**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observation, and interview, the facility failed to ensure an insulin pen (in use) contained the open date and the expiration date in Medication Cart 1 on [NAME] Hall. The facility further failed to ensure an expired medication on Medication Cart 2, on the [NAME] Hall, was removed from and not stored on the cart with medications currently in use for residents, in 2 of 8 medication carts reviewed.Findings include: Review of the facility policy titled, Medication Storage in the Facility, states as the policy: Medications and biological's are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier.The Procedure: . 9. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if a current order exists . 11. Multi-dose vials, ophthalmics, otics, and other sterile products will be dated and initialled with the first puncture of the vial or opening. Multi-dose vials including insulin may be used after opening for 28 days unless the manufacturer has data to support longer dating. During an observation on [DATE] at 7:40 AM, of Medication Cart 1, on [NAME] Hall, revealed a Humalog Insulin Pen Lot #R2FJ826, with no open date, no expiration, and no use-by date. The findings were confirmed by Licensed Practical Nurse (LPN)1, and the insulin pen was removed from storage. During an observation on [DATE] at 11:41 AM, of Medication Cart 2, on [NAME] Hall, revealed one bottle of Nasal Allergy Spray, manufactured by [NAME], Lot #4FK1249 was expired on [DATE]. The nasal spray was confirmed as expired by LPN2 and removed from the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to prevent a pressure ulcer from developing. This practice affected one (1) of six (6) sampled residents (Resident (R)1). The findings include: Review of R1's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, dementia, hypertension and benign prostatic hyperplasia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/23 revealed a Brief Interview for Mental Status (BIMS) score was done and coded a two (2) out of 15, which indicated severe cognitive impairment. Additional review of the MDS revealed bed mobility was coded three (3), which indicated the resident required extensive assistance to move from a lying position, turn side to side, and positioning body while in bed, and required one (1) person for physical assistance. The MDS transfer was coded four (4) which indicated the resident required total dependence when moving between surfaces including to and from bed, chair, and standing position. Review of the Care Plan, dated 10/27/22, revealed: Care Plan Description - Resident is at risk for skin impairments related to poor safety awareness. Care Plan goal read: resident will be at reduce risk for skin impairments with staff monitoring and interventions through next review. Interventions include monitor skin with all care for new area/changes and report to licensed nurse and medical doctor as needed. Review of Care Plan dated 10/27/22 revealed, Care Plan Description - Resident is at risk for skin breakdown related to incontinence and impaired mobility. Care Plan goal read: Resident will be at reduced risk for skin breakdown with staff monitoring and interventions through next review. Interventions included to monitor skin for changes/new areas with all care, body audit per orders, turn and reposition every two (2) hours and as needed, and incontinent care per standards of care. Review of Care Plan dated 1/19/23 revealed, Care Plan Description - Resident has actual pressure area on left buttocks. Care Plan goal read: Pressure area will continue to heal/resolve with staff monitoring and interventions through next review. Interventions read: Turn and position every two (2) hours and as needed, body audit as ordered, treatment to pressure area as ordered, and precautions as ordered. Review of a Licensed Practical Nurse (LPN) note dated 1/14/23 at 3:13 p.m. revealed, Deep issue injury, possible stage two (2) pressure ulcer to left buttock measuring 3 x 2.7 cm (centimeter), open wound with small amount of serosanguineous drainage. Review of pressure ulcer report dated 1/16/23, completed by the Wound Care Nurse (WCN) read: 1cm x 1 cm suspected deep tissue injury to right inner buttock measuring 1 cm x 1 cm with peri wound denuded. Left buttocks noted with intact maceration. A deep tissue injury is considered a localized area of discoloration that resulted from pressure and /or shear. Maceration occurs when the skin is in contact with moisture for a long period of time. Denuded skin is loss of epidermis, caused by prolonged moisture or friction. Record review revealed the resident was transferred to Trident Medical Center on 2/11/23 via a call to 911 and ambulance transportation for respiratory difficulties. He was diagnosed with a Pulmonary Emboli. The resident returned to the facility on 2/21/23 and was placed on hospice care. An observation of R1 on 6/22/23 at approximately 9:30 AM revealed an open wound to the left buttock. Pressure ulcer documentation dated 6/14/23 revealed, Stage lV (4) left buttocks 7.8 cm X 6 cm, depth 2 cm. During an interview with the WCN on 6/22/23 at 12:10 PM, she confirmed that R1's wound was acquired in the facility and was identified on 1/14/23 (Saturday). When asked about the facility's policy on prevention of pressure ulcers and reporting changes in residents' skin condition, she stated there was no official policy, however, Certified Nurse Aides (CNAs) were supposed to report changes in a resident's skin condition, such as redness, to the licensed nurse. Changes should also be documented on the resident's bath sheets when changes are observed during bathing. When asked if documentation was noted on the bath sheets, she stated, I don't remember. In an interview with the Directory of Nursing (DON) on 6/23/23 at approximately 9:45 AM, she confirmed that there was not a specific policy for wound prevention. She stated the CNAs usually do a good job reporting changes in skin condition to the nurse. The surveyor was unable to view R1's bath record for the months of December 12/2022 or 1/2023. The facility destroys records after three (3) months.

Based on observations, interviews, and facility policy review, the facility failed to follow facility infection control protocol by not wearing designated personal protective equipment (PPE) when entering a resident's room to provide care for one (1) of six (6) residents (R (R)3). The findings include: Review of the facility policy titled, Novel or Targeted Multidrug Resistance Organisms to Prevent the Spread of Novel or Targeted Multidrug Resistant Organisms (MDROs) approved 10/2019, read Implement Enhanced Barrier Precautions [EBP] for all residents residing in the same neighborhood who have .feeding tube, or open wound. Wear gloves and a gown for the following high-contact resident care activities . changing linens, proving hygiene, changing briefs, or assisting with toileting. An email titled, New Centers for Disease Control (CDC) Guidance on Enhanced Barrier Precautions dated 7/19/22 at 2:47 p.m. read: . Enhanced Barrier precautions should be followed for any resident in the facility with . an open wound requiring dressing change. The enhanced barrier precautions require the use of gown and gloves during high-contact resident care activities . On 6/22/23 at approximately 11:30 a.m., on Unit C (Colony) in the presence of the Wound Care Nurse (WCN), the surveyor observed three (3) Certified Nurse Assistants (CNAs) (CNAs 1, 2 and 3) inside R3's room. The CNAs did not put on (don) gowns as stated in the Infection Control Policy. Instructions in the door signage attached to R3's door indicated gown and gloves must be worn for all high contact resident care activities. The WCN stated the staff was providing peri-care. Peri-care, also known as perineal care, involved washing the genital and rectal areas of the body. Staff were observed exiting R3's room with soiled linen and soiled incontinent items in clear plastic bags, which indicated that high contact resident care was performed. On 6/22/23 at approximately 11:40 a.m. on Unit C (Colony) during pressure ulcer wound dressing change, CNA2 assisted the WCN with dressing change and did not don a gown, as was indicated as a necessary component of wound care in facility's Infection Control protocol. On 6/22/23 at 12:10 p.m, the Infection Control Nurse (ICN) confirmed that staff who provided perineal care for residents on EBP should don gowns and gloves to prevent the spread of infection. The ICN stated the facility implemented the Infection Control policy on 7/19/22. On 6/22/23 at 3:10 p.m. the Staff Development Coordinator confirmed that staff should don PPE when providing perineal care on residents who are on EBP.

Based on record review and interviews, the facility failed to ensure a resident was notified of changes to the medication regimen for 1 Resident (R)60 of 7 sampled residents reviewed for notification of changes in condition/treatment. Findings included: The survey team requested the facility's policy regarding resident/responsible party (RP) notification of changes in condition/treatment on 10/07/22; no policy was provided by the end of the survey. Review of a Face Sheet revealed R60 had diagnoses which included anxiety, depression, and gastroesophageal reflux disease (GERD - acid reflux). Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/09/22, revealed R60 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS indicated the resident received antianxiety and antidepressant medications on seven days during the seven-day assessment period. Review of a Care Plan, dated 05/13/22, revealed R60 was at risk for adverse side effects related to psychotropic medication usage for diagnoses of anxiety, depression, and insomnia. Interventions included: - Monitor for any adverse side effects of medication, record, and report to the physician, as necessary. - Administer medication as ordered. Further review of the care plan dated 05/13/22 revealed the resident was at risk for gastrointestinal (GI) distress related to the diagnosis of GERD. Interventions included: - Monitor for signs and symptoms of GI distress such as abdominal discomfort, pain, bloating, nausea, vomiting, and heart burn. - Administer medication as ordered for diagnosis of GERD and monitor for adverse effects. - Encourage resident to remain in upright position at least 30 minutes after meals. During an interview on 10/10/22 at 1:25 PM, R60 stated the facility staff did not let them know when there were changes in the medication or treatment regimen. Review of Physician Orders for the month of: October 2022 revealed R60 had physician's orders for the following: - Omeprazole (an acid reducer) DR (delayed release) 20 milligrams (mg) take one capsule by mouth daily, ordered 09/16/22. - Fluoxetine (an antidepressant) 40 mg take one capsule by mouth daily along with 10 mg to equal 50 mg total, ordered 10/05/22. Review of Medication Administration Records (MARs) revealed R60 received omeprazole 40 mg daily beginning 05/09/22 and continuing until the dose was changed to 20 mg daily on 09/16/22. Review of the electronic health record (EHR) revealed no documentation to indicate R60 was notified of the 09/16/22 omeprazole dose reduction. Further review of the MARs revealed R60 received Fluoxetine 40 mg daily beginning on 07/21/22 and continuing until the dose was changed to 50 mg daily on 10/05/22. Review of the EHR revealed no documentation to indicate R60 was notified of the 10/05/22 Fluoxetine dose increase. There was no progress note from the physician to indicate why the dose was changed. During an interview on 10/13/22 at 8:56 AM, Licensed Practical Nurse (LPN)3 stated if a resident had a medication change, they were put on acute charting, which would trigger a prompt asking if notifications were made. She stated if she was not able to complete the necessary notification on her shift, it would be passed on to the next shift to complete. She indicated the notification should be documented in the progress notes. During an interview on 10/13/22 at 9:16 AM, Unit Manager (UM)1 stated if a resident had a medication change, the family and the resident should be notified by the nurse who received the order, and the notification should be documented. She stated she was not sure if R60 was notified of the medication changes. During an interview on 10/13/22 at 11:43 AM, the Director of Nursing (DON) stated medication changes should be discussed with the resident by the nurse who took the order, and the notification should be documented in a nurse's note. The Administrator was unavailable for an interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observations, and interviews, the facility failed to promptly assist residents with activities of daily living (ADLs) for 2 Residents (R)79 and R112 of 4 dependent residents reviewed for ADLs. Specifically, the facility failed to provide timely incontinent care and repositioning for R79 and R112. Findings included: Review of a facility policy titled, Perineal Care, dated 10/10/2014, revealed, Peri-care [sic] usually considered a basic standard of care performed with bathing and after each incontinence. 1. Review of a Face Sheet revealed R79 had diagnoses which included dementia, muscle weakness, unsteadiness on feet, lack of coordination, and stiffness of the right knee, left knee, right hand, and right shoulder. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/23/22, revealed R79 was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status. The MDS indicated the resident was totally dependent on one to two people for all activities of daily living (ADLs). According to the MDS, the resident was always incontinent of bowel and bladder. Review of a Care Plan, dated 02/11/2019, revealed R79 required various levels of assistance with ADLs related to weakness and cognitive deficits. Interventions included that the resident had incontinences episodes and was to be provided with incontinence care per standard of care. Continuous observations on 10/12/22 from 9:30 AM until 12:27 PM revealed the following: - At 9:30 AM, R79 was sitting in a Broda (reclining wheelchair) chair in their room with their feet touching the floor. The resident was wearing a clothing protector. The resident was leaning forward and had their chin resting on their chest. - At 9:53 AM, an unidentified staff walked into the room and told R79 to lean back, then assisted the resident to recline the back of the Broda chair slightly. - At 10:27 AM, Licensed Practical Nurse (LPN)3 and another nurse who was being trained by LPN3 entered the room to administer R79's medications. - At 11:07 AM, R79 was leaning over in the chair. No staff had entered the room to check R79 for incontinence. The only repositioning that had been provided was when the unidentified staff member slightly reclined the back of the chair at 9:53 AM. - At 11:30 AM, an Activity Staff walked into the room and read to R79 for approximately eight minutes. The resident was unable to keep their head up but would look up briefly and then put their head back down. - At 12:03 PM, Certified Nursing Assistant (CNA)11 entered the room and asked R79 if they were okay and spoke to the resident for a moment. The CNA was in the room for less than a minute. - At 12:27 PM, an unidentified staff member delivered a lunch tray to R79 and sat down to feed the resident after pulling the privacy curtain. The resident had not been toileted or checked for incontinence since observations began almost three hours earlier. During an interview on 10/12/22 at 12:24 PM, CNA12 stated residents should be checked, changed, and repositioned every two hours, or more often if needed. She stated she was not assigned to care for R79. During an interview on 10/12/22 at 2:09 PM, CNA9 stated she was assigned to care for R79. She stated the resident should be checked, changed, and repositioned every two hours, or more often if needed. She stated R79 was toileted after breakfast and after lunch, because CNA9 was busying helping the other CNAs with other residents. During an interview on 10/13/22 at 8:56 AM, LPN3 stated incontinence care and repositioning should be done every two hours, which was standard, or sooner depending on whether the resident was a heavy wetter (indicating they urinated frequently or in large volumes). She stated R79 was total care and should be provided care at least every two hours. LPN3 stated she was not aware the resident did not receive incontinence care timely the previous day because she was focused on training the new nurse. During an interview on 10/13/22 at 9:08 AM, CNA13 stated residents should be toileted and repositioned every two hours or as needed (PRN). She stated R79 required total assistance and should be repositioned every two hours. She stated R79 would refuse at times and want to be on a certain side, but it should be documented if the resident refused. During an interview on 10/13/22 at 9:13 AM, CNA14 stated residents should be checked for incontinence, changed if needed, and repositioned every two hours. During an interview on 10/13/22 at 9:16 AM, Unit Manager (UM)1 stated dependent residents should be checked and changed every two hours and as needed. During an interview on 10/13/22 at 11:43 AM, the Director of Nursing stated the standard for providing ADL care, including toileting and repositioning, was every two hours. She stated R79 required total care and should be provided ADL care every two hours. The Administrator was unavailable for an interview. 2. Review of a Face Sheet revealed R112 had diagnoses which included multiple sclerosis (a disease that affects the central nervous system and causes communication problems between the brain and the rest of the body), dementia, stiffness of bilateral knees and hips, contractures of muscles, and muscle spasms. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R112 scored 5 on a Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The MDS indicated the resident was totally dependent on one to two people for all ADLs and was always incontinent of bowel and bladder. Review of a Care Plan, dated 04/06/22, revealed the resident required various levels of assistance with ADLs related to a diagnosis of multiple sclerosis. Interventions included that the resident was incontinent of bowel and bladder and was to be provided with incontinence care per standard of care and as needed. Continuous observations on 10/12/22 from 9:30 AM until 12:27 PM revealed the following: - At 9:30 AM, R112 was lying in bed; the resident's hair was uncombed, and the resident had not been shaved. The resident was lying on their back, tilted slightly to the right with a hospital gown on. - At 9:53 AM, an unidentified staff walked into the room and spoke to R112's roommate but did not address R112. - At 10:27 AM, LPN3 and another nurse who was being trained by LPN3 entered the room to administer medications to R112's roommate. They did not address R112. - At 11:07 AM, no staff had entered the room to check R112 for incontinence care or repositioning. - At 11:30 AM, an Activity Staff walked into the room and read to R112's roommate for approximately eight minutes. The staff did not address R112. - At 12:03 PM, Certified Nursing Assistant (CNA)11 entered the room and spoke with R112's roommate but did not address R112. - At 12:38 PM, CNA11 delivered a lunch tray to R112. The CNA set the tray down and walked out of the room. CNA11 returned at 12:41 PM with a clothing protector and sat down to feed R112. The resident had not been repositioned or checked for incontinence since continuous observations began over three hours earlier. During an interview on 10/12/22 at 12:24 PM, CNA12 stated residents should be checked, changed, and repositioned every two hours, or more often if needed. She stated she was not assigned to care for R112. During an interview on 10/12/22 at 2:09 PM, CNA9 stated she was assigned to care for R112. She stated the resident should be checked, changed, and repositioned every two hours, or more often if needed. She stated R112 was toileted after breakfast and after lunch, because CNA9 was busying helping the other CNAs with other residents. During an interview on 10/13/22 at 8:56 AM, LPN3 stated incontinence care and repositioning should be done every two hours, which was standard, or sooner, depending on whether the resident was a heavy wetter (indicating they urinated frequently or in large volumes). She stated R112 required total care and should be provided care at least every two hours. LPN3 stated she was not aware the resident did not receive incontinence care timely the previous day because she was focused on training the new nurse. During an interview on 10/13/22 at 9:08 AM, CNA13 stated residents should be toileted and repositioned every two hours or as needed (PRN). She stated R112 required total assistance and should be repositioned every two hours. During an interview on 10/13/22 at 9:13 AM, CNA14 stated residents should be checked for incontinence and changed if needed and repositioned every two hours. During an interview on 10/13/22 at 9:16 AM, Unit Manager (UM)1 stated dependent residents should be checked and changed every two hours and as needed. During an interview on 10/13/22 at 11:43 AM, the Director of Nursing stated the standard for providing ADL care, including toileting and repositioning, was every two hours. She stated R112 required total care and should be provided ADL care every two hours. The Administrator was unavailable for an interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of a facility policy titled, Tube Flush - Continuous Feeding, dated 05/10/18, revealed, 5. After checking for placement, instill/flush by gravity with amount of water as ordered by the physician to assure patency. Key Points - Head of bed elevated at all times. The policy did not specify to what degree the head of bed should be elevated during tube feedings. Review of ASPEN Safe Practices for Enteral Nutrition Therapy, Journal of Parenteral and Enteral Nutrition, Volume 41, Number 1, dated January 2017, Page 62, revealed a practice recommendation to prevent enteral nutrition-related pulmonary aspiration was to, Keep the HOB [head of bed] elevated at 30° [degrees] to 45° at all times during the administration of gastric enteral feedings. Review of a Diagnosis/History revealed R52 had diagnoses which included gastrostomy tube, Huntington's disease (a condition that leads to progressive degeneration of nerve cells in the brain, which affects movement, cognitive functions, and emotions), feeding difficulties, dysphagia (difficulty swallowing), muscle spasms, and convulsions. Review of a quarterly MDS, dated [DATE], revealed R52 was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status. The MDS indicated the resident was totally dependent on the assistance of one person for eating. According to the MDS, the resident had a feeding tube, through which the resident received 51% or more of the total daily caloric intake. Review of Physician Orders, revealed R52 had a physician's order dated 10/13/21 to receive nothing by mouth (NPO). Additionally, a physician's order dated 01/31/22 revealed the resident was to receive Jevity 1.5 via percutaneous endoscopic gastrostomy (PEG) tube at 45 milliliters per hour (mL/hr) continuously via feeding pump. The orders did not address the need to elevate the head of the bed during feedings. Review of a Care Plan, dated 06/29/21, revealed R52 was at risk for aspiration, dehydration, and fluid overload related to dependence on tube feedings related to dysphagia. Interventions included: - Monitor for signs and symptoms of aspiration such as coughing, cyanosis, and shortness of breath and notify the physician - Wedge under mattress as ordered. - Monitor for signs and symptoms of dehydration or fluid overload and notify the physician. The care plan did not instruct staff on the appropriate elevation of the head of the bed (HOB) during tube feedings. Review of the Physician's Assistant's (PA's) provider notes revealed on 07/07/22, the resident had a choking episode and cough. Review of Physician's notes revealed the following: - On 04/03/22, there were no wheezes, no rhonchi, and no crackles in the resident's lungs; however, the resident, obviously is high risk for aspiration and aspiration pneumonia due to the existing G-tube [gastrostomy tube]. - On 05/08/22, the resident's lungs were clear; however, the resident, obviously is high risk for aspiration and aspiration pneumonia due to the existing G-tube. - On 09/04/22, the resident had diminished breath sounds in both lung bases and, obviously is high risk for aspiration and aspiration pneumonia due to the existing G-tube. Observation on 10/10/22 at 10:40 AM revealed R52 in bed asleep, with an enteral feeding being administered via pump. The head of the bed (HOB) was elevated approximately 20 degrees. During an observation of medication administration by LPN1 on 10/11/22 at 8:32 AM, LPN1 lowered the HOB, so R52's legs/feet were higher than the resident's head. The LPN administered medications through the resident's G-tube with the resident in this position. During an interview on 10/12/22 at 2:06 PM, Certified Nursing Assistant (CNA)7 stated for a resident receiving a G-tube feeding, the HOB should be elevated to about 90 degrees or as close to it as possible. The CNA stated the goal was to prevent aspiration. During an interview on 10/12/22 at 2:12 PM, CNA2 stated a resident receiving a G-tube feeding had to be turned every two hours and staff should keep the head of the bed elevated to keep the resident from aspirating. The CNA did not define how high the bed should be elevated. During an interview on 10/12/22 at 2:19 PM, CNA4 stated she was trained to turn residents with a G-tube feeding from side to side every two hours and to keep a cushion under the mattress with the head of bed elevated at 90 degrees almost so the resident would not choke on the formula. During an interview on 10/12/22 at 2:21 PM, CNA5 stated she was trained to not block the tube, make sure not to kink it, to keep an eye on the G-tube site, and to keep the residents more upright so they would not throw up when they were getting a tube feeding. During an interview on 10/12/22 at 2:22 PM, CNA6 stated she was supposed to turn a resident with a G-tube every two hours side to side and use pillows to help keep the resident in position, like using a wedge under the resident's back. She stated she was taught to keep the resident's HOB upright because the resident could throw up and choke and suffocate. During an interview on 10/12/22 at 2:22 PM, LPN2 stated that for a tube-fed resident, the HOB should be elevated between 45 and 90 degrees to prevent choking and aspiration. During an interview on 10/12/22 at 2:27 PM, LPN1 stated the HOB for a resident receiving tube feedings should be elevated 30 to 45 degrees, including during medication administration. She stated she should have kept R52's HOB higher during med pass, and that the resident's feet should not have been above the level of the resident's head. She stated she monitored the CNAs and reminded them to keep the HOB elevated because the resident could not do it alone and tended to slump over. During an interview on 10/12/22 at 2:51 PM, Unit Manager (UM)1 stated the resident should have the HOB elevated 30 to 45 degrees to prevent aspiration. For medication administration, the nurse should have raised the HOB. UM1 stated she expected the nurses on the floor to monitor the CNAs by doing rounds and observe during medication pass if the residents were being repositioned. She stated all staff on the unit should round every two hours. During an interview on 10/12/22 at 3:06 PM, the Director of Nursing (DON) stated she thought the HOB should be at least 30 degrees for a tube-fed resident. She stated it was how she was taught, and it was a nursing standard of practice. The HOB should be elevated because that prevented the resident from aspirating. The DON stated the resident's bed had a wedge under the mattress so the mattress could not go completely flat. For medication administration, the HOB should be elevated to 30 degrees, and the resident's feet should not be higher than the head. The DON stated she expected the nurses to check for positioning during med pass, morning rounds, and periodic rounds during the shift, and at least every couple of hours. During an observation and interview with the DON in R52's room on 10/12/22 at 3:22 PM, there was a wedge on the bed, which the DON stated was to prevent the resident from ever lying flat. The DON agreed the wedge would not elevate the HOB to 30 degrees. During an observation on 10/13/22 at 9:49 AM, the head of R52's bed was elevated approximately 45 degrees; however, the resident had slid down in the bed to the point their head was not elevated. During an interview on 10/13/22 at 10:24 AM, the Speech Language Pathologist (SLP) stated that for a resident with a tube feeding (TF), aspiration precautions should include the HOB elevated at least at 30 degrees and a bed wedge should be placed so the resident did not lie completely flat. The SLP stated the bed wedge alone absolutely does not prevent aspiration. The SLP indicated the goal for the wedge was to prevent a new staff person or agency staff from allowing the resident to lie flat. The SLP stated other interventions to prevent aspiration might be for staff to monitor the resident more frequently because the resident did have body movements from the Huntington's and to include Occupational Therapy for positioning ideas. She stated tube fed residents got food directly into the abdomen, so reflux could happen, but those interventions could help prevent aspiration. Based on observations, interviews, record review, and facility policy review, the facility failed to ensure enteral feedings (tube feedings) were administered in accordance with physician's orders and accepted standards of nursing practice for 2 (R52 and R77) of 4 sampled residents reviewed for enteral feedings. Specifically, the facility: - failed to ensure a feeding was administered continuously for 20 hours as ordered by the physician to maintain adequate nutrition for R77. - failed to ensure the head of the bed was elevated during an enteral feeding to prevent potential aspiration for R52. Findings included: 1. Review of a facility policy, Tube Flush - Continuous Feeding, dated 05/10/2018, did not indicate how nursing staff were to ensure the physician's enteral feeding orders were correctly implemented. Review of a Face Sheet revealed R77 had diagnoses including dysphagia (difficulty swallowing), protein-calorie malnutrition, multiple sclerosis (a disease of the central nervous system that causes communication problems between the brain and the rest of the body), and chronic pain syndrome. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed R77 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS indicated the resident was totally dependent on the assistance of one person for eating. According to the MDS, the resident received greater than 50% of nutrition via feeding tube while a resident at the facility and had not experienced weight loss of greater than 5% in the past month or 10% in the past six months. Review of Physician Orders revealed R77 had a physician's order dated 05/09/22 for Jevity 1.5 to be administered at 55 milliliters (ml) per hour (mL/hr) via percutaneous endoscopic gastrostomy (PEG) tube over 20 hours daily from 4:00 PM to 12:00 PM (noon). Review of the medical record revealed R77 had no significant weight loss over the past six months. On 10/10/22 at 10:19 AM, an observation was made of R77 lying in bed with their eyes closed. A tube feeding pump was observed beside the bed. The pump was disconnected and there was no tubing or tube feeding present. On 10/10/22 at 12:30 PM, an observation was made of R77 lying in bed. The tube feeding pump was observed to be in the same position as the previous observation, disconnected, with no tubing or tube feeding present. On 10/10/22 at 4:00 PM, an observation was made of R77 lying in bed. The tube feeding pump remained disconnected beside the resident's bed, and there was no tubing or tube feeding present. The surveyor observed the door to the resident's room continuously from 4:00 PM to 4:30 PM, and no staff entered the room to initiate a tube feeding for R77. Review of the October 22 Medication Administration Record (MAR) revealed on 10/10/22, a check mark and a nurse's initials were documented, indicating the tube feeding was stopped at 12:00 PM and started at 4:00 PM as ordered, although the surveyor's observations revealed otherwise. On 10/11/22 at 7:35 AM, an observation was made of R77 lying in bed. A tube feeding of Jevity 1.5 was infusing at 55 mL/hr via a feeding pump connected to the resident's PEG tube. Approximately 350 mL remained in the bottle of Jevity. The label on the Jevity bottle did not include the initials of the nurse who started the feeding, nor the date/time the feeding was initiated. During an interview on 10/11/22 at 3:05 PM, Licensed Practical Nurse (LPN)2 stated when administering tube feedings, she referred to the order and administered the feedings per the order. LPN2 indicated R52 received tube feedings until 12:00 PM each day, but it was usually done by 11:00 AM. She was unable to state why the tube feeding ended at 11:00 AM and believed it was the way the pump was set. She stated the pump cut off even when there was tube feeding remaining to be delivered. LPN2 stated the order was written for continuous feeding to be delivered for 20 hours, and the feedings were started at 4:00 PM daily. She stated her process was to gather supplies and get everything ready at 3:30 PM so the feeding could be started at 4:00 PM. LPN2 stated she was the nurse who had hung the tube feeding at 4:00 PM on 10/10/22, but there was a lot going on so she could not be sure of what time it was hung. LPN2 stated if the tube feeding ended early (before 12:00 PM) and was started late (after 4:00 PM), the resident was not receiving the tube feeding as ordered by the physician. During an interview on 10/11/22 at 3:32 PM, the Registered Dietitian (RD) stated she made the recommendations for tube feedings based on the nutritional needs of the resident. The RD stated her expectation was for the resident to receive the feedings as scheduled, and if not administered as ordered, there was a risk for the resident not to receive the needed nutrition, which could lead to weight loss. The RD further stated R77 should be getting the full 20 hours of tube feeding due to the resident's past nutritional decline. During an interview on 10/13/22 at 8:35 AM, LPN6 stated that when administering tube feedings, the nurse must follow the orders, and when the tube feeding was completed, check the pump and ensure the right amount was administered per the order. LPN6 further stated she would do the math to make sure the amount given on the machine matched the order. During an interview on 10/13/22 at 10:10 AM, the Director of Nursing agreed R77 did not receive the tube feeding as ordered on 10/10/22, and it was her expectation that the nurses follow the physician orders and administer tube feedings as ordered. The Administrator was not available for interview.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to ensure proper infection control practices for 1 (R38) of 2 sampled residents reviewed for respiratory therapy. Specifically, the facility failed to clean and store R38's nebulizer equipment after each use to prevent potential respiratory infections. Findings include: Review of a facility policy titled, Handheld Nebulizer Machine, dated 09/30/2019, revealed, Care and Maintenance Guidelines: 1. Mask may be cleaned with a moist towelette as needed, or per manufacturer's guidelines. 2. Tubing and mask to be changed weekly, or per manufacturer's guidelines. Review of a Face Sheet revealed R38 had diagnoses which included acute respiratory failure with hypoxia (low oxygen level in the blood) and pneumonia. Review of a significant change Minimum Data Set (MDS), dated [DATE], revealed R38 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfer. Review of a care plan, dated 09/26/22, revealed R38 was at risk for respiratory distress secondary to a history of chronic obstructive pulmonary disease (COPD). Interventions included: - Monitor for signs and symptoms of respiratory distress such as wheezing, shortness of breath (SOB), and cyanosis (bluish skin color due to decreased oxygen) and notify the physician. - Monitor vital signs per standards of care and notify the physician of abnormal readings. - Administer medications as ordered for SOB/wheezing and observe for adverse effects/effectiveness. - Head of bed (HOB) elevated related to SOB if lying flat; the care plan indicated the resident could adjust the height of the HOB independently. Review of October 22 Physician Orders revealed R38 had physician's orders dated 09/26/22 for ipratropium bromide/albuterol sulfate (DuoNeb) 2.5 milligrams (mg) per 3 milliliter solution -give contents of one vial via handheld nebulizer (HHN) every six hours as needed (PRN) for SOB/wheezing. Change HHN and tubing every seven days and PRN, ordered 09/26/22. Review of the October 22 Medication Administration Record (MAR) revealed R38 received the DuoNeb nebulizer treatments on 10/03/22 at 9:54 PM and 10/04/22 at 7:24 AM. Observations on 10/10/22 at 10:45 AM revealed a nebulizer machine on the nightstand in R38's room, with the tubing and cannister still connected. The cannister and mouthpiece were lying on top of a dirty shirt that was on top of packaged nebulizer equipment. The tubing and cannister were not dated. Observations on 10/11/22 at 9:42 AM revealed the nebulizer tubing was attached to the machine with the cannister and mouthpiece lying on top of packages of nebulizer equipment. Observations on 10/12/22 at 9:30 AM revealed the nebulizer machine in R38's room was on the nightstand, with the canister and tubing connected to the machine lying on top of packaged nebulizer equipment. There was dried brown debris on the mouthpiece. R38 stated they used the machine occasionally and had to use it the previous day after dialysis. The resident stated the staff took care of the machine and equipment and the resident did not know what was supposed to be done to take care of it. Observations on 10/13/22 at 8:40 AM revealed R38's nebulizer equipment was in the same position with brown debris on the mouthpiece. During an interview on 10/13/22 at 8:56 AM, Licensed Practical Nurse (LPN)3 stated after the resident completed a nebulizer treatment, the mouthpiece or mask should be wiped off and stored in a bag. She stated she was not aware R38 was using a nebulizer machine. During an interview on 10/13/22 at 9:16 AM, Unit Manager (UM)1 stated that after a resident completed a nebulizer treatment, the resident should rinse their mouth to prevent thrush, and the equipment, including the mouthpiece and tubing, should be cleaned and placed in a bag. She stated it was the nurse's responsibility to change the equipment. During an interview on 10/13/22 at 11:43 AM, the Director of Nursing (DON) stated the nebulizer equipment should be bagged when not in use. She stated she was not sure about rinsing it out but stated the mouthpiece and tubing should be changed weekly. The Administrator was unavailable for interview.