**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to obtain a physician's order to maintain and specify frequency of catheter care for an indwelling urinary catheter for 1 resident (Resident #15) of 3 residents reviewed for indwelling urinary catheters. The findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses including Benign Prostatic Hyperplasia (a condition where the prostate and the surrounding tissue expands) and Obstructive and Reflux Uropathy (a condition where there is a hindrance to normal urine flow). Review of an admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #15 had Obstructive and Reflux Uropathy, severe cognitive impairment, and an indwelling urinary catheter. Review of a Care Plan dated 12/27/2022 showed Resident #15 had a plan of care for an indwelling catheter related to obstructive uropathy with an intervention of check tubing for kinks each shift during rounds and as needed. An observation on 3/7/2023 at 8:38 AM, showed Resident #15 was seated in a wheelchair and had a covered urinary catheter bag hanging below the level of the bladder on his wheelchair. Review of Resident #15's Physician's orders revealed no orders related to the indwelling urinary catheter. During an interview on 3/7/2023 at 4:00 PM, the Director of Nursing (DON) confirmed there were no Physician's orders for Resident #15's indwelling urinary catheter and she did not have a policy on the care of an indwelling catheter. During an interview on 3/8/2023 at 7:20AM, Certified Nurse Aide (CNA) #1 revealed the CNA [NAME] for Resident #15's catheter care instructions were .Check tubing for kinks each shift during rounds and PRN [as needed] . There were no instructions on cleaning the catheter. The CNA was able to verbalize correct catheter care. During an observation and interview on 03/8/2023 at 9:30 AM, CNA #2 stated he would check for kinks or sediment in tubing and a discharge and report any of those symptoms to the resident's nurse. The CNA sanitized his hands and donned gloves and provided appropriate catheter care. He stated Resident #15 had not, to his knowledge, had a Urinary Tract Infection (UTI) since admission. During an interview on 3/8/2023 at 9:49 AM, the Administrator stated her expectation would be for staff to document on the status of the catheter and any changes, and to clean the catheter and check it every shift. The Administrator expected a urinary catheter policy should be available, and orders should be transcribed. The Administrator confirmed there were no Physician's orders for the use of Resident #15's indwelling urinary catheter. Review of Resident #15's Physician's orders, nurses' notes and labs from 12/16/2022-3/8/2023 revealed the resident had no documentation to show urinary tract infections had occurred. During an interview on 3/8/2023 at 10:24 AM, Registered Nurse #1 stated Resident #15 had no urinary tract infections since admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS) for 1 resident (#12) of 14 residents reviewed for MDS accuracy. The findings include: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia, Psychosis, Mood Disorder, Wandering Disease, Repeated Falls, Generalized Anxiety Disorder, and Diverticulosis of Intestine. Medical record review of the Informed Consent For Use of Restraints documentation dated 9/17/18, revealed .Restraint: .Merriwalker [Merry Walker] [self-enclosed walker/chair combination device] .Purpose for recommended restraint: .assist c [with] ambulation . Medical record review of Resident #12's current comprehensive care plan, revised 8/20/18, revealed .Resident to use Merri-walker [Merry Walker] for increased safety while ambulating . Medical record review of Resident #12's Annual MDS dated [DATE], revealed the resident was severely cognitively impaired. Continued review revealed physical restraint use was not coded on the MDS. Medical record review of the Physician's Orders dated 9/1/19, revealed .Restraints .MerriWalker [Merry Walker] when out of bed to aid ambulation . Observation of Resident #12 on 10/22/19 at 1:24 PM, at the nurse's station, revealed the resident ambulating independently in her Merry Walker. Interview with MDS Coordinator #1 and the Administrator in Training on 10/22/19 at 10:33 AM, in the MDS office, confirmed Resident #12's Merry [NAME] was not coded as a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Mood Disorder with Depressive Features, Anxiety Disorder, Psychotic Disorder with Delusions, and Schizophrenia. Medical record review of the most recent PASRR Level 1 assessment dated [DATE] revealed Resident #23 had a mental health diagnosis of Anxiety Disorder. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #23 has diagnoses including Anxiety, Depression, and Psychotic Disorder. Observation on 10/21/19 at 9:42 AM, in the dining room, revealed Resident #23 sitting up in a reclining chair asleep. Interview with the DON on 10/23/19 at 8:17 AM, in the conference room, confirmed Resident #23's PASRR was completed by the hospital prior to admission and had not been reviewed for accuracy by the facility. Further interview confirmed a new PASRR was not submitted to include the diagnoses of Depression and Psychosis. Based on medical record review and interview, the facility failed to refer 2 residents (#8 and #23) after the residents were identified with possible serious mental disorders, to the state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) of 3 residents reviewed for PASARR. The findings include: Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance and Anxiety Disorders. Continued review revealed the diagnosis of Psychosis was added on 8/15/19. Medical record review of the most recent PASRR (PASARR) Level I assessment dated [DATE] revealed Resident #8 had mental health diagnoses of Anxiety Disorder and Depression. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had diagnoses including Dementia, Anxiety, and Depression. Observation on 10/21/19 at 10:05 AM, in the resident's room, revealed Resident #8 in bed watching television and eating a snack. Continued observation on 10/24/19 at 10:25 AM, in the resident's room revealed Resident #8 watching television and eating a snack. Interview with the Director of Nursing (DON) on 10/23/19 at 9:46 AM, in the DON's office, confirmed a new PASRR was not submitted after the diagnosis of Psychosis was added for Resident #8.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to develop a care plan for a restraint 1 resident (#12) of 14 sampled residents. The findings include: Review of the facility policy, Restraints, reviewed 8/2011, revealed .The residents care plan shall reflect the medical reason for the restraint, alternatives, declines in physical condition, potential complications, interventions .and any other pertinent interventions . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia, Psychosis, Mood Disorder, Wandering Disease, Repeated Falls, Generalized Anxiety Disorder, and Diverticulosis of Intestine. Medical record review of Resident #12's Annual Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired. Continued review revealed physical restraint use was not coded on the MDS. Medical record review of the Physician's Orders dated 9/1/19, revealed .Restraints .MerriWalker [Merry Walker] [self-enclosed walker/chair combination device] when out of bed to aid ambulation . Medical record review of Resident #12's current comprehensive care plan revealed no documentation of the Merry [NAME] as a restraint. Observation of Resident #12 on 10/22/19 at 1:24 PM, at the nurse's station revealed the resident ambulating independently in the Merry Walker. Continued observation revealed the resident smiling. Interview with MDS Coordinator #1 and the Administrator in Training on 10/22/19 at 10:33 AM, in the MDS office, confirmed the facility failed to care plan Resident #12's Merry [NAME] as a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia with Behavioral Disturbance, Enterocolitis Due to Clostridium Difficile [C- diff, a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon] 10/15/19, Cerebral Infarction, and Hemiplegia and Hemiparesis Following Cerebral Infarction. Medical record review of a Significant Change in Status Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. Continued review revealed the resident was always incontinent of bowel and bladder. Medical record review of the care plan dated 7/17/19 and last revised 8/8/19 revealed .The resident has C. Difficile [clostridium difficile infection] r/t [related to] infection, antibiotic use .CONTACT ISOLATION .Educate resident/family/staff regarding preventive measures to contain the infection . Observation on 10/21/19 at 9:40 AM, of Resident #11's room, revealed a Contact Isolation sign on the door of Resident #11's room with appropriate PPE hanging on the door available for staff use. Observation on 10/21/19 at 12:55 PM, in Resident #11's room, revealed CNA #1 opened up the resident's lunch tray without the use of a gown or gloves. Continued observation revealed CNA #1 touched Resident 11's over bed table with her bare hands. Further observation revealed CNA #1 then walked around the bed and leaned over the bedside to adjust items on the meal tray with her contaminated hands. Continued observation revealed the CNA #1's clothing came in contact with the side of Resident #11's bed. Interview with CNA #1 on 10/21/19 at 3:13 PM, in the hallway, confirmed she had entered Resident #11's room to deliver the lunch tray without wearing a gown or gloves. Further interview confirmed she touched the over bed table with her bare hands and leaned over the bed to adjust items on Resident #11's meal tray and her clothing came into contact with the resident's bed. Interview with the Infection Preventionist on 10/22/19 at 4:14 PM, in the conference room, confirmed staff were expected to wear gown and gloves when entering a contact isolation room for a resident with clostridium difficile infection. Based on facility policy review, medical record review, observation, and interview, the facility failed to follow infection control practices for isolation precautions for 2 residents (#4 and #11) of 2 residents on isolation precautions of 14 sampled residents. The findings include: Review of the facility policy Isolation Precautions Policy last revised 4/21/16 revealed .To interrupt the spread of infection by controlling transmission of highly infectious pathogens .Contact Precautions .for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment .Wear gloves when entering the room if your hands will have contact with the patient or times [items] in the patients room .Wear a clean gown when entering room if your clothing will have contact with the patient or items in the patient's room, or if the patient is incontinent [have no control over urination or defecation] .Droplet Precautions .Patient Placement .Door should be kept closed .Private room is indicated .Masks should be worn when entering room and must be worn if working within 3 feet of the patient .Obtain Isolation cart [cart containing personal protective equipment (PPE)] from central supply or clean storage room .Place Isolation sign on door .All associates entering an isolation room must carry out appropriate techniques . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), Hemiplegia and Hemiparesis Right Side, Type 2 Diabetes, Vascular Dementia with Behavioral Disturbance, Shortness of Breath, and Chronic Kidney Disease. Medical record review of laboratory result dated 10/21/19 revealed .Sputum .Methicillin Resistant Staph Aureus (MRSA) isolated .Called to and read back .This organism requires contact isolation. If isolation is not currently being used, place patient in isolation per infection control policy . Continued review revealed Licensed Practical Nurse (LPN) #1 initialed the laboratory result and wrote .MD .aware 10:20 AM .faxed . Medical record review of a telephone order dated 10/21/19 at 10:20 AM revealed .Respiratory Isolation . Medical record review of a nurse's note dated 10/21/19 at 3:18 PM revealed .Lab called a medic alert. MRSA in sputum, MD [medical doctor] .called and made aware at 10:20 AM .Respiratory isolation, droplet precaution . Observation on 10/21/19 at 12:00 PM, of Resident #4's room, revealed no isolation sign indicating isolation or see the nurse before entering the resident's room to alert visitors or staff regarding isolation. Continued observation revealed Certified Nursing Assistant (CNA) #2 adjusting Resident #4's oxygen nasal cannula without the use of PPE. Interview with the Administrator in Training on 10/21/19 at 12:00 PM, at the nurse's station, confirmed the resident had not been placed in respiratory isolation as ordered by the physician. Interview with CNA #2 on 10/21/19 at 12:35 PM, in the dining room, confirmed she was unaware Resident #4 had a respiratory infection which required respiratory isolation when she adjusted the resident's oxygen nasal cannula. Interview with the Infection Control Preventionist on 10/22/19 at 12:45 PM, in the conference room confirmed .as soon as you find out [resident has infection requiring isolation] they should be put in isolation immediately .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to ensure a complete medical record for 1 resident (#49) of 27 residents sampled. The findings include: Review of the facility policy Advance Directives revised 2/23/17, revealed .Documentation of advance directives and decisions regarding health care choices will be maintained in the resident's medical record . Further review revealed .Physician Order for Scope of Treatment (POST) .includes end of life treatment options to be discussed between physician and his/her patient . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including Dementia, Type 2 Diabetes, Hypothyroidism, Chronic Atrial Fibrillation, and Edema. Medical record review of Resident #49's current comprehensive care plan, last revised 11/6/18, revealed .Advanced Directives Full Code Status . Medical record review of the POST form dated 1/13/16 revealed the following sections were either incomplete or blank: Section B Medical Interventions was incomplete; Section C Artificially Administered Nutrition was incomplete; Section D The Basis for These Orders Is was incomplete; Signature of Patient .Guardian/Health Care Representative was incomplete; and the Health Care Professional Preparing Form was blank and incomplete. Interview with the Assistant Director of Nursing on 11/26/18 at 4:23 PM, at the nurse's station confirmed .it is missing a whole lot . Continued interview confirmed the facility failed to ensure the POST form was complete.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary pantry and kitchen with foods items not stored in a container with a tight-fitting lid, undated foods, unlabeled foods, and open to air food items, in 1 of 1 pantry and in 1 of 1 kitchen for the nursing home potentially affecting 54 residents. The findings include: Review of the facility policy Use and Storage of Food brought to Residents from the Outside, last revised 1/2018, revealed .Food brought in by family or other visitors is permitted, provided care is taken to ensure food is handled properly for safe and sanitary storage, and consumption .If the prepared food is not served immediately to the resident, the food must be stored in a container with a tight-fitting lid, clearly labeled with the resident's name and room number, the date the food was brought in to the resident . Review of the facility policy Food and Supply Storage, last revised 1/2017, revealed .All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Cover, label and date unused portions and open package .products are good through the close of business on the date noted on the label . Observation and interview with Dietary Manager (DM) #1 on 11/26/18 at 9:04-9:14 AM, in the pantry area, of the stand-alone refrigerator revealed: A) One 8 x 9 inch Styrofoam plate loosely covered with aluminum foil containing: ham, corn bread dressing, whole corn, and mashed potatoes with 50% consumed. Continued observation revealed the plate of food was undated, not in a container with a tight-fitting lid, and available for resident use. B) One 8 x 9 inch styrofoam plate loosely covered with aluminum foil containing 3 servings of pecan pie with 50% consumed. Continued observation revealed the plate of food was undated, not stored in a container with a tight-fitting lid, and available for resident use. C) One 8 x 9 inch styrofoam plate loosely covered with aluminum foil containing two servings of chocolate cake with 50% consumed, 1 slice of cherry pie partially consumed with a used plastic spoon and fork laying on the slice of cherry pie, 1/3 serving of apple pie with 50% consumed. Continued observation revealed the plate of food was undated, not stored in a container with a tight-fitting lid, and available for resident use. D) One 9 by 12 inch styrofoam plate containing cornbread dressing, whole corn kernels, mashed potatoes, green peas, ham with 50% consumed. Continued observation revealed the plate of food was undated, not stored in a container with a tight-fitting lid, and available for resident use. E) One 10 inch aluminum circle pie pan containing banana pudding, cherry soufflé, and marshmallow cream dessert, with approximately 50% of the food consumed. Continued observation revealed the food was undated, not stored in a container with a tight-fitting lid, and available for resident use. F) One 20 fluid ounce bottle of orange liquid appropriately 75% full, not labeled with a resident name, undated and available for resident use. G) One 10 fluid ounce bottle of water appropriately 50% full, not labeled with a resident's name, undated, and available for resident use. Interview with DM #1, at the same time as the observation, confirmed the food in the styrofoam plates was brought in by family or other visitors and stored in the pantry refrigerator. Continued interview confirmed DM #1 was unaware of how long the food had been in the pantry refrigerator. Further interview confirmed the food from the styrofoam plates had been placed back in the refrigerator after being partially consumed. Further interview confirmed the facility failed to maintain a sanitary pantry with foods stored in the refrigerator after being partially consumed, dirty used forks and spoons left in styrofoam plates, food items not stored in a container with a tight-fitting lid, and no date on the food items to inform staff when the food was stored in the refrigerator. Observation and interview with DM #1 on 11/26/18 at 9:21 AM of the countertop area in the pantry, revealed one 18 ounce box of cereal approximately 50% full in a plastic bag open to air, undated, and available for resident use. Interview with DM #1confirmed the facility failed to maintain a sanitary pantry with undated and unlabeled food. Observation and interview with DM #2 on 11/26/18 at 9:38 AM, in the kitchen, of the bread stand revealed: A) One 2 pound bag of bread containing 4 slices of bread open to air, and available for resident use. B) One 2 pound bag of bread containing 2 slices of bread open to air, and available for resident use. Interview with DM #2 confirmed the facility failed to maintain a sanitary kitchen with food items open to air, and available for resident use. Observation and interview with DM #2 on 11/26/18 at 9:43 AM, in the kitchen, of supplies over the prep table, revealed one 32 ounce bag of bread crumbs appropriately 50% full opened to air and available for resident use. Interview confirmed the facility failed to maintain a sanitary kitchen with food items open to air, and available for resident use. Observation with DM #2 on 11/26/18 at 9:46 AM, in the kitchen, of the walk-in freezer, revealed one brown bag of french fries approximately 1/3 full, open to air, undated, and available for resident use. Interview with DM #2 confirmed the facility failed to maintain a sanitary kitchen with food items open to air, undated, and available for resident use. Observation with DM #2 on 11/28/18 at 10:14 AM, in the kitchen, of the stand-alone cooler #1, revealed twelve pancakes in a clear plastic bag, on a shelf, undated with a use by date, and available for resident use. Interview with DM #2 confirmed the pancakes needed a use by date listed on the bag or a hand written date on the bag of pancakes. Continued interview confirmed the facility failed to maintain a sanitary kitchen with undated food items available for resident use.