**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to review and revise the care plan for 1 of 12 sampled residents (Resident #3). Failure to review and revise the care plan limited staff's ability to communicate needs, ensure continuity of care, and may negatively impact the care provided to the resident. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 06/19/24. This policy, dated 11/08/22, stated, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. Review of Resident #3's medical record occurred on all days of survey. A progress note, dated 04/07/24 at 11:04 a m., stated, Foley Cath [catheter] removed at 5 a.m. A quarterly MDS, dated [DATE], identified no Foley catheter, maximum assist required for transfers, not toileted, and no ambulation attempted. The current care plan identified Resident #3 had a Foley catheter and ambulated independently. During an interview on 06/19/24 at 5:01 p.m., an administrative staff member (#1) confirmed the facility failed to update Resident #3's care plan regarding removal of the Foley catheter and ambulation status.

Based on record review and staff interview, the facility failed to provide the resident or the resident's representative a written notice of transfer for 5 of 5 sampled residents (Resident #3, #5, #10, #23, and #28) transferred to the hospital. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of Resident #3, #5, #10, #23, and #28's medical records occurred on all days of survey and identified the following hospital transfers: * Resident #3: 10/27/23 and 05/07/24. * Resident #5: 08/04/23. * Resident #10: 04/05/24 and 04/26/24. * Resident #23: 05/03/24. * Resident #28: 04/29/24. The above residents' medical records lacked evidence the facility provided the resident and/or representative with a written transfer notice. During an interview on 06/18/24 at 2:13 p.m., an administrative staff member (#1) stated the facility does not have a Hospital Transfer policy. During an interview on 06/18/24 at 5:15 p.m., an administrative staff member (#1) confirmed the facility failed to complete a hospital transfer for the residents.

Based on record review, review of facility policy, and staff interview, the facility failed to provide a bed hold notice upon transfer to the hospital for 5 of 5 sampled residents (Resident #3, #5, #10, #23, and #28) transferred to the hospital. Failure to provide a bed hold notice does not allow residents or their legal representatives to make informed choices regarding their readmission rights. Findings include: Review of the facility policy titled Bed Hold occurred on 06/19/24. This policy, dated 04/17/24, stated, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital . Review of Resident #3, #5, #10, #23, and #28's medical records occurred on all days of survey and identified the following hospital transfers: * Resident #3: 10/27/23 and 05/07/24. * Resident #5: 08/04/23. * Resident #10: 04/05/24 and 04/26/24. * Resident #23: 05/03/24. * Resident #28: 04/29/24. The above residents' medical records lacked evidence the facility provided the resident and/or representative with a written bed hold notice. During an interview on 06/18/24 at 5:15 p.m., an administrative staff member (#1) stated they were unable to find written bed hold notices for the residents.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 1 of 12 sampled residents (Resident #32). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Care Plan Revisions occurred on 07/19/23. This policy, dated September 2022, stated, . the comprehensive care plan will be reviewed, and revised as necessary . the care plan will be updated with new or modified interventions . - Review of Resident #32's medical record occurred on all days of survey. A Physician's order, dated 06/22/23, stated, . foley catheter required for obstructive uropathy due to urinary retention. and included an order for Enhanced Barrier Precautions (EBP) (per CDC [centers for disease control and prevention]) related to medical device (indwelling catheter). The current care plan lacked goals and interventions related to Resident #32's indwelling catheter and EBP. During an interview on 07/19/23 at 9:20 a.m., an administrative nurse (#2) confirmed the facility staff failed to updated Resident #32's care plan with changes related to current conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policy, review of a professional reference, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 2 of 2 sampled residents (Resident #12 and #18) and 2 supplemental residents (#4 and #21) observed during a gait belt transfer. Failure to properly use a gait belt during transfers placed the resident at risk of accidents and injury. Findings include: Review of the facility policy Use of Gait Belt occurred on 07/19/23. This policy, dated October 2022, stated, . To prevent accidents . use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety . [NAME], [NAME], and Frandsen, Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 10th edition, Pearson Education, Inc., New Jersey, page 1054, stated, . If the client is a low safety risk . use a gait/transfer belt for standby assist as needed and assistive devices as needed . and 1-2 caregivers. Make sure the belt is pulled snugly around the client's waist and fastened securely. Grasp the belt at the client's back . Observations showed the following: * 07/17/23 at 2:50 p.m., showed a certified nurse aide (CNA) (#6) transferred Resident #12 from the wheelchair to the toilet without a gait belt. The CNA held onto the waist band of the resident's pants and shirt during the transfer. * 07/17/23 at 2:55 p.m., a CNA (#4) transferred Resident #18 from the wheelchair to the toilet. During the transfer, the CNA held on to the resident's hips and shirt and failed to use the gait belt. * 07/17/23 at 4:00 p.m., two CNAs (#3 and #5) transferred Resident #21 from the wheelchair to the toilet. During the transfer, one CNA (#5) held on to the waistband of the resident's pants and the other CNA (#3) held on to the resident's waist. The CNAs failed to use the gait belt during the transfer. * 07/17/23 at 4:08 p.m., a CNA (#6) transferred Resident #4 from the wheelchair to the toilet. During the transfer, the CNA held onto the resident's waistband and failed to use the gait belt during the transfer. During an interview on 07/17/23 at 4:15 p.m., an administrative nurse (#2) stated she expects staff to use a gait belt with transfers.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 3 sampled residents (Resident #12, #13 and #32) and 1 supplemental resident (#30) with orders for enhanced barrier precautions (EBP), and 2 of 12 sampled residents (Residents #1 and #15) observed during cares. Failure to practice infection control standards related to use of personal protective equipment (PPE) and hand hygiene has the potential to spread infection throughout the facility. Findings include: Review of the facility policy titled Enhanced Barrier Precautions occurred on 07/19/23. This undated policy, stated, . Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multi drug resistant organism] as well as those at risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Clear signage will be posted outside of the resident room indicating the type of precautions required personal protective equipment (PPE), and high-contact resident care activities that require the use of gown and gloves. High-contact resident care activities include: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting . Review of the facility policy titled Hand Hygiene occurred on 07/19/23. This policy, dated June 2023, stated, .Hand hygiene is a general term for cleaning your hands by hand washing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. ENHANCED BARRIER PRECAUTIONS: -Review of Resident 12's medical record occurred on all days of survey. The physician's orders included Enhanced Barrier Precautions related to a MDRO. Observation on all days of survey showed a cart containing isolation gowns and gloves located outside Resident #12's room. On 07/17/23 at 2:50 pm., a certified nurse aide (CNA) (#3) failed to donn the appropriate PPE and perform hand hygiene before and after toileting cares. -Review of Resident #13's medical record occurred on all days of survey. The physician orders included Enhanced barrier precautions related to a MDRO and . wear appropriate PPE and perform hand hygiene . Observations showed the following: * 07/17/23 at 2:11 p.m., resident companions (RC) (#7 and #8) entered Resident #13's room to deliver a meal tray and handled items in the room The RCs failed to perform hand hygiene upon entering and exiting the room. * 07/18/23 at 7:57a.m., an RC (#7) entered Resident #13's room and delivered a meal tray and assisted with sitting the resident up in bed. The RC failed to don PPE or perform hand hygiene upon entering and exiting the room. * 07/18/23 at 8:58 p.m, an RC (#7) entered Resident #13's room to deliver a meal tray and assist with set up of the meal tray. The RC failed to perform hand hygiene upon entering and exiting the room. - Review of Resident 30's medical record occurred on all days of survey. The care plan included, . Enhanced Barrier Precautions related to fragile skin . breakdown . Observations on 07/17/23 showed the following: * At 9:10 a.m., a CNA (#4) entered Resident #30's room and performed toileting cares. The CNA failed to don PPE or perform hand hygiene upon entering or exiting the room. * At 12:32 p.m., a CNA (#9) entered Resident #30's room to deliver and assist with set up of the meal tray, adjusted the residents' blankets, bedside table, and call light. The CNA failed to perform hand hygiene upon entering and exiting the room. During an interview on 07/17/23 at 12:15 p.m., an administrative nurse, (#2) confirmed she would expect staff to perform hand hygiene and wear appropriate PPE when entering, exiting, and performing cares with residents on enhanced barrier precautions. - Review of Resident #32's medical record occurred on all days of survey. The physician's orders included, . Enhanced Barrier Precautions (per CDC) [centers for disease control and prevention]) related to medical device. Observation on all days of survey showed a cart containing isolation gowns and gloves located outside Resident #32's room. Staff failed to post signage outside of the resident room to indicate the type of precautions requiring PPE and the high-contact resident care activities that require the use of gown and gloves. During an interview the afternoon of 07/19/23, an administrative nurse (#2) confirmed staff failed to post EBP signage outside Resident #32's room. HAND HYGIENE: - Observation on 07/17/23 at 2:30 p.m. showed two CNAs (#3 and #4) donned gloves and completed a mechanical lift transfer with Resident #1 from the wheelchair to the bed. The CNA (#3) removed Resident #1's wet brief, completed perineal cares, removed her gloves, donned a clean pair of gloves, applied the resident's clean brief, repositioned the resident in the bed, placed the bed in the low position, placed a mat on the floor next to the bed and removed her gloves. The CNA (#3) failed to perform hand hygiene between glove changes. - Observation on 07/18/23 at 9:04 a.m. showed a CNA (#6) knocked and entered Resident #15's bathroom. The CNA (#6) donned gloves, removed the wet incontinent product, applied a clean incontinent product, removed her gloves, donned a clean pair of gloves, assisted the resident with her shoes, then placed the call light next to the resident. The CNA (#6) failed to perform hand hygiene between glove changes. - Observation on 07/18/23 at 9:24 a.m. showed two CNAs (#3 and #5) donned gloves and completed morning cares for Resident #1. Both CNAs assisted with washing, drying, and dressing Resident #1's upper body and legs. The CNA (#5) removed the wet brief and completed perineal cares. Both CNAs completed the brief change, removed their gloves, donned a clean pair of gloves, placed the mechanical lift sling under the resident, and completed a mechanical lift transfer from the bed to the wheelchair. The CNAs (#3 and #5) failed to perform hand hygiene between glove changes. During an interview the afternoon of 07/19/23, an administrative nurse (#2) confirmed she expected staff to complete hand hygiene between glove changes.

Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#1) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 07/17/23 at 12:00 p.m., the dietary manager (#1) confirmed he has not completed the necessary courses required for the director of food and nutrition services. The facility failed to ensure the dietary manager (#1) completed the required education for a certified dietary manager, certified food service manager, or a national certification for food service management and safety from a national certifying body

Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 observation of a nebulizer treatment (Resident #18). Failure to clean the nebulizer equipment after each use may result in possible bacterial growth. Findings include: Review of the facility policy Medi-Mist occurred on 03/23/22. The undated policy, stated, . Switch off. Remove the mouth piece, T piece and tubing from the nebulizer. Wash all parts in warm soapy water or a recommended solution. Rinse all parts thoroughly with fresh water and allow them to air dry. When dry, replace all parts in the storage area to keep clean for next use. Review of Resident #18's medical record identified a physician order for Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligrams) /3 ML (milliliters) 1 dose inhale orally three times a day. The medication administration record identified the administration times at 8:00 a.m., 1200 noon, and 6:00 p.m. Observation on 03/23/22 at 7:59 a.m., showed a facility nurse (#1) administer Ipratropium-Albuterol Solution nebulizer to Resident #18. After completion of the treatment, the nurse (#1) removed the nebulizer mask and placed all the assembled nebulizer equipment in the storage bag. The nurse failed to disassemble the equipment, clean, and allow to air dry before placing in the storage bag as per the facility policy. During an interview on 03/23/22 at 8:32 a.m., an administration nurse (#2) confirmed staff are to rinse all nebulizer equipment after each use and let dry. During an interview on 03/23/22 at 11:39 a.m., a facility nurse (#1) stated she cleans the nebulizer at the end of her shift. The nurse (#1) stated she works 12 -16 hour day shifts and cleans the nebulizer at the end of her shift, clarifying all three nebulizer treatments could be given for that time period before cleaning.

Based on facility policy, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, record review, and staff interview, the facility failed to assess each resident's pneumococcal status and provide education to residents and/or their legal representatives regarding the benefits and potential side effects of receiving the vaccination for 3 of 5 residents (Resident #6, #20, and #35) reviewed for immunization status. Failure to offer pneumococcal vaccine to all residents, provide education to residents and their legal representatives, and document the administration or refusal has the potential for non-immunized residents to contact pneumonia and spread the infection to other residents, visitors, and staff. Findings included: Review of the facility policy titled INFLUENZA AND PNEUMOCOCCAL VACCINE occurred on 03/23/22. This policy, dated December 2009, stated, . Assessment: All new residents will be assessed by the long-term care staff, upon admission for status of influenza and pneumococcal immunization. Refusal of immunization: Resident and/or guardian must sign and date refusal. Each year, every resident will be offered the vaccination, even if it was refused the year prior. Review of the CDC: Vaccines and Preventable Diseases webpage(https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html), last reviewed December 6, 2017, stated, . CDC recommends pneumococcal vaccination (PCV13 or Prevnar13, and PPSV23 or Pneumovax23) for all adults 65 years or older: Give a dose of PCV13 to adults 65 years or older who have not previously received a dose. Then administer a dose of PPSV23 at least 1 year later. If the patient already received one or more doses of PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose of PPSV23. - Review of Resident #6's medical record occurred on 03/22/22. The record showed Resident #6's legal representative refused administration of the PPSV23 vaccine on the day of admission in 2017. The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. - Review of Resident #20's medical record occurred on 03/22/22. The record showed Resident #20 admitted in August 2020, received the PPSV23 vaccine on 01/13/20 (prior to admission). The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PCV13 immunization and/or provided education to the resident and/or their legal representative. - Review of Resident #35's medical record occurred on 03/22/22. The record showed Resident #35 admitted in May 2019, received the PCV13 vaccine on 12/09/18 (prior to admission). The record lacked evidence the facility assessed the resident's pneumococcal immunization status for the PPSV23 immunization and/or provided education to the resident and/or their legal representative. The facility failed to follow the CDC recommendations for pneumococcal vaccine administration and the facility's policy. During an interview on 03/23/22 at 11:25 a.m., two administrative nurses (#2 and #3) verified the facility failed to assess residents for pneumococcal immunization and/or follow the CDC recommendations for the pneumococcal vaccinations, and follow the facility policy.