**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to offer the pneumococcal vaccine and provide education regarding the benefits and potential side effects of the pneumococcal vaccine for two (Resident #30 and Resident #40) of six sampled residents reviewed for infection control. The facility census was 54. Findings include: 1. Record review revealed Resident #30 was admitted on [DATE]. Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/11/2025, revealed Resident #30's pneumococcal vaccination was not up to date and the pneumococcal vaccine was not offered to the resident. Resident #30's medical record revealed no evidence the resident was provided education regarding the benefits and potential side effects of the pneumococcal vaccine. Interview on 05/22/2025 at 11:59 AM, the Director of Nursing (DON) stated the pneumococcal vaccine was offered to all residents over the age of 60. The DON reviewed Resident #30's medical record and verified there was no evidence of documentation provided to the resident regarding the pneumococcal vaccine. 2. Record review revealed Resident #40 was admitted on [DATE]. Review of the admission MDS assessment, with an ARD of 05/04/2025, revealed Resident #40's pneumococcal vaccination was not up to date and the pneumococcal vaccine was not offered to the resident. Resident #40's medical record revealed no evidence the resident was provided education regarding the benefits and potential side effects of the pneumococcal vaccine. Interview on 05/22/2025 at 11:59 AM, the DON stated the pneumococcal vaccine was offered to all residents over the age of 60. The DON reviewed Resident #40's medical record and verified there was no evidence of documentation provided to the resident regarding the pneumococcal vaccine. Interview on 05/23/2025 at 8:45 AM, Resident #40 stated they did not recall anyone discussing the pneumonia vaccine with them upon admission to the facility. Interview on 05/23/2025 at 9:12 AM, the Infection Preventionist stated new residents should be provided education on immunizations and receive a vaccination if they want one. During a follow-up interview on 05/23/2025 at 10:51 AM, the DON stated her expectation was the facility staff would ask about and offer immunizations for residents who had not already received the vaccine. Interview on 05/23/2025 at 12:17 PM, the Administrator stated her expectation was that during the admission process, staff were to educate residents and document acceptance or refusal of immunizations.Review of the facility policy titled SNF [skilled nursing facility] Resident Immunization Policy, revised 11/08/2024, revealed all residents will receive immunizations and vaccinations that aid in preventing infectious diseases unless medical contraindicated or otherwise ordered by the resident's attending physician or the facility's medical director. The policy noted at bullet B. Pneumococcal vaccine 1. Each resident or the resident's legal representative receives education regarding the benefits and potential side effects of immunization. 2. All residents will be offered pneumococcal immunization, unless medically contraindicated or the resident has already been immunized on admission, regardless of date of admission. At bullet 6. Documentation in the medical record will include minimally a. That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal vaccination; and b. That the resident either received the pneumococcal vaccination or did not receive the immunization due to medical contraindications or refusal. c. If there is reason to believe that the vaccine was given previously but the date cannot be verified and this had an impact upon the decision regarding administration of the vaccine.

Based on observation, interview, and facility policy review, the facility failed to discard expired food items, label and date items stored in the refrigerator, and properly store food items in the refrigerator and freezer. These deficient practices had the potential to affect all 54 residents who received food from the kitchen. Findings include:Interview and observation of the cold storage on 05/19/2025 at 9:03 AM with the Food and Nutrition Services (FANS) Director, there was one case of sugar-free, orange gelatin with a use-by-date (UBD) of 04/15/2025. The FANS Director stated, More than likely we missed it. There was a half pan of pre-sliced onions covered with plastic wrap with a UBD of 05/18/2025. The FANS Director stated the pre-sliced onions should be discarded. There was a container of sliced mushrooms approximately a quarter full not dated with the date it was opened or a UBD. The FANS Director stated the container should have an opened and there should be UBD date on the label. There were six lemons that had been punctured with the interior exposed stored in a pan not wrapped or dated. The FANS Director stated the lemons should be labeled with a UBD and stored in a closed container. There was a plastic container of peeled garlic cloves with a UBD of 04/20/2025. The FANS Director stated the garlic cloves should be discarded. According to the FANS Director, the supervisors and entire dietary department was responsible for daily monitoring the refrigerator and freezer for expired items. Interview and observation of the frozen storage on 05/19/2025 at 10:03 AM with the FANS Director, there was an opened case of chicken breasts with an interior bag which was opened to air. The FANS Director stated the chicken breasts were not stored correctly as the bag should have been sealed and the box closed and not opened to air. Interview on 05/19/2025 at 9:40 AM, FANS Staff #4 stated she monitored the refrigerator and freezer for expired, outdated items and made sure the items were labeled with a date it was opened and a UBD. FANS Staff #4 stated she had been out for the past three days and had not gone in the refrigerator as of yet on 05/19/2025. Interview on 05/19/2025 at 9:44 AM, FANS Staff #5 stated she last checked the refrigerator before she left work on 05/15/2025 for expired and undated items. FANS Staff #5 stated she had not worked since 05/15/2025. Interview on 05/21/2025 at 9:38 AM, FANS Supervisor #18 stated she was the supervisor and the dietary staff was responsible to ensure all food items were labeled correctly, stored properly, and expired food items were discarded. Review of the facility policy titled Food Safety, dated 08/01/2006, revealed at bullet L. All foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers.Review of the facility policy titled Food Storage, dated 04/01/2008, revealed at bullet 2. Each container shall be labeled with the name of the product and the date of preparation or discard by date. Bullet H. Labeling of Leftovers 1. All prepared (leftovers) foods will be labeled and dated with a date of expiration by the person responsible for placing them in a storage refrigerator or freezer. 2. It is the responsibility of the cooks and supervisor to daily monitor the storage of leftover foods by examining the labels attached to foods stored in refrigerators. During an interview on 05/23/2025 at 9:18 AM, the Administrator stated she expected the staff in the dietary department to follow the policy regarding the correct food standards and approved real time monitoring. If the staff were expected to do daily check of the refrigerator and freezer, she expected the daily checks to occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete surgical wound treatments as ordered. This affected one (#53) of three residents reviewed for wounds. The census was 50. Findings include: Review of Resident #53's closed medical record revealed an admission date of 07/15/23. Diagnoses listed included paraplegia, neurogenic bowel, and neuropathic pain. Resident #53's was discharged to a local hospital on [DATE]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact, and was independent with bed mobility and dressing. Resident #53 was assessed with a surgical wound. Review of admission documentation revealed Resident #53 was admitted with a surgical flap repair of a stage four pressure ulcer (full-thickness skin and tissue loss) to the right upper posterior leg and buttocks area. Review of Resident #53's physician orders revealed an order dated 07/15/23 to change the dressing daily and removed the old dressing and packing. Staff were to apply a thin strip of Xeroform gauze (non-adherent wound dressing) to closed incision, pack a small amount of moist saline gauze to small open area of the incision near the scrotum, and apply an absorbent dressing to cover the entire Xeroform gauze and a moist gauze dressing with paper tape. Review of wound treatment record flowsheets revealed no documentation of wound treatments being completed to Resident #53's surgical flap repair on 07/16/23, 07/20/23, 07/21/23, and 07/23/23. Further review of Resident #53's medical record revealed no worsening of Resident #53's wound. During an interview on 10/24/23 at 12:05 P.M., Registered Nurse (RN) #80 confirmed no documentation of wound treatments being completed for Resident #53 on 07/16/23, 07/20/23, 07/21/23, and 07/23/23. During an interview on 10/24/23 at 2:30 P.M., Manager of Accreditation (MA) #100 confirmed no documentation of wound treatments being completed for Resident #53 on 07/16/23, 07/20/23, 07/21/23, and 07/23/23. This deficiency represents non-compliance investigated under Complaint Number OH00144979.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide pressure ulcer treatments as ordered. This affected one (#51) of three residents reviewed for wounds. The census was 50. Findings include: Review of Resident #51's close medical record revealed an admission date of 08/05/23. Diagnoses listed included quadriplegia, anxiety disorder, muscle weakness, depression, and urinary tract infection (UTI). Resident #10/05/23 was discharged to a local hospital on [DATE]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was totally dependent on staff for toileting and hygiene, and required extensive assistance with eating. Resident #51 was admitted to the facility with one stage two pressure ulcer (partial-thickness skin loss with exposed dermis) and one unstageable pressure ulcer (obscured full-thickness skin and tissue loss). Review of a wound assessment dated [DATE] revealed Resident #51 has an unstageable pressure ulcer to his coccyx that measured 7.0 centimeters (cm) long by 5.0 cm wide by 3.5 cm deep. The wound bed was covered with slough (non-viable yellow, tan, gray, green or brown tissue). Review of Resident #51's physician orders revealed on order dated 08/10/23 for the unstageable pressure ulcer for staff to clean the area around surrounding the skin with saline, pack with Dakin's solution (bleach based wound cleaner) moist gauze, and cover. The wound treatment was to be changed twice a day and as needed. Review of Resident #51's treatment administration records (TARs) revealed Dakin's solution was documented as being only being administered once a day on 08/11/23, 08/16/23, 08/17/23, 08/18/23, 08/21/23, 08/24/23, 09/03/23, 09/04/23, 09/05/23, 09/12/23, and 09/28/23. Further review of Resident #51's medical record revealed no worsening of Resident #51's wound. During an interview on 10/24/23 at 12:05 P.M., Registered Nurse (RN) #80 confirmed Dakin's solution was documented as only being administered once a day on 08/11/23, 08/16/23, 08/17/23, 08/18/23, 08/21/23, 08/24/23, 09/03/23, 09/04/23, 09/05/23, 09/12/23, and 09/28/23 for Resident #51. During an interview on 10/24/23 at 2:30 P.M., Manager of Accreditation (MA) #100 confirmed Dakin's solution was documented as being only being administered once a day on 08/11/23, 08/16/23, 08/17/23, 08/18/23, 08/21/23, 08/24/23, 09/03/23, 09/04/23, 09/05/23, 09/12/23, and 09/28/23 for Resident #51. This deficiency represents non-compliance investigated under Master Complaint Number OH00146760.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify a physician for follow up of abnormal laboratory results. This affected one (#53) of three residents reviewed for laboratory values. The census was 50. Findings include: Review of Resident #53's closed medical record revealed an admission date of 07/15/23. Diagnoses listed included paraplegia, neurogenic bowel, and neuropathic pain. Resident #53's was discharged to a local hospital on [DATE]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 was cognitively intact, and was independent with bed mobility and dressing. Review of nursing notes dated 07/17/23 at 7:23 P.M. revealed Resident #53 complained of pain during a straight urinary catheterization (temporary to obtain urine) and suspected an urinary tract infection (UTI). A night shift nurse and nurse practitioner were made aware. Review of Resident #53's physician orders revealed an order dated 07/17/23 for a urinalysis with reflex to microscopic. Review of Resident #53's urinalysis results dated 07/17/23 revealed abnormal laboratory values. Resident #53's urine was noted to be cloudy when clear was a normal value, contained protein of 100 milligram per deciliter (mg/dL) when negative was a normal value, have a moderate amount of blood when negative was a normal value, a large number of leukocytes when negative was a normal value, greater than 100 high power field (HPF) white blood cells when a normal value range was zero to five, and 96 HPF red blood cells when a normal value range was zero to three. Further review of Resident #53's closed medical record revealed no documentation of physician review or notification of the urinalysis abnormal results dated 07/17/23. Culture results were not obtained from Resident #53's urine on 07/17/23. Review of hospital records dated 07/26/23 revealed Resident #53 was positive for a UTI from a urine sample collected on 07/24/23. During an interview on 10/24/23 at 12:05 P.M., Registered Nurse (RN) #80 confirmed there was no documentation of a physician reviewing or being notified of Resident #53's abnormal urinalysis results dated 07/17/23. During an interview on 10/25/23 at 9:35 A.M., Manager of Accreditation (MA) #100 confirmed there was no documentation of a physician reviewing or being notified of Resident #53's abnormal urinalysis results dated 07/17/23. MA #100 confirmed Resident #53 was positive for an UTI on 07/24/23 after he was discharged from the facility. This deficiency represents non-compliance investigated under Complaint Number OH00144979.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interviews the facility failed to ensure residents were treated in a dignified manner with toileting and the removal of hospital bracelets. This affected two (#8 and #35) of three residents reviewed for dignity. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #35 was admitted on [DATE]. Diagnoses included aftercare following surgery for neoplasm, malignant neoplasm of tongue, encounter for attention to tracheostomy, encounter for attention to other artificial openings of digestive tract, type two diabetes mellitus, long term use of insulin, long term use of anticoagulants, atrial fibrillation, hypertension, insomnia, acute and chronic respiratory failure, restlessness and agitation and pneumonia. Review of Resident #35's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with transfers, bed mobility, dressing, toileting and personal hygiene. Resident #35 also required total dependence with eating. Observation of Resident #35 on 10/15/19 at 11:52 A.M. revealed the resident was wearing two white hospital bands. One of the hospital bands was dated 10/01/19 and the other hospital bracelet had the hospital name and resident's date of birth on it. Interview with Resident #35 on 10/15/19 at the time of the observation revealed the resident was not given a choice regarding his hospital bands being worn at the facility. Resident #35 stated no one at the facility had attempted to remove his hospital bands. Observation on 10/17/19 at 10:44 A.M. revealed the resident was lying in bed wearing two white hospital bands. One of the hospital bands was dated 10/01/19 and the other hospital bracelet had the hospital name and resident's date of birth on it. Interview with Case Manager Registered Nurse (RN) #900 verified Resident #35 was not given a choice regarding him wearing a hospital band. RN #900 stated the facility scans the hospital bands prior to administering medications. RN #900 reported the facility did not have a dignity policy in regards to wearing hospital bands. 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Admitting diagnoses included; hypertension, peripheral vascular disease, traumatic brain injury resulting in dementia with behaviors and dysarthia (speech that is slurred, slow and difficult to understand). Review of the quarterly MDS dated [DATE] identified Resident #8 as moderately impaired in cognition. The resident required extensive assist of one staff member for bed mobility, dressing and toileting. The MDS also identified the resident as being occasionally incontinent of urine but always continent of bowel. Review of the care plan identified as bowel elimination, date unidentified, revealed a intervention of anticipate and assist with toilrting needs. Review of the care plan identified as cognitive/linguistics, date unidentified, revealed diagnoses of dysarthria and unclear speech. Review of the wound assessment dated [DATE] identified a red abrasion to his right inner buttock, measuring 4.5 centimeters (cm) by 0.5 cm. On 10/15/19 at 10:00 A.M., this surveyor noted the call light on outside of Resident #8's room. He was loudly trying to talk. When the surveyor went in the resident was pointing between his legs, the only words understandable was up and s**t. There was a strong odor of a bowel movement. During this time no staff came in the room. The call light was still lit up outside the room and could be observed from both ends of the hallway. On 10/15/19 at 11:08 A.M., Resident #8's call light was still on. The surveyor asked Resident #8 if someone had assisted him. The resident shook his head no. He proceed to point between his legs again. He still had an odor of a bowel movement. Licensed Practical Nurse (LPN) #66 entered the room and asked the resident if he needed something. Again he tried to speak but the only word that was clear was up as he pointed between his legs. LPN #66 told him she would inform the aides. LPN #66 indicated the aides were down the all and they would be in to clean him up. LPN #66 then left the room. On 10/15/19 at 11:45 A.M., unit clerk #950 answered the call light for Resident #8 as the surveyor was in the room. Unit clerk #950 asked the resident if he needed something. The resident responded loudly up, up. The unit clerk asked again if the resident needed something before turning off the intercom. On 10/15/19 at 11:47 A.M., unit clerk #950 again asked if the resident needed some help. He attempted to communicate but as unable to make his need known. After a couple of attempts by unit clerk #950 she stopped asking what the resident needed. On 10/15/19 at 11:50 A.M., an interview was conducted with unit clerk #950, who shared that when a resident puts on his call light it sounds and lights up at the desk next to her. She could speak with the resident to see what they needed and then request for staff assistance. She also shared that when a call light comes on it rings on the nurses and State Tested Nurse Aide (STNAs) phones which they all carry. The light outside the room cannot be shut off until a nurse or STNA enters the room and shuts it off. On 10/15/19 at 11:55 A.M., LPN #66 entered Resident #8's room with clean linens. She provided incontinence care, changed his gown and applied a clean sheet. LPN #66 confirmed that Resident #8 had been waiting for over an hour for care. LPN #66 revealed Resident #8 was unable to clean himself up after being incontinent of stool.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, and interview the facility failed to ensure a resident that was discharged from Medicare Part A services was informed of his right to an expedited review of his terminated Medicare Part A services at least 48 hours prior to the services being terminated. This affected one (Resident #237) of three residents reviewed for beneficiary notices. The facility census was 54. Findings include: Review of the closed medical record review revealed Resident #273 was admitted on [DATE]. Diagnoses included congestive heart failure, legal blindness ischemic cardiomyopathy, non-rheumatic aortic valve stenosis, pleural effusion, other abnormalities of gait, diaphragmatic hernia without obstruction or gangrene, cataracts, diabetes mellitus, benign prostatic hyperplasia and gastro esophageal reflux disease. Resident #273 discharged from the facility on 04/26/19. Review of Resident #273's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required limited assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #273 also required supervision with eating. Review of the Centers for Medicare and Medicaid Services Skilled Nursing Facility Beneficiary Protection Notification Review form completed by the facility on 10/16/19 revealed Resident #273 was admitted to Medicare Part A services on 04/01/19 and discharged from Medicare Part A services on 04/25/19. Further review of the form revealed the facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. Further review of the medical record revealed the resident was admitted to Medicare Part A skilled services on 04/01/19 and had a last covered day of skilled services on 04/25/19. Further review revealed Resident #273's representative was notified on 04/24/19 by phone of the Notice of Medicare Non-Coverage (NOMNC) with a last covered day of 04/25/19. Resident #273's medical record did not contain a signed NOMNC. Interview with the Administrator on 10/16/19 at 1:42 P.M. verified Resident #273 or Resident #273's representative was not informed of and did not receive a NOMNC to inform the resident and his responsible party of his right to an expedited review of terminated Medicare Part A services within 48 hours of Resident #273's discharge from Medicare Part A services on 04/25/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interviews and review of facility policy the facility failed to implement their abuse policy and failed to thoroughly investigate a residents allegation of emotional and verbal and abuse. This affected one (#48) of 14 residents reviewed in the final sample. The facility census was 54 residents. Findings include: Review of Resident #48's medical record revealed an admit date [DATE] with diagnosis including but not limited to dehydration, acute kidney injury, complicated urinary tract infection, diabetes, urinary retention, peripheral arterial disease, and hyponatremia (low blood sodium). Review of Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition, no behaviors demonstrated, and extensive assist required for activities of daily living. Review of Medication Administration Record revealed Mag Citrate (a laxative) was given once on 10/04/19. Interview on 10/16/19 at 8:39 A.M. with Resident #48 reported a female State Tested Nurse Assistant (STNA) told him that he stunk. Resident #48 stated the STNA had wanted him to shower but he had taken a laxative called Mag Citrate and he wanted to wait until it worked before getting cleaned up. He stated he tried to explain to the STNA that he couldn't help smelling if he couldn't get help to the bathroom. The resident became tearful and stated he couldn't get what the STNA had said to him out of his mind. During the interview, Registered Nurse (RN) #47 entered Resident #48's room on 10/16/19 at 9:00 A.M. The resident was still crying and RN #47 joined the interview. Resident #48 called RN #47 by name and repeated that an STNA had hurt his feelings when she told him he stunk. The resident stated he wanted to wait for a shower until the laxative worked. Resident #48 told RN #47, while still tearful, that an STNA had talked to him bad and repeated it occurred after he had taken the Mag Citrate. Resident #48 reported the STNA had his complexion, had long plaits (similar to braids), that another STNA was in the room, and he could identify her if he saw her. Resident #48 also reported he thought he heard her a day or so later in the hall commenting to several people it was her birthday. RN #47 stated he would find an excuse to bring different staff into Resident #48's room and later Resident #48 could report which staff was involved. Interview on 10/16/19 at 10:09 A.M. with RN #47 stated Resident #48 was aware of what was going on and verified the resident as tearful during the interview. Interview on 10/16/19 at 1:22 P.M. with Unit Manager RN #16 denied knowing of Resident #48's allegations of verbal abuse. Observation on 10/16/19 at 1:55 P.M. revealed Patient Experience Manager RN #756 went into Resident #48's room. Review of progress note dated 10/16/19 at 2:04 P.M. revealed an entry that the patient advocate had spoken with Resident #48 regarding a nurse aide attitude. The aide that she had been rude made him feel not so good and hurt his feelings. Follow up was per complaint policy and addressed appropriately. Interview on 10/17/19 at 8:07 A.M. with the Administrator reported a patient experience report had been opened for Resident #48 and a Self Reported Incident (SRI) State Reported had been filed but the resident could not provide a date, time, or the name of the staff person involved and did not use the word abuse so he was given a card and encouraged to let staff know in real time. The Administrator stated no other residents nor staff were interviewed. He stated since he made rounds daily and asked residents if they were treated well he didn't feel interviews were necessary. The Administrator stated he felt a thorough investigation had been done per facility policy. Interview on 10/17/19 at 9:06 A.M. with Patient Experience Manager RN #756 reported no other staff or residents were interviewed about Resident #48's experience. She stated the report was shared with management and would be taken to the next all staff meeting. RN #756 stated other residents and staff were only interviewed if the reporting resident was able to identify the offender or gave a date of occurrence. She reported talking with RN #47 but denied he reported the description of the STNA or that it occurred on the date the resident had taken Mag Citrate. Interview on 10/17/19 at approximately 9:30 A.M. with RN #47 stated he gave a brief synopsis to his manager about Resident #48's complaint and since he saw Patient Experience staff go into Resident #48's room he thought the complaint was addressed. RN #47 denied being interviewed by Patient Experience staff or any administrative staff about the specifics of the complaint. Review of facility policy titled Abuse, Neglect, Misappropriation, and Exploitation of Residents/Patients, dated 03/2017, indicated a thorough investigation would be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interviews and review of facility policy the facility failed to thoroughly investigate a residents allegation of emotional and verbal and abuse. This affected one (#48) of 14 residents reviewed in the final sample. The facility census was 54 residents. Findings include: Review of Resident #48's medical record revealed an admit date [DATE] with diagnosis including but not limited to dehydration, acute kidney injury, complicated urinary tract infection, diabetes, urinary retention, peripheral arterial disease, and hyponatremia (low blood sodium). Review of Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition, no behaviors demonstrated, and extensive assist required for activities of daily living. Review of Medication Administration Record revealed Mag Citrate (a laxative) was given once on 10/04/19. Interview on 10/16/19 at 8:39 A.M. with Resident #48 reported a female State Tested Nurse Assistant (STNA) told him that he stunk. Resident #48 stated the STNA had wanted him to shower but he had taken a laxative called Mag Citrate and he wanted to wait until it worked before getting cleaned up. He stated he tried to explain to the STNA that he couldn't help smelling if he couldn't get help to the bathroom. The resident became tearful and stated he couldn't get what the STNA had said to him out of his mind. During the interview, Registered Nurse (RN) #47 entered Resident #48's room on 10/16/19 at 9:00 A.M. The resident was still crying and RN #47 joined the interview. Resident #48 called RN #47 by name and repeated that an STNA had hurt his feelings when she told him he stunk. The resident stated he wanted to wait for a shower until the laxative worked. Resident #48 told RN #47, while still tearful, that an STNA had talked to him bad and repeated it occurred after he had taken the Mag Citrate. Resident #48 reported the STNA had his complexion, had long plaits (similar to braids), that another STNA was in the room, and he could identify her if he saw her. Resident #48 also reported he thought he heard her a day or so later in the hall commenting to several people it was her birthday. RN #47 stated he would find an excuse to bring different staff into Resident #48's room and later Resident #48 could report which staff was involved. Interview on 10/16/19 at 10:09 A.M. with RN #47 stated Resident #48 was aware of what was going on and verified the resident as tearful during the interview. Interview on 10/16/19 at 1:22 P.M. with Unit Manager RN #16 denied knowing of Resident #48's allegations of verbal abuse. Observation on 10/16/19 at 1:55 P.M. revealed Patient Experience Manager RN #756 went into Resident #48's room. Review of progress note dated 10/16/19 at 2:04 P.M. revealed an entry that the patient advocate had spoken with Resident #48 regarding a nurse aide attitude. The aide that she had been rude made him feel not so good and hurt his feelings. Follow up was per complaint policy and addressed appropriately. Interview on 10/17/19 at 8:07 A.M. with the Administrator reported a patient experience report had been opened for Resident #48 and a Self Reported Incident (SRI) State Reported had been filed but the resident could not provide a date, time, or the name of the staff person involved and did not use the word abuse so he was given a card and encouraged to let staff know in real time. The Administrator stated no other residents nor staff were interviewed. He stated since he made rounds daily and asked residents if they were treated well he didn't feel interviews were necessary. The Administrator stated he felt a thorough investigation had been done per facility policy. Interview on 10/17/19 at 9:06 A.M. with Patient Experience Manager RN #756 reported no other staff or residents were interviewed about Resident #48's experience. She stated the report was shared with management and would be taken to the next all staff meeting. RN #756 stated other residents and staff were only interviewed if the reporting resident was able to identify the offender or gave a date of occurrence. She reported talking with RN #47 but denied he reported the description of the STNA or that it occurred on the date the resident had taken Mag Citrate. Interview on 10/17/19 at approximately 9:30 A.M. with RN #47 stated he gave a brief synopsis to his manager about Resident #48's complaint and since he saw Patient Experience staff go into Resident #48's room he thought the complaint was addressed. RN #47 denied being interviewed by Patient Experience staff or any administrative staff about the specifics of the complaint. Review of facility policy titled Abuse, Neglect, Misappropriation, and Exploitation of Residents/Patients, dated 03/2017, indicated a thorough investigation would be done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interviews the facility failed to ensure a significant change Minimum Data Sets (MDS) assessment was completed within 14 days after a resident had a significant change. This affected one (Resident #29) of 14 residents reviewed for significant change assessments. The facility census was 54. Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included cancer of the mouth, hypertension, dysphagia, acute blood loss anemia, type two diabetes mellitus and hypothyroidism. Review of Resident #29's admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #29 was also independent with eating. Resident #29 was identified as having a feeding tube and required tracheostomy care on her Review of Resident #29's 14 day MDS assessment dated [DATE] revealed the resident was cognitively intact and required limited assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #29 also required extensive assistance with eating. Resident #29 was also identified as having a feeding tube and required tracheostomy care on her 10/06/19 MDS. Review of Resident #29's 10/09/19 physician's visit revealed the residents feeding tube was removed on 10/09/19. Review of Resident #29's physician's visit dated 10/16/19 revealed her feeding tube was removed on 10/09/19 and her tracheostomy was removed on 10/02/19. Interview with Resident #29 on 10/15/19 at 2:42 P.M. revealed the resident no longer had a tracheostomy or feeding tube. Resident #29 was observed eating independently in her room. Interview with Case Manager Registered Nurse (RN) #900 on 10/17/19 at 11:08 A.M. revealed Resident #29 had her feeding tube removed on 10/09/19 and her tracheostomy removed on 10/02/19. RN #900 also confirmed that Resident #29's eating had improved since her feeding tube was removed. RN #900 verified Resident #900 did not have a significant change assessment completed within 14 days of her tracheostomy being removed and that a significant change assessment had not been completed since resident's feeding tube had been removed and her ability to eat had improved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to notify the state mental health authority with a significant change pre-admission screening and resident review (PASARR) for a resident with a change in their physical condition. This affected one (Resident #14) of one resident reviewed for significant change PASARR. The facility census was 54. Findings include: Review of the medical record revealed Resident #14 was admitted to the facility on [DATE]. Diagnoses included bipolar disorder, coronary artery disease, cancer, closed fracture of arm, depression, chronic obstructive pulmonary disease, depression, fracture of right femur, fracture of right hip, hyperlipidemia, lung nodule and thyroid nodule. Review of Resident #14's significant change Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and was independent with bed mobility, transfers, dressing, toileting, personal hygiene and eating. Further review of Resident #14's medical record revealed a hospital exemption from preadmission screening notification dated [DATE]. Further review revealed no PASARR present in the resident's chart after the resident's hospital exemption expired on [DATE]. Resident #14's medical record did not contain a notification to the state mental health authority or a significant change PASARR upon Resident #14's significant improvement in activities of daily living on [DATE]. Interview on [DATE] at 2:43 P.M. with Case Manager Registered Nurse (RN) #900 confirmed Resident #14 had a significant change MDS due to an improvement in activities of daily living. Interview with the Administrator on [DATE] at 11:50 A.M. verified the facility did not have a PASARR after Resident #14's hospital exemption expired on [DATE]. The Administrator also confirmed a notification to the state mental health authority or significant change PASARR was not completed upon Resident #14's significant change or improvement in activities of daily living on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews the facility failed to ensure a resident was given the opportunity to participate in the care planning process within seven days of the completion of their comprehensive assessment. This affected one (Resident #29) of 14 residents reviewed for care planning. The facility census was 54. Findings include: Review of the medical record revealed Resident #29 was admitted to the facility on [DATE]. Diagnoses included cancer of the mouth, hypertension, dysphagia, acute blood loss anemia, type two diabetes mellitus and hypothyroidism. Review of the admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #29 was also independent with eating. Review of the 14 day MDS assessment dated [DATE] revealed the resident was cognitively intact and required limited assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #29 also required extensive assistance with eating. Review of Resident #29's care plan revealed her care plan was developed on 09/23/19, while she was at the local hospital connected to the facility. Further review of the medical record revealed no information regarding the resident having a care conference or being invited to participate in care planning within seven days of the completion of her comprehensive assessments on 09/30/19 and 10/06/19. Interview with Resident #29 on 10/15/19 at 2:42 P.M. revealed she had not been invited to care conferences and had not been given the opportunity to participate in care planning. Interview with Licensed Social Worker (LSW) #902 on 10/17/19 at 12:25 P.M. verified Resident #29 did not have a care conference and was not invited to participate in care planning within seven days of the completion of her comprehensive assessment on 09/30/19 or 10/06/19. LSW #902 stated Resident #29 received a last covered day from her insurance on 10/13/19. LSW #902 stated she met with Resident #29 on 10/13/19 and Resident #29 decided to appeal the last covered day given on 10/13/19. LSW #902 confirmed Resident #29 did not receive a care conference and was not engaged in the care planning process prior to her meeting with Resident #29 on 10/13/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interviews the facility failed to provide activities of daily living (ADL) care for dependent residents. This affected three (#8, #25, and #41) of five residents reviewed for ADL and incontinence care. The facility census was 54 residents. Findings include: 1. Review of the medical record revealed Resident #25 was admitted on [DATE]. Diagnoses included chronic kidney disease, chronic obstructive pulmonary disease, pneumonia, seizures, and tracheostomy. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, had no refusals of care, and required extensive assist of one for transfers, dressing, toileting, bathing. Review of a care plan dated 09/20/19 revealed problems of self-care with interventions to assist with ADLs. Interview on 10/15/19 at 11:23 A.M. with Resident #25 reported she had only received one shower since her admission and no one had washed her hair. She stated she liked to have hair washed at least weekly and had asked again today for it to be done. Interview on 10/15/19 with State Tested Nurse Assistant (STNA) #33 reported the facility did not have any equipment to wash Resident #25's hair. STNA #33 denied being able to wash the resident's hair in the shower since the resident had a tracheostomy and the facility had no means (sink, basin, or such) to wash the residents' hair. Interview on 10/17/19 at 8:53 A.M. with Unit Manager Registered Nurse (RN) #16 reported she had spoken with Resident #25 about her lack of showers after STNA #33 reported the concerns to her. RN #16 verified Resident #25 had only received one shower on 09/24/19 by occupational therapy (OT). RN #16 said she had asked OT to revisit the resident. RN #16 stated she had not thought to ask OT washing the residents hair. 2. Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included infection of a wound, renal cell cancer, migraines, hypertension, bipolar disorder, and end stage renal disease. Review of an admission MDS assessment dated [DATE] indicated the resident was cognitively intact, had no rejections of care or behaviors, and required extensive assist of one for bed mobility, dressing, toileting, and hygiene. Review of a care plan dated 08/30/19 revealed a problem of decreased endurance, weakened upper extremities, need to return to prior level of function. Interview on 10/15/19 at 8:47 A.M. with Resident #41 reported he had not received any bathing in greater than one week and had not been shaved since his admission date. He reported shaving daily before being admitted and that he had asked for a shave numerous times but staff just say they will ask the next shift to shave him. Interview on 10/17/19 at 8:33 A.M. with Case Manager RN #900 verified Resident #41's shower record did not include any documentation of bathing or shaving. Interview on 10/17/19 at 8:52 A.M. with Unit Manager RN #16 reported she would ask OT to work with Resident #41 to shave. She verified Resident #41 had long facial hair stating she wanted to ask him about shaving but did not want to embarrass him. She was unable to explain why the STNA's had not assisted him with shaving. 3. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Admitting diagnoses included; hypertension, peripheral vascular disease, traumatic brain injury resulting in dementia with behaviors and dysarthia (speech that is slurred, slow and difficult to understand). Review of the quarterly MDS dated [DATE] identified Resident #8 as moderately impaired in cognition. The resident required extensive assist of one staff member for bed mobility, dressing and toileting. The MDS also identified the resident as being occasionally incontinent of urine but always continent of bowel. Review of the care plan identified as bowel elimination, date unidentified, revealed a intervention of anticipate and assist with toilrting needs. Review of the care plan identified as cognitive/linguistics, date unidentified, revealed diagnoses of dysarthria and unclear speech. Review of the wound assessment dated [DATE] identified a red abrasion to his right inner buttock, measuring 4.5 centimeters (cm) by 0.5 cm. On 10/15/19 at 10:00 A.M., this surveyor noted the call light on outside of Resident #8's room. He was loudly trying to talk. When the surveyor went in the resident was pointing between his legs, the only words understandable was up and s**t. There was a strong odor of a bowel movement. During this time no staff came in the room. The call light was still lit up outside the room and could be observed from both ends of the hallway. On 10/15/19 at 11:08 A.M., Resident #8's call light was still on. The surveyor asked Resident #8 if someone had assisted him. The resident shook his head no. He proceed to point between his legs again. He still had an odor of a bowel movement. Licensed Practical Nurse (LPN) #66 entered the room and asked the resident if he needed something. Again he tried to speak but the only word that was clear was up as he pointed between his legs. LPN #66 told him she would inform the aides. LPN #66 indicated the aides were down the all and they would be in to clean him up. LPN #66 then left the room. On 10/15/19 at 11:45 A.M., unit clerk #950 answered the call light for Resident #8 as the surveyor was in the room. Unit clerk #950 asked the resident if he needed something. The resident responded loudly up, up. The unit clerk asked again if the resident needed something before turning off the intercom. On 10/15/19 at 11:47 A.M., unit clerk #950 again asked if the resident needed some help. He attempted to communicate but as unable to make his need known. After a couple of attempts by unit clerk #950 she stopped asking what the resident needed. On 10/15/19 at 11:50 A.M., an interview was conducted with unit clerk #950, who shared that when a resident puts on his call light it sounds and lights up at the desk next to her. She could speak with the resident to see what they needed and then request for staff assistance. She also shared that when a call light comes on it rings on the nurses and State Tested Nurse Aide (STNAs) phones which they all carry. The light outside the room cannot be shut off until a nurse or STNA enters the room and shuts it off. On 10/15/19 at 11:55 A.M., LPN #66 entered Resident #8's room with clean linens. She provided incontinence care, changed his gown and applied a clean sheet. LPN #66 confirmed that Resident #8 had been waiting for over an hour for care. LPN #66 revealed Resident #8 was unable to clean himself up after being incontinent of stool.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews the facility failed to monitor the bowel function of a resident who required several different medications for constipation. This affected one (#48) of two residents reviewed for bowel and bladder function. The facility census was 54 residents. Findings include: Review of the medical record revealed Resident #48 was admitted on [DATE]. Diagnoses included dehydration, acute kidney injury, complicated urinary tract infection, diabetes, urinary retention, peripheral arterial disease, buttocks skin ulcer, and hyponatremia (low blood sodium). Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated impaired cognition, no behaviors demonstrated, and extensive assist required for activities of daily living. The resident was continent of bowel and bladder. Review of bowel and bladder assessment dated [DATE] revealed Resident #48 was continent of bowel and bladder. There was no tracking of the residents bowel activity. Review of an occupational therapy daily note dated 10/14/19 revealed Resident #48 was released to utilize rolling walker independently for ambulation since progress had been made. Review of Resident #48's October 2019 Medication Administration Record (MAR) revealed orders for Colace (bowel softener) 200 milligrams (mg) twice a day started 10/09/19, Lactulose 10 grams twice a day started on 09/21/19 and Mag Citrate (a laxative) given once on 10/04/19. The MAR revealed medications were administered daily that could cause frequent constipation to include iron tablets and narcotics. Interview on 10/16/19 at 8:39 A.M. with Resident #48 reported he had an occurrence of constipation and was given an as needed medication, Mag Citrate, which caused bowel incontinence. He stated he took routine medications to prevent the constipation now. Interview on 10/17/19 at 8:32 A.M. with Case Manager RN #900 verified bowel movement tracking had not been completed. She verified tracking had only been done on 09/21/19- watery stools twice and on 10/04/19 -soft blobs of stool. RN #900 stated bowel movements should be tracked daily for all residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of National Pressure Ulcer Advisory Panel (NPUAP) the facility failed to consistently monitor residents pressure ulcers. This affected one (Resident #35) of one resident reviewed for pressure ulcers. The facility census was 54. Findings include: Review of the medical record review revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included aftercare following surgery for neoplasm, malignant neoplasm of tongue, encounter for attention to tracheostomy, encounter for attention to other artificial openings of digestive tract, type two diabetes mellitus, long term use of insulin, long term use of anticoagulants, atrial fibrillation, hypertension, insomnia, acute and chronic respiratory failure, restlessness and agitation and pneumonia. Review of Resident #35's admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance with transfers, bed mobility, dressing, toileting and personal hygiene. Resident #35 also required total dependence with eating and had one stage three pressure ulcer. Further review of Resident #35's medical record revealed the resident had moisture associated skin damage and pressure area to the coccyx that developed on 09/14/19 prior to admission to the facility. Further review revealed the resident's moisture associated skin damage and pressure area to the coccyx was initially measured on 10/03/19 and was found to be a stage three that was red, clean and dry. The area was measured to be 1.5 centimeters (cm) by 0.5 cm by 0.4 cm. Review of Resident #35's physician order dated 10/01/19 revealed an order for 71 grams (g) of topical ointment to the wound as needed for wound care for the moisture associated skin damage and pressure area to the coccyx. Review of Resident #35's care plan dated 10/02/19 revealed the resident had a skin integrity care plan that indicated the facility would assess and monitor skin integrity. Further review of the medical record revealed no measurements of Resident #35's moisture associated skin damage or pressure area to the coccyx from 10/03/19 to 10/17/19. There also was no measurements when the the resident was admitted on [DATE]. Observation of Resident #35's wound on 10/17/19 at 2:00 P.M. with Registered Nurse (RN) #20 revealed Resident #35's moisture associated skin damage and pressure area to the coccyx was 1.5 cm by 0.4 cm. The area appeared to be dry with red flaking to the open area. RN #20 was observed to clean the area with normal saline and to apply topical ointment to the area. Interview with RN #20 on 10/17/19 at 2:11 P.M. verified Resident #35's moisture associated skin damage and pressure area to the coccyx was not measured from 10/03/19 to 10/17/19. Review of the facility's Wound Assessments and Documentation policy dated 08/01/06 revealed all alternation in skin integrity including pressure ulcers will be assessed within 24 hours of admission and weekly thereafter and upon any change in the condition of the wound. Review of the NPUAP clinical guidelines revealed treatment needs of a pressure ulcer change over time, in terms of both healing and deterioration, and that treatment strategies should be continuously re-evaluated based on the current status of the ulcer. Further review of the guidelines revealed that signs of deterioration such as an increase in wound dimensions, change in tissue quality, increase in wound exudate or other signs of clinical infection should be addressed immediately, and that nurses should assess and document physical characteristics of the wound including location, category/stage, size, tissue type(s), color, condition, wound edges, exudate, and odor on a consistent basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital discharge record review, and interview, the facility failed to ensure residents received the appropriate care and services to maintain suprapubic catheter. This affected one (#13) of 14 sampled residents. The facility identified seven residents at the facility with urinary catheters. The facility census was 54 residents. Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included anemia, cervical stenosis of spinal canal, hypertension, hypothyroidism, neurogenic bladder with suprapubic catheter insertion, obesity, quadriparesis, colostomy, seizure disorder, swollen ankles and feet, venous insufficiency, and tuberous sclerosis. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition. The resident was dependent on staff for bed mobility, dressing, toilet use, and personal hygiene tasks. The resident had catheter and ostomy placement. Review of the care plan dated 08/15/19, revealed the resident was at high risk for urinary tract infection (UTI) due to indwelling catheter. Interventions included using catheter type: indwelling size 20 French with 10 cubic centimeters (cc), size 5 cc balloon or 30 cc balloon could be filled with 10 cc, secure catheter to thigh, change catheter every two to three weeks per order, maintain drainage bag and tubing below level of urinary bladder, assess catheter for patency, if occluded, remove and replace, monitor for infection, maintain sterile technique with catheter changes, administer urinary medications as ordered (Ditropan), report abnormal lab values to physician, educate patient/family on signs and symptoms of urinary tract infection, provide catheter care, and followed by urology, order consults as appropriate. Review of the hospital discharge orders dated 08/15/19, revealed staff were to provide suprapubic catheter management per nursing standard. Monitor for urinary retention, urinary incontinence, and output daily. Suprapubic catheter was changed on 08/05/19 (prior to facility admission), exchange again in three weeks on 08/27/19. Further review of the discharge/admission orders revealed, they did not indicated the size of the catheter to be used including the balloon size. The orders also did not include how often and when catheter care should be conducted. There was no evidence in the record, the resident's suprapubic catheter had been changed on 08/27/19 as ordered. The only documented evidence the suprapubic catheter was changed, was on 09/21/19. In addition, during review of the flow sheets for the suprapubic catheter, it was revealed staff were to check off or initial when catheter care was administered. There was no documentation on the flow sheet from 10/01/19 through 10/16/19 that catheter care was provided. During interview with the resident on 10/15/19 at 11:24 A.M., she stated her suprapubic catheter was leaking ever since they changed it. She stated she thought they had used a different sized catheter. During an interview on 10/15/19 at 5:15 P.M., Licensed Practical Nurse (LPN) #66, said the resident had an appointment with the urologist in about two weeks due to leaking around the suprapubic catheter. She also stated due to the leaking, the resident was wearing an incontinence brief. During an interview on 10/16/19 at 4:03 P.M., Registered Nurse (RN) #106 confirmed there were no orders found from the physician upon discharge from the hospital for the care of the catheter including the size of the catheter to be used. There also were no orders for how often and when catheter care was to be administered, and how often the urinary drainage bag was to be changed. RN #106 confirmed there was no evidence the resident's suprapubic catheter was changed on 08/27/19 in accordance to physician orders and that there was no evidence catheter care had been administered between 10/01/19 through 10/16/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interviews the facility failed to assess the accuracy of resident weights, failed to track acceptance of physician order supplements, and failed to notify physician of a failed physician ordered calorie count. This affected two (#41, #48) four residents reviewed for nutrition. The facility identified 11 residents as having significant weight changes. Findings include: 1. Review of Resident #41's medical record revealed an admit date of 08/12/19. Diagnoses including infection of a wound, depression, renal cell cancer, migraines, hypertension, bipolar disorder, and end stage renal disease. An admission Minimum Date Set (MDS) assessment dated [DATE] indicated the resident was cognitively intact, had no rejections of care or behaviors, and required extensive assist of one for bed mobility, dressing, toileting, hygiene, and required set up for meals. Review of a care plan dated 08/30/19 revealed a problem of nutrition with interventions of monitoring meal acceptance and weight. Review of a nutrition progress note dated 10/11/19 indicated Resident #41 had a weight gain of 39 pounds in one month and had an order for Boost Breeze, a supplement, three times a day. Review of weight record revealed on 09/29/19 the resident weighed 160 pounds on 10/14/19 the resident weighed 201 pounds. Further review of the medical record revealed no evidence of monitoring the amount of Boost Breeze the resident was drinking. Interview on 10/15/19 at 8:47 A.M. with Resident #41 reported he had lost a huge amount of weight but was unable to give the amount lost, or any specifics of the weight. Interview on 10/17/19 at 9:58 A.M. with Dietician #901 verified Resident #41's medical record failed to demonstrate the amounts of supplement accepted. She stated nursing staff was asked for reweighs when a questionable weight was obtained but had no reweighs for the 39-pound discrepancy. 2. Review of Resident #48's medical record revealed an admit date [DATE]. Diagnoses included dehydration, acute kidney injury, complicated urinary tract infection, diabetes, urinary retention, peripheral arterial disease, and hyponatremia (low blood sodium). Review of MDS assessment dated [DATE] indicated the resident had impaired cognition, no behaviors demonstrated, and extensive assist required for activities of daily living except eating which required set up. Review of nutrition progress notes dated 09/21/19 indicated a consult was ordered to nutritional services, a therapeutic diet was provided, chocolate boost was ordered three times a day to increase calories and protein, meal set up was required, and dietary intake would be monitored daily. A subsequent note dated 10/01/19 indicated a calorie count ordered 09/27/19 was not completed and Gatorade red was to be provided twice a day. Review of weight record revealed on 09/29/19 the resident weighed 156 pounds and on 10/08/19 the resident weighed 145 pounds. Review of Resident #48's October 2019 Medication Administration Record (MAR) revealed no supplement acceptance after 10/08/19. Interview on 10/16/19 at 1:32 P.M. with Unit Manager Registered Nurse (RN) #16 verified Resident #48's medical record contained no documentation of nutritional supplement acceptance after 10/08/19. Interview on 10/17/19 at 9:47 A.M. with Dietician #901 verified physicians were not notified of the failed calorie count that was ordered on 09/27/19 and supplement acceptance was not documented since 10/08/19. The facility did not provide a policy for supplements or calorie counts after three requests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record interviews and interviews, the facility failed to ensure as needed (PRN) psychotropic medications were limited to 14 days. This affected two (#22 and #35) of five residents reviewed for unnecessary medications. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included aftercare following surgery for neoplasm, malignant neoplasm of tongue, encounter for attention to tracheostomy, encounter for attention to other artificial openings of digestive tract, type two diabetes mellitus, long term use of insulin, long term use of anticoagulants, atrial fibrillation, hypertension, insomnia, acute and chronic respiratory failure, restlessness and agitation and pneumonia. Review of the admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with transfers, bed mobility, dressing, toileting and personal hygiene. Resident #35 also required total dependence with eating. Review of physician orders dated 10/01/19 revealed Buspar 5 milligrams (mg) three times a day as needed for anxiety. Further review revealed there was no stop date until surveyor intervention on 10/17/19. Review of the medication administration record (MAR) for October, 2019 revealed the resident received the Buspar 5 mg three times a day as needed for anxiety on 10/02/19, 10/06/19, 10/09/19 and on 10/11/19. Interview with Registered Nurse (RN) #900 on 10/17/19 at 12:17 P.M. verified Resident #35's Buspar 5 mg three times a day as needed for anxiety ordered on 10/01/19 did not have a stop date. 2. Review of the medical record revealed Resident #22 was admitted on [DATE]. Diagnoses included spinal injury, colitis, thigh wound, anxiety, depression, and spasms of lower extremities. Review of the MDS dated [DATE] indicated intact cognition, no behaviors or rejections of care, and extensive assist of one for bed mobility, toileting, hygiene, and extensive assist of two for transfers. Review of physician orders dated 09/16/19 revealed Valium 5 mg nightly PRN for muscle spasms. Review of October 2019 MAR revealed the PRN Valium was administered nightly. Review of a care plan dated 10/10/19 did not address the PRN Valium usage or muscle spasms. Interview on 10/17/19 at 8:28 A.M. with Unit Manager RN #16 reported when Resident #22 was admitted she was on Valium twice daily and the facility pharmacy recommended it to be PRN nightly based on past usage. She verified the Valium order exceeded the allowable 14 day period for PRN psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, facility policy review, review of manufacturer's guidelines, and review of online clinical resources, the facility failed to properly store resident ophthalmic medications, topical medications, and injectable medications. This affected two (#19 and #270) of five residents observed for medication administration. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #19 was admitted on [DATE] with a diagnosis of diabetes. Review of the [DATE] physician orders revealed orders for artificial tears eye drops, Polysporin eye ointment, atropine eye drops, prednisone eye drops and Humalog insulin. Observation on [DATE] at 9:13 A.M. of the medication storage cabinet in Resident #19's room with Licensed Practical Nurse (LPN) #62 revealed the following open and undated ophthalmic medications: artificial tears eye drops, Polysporin eye ointment, atropine drops, and prednisone eye drops and two expired and opened bottles of Humalog insulin, one with an expiration date of [DATE] and another with an expiration date of [DATE]. Interview at the time of the observation with LPN #62 confirmed that the artificial tears, Polysporin ointment, atropine, and prednisone eye drops for Resident #19 had not been dated when opened. She indicated she could not be certain if or when they expired. LPN #62 also confirmed that opened vials of Humalog insulin were both expired. 2. Review of the medical record revealed Resident #270 was admitted on [DATE] with a diagnosis of diabetes. Review of physician orders for [DATE] revealed orders for Anusol rectal cream twice daily for hemorrhoids, Humalog insulin injectable for diabetes three times daily, and Timolol eye drops twice daily. Observation on [DATE] at 9:18 A.M. of the medication storage cabinet in Resident #270's room with LPN #62 revealed that Anusol hemorrhoid cream, Humalog insulin injectable, and Timolol eye drops were stored on the same shelf and the containers were touching one another. Further observation revealed that the vial of Humalog insulin and the bottle of Timolol eye drops were both opened but hadn't been dated when opened. Interview on at the time of the observation with LPN #62 confirmed that the the Anusol, Humalog insulin and Timolol eye drops should have been stored in separate compartments. LPN #62 also confirmed that the Humalog insulin and Timolol eye drops had not been dated when opened. Review of manufacturer's recommendations undated for Timolol eye drops revealed the bottle of medication could become contaminated with bacteria and could cause eye infections leading to serious eye damage or even loss of vision and that contamination should be avoided. Review of manufacturer's recommendations for Humalog insulin vials, revealed opened vials should be discarded after 28 days. Review of The International Pharmacopeia, Seventh Edition, dated 2017 revealed multidose ophthalmic drop preparations may be used for up to four weeks (28 days) after the container is initially opened. Review of facility policy titled Medication Storage Requirements dated [DATE] revealed medications that are expired should be removed from stock and should be destroyed, and that medications would be stored in accordance with applicable standards to promote resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement resident's behavior and nutritional care plans. The facility also failed to develop care plans to address resident's constipation needs, dialysis care, medical conditions and medications. This affected four (#22, #35, #41 and #48) of 14 residents reviewed for care planning. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #35 was admitted on [DATE]. Diagnoses included aftercare following surgery for neoplasm, malignant neoplasm of tongue, encounter for attention to tracheostomy, encounter for attention to other artificial openings of digestive tract, type two diabetes mellitus, long term use of insulin, long term use of anticoagulants, atrial fibrillation, hypertension, insomnia, acute and chronic respiratory failure, restlessness and agitation and pneumonia. Review of Resident #35's admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with transfers, bed mobility, dressing, toileting and personal hygiene. Resident #35 also required total dependence with eating. Review of Resident #35's care plan dated 10/02/19 revealed the resident was care planned to have daily weights to monitor his nutrition. Review of Resident #35's weights revealed on 10/01/19 the resident weighed 292 pounds (lbs) and on 10/17/19 the resident weighted 311 lbs. No additional weights were found in Resident #35's chart. Interview with Registered Dietician (RD) #901 on 10/17/19 at 10:19 A.M. verified Resident #35 was weighed on 10/01/19 and on 10/17/19. RD #901 verified Resident #35 did not receive daily weights as care planned. 2. Review of Resident #22's medical record revealed an admission date of 09/16/19. Diagnosis with diagnosis including spinal injury, colitis, thigh wound, anxiety, depression, and spasms of lower extremities. Review of the MDS assessment dated [DATE] indicated intact cognition, no behaviors or rejections of care, and extensive assist of one for bed mobility, toileting, hygiene, and extensive assist of two for transfers. Review of physician orders for October 2019 revealed an order dated 09/16/19 for Valium 5 milligrams (mg) nightly as needed (PRN) for muscle spasms. Review of October, 2019 Medication Administration Record (MAR) revealed administration of the PRN Valium nightly. Review of a care plan dated 10/10/19 failed to address Valium usage or muscle spasms. Interview on 10/17/19 at 8:28 A.M. with Registered Nurse (RN) #16 reported Resident #22 admitted with Valium twice daily PRN and the facility pharmacy had recommended nightly as needed based on past usage. She verified the Valium medication nor spasms were included in Resident #22's care plan. 3. Review of the medical record revealed Resident #41 was admitted on [DATE]. Diagnoses included infection of a wound, renal cell cancer, migraines, hypertension, bipolar disorder, and end stage renal disease. Review of an admission MDS assessment dated [DATE] indicated the resident was cognitively intact, had no rejections of care or behaviors, and required extensive assist of one for bed mobility, dressing, toileting, and hygiene. Review of a care plan dated 08/30/19 revealed a problem of hemodialysis treatment but failed to address location of dialysis provider or any specifics for time, contact information, or transportation. During an observation on 10/15/19 at 8:47 A.M. of Resident #41 a dressing was noted on his right chest. Interview at the time of observation, Resident #41 reported he received dialysis at the local hospital and that is why he had a dressing on his right chest. Interview on 10/17/19 at 8:32 A.M. with RN #900 verified the care plan did not address specifics for Resident #41's dialysis treatment. 4. Review of the medical record revealed Resident #48 was admitted on [DATE]. Diagnoses included dehydration, acute kidney injury, complicated urinary tract infection, diabetes, urinary retention, peripheral arterial disease, and hyponatremia (low blood sodium). Review of a MDS assessment dated [DATE] indicated the resident had impaired cognition, no behaviors demonstrated, and extensive assist required for activities of daily living. The MDS also indicated the resident was continent of bowel and bladder. Review of Resident #48's October 2019 MAR revealed orders for Colace (bowel softener) 200 milligrams (mg) twice a day started 10/09/19 and Lactulose 10 grams twice a day started on 09/21/19 and Mag Citrate (a laxative) given once on 10/04/19. The MAR revealed medications were administered daily that could cause frequent constipation- iron tablets and narcotics. Interview on 10/16/19 at 8:39 A.M. with Resident #48 reported he had an occurrence of constipation and was given an as needed medication, Mag Citrate, which caused bowel incontinence. He stated he took routine medications to prevent the constipation now. Interview on 10/17/19 at 8:33 A.M. with Case Manager RN #900 verified Resident #48's care plan was silent to bowel function and the use of medications to prevent constipation. The facility denied having a policy for care planning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and review of facility policy the facility failed to ensure hot water was maintained at a safe temperature on the second floor. The facility also failed to ensure a medication storage cabinet in the resident's room was locked. This affected four (#6, #29, #35 and #270) out of four residents reviewed for accidents and had the potential to affect five facility identified cognitively impaired and independently mobile residents (#206, #209, #262, #268, and #269) residing on the second floor. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE]. Diagnoses included aftercare following surgery for neoplasm, malignant neoplasm of tongue, encounter for attention to tracheostomy, encounter for attention to other artificial openings of digestive tract, type two diabetes mellitus, long term use of insulin, long term use of anticoagulants, atrial fibrillation, hypertension, insomnia, acute and chronic respiratory failure, restlessness and agitation and pneumonia. Review of the admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident had intact cognition and and required extensive assistance with transfers, bed mobility, dressing, toileting and personal hygiene. Resident #35 also required total dependence with eating. Observation on 10/15/19 at 12:12 P.M. revealed Maintenance #909 took the water temperature in Resident #35's room and the water temperature was 123.6 degrees Fahrenheit (F). Interview with Maintenance #909 at the time of the observation verified the water temperature in Resident #35's room was 123.6 degrees F. 2. Review of the medical record revealed Resident #29 was admitted on [DATE]. Diagnoses included cancer of the mouth, hypertension, dysphagia, acute blood loss anemia, type two diabetes mellitus and hypothyroidism. Review of Resident #29's admission MDS assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #29 was also independent with eating. 3. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE]. Diagnoses included fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with healing, other abnormalities of gait, need for assistance with personal care, personal history of healed traumatic fracture, anemia personal history of transient ischemic attach and cerebral infarction and moderate protein malnutrition. Review of Resident #6's change of therapy MDS assessment dated 08/0719 revealed the resident had severely impaired cognition nd required extensive assistance with bed mobility, eating, transfers, dressing, toileting and personal hygiene. Observation on 10/15/19 at 12:12 P.M. revealed Maintenance #909 took the water temperature in Resident #6 and Resident #29's room and the water temperature was 123.4 degrees Fahrenheit. Interview with Maintenance #909 at the time of the observation verified the water temperature in Resident #6 and Resident #29's room was 123.4 degrees F. Review of the facility's Water Distribution system policy dated 10/01/05 revealed the temperature of the domestic hot water system will be maintained at a constant water temperature to ensure safety and to prevent residents from coming in contact with scalding water. The policy also revealed water temperatures should be maintained between 105 and 110 degrees Fahrenheit at all times. 4. Review of the medical record revealed Resident #270 was admitted on [DATE] with a diagnosis of diabetes. Review of physician orders for October 2019 revealed orders for Anusol rectal cream twice daily for hemorrhoids, Humalog insulin injectable for diabetes three times daily, and Timolol eye drops twice daily. Observation on 10/17/19 at 9:18 A.M. of the medication storage cabinet in Resident #270's room with Licensed Practical Nurse (LPN) #62 revealed the medication storage cabinet was not locked and contained an open tube of Anusol rectal cream, an open vial of Humalog insulin, and an open bottle of Timolol eye drops. Interview at the time of the observation with LPN #62 confirmed the medication storage cabinet was not locked, that she was not certain who had unlocked the cabinet or how long it had been unlocked. LPN #62 further confirmed that medication storage cabinets were supposed to be locked for resident safety when not attended by staff. The facility identified Residents (#206, #209, #262, #268 and #269) as residing on the second floor and being cognitively impaired and independently mobile. Review of policy titled Medication Storage Requirements dated 11/17/17 revealed the facility would secure medications to promote resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews the facility failed ensure the risk and benefits of bed rails was reviewed with residents and their representatives and informed consent was obtained prior to the installation of bed rails. This affected four (#48, #207, #211 and #259) of four residents reviewed for bed rails. The facility census was 54. Findings include: 1. Review of the medical record revealed Resident #259 was admitted on [DATE]. Diagnoses included chronic respiratory failure, epilepsy, atherosclerotic heart disease, hypertension, tracheostomy status, congestive heart failure, anemia, cardiac pacemaker, encounter for attention to gastrostomy and personal history of traumatic brain injury. Review of the Minimum Data Sets (MDS) assessments revealed no assessment had been completed due to the resident being newly admitted on [DATE]. Review of the baseline care plan dated 10/15/19 revealed the resident was cognitively impaired and required assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Further review of the baseline care plan revealed Resident #259 was to have her call light in reach, her bed in low position, the wheels to her bed locked and the side rails up. Review of Resident #259's side rail assessment dated [DATE] revealed Resident #256 was assessed for right and left upper side rails for turning and positioning. Further review of the medical record revealed no documentation that the risk and benefits of bed rails was reviewed with Resident #259 or Resident #259's representative. The medical record did not contain any information regarding informed consent being obtained by the facility prior to the bed rails being installed. Observation of Resident #259 on 10/15/19 at 2:14 P.M. revealed the resident was lying in bed with her upper side rails in place. Observation of Resident #259 on 10/17/19 at 10:52 A.M. revealed the resident was lying in bed with her upper side rails in place. Interview with Registered Nurse (RN) #900 on 10/17/19 at 1:16 P.M. verified the facility did not obtain informed consent prior to the bed rails being installed on Resident #259's bed. RN #900 also confirmed there was no documentation that the risk and benefits of bed rails was reviewed with Resident #259 or Resident #259's representative. 2. Review of Resident #48's medical record revealed an admit date [DATE]. Diagnoses included dehydration, acute kidney injury, complicated urinary tract infection, diabetes, urinary retention, peripheral arterial disease, and hyponatremia (low blood sodium). Review of MDS assessment dated [DATE] indicated the resident had impaired cognition, no behaviors were demonstrated, and extensive assist was required for activities of daily living. The MDS indicated restraints were not used. Review of a side rail assessment dated [DATE] indicated a right upper and left upper side rail was used to assist resident to reposition self. Observation on 10/16/19 at 8:45 A.M. revealed Resident #48 was lying in bed with both upper side rails and left lower side rails in the upright position. Interview on 10/16/19 at 9:50 A.M. with RN #47 verified the left and right upper side rails were in place along with left lower side rail. RN #47 stated only the upper side rails should be in use. Interview on 10/17/19 at 1:16 P.M. with Case Manager RN #900 verified the side rail assessment indicated only two upper rails were to be used and there was no documentation of the side rail risk and benefits explanation or consent. 3. Review of Resident #207's medical record revealed an admit date of 10/10/19. Diagnosis included fracture of right ankle. An admission MDS dated [DATE] indicated the resident had intact cognition and extensive assist of one for bed mobility, dressing, hygiene, and toileting. The MDS indicated restraints were not used. Review of a side rail assessment dated [DATE] indicated right and left upper bed rails were to be used for resident to turn and reposition self. Observation on 10/16/19 at 9:41 A.M. and on 10/17/19 at 9:30 A.M. revealed Resident #207 lying in bed with four side rails in the up position, right and left upper and lower. Interview on 10/17/19 at 9:30 A.M. with State Tested Nurse Assistant (STNA) #36 stated four side rails were up but only three were to be used on all residents. She verified the right and left upper and lower side rails were in use. Interview on 10/17/19 at 1:16 P.M. with Case Manager RN #900 verified the side rail assessment indicated only two upper rails were to be used and there was no documentation of side rail risk and benefits explanation or consent. 4. Review of Resident #211's medical record revealed an admit date of 10/08/19. Diagnoses included quadriplegia and skin ulcer. An admission MDS dated [DATE] indicated the resident had intact cognition and extensive assist of two for bed mobility, transfers, toileting, dressing, hygiene, and eating. Observation on 10/15/19 at 11:20 A.M. and on 10/17/19 at 8:55 A.M. revealed Resident #211 lying in bed with four side rails in place, upper and lower left and right. Interview on 10/17/19 at 8:55 A.M. with STNA #35 verified four side rails were in use for Resident #211 so he did not roll off the bed during care. Interview on 10/17/19 at 9:00 A.M. with Unit Manager RN #16 verified four side rails were in use for Resident #211. She stated she was unfamiliar with the special beds and maybe the rails made the beds work. Interview on 10/17/19 at 1:16 P.M. with Case Manager RN #900 verified the side rail assessment indicated only two upper rails to be used and there was no documentation of side rail risk and benefits explanation or consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #21 revealed the resident was admitted on [DATE]. Diagnosis included chronic respiratory failure. Review of the MDS dated [DATE] revealed the resident had severely impaired cognition. the resident was totally dependent on the assistance of two staff with all activities of daily living. Review of October 2019 physician orders revealed orders for tracheostomy care every shift and an order for resident to be on contact precautions. Review of physician's progress note dated 10/12/19 revealed the resident had a history of Multi-Drug Resistant Organism (MDRO) infections. The resident was admitted to the hospital from [DATE] to 04/24/19 for pneumonia with pseudomonas, an MDRO infection. Resident # 21 was admitted to the facility on [DATE], with diagnoses including; hypertension, diabetic mellitus, irregular heart rhythm, anoxic brain damage, persistent vegetative state and multi drug resistant organism (MDRO). Review of the quarterly minimum data set (MDS) assessment, dated 09/12/19, identified the resident as being in a vegetative state and was totally dependant upon staff for all activities of daily living. Review of the October 2019 physician order set revealed he was to receive oxygen 28% per cool air tracheostomy mist. Observation on 10/15/19 at 10:10 A.M., revealed Resident #21 had a sign on the door to see the nurse before entering. There was isolation supplies outside of the room. Resident #21 was laying in bed with a cool air mist mask over his tracheostomy. There was blue corrugated tubing leading from the resident up to the oxygen flow meter on the medical panel behind the head of the bed. There was no date identified on the tubing as to when it was put in to place. Interview with Licensed Practical Nurse (LPN) #103 on 10/17/19 at 9:00 A.M. confirmed Resident #21 was on contact precautions due to history of MDRO infection. Observation of Resident #21's room on 10/17/19 at 10:01 A.M. revealed there was a cart outside the resident's room containing PPE. There was also red bags for infectious waste and signage on the door indicating to see the resident's nurse before entering the room. Observation of tracheostomy care on 10/17/19 at 10:05 A.M. per RT #550 revealed after care, the RT disposed of the visibly soiled tracheostomy dressing, inner cannula, and suction catheter in the resident's regular room trash and did not utilize a red bag for infectious waste. Interview on 10/17/19 at 10:10 A.M. with RT #550 confirmed that he was aware that Resident #21 was on contact precautions but he was unsure of the reason for this. RT #550 revealed that even though there were red bags available for disposal of infectious waste, he had disposed of the visibly soiled items (tracheostomy dressing, inner cannula, and suction catheter) in the resident's room trash following tracheostomy care. RT #550 revealed that staff do not date the corrugated tubing which supplies oxygen. RT #550 indicated the tubing is only changed as needed, for example if the tubing was visibly soiled. RT #550 confirmed Resident #21 was in isolation due to MDRO. RT #550 revealed since the resident was a long term resident he could utilize the same tubing for a long period of time. Review of facility policy for Contact Precautions dated 10/11/18 revealed items contaminated with body substances should be handled as infectious waste and placed in red bag, and that if a resident had an MDRO infection within the last 12 months that resident should be on contact precautions. Based on medical record review, observation, interviews and review of facility policy the facility failed to maintain acceptable infection control measures. The facility failed to ensure staff utilized personal protective equipment (PPE) when entering isolation rooms. The facility also failed to ensure staff washed their hands. The facility also failed to ensure staff maintain acceptable infection control practices with delivery of meal trays, disposing of infectious materials, wearing gloves and maintaining respiratory equipment. This directly affected five (#04, #11, #21, #25, and #41) residents during random facility observations. This had the potential to affect all residents of the facility. The census was 54. Findings include: 1. Review of Resident #11's medical record revealed the resident was admitted on [DATE]. Diagnoses included fractured lower leg, infection of open fracture, depression, falls, and hepatitis. Observation on 10/15/19 at 8:37 A.M. revealed Housekeeper #89 was in Resident #11's room mopping the floor, the only PPE she was wearing was gloves. A sign on the room door indicated to check with nurse before entering the room, a gown and gloves were required, and to wash hands on exit. Housekeeper #89 exited the room with the same gloves on and placed the mop on a cart before picking up a bottle of cleaning solution. Interview with Housekeeper #89 on 10/15/19 at 8:40 A.M. verified a gown and gloves were required to enter the room. Housekeeper #89 stated she did not have a gown on since the resident was not in his room. She also verified she exited the room with the mop with gloves on. 2. Review of Resident #41's medical record revealed the resident was admitted on [DATE]. Diagnoses included infection of a wound, renal cell cancer, migraines, hypertension, bipolar disorder, retro peritoneal abscess infection, and end stage renal disease. Observation on 10/15/19 at 8:54 A.M. of Resident #41's room revealed a sign on the room door that indicated to check with nurse before entering the room, a gown and gloves were required, and to wash hands on exit. Dietary staff #93 entered Resident #41's room without any PPE on and was calling the residents name. At this time the surveyor was interviewing the resident. Dietary staff #93 exited the room and reentered wearing a gown and gloves on. Dietary staff #93 sat the residents breakfast tray down on the over bed table within one inch of his urinal which contained urine. She adjusted his table three times before exiting the room, removing gown and gloves. She then applied alcohol sanitizer to her hands before reaching into the cart for another resident's tray. Interview on 10/15/19 at 8:57 A.M. with dietary staff #93 verified she only used alcohol sanitizer on her hands and the sign on Resident #41's door indicated hands must be washed after exiting the room. When asked why she placed his breakfast tray next to a urinal she stated she could not move his items as that was something the aides did. Review of facility policy titled Standard and Transmission-Based (Isolation) Precautions, dated 01/01/1998 and revised 11/01/18, revealed Contact precautions- use only soap and water for hand hygiene upon exit (no alcohol rub). 3. Observation on 10/15/19 at 10:48 A.M. revealed housekeeper #90 carried a full sharps container though the hall while wearing gloves. She entered a biohazard room, left the sharps container and exited the room wearing the same contaminated gloves. Housekeeper #90 went further down the hallway and removed a bag of garbage from a container next to a medication dispenser. Interview on 10/15/19 at 11:02 A.M. with housekeeper #90 verified she wore gloves to touch the sharps container and entered the biohazard room. She verified she exited the room with the same gloves and began to gather trash in the hallway. When asked why she was wearing gloves she stated to protect herself. 4. Review of Resident #25's medical record revealed the resident was admitted on [DATE]. Diagnosis included chronic kidney disease, chronic obstructive pulmonary disease, pneumonia, seizures, and tracheostomy. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had intact cognition. The resident had no refusals of care, and required extensive assist of one for transfers, dressing, toileting, bathing. Review of a care plan dated 09/20/19 revealed problems of respiratory infection related to lung disease and tracheostomy status. Interview on 10/15/19 at 11:23 A.M. with Resident #25 reported her oxygen tubing nor tracheotomy mist tubing had been changed since her admission. She was observed with oxygen cannula in use to her nose at three liters per minute and a humidifier on her bedside table with blue corrugated tubing attached to a trach mask. Interview on 10/16/19 at 11:01 A.M. with Respiratory Therapist (RT) #902 reported Resident #25 had not had any oxygen or mist tubing changes. RT #902 reported the humidification bottle was changed on 10/03/19 and 10/16/19. She reported RTs were not notified of any respiratory infections to change tubing. Interview on 10/16/19 at 2:45 P.M. with RT #901 denied any policy for tubing changes. Interview on 10/17/19 at 8:53 A.M. with Unit Manager Registered Nurse (RN) #16 reported oxygen tubing and mist tubing was only changed as needed. RN #16 further reported respiratory therapist did all tubing changes, and she was unable to give parameters of what would prompt changing the tubing. She revealed Resident #25 was treated with antibiotics in September 2019 for a lung infection and there was not a procedure in place to notify respiratory therapist of any respiratory infections. Review of facility policy titled Storage and Transportation of Oxygen, revised 02/2017 did not address changing of the tubings. 6. Review of the medical record for Resident #4 revealed the resident was admitted on [DATE]. Diagnoses included status post a motor vehicle accident, traumatic brain injury, seizure disorder, diabetes cellulitis and hydrocephalus. Review of the significant change MDS dated [DATE] identified the resident was totally dependant upon staff for all activities of daily living and was in a vegetative state. Review of the October, 2019 physician order set revealed the resident was to receive 21 % oxygen per a cool air tracheostomy mist. Observation on 10/15/19 at 10:20 A.M., revealed the resident was laying in bed with a cool air tracheostomy mist mask over his tracheostomy. The corrugated blue tubing extended from the resident up to the oxygen flow control on the medical panel behind the head of the bed. There was no date observed on the tubing as to when it was put into place. On 10/17/19 at 12:04 P.M., an interview was conducted with RT #550. He indicated that the corrugated oxygen tubing was only changed if it was visibly soiled even with residents who were on isolation. He indicated he learned this from other facilities and through a university however he was unable able to provide documentation to support not changing the corrugated tubing.