**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to revise care plans for 2 of 24 (Resident #16, and #91) sampled residents reviewed for care planning. The findings include: 1. Review of the facility's policy titled .Clinical Comprehensive Care Plan Policy, dated 3/1/16 (2016), revealed .information gathered from the Minimum Data Set [MDS], family and Resident interview/assessments to develop, review and revise the Resident's Comprehensive Plan of Care. The Comprehensive Plan of Care will be individualized and include measurable objectives and timetables to meet the Resident's medical, nursing, mental and psychological needs .develops and maintains a comprehensive plan of care for each Resident that identifies the Resident's unique problems/weaknesses, strengths, preferences, goals and interventions for Resident's to attain the highest level of functioning . 2. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses of Atrial Fibrillation, Respiratory Failure, Pneumonia, and Post-Traumatic Stress Syndrome. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated he had moderate cognitive impairment and was coded for oxygen. Review of the Physician's order dated 10/3/2023 revealed .O2 [oxygen] at 2L [Liters] via NC [nasal cannula] to keep sats [saturation] =/> [equal to or greater than] than 92% [percentage] May titrate up to 5L . Review of the Care Plan dated 10/10/2023 revealed Resident #16 did not have a care plan to address the oxygen. Observations in the Resident's room on 10/16/2023 at 9:31 AM, and 10/18/2023 at 3:18 PM, revealed Resident #16 had oxygen binasal cannula (medical device to provide supplemental oxygen therapy) in place. 3. Review of medical record revealed Resident # 91 was admitted to the facility on [DATE], with diagnoses of Dementia, Post-Traumatic Stress Disorder, Depression, Diabetes, and Psychosis. Review of the quarterly MDS dated [DATE], revealed Resident #91 had a BIMS score of 14, which indicated he was cognitively intact. Review of the Physician's Orders dated 6/19/2023, revealed .Apixaban [used to treat and prevent blood clots] Oral Tablet 5 MG [milligrams] .Give 1 tablet by mouth two times a day . Review of the Care Plan with a revision date of 8/7/2023, revealed Resident #91 did not have a care plan to address the anticoagulant medication. During an interview on 10/19/23 at 11:44 AM, the Director of Nursing (DON) was asked should oxygen be on Resident #16's care plan. The DON stated Yes. The DON was asked should anticoagulant medications be on Resident #91's care plan. The DON stated, Yes ma'am.

Based on policy review, observation, and interview, the facility failed to ensure proper infection control practices when 1 of 14 staff members (Certified Nursing Assistants (CNA) #7) handled the residents food with bare hands, when 1 of 14 staff members (CNA #2) placed a dirty tray back on the tray cart with clean trays, and when 1 of 14 staff members (CNA #5) failed to perform hand hygiene during dining observation. The findings include: 1. Review of the facility's policy titled .Handwashing/Hand Hygiene, dated 4/4/2018 revealed .Hand washing/hand hygiene is regarded by this organization as the single most important means of preventing the spread of infections. Most germs that cause serious infections in healthcare are spread by people's actions. Hand hygiene is a great way to prevent infections .All personnel shall follow the organization's handwashing/hand hygiene procedures to prevent the spread of infection and disease to other personnel, residents and visitors .After handling items potentially contaminated .Before and after handling food .Before and after direct resident contact .Before and after assisting a resident with meals .After handling soiled or used linens . 2. Observation in a resident's room on 10/16/2023 at 11:57 AM, revealed CNA #7 opened a wrapped sandwich, removed the sandwich from the wrapper and placed the sandwich on the tray with their bare hands. Observation on 10/16/2023 at 12:14 PM, revealed CNA #2 removed a dirty meal tray from a resident's room and placed it back on the cart with 3 clean unserved meal trays. During an interview on 10/16/2023 at 12:15 PM, CNA #2 was asked should she have placed a dirty tray back on the clean dining cart. CNA #2 stated, No .I didn't know what to do .he refused the rest of it . 3. Observation in a resident's room on 10/18/2023 at 5:15 PM, revealed CNA #5 picked up a pillow from the floor, placed it on the resident's bed, opened drawers looking for an item, and touched the privacy curtain. CNA #5 failed to wash her hands and preceded to open the straw, placed the opened straw in a glass, and then laid the opened straw on the meal tray. CNA #5 poured water into the glass, picked up the opened straw and gave the resident a drink. CNA #5 failed to perform hand hygiene after handling contaminated items in the environment before assisting with the tray setup. During an interview on 10/19/2023 at 12:17 PM, the Director of Nursing (DON) was asked should staff handled items in environment and then setup the meal trays without performing hand hygiene. The DON stated, .No, they should perform hand hygiene . The DON was asked should a tray that has been carried into a resident's room be brought back out and placed back on the clean dining cart with clean trays. The DON stated, .No, the tray should not be placed back on the clean dining cart with clean trays . The DON was asked should the staff member handle the resident's food with their bare hands. The DON stated, .No, they should not .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 6 sampled residents (Resident #85) for self-administration of medications. The findings include: Review of the facility's policy titled, Self-Administration of Drugs, dated 2/20/2003, revealed .Residents who wish to self-administer medications will be evaluated by the attending Physician and the Interdisciplinary Team (IDT) for safety .Document the assessment findings in the residents medical record .Residents who are deemed safe to self-administer medications will be provided with a locked box to keep medications secure . Review of the medical record, revealed Resident #85 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Congestive Heart Failure, Hypertension, and Oxygen Dependence. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #85 had a Brief Interview for Mental Status (BIMS) of 14, which indicated he was cognitively intact. Observation in the resident's room on 11/16/2021 at 8:38 AM, revealed Resident #85 had an unidentified nebulizer treatment in progress and there were no staff present in the room. At 8:41 AM, Licensed Practical Nurse (LPN) #6 entered the room and removed the nebulizer treatment. The facility was unable to provide a self-administration assessment for nebulizer treatments for Resident #85. During an interview on 11/17/2021 at 8:26 AM, the Director of Nursing (DON) confirmed the nurse should stay with the resident during the nebulizer treatment unless the resident has had a self-administration assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure 1 of 5 nurses (Licensed Practical Nurse (LPN #6) administered medications according to Physician's Orders for 1 of 6 sampled residents (Resident #85) reviewed for medication administration. The findings include: Review of the medical record, showed Resident #85 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Congestive Heart Failure, Hypertension, and Oxygen Dependence. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #85 was cognitively intact. Review of the Care Plan with a revision date of 10/18/2021, revealed .at risk for respiratory distress .Give meds [medications] as ordered and observe effectiveness . Review of the Physician's Orders dated 10/27/2021, revealed there was no active Physician's Order for a nebulizer treatment. Observation in the resident's room on 11/16/2021 beginning at 8:38 AM, revealed Resident #85 had a nebulizer treatment in progress. During an interview on 11/17/2021 at 7:37 PM, the Director of Nursing (DON) confirmed all medication orders should be entered in the computer. The DON confirmed medications should not be administered without a Physician's Order. The DON was asked if there was a Physician's Order for the nebulizer treatment. The DON stated, He [Resident #85] went out to the hospital and it was a prn [as needed] order, the order fell off when he came back .he's always had breathing treatments .a lot of this is they [staff] know their patients and they [staff] know the fact that they've had an order . The DON confirmed that there was not a Physician's Order for the breathing treatment.

Based on policy review, observation, and interview, the facility failed to ensure medications were labeled and stored appropriately when unsecured medications were observed in 1 of 68 resident rooms (Resident #29's room) which could have potentially affected the 3 identified wandering residents (Resident #8, #74, and #94) in the facility. The findings include: Review of the facility's policy titled, Storage and Expiration of Medications, Biologicals ., dated 12/1/2007, revealed .Facility should ensure that all medications and biologicals .are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors . Observation in the resident's room on 11/16/2021 at 7:33 AM, revealed the following medications on Resident #29's over bed table: a. 2 boxes of 2.1-ounce tubes of Capsaicin Cream 0.025 percent (%). b. 1 box of Fluticasone/Salmeterol inhaler. The facility identified 3 wanderers (Resident #8, #78, and #94) who could have potentially been affected by unsecured medications left unattended in the resident's room. During an interview on 11/17/2021 at 8:26 AM, the Director of Nursing (DON) confirmed medications should not be left at the bedside unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, and interview, the facility failed to ensure the environment was free of accident hazards when unsecured sharps were observed in 4 of 68 resident rooms (room [ROOM NUMBER], #16, #15, and #19) for 6 of 103 sampled residents (Resident #4, #11, #42, #68, #98, and #106) observed for accident hazards. The findings include: Review of the facility's policy titled, .Accident Policy, dated 5/30/2018, revealed .The [Named Long Term Care Facility] will strive to ensure that Residents environment remains as free of accident hazards as possible .Accident refers to any unexpected or unintentional incident, which may result in injury or illness to a Resident .Avoidable accident means that an accident occurred because a facility failed to identify environmental hazards, identify a Resident's individual risk for accidents .implement interventions . Review of the medical record, revealed Resident #42 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Stage 3 Chronic Kidney Disease, Depression, Anxiety, Dysphagia, Hypertension, and Heart Failure. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #42 was cognitively intact. Review of the medical record, revealed Resident #98 was admitted to the facility on [DATE] with diagnoses of Intracranial Injury, Anxiety, Vascular Dementia, Depression, Aphasia, Hypertension, Cerebral Vascular Accident, and Hemiplegia. Review of the admission MDS dated [DATE], revealed Resident #98 had severe cognitive impairment. Observation in Resident #42 and #98's shared bathroom (room [ROOM NUMBER]) on 11/15/2021 at 9:39 AM and 3:19 PM, revealed 6 disposable razors in a cup. Observation in Resident #42 and #98's shared bathroom (room [ROOM NUMBER]) on 11/16/2021 at 8:05 AM and 3:27 PM, revealed 5 disposable razors in a cup. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Anemia, Neuropathy, Hypertension, Heart Disease, and Dysphagia. Review of the admission MDS dated [DATE], revealed Resident #11 had severe cognitive impairment. Observation in Resident #11's bathroom (room [ROOM NUMBER]) on 11/15/2021 at 10:07 AM and 3:23 PM, and on 11/16/2021 at 8:53 AM and 4:26 PM, revealed a wash basin containing an opened package with 8 disposable razors and 9 loose disposable razors on the sink counter. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Cerebral Vascular Accident, Hemiplegia, Hemiparesis, Anxiety, Depression, Aphasia, and Amnesia. Review of the quarterly MDS dated [DATE], revealed Resident #4 had moderately impaired cognition. Review of the medical record, revealed Resident #106 was admitted to the facility on [DATE] with diagnoses of Polyosteoarthritis, Depression, Heart Failure, and Chronic Kidney disease. Review of the quarterly MDS dated [DATE], revealed Resident #106 was cognitively intact. Observation in Resident #4 and Resident #106's shared bathroom (room [ROOM NUMBER]) on 11/15/2021 at 10:17 AM, revealed a gray wash basin containing 2 razors on the right side of the sink. Observation in Resident #4 and Resident #106's shared bathroom (room [ROOM NUMBER]) on 11/15/2021 at 11:18 AM and 3:25 PM, and on 11/16/2021 at 1:15 PM, revealed a gray wash basin containing 1 razor and 4 replaceable razor cartridges on the left side of the sink. Review of the medical record, revealed Resident #68 was admitted to the facility on [DATE] with diagnoses of Diabetes, Hypertension, Cirrhosis of the Liver, Cerebral Vascular Accident, Hemiplegia, and Hemiparesis. Review of the quarterly MDS dated [DATE], revealed Resident #68 was cognitively intact. Observation in Resident #68's bathroom (room [ROOM NUMBER]) on 11/15/2021 at 11:27 AM and 3:26 PM, and on 11/16/2021 at 9:33 AM and 4:30 PM, revealed a gray wash basin with 3 disposable razors on the sink counter. During an interview on 11/17/2021 at 8:29 AM, the Director of Nursing (DON) confirmed razors should not be left in residents' bathrooms.

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, Time and Attendance Reports, staff screening logs, and interview, the facility failed to properly prevent and/or contain COVID-19 when 53 of 173 staff members (Environmental Services Staff #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13, Registered Nurse (RN) #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, #6, #7, and #8, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29) failed to complete screenings prior to working on 13 of 13 days (10/29/2021, 10/30/2021, 10/31/2021, 11/1/2021, 11/2/2021, 11/3/2021, 11/4/2021,11/5/2021, 11/6/2021, 11/7/2021, 11/8/2021, 11/9/2021, and 11/10/2021) reviewed. This could have potentially affected the 103 residents residing in the facility. The findings include: Review of the Centers for Disease Control and Prevention (CDC) document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/10/2021, revealed .Establish a process to identify anyone entering the facility, regardless of their vaccination status .so that they can be properly managed .Options could include .individual screening on arrival at the facility .before entering the facility. Review of the facility's policy titled, Occupational Health- COVID-19, dated 3/6/2020, revealed .Employees will be screened prior to starting a shift by having their temp [temperature] taken, as well as being screened for recent travel, signs or symptoms or exposure . Review of the Employee Screening Logs and Time and Attendance Reports from 10/29/2021 - 11/10/2021, revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19: a. 10/29/2021 - Environmental Services Staff #4, #5, and #6; CNA #1, #2, and #3; RN #4. b. 10/30/2021 - Environmental Services Staff #1, #2, and #3; CNA #4 and #5. c. 10/31/2021 - CNA #1, #6, #7, and #8. d. 11/1/2021 - Environmental Services Staff #1 and #5; RN #4. e. 11/2/2021 - Environmental Services Staff #12 and CNA #10. f. 11/3/2021 - Environmental Services Staff #3, #10, and #12; CNA #11 and #29; LPN #1, #2, #3 and #4. g. 11/4/2021 - Environmental Services Staff #10 and #13; CNA 1, #4, #11 #12, #13, #14, and #15; RN #2. h. 11/5/2021 - Environmental Services Staff #3, #4, #5, #9, and #10; CNA #13, #12, and #16; LPN #5, #6, #7; RN #4. i. 11/6/2021 - Environmental Services Staff #11; CNA #16, #17, #18, and #19. j. 11/7/2021 - Environmental Services Staff #3, #4, #5, #6, and #7; CNA #18, #21, and #22. k. 11/8/2021 - Environmental Services Staff #3, #4, #5, #6, and #7; CNA #10, #16, #24, and #23; LPN #8; RN #1. l. 11/9/2021 - Environmental Services Staff #8 and #10; CNA #25, #26, and #27; RN #2, #3, and #4. m. 11/10/2021 - Environmental Services Staff #1, #2, #3, and #10; CNA #12, #20, and #28. During an interview on 11/17/2021 at 8:52 PM, the Director of Nursing (DON) stated, .the staff is supposed to stop and get screened in each day .they get temp [temperature] taken .screen for signs and symptoms of respiratory illness or exposure to COVID 19 .it's done by the nursing department .if no one is there to screen .we are called to front by Receptionist .all staff members should be screened before entering the building .