM and 1:00 AM then again at 4:00 AM and around 6:00 AM. She said she did not provide a full bath. On 10/13/22 at 3:30 PM the Director of Nursing (DON) stated the NA should be checking the residents more frequently as least every 2-3 hours and a resident should not remain in wet briefs for an entire shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, staff and Nurse Practitioner interviews the facility failed to perform blood glucose monitoring as ordered for 1 of 4 residents (Resident #77) reviewed for medication administration. Findings included: Resident #77 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A review of her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. She received insulin injections on 7 of 7 look back days of the assessment. A review of the current comprehensive care plan for Resident #77 revealed a focus area last reviewed on 9/14/22 of insulin dependent diabetes with risk for hypo/hyper glycemia (low/high blood glucose). The goal was for Resident #77 to have any signs or symptoms of hypo/hyper glycemia detected, treated, and resolved early. An intervention was to check blood glucose and administer medication as ordered. A review of her active October 2022 physician's orders revealed the following: Finger Stick Blood Glucose (FSBG) before meals (AC) and at hour of sleep (HS) Insulin Aspart (a short acting injectable insulin to treat diabetes) inject 5 units (U) subcutaneously (SUB-Q) before meals. Hold for blood glucose less than 180. Insulin Aspart Sliding Scale for blood glucose greater than 270 give additional 1 U, greater than 300 give additional 2 U, greater than 350 give additional 3 U, greater than 400 give additional 4 U. On 10/11/22 at 5:51 PM an observation of medication administration with Nurse #5 revealed she did not check Resident #77's blood glucose before her dinner meal. Resident #77 was observed to have already eaten her dinner meal which was still present on her bedside table when Nurse #5 checked Resident #77's FSBG. The result was 137. An interview with Nurse #5 at that time indicated she cared for Resident #77 before and was familiar with her. She stated Resident #77 liked to take her insulin and have her FSBG taken after she ate because her blood glucose levels were unpredictable. Nurse #5 went on to say Resident #77 told her she was afraid if she took her insulin before she ate and then didn't eat her blood glucose level would drop. Nurse #5 stated she had educated Resident #77 on the reason she should have her blood glucose taken and her insulin given before her meals and Resident #77 told her she understood this but liked to be in control of her care and still wanted this done after she ate. Nurse #5 stated she did it this way when she cared for Resident #77. She further indicated she had last cared for Resident #77 on 10/5/22. She went on to say she had not documented this anywhere and had not shared the information with the Assistant Director of Nursing (ADON), the Director of Nursing (DON) or Resident #77's medical provider. On 10/11/22 at 5:53 PM an interview with Resident #77 indicated she understood the physician's order was for her to have her blood glucose checked and insulin given before her meals but she knew her body and preferred this be done after she ate. She stated her blood glucose was very unpredictable and she was afraid if she did this before her meal and then didn't eat her blood glucose level would drop too low. She stated she had not spoken about this to her medical provider. On 10/11/22 at 6:17 PM an interview with the Assistant Director of Nursing (ADON) indicated she was familiar with Resident #77. She stated Resident #77 was alert and oriented and liked to be involved with her care. She went on to say she had not been made aware Resident #77 had expressed a desire to have her blood glucose checked and her insulin administered after her meals instead of before like the physician ordered. The ADON further indicated this was important information that needed to be communicated to the provider so the provider was aware that the documented blood glucose results reflected Resident #77's blood glucose after her meals. She stated the provider could then have changed the order if it was appropriate. She went on to say this was also something that that needed to be reflected in Resident #77's plan of care so everyone was doing things consistently. The ADON stated if the physician's order was for Resident #77 to have her blood glucose taken and her insulin given before her meals then that is what should be happening unless there was communication with Resident #77's medical provider and an order was given for something else. On 10/13/22 at 3:37 PM a telephone interview with Resident #77's medical provider Nurse Practitioner (NP) #1 indicated the physician's order was for Resident #77 to have her blood glucose checked and her insulin given before her meals. He went on to say he was not aware this was being done after her meals. He stated Resident #77 was very involved in her care and it was important for her to have some control. He further indicated knowing whether the blood glucose result reflected Resident #77's status after her meal rather than before would be important information. He went on to say he would expect the nurses to be communicating with him and documenting in the progress notes if Resident #77 was expressing the desire and having her blood glucose taken and her insulin given after her meals rather than before so he could address the issue with Resident #77, monitor trends and change the order if appropriate. On 10/13/22 at 4:15 PM an interview with the Director of Nursing (DON) indicated if Resident #77 was expressing the desire to do something other than the provider ordered, nurses should be communicating with the provider so the provider could have a discussion with Resident #77 and address the issue with her. She stated checking Resident #77's blood glucose after her meals would not be following the physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to apply a protective boot in accordance with the physician's order for 1 of 4 residents (Resident #37) reviewed for pressure ulcers. Findings included: Resident #37 was admitted to the facility on [DATE] with diagnoses of dementia, chronic kidney disease and muscle weakness. A review of the quarterly Minimum Data Set (MDS) assessment for Resident #37 dated 8/2/2022 revealed she was severely cognitively impaired. She required the extensive assistance of one person for bed mobility. Resident #37 was at risk for pressure ulcers and had one unstageable pressure ulcer that was not present on her admission to the facility. She had a pressure reducing device to her bed, nutrition, or hydration interventions to manage her skin problem and pressure ulcer care in place. A review of the current comprehensive care plan for Resident #37 revealed a focus area dated 8/2/22 of at risk for pressure ulcers related to impaired mobility. It further revealed Resident #37 had an unstageable pressure ulcer to her left foot that had healed on 9/7/22. The goal was the risk of new skin breakdown would be minimized through the next review. Interventions included administer treatments as ordered by the physician and use pillows, pressure reducing mattress and other supportive/protective devices to assist with positioning. A review of Resident #37's October 2022 Treatment Administration Record (TAR) on 10/12/202 revealed an active physician's order for Prevalon to be always in place except during ADL care. The information regarding the Prevalon boot placement was noted to be for your information (FYI). On 10/12/22 at 6:45 AM an observation of Resident #37 with Nurse Aide (NA) #3 revealed she was in bed. No Prevalon boot was observed to be in place. An interview with NA #3 at that time indicated the nurse would usually let her know if a resident needed a Prevalon boot. She stated she was not aware of Resident #37 having Prevalon boot that needed to be in place. She went on to say she had been caring for Resident #37 from 11PM on 10/11/22 and Resident #37 had not had a protective boot on all night. On 10/12/22 at 6:49 AM an interview with Nurse #2 indicated she took over the care of Resident #37 at 6:00 AM that morning from Nurse #3. She stated Nurse #3 gave her a report regarding Resident #37's status but had not said anything about Resident #37 needing a protective boot. She went on to say if a resident needed a protective boot, it would normally be on the TAR. Nurse #2 further indicated she had not checked the TAR when she took over the care for Resident #37 at 6:00 AM that morning. She stated if Resident #37 had a physician's order for a Prevalon boot to be always in place except during ADL care then she should have had it on. On 10/12/22 at 3:55 PM an observation of Resident #37 with the facility Treatment Nurse revealed Resident #37 was in bed. A protective boot was observed on Resident #37's left foot. The skin to Resident #37's left foot was observed to be intact without any breakdown. An interview with the Treatment Nurse at that time indicated Resident #37 had a deep tissue injury to her left foot that had healed. She went on to say Resident #37 currently had an active physician's order for her boot to be always in place except during ADL care to prevent any further skin breakdown. On 10/13/22 at 8:29 AM a telephone interview with Nurse #3 indicated she cared for Resident #37 from 11:00 PM on 10/11/22 until 6:00 AM on 10/12/22. She stated this was her first time ever caring for Resident #37. She went on to say she was not aware Resident #37 needed to have a protective boot on. Nurse #3 stated she had access to Resident #37's care plan and TAR which were at the nurse's station but she was used to having access to these things on a computer. She further indicated she would not realistically review a resident's care plan in a paper chart. She stated Resident #37 did not have any wound care due on her shift so she had not checked the TAR. On 10/13/22 at 3:37 PM a telephone interview with Resident #37's Nurse Practitioner (NP #1) indicated at one time Resident #37 had a bad wound to her left foot from constant pressure. He stated this had healed. He went on to say the physician's order for the Prevalon could probably have been discontinued. He further indicated staff should either be following the physician's orders or communicating with the provider to have the order discontinued and something else put in place. On 10/13/22 at 4:15 PM an interview with the Director of Nursing (DON) indicated if Resident #37 had an active physician's order for a Prevalon boot to be always in place except during ADL care then she should have had it on. She stated NAs did not have access to TARs. She went on to say nurses should be checking resident's TARs and care plans when caring for residents to be sure they weren't missing anything and communicating needed information to NAs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #30 was admitted to the facility on [DATE] with a diagnosis of seizures. A review of her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. She required the extensive assistance of one person for bed mobility, transfers and locomotion and the total assistance of one person for personal hygiene. She received tracheostomy (a hole in the front of the neck where a tube is inserted to help with breathing) care and oxygen therapy. A review of the current comprehensive care plan for Resident #30 revealed a focus area last updated on 8/3/22 of respiratory risk related to tracheostomy on 2 liters (L) of oxygen (O2) via tracheostomy collar. The goal was for respiratory risks to be minimized with interventions. Interventions included notify the physician or nurse practitioner (NP) of change in status and monitor O2 saturations. The October 2022 active physician's orders for Resident #30 included O2 2L via tracheostomy. A review of Resident #30's Medication Administration Record (MAR) for October 2022 revealed an order for O2 at 2L via tracheostomy. There were initials present on the MAR on 10/11/22 for the 7AM-3PM shift indicating staff verified this flow rate. It further revealed initials present on 10/11/22 for the 11PM-7AM shift indicating staff verified this flow rate. On 10/11/22 at 8:26 AM an observation of Resident #30 revealed her O2 flow rate was set to 4.5 L which she was receiving via her tracheostomy. Resident #30 was in bed, smiling and did not appear to be in any distress. On 10/12/22 at 6:38 AM an observation of Resident #30 revealed she was in bed. Her O2 flow rate was set to 4.5 liters which she was receiving via her tracheostomy. She was smiling and did not appear to be in any distress. On 10/12/22 at 6:41 AM an observation of Resident #30 with Nurse #2 revealed her O2 flow rate was set at 4.5L. An interview with Nurse #2 at that time indicated Resident #30's physician's order for O2 was 2L via tracheostomy. Nurse #2 stated she took over the care of Resident #30 at 6:00 AM that morning from Nurse #3. She stated she did look in on Resident #30 at 6:00 AM when she assumed her care but did not specifically check her O2 flow rate. She went on to say Nurse #3 had not reported any changes in Resident #30's respiratory status. Nurse #2 further indicated she had not changed Resident #30's O2 flow rate from 2L to 4.5L and did not know why it would be at 4.5L. Nurse #2 was observed to change Resident #30's O2 flow rate from 4.5L to 2L. A review of Resident #30's O2 saturations monitoring documented on her October 2022 MAR revealed the following: 10/11/22 7AM-3PM 95% on O2 2L 10/11/22 3PM-11PM 96% on O2 2L 10/11/22 11PM-7AM 96% on O2 2L On 10/12/22 at 6:44 AM an interview with Nurse Aide (NA) #3 indicated she provided care to Resident #30 since 11PM on 10/11/22. She stated NAs did not change the O2 flow rates. She went on to say only nurses could do that. NA #3 stated she did not think Resident #30 would be able to reach her O2 or change the settings herself. She further indicated she provided Resident #30 with a bath that morning about 6:00 AM but had not noticed what her O2 flow rate was set at. On 10/13/22 at 8:29 AM a telephone interview with Nurse #3 indicated she cared for Resident #30 from 11PM on 10/11/22 until 6AM on 10/12/22 when she reported off to Nurse #2. She stated she did not know why Resident #30's O2 flow rate would be set at 4.5 liters. She went on to say Resident #30's physician's order was for O2 at 2L. Nurse #3 further indicated she checked Resident #30's O2 flow rate that morning when Resident #30 was receiving her bath and it was set at 2L. On 10/13/22 at 10:45 AM an interview with NA #4 indicated she was familiar with Resident #30 and cared for her often. She stated Resident #30 required total assistance. She went on to say she did not think there any way Resident #30 could change her O2 settings herself. On 10/13/22 at 4:15 PM an interview with the Director of Nursing (DON) indicated Resident #30 should be receiving O2 at the flow rate ordered by her physician. Based on observations, staff interviews, and record review the facility failed to provide tracheostomy care following sterile technique when a nurse did not don sterile gloves prior to suctioning a resident's tracheostomy (Resident #45) and failed to set oxygen as ordered (Resident #30) for 2 of 4 residents reviewed for tracheostomy and respiratory care. Findings included: 1. Resident #45 was admitted to the facility on [DATE]. Her active diagnoses included chronic respiratory failure with hypoxia, alveolar hypoventilation (a disorder where a person does not take enough breaths per minute), and tracheostomy. Resident #45's minimum data set assessment dated [DATE] revealed she was assessed as severely cognitively impaired. She required extensive assistance with personal hygiene. She was documented to receive tracheostomy care in the facility. Review of Resident #45's care plan dated 8/4/22 revealed she was care planned for respiratory risk related to the presence of a tracheostomy. Review of Resident #45's orders revealed on 10/1/22 she was ordered to have tracheostomy care to be done every shift. During observation on 10/11/22 at 8:07 AM Nurse #1 was observed providing tracheostomy care to Resident #45 in the resident's room. The nurse performed hand hygiene, donned clean gloves, and opened the tracheostomy supplies for care. With the same gloves, she removed the tracheostomy suctioning catheter from the packaging and attached it to the bedside suctioning device. Sterile gloves were observed left in the tracheostomy kit package. Continuing to use the clean gloves, the nurse suctioned Resident #45's tracheostomy. During an interview on 10/11/22 at 10:48 AM Nurse #1 stated she did not remember tracheostomy suctioning was a sterile procedure and she should have donned sterile gloves prior to completing preparation of her sterile field and suctioning of the resident's tracheostomy. During an interview on 10/11/22 at 11:15 AM the Director of Nursing stated sterile technique should be followed by staff during tracheostomy suctioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to accurately document the administration of Sliding Scale Insulin coverage (Resident #77) and failed to accurately document when a medication was not administered (Resident #17) for 2 of 5 residents whose medications were reviewed. Findings included: 1.Resident #77 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A review of her active October 2022 physician's orders revealed the following: Finger Stick Blood Glucose (FSBG) before meals (AC) and at hour of sleep (HS) Insulin Aspart Sliding Scale for blood glucose greater than 270 give additional 1 U, greater than 300 give additional 2 U, greater than 350 give additional 3 U, greater than 400 give additional 4 U. A review of Resident #77's October 2022 Medication Administration Record (MAR) revealed the following documentation: On 10/1/22 at 11:30 AM Resident #77's FSBG was 310. On 10/2/22 at 11:30 AM Resident #77's FSBG was 328. On 10/5/22 at 4:30 PM Resident #77's FSBG was 278. No documentation was present on Resident #77's MAR on these instances to indicate Sliding Scale insulin coverage was provided. On 10/11/22 at 5:51 PM an interview with Nurse #5 indicated she cared for Resident #77 on 10/5/22 at 4:30 PM when her FSBG result was documented as 278. She stated she did administer the additional 1 U of insulin per the Sliding Scale insulin coverage but must have forgot to document it. She went on to say she knew she should have documented this on Resident #77's MAR but must have gotten distracted and forgot. On 10/13/22 at 1:04 PM a telephone interview with Nurse #6 indicated she cared for Resident #77 on 10/1/22 at 11:30 AM when her FSBG result was documented as 310. She stated she did administer the additional 2 U of insulin per the Sliding Scale insulin coverage but forgot to document it. She went on to say she knew she should have but it was an oversight on her part. Nurse #6 further indicated she also cared Resident #77 on 10/2/22 at 11:30 AM when her FSBG result was documented as 328. She stated she did administer the additional 2 U of insulin per the Sliding Scale insulin coverage but forgot to document it. She went on to say she knew she should have but this was also an oversight on her part. On 10/13/22 at 4:15 PM an interview with the Director of Nursing (DON) indicated nurses should be accurately documenting the medication they administered on the resident's MAR.2. Resident #17 was admitted to the facility on [DATE]. His active diagnoses included vitamin D deficiency. Review of Resident #17's orders revealed on 9/20/22 he was ordered ergocalciferol vitamin D2 50,000 units per 1.25 milligrams take one capsule by mouth every month on the 28th. Review of Resident #17's medication administration record for October 2022 revealed on 10/1, 10/2, 10/3, 10/4, 10/5, 10/6, 10/7, 10/9, and 10/10 at 8:00 AM ergocalciferol vitamin D2 50,000 units per 1.25 milligrams was initialed by the nurse. During an interview on 10/12/22 at 8:49 AM Nurse #1 stated if a medication is initialed on the medication administration record on a day, then the medication was given that day. The nurse showed the surveyor the medication in question was not available on the cart to be given yet in October 2022. She continued and stated their pharmacy sent resident medications weekly and the medication would not be in the cart for this month until Monday 10/24/22 as the medication was due on Friday 10/28/22. Upon review of the medication administration record, the nurse stated she did not have a reason she initialed the medication administration record as she did not give the medications those days. During an interview on 10/12/22 at 8:50 AM the Director of Nursing stated initials on the medication administration record indicated the medication would have been given, however, the medication would not have been available on the cart to have been given on the dates in question. The Director of Nursing concluded the medication administration record had been marked in error and should not have been initialed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #25 was re-admitted to the facility on [DATE]. A review of his quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Weight loss of 5 percent (%) or more in the last month or 10% or more in the last 6 months was no. A review of Resident #25's October 2022 active physician's orders revealed a diet order of mechanical soft large (double) portions. On 10/13/2022 at 1:36 PM a telephone interview with the facility Registered Dietician (RD) indicated she was familiar with Resident #25. She stated when Resident #25 was first admitted to the facility, he shared with staff that he was not getting enough food on his meal trays. She went on to say this was addressed with a physician's order for large portions. The RD stated the portion size was increased because of Resident #25's choice and preference and not based on nutritional needs or because he was losing weight. She went on to say Resident #25's weight was currently stable. On 10/10/2022 at 12:36 PM an interview with Resident #25 indicated he was not getting enough food on his meal trays. He stated he spoke with someone from dietary about this and was told he would be getting large portions but he had not been. He went on to say he wasn't still hungry because his family brought him snacks. Resident #25 stated did not think he had lost weight but he felt he should be getting more food during his meals. On 10/13/2022 at 12:37 PM an observation of Resident #25's lunch meal tray ticket present on his lunch meal tray with the District Dietary Manager (DDM) revealed his serving sizes for the meal were listed as a #8 scoop (4 ounces) of ground baked chicken breast, 2/3 cup of buttered macaroni noodles, 2/3 cup of roasted green beans, a roll and a #16 scoop (2 ounces) of pureed sugar cookie. The lunch meal ticket indicated Resident #25 was to receive large portions. An interview with the DDM at that time indicated Resident #25 did not have large or double portions of food on this lunch meal tray. She stated the portion sizes of food present on Resident #25's lunch meal tray were standard size portions. On 10/13/2022 at 1:10 PM an interview with [NAME] #1 indicated he plated the food present on Resident #25's lunch meal tray that day. He stated a dietary aide read each meal ticket out loud in the kitchen to him and would have read out the large portion instruction which was present at the bottom of Resident #25's lunch meal ticket. He stated when this was read, he should have added additional portions of food to Resident #25's meal. [NAME] #1 stated he must have either misheard or not heard the dietary aide that day because he had not added additional portions of food for Resident #25. On 10/13/2022 at 4:15 PM an interview with the Director of Nursing (DON) indicated Resident #25 should be receiving what was listed on his meal ticket and what he requested Based on observation, record review, resident and staff interviews, the facility failed to (1) honor resident choice to receive a shower for 2 of 2 residents (Resident #82 and Resident #77), (2) honor resident choice when to receive tracheostomy care and enteral feedings for 1 of 1 resident (Resident #16) and the facility failed to (3) honor resident choice to receive double portions as ordered by the Physician for 1 of 1 resident (Resident #25) reviewed for choices. Findings included: 1 Resident #82 was admitted to the facility on [DATE] with multiple diagnoses that included hemiplegia affecting nondominant side. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 was mildly cognitively impaired with no documentation of refusal of care. The MDS documented Resident #82 required extensive assistance with one person for bed mobility, dressing, personal hygiene, total assistance with 2 people for transfers and total assistance with one person for toileting and bathing. The MDS also documented Resident #28 choosing a tub or bed bath or shower was very important to him. Resident #82's care plan dated 9-2-22 revealed a goal of Activities of Daily Living (ADL) constant. The interventions for the goal were provide a shower on scheduled shower days. An attempt was made to locate the facility's shower schedule for Resident #82 however there was not a shower schedule available. Review of Resident #28's bathing documentation from August 2022 through October 2022 revealed the resident had not received a shower but had consistently received a bed bath. Resident #82 was interviewed on 10-10-22 at 11:20am. The resident discussed receiving a bed bath daily but stated he would like to have a shower at least once a week. Resident #82 commented he had not received a shower in a very long time. Nursing Assistant (NA) #13 was interviewed on 10-12-22 at 7:13am. The NA stated he had been working at the facility for a month and had never seen a shower schedule. He discussed never providing a shower to a resident nor being informed that he needed to be providing showers to residents. NA #13 stated he had been assigned to Resident #82 and that the resident had requested a shower, but he did not provide a shower to him because he was not aware he needed to provide showers. An interview with NA #14 occurred on 10-12-22 at 7:20am. NA #14 stated the facility did not have care guides for the residents, but the NAs could look in the computer for the residents required care. She stated she was familiar with Resident #82 and said she was not aware of the resident's shower days because they no longer had a shower schedule. NA #14 stated she could not remember if the resident ever requested a shower and she had never provided a shower to Resident #82. During an interview with NA #11 on 10-12-22 at 7:24am, the NA stated she had not seen a shower schedule but would provide a shower if the resident requested. NA #11 stated she was familiar with Resident #82 and said he had requested a shower in the past, but she did not give him one because she did not feel comfortable showering the resident. Nurse #7 was interviewed on 10-12-22 at 7:28am. The nurse discussed the facility stopping all showers when COVID19 started 2 years ago. She stated since then she had not been provided a shower schedule for the residents and had not seen any of the residents including Resident #82 receive a shower. The Assistant Director of Nursing (ADON) was interviewed on 10-12-22 at 7:55am. The ADON stated showers had stopped when COVID19 started but said she did not know why. She explained the staff were educated 2 months ago on resident showers restarting. The ADON explained the showers were supposed to start back on hall 200 west first and then the facility would gradually start showers back on the other halls. She explained since Resident #82 resided on hall 200 east there would not be a shower schedule for him yet since the new schedule started on hall 200 west. The Director of Nursing (DON) was interviewed on 10-12-22 at 8:05am. The DON stated the facility had not been providing showers to the residents since the start of COVID. She explained the facility had to work on preparing the shower rooms by disinfecting before showers could resume. The DON discussed hall 200 west was supposed to start back showering the residents on their assigned days but said the facility had struggled in reimplementing showers into the NAs schedule. 2. Resident #77 was admitted to the facility on [DATE] with multiple diagnoses that included paraplegia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #77 was cognitively intact with no documentation of refusing care. The MDS documented the resident required extensive assistance with one person for bed mobility, dressing, personal hygiene, extensive assistance with 2 people for transfers and total assistance with one person for toileting and bathing. Resident #77's care plan dated 8-31-22 revealed a goal of Activities of Daily Living (ADL) constant. The interventions for the goal were record personal hygiene and record bathing. An attempt was made to locate the facility's shower schedule for Resident #77 however there was not a shower schedule available. Review of Resident #77's bathing documentation from August 2022 through October 2022 revealed the resident had not received a shower but had consistently received a bed bath. Resident #77 was interviewed on 10-10-22 at 11:28am. The resident discussed receiving a bed bath but stated she had never received a shower. Resident #77 stated she would like to have a shower 1-2 times a week. She stated she had asked several times for a shower but was told the NAs were not able to provide a shower. Nursing Assistant (NA) #13 was interviewed on 10-12-22 at 7:13am. The NA stated he had been working at the facility for a month and had never seen a shower schedule. He discussed never providing a shower to a resident nor being informed that he needed to be providing showers to residents. NA #13 stated he had been assigned to Resident #77 and that the resident had requested a shower, but he did not provide a shower to him because he was not aware he needed to provide showers. An interview with NA #14 occurred on 10-12-22 at 7:20am. NA #14 stated the facility did not have care guides for the residents, but the NAs could look in the computer for the residents required care. She stated she was familiar with Resident #77 and said she was not aware of the resident's shower days because they no longer had a shower schedule. NA #14 stated she could not remember if the resident ever requested a shower and she had never provided a shower to Resident #77. During an interview with NA #11 on 10-12-22 at 7:24am, the NA stated she had not seen a shower schedule but would provide a shower if the resident requested. NA #11 stated she was familiar with Resident #77 and said she can not remember if the resident ever requested a shower but stated she had not ever provided a shower to Resident #77. Nurse #7 was interviewed on 10-12-22 at 7:28am. The nurse discussed the facility stopping all showers when COVID19 started 2 years ago. She stated since then she had not been provided a shower schedule for the residents and had not seen any of the residents including Resident #77 receive a shower. The Assistant Director of Nursing (ADON) was interviewed on 10-12-22 at 7:55am. The ADON stated showers had stopped when COVID19 started but said she did not know why. She explained the staff were educated 2 months ago on resident showers restarting. The ADON explained the showers were supposed to start back on hall 200 west first and then the facility would gradually start showers back on the other halls. She explained since Resident #77 resided on hall 200 east there would not be a shower schedule for her yet since the new schedule started on hall 200 west. The Director of Nursing (DON) was interviewed on 10-12-22 at 8:05am. The DON stated the facility had not been providing showers to the residents since the start of COVID. She explained the facility had to work on preparing the shower rooms by disinfecting before showers could resume. The DON discussed hall 200 west was supposed to start back showering the residents on their assigned days but said the facility had struggled in reimplementing showers into the NAs schedule. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator stated he expected staff to be providing showers to residents when the resident had asked. 3. Resident #16 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was moderately cognitively impaired. He received tube feedings and tracheostomy care. A review of the physician's orders for October 2022 revealed his tube feeding order was for 250 ml (milliliters) the name brand tube feeding formula 5 times per day. The scheduled times were 10:00 AM, 2:00 PM, 6:00 PM and 10:00 PM and 7:00 AM. The orders also included a water flush of 100 ml before and after each bolus which was scheduled for 10:00 AM, 2:00 PM, 6:00 PM 10:00 PM and 02:00 AM. The order for the tracheostomy care was scheduled as every shift without a specific designated time. The change of the inner cannula was ordered daily on the 7:00 AM to 3:00 PM shift and as needed. A review of the Medication Administration Record for October 2022 revealed the 7:00 AM tube feeding was marked through and changed to 02:00 AM. It was signed as being given at 02:00 AM from 10/05/22 through 10/12/22. The Medication Administration Record documented the tracheostomy care was provided during the 11:00 PM to 7:00 AM shift but no specific time was documented. On 10/10/22 at 10:09 AM during an interview with Resident #16 he communicated he did not like that he received tracheostomy care and tube feedings between 1:00 AM and 2:00 AM. He did not like to be awakened at that time to receive this care and felt it could be scheduled at a different time, so he was not awakened in the middle of the night. On 10/13/22 at 3:21 PM during a follow-up interview Resident #16 communicated he was frustrated by being awakened during the night for changing out his tracheostomy tube and getting tube feedings. On 10/12/22 at 3:55 PM Nurse #8 who worked on the 3:00 PM to 11:00 PM shift stated Resident #16 received tube feedings 2 times on her shift and also received tracheostomy care once on her shift. Nurse #8 said Resident #16 also received a feeding on the 11:00 PM to 7:00 AM shift. A telephone interview was attempted with the 3rd shift nurse, Nurse #8. She was unable to be reached. On 10/13/22 at 3:30 PM the Director of Nursing stated she was not aware Resident #16 had expressed concerns for being awakened during the night to have his tracheostomy changed and to receive a bolus tube feeding. She said he should not have to be awakened during regular sleeping hours to have this type of care provided and it should be scheduled differently to provide the resident quality sleep.

Based on observation and staff interviews the facility failed to ensure (1) 16 of 22 dishware were dry before being stacked and ready for use and (2) 2 of 10 dented cans were removed from the cart ready for use. The facility also failed to ensure 6 of 20 plates and bowels were clean prior to placing them on the tray line ready to use. These practices had the potential to affect food served to the residents. Findings included: 1.The initial tour of the kitchen was conducted on 10-10-22 at 10:05am with the Dietary Manager. The tour revealed the following: a. One 3-inch steam table pan was stacked wet on the rack labeled ready for use. b. one large flat metal pan was stacked wet and placed on a rack labeled ready for use. c. One 6 pound can of tropical fruit salad and one 6 pound can of pineapple tidbits were dented around the rim of the cans and placed on the rack ready for use. The Dietary Manager was interviewed on 10-10-22 at 10:20am. The Dietary Manager stated the pans, and the cans were ready to be used. She explained she was unaware of the pans being stacked wet or the cans being dented. The Dietary Manager explained the pans were to be left separated during the drying process on the shelf and the cans should have been removed from the rack and placed on the shelf marked dented cans. 2. A second observation of the kitchen occurred on 10-12-22 at 11:30am with the Dietary District Manager. The second tour revealed the following: a.14 of 30 plastic dome plate lids on the tray line ready for use were observed to be stacked wet. b. 3 of 15 meal plates on the tray line ready for use were observed to have dried food particles. c. 3 of 10 small bowls on the tray line ready for use were observed to have dried food particles. The Dietary District Manager was interviewed on 10-12-22 at 11:45am. The Dietary District Manager stated she was unaware of the issues with the plate lids, plates and bowls. She explained staff were to inspect the dishes for cleanliness prior to placing them on the tray line and stated the kitchen did not have enough rack space for the plate lids to be separated so they could dry and so staff were stacking the plate lids wet and placing them on the tray line. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator stated the dirty bowls and plates should not have been placed on the tray line and that he had already spoken with the Dietary District Manager.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and Physician interviews the facility failed to follow infection control practices when 2 of 2 nursing assistants (NA) (NA #11 and NA #12) failed to perform hand hygiene between resident contact while passing meal trays. Findings included: Review of the facility's Hand Washing policy and procedure dated October 2014 revealed in part all personnel shall follow established hand washing procedures to prevent the spread of infection and disease. Alcohol based sanitizers may be used instead of soap and water if hands are not visibly dirty. Hand washing is performed before and after resident contact. Review of the Hand Hygiene: Why, How and When education revealed all staff received education on hand washing 9-14-22. The education included when to use alcohol-based sanitizer and when to use soap and water. a.A continuous observation of lunch trays being passed occurred on 10-10-22 from 12:17pm through 12:20pm. NA #11 was observed in resident room [ROOM NUMBER] touching the resident's silverware, the drinking glasses and holding the resident's hand. NA #11 walked out of room [ROOM NUMBER] without performing hand hygiene, opened the meal cart, retrieved another lunch tray off the meal cart and entered resident room [ROOM NUMBER], approaching the resident in bed A. NA #11 was observed touching the resident's silverware and drinking glasses then holding the resident's hand. She exited room [ROOM NUMBER] without performing hand hygiene, walked to the meal cart, obtained a meal tray and walked into resident room [ROOM NUMBER]. She approached the resident in bed A touching the resident's tray table and removing the lid off the resident's meal. NA #11 exited room [ROOM NUMBER] without performing hand hygiene. NA #11 was interviewed on 10-10-22 at 12:20pm. The NA stated she had received education on hand hygiene last month but stated she thought she only had to perform hand hygiene when her hands were visibly dirty. NA #11 commented she did not think she had to perform hand hygiene between resident interactions if her hands were not dirty. NA #11 was observed to perform hand hygiene before continuing to provide lunch trays to the residents. On 10-10-22 at 12:35pm, Nurse #7 was interviewed who stated she was responsible for supervising the NAs but said she cannot monitor them closely when she was trying to pass medications. The nurse discussed NA #11 needing to perform hand hygiene between each resident encounter and stated she would discuss hand hygiene with the NA. b. On 10-11-22 from 9:16am to 9:18am, a continuous observation of delivery of breakfast trays occurred. NA #12 was observed entering resident room [ROOM NUMBER] and approaching the resident in bed B with the breakfast tray. She was observed touching the resident's tray table, silverware and drinking glasses. NA #12 exited room [ROOM NUMBER] without performing hand hygiene and walked to the meal cart to retrieve another breakfast tray. She entered room [ROOM NUMBER] and approached the resident in bed A, touching the residents tray table, silverware and drinking glasses. NA #12 exited room [ROOM NUMBER] without performing hand hygiene, walked to the meal cart and retrieved another breakfast tray. The NA entered resident room [ROOM NUMBER] and approached the resident in bed A. She was observed touching the resident's tray table and the lid to the resident's meal. NA #12 exited room [ROOM NUMBER] without performing hand hygiene. NA #12 was interviewed on 10-11-22 at 9:19am. The NA stated she had received education on hand hygiene yesterday (10-10-22). The NA retrieved a bottle of hand sanitizer from her pocket and stated I am supposed to be sanitizing my hands between each resident encounter. I just forgot. NA #12 was observed to perform hand hygiene before continuing to provide breakfast trays to the residents. The Assistant Director of Nursing (ADON) was interviewed on 10-10-22 at 1:15pm. The ADON stated staff had received education on hand hygiene but could not remember when the education occurred. She stated she expected staff to perform hand hygiene between each resident encounter. During an interview with the Infection Preventionist (IP) Nurse on 10-10-22 at 1:47pm, the IP nurse discussed the staff had received education on hand hygiene last month. She stated the education included washing hands between each resident encounter and that she expected staff to perform hand hygiene between each resident encounter. The IP nurse stated she did not know why staff was not performing hand hygiene but planned on providing further education. The Director of Nursing (DON) was interviewed on 10-11-22 at 9:20am. The DON discussed staff receiving education on hand hygiene last month and stated management had started re-educating staff on hand hygiene yesterday (10-10-22). The DON said she thought NA #12 had not performed hand hygiene between each resident contact because she was nervous but expected staff to perform hand hygiene between each resident encounter. A telephone interviewed with the facility Physician occurred on 10-13-22 at 3:15pm. The Physician discussed the recommendation for hand hygiene was to be completed between each resident contact and stated staff should be performing hand hygiene between residents. The Physician also stated there could be a possibility of infections to be spread from one resident to another when hand hygiene was not performed. The Administrator was interviewed on 10-13-22 at 3:58pm. The Administrator discussed hand hygiene education was provided to staff almost monthly and did not know why staff were not completing hand hygiene between each resident contact.

Based on record review and staff interviews the facility failed to review and annually update the Facility Assessment. Findings included: Review of the Facility Assessment revealed the assessment was last updated in September 2022. The document indicated the facility had a facility based and community-based risk assessment utilizing an all-hazards approach however there was not a risk assessment completed in the document. The Facility Assessment also indicated the facility had an Emergency Preparedness Plan that was up to date however the Emergency Preparedness Plan that was present was not complete. The Administrator was interviewed on 10-13-22 at 5:07pm. The Administrator stated he was not able to produce a facility based and community-based risk assessment. He explained he thought it was completed but said he was unable to locate the assessment. The Administrator also discussed not being aware the Emergency Preparedness plan was not complete at the time the Facility Assessment was updated.