**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interview, the facility failed to implement interventions on the Care Plan for 1 of 30 sampled residents (Resident # 28) reviewed. The findings include: Review of the facility's policy titled, SECTION VII: PATIENT CARE PLANS, dated 10/2021, revealed, .Problems are patient conditions, needs, or weaknesses which currently do, or potentially could, prevent the patient from achieving or maintaining the highest practicable level of well-being .Care Plan Approaches are specific, individualized steps partners and patients will take together to assist the patient to achieve the goal .Approaches serve as instructions for patient care .Responsibility for each approach is taken by the individuals and/or departments who added them to the care plan . Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses which included Hypertensive Heart and Chronic Kidney Disease, Heart Failure, Osteoporosis, and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 required extensive assist with activities of daily living (ADLs). Review of the Care Plan dated 6/21/2022 to present revealed a plan of care developed to address falls with the approach for bedside mat in place to prevent injury due to poor safety awareness. Observation in Resident #28's room on 8/29/2022 at 11:30 AM, 12:16 PM, 8/30/2022 at 8:10 AM, 8/31/2022 at 9:20 AM and 8/31/2022 at 9:20 AM revealed no bedside mat in place. Observation and Interview in Resident #28's room on 8/31/2022 at 10:00 AM Licensed Practical Nurse (LPN) #6 revealed she was the fall champion for the facility. LPN #6 confirmed Resident #28 had a care plan approach for a bedside mat and mat was not in place in her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure 1 of 30 sampled residents (Resident #39) had clean and groomed fingernails. The findings include: Review of facility's policy titled, Fingernails/Toenails, Care of, dated 2/2018, revealed .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .nail care included daily cleaning and regular trimming .proper nail care can aid in the prevention of skin problems around the nail bed . Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease, Anemia, and Hyperlipidemia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a staff assessment for mental status that revealed poor short term and long term memory. Continued review revealed Resident #39 required extensive assistance with personal hygiene and extensive assistance with bathing. Observation in Resident #39's room on 8/29/2022 at 12:20 PM, 8/29/2022 at 3:35 PM, and 8/30/2022 at 8:10 AM, revealed brown dried debris under his fingernails on both hands. Observation and interview in Resident #39's room on 8/30/2022 at 8:15 AM, Licensed Practical Nurse (LPN) #2 stated his fingernails need immediate attention and confirmed his fingernails were dirty and need to be trimmed. During an interview on 8/30/2022 at 8:25 AM, the Director of Nursing (DON) confirmed a resident's fingernails should be cleaned and trimmed when dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for 1 of 3 sampled residents (Resident #29) who required a midline intravenous catheter (used for vascular access for treatments) dressing change. The findings include: Facility policy review titled, Midline Dressing Changes, revised April 2016 revealed, .Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure, Pneumonia and Chronic Obstructive Pulmonary Disease (COPD). Review of Physician's Order dated 8/3/2022, revealed Resident #29 had an order to change midline dressing weekly on Mondays. Observation in Resident #29's room on 8/29/2022 at 12:35 PM, 2:53 PM, and 3:13 PM, revealed midline dressing was dated 8/17/2022. Observation and interview in Resident #29's room on 8/29/2022 at 3:43 PM, Licensed Practical Nurse (LPN) #1 confirmed the midline dressing was dated 8/17/2022 and was ordered to be changed on 8/22/2022 and 8/29/2022. During an interview on 8/29/2022 at 4:27 PM, the Director Of Nursing (DON) confirmed Resident #29's midline dressing was not changed on 8/22/2022 or 8/29/2022. She stated the midline dressing was to be changed weekly on Mondays to prevent infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility procedure guide review, medical record review, observation, and interview, the facility failed to store nebulizer equipment in a safe and sanitary manner for 3 of 34 residents (Resident #26, Resident #29, and Resident #386) who required respiratory treatments. The findings include: Review of the undated facility procedure guide, titled, Nebulized Aerosol Therapy, revealed, .Place nebulizer circuit in equipment bag and store. Nebulizer assembly can become contaminated if not stored properly . Review of medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses which included Emphysema and Acute and Chronic Respiratory Failure with Hypoxia. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure, Pneumonia and Chronic Obstructive Pulmonary Disease (COPD). Review of the medical record revealed Resident #386 was admitted to the facility on [DATE] with diagnoses which included Pneumonia, Essential Hypertension, and Spinal Stenosis. Observation in Resident #26's room on 8/29/2022 at 12:45 PM and 3:15 PM, revealed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation and interview in Resident #26's room on 8/29/2022 at 3:52 PM, Licensed Practical Nurse (LPN) #1 confirmed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation in Resident #29's room on 8/29/2022 at 12:35 PM and 3:13 PM, revealed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation and interview in Resident #29's room on 8/29/2022 at 3:43 PM, LPN #1 confirmed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation in Resident #386 room on 8/29/2022 at 12:40 PM and 3:14 PM, revealed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation and interview in Resident #386's room on 8/29/2022 at 3:52 PM, LPN #1 confirmed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. During an interview on 8/30/2022 at 4:30 PM, the Director of Nursing (DON) stated she expected nebulizer tubing and mouthpiece to be stored in a bag when not in use to prevent infection.

Based on facility policy review, observation, and interview, the facility failed to store an ice scoop used to serve ice and failed to maintain clean dietary equipment in accordance with professional standards of practice for food service safety. The findings include: Review of the facility's policy titled, Safety and Sanitation Best Practice Guidelines, revised 11/2017, revealed, .Use a clean, sanitized container .and ice scoop to transfer ice .Scoops must be stored .in a protected fashion .Cleaning Procedures .Daily and weekly .range .daily, wipe up spills as they occur .loosen all burned-on particles .rinse and wipe dry .clean back apron and drip tray .drip tray may be washed in pot and pan sink .wipe dry .return grids and drip tray to range .Cleaning Equipment .equipment must be cleaned and/or sanitized after use . Observation and interview in the kitchen on 8/29/2022 at 10:50 AM, revealed the small and large drip pan with large amount of black, brown debris. The Dietary Manager confirmed the drip tray had a large amount of dried debris and should be cleaned after every use. He stated, It has been a while since it has been cleaned. Observation and interview on the 3rd Floor East Hall on 8/31/2022 at 1:31 PM, revealed an unprotected ice scoop laying on the cart beside the ice chest. Interview revealed Licensed Practical Nurse (LPN) #3 confirmed the ice scoop was not covered. She stated the ice scoop should be stored in a container to prevent contamination when not in use. During an interview on 8/31/2022 at 2:04 PM, the Director of Nursing (DON) stated she expected staff to store an ice scoop in a protective covering when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility's documentation guidelines review, medical record review, observation, and interview, the facility failed to ensure accurate documentation of code status preference for 1 of 30 sampled residents (Resident #11) reviewed. The findings include: Review of the facility's Documentation Guidelines reviewed and updated 9/2021, revealed, .DO NOT RESUSCITATE [DNR] Orders: An order entered by the patient's treating physician in the patient's record which states that in the event the patient suffers cardiac arrest, cardiopulmonary resuscitation should not be attempted . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease, Chronic Atrial Fibrillation, and Type 2 Diabetes Mellitus with Diabetic Autonomic (poly) neuropathy. Review of the Comprehensive Care Plan for Resident #11 revealed, .Code Status: Full Code .Edited: [DATE] .Full Code (See Post Form) . Review of the Physician Order Report for Resident #11 dated [DATE]-[DATE], revealed, XXX[DATE]-Open Ended FULL CODE: CPR [Cardiopulmonary Resuscitation] . Review of the Tennessee Physician Orders for Scope of Treatment (POST) form signed by the physician on [DATE], revealed Resident #11's code status was DNR. Observation and interview on [DATE] at 11:51 AM, the Director of Nursing (DON) reviewed the medical record for Resident #11 and confirmed the code status on the Electronic Health Record (EHR) banner indicated DNR. She confirmed the Physician Order dated [DATE] and the POST form indicated Resident #11's code status was Full Code. She stated a new POST form had been signed on [DATE] indicating DNR code status. She stated there was no order for the DNR code status in the medical record. She stated the DNR POST form was not scanned into the medical record. She stated she expected the EHR to reflect accurate and up to date orders for a resident's code status.

Based on facility policy (Centers for Disease Control and Prevention (CDC) guidelines) review, facility document review, manufacturer's guideline review, observation, and interview, the facility failed to conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests. The findings include: Review of the facility's policy titled, Testing Plan, revised 11/29/2021, revealed, .will utilize the CDC website for the policy/procedure .Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 test .Collecting and handling specimens correctly and safely is imperative to ensure the accuracy of test results and prevent any unnecessary exposures .During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment . Review of the facility's document titled, Anterior nares COVID self-collection of specimen competency, dated 6/16/2020, revealed the first and last step of the testing process was, Performs Hand Hygiene. Review of the manufacturer's guideline for BinaxNow Covid-19 Ag Card dated 12/2020, revealed, .In order to ensure proper test performance, it is important to read the results promptly at 15 minutes, and not before .Results should not be read after 30 minutes . Observation of employee Covid-19 testing site on 8/29/2022-8/31/2022 at various times revealed no hand sanitizer or gloves available for use during test procedure. Continued observation revealed a red biohazard bag open and taped to the desk used during testing procedure. Observation of employee self test for Covid-19 on 8/31/2022 at 7:30 AM, revealed a Respiratory Therapist completed her self test without performing hand hygiene before and after testing procedure. Observation of employee self test for Covid-19 and interview on 8/31/2022 at 2:25 PM, revealed a Restorative Tech completed her self test without performing hand hygiene before and after testing. She placed her Covid-19 test in the form for testing and put the test in a box on top of the desk. During interview she stated she had entered the facility at 11:00 AM, and had waited until 2:25 PM to complete her self testing. She stated she had put the test in the box on top of the desk to be read by a nurse. She was not sure what nurse would be reading the test or what time the test would be read. Observation of the employee self testing site and interview on 8/31/2022 at 2:43 PM, revealed no hand hygiene available for performing specimen collection. Continued observation revealed a red biohazard bag open and taped to the desk of the testing site. The biohazard bag contained used Covid-19 testing supplies. A box containing used Covid-19 test pending results was sitting on top of the desk. During interview the Director of Nursing (DON) stated the manufacturer's guidelines were not followed for reviewing the Covid-19 test results for the daily tests contained in the box. She confirmed there was no hand hygiene available at the self testing site as required by infection control guidelines and the biohazard bag should be in a closed container. During an interview on 8/30/2022 at 1:30 PM, the receptionist seated at the front desk stated employees self-tested twice a week before going into the patient care areas of the facility. She provided a step by step verbal statement of the testing procedure. She stated employees that self tested did not have to use hand hygiene during testing because they were collecting their own specimen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review and interview the facility failed to ensure 3 (#3, #18, #56) of #35 residents reviewed was free from abuse. The findings include: Facility policy review Abuse, Neglect, Misappropriation of Funds, revised 9/28/19 revealed, .to establish a policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .the facility has a zero tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing .allegation of Abuse and/or Serious Bodily Injury-2 Hour Limit: if the events that cause the reasonable suspicion of abuse immediately, but not later than 2 hours after forming the suspicion . Review of the facility investigation dated 11/4/19 revealed a witnessed altercation between Resident #3 and Resident #56. Continued review revealed Resident #56 slapped Resident #3 on 11/3/19. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and hemiparesis. Dementia without Behavioral Disturbance, Anxiety Disorder and Major Depressive Disorder. Medical record review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and Vascular Dementia with Behavioral Disturbance. Medical record review of Resident #56's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 99 indicating the resident was unable to complete the interview. Continued review revealed the resident exhibited verbal behaviors. Interview with Certified Nursing Technician (CNT) #3 on 12/11/19 at 12:50 PM in the Atrium Dining room revealed Residents #3 and #56 had a physical altercation. Continued interview revealed Resident #56 smacked Resident #3. Interview with the Director Of Nursing (DON) on 12/11/19 at 3:18 PM in her office revealed she was informed on 11/3/19 of a verbal atercation between Resident #3 and #56. Continued interview revealed she was notified the next day 11/4/19 the altercation between Resident #3 and Resident #56 became physical. Continued interview when asked to look at the incident date and the reporting date confirmed It was turned in late because I wasn't aware of the possible hitting until the next day after the incident. Review of facility investigation initiated on 11/2/19 revealed an unwitnessed altercation occurred between Resident #29 and Resident #56. Medical record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease. Medical record review of Resident #29's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 13 indicating the resident had no cognitive impairment. Continued review revealed the resident exhibited no behaviors. Interview with CNT #1 on 12/9/19 at 2:28 PM in the 3rd floor nurse station revealed Resident #56 was in Resident #29's room; Resident #29 was telling Resident #56 she needed to leave because that wasn't her room. Continued interview she stated I didn't see anything but Resident #29 told me Resident #56 hurt her finger and smacked her arm; I removed Resident #56 and notified the nurse. Interview with Resident #29 on 12/09/19 at 11:34 AM in her room when asked concerning an altercation with her and Resident #56 she stated, I was in my room watching T.V. [television] when the lady came into my room; I asked her to leave the room and she kept coming, she tried going around the corner of my bed so I tried to put my table in front of her to keep her from coming into my room. I kept pushing the table in front of her and she kept kicking my table then she hit me on my right arm. Interview with the DON on 12/11/19 at 3:17 PM in her office revealed she was notified that Resident #56 hit Resident #29 on the arm. Continued interview confirmed Resident #56 hit Resident #29. Review of the facility's investigation dated 11/27/19 revealed an unwitnessed physical altercation between Resident #18 and Resident #26. Further review revealed Resident #26 told the Director of Nursing that she became frustrated because she was trying to watch television when Resident #18 and Resident #3 were arguing; she (named Resident #26) asked them (Resident #3 and #18) to be quiet and they wouldn't be quiet so she slapped Resident #18 on the face. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses which included Convulsions and Mood Disorder. Review of Resident #26's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 14, indicating the resident had no cognitive impairment. Interview with Resident #26 on 12/9/19 at 3:02 PM in the third floor dining room when asked about the incident between her and Resident #18 she stated, We were kind of fussing last Thursday in the dining room; she didn't want me to sit where I was sitting and cussed me so I slapped her (named resident #18) across the face. Interview with the DON on 12/10/19 at 6:40 PM in her office revealed a physical altercation between Resident #18 and Resident #26 was reported to her on 11/27/19. Continued interview revealed Resident #26 slapped Resident #18 across the face. Review of the facility investigation dated 12/3/19 revealed a physical altercation between Resident #65 and Resident #18 occurred in the dining room witnessed by Resident #58. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis. Medical record review of Resident #18's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 4, indicating the resident had severe cognitive impairment. Medical record review revealed Resident #58 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes. Medical record review of Resident #58's MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident had no cognitive impairment. Resident #65 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis. Review of Resident #65's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident had no cognitive impairment. Interview with the Resident #65 on 12/9/19 at 2:53 PM in the third floor dining room when asked about an incident between her and Resident #18, she stated (named Resident #18) has a tendency to cuss me and I got mad and just went off and hit her. Interview with CNT #2 on 12/10/19 at 3:35 PM in the third floor nurses station when asked about the altercation between Resident #18 and #65 she stated, I heard (named Resident #18) screaming and I went in the dining room and she was sitting at the table with a cup of coffee and (named Resident #65) had a hold of (named Resident #18) arm. Continued interview revealed she removed Resident #18 and notified her supervisor. Interview with Resident #58 on 12/10/19 at 4:02 PM in the resident's room when asked if she witnessed an altercation between two residents she stated (named Resident #65) can't get along with (named Resident #18); They started arguing and (named Resident #65) went to (named Resident #18) table and started fighting with her (named Resident #18), hitting her. Interview with the DON on 12/10/19 at 6:52 PM in her office revealed the nursing supervisor notified her of a physical altercation between Resident #18 and Resident #65. Continued interview confirmed Resident #65 grabbed Resident #18's arm and Resident #18 hit Resident #65.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review and interview the facility failed to report an allegation of abuse timely for Resident #3. The findings include: Facility policy review Abuse, Neglect, Misappropriation of Funds, revised 9/28/19 revealed, .to establish a policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .the facility has a zero tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing .allegation of Abuse and/or Serious Bodily Injury-2 Hour Limit: if the events that cause the reasonable suspicion of abuse immediately, but not later than 2 hours after forming the suspicion . Review of the facility investigation dated 11/4/19 revealed a witnessed altercation between Resident #3 and Resident #56. Continued review revealed on 11/3/19 Resident #56 slapped Resident #3. Further review revealed the Director of Nursing (DON) was notified of the incident on 11/4/19. Continued review revealed the DON reported the incident to the state agency on 11/4/19. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis, Dementia without Behavioral Disturbance, Anxiety Disorder and Major Depressive Disorder. Medical record review of Resident #3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and Vascular Dementia with Behavioral Disturbance. Medical record review of Resident #56's MDS dated [DATE] revealed the resident had a BIMS score of 99, indicating the resident was unable to complete the interview. Continued review revealed the resident exhibited verbal behaviors. Interview with Licensed Practical Nurse (LPN) #2 on 12/11/19 at 10:40 AM on the third floor hallway revealed he didn't witness the altercation between Resident #3 and #56. Continued interview revealed he was unaware of the incident until he was going to clock out and an unnamed tech informed him of a physical altercation between Resident #3 and Resident #56. Continued interview revealed he reported the incident to his supervisor. Interview with Certified Nursing Technician (CNT) #3 on 12/11/19 at 12:50 PM in the Atrium Dining room revealed Resident #3 and Resident #56 had a physical altercation. Further interview revealed Resident #56 smacked Resident #3. Continued interview revealed CNT #3 reported the incident to her supervisor. Interview with the Director Of Nursing on 12/11/19 at 3:18 PM in her office revealed the staff informed her on 11/4/19 of an altercation between Resident #3 and Resident #56 that occurred on 11/3/19. Continued interview when asked to look at the incident date and the reporting date confirmed It was turned in late because I wasn't aware of the possible hitting until the next day after the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to revise a care plan for 1 (#20) of 35 residents reviewed for care plans. The findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .At least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included Respiratory Failure. Medical record review of Resident #20's Physician Orders dated 9/29/19 revealed Isolation: Patient on contact and droplet for Extended Spectrum Beta-Lactamases (ESBL)-Escherichia Coli (E-Coli) in urine and Pseudomonas in Sputum. Medical record review of Resident #20's comprehensive care plan dated 9/10/19 revealed Resident #20 required isolation related to DX (diagnosis) ESBL in her urine. Continued review revealed no care plan for Isolation related to Pseudomonas in Sputum. Interview with the MDS Coordinator on 12/11/19 at 8:30 PM in the conference room confirmed physician orders were reviewed with MDS updates and care plans were updated according to the orders. Further interview confirmed Resident #20's care plan was not updated for respiratory precautions. She stated I missed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to follow physician's orders for 2 (#'s 4, #82) residents of 35 residents reviewed for physician orders being followed. The findings include: Facility policy review, Physician Orders, revised June 2004, revealed .Physician orders must be given and managed in accordance with applicable laws and regulations .all staff providing care to residents must follow the physician orders . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Guillain-Barre syndrome-[NAME] Syndrome Variant, Dependence on Respirator Status and Diabetes. Medical record review of Resident #4's Physician Order Report dated 7/8/19 revealed .HgbA1C [glycated hemoglobin, a blood test to determine blood sugar levels over a 3 month period] every 3 months . Medical record review of Resident #4's laboratory results revealed there was no HgbA1C obtained for the month of October 2019. Interview with the Assistant Director of Nursing on 12/11/19 at 2:50 PM in the conference room confirmed Resident #4 did not have a HgbA1C obtained in October 2019. She stated the nurse who put the order in the computer placed the order in the general orders instead of the lab order; so it didn't get done. Interview with the Director of Nursing (DON) on 12/11/19 at 3:18 PM in her office confirmed the HgbA1C was not obtained in October 2019 for Resident #4. Medial record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis, Altered Mental Status, Bipolar Disorder, Generalized Anxiety Disorder and Mood Disorder. Medical record review of Resident #82's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #82 has a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment, Continued review revealed limb restraint used daily. Medical record review of Resident #82's Physician's Orders dated 6/9/19 revealed .Quarterly Restraint Reduction Assessment once a day every 90 days . Medical record review revealed Resident #82 had no quarterly restraint reduction assessments. Interview with the Director of Nursing (DON) on 12/11/19 at 2:20 PM in her office confirmed no quarterly restraint reduction assessments for Resident #82 had been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility procedure review, medical record review, observation and interview, the facility failed to properly store suction tubing prevent the spread of infection for 1 resident (#41) of 48 residents who received respiratory services. The findings include: Facility procedure review, Tracheostomy Suction, undated, and Inline Tracheostomy Suction, undated, revealed .Attach connective tubing to closing cap on lid of canister . Medical record review revealed Resident #41 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure With Hypoxia, Encounter for Attention To Tracheostomy, Infection of Tracheostomy stoma, and Dysphagia. Medical record review of Resident #41's Physician Orders dated 2/8/19 revealed .Tracheal Suction . Observation on 12/9/19 at 12:43 PM in Resident #41's room revealed suction tubing laying on bedside table, not connected to machine and exposed Interview with Respiratory Therapist #2 on 12/9/19 at 12:43 PM in Resident #41's room confirmed suction tubing was left exposed and not connected to the suction canister. Interview with the Respiratory Director on 12/11/19 at 8:52 AM in the conference room confirmed if there is an open tube it should be covered while not in use and if found uncovered the tubing would be changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview the facility failed to write a stop date for an as needed Psychotropic medication for 2 (#33, #56) of 14 residents reviewed for psychotropic medications. The findings include: Facility policy review, Antipsychotic Medication Use, dated 3/15/18 revealed .The need to continue PRN [as needed] orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order . Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorder. Medical record review of Resident #33's Physician Orders dated 11/7/19 revealed .alprazolam [an antianxiety medication] tablet 0.25 mg[milligram]1 tab [tablet] gastric tube Three Times A Day - PRN . Medical record review of Resident #33's Pharmacy Communication/Recommendations dated 11/27/19 revealed .Alprazolam 0.25mg .PRN psychotropic medications are limited to 14 days, unless a prescriber documents in the medical record rationale, including duration, for extended therapy . Interview with the Director of Nursing (DON) on 12/11/19 at 6:55 PM in her office revealed when asked to review Resident #33's Physician Order dated 11/7/19 for PRN Alprazolam confirmed there was no stop date for the as needed anti-anxiety medication. Medical record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses which included Alzheimers Disease, Vascular Dementia with Behavioral Disturbances and Generalized Anxiety Disorder. Medical record review of Resident #56's Physician Orders dated 11/15/19 revealed .Ativan (lorazapam) [medication used to treat anxiety] Schedule IV tablet; 0.5 mg; oral Special Instructions: anxiety and tremors every 3 hours-PRN . Medical record review of Resident #56's Pharmacy Communication/Recommendations dated 11/25/19 revealed .Ativan 0.5 mg .PRN psychotropic medications are limited to 14 days, unless a prescriber documents in the medical record rationale, including duration, for extended therapy . Medical record review of Resident #56's Medication Administration Record dated December 2019 revealed the resident received Ativan on 12/3/19 at 10:19 PM and December 4, 2019 at 10:41 PM. Interview with the Director of Nursing on 12/11/19 at 8:55 AM in her office confirmed there was no stop date for Resident #56's PRN Ativan. Interview with Resident #33 and #56's Physician on 12/11/19 at 6:45 PM at the second floor nurse station he stated generally don't write stop dates and the resident needs these medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation and interview, the facility failed to post correct signage for droplet isolation precautions for 1 resident (#20) and failed to wear proper personal protective equipment (PPE) before entering the room for 1 (#38) of 14 residents reviewed for transmission based precautions. The findings include: Facility policy review, Isolation, dated May 1, 2008 and revised October 2016 revealed .Signs-Use color coded signs and/or other measures to alert staff of the implementation of Isolation or Droplet Precautions .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection .In addition to Standard Precautions, Implement Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by droplets . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included Renal Insufficiency, Renal Failure, or End Stage Renal Disease (ESRD), Diabetes Mellitus (DM), Respiratory Failure and Dependence on Renal Dialysis. Medical record review of Resident #20's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required suctioning and tracheostomy care. Medical record review of Resident #20's Physician Orders dated 9/29/19 revealed .Isolation: Patient on contact and droplet for Extended Spectrum Beta-Lactamases (ESBL)-Escherichia Coli (E-Coli) in urine Pseudomonas in Sputum . Observation on 12/9/19 at 11:20 AM outside of Resident #20's room revealed signage on the door was for contact isolation and no signage for respiratory isolation. Observation on 12/10/19 at 9:49 AM outside of Resident #20's room revealed Respiratory Signage speak with nurse before entering room .wash hands, mask and gloves . Interview with the Registered Respiratory Therapist (RRT) on 12/09/19 at 11:25 AM revealed resident #20 was in contact and droplet isolation. Further interview confirmed the Droplet Precautions were not posted. Interview with the ADON on 12/11/19 at 4:13 PM in her office confirmed she expected to find the correct isolation signage and PPE's on respective doors per facility policy. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses which included Encounter for attention to Tracheostomy, Dependence on Supplemental Oxygen and Dependence on Renal Dialysis. Medical record review of Resident #38's admission MDS dated [DATE] revealed the resident received suctioning and tracheostomy care. Medical record review of Resident #38's Physician Orders dated 11/25/19 revealed .Isolation: Patient on droplet isolation for Pseudomonas Sputum . Observation on 12/11/19 at 8:15 AM outside of Resident #38's room revealed Registered Nurse (RN) #1 entered the resident's room without applying proper PPE. Interview with RN #1 confirmed she did not apply the proper PPE before entering resident #38's room. Interview with the Director of Nursing (DON) on 12/11/19 at 8:15 AM in her office confirmed nursing must apply proper PPE prior to entering isolation rooms at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to have appropriate signage for transmission-based precautions for 1 (#9) of 21 residents reviewed on transmission-based precautions. The findings include: Review of the facility policy, Isolation, dated 10/2016 revealed .Transmission-Based Precautions shall be used when caring for resident who are documented or suspected to have communicable diseases .Signs--use coded signs and/or other measures to alert staff of the implementation of Isolation or Droplet Precautions .place a sign at the doorway . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia and Dependence on Oxygen, Nodule of Right Lung Middle Lobe, Tracheostomy (a tube for breathing), Pseudomonas aeruginosa (CRPA-Carbapenem Resistant Pseudomonas) in the Sputum (a bacterial organism not normally found in the lungs), and Clostridium Difficile (C diff) (a bacterial organism not normally found in the colon). Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #9 had an infection requiring transmission based precautions. Medical record review of a comprehensive care plan dated 1/24/19 revealed Resident #9 was monitored and assessed for transmission based precautions both contact and droplet. Continued review revealed the transmission based precautions were for C diff and CRPA, respectively. Observation of Resident #9's doorway on 1/28/19 at 5:37 AM and 3:10 PM on the 3rd floor west hall revealed no signage identifying transmission based precautions required. Interview with Licensed Practical Nurse (LPN) #1 on 1/28/19 at 5:37 AM at the 3rd floor west hall medication cart confirmed Resident #9 was on contact and droplet transmission based precautions for C diff and CRPA respectively. Interview with LPN #4 and Registered Nurse (RN) #1 on 1/28/19 at 3:10 PM in the 3rd floor west hall confirmed no signage to indicate transmission based precautions was present on Resident #9's doorway.

Based on observation and interview, the facility dietary department failed to maintain dietary equipment in a sanitary manner in 1 of 4 observations of the dietary department. The findings include: Observation on 1/28/19 at 5:10 AM in the dietary department revealed the reach-in refrigerator next to the trayline had red dried spattered debris on the bottom interior surface. Observation on 1/28/19 at 7:00 AM in the dietary department revealed the 6 gas burner range top foil lined spill pan had a heavy accumulation of dried food debris. Further observation revealed all the hood filters over the production equipment, including fryer, range top, steamer, convection oven, grill and range top combination, had an accumulation of blackened debris and grease accumulation in the filters in the hood. Observation of the interior and exterior of the convection oven doors revealed a sticky brown accumulation of debris. Observation of the corners of the grill revealed a heavy accumulation of blackened debris. Observation of the 2 gas burner range, attached to the grill, revealed the foil lined spill pan had a heavy accumulation of dried food debris. Observation revealed the reach-in refrigerator next to the trayline had red dried spattered debris on the bottom interior surface. Observation on 1/28/19 at 9:55 AM in the dietary department dishroom, with the Director of Dietary Services present, revealed the dish machine was in operation and dishes were being stored in the clean areas. Further observation revealed a wall mounted fan in operation and directed at the clean dishes. Further observation revealed the fan grate, the blades and the wall surrounding the fan had a blackened accumulation of debris and could contaminate the cleaned dishes. Observation and interview, with the Director of Dietary Services, on 1/28/19 at 10:00 AM in the dietary department confirmed the dietary equipment, including the reach-in refrigerator by the trayline, the 6 and 2 burner range top spill pans, the grill, the filters in the hood, the convection oven doors, and the wall mounted fan in the dishroom, had not been maintained in a sanitary manner.