**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #9, Resident #367, and Resident #371) residents reviewed for resident rights. The facility failed to ensure CNA A and CNA B knocked on Resident #9, Resident #367, and Resident #371's door when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #9's Face Sheet dated 02/06/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9's diagnoses included hypertension (high blood pressure), hyperlipidemia (high cholesterol), hyperthyroidism (excessive production of thyroid hormones), muscle weakness, unsteadiness on feet, cognitive communication deficit (problems with communication), epilepsy (seizure disorder), insomnia (sleep difficulty), post-traumatic stress disorder and constipation. Record review of Resident #9's Quarterly MDS assessment dated [DATE] revealed that Resident #9's BIMS score was 15 which means resident had intact cognition. Review of Resident #367's Face Sheet dated 02/06/2025 revealed he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #367's diagnoses included muscle spasm, reduced mobility, history of falling, elevated white blood cells, hypertension (high blood pressure), gout (inflammatory arthritis with recurring attacks of pain in a red, tender, hot and swollen joint ), syncope and collapse (fainting), heart disease, unsteadiness on feet, fluid overload, dysphagia (difficulty swallowing), hypomagnesemia (low magnesium in the blood), cognitive communication deficit (problems with communication), type 2 diabetes mellitus without complications (high blood sugar), and retention of urine. Record review of Resident #367's Quarterly MDS assessment dated [DATE] revealed that Resident #367's BIMS score was 06 which means resident had severe cognitive impairment. Review of Resident #371's Face Sheet dated 02/06/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #371's diagnoses included hypertension (high blood pressure), hyperlipidemia (high cholesterol), hyperthyroidism (excessive production of thyroid hormones), chronic obstructive pulmonary disease (chronic progressive lung disease), muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, cognitive communication deficit (problems with communication), reduced mobility, need for assistance with personal care, history of falls, nausea and constipation. Record review of Resident #371's Quarterly MDS assessment dated [DATE] revealed that Resident #371's BIMS score was 13 which means resident had intact cognition. Observation done on 300 hall on 02/04/2025 at 11:59am revealed CNA A did not knock on Resident #367 and Resident #371's door before entering the residents' room. Observation done on 600 hall on 02/04/2025 at 12:14 pm revealed CNA B did not knock on Resident #9's door before entering the resident's room. During an interview with Resident #367 on 02/06/2025 at 8:07am he said that staff do not knock all the time on Resident #367's door. He stated that he would prefer that the staff knock all the time. He also said that he does not get upset when staff do not knock. During an interview with Resident #371 on 02/06/2025 at 9:12am she said staff do not always knock on the Resident #371's door. She said that she would prefer for them to knock all the time especially at night. She also said that sometimes when staff leave to go get something, when they come back, they do not knock. During an interview with Resident #9 on 02/06/2025 at 8:31am she said that staff do not knock all the time. She said the staff do not knock at least two or three times a day. She said that staff will not knock if they forgot something. She said she does not get upset when staff do not knock. She said that she would like for the staff to knock but it did not bother her if the staff did not knock. During an interview with CNA B on 02/06/2025 at 10:26am she said she had been trained on resident rights. She said that staff were supposed to knock on the residents' doors any time staff wanted to enter the resident's room. She said that residents may feel that staff are rude for not knocking. She also said that the facility was their home, and she would not want anyone just walking into her house. She said the nurse was responsible for monitoring to ensure staff knocked on residents' doors. She said knocking was monitored by observations. She also said she did not know why she did not knock on Resident #9's door. She said she knows she was supposed to knock. During an interview with the DON on 02/06/2025 at 10:51am she said that she had been trained on resident rights. She said staff were to knock on the residents' doors before entering. She said that if staff had their hands full, they should be saying knock, knock before entering. She said that residents might not like someone just walking in. She also said that the residents need to know someone is entering their room. She said she was not sure why staff were not knocking before entering residents' rooms. She said that it was not usual practice. She said all management were supposed to monitor to ensure staff were knocking on residents' doors. She said it was monitored by frequent rounding. During an interview with CNA A on 02/06/2025 at 2:16pm she said that she had been trained on resident rights. She said that staff were to knock on the residents' doors every time they wanted to enter the resident's room. She also said that staff were to introduce themselves and inform the resident what was going to be done. She said that staff would not want anyone to just walk into their home and the resident might see it as rude. She said that she did not know why she did not knock on Resident #367 and Resident #371's door, but she knows she should have. She said the nurse was responsible for ensuring that staff were knocking. She said it was monitored by observations and that the nurses are always on the halls. During an interview with the ADM on 02/06/2025 at 1:34pm she said that she had been trained on resident rights. She said that staff were supposed to knock, announce themselves and wait for the resident to invite them in. She also said that the staff should also let the resident know why they are there. She said if staff do not knock that is a violation of the resident's privacy. She said staff may not have knocked because they were in a hurry, but she can only guess. She said that the facility had a monitoring tool in place. She said that management or charge nurses were responsible for monitoring. She said knocking was monitored through the monitoring tool and that she watches for patterns of not knocking. Record review of Quality-of-Life Policy (not dated) revealed that Staff members are trained and reminded to respect each resident's private space and property. Staff members knock on room doors and request permission to enter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. Also, provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 6 of 11 residents (Resident #52, Resident #63, Resident #10, Resident #8, Resident #97, and Resident #46) reviewed for infection control. The facility failed to ensure [NAME] E was practicing proper hand hygiene while preparing foods and CNA C while lunch passing trays. This failure could place residents who were served from the kitchen at risk for consuming contaminated food, developing foodborne illnesses, and decreased quality of life. Findings included: Record review of Resident #52's face sheet reflected an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses of dementia (a group of thinking and social symptoms that interfere with daily functioning), rheumatoid arthritis (A chronic inflammatory disease that affects the joints, resulting in painful joints, swelling and stiffness in the joints), Parkinson's disease (a nervous system disorder due to reduced levels of dopamine), chronic kidney disease, and major depressive disorder. Record review of Resident #52's Quarterly MDS Assessment, dated 10/30/24, reflected the resident had a BIMS Score of 12, which indicated the resident had a moderate cognitive impairment. Resident #52 required verbal cues and/or touching assistance to eat her meal. Record review of Resident #52's undated Care Plan reflected a focus area of ADL self-care performance. Interventions included staff provided supervision with meal set-up. Record review of Resident #63's face sheet reflected a [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses of diabetes mellitus type 2, polyneuropathy (condition in which a person's peripheral nerves are damaged, affecting the nerves in your skin, muscles, and organs), polyarthritis (medical definition of arthritis that affects five or more of your joints), pain, hypertension, and major depressive disorder. Record review of Resident #63's Quarterly MDS Assessment, dated 12/19/24, reflected the resident had a BIMS Score of 15, which indicated the resident had no cognitive impairment. Record review of Resident #26's Care Plan reflected a focus area for ADL self-care. Interventions included Resident #26 was able to feed self, required delivery and set-up of tray and assist with meal as needed. Record review of Resident #10's face sheet reflected an [AGE] year-old female who admitted to the facility on [DATE]. She had diagnoses of Alzheimer's disease, dementia (a group of thinking and social symptoms that interfere with daily functioning), chronic obstructive pulmonary disease (chronic lung disease), dysphagia (difficulty swallowing), pulmonary embolism (history of a blood clot in lung), and hypertension. Record review of Resident #10's Quarterly MDS Assessment, dated 11/17/2024, reflected the resident had a BIMS Score of 3, which indicated the resident had severe cognitive impairment. Record review of Resident #10's Care Plan reflected she needed the assistance of one staff to eat. Record review of Resident #8's face sheet reflected a [AGE] year-old male who admitted to the facility on [DATE]. He had diagnoses of anoxic brain damage (when the brain is deprived of oxygen for an extended period of time, leading to cell death and brain damage), age-related physical debility (gradual decline in physical function and strength that occurs with aging), diabetes mellitus type 2, dysphagia, chronic pain, hemiplegia, and hemiparesis ( following cerebral infarction (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), dementia (a group of thinking and social symptoms that interfere with daily functioning), and traumatic brain injury. Record review of Resident #8's Quarterly MDS Assessment, dated 01/01/25, reflected the resident had a BIMS Score of 6, which indicated the resident had a severe cognitive impairment. The MDS further reflected Resident #8 was dependent with eating and required staff to assist him with meals. Record review of Resident #8's Care Plan reflected he was dependent on staff for meeting his physical needs related to immobility and physical limitations. Observations of [NAME] E preparing food on 02/04/2025 at 9:11 AM, revealed that [NAME] E threw trash away without washing or sanitizing their hands before going back to preparing food. [NAME] E was witnessed on one occasion using the trashcan foot press to open the trashcan lid to dispose of trash but used their right hand without wearing gloves to close the lid and put on a new pair of gloves without hand washing in between. In another observation, [NAME] E touched the trashcan lid again and returned to the prepping station to grab a tray of baked cornbread with their bare hands without handwashing in between. [NAME] E went on to touch the food warming station and food prep counter before putting on gloves without hand washing and sanitization. It was observed throughout the kitchen area posted signs for proper hand hygiene. An observation on 02/04/25 at 12:00 PM revealed CNA C exited a resident's room and picked up a lunch tray for Resident #52 and brought it into her room. CNA C did not conduct hand hygiene between the residents. CNA C then went to the nurse's station for a cup of ice and brought it to Resident #52. CNA C was then observed bringing a lunch tray to Resident #63, who was Resident #52's roommate. CNA C did not conduct hand hygiene between residents. CNA C brought a lunch tray to Resident #8 and then to Resident #97, who was Resident #8's roommate. CNA C did not conduct hand hygiene between the residents. CNA C then brought a tray to Resident #10, and with no hand hygiene conducted she brought a lunch tray to Resident #46. CNA C was then observed conducting hand hygiene from a hand sanitizer unit located on the wall. An interview on 02/04/25 at 12:18 PM revealed CNA C had forgotten to conduct hand hygiene when passing lunch trays. CNA C stated the importance of conducting good hand hygiene during resident care was to prevent the spread of infection, and the impact on the resident could be an infection. In an interview with [NAME] F on 02/05/2025 at 10:00 AM, it was found that [NAME] E quit and no longer works at the facility. [NAME] F and Dietician stated that [NAME] E quit without notice that morning. Due to [NAME] E quitting and no longer working at the facility as of 02/05/2025, additional observations of [NAME] E and full interview with [NAME] E was not able to be conducted to discuss sanitary food preparation and hand hygiene. In an interview with Dietician on 02/06/2025 at 11:05AM, Dietician stated the following: the expectations when it comes to hand hygiene is for all kitchen staff to maintain cleaning and washing hands in between changing gloves, handling objects, and during prepping food. Dietician stated the reasoning to follow hand hygiene is to not cross-contaminate foods such as, meats, vegetables, fruits, and or other potential kitchen surfaces. Dietician H stated the expectation is for everyone that enters the kitchen area to follow those guidelines the facility has in place. In an interview with [NAME] G on 02/05/2025 at 11:10 AM, [NAME] G stated the following: the expectations for maintaining hand hygiene are making sure fingernails are clean. [NAME] G stated staff are to make sure to wash hands in between any transferring of food, changing gloves, and making sure there is no chance of cross-contamination. [NAME] G stated everyone who enters the kitchen is to wash hands for 30 seconds and to help with keeping track of 30 seconds, they can sing the Happy Birthday song or say the ABC's. [NAME] G stated no one should be touching the trashcan lid and touching food after can cause issues. [NAME] G stated if that was witnessed, then it would be brought up to that person to not do that again and explain the reasoning as it could harm a resident, and make sure they wash their hands. [NAME] G stated if staff are not following hand hygiene, it can lead to a resident getting sick or lead to serious harm if they have a lower immune system and it could potentially be fatal. [NAME] G stated it's expected that hand washing is to be followed. In an interview with Administrator on 02/05/2025 at 11:16 AM, Administrator stated the following: the expectations for washing and cleaning hands in the kitchen area are to be followed. Administrator stated it's expected that before touching anything in the kitchen, staff are to wash their hands. Administrator stated staff are expected to maintain hand washing in between touching objects or handling foods including during glove changing. Administrator stated if not followed, it could cause harm to a resident wearing or without wearing gloves if hand washing in between isn't followed. Administrator stated kitchen staff should not be touching the trashcan and then grabbing any surfaces or food, they are expected to wash their hands. Administrator stated staff not following hand hygiene can get a resident sick or cause potential harm to residents with a lower immune system. Administrator stated they teach staff by conducting repeat demonstrations methods in which they show the staff member how to appropriately handle food and follow through with hand hygiene, then have the individual demonstrate proper food handling and cleanliness. Administrator stated Infection Preventive does 10 random monthly observations to monitor hand hygiene and proper handling of food. Administrator stated Dietician and Infection Preventive go in monthly to teach kitchen staff about safety, hygiene, and food handling to prevent cross-contamination and foodborne illness. Administrator stated that all staff go through in-service trainings and have been trained. An interview on 02/06/25 at 01:43 PM with the DON revealed it was the charge nurse, ADON, IP, and ultimately the DON responsibility for ensuring staff members were conducting hand hygiene between each resident when passing meal trays on the halls. The DON stated her expectation was for all staff to be conducting hand hygiene between each resident when passing trays in hallways. The DON stated she would conduct hand hygiene before getting started, and then conduct hand hygiene between each resident when passing meal trays on hallways. Record review of the Kitchen Hand Hygiene Policy dated 2018 stated the following: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Foodservice employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Procedure: 1. Hand-washing Stations a. Make sure hand washing stations are in food preparation areas to encourage employees to wash their hands frequently. b. Make sure there are hand-washing stations in all areas that employees hands may become contaminated, including food preparation areas, service areas, dishwashing areas and restrooms. c. Make sure all hand-washing stations are equipped with the following: i. Hot and cold running water. ii. Hand-cleaning liquid, powder or bar soap. iii. Individual, disposable towels, a continuous towel system that supplies the user with a clean towel or a heated-air hand-drying device. iv. A receptacle for disposable towels. v. A sign that indicates employees must wash hands before returning to work. d. Sinks used for food preparation or washing utensils, or a service sink or curbed cleaning facility used to dispose of mop water or similar wastes cannot be used as a hand-washing station. 2. Hands should be washed after the following occurrences: a. a. Using the Restroom b. Handling raw food (before and after) c. Touching the hair, face, or body Sneezing or coughing d. Smoking f. Eating or drinking g. Handling chemicals h. Taking out garbage i. Clearing tables j. Touching clothing or aprons k. Touching un-sanitized equipment, work surfaces, or wash cloths l. Assisting residents 3. Hand-washing steps a. Wet hands and exposed arms with hot water at least 100°F. b. Apply soap. c. Scrub hands, exposed arms and fingernails for a minimum of 20 seconds being sure to apply a vigorous friction. d. Rinse hands and exposed arms thoroughly under hot running water. e. Dry hands and arms with a paper towel. f. Turn off the faucet with the paper towel to avoid contaminating hands and discard towel. Review of 2022 Food Code 2-301.14 states: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD. A record review of the facility's policy titled Infection Control - Surveillance for Infections dated September 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for pharmaceutical services. The facility failed to administer Resident #1's Amlodipine and Metoprolol (blood pressure medications) for eight days after being admitted to the facility on [DATE]. This failure could affect residents by putting them at risk of exacerbation and/or deterioration of their health conditions. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular/rapid heart rhythm), history of stroke and heart attack, and hypertension (high blood pressure). Review of Resident #1's admission MDS assessment, dated 11/13/24, reflected a BIMS was not completed. Section I (Active Diagnoses) reflected she had hypertension. Review of Resident #1's admission care plan, dated 11/11/24, reflected she had altered cardiovascular status r/t acute stroke, hyperlipidemia (high cholesterol), hypertension, and A-fib with an intervention of administering medications per MD orders. Review of Resident #1's hospital discharge paperwork, dated 11/11/24, reflected orders for the following medications: Amlodipine Besylate Oral Tablet - 2.5 MG - once a day; Metoprolol Succinate ER Oral Tablet - take 25 MG once a day. Review of Resident #1's physician order, with a start date of 11/12/24 and a D/C date of 11/12/24 reflected Amlodipine Besylate Oral Tablet - 2.5 MG - give one tablet by mouth one time a day for HTN and Metoprolol Succinate ER- 25 MG Tablet - Give 1 tablet by mouth at bedtime related to HTN. . Review of Resident #1's November 2024 MAR, reflected she was administered Amlodipine and Metoprolol on 11/12/24. Review of Resident #1's blood pressure readings in her EMR, dated 11/21/24, reflected the following: 11/21/24 7:56 AM - 200/90 mmHg 11/21/24 8:00 AM - 200/90 mmHg 11/21/24 8:01 AM - 200/90 mmHg Review of Resident #1's physician order, with a start date of 11/21/24, reflected Metoprolol Succinate ER- 25 MG Tablet - Give 1 tablet by mouth one time a day related to HTN. Review of Resident #1's November 2024 MAR reflected Amlodipine and Metoprolol were administered on 11/12/24 and no blood pressure medications were administered again until 11/21/24 when she was administered Metoprolol. During a telephone interview on 12/11/24 at 12:54 PM, LVN A stated Resident #1 was admitted from the hospital with blood pressure medication. He stated he gave the orders to the NP who okayed them, and he put them in the system. He stated he never discontinued the orders . During an interview on 12/11/24 at 1:46 PM, the DON stated there was a miscommunication between the nurse and NP regarding Resident #1's medications upon admission. She stated the NP wanted to discontinue one of the blood pressure medications and verbally told the nurse. She stated somehow both of the blood pressure medications got discontinued. She stated after this incident she conducted in-services on following hospital discharge orders and putting in orders after NP verification. She stated they no longer allow just a verbal order if the NP is in the facility. She stated a negative outcome of not being administered prescribed blood pressure medication could be a lot of things including cardiac issues . Review of a grievance form, dated 11/20/24 and voiced by Resident #1's RP, reflected the following: Concern/Details: Complaint of high BP and no one did anything about it . Meds were changed and discontinued that weren't to be changed . Action Taken: NP Restarted BP meds in question. Review of the facility's Medication and Treatment Orders Policy, revised July 2016, reflected the following: Orders for medications and treatments will be consistent with principles of safe and effective order writing. . 7. Verbal orders must be signed (written or e-signed) by the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 6 residents (Residents #1, and #2) reviewed for infection control, as indicated by: The facility failed to ensure MA A cleaned and disinfected the wrist blood pressure monitor while using it on Residents in Hall 6 of the facility; on Resident #1 and Resident # 2. This failure could place the residents at risk of transmission of disease and infection. Findings included: Review of Resident #1's face sheet dated 08/01/24 reflected, Resident #1 was admitted to the facility on [DATE]. She was a [AGE] year-old female diagnosed with Type 2 Diabetes, Legal Blindness, Muscle weakness, Reduced Mobility, Hypertension, and Retention of Urine. Record review of Resident #1's MDS assessment dated [DATE], reflected her BIMS score was 03, indicating her cognition was severely impaired. Record review of Resident #1's care plan dated 07/05/24 revealed she had hypertension with the potential for abnormal blood pressures and the relevant intervention was monitoring the hypertension. Review of Resident # 1's MAR for August 2024, reflected: Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate): Give 10 mg by mouth one time a day related to Essential (primary) Hypertension. Notify NP of SBP >165. Review of Resident #2's face sheet, dated 08/01/24, reflected Resident #2 was admitted to the facility on [DATE]. She was an [AGE] year-old female diagnosed with Pain, COPD, Muscle Weakness, Dysphagia (Difficulty to swallow), Need for Assistance with Personal Care, and Cognitive Communication Deficit. Record review of Resident #2's quarterly MDS dated [DATE], reflected her BIMS was 03, indicating her cognition was severely impaired. Record review of Resident #2's care plan dated 06/20/24 revealed, she was potential for fluid volume deficit related to diuretic use and the relevant intervention was monitoring /documenting/reporting PRN any sign and symptoms of dehydration. Review of Resident #2's MAR for August 2024 reflected: Furosemide Oral Tablet 20 MG (Furosemide): Give 1 tablet by mouth one time a day for pleural effusions hold for SBP less than or equal to 110. An observation on 08/01/24 at 11:10 a.m., revealed MA A failed to sanitize the wrist blood pressure monitor before and after using it on Resident #1 and Resident #2. There were 37 residents residing on Hall 6. MA A was administering medications on Hall 6, and at that time, out of 37 residents, 3 residents were left for receiving medication. MA A took the blood pressure of Resident #1 with the wrist blood pressure monitor and without sanitizing the monitor; she kept it on the top of the medication cart. After administering the medications to Resident #1, she moved on to Resident #2 and used the same blood pressure monitor on her without sanitizing it. When the investigator asked for sanitizing wipes, MA A searched all the drawers of the med cart approximately for about 30 seconds and stated most likely it was taken away by her colleague. She then searched the drawers once again thoroughly and found one packet of sanitizing wipe in one of the deep corners of a drawer. During an interview on 08/01/24 at 1:30 p.m., the DON stated she was already informed by MA A that she forgot to sanitize the blood pressure cuff in between the residents. The DON added, however, she was not aware that this noncompliance occurred with all the residents in Hall 6. The DON stated the facility policy provided very clear guidelines about the importance of sanitizing medical equipment. She stated the expectation was, the nursing staff followed the facility policy/procedure for handwashing and sanitization of medical equipment that included sanitizing the blood pressure monitor, every time after the use on residents. She added, this was essential to stop spreading transmittable diseases. Review of the in-service records from 04/01/24 to 07/16/24 revealed there were no in-services conducted on disinfection of medical equipment. Review of facility's policy titled Cleaning and disinfection of Resident care Items and equipment revised in October 2018 reflected: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogens standard . 1. The following categories are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care d. Reusable items: They are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for 1 of 21 residents (Resident #29) reviewed for advance directive. Resident #29's Out of Hospital Do Not Resuscitate order did not have a physician's signature. This failure placed residents at risk of traumatic, undesired resuscitation. Findings included: Review of the undated face sheet for Resident #29 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of cerebral infarction, stage, three, chronic kidney disease, muscle wasting and atrophy, protein, calorie, malnutrition, vascular, dementia, reduced mobility, repeated, falls, age related, physical debility, malaise history of transient, ischemic, attack, asthma, benign, prosthetic, hyperplasia, bipolar disorder, cognitive, communication deficit, irritable, bowel syndrome, anxiety, disorder, major depressive disorder, hyper lipidemia, hypertension, and insomnia. Review of the quarterly MDS assessment for Resident #29 dated [DATE] reflected a BIMS score of 08, indicating moderate cognitive impairment. Review of the care plan for Resident #29 dated [DATE] reflected the following: Advanced Directives General PT IS NOW DNR CODE STATUS. Resident's Advanced Directives Wishes Will Be Known. Review Advanced Directives on file, if applicable. Review of the Out of Hospital DNR for Resident #29 dated [DATE] reflected there was no physician signature on the document. During an interview on [DATE] at 03:08 PM, the SW stated she was responsible for ensuring the Out of Hospital DNRs were completed. She stated she was sure she had prepared Resident #29's OOHDNR, though she could not remember it exactly. The SW stated a physician signature was required for the DNR to make it legal. She stated the potential negative impact on a resident of not having a legal OOHDNR on file was they could receive CPR, which would be dreadful . The SW stated she had learned from this situation that she needed to put a more official procedure in place to monitor to ensure residents who wished to have a DNR status had their wishes honored. During an interview on [DATE] at 03:51 PM, the DON stated the SW was responsible for ensuring OOHDNRs. The DON stated they monitor to ensure the DNRs are legal by using a checklist for all new admissions. The DON stated they reviewed in quarterly IDT meetings for each resident, as well. The DON stated they entered an order for each OOHDNR, and she was not sure how the physician signature on Resident #29's DNR was missed. The DON stated the potential negative impact of such a failure was first responders might not have the right information, and that could result in a resident who did not want to prolong end of life being treated as if he were a full code. Review of facility policy dated [DATE] and titled Advance Directives reflected the following: Advanced directives will be respected in accordance with state law and community policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for 1 of 6 halls (hall 600) and 1 of 24 residents (Resident #11) reviewed for accident hazards. The shower room located next to room [ROOM NUMBER] was unlocked due to a broken lock. Residents had full access to the room. Toxic solutions with poison control warnings and hazardous sharps items were stored in the room unsecured. The locking cabinet inside the room was missing a lock. Resident #11 had an unmonitored bottle of hand sanitizer on the resident bedside table. The bottle had a poison control warning. These deficient practices place residents in the facility at risk for avoidable accidents and hazards. Findings include: A record review of Resident #11's Care Plan and admission record reflects, I have impaired cognitive function I display impaired decision making. Date initiated 12/13/18 Revision 4/28/2020 and a diagnosis of Schizophrenia, unspecified. A record review of Resident #11 MDS assessment reflects MDS Diagnosis indicated as 02 Non-Traumatic Brain Dysfunction Brief interview for Mental Status (BIMS) score is 10 . An observation on 01/03/24 at 09:48 a.m. revealed Resident #11 had a bottle of Purell hand sanitizer on her bedside table. Residents state Mine when the surveyor touched the bottle . She was able to get the bottle herself. The bottle ingredients listed active ingredients as Ethyl Alcohol 70%. The warnings on the label include: do not use in eyes, keep out of reach of children .If swallowed get medical help or contact poison control right away. An observation on 01/03/24 at 10:08 a.m. revealed an unlocked shower room located next to room [ROOM NUMBER]. The room contained an overflowing sharps container with approximately 7 disposable shaving razors laying on top or partially protruding out of the sharp container and dirty nail clippers laying on the sink counter. An unlocked cabinet in the room contained multiple bottles of [NAME] Mouthwash with a product warning saying, Keep out of reach of children. In case of accidental ingestion, seek professional assistance or contact a poison control center immediately. The room also contained overflowing trash container and used bath towels laying on the floor . The door of the shower room had a number pad lock that a passing staff member stated was broken and 2 holes drilled through the door approximately ½ inch in diameter. Paper had been stuffed in the holes to protect privacy. During an interview on 1/3/24 at 10:08a.m. CNA H stated they do not use the shower room on hall 600room for residents as they are bathed in the front shower; it is just used for storage. She said the door should have been locked. She stated that the clippers are dirty and would not be used on a resident. She stated the locking code was out of order. Regarding the risk to residents, CNA H stated that they would have to take the lid off razors to get hurt but it is a possibility. During an interview regarding the shower room on 01/03/24 at 10:21 a.m. RN C stated, so it needs a lock pretty much. She stated the potential risk is harm if a patient gets in. She denied knowing when the lockwent out of service. During an interview on 1/5/24 at 3:33 pm ADON stated that her expectations on areas with hazardous material was I wouldn't want them going in there. She stated that overflowing sharps containers should be changed at the full line and that she would consider that hazardous if they were overflowing. ADON stated that alcohol hand sanitizers should up out of reach from residents-Ideally locked up. She stated that she would consider unmonitored mouthwash and alcohol sanitizers to be potentially hazardous for cognitively impaired residents. She said the potential risk would be if residents were to get these items, confused resident could ingest them. During an interview on 1/5/24 at 4:12 pm DON stated that her expectations on areas with hazardous material for residents was Expect they can't get to the material. She stated that overflowing sharps containers should be emptied, locked, secured and put away in the Biohazard room and that she would consider that hazardous if they were overflowing. DON stated that regarding alcohol hand sanitizers in patient rooms Ideally no but, some have preferences after covid. We try to avoid that happening. She stated that she would consider unmonitored mouthwash and alcohol sanitizers to be potentially hazardous for cognitively impaired residents. She said the potential risk to residents would be Poison control - risk of ingesting. During an interview on 1/5/24 at 4:45 pm ADM stated that her expectations on areas with hazardous material for residents was the areas should be locked and residents do not have access. She stated that overflowing sharps containers should not exist and that they would consider them very much so a hazard. The ADM stated that alcohol hand sanitizers in resident's room should not be accessible to them. She said unmonitored mouthwash and alcohol hand sanitizer could possibly be hazardous for cognitively impaired resident depending on ingredients. They should not have access. ADM stated the risk would be that they could get ill to the point of harm. A record review of the policy titled Sharps Disposal Policy Statement from the Infection Control Section of Nursing Services Policy and Procedure Manual for Long Term Care 2001 Med-Pass, Inc,(Revised January 2012) reflects Designated individuals will be responsible for sealing and replacing containers when they are full to protect employees from punctures and/or needlesticks when attempting to push sharps in to the container. A record review of the policy titled Hazardous Areas, Devices and Equipment from the Resident Safety Section of Nursing Services Policy and Procedure Manual for Long Term Care 2001 Med-Pass, Inc,(Revised January 2017) reflects, All hazardous areas, devices and equipment in the community will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. The policy also reflects, Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous .The safety committee will periodically check for the implementation and integrity of measures intended to prevent residents from accessing hazardous areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 24 residents (Resident #42) reviewed for pharmaceutical services. The facility failed to ensure that Resident #42 received his medications on the morning of 01/03/24. This failure placed residents at risk of not receiving medication therapy. Findings included: Review of the undated face sheet for Resident #42 reflected a [AGE] year-old male admitted to the facility on [DATE] with chronic obstructive pulmonary disease, type two diabetes mellitus, obstructive sleep apnea, atrial fibrillation, morbid obesity due to excess calories, lack of coordination, need for assistance with personal care, ataxic gait, age related, physical debility, muscle wasting and atrophy, unsteadiness on feet, insomnia, difficulty in walking, asthma, muscle weakness, vitamin D deficiency, cellulitis, hyperlipidemia, constipation, hypokalemia, edema, anxiety disorder, heart failure, canis of skin and nail, acquired absence of kidney, cognitive communication deficit, major depressive disorder, dementia, obstructive and reflux neuropathy, gastroesophageal reflux disease, and anemia. Review of the annual MDS assessment for Resident #42 dated 12/17/23 reflected a BIMS score of 15, indicating intact cognition. Review of the care plan for Resident #42 last revised 12/18/23 reflected the following: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. Administer ANTIDEPRESSANT medications as ordered by physician Monitor/document side effects and effectiveness Q-SHIFT. Give medications as ordered. Monitor for side effects, effectiveness. Give cardiac medications as ordered. Review of the physician orders for Resident #42 dated 01/05/24 reflected the following: -Flonase Suspension 50 mcg/act 1 spray in both nostrils one time a day for SR start date 04/07/23 -Olmesartan Medoxomil Oral Tablet 20 mg give one tablet by mouth one time a day related to essential hypertension. Hold for SBP less than 110. Start date 06/03/23. -Potassium chloride ER tablet extended release 10 MEQ give 1 tablet by mouth one time a day for hypokalemia start date 11/10/22 -Slow-Mag Tablet Delayed Release 71.5-119 mg (magnesium CL - calcium carbonate) give one tablet by mouth one time a day for hypo magnesium start date 11/10/22 -Tamsulosin HCL capsules 0.4 MG give one capsule by mouth, one time a day related to disorder of kidney and ureter unspecified; obstructive and reflux neuropathy; do not open or crush capsule start date, 01/19/21 -Torsemide oral tablet 20 mg give one tablet by mouth one time a day related to heart failure start date 08/18/23 -Vitamin D3 capsule give 1000 IU by mouth one time a day related to vitamin D deficiency start date 10/15/2022 -Xarelto oral tablet 20 MG give one tablet by mouth one time a day related to paroxysmal atrial fibrillation start date 07/02/23 -Zoloft tablets give 75 MG by mouth, one time a day for depression start date 09/01/20 -Zyrtec allergy tablet 10 MG give one tablet by mouth one time a day related to other asthma start date 08/31/21 -Guaifenesin ER tablet extended release 12 hour 600 MG give one tablet by mouth two times a day for congestion start date 12/27/23 -Tramadol HCL tablet 50 MG 50 MG by mouth two times a day for pain start date 05/12/23 -Tylenol extra strength tablet 500 MG give 1000 MG by mouth two times a day for pain do not exceed 3G in 24 hours Review of the January 2023 MAR for Resident #42 reflected the following medications were documented as administered on 01/03/24 at the respective times listed: -Flonase Suspension 50 mcg/act 09:00 AM by MA L -Potassium chloride ER tablet extended release 10 MEQ 06:30 AM by MA L -Slow-Mag Tablet Delayed Release 71.5-119 mg (magnesium CL - calcium carbonate) 06:00 AM- 10:00 AM by MA L -Tamsulosin HCL capsules 0.4 MG 06:00 AM-10:00 AM by MA L -Torsemide oral tablet 20 mg 06:00 AM-10:00 AM by MA L -Vitamin D3 capsule 06:00 AM-10:00 AM by MA L -Xarelto oral tablet 20 MG 06:00 AM- 10:00 AM by MA L -Zoloft tablets give 75 MG 06:00 AM-10:00 AM by MA L -Zyrtec allergy tablet 10 MG 06:00 AM-10:00 AM by MA L -Guaifenesin ER tablet extended release 12 hour 600 MG 06:00 AM-10:00 AM by MA L -Tramadol HCL tablet 50 MG 06:00 AM-10:00 AM by MA L -Tylenol extra strength tablet 500 MG 06:00 AM-10:00 AM by MA L The following medication was not marked as administered , and there was a blank spot in the administration record: -Olmesartan Medoxomil Oral Tablet 20 mg 06:00 AM-10:00 AM Review of the medication audit document for Resident #42 for 01/03/24 reflected the following actual administration times: -Flonase Suspension 50 mcg/act 12:22 PM by MA L -Olmesartan Medoxomil Oral Tablet 20 mg 06:00 AM-10:00 AM 09:31 PM by the ADON -Potassium chloride ER tablet extended release 10 MEQ 12:21 PM by MA L -Slow-Mag Tablet Delayed Release 71.5-119 mg (magnesium CL - calcium carbonate) 12:20 PM by MA L -Tamsulosin HCL capsules 0.4 MG 12:22 PM by MA L -Torsemide oral tablet 20 mg 12:22 PM by MA L -Vitamin D3 capsule 12:20 PM by MA L -Xarelto oral tablet 20 MG 12:22 PM by MA L -Zoloft tablets give 75 MG 12:21 PM by MA L -Zyrtec allergy tablet 10 MG 12:20 PM by MA L -Guaifenesin ER tablet extended release 12 hour 600 MG 12:22 PM by MA L -Tramadol HCL tablet 50 MG 12:22 PM by MA L -Tylenol extra strength tablet 500 MG 12:20 PM by MA L During an observation and interview on 01/03/24 at 01:27 PM, Resident #42 stated he had not received his morning medication that day. He stated he was not feeling any negative effects, but he was angry about the oversight. He stated he had filed a grievance about the incident. Observation of Resident #42 at this time revealed he was not exhibiting any signs of pain and had no unusual swelling of his extremities. He was not sweating or short of breath, and his skin color was normal. His demeanor was not agitated or resigned; rather he was laughing about the missed medications. During an interview on 01/05/24 at 01:48 PM, MA L stated she was from a staffing agency and had only worked a few times at the facility. She stated she had been assigned to work Resident #42's hall on 01/03/24. She stated morning administration workload could be a little heavy especially when she had to look for the residents somewhere else in the building. MA L stated someone could have told her where Resident #42 would be, but she did not think to ask, and she did not find him in his room. MA L stated when she arrived at his room, he had gone to breakfast, and she cannot administer medications in the dining room. She stated she revisited his room after breakfast, but he was not there, and she did not ask anyone to help her find him. MA L stated by the time she went looking for him, it was past the time for his medications, and they were late. MA L stated he refused his medications at that time. She stated it was close to 02:00 PM on 01/03/24 when he refused his medications officially. She stated she did not report the refusal to a nurse or anyone else. She stated she documented the medications as administered in the MAR, because she did not know what else to do and did not ask. MA L stated the DON had given her an in-service the following day on 01/04/24 about the correct procedure for medication administration and documentation. During an interview on 01/05/24 at 03:54 PM, the DON stated Resident #42 had filed a grievance about not receiving his morning medications on 01/03/24, and she had conducted a one on one in-servicing with MA L. The DON stated when they learned he had not received his morning medications, they had requested and obtained a one-time order to give the medications late , but he refused at that time, even taking his blood pressure. The DON stated she had notified the NP about the missed medications. The DON stated she was not aware of any adverse effect, and the nurses had been monitoring for that. The DON stated she had followed up again herself yesterday 01/04/24 and made sure Resident #42 was okay. The DON stated potential negative impacts of missing doses of the medication Resident #42 missed were Increase in blood pressure, complaints of pain, or fluid overload. During an interview on 01/05/24 at 04:29 PM, the ADM stated she understood the medication aide went to Resident #42 later than the administration window, and he was frustrated and said she was too late. The ADM stated she ensured medications were administered on time by relying on the EMR, which shifts colors and tells the staff when medications were late. She stated the ADON also periodically pulled a report to see if there were any late or missing medications. The ADM stated the potential negative outcome for residents depended on what medications were missed and what they were used for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview, and record review, the facility failed to make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS for 3 of 9 residents (Resident #32, Resident #41, and Resident #103) reviewed for comprehensive assessments. Interviews for activity preferences for Residents #32, #41, and #103 were not completed in the most recent comprehensive MDS assessments. This failure placed residents at risk of not having their recreational needs met. Findings included: Review of the undated face sheet for Resident #32 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure, congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), pleural effusion (accumulation of excess fluid in the area surrounding the lungs), metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), symbolic dysfunctions, need for assistance with personal care, speech disturbances, unsteadiness on feet, muscle weakness, lack of coordination, psychophysiological insomnia (sleep disorder due to imbalances in physical and psychological condition), major depressive disorder, dysthymic disorder (a long term and chronic form of depression), chronic pain, and encounter for palliative care (comfort support for end of life care). Review of the admission MDS assessment for Resident #32 dated 09/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #32 dated 10/03/23 reflected no care planning for activities or activity preferences. It reflected the following: The resident uses antidepressant medication, and The resident has an ADL self-care performance deficit r/t weakness/debility. Encourage the resident to participate to the fullest extent possible with each interaction. Observation and interview on 01/04/24 at 09:25 AM revealed Resident #32 was transferred by mechanical lift from his bed to his wheelchair. The CNAs who transferred him placed his bedside table in front of him with a remote and a pitcher of ice water and asked if he wanted anything else before leaving the room. Resident #32 stated he spent his days at the facility watching television and had nothing to do. He stated he was not sure what he would want to do, because he did not know what there was to do. Review of the undated face sheet for Resident #41 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction (death of brain tissue), aphasia (speech difficulties), history of transient ischemic attack (minor stroke), unsteadiness on feet, reduced mobility, difficulty in walking, protein-calorie malnutrition, weakness, cognitive communication deficit (communication difficulty caused by impaired cognition), fluency disorder (interruption in the flow of speaking), muscle weakness, speech disturbances, bipolar disorder, hearing loss, and lack of coordination. Review of the significant change MDS for Resident #41 dated 10/20/23 reflected a BIMS score of 03, indicating severe cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #41 dated 10/18/23 reflected the following: I can hear okay in some settings but not as well in large groups or large rooms. Has a variety of activity interests and a general willingness to take part in 1:1 activities. I will express daily satisfaction with daily social contacts and leisure activities by next reevaluation date. Encourage low-commitment, short 1:1 duration social activities to gain comfort due to my recent decline. Decrease the background noise. Encourage and praise attendance, engagement and participation within activities. I love to read. I will be offered reading material on a daily bases (sic). I will be offered adapted TV(closed captioning, magnified screen, or earphones). I will make selections and decisions within activities. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Observation on 01/05/24 at 09:36 AM revealed Resident #41 seated in a geriatric chair in the day area between 500 and 600 halls. He was staring toward the wall and made eye contact but did not respond when addressed. Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of humerus fracture (bone of upper arm), dysthymic disorder (a long term and chronic form of depression), epilepsy, history of malignant neoplasm of breast (breast cancer), major depressive disorder, secondary malignant neoplasm of brain (the breast cancer has spread to the brain), protein-calorie malnutrition, weakness, malaise, unsteadiness on feet, lack of coordination, and reduced mobility. Review of the admission MDS for Resident #103 dated 09/30/23 reflected a BIMS score of 13, indicating intact cognition . The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #103 dated 11/21/23 reflected no care planning for activities or activity preferences. It reflected the following: Impaired Coping. Resident Will Demonstrate Effective Coping Mechanisms. Monitor for signs / symptoms of depression. Provide care in a calm and reassuring manner. Observation on 01/05/24 at 08:50 AM revealed Resident #103 sitting on her bed, which was in low position, and touching her shoes and shoelaces. She made eye contact and engaged when approached, but when she tried to speak, her words could not be deciphered. She had an anxious expression on her face and continued to make eye contact as if she were trying to communicate but could not. During an interview on 01/05/24 at 02:37 PM, the AD stated she had been the AD for seven years until last year, had worked in a different role for over a year, and had just gotten back into the role in October 2023. The AD stated she was responsible for the activity preferences section of the MDS. She stated she had noticed a lot of the MDS activity assessments had not been done while she was not in the role. The AD stated she was not waiting until the next comprehensive MDS assessments were due but was catching up on the assessments as she could and triggering the activities task on the quarterly assessments. The AD stated she also completed the care plans, but since the MDS assessments were not conducted, the care plans were not triggered. She stated she was not sure the potential impact on the resident of not having activities assessed or care planned, but some residents might not be able to do the activities they most enjoyed. During an interview on 01/05/24 at 02:55 PM, MDSN A stated he was the MDS nurse for the long-term side of the facility, so he oversaw the assessments, including the activities section. He stated the activities section should have been completed by the AD, but if the sections were not completed, he should have prompted the AD to fill them out. He stated the problem was the assessment questions had been answered with the answers Not Assessed in the most recent comprehensive assessments for Residents #32, #41, and #103, so the section turned green in the EMR, and it made him think they had been completed. During an interview on 01/04/24 at 02:18 PM, the ADM stated the facility used the CMS RAI Manual to determine procedure for MDS assessments and did not have a distinct facility policy. Review of undated facility policy titled Activities Program reflected the following: Complete activity/recreation services assessments are maintained by the activity department and are updated as necessary, but at least annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident for 3 of 8 (Resident #2, Resident #32, and Resident #103) residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #32's and Resident #103's care plans addressed their activity preferences. 2. The facility failed to ensure Resident #2's care plan reflected her current wounds. These failures placed residents at risk of not having interventions in place to address wounds and activities. Findings included: 1. Review of the undated face sheet for Resident #32 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure, congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), pleural effusion (accumulation of excess fluid in the area surrounding the lungs), metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), symbolic dysfunctions, need for assistance with personal care, speech disturbances, unsteadiness on feet, muscle weakness, lack of coordination, psychophysiological insomnia (sleep disorder due to imbalances in physical and psychological condition), major depressive disorder, dysthymic disorder(a long term and chronic form of depression), chronic pain, and encounter for palliative care (comfort support for end of life care). Review of the admission MDS assessment for Resident #32 dated 09/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #32 dated 10/03/23 reflected no care planning for activities or activity preferences. It reflected the following: The resident uses antidepressant medication, and The resident has an ADL self-care performance deficit r/t weakness/debility. Encourage the resident to participate to the fullest extent possible with each interaction. Observation and interview on 01/04/24 at 09:25 AM revealed Resident #32 was transferred by mechanical lift from his bed to his wheelchair. The CNAs who transferred him placed his bedside table in front of him with a remote and a pitcher of ice water and asked if he wanted anything else before leaving the room. Resident #32 stated he spent his days at the facility watching television and had nothing to do. He stated he was not sure what he would want to do, because he did not know what there was to do. During an interview on 01/04/24 at 09:25 AM, CNA Q stated Resident #32 only ever sat in his chair watching television. CNA Q stated hhe ad never seen Resident #32 be offered or participate in any activities. Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of humerus fracture (bone of upper arm), dysthymic disorder (a long term and chronic form of depression), epilepsy, history of malignant neoplasm of breast (breast cancer), major depressive disorder, secondary malignant neoplasm of brain (the breast cancer has spread to the brain), protein-calorie malnutrition, weakness, malaise, unsteadiness on feet, lack of coordination, and reduced mobility. Review of the admission MDS for Resident #103 dated 09/30/23 reflected a BIMS score of 13, indicating intact cognition. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #103 dated 11/21/23 reflected no care planning for activities or activity preferences. It reflected the following: Impaired Coping. Resident Will Demonstrate Effective Coping Mechanisms. Monitor for signs / symptoms of depression. Provide care in a calm and reassuring manner. Observation on 01/05/24 at 08:50 AM revealed Resident #103 sitting on her bed, which was in low position, and touching her shoes and shoelaces. She made eye contact and engaged when approached, but when she tried to speak, her words could not be deciphered. She had an anxious expression on her face and continued to make eye contact as if she were trying to communicate but could not. During an interview on 01/05/24 at 02:37 PM, the AD stated she had been the AD for seven years until last year, had worked in a different role for over a year, and had just gotten back into the role in October 2023. The AD stated she was responsible for the activity preferences section of the MDS. She stated she had noticed a lot of the MDS activity assessments had not been done while she was not in the role. The AD stated she was not waiting until the next comprehensive MDS assessments were due but was catching up on the assessments as she could and triggering the activities task on the quarterly assessments. The AD stated she also completed the care plans, but since the MDS assessments were not conducted, the care plans were not triggered. She stated she was not sure the potential impact on the resident of not having activities assessed or care planned, but some residents might not be able to do the activities they most enjoyed. During an interview on 01/05/24 at 02:55 PM, MDSN A stated he was the MDS nurse for the long-term side of the facility, so he oversaw the assessments, including the activities section. He stated the activities section should have been completed by the AD, but if the sections were not completed, he should have prompted the AD to fill them out. He stated the problem was the assessment questions had been answered with the answers Not Assessed in the most recent comprehensive assessments for Residents #32 and #103, so the section turned green in the EMR, and it made him think they had been completed. The MDSN A stated he was only responsible for the nursing portion of the care plans, and the other department heads were supposed to complete their own care plan items. He stated he might remind the other department heads to complete their portions of the care plan, but he had no actual authority over them, and it was up to the administrator to enforce. 2. A record review of Resident #2's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of multiple sclerosis (autoimmune disease), paraplegia (impairment in motor or sensory function), and pressure ulcer of unspecified site, unstageable (the wound is covered with a dark tissue known as eschar and the depth and staging cannot be determined). A record review of Resident #2's Medicare 5-day MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. Section M (Skin Conditions) reflected she had one or more unhealed pressure ulcers/injuries. A record review of Resident #2's surgical note authored by the Wound Care Physician dated 10/31/2023 reflected she had a stage 4 pressure injury to left hip, thoracic spine, and left fibula, and a stage 3 pressure injury to the left lateral lower extremity. A record review of Resident #2's weekly wound progress report dated 11/01/2023 reflected she had four pressure injuries-one on the upper-mid vertebrae, one on the left trochanter (hip), and two on the left lower leg. A record review on 1/03/2024 of Resident #2's care plan reflected it was revised on 1/03/2024 to include a wound to her left ischial area, left leg and left sacral area. Prior to 1/03/2024, Resident #2's care plan had been revised on 10/24/2023 to reflect she had increased risk for further pressure ulcer development and on 12/10/2023 to reflect she had been re-admitted with a surgical flap to the lumbar spine.] During an interview and observation on 1/04/2024 at 3:02 p.m., Resident #2 was observed lying in bed. Resident #2 stated she had been there since October 2023, had wounds when she came in, and said she thought they had been getting better. During an interview on 1/05/2024 at 3:01 p.m., MDSN A stated he revised care plans for the long-term side of the facility, and that MDSN B was responsible for revising care plans on the 200 and 300 halls where Resident #2 resided. MDSN A stated MDSN B had been in that role for six years. MDSN A stated if care plans did not reflect a resident's current wounds, there could be a potential negative outcome if the resident were to transfer to another facility. MDSN A stated yes he considered two months to be a delay in revising Resident #2's care plan. MDSN A stated he could not say what happened in Resident #2's case. MDSN A stated MDSN B was on extended leave and not available for interview. During an interview on 1/05/2024 at 4:19 p.m., the DON stated the MDS coordinators were the ones who revised care plans, but other staff could revise them too. The DON stated ideally, they were revised when there was a change or something new. The DON stated at the time Resident #2 was admitted , there was not a dedicated treatment nurse and it should have been reflected on time. The DON stated MDSN B covered that side of the facility, and it would have been up to her to update Resident #2's care plan. The DON stated she had taken on the role of treatment nurse, and she would create lists and wound reports which MDSN B reviewed. The DON stated, I realized it was missed. The DON stated if care plans did not reflect residents' current wounds, a potential negative resident outcome could include inventions not being followed through. The DON stated with Resident #2, her interventions were put in via orders. The DON stated the facility wanted to make sure it was care planned so it popped up on their electronic records system for nurses to see. The DON stated the facility did not have a written care plan policy, but they went by the RAI manual. During an interview on 1/05/2024 at 4:50 p.m., the ADM stated she started working at the facility on 11/20/2023. The ADM stated yes wounds were supposed to be included in residents' care plans and resolved once something was healed. The ADM stated the facility monitored for care plans during their morning clinical meetings. The ADM stated sometimes the treatment nurse would take over the skin part of the care plan, and right then they did not have a permanent treatment nurse. The ADM clarified that this was how it worked at her last facility. The ADM stated the MDS nurses, ADON, DON or charge nurses could revise care plans. The ADM stated there was a possibility of missing a treatment if staff did not have the resident's full plan of care. Review of undated facility policy titled Activities Program reflected the following: Complete activity/recreation services assessments are maintained by the activity department and are updated as necessary, but at least annually. The activity care plan contains a listing of activities that the veteran/resident enjoys, or may enjoy, and that has been approved by the veteran/resident and his or her attending physician. Individualized activity plans are integrated into the veteran/resident's total care plan and are reviewed at least quarterly. The plan is reviewed every time there is a change in the veteran's/resident's physical or mental condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 4 residents of 24 residents (Resident #32, Resident #41, Resident #103, and Resident #104) reviewed for activities. 1. Residents #32 and #103 were not engaged in a person-centered activity program and were not receiving activities. 2. The group activity program did not occur as scheduled from 01/04/24 to 01/05/24, and there were no activities scheduled on 01/03/24. 3. Residents #41, and #104 were observed sitting and doing nothing for hours in a common area of the facility. 4. Residents #32, #41, and #103 did not receive activity assessments on their comprehensive assessments. These failures placed residents at risk of boredom, depression, and a diminished quality of life. Findings included: Review of the undated face sheet for Resident #32 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of acute and chronic respiratory failure, congestive heart failure (progressive heart disease that affects pumping action of the heart muscles), pleural effusion (accumulation of excess fluid in the area surrounding the lungs), metabolic encephalopathy (condition in which brain function is disturbed due to different diseases or toxins in the body), symbolic dysfunctions, need for assistance with personal care, speech disturbances, unsteadiness on feet, muscle weakness, lack of coordination, psychophysiological insomnia (sleep disorder due to imbalances in physical and psychological condition), major depressive disorder, dysthymic disorder (a long term and chronic form of depression), chronic pain, and encounter for palliative care (comfort support for end of life care). Review of the admission MDS assessment for Resident #32 dated 09/30/23 reflected a BIMS score of 12, indicating moderate cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #32 dated 10/03/23 reflected no care planning for activities or activity preferences. It reflected the following: The resident uses antidepressant medication, and The resident has an ADL self-care performance deficit r/t weakness/debility. Encourage the resident to participate to the fullest extent possible with each interaction. Review of initial activity evaluations for Resident #32 from his admission on [DATE] to 01/05/24 reflected one had not been completed. Review of activity logs for Resident #32 from 12/06/23 to 01/05/24 reflected no activities documented. Observation on 01/03/24 from 08:30 AM to 03:20 PM revealed Resident #32 was in his room and not engaged in any activities. Observation and interview on 01/04/24 at 09:25 AM revealed Resident #32 was transferred by mechanical lift from his bed to his wheelchair. The CNAs who transferred him placed his bedside table in front of him with a remote and a pitcher of ice water and asked if he wanted anything else before leaving the room. Resident #32 stated he spent his days at the facility watching television and had nothing to do. He stated he was not sure what he would want to do, because he did not know what there was to do. Observation on 01/05/24 from 08:30 AM to 01:05 PM revealed Resident #32 was in his room and not engaged in any activities. Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnosis of humerus fracture (bone of upper arm), dysthymic disorder (a long term and chronic form of depression), epilepsy, history of malignant neoplasm of breast (breast cancer), major depressive disorder, secondary malignant neoplasm of brain (the breast cancer has spread to the brain), protein-calorie malnutrition, weakness, malaise, unsteadiness on feet, lack of coordination, and reduced mobility. Review of the admission MDS for Resident #103 dated 09/30/23 reflected a BIMS score of 13, indicating intact cognition. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #103 dated 11/21/23 reflected no care planning for activities or activity preferences. It reflected the following: Impaired Coping. Resident Will Demonstrate Effective Coping Mechanisms. Monitor for signs / symptoms of depression. Provide care in a calm and reassuring manner. Review of initial activity evaluations for Resident #103 from her admission on [DATE] reflected one had not been completed. Review of activity logs for Resident #103 from 12/06/23 to 01/05/24 reflected no activities documented. Observation on 01/03/24 at 08:50 AM revealed Resident #103 sitting on her bed, which was in low position, and touching her shoes and shoelaces. She made eye contact and engaged when approached, but when she tried to speak, her words could not be deciphered. She had an anxious expression on her face and continued to make eye contact as if she were trying to communicate but could not. Review of the undated face sheet for Resident #41 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral infarction (death of brain tissue), aphasia (speech difficulties), history of transient ischemic attack (minor stroke), unsteadiness on feet, reduced mobility, difficulty in walking, protein-calorie malnutrition, weakness, cognitive communication deficit (communication difficulty caused by impaired cognition), fluency disorder (interruption in the flow of speaking), muscle weakness, speech disturbances, bipolar disorder, hearing loss, and lack of coordination. Review of the significant change MDS for Resident #41 dated 10/20/23 reflected a BIMS score of 03, indicating severe cognitive impairment. The section for Activity Preferences reflected Not Assessed for every question in both the resident interview and staff interview for resident preferences. Review of the care plan for Resident #41 dated 10/18/23 reflected the following: I can hear okay in some settings but not as well in large groups or large rooms. Has a variety of activity interests and a general willingness to take part in 1:1 activities. I will express daily satisfaction with daily social contacts and leisure activities by next reevaluation date. Encourage low-commitment, short 1:1 duration social activities to gain comfort due to my recent decline. Decrease the background noise. Encourage and praise attendance, engagement and participation within activities. I love to read. I will be offered reading material on a daily bases (sic). I will be offered adapted TV(closed captioning, magnified screen, or earphones). I will make selections and decisions within activities. Encourage the resident to use bell to call for assistance. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Review of activity logs for Resident #41 from 12/06/23 to 01/05/24 reflected no activities documented. Observations on 01/03/24 at 08:30 AM, 10:00 AM, and 12:55 PM revealed Resident #41 seated in a geriatric chair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. Observations on 01/04/24 from 10:12 AM to 11:57 AM and again from 01:10 PM to 03:00 PM revealed Resident #41 seated in a geriatric chair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. Observation on 01/05/24 at 09:36 AM revealed Resident #41 seated in a geriatric chair in the day area between 500 and 600 halls. He was staring toward the wall and made eye contact but did not respond when addressed. Review of the undated face sheet for Resident #104 reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia, protein-calorie malnutrition, unsteadiness on feet, lack of coordination, cognitive communication deficit, muscle weakness, malaise, and dysthymic disorder. Review of the admission MDS assessment for Resident #104 dated 10/27/23 reflected a BIMS score of 06, indicating severe cognitive impairment. The activity preferences section of the assessment reflected staff assessed that it was important to Resident #104 to engage in listening to music, keeping up with the news, doing things with groups of people, and participating in his favorite activities. Observations on 01/03/24 at 08:30 AM, 10:00 AM, and 12:55 PM revealed Resident #104 seated in a wheelchair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. He stared into space. Observations on 01/04/24 from 10:12 AM to 11:57 AM and again from 01:10 PM to 03:00 PM revealed Resident #104 seated in a wheelchair in the day area between the 500 and 600 halls. No one was interacting with him, and he was not engaged in anything. Observation and interview on 01/05/24 at 09:36 AM revealed Resident #104 seated in a wheelchair in the day area between 500 and 600 halls. Resident #104 said he was fine and did not know where he was or what was going on. Review of the activity calendar for January 2024 reflected no activities scheduled for 01/03/24. On 01/04/24 was scheduled the following: 10:00 AM Independent Activity of Your Choice 11:00 AM Chicken Foot Game 01:00 PM Uno Card Game 02:00 PM Skip-Bo Card Game 03:00 PM Dominos On 01/05/24 was scheduled the following: 08:30 AM Reflect & Pray 10:00 AM Bingo w/ (volunteer) 11:00 AM 1431 Café Outing 02:00 PM Residents Choice Observation on 01/03/24 between 08:30 AM and 02:00 PM revealed no activities going on. At 03:00 PM, a volunteer arrived at the facility to call bingo. Observation on 01/04/24 at 11:10 AM, 01:10 PM, 02:15 PM, and 03:20 PM revealed Chicken Foot, Uno, Skip-Bo, and Dominos were on a table in the activity room. There was no one in the activity room facilitating the games. Observation on 01/05/24 between 08:30 AM and 03:30 PM revealed none of the scheduled activities occurring. During a confidential interview with nine anonymous residents, they all agreed that activities had barely been occurring and anyone who was not part of the core group of residents who participated in group activities was not receiving any activities at all. They all said the AD was back, and they loved her, but she was too busy going to meetings or something else to assist them with the activities they liked to do. They stated there was always an excuse, and they did not really know what the problem was, but they had complained about it, and nothing had changed . During an interview on 01/05/24 at 02:37 PM, the AD stated she had been the AD for seven years until last year, had worked in a different role for over a year, and had just gotten back into the role in October 2023. The AD stated she was responsible for the activity preferences section of the MDS. She stated she had noticed a lot of the MDS activity assessments had not been done while she was not in the role. The AD stated she was not waiting until the next comprehensive MDS assessments were due but was catching up on the assessments as she could and triggering the activities task on the quarterly assessments. The AD stated she also completed the care plans, but since the MDS assessments were not conducted, the care plans were not triggered. She stated she was not sure the potential impact on the resident of not having activities assessed or care planned, but some residents might not be able to do the activities they most enjoyed. The AD stated Resident #104 was offered individualized activities and mostly liked to watch television. She stated she had offered individualized activities but had not documented and did not document activities in any log for any resident. The AD stated Resident #103 had moved from short term to long term at the facility, and the AD had not interacted with her since she had been there. The AD stated she did not know if Resident #103 was receiving any activities. The AD stated she had seen Resident #103 in bingo, but Resident #103 did not participate. The AD stated she did not know what Resident #103 liked. The AD stated that she did not know Resident #32 and had not assessed him or engaged with him in any way. The AD stated she had received grievances from the resident council about the activities program. She stated they have mostly told her they would like her to be more present. The AD stated she was not present, because she was busy in care plan meetings and doing MDS assessments. The AD stated things had fallen through the cracks but would not elaborate on what she meant. The AD stated none of the residents had withdrawn or become more depressed that she was aware of. She stated she had been sick for the previous couple of days and had been catching up that day 01/05/24. She stated nobody was designated to take over activities when she was not there. She stated some people called bingo while she was gone, but the regular activities that were scheduled on the calendar had not occurred in her absence. The AD stated it was important for all residents to receive recreational therapy because without it, they could decline, have poor motivation, not want to eat, lose weight, or become more depressed. The AD stated when she had the role of activity director before, she had an assistant, but she no longer had one. She stated it was very hard to meet the recreational needs of over 100 residents with just one person, especially when she was catching up on assessments and care plans. During an interview on 01/05/24 at 02:55 PM, MDSN A stated he was the MDS nurse for the long-term side of the facility, so he oversaw the assessments, including the activities section. He stated the activities section should have been completed by the AD, but if the sections were not completed, he should have prompted the AD to fill them out. He stated the problem was the assessment questions had been answered with the answers Not Assessed in the most recent comprehensive assessments for Residents #32, #41, and #103, so the section turned green in the EMR, and it made him think they had been completed. The MDSN A stated he was only responsible for the nursing portion of the care plans, and the other department heads were supposed to complete their own care plan items. He stated he might remind the other department heads to complete their portions of the care plan, but he had no actual authority over them, and it was up to the administrator to enforce. During an interview on 01/05/24 at 04:33 PM, the ADM stated there were lots of opportunities to improve the activities program. She stated she had not addressed activities formally with the QAPI , but she needed to work with the AD. The ADM stated she did not think the entire facility's activity needs could be met by one person. The ADM stated residents were all entitled to recreation based on their abilities and preferences and potential negative impacts of not receiving activities were boredom, weight loss, and increased behaviors. Review of undated facility policy titled Activities Program reflected the following: The community provides an ongoing, organized program of activities designed, in accordance with the comprehensive assessment, to meet the interests and to maintain the physical, mental, and psychosocial well-being of each veterans/resident. The activities program is an essential component of the community's fulfillment of its obligation to care for its veterans/residents in a manner and environment that maintain or enhance each veteran/resident's quality of life. The activity program is designed to encourage restoration of self-care and maintenance of normal activity and is geared to meet the individual veterans/resident's needs. The activities program consists of individualized and group sessions, and: flexible schedules, choices, and rights of the veteran/resident; is offered at hours convenient to the veterans/residents, including evenings, holidays, and weekends; reflects the cultural and religious interests of the veterans/residents; appeals to both men and women, as well as to all age groups of veterans/residents residing in the community. The activity program consists of individual and small and large group activities that are designed to meet the needs and interests of each veteran/resident and includes, at a minimum: -social activities -Indoor and outdoor activities -Activities away from the community -Religious programs -Creative activities -Intellectual and educational activities -Exercise activities -Individualized activities -In room activities -Community activities -Military holidays and observance Each resident must have an individualized care plan, and the community is obligated to provide activities that meet each resident's individual needs. Once the veteran/resident is admitted , complete an activity service assessment to identify his or her past and present interests. This assessment is used to develop an individual activity plan that will allow the resident to participate in activities of his or her choice and interest. Sometimes physical and mental conditions prevent residents from participating in activities they have enjoyed throughout their lifetimes. These preferences and passions are noted and included in the assessment. When there is limitation on their ability to participate, the community should find alternative means of addressing the interest. Complete activity/recreation services assessments are maintained by the activity department and are updated as necessary, but at least annually. The activity care plan contains a listing of activities that the veteran/resident enjoys, or may enjoy, and that has been approved by the veteran/resident and his or her attending physician. Individualized activity plans are integrated into the veteran/resident's total care plan and are reviewed at least quarterly. The plan is reviewed every time there is a change in the veteran's/resident's physical or mental condition. Activities are conducted in accordance with the activity schedule, which should include input from the community's resident council. The Activity Director is responsible for keeping appropriate departmental records in order to maintain, plan, and develop the activity programs. The following records, at a minimum are maintained by activity department personnel: -Activities services -Attendance records -Calendar of events -Activity, progress, notes -Individualized activity plan -Quarterly MDS assessments -Record of reviews and updates -Other recordkeeping reports as necessary and appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Resident #51, Resident #65, Resident #97 and Resident #314) reviewed for infection control, in that: 1. The facility failed to ensure Resident #97's enteral formula was timed and initialed after it was opened. 2. LVN E did not wash or sanitize her hands during glove change following removal of Resident #314's old wound care dressing. 3. Resident #65's oxygen nasal canula was not dated and was laying on the floor and Resident #51's oxygen nasal cannula was laying on the floor. These deficient practices place residents in the facility at risk for infections due to improper care practices. Findings include : A record review of Resident #51's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, epilepsy, metabolic encephalopathy (disturbed brain function), and cognitive communication deficit. A record review of Resident #51's 5-day MDS assessment dated [DATE] reflected a BIMS score of 07, which indicated severely impaired cognition. Resident #51 required moderate to extensive assistance from another person and frequent bowel and bladder incontinence. A record review of Resident #65's face sheet dated 1/05/2024 reflected a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses of Fracture right femur, metabolic encephalopathy (disturbed brain function), transient cerebral ischemic attack, hypertension, atrial fibrillation, and hypertension. A record review of Resident #65's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderately impaired cognition. Resident #65 required extensive assistance from another person and had bowel and bladder incontinence. A record review of Resident #97's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of aphasia (difficulty communicating), metabolic encephalopathy (disturbed brain function), dysphagia (difficulty swallowing), gastrostomy status (artificial external opening into the stomach for nutritional support), gastro-esophageal reflux disease (acid reflux) and adult failure to thrive. A record review of Resident #97's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. A record review of Resident #97's care plan last revised on 10/24/2023 reflected she received tube feedings related to dysphagia and she was to receive 1 carton of [enteral formula] 1.5 via bolus (intermittent) feedings TID. A record review of Resident #314's face sheet, dated 01/05/24, reflected an [AGE] year-old female admitted on [DATE] with diagnoses of osteoarthritis of left hip, atrial fibrillation, chronic pain syndrome, diabetes mellitus type 2, hypertension, cognitive communication deficit, restless leg syndrome, reduced mobility and unsteadiness on feet. A record review of Resident #314's admission MDS assessment dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Resident #314 required extensive assistance via wheelchair and walker, and bowel and bladder incontinence. A record review of Resident #314's care plan initiated on 12/28/23 reflected she was admitted to skilled services/therapy due to weakness/debility w/potential for decreased functional abilities with acute illness and/or injury, and Resident #314 has actual impairment to skin integrity of the left heel which was initiated on 01/03/24. Intervention for left heel blister initiated on 01/04/24 included to cleanse left heel blister with normal saline and pat dry, apply calcium alginate and cover with dry dressing daily. Replace dressing PRN if soiled, loose, or removed. An observation on 1/03/24 at 8:20am revealed Resident #51's oxygen nasal canula was not dated and was laying on the floor. CNA I entered the room and placed the nasal canula in the resident's nose without cleaning it. An observation on 1/03/2024 at 9:05 a.m. revealed Resident #97 was lying in bed sleeping. There was an opened container of enteral formula dated 1/2/24 sitting on Resident #97's dresser. The formula was not timed or initialed. Resident #97 was non-interviewable. An observation on 1/3/24 at 11:30am revealed Resident #65's O2 nasal cannula on the floor. CNA J picked up the canula to place it back on the resident, but the resident refused to wear it at that time. The cannula was then draped on the resident's left shoulder so he could put it in his nose when needed. The canula was not cleaned by the CNA. An observation on 1/03/2024 at 11:59 a.m. revealed the formula dated 1/2/24 was sitting in the same spot located on Resident #97's dresser. An observation on 1/04/2024 at 9:24 a.m. revealed there was a one third full container of enteral formula dated 1/4/24 on Resident #97's dresser. The formula was not timed or initialed. During an interview on 1/04/2024 at 9:28 a.m., LVN P stated Resident #97 ate food by mouth but if she did not eat, she received extra formula. LVN P stated that morning Resident #97 had refused breakfast, so she got extra formula. An observation on 01/04/24 at 01:26 PM of wound care for Resident #314 with LVN E revealed LVN E washed her hands, donned gloves, and disinfected the bedside table. LVN E removed gloves, placed wax paper on the clean surface, and gathered wound care supplies. DON washed hands, donned gloves, and assisted with Resident #314's left lower limb positioning. LVN E removed the old dressing from the left heel and changed gloves. Resident #314's left heel blister was observed a deep purple color and approximately 3.5cm x 3.0cm. LVN E cleansed the left heel blister with normal saline and 4 x 4 gauze. LVN E changed her gloves, and no handwashing or hand hygiene was observed with the glove change. LVN E applied calcium alginate to the left heel wound and covered it with an adhesive dressing that was initialed and dated. LVN E and DON conducted handwashing upon completion of wound care. During an interview on 01/04/24 at 01:46 PM with LVN E revealed she should have brought hand sanitizer to the bedside while conducting wound care for Resident #314, and an adverse outcome of not sanitizing hands when changing gloves would be a possible wound infection. During an interview on 1/5/24 at 10:30 am CNA G stated that she was trained on infection control and resident items on the floor would concern her. She stated that she would sanitize them first before residents handle them. She stated that a nasal canula on the floor should be trashed and replaced with a new one. If it could not be replaced, she stated it should be sanitized. Failing to sanitize could lead to an infection for the resident. During an interview on 1/5/24 at 10:43am RN C stated that if a nasal canula was on the floor she would discard it and get a new one. She stated if a new one was not available, she would sanitize before use. She indicated that failing to sanitize would create a source of infection as they did not know what is on the floor. During an interview on 1/05/2024 at 3:37 p.m., the ADON stated she oversaw the short-term wing where Resident #97 resided. The ADON stated as long as formulas were dated, they could be used at room temperature for 24 hours as long as they were capped. The ADON stated nurses administered formula and they had all been trained on how to store it. The ADON stated nurses were supposed to date, time and initial the bottle when it was opened. During an interview on 01/05/24 at 03:47 PM with DON revealed her expectation of hand hygiene while providing wound care to residents was handwashing/hand hygiene and glove change should be conducted when going from dirty to clean, such as after removing and disposing of the old dressing, and after going from clean to dirty, such as gathering and setting up wound care field and then removing old dressing. DON further stated an adverse outcome of staff not following infection protocol while providing resident care would be a possible wound infection. During an interview on 1/05/2024 at 3:52 p.m., the DON stated opened enteral formulas were dated and timed and said they were good for 24-48 hours. The DON stated opened containers could be used later but if it was not marked with what time it was opened, nurses should discard it. The DON stated Resident #97's enteral formula was on backorder, so they had to order larger containers. The DON stated nurses monitored other nurses to ensure enteral formulas were labeled appropriately. The DON stated formula administered past its recommended storage time could result in a less potent formula or GI symptoms such as upset stomach. During an interview on 1/05/24 at 4:30 p.m., the DON stated her expectation of a nasal canula on the floor would be to change it. She stated an alternative if they could not change it, is to disinfect following the time guidelines on the wipes. She indicated the risk of not disinfecting or replacing the nasal cannula could cause a respiratory infection. During an interview on 1/5/24 at 4:45 p.m., the ADM stated her expectation for a nasal cannula on the floor would be to replace it. If it could not be replaced, then sanitize and date it to avoid the risk of infection. During an interview on 01/05/24 at 04:47 PM with ADM revealed her expectation for infection control protocol during wound care was for staff to conduct handwashing before and after to prevent spread of infection. ADM further stated the potential adverse outcome of staff not following infection control protocol during resident care would be cross contamination of wound care products. A record review of the physician orders dated 6/16/23 reflected Resident #65 was prescribed 2-3 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of the physician orders dated 12/6/23 reflected Resident #51 was prescribed 2 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of the facility's policy titled Handwashing dated 10/24/22 reflected, All staff members are required to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice. The CDC guidelines regarding handwashing are to be followed by staff members after each resident contact. A record review of the facility's policy titled Infection Control - Surveillance for Infections dated September 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility. A record review of the facility's policy titled Enteral Feedings - Safety Precautions dated November 2018 reflected the following: Purpose To ensure the safe administration of enteral nutrition. General Guidelines Preventing contamination 2. Maintain strict adherence to storage conditions and timeframes. a. Store unopened liquid enteral formulas in temperature and light-controlled conditions (cool, away from direct sunlight). b. Maintain inventory controls and discard any formula past the expiration date. 3. Maintain strict adherence to maximum hang times: a. Powdered, reconstituted formula and formula with additives have a maximum infusing (hang) time of 4 hours. b. Sterile formula in a closed system has a maximum hang time of 48 hours. Preventing errors in administration 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order. Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 6 residents (Resident #51, Resident #65, Resident #97 and Resident #314) reviewed for infection control, in that: 1. The facility failed to ensure Resident #97's enteral formula was timed and initialed after it was opened. 2. LVN E did not wash or sanitize her hands during glove change following removal of Resident #314's old wound care dressing. 3. Resident #65's oxygen nasal canula was not dated and was laying on the floor and Resident #51's oxygen nasal cannula was not dated and was laying on the floor. These deficient practices place residents in the facility at risk for infections due to improper care practices. Findings include: A record review of Resident #51's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of Dementia, acute respiratory failure with hypoxia (low oxygenation), chronic obstructive pulmonary disease (lung disease), epilepsy (seizure disorder), metabolic encephalopathy (disturbed brain function), and cognitive communication deficit. A record review of Resident #51's 5-day MDS assessment dated [DATE] reflected a BIMS score of 07, which indicated severely impaired cognition. Resident #51 required moderate to extensive assistance from another person and frequent bowel and bladder incontinence. A record review of the physician orders dated 12/6/23 reflected Resident #51 was prescribed 2 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of Resident #65's face sheet dated 1/05/2024 reflected a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE] with diagnoses of Fracture right femur (hip bone), metabolic encephalopathy (disturbed brain function), transient cerebral ischemic attack (blood clot in brain), hypertension, atrial fibrillation, and hypertension. A record review of Resident #65's quarterly MDS assessment dated [DATE] reflected a BIMS score of 08, which indicated moderately impaired cognition. Resident #65 required extensive assistance from another person and had bowel and bladder incontinence. A record review of the physician orders dated 6/16/23 reflected Resident #65 was prescribed 2-3 Liters per nasal cannula to maintain oxygen saturation above 92%. A record review of Resident #97's face sheet dated 1/05/2024 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of aphasia (difficulty communicating), metabolic encephalopathy (disturbed brain function), dysphagia (difficulty swallowing), gastrostomy status (artificial external opening into the stomach for nutritional support), gastro-esophageal reflux disease (acid reflux) and adult failure to thrive. A record review of Resident #97's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, which indicated severely impaired cognition. A record review of Resident #97's care plan last revised on 10/24/2023 reflected she received tube feedings related to dysphagia and she was to receive 1 carton of [enteral formula] 1.5 via bolus feedings TID. A record review of Resident #314's face sheet, dated 01/05/24, reflected an [AGE] year-old female admitted on [DATE] with diagnoses of osteoarthritis of left hip, atrial fibrillation, chronic pain syndrome, diabetes mellitus type 2, hypertension, cognitive communication deficit, restless leg syndrome, reduced mobility and unsteadiness on feet. A record review of Resident #314's admission MDS assessment dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. Resident #314 required extensive assistance via wheelchair and walker, and bowel and bladder incontinence. A record review of Resident #314's care plan initiated on 12/28/23 reflected she was admitted to skilled services/therapy due to weakness/debility w/potential for decreased functional abilities with acute illness and/or injury, and Resident #314 has actual impairment to skin integrity of the left heel which was initiated on 01/03/24. Intervention for left heel blister initiated on 01/04/24 included to cleanse left heel blister with normal saline and pat dry, apply calcium alginate and cover with dry dressing daily. Replace dressing PRN if soiled, loose, or removed. An observation on 1/03/24 at 8:20am revealed Resident #51's oxygen nasal canula was not dated and was laying on the floor. CNA I entered the room and placed the nasal canula in the resident's nose without cleaning it. An observation on 1/03/2024 at 9:05 a.m. revealed Resident #97 was lying in bed sleeping. There was an opened container of enteral formula dated 1/2/24 sitting on Resident #97's dresser. The formula was not timed or initialed. Resident #97 was non-interviewable. An observation on 1/3/24 at 11:30am revealed Resident #65's O2 nasal cannula on the floor. CNA J picked up the canula to place it back on the resident, but the resident refused to wear it at that time. The cannula was then draped on the resident's left shoulder so he could put it in his nose when needed. The canula was not cleaned by the CNA. An observation on 1/03/2024 at 11:59 a.m. revealed the formula dated 1/2/24 was sitting in the same spot located on Resident #97's dresser. An observation on 1/04/2024 at 9:24 a.m. revealed there was a one third full container of enteral formula dated 1/4/24 on Resident #97's dresser. The formula was not timed or initialed. During an interview on 1/04/2024 at 9:28 a.m., LVN P stated Resident #97 ate food by mouth but if she did not eat, she received extra formula. LVN P stated that morning Resident #97 had refused breakfast, so she got extra formula. An observation on 01/04/24 at 01:26 PM of wound care for Resident #314 with LVN E revealed LVN E washed her hands, donned gloves, and disinfected the bedside table. LVN E removed gloves, placed wax paper on the clean surface, and gathered wound care supplies. DON washed hands, donned gloves, and assisted with Resident #314's left lower limb positioning. LVN E removed the old dressing from the left heel and changed gloves. Resident #314's left heel blister was observed a deep purple color and approximately 3.5cm x 3.0cm. LVN E cleansed the left heel blister with normal saline and 4 x 4 gauze. LVN E changed her gloves, and no handwashing or hand hygiene was observed with the glove change. LVN E applied calcium alginate to the left heel wound and covered it with an adhesive dressing that was initialed and dated. LVN E and DON conducted handwashing upon completion of wound care. During an interview on 01/04/24 at 01:46 PM with LVN E revealed she should have brought hand sanitizer to the bedside while conducting wound care for Resident #314, and an adverse outcome of not sanitizing hands when changing gloves would be a possible wound infection. During an interview on 1/5/24 at 10:30 am CNA G stated that she was trained on infection control and resident items on the floor would concern her. She stated that she would sanitize them first before residents handle them. She stated that a nasal canula on the floor should be trashed and replaced with a new one. If it could not be replaced, she stated it should be sanitized. Failing to sanitize could lead to an infection for the resident. During an interview on 1/5/24 at 10:43am RN C stated that if a nasal canula was on the floor she would discard it and get a new one. She stated if a new one was not available, she would sanitize before use. She indicated that failing to sanitize would create a source of infection as they did not know what is on the floor. During an interview on 1/05/2024 at 3:37 p.m., the ADON stated she oversaw the short-term wing where Resident #97 resided. The ADON stated as long as formulas were dated, they could be used at room temperature for 24 hours as long as they were capped. The ADON stated nurses administered formula and they had all been trained on how to store it. The ADON stated nurses were supposed to date, time and initial the bottle when it was opened. During an interview on 01/05/24 at 03:47 PM with DON revealed her expectation of hand hygiene while providing wound care to residents was handwashing/hand hygiene and glove change should be conducted when going from dirty to clean, such as after removing and disposing of the old dressing, and after going from clean to dirty, such as gathering and setting up wound care field and then removing old dressing. DON further stated an adverse outcome of staff not following infection protocol while providing resident care would be a possible wound infection. During an interview on 1/05/2024 at 3:52 p.m., the DON stated opened enteral formulas were dated and timed and said they were good for 24-48 hours. The DON stated opened containers could be used later but if it was not marked with what time it was opened, nurses should discard it. The DON stated Resident #97's enteral formula was on backorder, so they had to order larger containers. The DON stated nurses monitored other nurses to ensure enteral formulas were labeled appropriately. The DON stated formula administered past its recommended storage time could result in a less potent formula or gastrointestinal symptoms such as upset stomach. During an interview on 1/05/24 at 4:30 p.m., the DON stated her expectation of a nasal canula on the floor would be to change it. She stated an alternative if they could not change it, is to disinfect following the time guidelines on the wipes. She indicated the risk of not disinfecting or replacing the nasal cannula could cause a respiratory infection. During an interview on 1/5/24 at 4:45 p.m., the ADM stated her expectation for a nasal cannula on the floor would be to replace it. If it could not be replaced, then sanitize and date it to avoid the risk of infection. During an interview on 01/05/24 at 04:47 PM with ADM revealed her expectation for infection control protocol during wound care was for staff to conduct handwashing before and after to prevent spread of infection. ADM further stated the potential adverse outcome of staff not following infection control protocol during resident care would be cross contamination of wound care products. A record review of the facility's policy titled Handwashing dated 10/24/22 reflected, All staff members are required to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice. The CDC guidelines regarding handwashing are to be followed by staff members after each resident contact. A record review of the facility's policy titled Infection Control - Surveillance for Infections dated September 2017 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility. A record review of the facility's policy titled Enteral Feedings - Safety Precautions dated November 2018 reflected the following: Purpose To ensure the safe administration of enteral nutrition. General Guidelines Preventing contamination 2. Maintain strict adherence to storage conditions and timeframes. a. Store unopened liquid enteral formulas in temperature and light-controlled conditions (cool, away from direct sunlight). b. Maintain inventory controls and discard any formula past the expiration date. 3. Maintain strict adherence to maximum hang times: a. Powdered, reconstituted formula and formula with additives have a maximum infusing (hang) time of 4 hours. b. Sterile formula in a closed system has a maximum hang time of 48 hours. Preventing errors in administration 2. On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication storage rooms (Transition Care Unit Storage room) and 4 of 5 medication carts (600 Hall MA cart, 600 Hall Nurse cart, 300 Hall Nurse cart, 400/500 Hall MA cart) reviewed. The facility failed to ensure expired medications were removed, food products were not in the carts and failed to ensure the carts were clean of potential contaminants. These failures could place residents who receive medications at risk for receiving outdated or contaminated medications which could result in residents not receiving the intended therapeutic effects of their medications. Findings included: Observation on 1/04/20243 at 7:40 AM in the medication storage room on the Transitional Care Unit revealed 1 bottle of Slow-Mag plus Ca with expiration date 10/2023 and 3 bottles of Slow-Mag plus Ca with expiration date 11/2023, MVI with expiration date 12/2023, Ca plus D 5 mcg with expiration date 05/2022, Thiamin B-1 100 mg with expiration date 12/2023, Ocular Vitamins expired 10/2023, 2 bottles Mucus relief Dextromethorphan with expiration dates 03/2023 and 09/2022. In an interview on 01/04/2024 at 7:49 AM ADON stated expired medications could possibly do harm to a patient if given and would not be as effective. Observation on 01/04/2024 at 8:10 AM of the 600 Hall MA cart revealed 1 bottle of Vit B-12, 1,000 mg expired 01/2023, Slow-Mag with Ca expired 11/2023, Vision eye drops expired 12/2023 and Sodium Chloride 1 gm expired 11/2023. In an interview on 01/04/2024 at 8:16 AM the CS/MR stated she had worked in the facility full-time for one year but was still learning her role as the person responsible for checking expired dates on medications. She stated she had not been able to check the carts due to training for medical records and being off for vacation. She stated she tried to check the medication carts once a week on Mondays. Observation on 01/04/2024 at 8:25 AM of the 600 Hall Nurse cart revealed 2 packages of petroleum-based dressings open and with sticky residue on them in the cart with other medications. There were 4 NS 100 ml with expiration dates 11/30/2022, an Albuterol Sulfate inhaler expired on 07/25/2023 and an Albuterol Sulfate Inhaler expired on 10/23/2023. A bottle of Chlorhexidine Gluconate solution (antimicrobial and antiseptic) had an expiration date of 09/2021. In an interview on 01/04/2024 at 8:48 AM RN C stated every nurse is responsible for ensuring medications are not expired. She stated the petroleum-based dressing should have been bagged and dated but would be thrown away. She stated she was supposed to check the cart every day, but she had not checked medications for expired dates on 01/04/2023. She stated she checked the dates on the medications she was administering but no one person was responsible for ensuring expired medications were not on the carts. She further stated the risk to the resident could be adverse side effects and potential harm. Observation on 01/04/2024 at 9:25 AM of the 300 Hall nurse cart revealed tea bags and artificial sweetener in the top drawer of the cart. A loose white powder was observed in the bottom of a box that contained several topical medications. In an interview on 01/04 2024 at 9:30 AM LVN F stated tea bags should not be in the cart. She stated she did not know what the white powder was in the box with the topical medications but speculated it might have been an antifungal power. She further stated the loose powder could potentially contaminate the other medications in the box. Observation on 01/04/2024 at 9:39 AM of the 400/500 Hall MA cart revealed a vitamin herbal complex with an expiration date of 11/2023. In an interview on 01/04/2024 at 9:45 AM MA K stated she had worked at the facility for three years. She stated a resident should not take expired medications as they could have an adverse reaction and the potency would not be as good. In an interview on 01/05/2024 at 11:18 AM the DON stated nurses should be checking the medication expiration dates prior to administering. She stated the CS/MR was responsible for checking the medication storage rooms and they should have been checked prior to her leaving on vacation. She stated she was surprised the Pharmacist did not catch the expired medications. She stated the nurses and medication aides are responsible for keeping the carts clean and that food items are not acceptable in the medication carts. She stated if medications are past their expiration dates it could affect their potency. She stated her expectation was for the medication carts and medication storage rooms to be audited at least weekly for expired medications. In an interview on 01/05/2024 at 1:40 PM the RPh stated she would recommend audits of the medication storage rooms and medication carts either at the beginning or end of the month. She stated the potential risk for residents receiving expired medications would be they would not receive the full potency of the medication. In an interview on 01/05/2024 at 1:43 PM the DRC stated her expectation was for the facility to remove expired medications from the medication carts and storage rooms. She stated food items should not be on the medication carts. She stated the opened petroleum gauze should have been bagged and the resident's name written on it, otherwise it should have been discarded. She stated the carts should be kept clean to prevent contamination of medications. In an interview on 01/05/2024 at 4:50 PM the ADM stated there should not be any expired medications on the carts or in the medication storage rooms. She stated the potential negative outcome to a resident if they received an expired medication was the effectiveness would be changed and it would not treat their medical issue appropriately. She further stated the carts should be kept clean to prevent contamination of medications and to prevent any harm to the nurse handing the medications. She stated any opened wound care products should have been discarded and food items should not be kept in the carts. Record review of the facility Policy and Procedure for Pharmacy Services revised on 12/01/2021 reflected Receipt of medication: Upon delivery by the pharmacy, the facility nurse or designee will assume responsibility for the receipt, proper storage, and distribution of medications. The consultant pharmacist will ensure the proper labeling and storage of all pharmaceutical products, to include medications and biologicals are stored safely, securely, and properly based on manufacturers recommendations and/or currently accepted professional standards.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for food storage and sanitation. The facility failed to ensure all foods were properly covered, labeled, dated and discarded. The facility failed to ensure chemicals were not stored near food items. The facility failed to ensure the trash can was covered when not in use. The facility failed to ensure CK N washed her hands in between tasks. The facility failed to ensure sanitized the food processor after washing it. These failures placed residents at risk for foodborne illness. Findings included: An observation of the kitchen's walk-in refrigerator on 1/03/2024 at 8:17 a.m. revealed a steam pan of leftover enchiladas dated 12/29/2023. The steam pan was halfway covered with plastic wrap, leaving half of the pan exposed to air. An observation of the kitchen's walk-in refrigerator on 1/03/2024 at 8:18 a.m. revealed a steam pan of unidentifiable substance unlabeled and undated. There was also a 12-quart container of an unidentifiable liquid unlabeled and undated. During an interview on 1/03/2024 at 8:24 a.m., DA O stated the unidentifiable substances were pasta salad and soup from the night prior and they forgot to put a date on it. When asked if the enchiladas should be covered, DA O stated, it's trash and stated leftovers were only kept for three days. An observation of the kitchen's prep area on 1/03/2024 at 8:30 a.m. revealed CK N was preparing a food item at the prep table approximately four feet away from an uncovered trash can which was not in use. An observation of the kitchen on 1/03/2024 at 10:31 a.m. revealed CK N was pureeing green beans. Observed CK N take the food processor to a two-compartment prep sink, wash it, and return it to the prep counter. The two compartment sink did not contain sanitizer. CK N removed her gloves and put on new gloves without washing her hands. CK N proceeded to puree fried chicken. An observation on 1/03/2024 at 10:45 a.m. revealed CK N took off her gloves after she finished pureeing fried chicken, put on new gloves, and rinsed off and scrubbed the food processor using a sudsy liquid from a small red bucket. CK N then removed her gloves and put on new gloves without washing her hands. CK N proceeded to puree scalloped potatoes. During an interview on 1/03/2024 at 10:48 a.m., CK N stated the small red bucket contained dish soap. Observations of the kitchen's dry room storage on 1/03/2024 at 10:59 a.m. revealed one gallon container of Italian dressing and three-gallon containers of pickles with no received date. There were also two boxes filled with 6 bottles each of bleach stored in proximity to food items. An observation of the kitchen's prep area on 1/03/2024 at 11:08 a.m. revealed CK M was preparing cookies approximately 5 feet away from an uncovered trash can which was not in active use. An observation of the puree process on 1/04/2024 at 10:28 a.m. revealed CK N pureed green peas, took the food processor to the three compartment sink in the dish room, and washed, rinsed and sanitized it using a sprayer to squirt sanitizer on the processor. The third compartment did not contain sanitizer. An observation on 1/04/2024 at 10:36 a.m. revealed that after washing the food processor, CK N removed her gloves, put on new gloves, and began pureeing rice. CK N did not wash her hands. An observation on 1/04/2024 at 10:43 a.m. revealed the three compartment sink was then filled with sanitizer solution. CK N washed, rinsed and submerged the food processor in sanitizer. CK N then removed her gloves and put on new gloves but did not wash her hands. CK N proceeded to puree meat. An observation of the kitchen's prep area on 1/04/2024 at 10:53 a.m. revealed CK M was preparing a dessert item approximately four feet from an uncovered trash can which was not actively being used. During an interview on 1/04/2024 at 10:53 a.m., CK N stated she usually used the three compartment sink to wash the food processor but she did not do that the day prior (1/03/2024) because they were working on it. CK N explained that someone else had been using the sink at that time. CK N stated yes that items needed to be submerged in sanitizer solution for them to be sanitized. CK N stated she usually washed her hands after handling dirty dishes, but she had not done that because she wanted to speed it up. During an interview on 1/05/2024 at 8:59 a.m., the DM stated he would need to refer to the facility's written policy to cite what it said in regard to food storage. The DM stated foods should be covered in airtight bags with a label and date. The DM stated yes items also needed a received date. The DM stated they did not have lids for the trash cans, they had been trying to get some, but they were not available through their supplier. The DM stated they tried to keep the trash far away from the prep area. The DM stated chemicals were stored off the ground in the dish room or in a utility closet. The DM stated he was aware of there being bleach in the dry storage room and said, I think we just put it there. The DM stated it was off the ground and not over or under anything, but said he guessed he could find room somewhere else. The DM stated the process for sanitizing dishes was to wash, rinse, sanitize and air dry and said hands needed to be washed in between handling dirty dishes and preparing a food item. The DM stated he monitored the kitchen for food storage and sanitation through daily walk throughs and checklists. The DM stated all dietary staff had been trained in those areas. The DM stated he did not know whether he had done an in-service on food storage in a while but said everyone knew to label and date. The DM stated he had recently completed an in-service on handwashing and said he did hands-on training with staff as well. The DM stated the RD monitored via monthly kitchen audits. The DM said he had worked in the facility for a year and a half and said the facility was a rough one when he first started. The DM stated if food storage and sanitation practices were not followed, it could result in sickness and in this population it's extremely important. During an interview on 1/05/2024 at 1:45 p.m., the RD stated he would have to look up the exact wording of the facility's food storage policy. The RD stated he was unaware of why the kitchen did not have lids to the trash can, stated his company's policy was to discard leftovers after 72 hours, and said he would need to get back to the surveyor on when dietary staff needed to wash their hands. The RD stated if food was not stored properly and sanitation practices were not followed, it could lead to foodborne illness. During an interview on 1/05/2024 at 4:27 p.m., the ADM stated leftovers needed to be labeled, dated and stored for no more than 72 hours. The ADM stated food should not be open to air when stored on the shelf. The ADM stated items needed to be dated when they were received, and she would not expect chemicals to be stored in the same room as food. The ADM stated no the sanitizing process should not be skipped and said hands needed to be washed after washing equipment. The ADM stated the DM, the RD and herself monitored the kitchen for food storage and sanitation through rounding. The ADM stated the trashcan should be covered when not in use. The ADM stated if foods were not stored properly or sanitation practices were not followed, it could lead to contamination of the food which could make residents ill. A record review of the FDA's 2017 Food Code reflected the following: 7-201.11 Separation. POISONOUS OR TOXIC MATERIALS shall be stored so they can not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLESERVICE and SINGLE-USE ARTICLES by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning; P and (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE or SINGLE-USE ARTICLES. This paragraph does not apply to EQUIPMENT and UTENSIL cleaners and SANITIZERS that are stored in WAREWASHING areas for availability and convenience if the materials are stored to prevent contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. 7-201.11 Separation. POISONOUS OR TOXIC MATERIALS shall be stored so they can not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLESERVICE and SINGLE-USE ARTICLES by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning; P and (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE or SINGLE-USE ARTICLES. This paragraph does not apply to EQUIPMENT and UTENSIL cleaners and SANITIZERS that are stored in WAREWASHING areas for availability and convenience if the materials are stored to prevent contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms (B) After using the toilet room (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B) (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. A record review of the facility's in-service dated 10/07/2023 reflected dietary staff were in-serviced on the sanitization procedure. A record review of the facility's policy titled Garbage Receptacles dated June 1 2019 reflected the following: Policy: The facility will maintain garbage receptacles in a clean and sanitary manner to minimize the risk of food hazards. Indoor receptacles: Waste handling units for refuse and for use with materials containing food residue shall be durable, cleanable, insect and rodent resistant, leak proof, and nonabsorbent. Trash cans will be kept with lid in place when not in use. A record review of the facility's policy titled Manual Cleaning and Sanitizing of Utensils and Portable Equipment dated October 1 2018 reflected the following: Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. Procedure: 1. Use a three-compartment sink with running hot and cold water for cleaning, rinsing and sanitizing. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75°F or ii. A minimum of 12.5 parts per million of available iodine in a solution with a pH not higher than five and a temperature not less than 75°F or iii. Any other chemical sanitizing agent which has been demonstrated to be effective and non-toxic under use conditions and for which a suitable field test is available. Such other sanitizing agents, in-use solutions, shall provide the equivalent sanitizing effect of a solution containing at least 50 parts per million of available chlorine at a temperature not less than 75°F. The concentration and contact time for quaternary ammonium compounds shall be in accordance with the manufacturer's label directions. A record review of the facility's policy titled Food Storage dated June 1 2019 reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedures: 1. Dry storage rooms i. Do not use or store cleaning materials or other chemicals where they might contaminate foods. Label and store them in their original containers when possible. Store in a locked area away from any food products. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to inform the resident or resident representative of their right to establish advance directives as set forth in the laws of the State and provide assistance if the resident wishes to execute one or more directive(s) for one (Resident #93) out of 20 residents reviewed for advanced directives, in that: Resident 93 was not provided information when she was admitted to the facility to have an option to formulate an advance directive. This failure could place residents who are admitted to the facility and could result in a resident's advanced care wishes not being noted or executed. The findings included: Record review of Resident #93's Face Sheet dated [DATE] documented a [AGE] year-old female admitted [DATE] with the diagnoses of: Unspecified fracture of right femur, history of falling, repeated falls, generalized weakness. Record review of Resident #93's admission packet paperwork dated [DATE] which included Advanced Directives was not completed. Record review of Resident #93's Significant Change Minimum Data Set, dated [DATE] revealed she had a brief interview of mental status score of 12 - moderately impaired cognition. Further review in Section F-Preferences for Customary Routine and Activities revealed it was very important for her to make her own choices. Record review of Resident #93's [DATE] Physician Orders revealed there were no orders for advance directives (code status). Record review of Resident #93's comprehensive care plan dated [DATE] documented Resident wishes their code status to be DNR (Do Not Resuscitate). Record review of Resident #93's electronic medical record revealed there was no other mention of an advance directive, other than her comprehensive care plan. Interview with Resident #93 on [DATE] at 2:04 PM revealed she was lying in her bed with her eyes open. Resident #93 was able to correctly state her name, age, location and time of day. Resident #93 said she did not want to be resuscitated if she were to stop breathing or her heart were to stop. I made that clear to my son and daughter. Resident #93 said she did not recall if the facility knew or documented her code status preference. Interview with RN A on [DATE] at 3:01 PM revealed he identified himself as Resident #93's nurse. When asked what was Resident #93's code status, RN A said Let me check. After RN A reviewed Resident #93's electronic record, he said There isn't a code status listed on her profile or in her doctors orders. The code status should be indicated in the doctor's orders. I can't find a Do Not Resuscitate (DNR) Form so I have to assume she is a full code, meaning if she stopped breathing or her heart stopped, we would try all attempts to revive her. RN A said it was Very important to have a code status identified Resident #93's profile and physician order so that staff could implement the correct resuscitation measures. Interview with the DON on [DATE] at 4:17 PM revealed she said Resident #93's electronic record should have had an updated and definite code status. The DON said she did not know why Resident #93's code status was not received and documented or how her care plan included a DNR status if Resident #93 did not have a legal DNR signed document. The DON said the code status of each resident was important to have documented and readily available to all staff to ensure We are fulfilling the resident and the family's wishes. We do not want to resuscitate anyone that wished not to be and [NAME] versa. The DON said monthly audits were conducted of care plans, including code status to ensure compliance. I think we would have picked it up on the next audit. The DON said she and the licensed nurses caring for the residents were responsible for ensuring physician orders and care plans were correct. Record review of the facility's undated Advance Directives policy and procedure documented To provide all individuals with information relating to the individual's rights under Texas law to make decisions concerning medical care, including the right to accept or refuse medical and surgical treatment and the right to formulate Advance Directives All advance directive information and forms are provided to the resident and/or responsible party at the time of admission to the community. The resident's chart will reflect all decisions made related to advance directives. A copy of the advance directives will be maintained in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframe's to meet a resident's medical and nursing needs for one (Residents #29) of 20 residents reviewed for person-centered care plans: The facility failed to recognize, develop, and implement a correct advance directive objective and care interventions in Resident #29's comprehensive person-centered care plan. These failures could affect residents in the facility by placing them at risk of not being provided necessary care and services, and not having plans developed to address their needs. The findings included: Record review of Resident #29's Face Sheet dated [DATE] documented a [AGE] year-old male admitted on [DATE] with the diagnoses of: Acute respiratory failure and malignant neoplasm [cancer] of lung and bone. Record review of Resident #29's Out of Hospital Do Not Resuscitate (DNR - a medical order written by a doctor that instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a person's breathing stopped or if the heart stopped) Order dated [DATE] revealed a signed declaration for a DNR order. Record review of Resident #29's significant change Minimum Data Set, dated [DATE] documented he had an active diagnosis of cancer and the resident has a condition or chronic disease that may result in a life expectancy of less than 6 months. Record review of Resident #29's [DATE] Physician's Orders documented [DATE] - Admit to Silverado Hospice with diagnosis: Malignant neoplasm [cancer] of lung Record review of Resident #29's comprehensive care plan dated [DATE] documented Resident wishes their code status to be full code. Interview with Registered Nurse (RN) A on [DATE] at 3:01 PM revealed he identified himself as Resident #29's current nurse. RN A said Resident #29 was considered a DNR code status. After RN A reviewed Resident #29's electronic profile and current physician orders, he said Yes, he is listed as DNR. When asked to review Resident #29's most recent care plan, RN A said It says he is a full code but I know that is not right because he just got picked up by hospice at the beginning of this month. RN A said Resident #29's care plan should have been updated at the time his DNR went into effect. RN A said it was important to ensure Resident #29's code status was correct to ensure the correct resuscitation was performed, at the resident's request, when needed. Interview with the Minimum Data Set Coordinator (MDSC) on [DATE] at 3:41 PM revealed he said he was responsible for ensuring that long term stay resident's care plans were updated and accurate. The MDSC said the care plan was a plan created that documented the care and interventions the resident needed to promote their most optimal well-being. The MDSC said the care plan was a reference for all staff caring for the resident to refer to to implement the care needed. The MDSC reviewed Resident #29's care plan dated [DATE] and said the care plan documented that Resident #29 was a full code. The MDSC said Resident #29 was recently admitted to hospice.The MDSC did not respond to why Resident #29's care plan was not updated. In an interview with the Director of Nurses (DON) on [DATE] at 11:16 AM, she said the usual process was that the code status was put in the system upon admission. The DON said the code status of each resident was important to have documented and readily available to all staff to ensure We are fulfilling the resident and the family's wishes. We do not want to resuscitate anyone that wished not to be and [NAME] versa. The DON said monthly audits were conducted of care plans, including code status to ensure compliance. The DON said she, the MDS Coordinator, and the licensed nurses caring for the resident were responsible for ensuring physician orders and care plans were correct. Record review of the facility's Care Plans, Comprehensive Person-Centered policy and procedure dated [DATE] documented A comprehensive. person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial ad functional needs is developed and implemented for each resident The care planning process will incorporate the resident's personal and cultural preferences in developing the goals of care. The plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that 1 of 4 (Resident #56) residents receiving oxygen on hallway 400 reviewed for respiratory care was provided care inconsistent with professional standards of practice. Resident #56's oxygen tubing was not dated and was on the floor. This deficient practice could affect residents who received oxygen treatments and result in a respiratory infection. The findings included: Review of Resident #56's quarterly MDS dated [DATE] revealed an admission date of 9/29/2021 with diagnoses of Chronic Obstructive Pulmonary Disease with (acute) exacerbation. Observation on 10/26/22 beginning at 10:54 AM revealed nasal cannula being worn by Resident #56 while lying in bed. Resident #56's Oxygen tubing was on the floor and was undated. Interview on 10/26/2022 at 11:08 AM DON revealed she stated the tubing should be dated and should not be on the floor. The DON then immediately changed out the oxygen tubing with new tubing and dated it. Review of Resident 56's Physician Orders dated 10/02/21 and revised 10/09/21 documented Change nasal cannula and humidifier every week on Saturdays. Date tubing and humidifier when changing. Clean oxygen filter and concentrator every night shift, every Saturday. Interview on 10/27/2022 at 10:30 AM, Administrator was asked what could happen if oxygen tubing was left on the floor and undated. She stated So, it could be infection control. Something unclean, on the floor on a medical piece of equipment. Interview on 10/27/2022 at 11:00 AM with the DON concerning Oxygen tubing, DON stated, We know that there is risk for infection. The tubing can get tangled, increases the fall risk. Safety hazard as well. Review of the facility's policies and procedures titled MED-PASS, Inc Oxygen administration dated 2001 (revised 2010) includes instructions to check for kinks in the hose after placement but no instructions to date tubing. Review of In-service dated 10/25/2022 titled Oxygen and Continuous Positive Airway Pressure and Nebulizer included instructions to make sure tubing is not on the floor and is dated.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments on 1 of 9 medication carts reviewed for storage of drugs. 400 hall Nurses' Medication Cart was left unlocked by the 200/300 hall nurse's station area. This deficient practice could affect residents who have medications on the Nurses' Medication Cart and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications. The Findings included: Observation on 10/25/22 at 2:18 PM revealed 400 hall nurse medication cart unlocked and unattended. A resident was on the right side of the medication cart less than one foot away. Six staff members were around the nurses station conducting shift change report. This surveyor opened the top drawer recognizing the cart being unlocked. Multiple medications in bulk bottles were easily assessable and removable. This surveyor was able to open all drawers and go through various medications for approximately 5 minutes before a nurse came around and asked what I needed. Interview on 10/25/22 at 2:23 PM revealed LVN H came around nurse's station and identified herself as being responsible for the unlocked medication cart. LVN H stated, I have never worked here before (was LVN H's first day of employment at the facility) and I apologize. I haven't even been here for an hour. This surveyor asked if leaving the nurse medication cart unlocked is normal practice for her and LVN H stated, no, I usually always lock my cart. This surveyor asked why it is important to keep nurse cart locked and LVN H stated, so people are not able to get into the cart that are not supposed to. Interview on 10/26/22 at 01:38 PM with Administrator and DON revealed Competency Training is conducted for all new staff and agency staff on their first shift. DON stated, the training includes, introduction to staff and residents, as well as, hand washing, medication administration, g-tubes, transfer, peri care and anything pertaining to the care the nurse/staff will be providing on their shift. [NAME] stated, random audits are conducted on new staff and agency staff to ensure competency. DON stated nursing staff informed her that they saw this surveyor open and look through the nurse's medication cart and assumed this surveyor was given access to the cart. I informed DON, this surveyor was not given access and found the nurse medication cart unlocked and unattended. Interview with DON revealed the facility began In-service on 10/26/2022 for Locked Medication Carts for all staff. Record review of Locked Medication Carts reviewd and verified. 10/26/22 01:32 PM Record review of Controlled Substances Policy dated April 2019 line 4 states; Access to controlled medication remains locked at all times and access is recorded. 10/26/22 Record review of the Facility's Administering Medication Policy dated April 2019, states; Line 19 During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medication and all outward sides must be inaccessible to residents or others in passing by.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an Infection Prevention and Control Program designed to help prevent the standard and transmission based precautions to be followed to prevent the spread of infections or diseases for three residents (Resident #70, #87, and #96) of seven residents reviewed for medication pass and tracheostomy care. 1.) CMA B did not clean or disinfect the electronic blood pressure cuff and monitor before or after it was used on Resident # 70 and then Resident #96. 2.) RN D failed to maintain a sterile field as per facility protocols. These failures could have affect residents who receive personal medical care at risk for improper care, infections, and illnesses. Findings included: 1.) Record review of Resident #70's October 2022 Physician Orders revealed his orders included to check blood pressure daily and document and Metoprolol Tartrate (used to lower high blood pressure) 25 mg daily for Hypertension (high blood pressure). Record review of Resident #96's October 2022 Physician Orders revealed her orders included to check blood pressure daily and document and Metoprolol Succinate (used to lower high blood pressure) 25 mg daily for Hypertension. Observation of medication pass performed by CMA B on 10/25/22 beginning at 9:50 AM revealed CMA B retrieved an electronic blood pressure cuff and monitor from the top drawer of her medication cart. CMA B used the blood pressure cuff and monitor to check Resident #70's blood pressure on his right upper arm. CMA did not clean or disinfect the blood pressure cuff prior to or after using it. At 10:07 AM, CMA B used the same blood pressure cuff and monitor to check Resident #96's blood pressure on her left upper arm. CMA B did not disinfect the blood pressure cuff or monitor before or after using the it. In an interview with CMA B on 10/25/22 at 10:35 AM, she said she should have disinfected the blood pressure cuff and monitor after each use, between resident use. CMA B said she did not disinfect the cuff this time because I forgot, but I know I'm suppose to disinfect it after I use it to prevent cross contamination. When asked what she used to disinfect the blood pressure cuff, CMA B said We use the bleach disinfecting wipes but I don't have any in my cart. CMA B said it was important to disinfect the cuff/monitor to prevent infection. CMA B said she was in-serviced on infection control approximately one month ago. During an interview with the Director of Nurses (DON) on 10/27/22 at 11:21AM, she said it was important for staff to disinfect the reusable equipment between resident use for infection control purposes, we do not want to spread any infections from one resident to the other. The DON said she had presented an in-service regarding disinfecting of resident care equipment in the past several months and the facility contract pharmacy assists us with med pass and med carts audits on a monthly basis. The DON explained the pharmacy conducted random medication pass observations to ensure staff compliance. Record review of the facility's Cleaning and Disinfection of Resident Care Items and Equipment policy and procedure dated October 2018 documented Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control recommendations for disinfection .c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. Most non-critical reusable items can be decontaminated where they are used. ----Reusable items are cleaned and disinfected or sterilized between residents (stethoscopes, blood pressure cuffs, durable medical equipment . 3. Durable medical equipment must be cleaned and disinfected before reuse by another resident . 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer instructions. Record review of the facility's Record of In-Service dated 06/09/22 documented All equipment taken into rooms and/or used on residents must be cleaned thoroughly with disinfectant. Equipment examples: vital sign equipment and glucometers CMA B's signature was on the back of the in-service which indicated she received the in-service. 2.) Record review of Resident #87's clinical file revealed a [AGE] year-old male, with an original admission date of 11/03/2017. Diagnosis included, Anoxic Brain Damage (type of brain injury that isn't usually caused by a blow to the head. Instead, anoxic brain injury occurs when the brain is deprived of oxygen), Age related physical debility, Type 2 Diabetes Mellitus (A condition results from insufficient production of insulin, causing high blood sugar), dysphagia (A condition with difficulty in swallowing food or liquid. This may interfere in a person's ability to eat and drink), Artificial Opening Status, (an opening in the body that has been created by a health care provider), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), Muscle weakness, Cognitive communication deficit (difficulties with communication that have an underlying cause in a cognitive deficit more than a language or speech deficit), Dysarthria and Anarthria (Difficulty in speech due to weakness of speech muscles), Chronic Pain, Cerebral Infarction (pathologic process that results in an area of necrotic tissue in the brain), Lack of Coordination, Hemiplegia and Hemiparesis (Weakness on half of the body), Traumatic Brain Injury, Dementia ( A group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident #87's most recent Care Plan for Tracheostomy care reviewed, and included: The resident has a tracheostomy r/t injury anoxic brain injury. oThe resident will have clear and infection through the review date. oThe resident will have no abnormal drainage around trach site through the oThe resident will have temp within normal limits through review date. oThe resident will have WBC count within normal limits through review date. o6/26: Resp therapist to change out Trach oCHANGE TRACH COLLAR every Mon. *NO DRAIN SPONGE TO SITE* oCLEAN PASSY MUIR VALVE WITH WARM SOAPY WATER, RINSE THOROUGHLY IN WARM RUNNING WATER, DRY COMPLETELY BEFORE REPLACING oEnsure that trach ties are secured at all times. oMonitor/document for restlessness, agitation, confusion, increased heart rate (Tachycardia), and bradycardia. oMonitor/document level of consciousness, mental status, and lethargy PRN. oMonitor/document respiratory rate, depth and quality. Check and document q shift/as ordered. oProvide good oral care daily and PRN. oReassure resident to decrease anxiety. oSuction as necessary. oTRACH CARE Q SHIFT. ENSURE TRACH TIES ARE SECURE, MAKE SURE 2 FINGERS ONLY CAN FIT BETWEEN NECK AND TRACH TIE. DO NOT CHANGE TRACH COLLAR ONLY CHANGED ON MONDAYS. CHANGE DISPOSABLE INNER CANULA SHILEY #6 every day shift oTUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help IMMEDIATELY. oUse UNIVERSAL PRECAUTIONS as appropriate. Record review of Resident #87's most recent MDS data dated 09/25/22 identified a brief interview of mental status score of 12- moderately cognitively impaired. Resident #87 required total dependance on bed mobility, transfers, locomotion on and off unit, eating, toilet use, personal hygiene, bathing and is an extensive assist with dressing. Tracheostomy Care Observation on 10/27/22 at 01:32 PM by RN D and ADON revealed RN D did not maintain a sterile field while changing Resident #87's old tracheostomy cannula with a new one. RN D put on sterile gloves and used both sterile hands to remove tracheostomy cannula and proceeded to grab the new sterile tracheostomy cannula with both hands and inserted new tracheostomy cannula. Interview with RN D on 10/27/22 02:22 PM revealed she took responsibility for not maintaining a sterile field during tracheostomy cannula changes. RN D stated, I was nervous, and I was having trouble removing the cannula with the one hand so I used both hands. Simultaneous Interview with Administrator and DON on 1/27/22 at 02:49 PM revealed the facility is planning on having a Respiratory therapist comes and conduct in person training for nursing staff on respiratory care. DON stated Resident #87 is the only tracheostomy resident in the facility at this time and RN D has not provided tracheostomy care in a while since resident was out and just returned to the facility. DON stated they are currently working on getting in person tracheostomy care training as soon as possible. This surveyor asked what some risk factors Resident #87 could face due to RN D not maintaining a sterile field, and DON stated, well, an increase risk for infection and cross contamination. Possibly pneumonia or an upper respiratory infection. Administrator stated she does not have a clinical background but stated, Resident #87 is at risk for cross contamination and possible infection. DON stated, they were going to change out the tracheostomy cannula that was placed by RN D with a new sterile one. DON reiterated that the facility has not had a tracheostomy patient in a while and will be conducting the in person respiratory training. DON stated she asked RN D to get her prior to performing traceostomy care so she could assist but, RN D did not inform her and proceeded without her. Last Respiratory Therapy in service training could not be provided by time of exit. DON stated she has not been with the facility long and was not sure were previous DON placed those records. Record review of the facility Tracheostomy Care Policy, dated August 2013 documented Clean and Removable Inner Cannula, lines 8 through 12; 8. Put on sterile gloves. 9. Secure the outer neck plate with non-dominate hand. 10. Unlock the inner cannula with gloved dominate hand. 11. Gently remove the inner cannula, rotating counterclockwise while lifting away from the resident. Tracheostomy Care Policy General Guidelines line 1 (b, c) 1.Aseptic technique must be use:( Aseptic technique is employed to maximize and maintain asepsis, the absence of pathogenic organisms, in the clinical setting. The goals of aseptic technique are to protect the patient from infection and to prevent the spread of pathogens.) b. During all dressing changes until the tracheostomy wound has granulated (healed); and c. During tracheostomy tube changes, either reusable or disposable.