**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 2 of 14 residents (Resident #35 and Resident #41) reviewed for resident rights. The facility failed to ensure RN C provided privacy during wound care for Resident #35 and Resident #41. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings included: Resident #35 Record review of Resident 35's face sheet, dated 02/18/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include adult failure to thrive (a syndrome of weight loss, poor nutrition, and inactivity that affects older adults), anxiety, dementia (memory loss that interferes with daily life), stage 2 pressure ulcer to left buttock, and hypertension (high blood pressure). Record review of Resident #35's current physician's orders, with a start date of 01/21/25, revealed an order to cleanse stage II pressure ulcer to left buttock with wound cleanser and apply zinc daily. Record review of Resident #35's admission MDS, dated [DATE], revealed a BIMS score of 12, which indicated the resident's cognition was mildly impaired. Section M-Skin Conditions revealed a stage 2 pressure ulcer that was present upon admission. Record review of Resident #35's comprehensive care plan dated 02/10/25 revealed the resident was admitted to the facility with a Stage II pressure injury to the left buttock. Interventions included: Administer treatments as ordered and monitor for effectiveness. During a wound care observation on 02/18/25 at 12:33 PM for Resident #35, RN C failed to fully pull the privacy curtain and close the window blind before performing wound care to the resident's left buttock, which placed the resident at risk of bodily exposure to the hallway and facility exterior. Resident #35's bed position was nearest the window and there was a roommate occupying the other bed in the room. During an interview on 02/20/25 at 11:33 AM, RN C stated she did not completely pull the curtain or close the window blind prior to performing wound care for Resident #35. She stated blinds and curtains should always be closed during personal care to provide privacy to the resident. RN C stated she just didn't see that the blind was open and stated staff attempt to work in a timely manner when providing personal care to Resident #35 because he gets agitated if we take too long. She stated she had been trained by nursing administration to provide privacy during personal care. RN C stated a potential negative outcome for failure to provide privacy during personal care would be that the resident's mental health could be negatively affected, the resident could suffer shame or lose trust in staff. Resident #41 Record review of Resident 41's face sheet, dated 02/18/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include age-related cognitive decline, chronic kidney disease, weakness, macular degeneration (an eye disease that causes vision loss), and hypertension (high blood pressure). Record review of Resident #41's significant change MDS, dated [DATE], revealed a BIMS score of 06, which indicated the resident's cognition was moderately impaired. Section M-Skin Conditions revealed a stage 2 pressure ulcer that was present upon admission. Record review of Resident #41's current physician's orders, with a start date of 12/14/24, revealed an order to cleanse stage II wound to the sacrum (area above the tailbone) with wound cleanser and apply ordered treatment and dressing daily. During a wound care observation on 02/18/25 at 12:56 PM for Resident #41, RN C failed to fully pull the privacy curtain and close the window blind before performing wound care to the resident's sacrum, which placed the resident at risk of bodily exposure to the hallway and facility exterior. Resident #41's bed position was nearest the window and there was a roommate occupying the other bed in the room. During an interview on 02/20/25 at 11:35 AM, RN C stated she did not completely pull the curtain or close the window blind prior to performing wound care for Resident #41. She stated she should have closed the curtain and window blind before she began wound care for Resident #41, but she was concentrating on the steps of proper wound care and forgot. She stated she had been trained by nursing administration to provide privacy during personal care. RN C stated a potential negative outcome for failure to provide privacy during personal care would be that the resident's mental health could be negatively affected, the resident could suffer shame or lose trust in staff. During an interview on 02/25/25 at 11:38 AM with the ADM, she stated she was not aware that staff were not providing privacy to residents during personal care. She stated the door, privacy curtain and window blinds should be closed during personal care to provide as much privacy as possible to the resident. She stated her expectation of staff was that they always provide privacy to residents during personal care by following the facility policies for dignity and privacy and closing doors, curtains, and blinds. The ADM stated a potential negative outcome for failure to provide privacy during care was that the resident would not have the privacy they desire. Record review of the facility's policy titled; Dignity, date revised February 2021 revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are always treated with dignity and respect. . 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 14 residents (Resident #39) reviewed for resident rights. The facility failed to obtain a signed consent for antipsychotic medication, Trazadone, administered to Resident #39 for depressive episodes. The failure affected residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent. Finding included: Record review of Resident #39's face sheet, dated 02/19/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include depressive episodes, dysphasia (swallowing difficulties), cognitive communication deficit (a difficulty in communication that arises from an impairment in cognitive functions), reduced mobility, and aphasia difficulty in communicating). Record review of Resident #39's Comprehensive MDS, dated [DATE], revealed: Section C BIMS score revealed a score of 06, which indicated the resident's cognition was severely impaired. Section N-Medications [N0415] High Risk Drug Classes: Use and Indication revealed Resident #39 was taking an antidepressant. Record review of Resident #39's care plan, dated 09/12/24, revealed Resident #39 received antidepressant medications with the potential for drug-related adverse side effects like nausea, dizziness, drowsiness, dizziness, dry mouth, diarrhea, upset stomach, or trouble sleeping. Record review of Resident #39's Physician Order's, dates 02/18/25, revealed: Trazadone 100 MG; give 1 tablet by mouth one time a day for depressive episodes (Order date 08/25/23; Start date 10/01/24) Record review of Resident #39's Medication administration Record, February 2025, revealed: Resident #39 received Trazadone 100 MG; give 1 tablet by mouth one time a day for depressive episodes from 02/01/25-02/17/25. During an interview on 02/19/25 at 3:00 PM, the MDS Coordinator, stated she was familiar with the facility policy regarding medication consent. She stated the PNO was the facility could get sued. She stated the residents or family could allege that a medication was given that was not effective. She stated the purpose was to receive consent to administer the medication. She stated that consent should be obtained before then. The MDS Coordinator stated she was unaware of any residents missing medication consents. She stated the system to monitor medication consents was as soon as a doctor gave an order, the nurse should do the paperwork immediately. She stated there were instances where they will get verbal consent from the resident or the family, but they get all consents in writing as soon as possible. She stated if verbal consent had been obtained, it would be documented in the resident's EMR. The MDS Coordinator stated she expected all consents (written/verbal) should be obtained as soon as the doctor order was given. She stated all the nurses who receive orders were responsible. She stated if there were any missed medication consents, she did not have a reason it was not obtained. During an interview on 02/19/25 at 3:22 PM, the DON stated regarding medication consents, she was familiar with the facility policy and the purpose of medication consents was to make sure that everyone (resident and their family) was aware of the medication and that they were permitted to receive it. She said the PNO of not obtaining medication consent was that staff could end up giving the resident a medication that they do not want or may even receive medication to which they were allergic. The DON stated she was unaware of any residents who did not have medication consent for psychotropic medications. She stated the system to monitor medication consents was that the ADON or the MDS Coordinator will go through and ensure everything is up to date for all residents. She stated she, as the DON, would follow up. She stated she would also go through the resident medication consents when she is thinning their physical charts. She stated that she had been trained that all psychotropic medications required a consent before administering the medication. She stated she expected all appropriate medications to have the required consents. She stated she did not have a reason for the missing medication consents. She stated the nurse present when the medication is ordered was responsible for ensuring that the consents were obtained. During an interview on 02/19/25 at 3:55 PM, the ADM stated she was familiar with the facility's policy regarding medication consents. She stated the purpose of medication consent was if staff were going to administer psychotropic medications, they would have permission/consent from the resident and family. She said the PNO of not obtaining medication consent before administration was the facility would be liable if the resident could not make decisions. She stated it could be detrimental if the resident does not get the correct medication. She stated she was unaware of any residents who did not have the appropriate medication consent. She stated her system to monitor medication consent for psychotropic medications was that she relied on the DON. She stated she had not had specific training on obtaining medication consent because she is the administrator. She stated the nursing staff was responsible and did not have a reason it was not done if it was not done. She stated that she expected all appropriate psychotropic medications to have consents before administration. During an interview on 02/19/25 at 4:48 PM, the ADON stated she was familiar with the facility's policy on medication consents for psychotropic medications. She stated the purpose of obtaining consent was to ensure families and the residents knew what they were getting and the potential side effects. She stated the PNO was something bad could happen to the resident, or they could have a decline in health. She stated she was unaware of any residents not having medication consent until it was brought to her attention by the investigator. She stated the system to monitor consent for psychotropic medications was the nurse that receives the order would get the consent. She stated if the resident came into the facility with the medication, the admission nurse would obtain the consent. She stated she had been trained to obtain written consent before the administration of psychotropic medications. She stated she expected all appropriate medications to have an appropriate consent if applicable. She stated the nurses were responsible for getting consent and that she did not have a reason any resident consent was not obtained. During an interview on 02/20/25 at 9:10 AM, Resident #39 could not speak. He could not provide any information regarding administration of psychotropic medications. Record review of facility policy, Psychotropic Medication Use, dated July 2022, revealed: Policy Statement Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation A Psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: Anti psychotics Anti-anxiety medications Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: Indications for use Dose Duration Adequate monitoring for efficacy and adverse consequences Preventing, identifying and responding to adverse consequences Residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. Record review of facility policy, Resident Rights, revised February 2021, revealed: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Be informed of, and participate in, his or her care planning and treatment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 14 residents (Resident #27) whose records were reviewed for code status. The facility failed to obtain a DNR order and update the EMR for Resident #27 based on his completed DNR, dated [DATE]. This failure could place residents at risk for having their end of life wishes dishonored, and of having CPR performed against their wishes. Findings included: Record review of Resident #27's face sheet, dated [DATE], revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Parkinson's (brain disorder that worsens), constipation (infrequent or uncomfortable bowel movements) and lack of coordination. Resident #27's face sheet revealed that his code status was full code. Record review of Resident #27's Comprehensive MDS, dated [DATE], revealed: Section C BIMS score revealed a score of 09, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 06. Urinary Incontinence Section B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. B1000. Corrective Lenses: Yes. Section H-Bowel and Bladder. H0300. Urinary Continence Coded 3=Always incontinent (no episodes of continent voiding). H0400. Bowel Continence Coded 3=Always incontinent (no episodes of continent Bowel Movement) Record review of Resident #27's care plan, dated [DATE], revealed no care plan for visual function or urinary incontinence. Resident #27 had a care plan stating he did not want CPR and a goal of having an order for no CPR accepted/followed daily for the next 90 days. The intervention included to ensure all of Resident #27's needs are being met, ensure that all staff understand his no CPR status and having a OOH-DNR on file. Record review of Resident #27's OOH-DNR, dated [DATE], revealed that Family Member D declared as an agent in a Medical Power of Attorney on [DATE] that on the behalf of Resident #27 that she did not want any resuscitation measures to be initiated or continued. The OOH-DNR was valid with the medical power of attorney, notary and doctor's signature. During an interview on [DATE] at 9:23 AM, Resident #27 stated he knew what a DNR was. He said it was tough to answer the question about his preference. He was unable to report if he had a DNR in place. During an interview on [DATE] at 9:34 AM, LVN A stated regarding if a resident code (the resident was experiencing a cardiac arrest, where their heart had stopped beating, requiring immediate life-saving measures like CPR from a medical team) they would call for assistance from other staff. She stated that they had not had anyone code in a while. She stated whether a resident wanted CPR or was a DNR status, they, as the nurses, should know. She stated the first place that she would look was the computer. She stated there was a list of residents who wished to receive CPR at the nurse's station, but it had been moved. She stated Resident #27 was a full code and would require CPR. Observed LVN A on [DATE] at 9:35 AM, looked in Resident #27 EMR and reported he was a resident listed as full code status. No observation of a list of residents who wished to be a DNR was observed at the nurses' station on [DATE]. During an interview on [DATE] at 9:48 AM, RN B stated if someone coded, it is their duty to determine their code status. She said there was a list of residents wishing to receive CPR at the nurses' station. She stated that she had been a nurse at the facility since [DATE], and no one had coded. She said staff could find residents' code status on the computer and the list at the nurses' station. She stated Resident #27's code status was full, which meant they would perform CPR. Observed RN B on [DATE] at 9:49 AM, look in Resident #27's EMR and report that his code status was full code. During an interview on [DATE] at 9:56 AM, the MDS Coordinator stated if a resident codes, they will immediately check to see their code status. She stated the first place would be the computer. She stated if they did not have the information on the computer, she was unsure where the second place would be. She said the PNO for the resident, if the correct code status were not administered, was they, as the staff, may give the resident CPR, and this could make the family mad. She stated there could be many issues. She stated they could bring the resident back, which may not be what they wanted. She stated it was a violation of the resident's rights. During an interview on [DATE] at 10:27 AM, RN C stated if a resident coded, they immediately check to see if they were full code (Required CPR). She stated they would check the computer first and then the grey physical charts. She stated if those two do not coincide or the information was inconsistent, trying to find the correct answer could delay treatment. She stated the staff would have to have the correct information to start the correct code. She stated the PNO was the facility could receive a lawsuit. She stated the resident and or the family would not be happy. She stated if it were her, she would not be happy if the incorrect treatment was performed. She stated the computer was the first place to look, and the charge nurse was responsible for relaying the information on the code status. During an interview on [DATE] at 10:27 AM, Family Member D stated she still wanted the DNR in place. She stated she could not remember who helped her complete the paperwork, but that is a wish and desire of hers and her family. She said she had medical power of attorney, and it states no matter the capacity of his mental status, she could make medical decisions for Resident #27. She stated Resident #27 thinks he can walk and cannot, and his mental status fluctuates. During an interview on [DATE] at 3:22 PM, the DON stated she if a resident codes, and they have DNR code status, she does not expect CPR to be administered. She stated if the resident is a full code, she expected CPR to be administered. She stated the code status in the physical chart and the computer (EMR). She stated that the charge nurse would typically go to the physical chart, but all information should be consistent. Regarding DNR documentation, she was familiar with the facility policy. She stated not having consistent information in the EMR, physical charts, and care plan could affect all involved. She said the PNO of not having the correct code status was if it is not consistent or accurate, a resident could receive the wrong treatment. She said she was unaware of any residents who did not have the correct code status. She stated the system to monitor consistency in code status information was to check all residents' information every quarter. She stated by doing this, they had not identified any inconsistencies. She stated that she expected all information regarding code status to be consistent and accurate. She stated she did not have a reason Resident #27 EMR reflected he was a full code, and the remainder of his information reflected that he was a DNR. She said she was responsible for ensuring that this information was correct. During an interview on [DATE] at 3:55 PM, the ADM stated if a resident codes, she expected her staff to know the resident's code status. She stated each resident's code status was in the EMR. She stated after the staff checks the EMR, they should be able to provide appropriate care. She stated the code status should also be kept in the hard chart. She stated the information should be consistent and accurate. The ADM stated she was familiar with the policy regarding DNR and the accuracy of information regarding code status. She stated the PNO of if code status was inaccurate or inconsistent across platforms, the resident's health and life could be affected. She stated the purpose of having consistent information across facility platforms was that, potentially, the resident's wishes may not be met. She stated she was unaware of residents whose code status was inconsistent across all facility platforms, such as the EMR, care plan, and physical charts. She stated she had been trained that code status should be updated and accurate. She stated the ADON was responsible for updating the resident's EMR and maintaining DNR accuracy. During an interview on [DATE] at 4:48 PM, the ADON stated that the nurse should get a crash cart if a resident coded. She stated the nurse could look in the computer in the resident's EMR to determine their code status. She stated that if there is an advance directive, the attached DNR should be there for staff viewing. She stated she expected all code status information to be consistent across facility platforms, such as the EMR, care plan, and physical chart. She stated the DON was responsible for ensuring that all information across the facility platforms was consistent regarding resident code status. She stated she did not have a reason the information was not consistent for Resident #27. Record review of facility policy, Advance Directives, dated [DATE], revealed: Policy Statement The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Definitions Do Not Resuscitate (DNR) – indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. Determining Existence of Advance Directive If the Resident Has an Advance Directive If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. The director of nursing services (DNS) or designee notifies the attending physician of advance directives (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care. The attending physician is not required to write orders for which he or she has an ethical or conscientious objection. The residents wishes are communicated to the residents direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. Facility staff are not required to provide care that conflicts with an advance directive. If advance directive documents were developed in another state, the resident must have such documents reviewed and revised (as necessary) by his/her legal counsel in this state before the facility may honor such directives. Changes or revocations of a directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on 1 of 1 medication cart (cart for hall 100) reviewed for pharmaceutical services. The facility failed to ensure the medication cart for hall 100 did not contain expired medication. This failure could place residents at risk of not receiving prescribed medications as ordered and receiving medications that are less effective or have altered composition. The findings included: An observation 02/19/25 at 9:11 AM of the medication cart for hall 100 with RN B revealed a bottle of expired over-the-counter medication. The medication was labeled: Acetaminophen 500 mg/Diphenhydramine HCl 25 mg and had an expiration date of 11/2024. RN B confirmed that the date of the medication was past the manufacturer's expiration date. During an interview on 02/19/25 at 9:20 AM, RN B stated there should not be expired medication on the medication cart. She stated she did not know why the medication cart contained expired medication. She stated it was the responsibility of the nursing staff to check the cart for expired medications. RN B stated she had only been employed by the facility for a couple of months and was not sure how often the carts were audited by nursing administration for proper medication storage. RN B stated a potential negative outcome for expired medication on the cart would be that a resident could have an adverse reaction or may not receive the therapeutic effect of the ordered medication. During an interview on 02/20/25 at 10:05 AM the DON stated she was not aware that the medication cart contained expired medication. She stated it was the responsibility of the nursing staff on duty to assure expired medications were removed from the medication cart. The DON stated staff were trained and carts were monitored through periodic cart audits conducted by the pharmacy consultant and nursing administration. She stated her expectation of staff was to monitor carts and assure expired medications were removed from the medication cart for destruction. The DON stated a potential negative outcome for expired medication on the cart was that medications may lose potency and the resident would not get the full effect of the medication. During an interview on 02/20/25 at 10:51 AM the ADM stated she was not aware that there was an expired medication on the medication cart. She stated nursing staff and nursing administration were responsible to assure expired medications were removed from the cart. She stated her expectation of staff was to monitor expiration dates of medications and to follow policy at all times. The ADM stated a potential negative outcome of expired medication on the cart was that a resident's health could be negatively affected if an expired medication were administered. Record review of the facility-provided policy titled, Medication Labeling and Storage; revised February 2023 revealed: Policy Interpretation and Implementation Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 1 medication carts (medication cart for Hall 100), reviewed for medication storage. The medication cart assigned to Hall 100 contained loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered, receiving medications that are less effective or have altered composition, and drug diversions. The findings included: On 2/19/25 at 9:11 AM an observation of the medication cart for Hall 100 was conducted with RN B. Two loose pills were found in the drawer of the medication cart. RN B placed the pills in a dispensing cup and the ADON identified the medications as Furosemide 40 mg (1 tablet) and Cyclobenzaprine 10 mg (1 tablet). RN B destroyed the loose pills by placing them in the sharps container on the medication cart. During an interview on 02/19/25 at 9:20 AM, RN B stated there should not be loose pills on the medication cart. She stated she was not sure why the medication cart contained loose pills. She stated it was her responsibility to check the cart for proper medication storage each time when reporting for duty. RN B stated she received training on proper medication storage through her nursing education. She stated she had only been employed by the facility for a couple of months and was not aware of how often training on proper medication storage was provided by the facility. RN B stated she was trained by nursing administration to assure medication blister packs were kept in hard plastic sleeves in the drawers of the cart to reduce the risk of loose medications. RN B stated a potential negative outcome of loose medications on the cart would be that a resident may miss a scheduled dose of medication. During an interview on 02/20/25 at 10:05 AM the DON stated she was not aware that there were loose pills on the medication cart. She stated it was the responsibility of the nurse on duty as well as nursing administration to assure medications were stored properly on the medication cart. The DON stated staff were trained and carts were monitored through periodic cart audits conducted by the pharmacy consultant and nursing administration. She stated her expectation of staff was to keep medications secured by monitoring carts and assuring pill packs were in protective plastic covers to prevent medications from falling out of blister packs. The DON stated a potential negative outcome for loose pills on the cart was that medications may lose potency and the resident would not get the full effect of the medication. During an interview on 02/20/25 at 10:51 AM the ADM stated she was not aware that there were loose pills on the medication cart. She stated the nurse on duty and nursing administration were responsible to assure medications were stored properly on the cart. She stated her expectation of staff for proper storage of medications was to follow policy at all times. The ADM stated a potential negative outcome for failure to properly store medications was that medications could be more easily accessed, placing the facility at risk of drug diversions and residents could receive the wrong medications. Record review of the facility-provided policy titled, Medication Labeling and Storage; revised February 2023 revealed: Policy Interpretation and Implementation Medication Storage 1. Medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received . 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. . 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 2 of 4 residents (Residents #35, and Resident #151) and 2 of 4 staff (RN C and CNA E) reviewed for infection control. RN C failed to sanitize her hands between gloves changes during wound care for Resident #35. CNA E failed to wear PPE during catheter care for Resident #151 who was on EBP. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #35 Record review of Resident 35's face sheet, dated 02/18/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include adult failure to thrive (a syndrome of weight loss, poor nutrition, and inactivity that affects older adults), anxiety, dementia (memory loss that interferes with daily life), stage 2 pressure ulcer to left buttock, and hypertension (high blood pressure). Record review of Resident #35's current physician's orders, with a start date of 01/21/25, revealed an order to cleanse stage 2 (partial thickness skin loss) pressure ulcer to left buttock with wound cleanser and apply zinc daily. Record review of Resident #35's admission MDS, dated [DATE], revealed a BIMS score of 12, which indicated the resident's cognition was mildly impaired. Section M-Skin Conditions revealed a stage 2 pressure ulcer that was present upon admission. Record review of Resident #35's comprehensive care plan dated 02/10/25 revealed the resident was admitted to the facility with a stage 2 pressure injury to the left buttock. Interventions included: Administer treatments as ordered and monitor for effectiveness. During a wound care observation on 02/18/25 at 12:33 PM for Resident #35, revealed RN C entered the room, washed her hands, and put on a gown and gloves. RN C explained the procedure to Resident #35 then assisted him to roll to his left side. RN C removed the dressing to the resident's left buttock and placed it in the trash. RN C then removed her gloves, put on new gloves and cleansed the resident's wound, according to the physician's orders. RN C placed a new dressing to the wound and repositioned the resident for comfort. RN C did not sanitize her hands between the glove change. During an interview on 02/18/25 at 1:19 PM, RN C stated she did not sanitize her hands between the glove change. She stated hand hygiene should be performed each time gloves were changed during wound care. RN C stated she realized she failed to sanitize her hands after she had already changed her gloves and continued with wound care. She stated she forgot to set her bottle of hand sanitizer on the prepped table, which would have reminded her to sanitize her hands. RN C stated she was trained on hand hygiene through in-services conducted by nursing administration annually and as needed. RN C stated a potential negative outcome of failure to sanitize hands between glove changes was that bacteria could be spread from resident to resident and wounds could become infected. Resident #151 Record review of Resident 151's face sheet, dated 02/18/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (a disorder of the central nervous system that affects movement), dementia, hypertension (high blood pressure), anxiety, and overactive bladder (a disorder of bladder function that causes the sudden need to urinate). Record review of Resident #151's current physician's orders, with a start date of 02/03/25, revealed an order to change Foley catheter monthly and provide catheter care daily on each shift. Record review of Resident #151's admission MDS, dated [DATE], Section H-Bowel and Bladder revealed the resident had an indwelling catheter. During a perineal care and catheter care observation on 02/18/25 at 1:36 PM for Resident #151, revealed CNA E entered the room, washed her hands, and put on gloves. CNA E explained the procedure to Resident #151 then performed female perineal care and catheter care. CNA E repositioned the resident in bed, removed her gloves and washed her hands. CNA E did not put a gown on prior to performing care for the resident. A sign was observed above Resident #151's bed which reflected a gown and gloves were required while performing direct care for the resident. During an interview on 02/18/25 at 1:54 PM, CNA E stated she did not put a gown on prior to performing perineal care and catheter care for Resident #151. She stated she should have worn a gown while performing care because the resident had a catheter. CNA E stated a resident on EBP would require staff to wear a gown and gloves while performing care in order to prevent bacteria from entering wounds and catheters. She stated staff were informed of a resident being on EBP through the report given at shift change. She stated, Most of the time, there is a sign in the room that tells us if we need to put on a gown. CNA E stated she had been trained on EBP through in-services conducted by the ADON. CNA E stated a potential negative outcome for failure to use proper PPE on a resident on EBP would be that the resident could get an infection. During an interview on 02/20/25 at 10:05 AM the DON stated she was not aware that staff were not following proper hand hygiene and EBP protocol. She stated hand hygiene should be performed after each glove change and a gown and gloves should be used when caring for a resident on EBP. She stated it was the responsibility of nursing administration to assure staff were properly trained on hand hygiene and EBP through in-services conducted periodically at the facility. The DON stated her expectation of staff was to follow protocol for hand hygiene and EBP at all times. The DON stated a potential negative outcome for failure to observe proper hand hygiene and EBP protocol would be cross-contamination and the spread of infection. During an interview on 02/20/25 at 10:51 AM the ADM stated she was not aware that staff were not following proper hand hygiene and EBP protocol. She stated it was the responsibility of nursing administration to assure staff were properly trained on hand hygiene and EBP. The ADM stated her expectation of staff was to always follow protocol for hand hygiene and EBP by sanitizing hands and wearing proper EBP when necessary. The ADM stated a potential negative outcome for failure to observe proper hand hygiene and EBP protocol would be that residents and employees were at higher risk of infection. Record review of the facility-provided in-service, dated 03/27/24, revealed: Subject: New State Guidelines for Residents with wounds, feeding tubes and catheters. The document was signed by 28 staff members and had a memorandum attached from the Centers for Medicare and Medicaid Services with a subject of Enhanced Barrier Precautions in Nursing Homes. Record review of the facility-provided policy, date revised March 2024, titled Enhanced Barrier Precautions revealed: Policy Statement Enhanced Barrier Precautions (EBP's) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment {PPE} is changed before caring for another resident. . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review the facility failed to provide each resident or the resident's representative education regarding pneumococcal immunization and failed to document evidence of receiving, refusal, or education regarding pneumococcal immunization, for 2 of 14 residents (Residents #10 and #39). The facility failed to document the influenza immunization status for Resident #10 The facility failed to document the influenza immunization status for Resident #39 This failure placed residents who wanted but did not receive the pneumococcal vaccine, who are at risk for infections and decreased quality of life. Findings included: Resident #10 Record review of Resident #10's face sheet, dated 02/19/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss). Record review of Resident #10's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 4, which indicated the resident's cognition was severely impaired. Section O [O0250] Influenza Vaccine revealed Resident #10 did not receive the influenza vaccine in the facility because she was not in the facility. Record review of Resident #10's Physician Order's, dated 02/18/25, revealed: Influenza Vaccination intramuscular solution Prefilled Syringe .5 ML (Order date 07/02/24 Start Date 10/01/24). Record review of Resident #10's progress notes dated 10/01/24-02/18/25, did not reveal any documentation indicating that the resident had received or refused the influenza vaccination. During an interview on 02/20/25 at 9:19 AM, Resident #10 could not provide any information regarding whether the flu immunization had been offered or refused. Resident #39 Record review of Resident #39's face sheet, dated 02/19/25, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include depressive episodes, dysphasia (swallowing difficulties), cognitive communication deficit (a difficulty in communication that arises from an impairment in cognitive functions), reduced mobility, and aphasia difficulty in communicating). Record review of Resident #39's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 06, which indicated the resident's cognition was severely impaired. Section O [O0250] Influenza Vaccine revealed Resident #39 did not receive the influenza vaccine in the facility and no reason was given. Record review of Resident #39's Physician Order's, dates 02/18/25, revealed: Influenza Vaccination intramuscular solution Prefilled Syringe .5 ML (Order date 08/25/23 Start Date 10/01/24). Record review of Resident #39's progress notes dated 10/01/24-02/18/25, did not reveal any documentation indicating that the resident had received or refused the influenza vaccination. During an interview on 02/18/25 at 11:42 AM, Resident #39 could not answer any questions. Resident #39 could not answer questions about whether he had been offered or refused immunizations. During an interview on 02/19/25 at 3:00 PM, the MDS Coordinator stated she was familiar with the facility's immunization policy. She stated the purpose of offering immunizations to residents was so they could fight illnesses. The MDS Coordinator said the PNO of not offering necessary immunizations was the residents could get sick and pass illnesses to other residents. The MDS Coordinator stated she was unaware of residents not being offered the influenza (flu) immunization. She stated the system to monitor immunizations was that the ADON headed the process. She stated they were provided a list of names and then went down the list. She stated they do the flu shots in October or November. She stated she had been trained that all immunizations were offered upon admission and during the applicable seasons. She stated she expected all residents to be offered immunizations. She stated she did not have a reason if any immunizations were not offered but that the ADON was responsible. During an interview on 02/19/25 at 3:22 PM, the DON stated regarding resident immunizations she was familiar with the facility policy. She stated the purpose for offering and administering resident immunizations was that it helped prevent the flu. She stated she was unaware of any resident missing immunizations or not being offered until 2/19/25. She stated the system to monitor resident immunizations was the ADON normally kept up with it since she was the infection prevention nurse. She stated she had been trained to offer all applicable immunizations, such as flu, TB, and COVID-19. She stated she did not have a reason the flu immunization was not offered to Resident #10 and Resident #39. She stated she and the ADON were responsible for resident immunizations. During an interview on 02/19/25 at 3:55 PM, the ADM stated regarding resident immunizations she was familiar with the policy but only a little. She stated she read the policy. She stated the purpose of offering residents immunizations was to give them a choice of what they want regarding preventative care. She stated it was the resident's right to choose. She stated the PNO of not offering or administering their choice in preventative care was the residents would not be able to decide what they wanted for preventative care. She stated she was unaware of residents who had not been offered or received their flu shot. She stated the system to monitor resident immunizations was the ADON kept up with it. She stated she had not had specific training but read the policy. She stated the ADON was responsible for resident immunizations. The ADM stated she did not know why resident immunizations were not offered or administered. During an interview on 02/19/25 at 4:48 PM, the ADON stated she was familiar with the resident immunization policy. She stated the purpose of offering or administering immunizations was so that residents could receive their immunizations if they wanted them. She stated the PNO for not offering or administering the flu immunization was so the resident would not get the flu. She stated she was unaware that Residents #10 and #39 had no flu vaccines. She stated the system that she used to monitor resident immunizations was that she would make a list. She said she would then give it to the nurses so they could offer and administer the immunization. She stated they offered upon admission, and starting in October, they began with flu immunizations. She stated last year (2024), most residents received their flu immunizations in November and late December because of a wave of sickness that occurred in October. She stated even if the resident was admitted after December 2024, the resident would have still been offered the flu shot. She stated she had been trained on resident immunizations and expected all residents to be offered immunizations upon admission and in the appropriate seasons. She stated she, as the ADON, was responsible, and there was no reason the two residents (Resident #10 and #39) had not received their flu shot or been offered. Record review of facility policy, Director of Nursing Services, dated August 2022, revealed: Policy Statement The nursing services department is under the direct supervision of a registered nurse. Policy Interpretation and Implementation The director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: overseeing standards of nursing practice; coordinating nursing services with other resident services; recruiting and retaining the number and skill levels of nursing personnel necessary to meet the nursing care needs of each resident; Record review of facility policy, Resident Rights , revised February 2021, revealed: Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Be informed of, and participate in, his or her care planning and treatment Record review of facility policy, Influenza Vaccine , dated March 2022, revealed: Policy Statement All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives) Policy Interpretation Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident has already been immunized. Residents admitted between October 1st and March 31st shall be offered the vaccine within 5 working days of the resident admission to the facility. A resident refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention recommendations at the time of the vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 6 of 14 residents (Resident #10, #24, #27, #34, #36 and #39) reviewed for care plans in that: The facility failed to ensure that Resident #10's care plan was revised, updated and individualized with interventions and goals to address Resident #10's vison and communication. The facility failed to ensure that Resident #24's care plan was revised, updated and individualized with interventions and goals to address Resident #24's vision and communication. The facility failed to ensure that Resident #27's care plan was revised, updated and individualized with interventions and goals to address Resident #27's vision and urinary incontinence. The facility failed to ensure that Resident #34's care plan was revised, updated and individualized with interventions and goals to address Resident #34's vision. The facility failed to ensure that Resident #36's care plan was revised, updated and individualized with interventions and goals to address Resident #36's vision. The facility failed to ensure that Resident #39's care plan was revised, updated and individualized with interventions and goals to address Resident #39's vison, communication, urinary incontinence and psychosocial wellbeing. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address specific needs or concerns. Findings included: Resident #10 Record review of Resident #10's face sheet, dated 02/19/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), . Record review of Resident #10's Comprehensive MDS, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 4, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 03. Visual Function 04. Communication Section B0200. Hearing Coded 1= Minimal difficulty= difficulty in some environments. B0800 Ability to understand others- Coded 1= Usually understands= misses some part/intent of message but comprehends most conversation. B1000. Vision - coded 1 =impaired - sees large print, but not regular print in newspapers/books. B1200 Corrective Lenses: Yes. Record review of Resident #10's care plan, dated 07/15/24, revealed no care plan for visual function or communication. Record review of Resident #10's Physician Order's, dates 02/18/25, revealed: Influenza Vaccination intramuscular solution Prefilled Syringe .5 ML (Order date 07/02/24 Start Date 10/01/24) During an interview on 02/20/25 at 9:17 AM, LVN A stated when talking to Resident #10, staff must speak to her in her right ear and speak loudly. She said she learned this through trial and error. She also stated that Resident #10 wears glasses. During an interview on 02/20/25 at 9:18 AM, RN C stated staff must speak in Resident #10's right ear. She said she learned this through trial and error. She noticed Resident #10 would answer more questions on her right side. During an interview on 02/20/25 at 9:19 AM, Resident #10 could not provide any information regarding her vision and communication ability. Observed on 02/20/25 at 9:19 AM, Resident #10 had her glasses on and had a puzzle book in her lap. Resident #24 Record review of Resident #24's face sheet, dated 02/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer (memory loss) and schizophrenia (chronic mental illness). Record review of Resident #24's Comprehensive MDS, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 5, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication Section B0200. Hearing Coded 1= Minimal difficulty= difficulty in some environments. B0700. Ability to understands others. Coded 1= Usually understands- misses some part. intent of message but comprehends most conversation. B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. B1000. Corrective Lenses: No Record review of Resident #24's care plan, dated 07/19/24, revealed no care plan for visual function and communication. During an interview on 02/20/25 at 10:34 AM, Resident #24 did not provide any additional information regarding his ability to communicate and vision. He stated he could communicate and see. During an interview on 02/20/25 at 10:35 AM, CNA L stated Resident #24 can be demanding and usually communicates in a demanding manner. She also stated Resident #24 can be hostile. She said she practices asking him politely, which usually works even if he was communicating in a demanding manner. She stated that she knew this by working with him but did not know what a care plan was. She said that she believes Resident #24 can see well. Resident #27 Record review of Resident #27's face sheet, dated 02/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Parkinson's (brain disorder that worsens), constipation (infrequent or uncomfortable bowel movements) and lack of coordination. Resident #27's face sheet revealed that his code status was full code. Record review of Resident #27's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 06. Urinary Incontinence Section B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. B1000. Corrective Lenses: Yes. Section H-Bowel and Bladder. H0300. Urinary Continence Coded 3=Always incontinent (no episodes of continent voiding). H0400. Bowel Continence Coded 3=Always incontinent (no episodes of continent Bowel Movement) Record review of Resident #27's care plan, dated 01/06/25, revealed no care plan for visual function or urinary incontinence. During an interview on 02/20/25 at 10:30 AM, Resident #27 stated he wore glasses and needed them. He stated he could clean them, but preferred staff do so because they do a better job than he does. He stated that he had three pairs of glasses. He stated he can go to the restroom by himself and does not need any help but likes to have help sometimes when he goes to the restroom. During an interview on 02/20/25 at 11:10 AM, CNA K stated regarding Resident #27, they must assist him in the restroom all the time. She said he used his briefs most of the time but can assist when standing. She stated Resident #27 had dementia, but she typically goes by what the resident says if they tell her any information about themselves. She stated Resident #27 wears glasses, and he cleans his glasses. Resident #34 Record review of Resident #34's face sheet, dated 02/20/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include anxiety, dementia, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), depression, muscle weakness, pain, heart disease, and hypertension (high blood pressure). Record review of Resident #34's Admission's Minimum Data Set (MDS), dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 7, which indicated the resident's cognition was impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function Section B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. Record review of Resident #5's care plan, dated 11/24/24, revealed no care plan for visual function. Record review of Resident #34's Care Plan on 02/19/2025 at 9:50 AM, revealed: Resident #34 was at risk for injuries due to falls due to confusion and weakness. I have impaired vision and wear glasses. I require moderate assist for transfers. I use a walker when ambulating. The goals indicated that Resident #34 would not have injuries due to falls in the next 90 days. The interventions stated: ensure that Resident #34 is wearing glasses, and they are clean, provide a well-lit room to enhance vision. During an interview with Resident #34 on 2/20/2025 at 11:32 AM. Resident #34 stated that she had not been to the eye doctor in a while but does not remember how long it had been. Resident #34 stated that she can see out of her glasses. Resident #34 stated that she can clean her own glasses. Resident #34 stated that she had brought her glasses from home. Resident #34 stated Resident #36 Record review of Resident #36's face sheet, dated 02/19/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, headache, and dizziness. Record review of Resident #36's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C score revealed a score of 14, which indicated the resident's cognition was not impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 03. Visual Function Section B1000. Vision - coded 1 = impaired - sees large print, but not regular print in newspapers/books. B1200. Corrective Lenses: Yes Record review of Resident #36's care plan, dated 05/27/24, revealed no care plan for visual function. During an interview on 02/20/25 at 9:13 AM, Resident #36 stated she wore glasses only when she completed her puzzles. She said that she was independent and can clean her glasses. She stated she had multiple pairs and liked to have them match her clothing. Resident #36 stated that when she does not wear her glasses and attempts to do puzzles or read, she gets a headache. Resident #39 Record review of Resident #39's face sheet, dated 02/19/25, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include depressive episodes, dysphasia (swallowing difficulties), cognitive communication deficit (a difficulty in communication that arises from an impairment in cognitive functions), reduced mobility, and aphasia difficulty in communicating). Record review of Resident #39's Comprehensive Minimum Data Set (MDS), dated [DATE], revealed: Section C BIMS revealed a score of 06, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication 06. Urinary Incontinence 07. Psychosocial Well-Being Section B0600. Speech Clarity Coded 1 Unclear Speech- slurred or mumbled words. B0700 Makes self understood Coded 3= Rarely/never understood. B0800 Ability to Understand Others Coded 1 Usually understands= misses some part/intent of message but comprehends most conversation. B1000. Vision - coded 2 = Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects. B1200 Corrective lenses: No. Section H-Bowel and Bladder. H0300. Urinary Continence Coded 3=Always incontinent (no episodes of continent voiding). H0400. Bowel Continence Coded 3=Always incontinent (no episodes of continent Bowel Movement) Record review of Resident #39's care plan, dated 09/12/24, revealed no care plan for visual function, communication, urinary incontinence, and psychosocial wellbeing. Record review of Resident #39's Physician Order's, dates 02/18/25, revealed: Influenza Vaccination intramuscular solution Prefilled Syringe .5 ML (Order date 08/25/23 Start Date 10/01/24). During an interview on 02/20/25 at 9:08 AM, CNA K stated regarding Resident #39, they figured it out regarding communicating with him. She stated when he gets mad because they do not understand him, she returns and tries again later. She stated she knows to do this because of her certified nurse aide experience. She stated not many staff can communicate with him. She stated Resident #39 used briefs and required total assistance from the staff. She stated Resident #39 does not get sad but gets angry often and does not want to do activities. She stated the staff had to tread lightly with Resident #39. During an interview on 02/20/25 at 9:10 AM, Resident #39 could not speak. He pointed at his TV and his nightstand. During an interview on 02/18/25 at 11:42 AM, Resident #39 could not answer any questions. He had a tough time communicating. After a few attempts to communicate with Resident #39, he became frustrated and waved the investigator out of his room. Resident #39 could not answer questions about his communication preference, vision, psychosocial well-being, and urinary. During an interview on 02/19/25 at 3:00 PM, the MDS Coordinator, stated she was familiar with the care plan policy regarding missing care plans. She stated that a care plan was when there was an identified problem or things that the resident needed to work on. The MDS Coordinator stated there was a goal set and then they (staff and resident) would see if the resident could meet the goal. She stated the PNO of the care plan was not accurate or up to date because the resident could not get proper care. She stated the PNO for a resident who required a vision care plan, and they did not have it, was that the resident could lose their vision if they were not receiving the proper treatment. She stated the PNO for a resident who required a urinary care plan and did not have it was that they could have issues with skin integrity. She stated the PNO for a resident that required a communication care plan, and they did not have it, the resident may be overlooked. Staff would not know to take their time and wait for the resident to communicate if that was the case. She stated the resident's communication could get worse, and the resident could become depressed. She stated the PNO for a resident that required a psychosocial well-being care plan, and they did not have it, so there may not be adequate monitoring for the resident. The MDS Coordinator stated she was unaware of any missing care plans. She stated that the system to monitor care plans was she would put the assessment date on the calendar as the MDS Coordinator. She stated after she completed the MDS assessment she is unsure what happened with the resident care plans. She stated she did not collaborate with the DON regarding the creation/revision and did not know how the care plan connected to the MDS assessment. She stated she had been trained on how to do the MDS assessment but had no training regarding care plans. She said she expected all resident care plans to be updated and accurate. She stated the DON was responsible for the care plans. She stated she was responsible for the MDS assessment, and if there were missing care plans, she did not have a reason. She stated she believed the MDS assessment pulled information from the care plan. She stated the DON creates the CAAs, and she does not deal with section V (CAAs) of the MDS assessment. During an interview on 02/19/25 at 3:22 PM, the DON stated she had been trained on the care plan policy. She stated that the resident plan's purpose was to provide continuous care, so all staff knew what was happening with the resident. She stated if there were any missing care plans, then the PNO, which is the resident, may not get the care they need. She stated the care plan is created based on what was triggered on the MDS assessment (section V). She stated the PNO for a resident who required a vision care plan, and if they did not have it, it could impact their falls. She stated the PNO for a resident who required a urinary care plan, and they did not have it, was that the resident could have skin breakdown. She stated the PNO for a resident that required a communication care plan, and they did not have it, the resident will not be able to be understood and may not understand who is speaking with them. She stated the PNO for a resident that required a psychosocial well-being care plan, and they did not have it, the resident may feel down and may not get out of their room, and it could lead to depression. She stated she was unaware of any missing resident care plans. She stated her system to monitor care plans was that she sometimes would combine triggered care areas to ensure that she had them all care planned. She stated she had been trained on how to complete care plans. She stated that she expected all care plans to be updated and accurate. She stated that as the DON, she was responsible for resident care plans. She stated she did not have a reason for missing care plans as she believed all care plans had been created according to Section V of the MDS assessment. During an interview on 02/19/25 at 3:55 PM, the ADM stated regarding the accuracy and creation of resident care plans, she was familiar with the facility policy. She stated the resident care was to inform staff about the resident care and family information. She said the PNO of not having accurate and triggered care plans was the resident may not receive the care they should be receiving. She stated the PNO for a resident who required a urinary care plan, and they did not have the staff would not know if the resident was incontinent. She stated the PNO for a resident that required a communication care plan, and they did not have it was the staff may not know if they had any assistive devices to help them communicate. She stated the PNO for a resident who required a psychosocial well-being care plan and did not have it, the staff may not know if there were any services the resident will need to attend or if there were medications they were required to have. The staff may not know if the resident is acting out of character. She stated she was unaware of any residents missing care plan. She stated the system to monitor resident care plans was they were discussed in morning meetings and that it may be on the dashboard in the EMR (PCC). She stated since she is not a nurse, she may not have access to this information. She stated she had not had specific training on resident care plans but had always consulted with the DON. She stated she expected all care plans to be updated and accurate. She stated the DON was responsible, and the only reason she could think of why there were missing care plans was that they were transitioning from one EMR to another. During an interview on 02/19/25 at 4:48 PM, the ADON stated she was familiar with the facility policy regarding resident care plans. She stated that the purpose of resident care plans was that they were detailed plans of care. Ashe stated that the resident's care plan was tailored to each resident. She stated that everyone used the care plan to provide care. She stated that the PNO was if the care plan was not updated and accurate, the resident may not receive the care they need. She stated the PNO for a resident that required a vision care plan, and they did not have it the resident would not get the care that they needed. She stated the PNO for a resident who required a communication care plan and did not have it, staff would be unable to communicate with the resident or provide the communication devices they may need. She stated the PNO for a resident who required a urinary care plan and did not have it then placed the resident at risk for skin breakdown. She stated the PNO for a resident that needed a psychosocial well-being care plan, and they did not have it she was unsure what the negative outcome would be for the resident. She stated she was unaware of any residents missing any triggered care plans. She stated she did not know the system they used to monitor the care plans. She stated she had not been trained on how to create care plans. She stated the DON was responsible for care plans and was unsure why there would be any missing ones. Record review of facility policy, Care Area Assessments, dated November 2019, revealed: Policy Statement Care area assessments (CAAs) are used to help analyze data obtained from the MDS and to develop individualized care plans. Triggered care areas are evaluated by the interdisciplinary team to determine the underlying causes, potential consequences and relationships to other triggered care areas. Document interventions on the care plan: Include specific interventions, including those that address common causes of multiple issues; and Include recommendations for monitoring and follow-up timeframes CAA documentation explains the basis for the care plan. This documentation should include: causes and contributing factors for the triggered care areas; the nature of the condition or issue (i.e., What exactly is the problem and why is it a problem?); complications contributing to (or caused by) the care area; risk factors related to the condition; Record review of facility policy, Care Planning, dated March 2022, revealed: Policy Statement The interdisciplinary team is responsible for the development of resident care plans. Resident care plans are developed according to the timeframes and criteria established by §483.21. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). Record review of facility policy, Comprehensive Assessments, dated March 2022, revealed: Policy Statement Comprehensive assessments are conducted to assist in developing person-centered care plans. Annual Assessment: Its completion dates (MDS/CAA(s)/ care plan) depend on the most recent comprehensive and past assessments ' ARDs and completion dates. Completed assessments are maintained in the residents active record for a minimum of 15 months. These assessments are used to develop, review and revise the residents comprehensive care plan. Record review of facility policy, Goals and Objectives, Care Plans, dated April 2009, revealed: Record review of facility policy, , date/revised, revealed: Policy Statement Care plans shall incorporate goals and objectives that lead to the residents highest obtainable level of independence. Policy Interpretation and Implementation Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Care plan goals and objectives are derived from information contained in the residents comprehensive assessment and: are resident oriented; are behaviorally stated; are measurable; and contain timetables to meet the residents needs in accordance with the comprehensive assessment. Goals and objectives are entered on the residents care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved.

Based on interviews and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week for 4 days out of 33 days (1/25/25, 1/26/25, 2/8/25 and 2/9/25) reviewed for nursing services. The facility failed to ensure a registered nurse was scheduled for eight consecutive hours per day, seven days per week on the following dates: 1/25/25, 1/26/25, 2/8/25 and 2/9/25. This deficient practice could place residents at risk of not receiving adequate care. Findings included: During an interview on 02/19/25 at 9:48 AM, RN B stated she was an RN. She said she worked every other weekend. As an RN, she had the ability to pronounce death. She stated they were also in the facility if the LVN needs guidance. She said there were times when an LVN may not be able to get a catheter in but will ask for assistance. During an interview on 02/19/25 at 10:27 AM, RN C stated occasionally, she worked the weekends. She stated she had not in a while, but if she did, she clocked in. She stated as an RN, she could pronounce death. She stated if there was an IV, the RN would start them. She stated she does not believe that they did IVs in their facility. She stated the RN assists the LVN with decision-making in critical situations. She stated LVNs could not complete or create a care plan for the residents. She stated if the resident did not feel comfortable the RN could help comfort and be available to the residents. During an interview on 02/19/25 at 3:22 PM, the DON stated she had been trained on the RN coverage policy. The DON stated the purpose of having an RN in the facility was to provide continuous daily care. She stated the RN was there so that they could oversee the shift. She stated the RN could pronounce death if someone passed away. She stated the RN can oversee the care the LVN and CNAs provide. She said the PNO of not having an RN in the facility, according to the policy, was that if something went wrong, they would not be present to give professional oversight. She stated she was unaware of any uncovered days. She stated the system to monitor RN coverage was the ADON ensured it was covered. If there is no coverage, the ADON needed to get an agency and find someone to cover. The DON stated if the ADON could not find coverage and she (the DON) was available, she would come in. She stated she was not available to come in on the days identified. During an interview on 02/19/25 at 3:55 PM, the ADM stated she was familiar with the facility policy regarding RN coverage. She stated the purpose was that it was a state requirement. She stated the PNO of not following the state requirement regarding RN coverage was they would be out of compliance. She stated the LVN can do only so much. She stated the RN could pronounce death. She stated the RN can guide LVNs in the decision-making process. She stated she was unaware of any uncovered days until 02/19/25 when she looked at the time sheets. She stated her system to monitor RN coverage relied on the DON. She stated she had not been trained on the expectations but had read the policy. She stated she expected the policy to be followed. She stated the DON was responsible for ensuring that the facility had the appropriate RN coverage. She stated there was no RN coverage because an RN volunteered to help but then called in. She did not specify the date. She stated if they did not have coverage, they could call agency help. During an interview on 02/19/25 at 4:48 PM, the ADON stated she was familiar with the RN coverage policy. She stated she was unsure of the purpose of having an RN every day for 8 consecutive hours. She stated she was unsure what additional duties or assessments an RN can do vs what an LVN can do outside of pronouncing death. She stated she was unaware of multiple days that were uncovered. She stated she was aware of just one day. She stated she had a volunteer, but the volunteer called in. She stated as a result of the call in, she did not think she made any additional effort to cover the shift. She said they needed to call the agency nurses if they could not find RN coverage. She stated this had been mentioned before but when the volunteer did not come in, she did not think of calling agency. She stated it is typically unsuccessful when they attempt to get an RN at the last minute. She stated the system she used to monitor RN coverage was that every other weekend was always covered, and she typically had no issues covering the alternate weekend. She stated if it is not covered then they attempt to find coverage. She stated she had been trained that the facility had to have RN coverage 7 days a week for 8 consecutive hours. She stated she expected the facility to have RN coverage 7 days a week for 8 consecutive hours. She sated she was responsible for making the schedule. She stated she did not have a reason the four days did not have RN coverage for 8 consecutive hours. Record review of RNB, C, P and Q time sheets for the time period of 1/17/25-02/18/25 revealed there was no RN coverage for 1/25/25, 1/26/25, 2/8/25 and 2/9/25. Record review of facility policy, Director of Nursing Services, dated August 2022, revealed: Policy Statement The nursing services department is under the direct supervision of a registered nurse. Policy Interpretation and Implementation The director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: overseeing standards of nursing practice; coordinating nursing services with other resident services; recruiting and retaining the number and skill levels of nursing personnel necessary to meet the nursing care needs of each resident; Record review of facility policy, Departmental Supervision, dated August 2022, revealed: Policy Statement The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. Policy Interpretation and Implementation A licensed nurse (RN/LPN/LVN) is on duty twenty-four hours per day, seven (7) days per week, to provide resident care services and supervise the nursing services activities provided by unlicensed staff. A licensed nurse is designated as a charge nurse on each shift. A licensed nurse may be a licensed practical nurse (LPN), licensed vocational nurse (LVN), or registered nurse (RN). A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care. The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident. A registered nurse (RN) is employed as the director of nursing services (DNS). The DNS is on duty a minimum of 40 hours per week. Record review of facility policy, Staffing, Sufficient and Competent Nursing, dated August 2022, revealed: Policy Statement Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

Based on observation, interview, and record review, the facility must store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Services food service sanitation requirements. in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to ensure canned foods were not expired and dented. 2. The kitchen staff member failed to use proper hand washing while preparing eating utensils. 3. The facility failed to label and properly date foods. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 02/18/25 beginning at 09:07 AM during initial observation of the kitchen: Observed the following in the storage panty: 1. 1 can Sweetened Condensed milk (14 oz) with a dent. 2. 2 cans Velvet Evaporated milk; vitamin added (12 oz) dented 3. 4 boxes of Ritz crackers (3.4 oz.) with an expiration of 1/17/2025. 4. 3 bags (1 lbs.) of Fritos (chips) with an expiration date 1/14/2025. 5. 2 boxes of white chocolate pudding with an expiration date of 02/16/2025. 6. 1 zip top sandwich baggie with contents that looked like quarter baggie of coffee grounds, with no label with a date as 02/11 but no year. 7. 2 packages of Ranch Dressing with an expiration date of 05/19/2024. 8. 1 can of green chili peppers with the expiration date of 09/22/2024. During an observation on 02/18/2025 at 10:15 AM, revealed the Dishwasher was observed wrapping silverware in napkins while touching the forks and spoons on the end that went in the mouth without washing her hands and they had no gloves on. During an observation on 02/19/25 at 9:22 AM, revealed a quarter amount of butter was left out on the counter unwrapped and unattended, for approximately thirty-minutes. During an observation on 02/18/2025 at 10:34 AM, revealed the Dishwasher was observed again wrapping silverware in napkins while touching the forks and spoons on the end that went in the mouth without washing her hands and had no gloves on. During an interview on 02/20/2025 at 10:41 AM, the dishwasher stated that she did not know why she was not wearing gloves or did not wash her hands to wrap the silverware and stated that she just did. The dishwasher stated that she had been trained to wash her hands and wear gloves prior to wrapping the silverware. She stated that the manager was responsible for overseeing the training. The dishwasher stated that their training consisted of in-services every couple of weeks. The dishwasher stated that by not wearing gloves or washing her hands while wrapping the utensils it could spread germs and infections. During an interview on 02/20/2025 at 11:10 AM, the Kitchen Manager stated that he was responsible for the training of the staff and had just recently trained on washing hands, last week. The Kitchen Manager stated that he had not realized that there were expired foods in the storage room. He stated that all staff were responsible for helping to clear out the expired foods, but mainly it was his responsibility to make sure that all expired foods are cleared out of the pantry. He stated that staff were to bring the expired foods to his office so he can properly waste them. The Kitchen Manager stated that for the butter that was left out unattended it should have been put up in the refrigerator as soon as it was done being used. The Kitchen Manager stated that the Dishwasher that was observed wrapping the silverware, should have washed her hands and put on gloves. He stated that all staff had been trained through in-services and meetings. He stated that he had covered those topics with the staff several times and he would now resort to disciplinary actions. The Kitchen Manager stated that the negative potential outcome would have been the spread of germs, food poisoning, cross contamination, and foodborne illnesses. During an interview on 02/20/2025 at 11:21 AM the he Dietary Manager stated that she would expect food to be properly disposed if they were outside of the expirations date because it could cause illnesses. The Dietary Manager stated that anyone handling silverware or utensils should properly wash their hands and use gloves because it could cause germs to spread to residents and cause a decline in their health. The Dietician Manager stated that she could be in-serviced on these particular topics. During an interview on 02/20/2025 at 11:43 AM the Administrator stated that she expected staff to follow the policy for all situations especially handling foods and utensils. The Administrator stated that the dietary manager was responsible for training. The Administrator stated that the negative outcome was that it could have affected residents' health. During an interview on 02/20/2025 at 11:50 AM the Administrator stated that she could not find a policy related to expired canned goods. Record review of the FDA Food Code 2022, revised November 2022 reflected the following: Food Codes: 2-301.11-Personal Cleanliness: FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean. 2-301.12 (A) Cleaning Procedure: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under § 5-202.12 and Subpart 6-301. 2-301.14 When to wash: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms. (D) After coughing, sneezing, using a handkerchief or disposable tissue, using Tobacco Products, eating, or drinking. (E) After handling soiled Equipment or Utensils. (H) Before donning gloves to initiate a task that involves working with Food. 3-602 Food Labeling: (A) Food Packaged in a Food Establishment, shall be labeled as specified in Law, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) The common name of the Food, or absent a common name, an adequately descriptive identity statement. Record review of the facility policy, titled Food Receiving and Food Storage, revised November 2022 reflected the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Dry Food Storage: 4. Dry foods that are stored in bins are removed from original packaging, labeled, and dated (use by date) such foods are rotated using a first in-first out system. Record review of the facility policy, titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, revised November 2022 reflected the following: Policy Statement: Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illnesses. Policy Interpretation: All employees who handle, prepares, or serves food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food to residents. Hand Washing/ Hand Hygiene: a. after personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.). c. whenever entering or re-entering the kitchen. d. before coming in contact with any food surfaces. f. after handling soiled equipment or utensils. Gloves and Direct Food Contact: 9. Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed, and gloves are replaced. a. after direct contact with resident. d. between handling soiled and clean dishes. 10. The use of disposable gloves does not substitute for proper handwashing. 12. Gloves are used when serving residents who are on transmission-based precautions. 14. Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 15 residents (Residents #6 and #13) reviewed for advance directives. 1. Resident #6's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was in the physical paper chart, but the resident was listed as a Full Code in the Electronic Health Record (EHR). 2. Resident #13's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was in the physical paper chart and uploaded in the EHR documents, but the resident was listed as a Full Code in the Electronic Health Record (EHR). 3. The facility failed to ensure Residents #6 and #13's OOH-DNR and care plan advanced directives were consistent. 4. The facility failed to ensure Residents #6 and #13's OOH-DNR and physician orders were consistent. 5. The facility failed to ensure Residents #6 and #13's OOH-DNR and face sheets were consistent. These failures could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Record review of the EHR of Resident #6's current undated face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include cerebral infarction unspecified (stroke), dysphagia (impairment of speech resulting from brain disease or damage), insomnia (difficulty sleeping), hypertension (high blood pressure), depression, and anxiety. Additionally, the advance directive was listed as full code. Record review of the physical paper chart of Resident #6's face sheet dated [DATE] revealed the advance directive was listed as attempt CPR. Record review of the ERH of Resident #6's physician order summary dated [DATE] revealed physician orders listed as full code. Record review of the physical paper chart of Resident #6's physician order summary dated [DATE] revealed physician orders listed as full code. Record review of Resident #6's care plan dated [DATE] revealed a care plan goal for Full Code and the intervention was I do want CPR. Record review of Resident #6's Out of Hospital Do Not Resuscitate form dated [DATE] revealed it was completed by a qualified relative, two witnesses, Physician's Statement, and a physician. Record review of the EHR of Resident #13's current undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include unspecified symptoms and signs involving the nervous system, gastro-esophageal reflux (acid reflux), calculus of kidney (kidney stones), hypertension (high blood pressure), cerebral infarction unspecified (stroke), and osteoarthritis (arthritis). Additionally, the advance directive was listed as full code. Record review of the EHR of Resident #13's physician order summary dated [DATE] revealed physician orders listed as full code. Record review of Resident #13's care plan dated [DATE] revealed a care plan goal for Full Code and the intervention was I do want CPR. Record review of Resident #13's Out of Hospital Do Not Resuscitate (OOH-DNR) form dated [DATE] revealed it was completed by a qualified relative, Physician's Statement, and signed by a physician. During an interview on [DATE] at 3:20 PM, LVN A said she was not aware the was a change of the advance directive for Resident #6 from Full Code to Do Not Resuscitate (DNR). She said she was not aware there was a signed Out-of-Hospital Do Not Resuscitate (OOH-DNR) document in Resident #6's physical paper chart. She said she was aware Resident #6 was receiving hospice services. She said she did not know if it was possible for a resident to receive hospice services and still have an advance directive of full code. She said herself and all nursing staff prefer to use the Electronic Health Record (EHR) instead of the resident's physical paper chart when referring to a resident's medical records and information. She said she and all other nursing staff would refer to the EHR to verify the advance directive for a resident and would follow that directive in the event of a medical emergency (cardiac emergency). She said all facility staff (including but not limited to nursing staff, other direct care staff, business staff, administrative staff) prefer to use EHR instead of looking in the physical paper chart as they were in the process of making all records electronic and paperless. She said the only time she and other nursing staff would look in the physical paper chart to obtain information on a resident's advance directive, was if it was not listed in the EHR. She said herself, ADON, and DON were responsible for updating advance directives in all the resident's EHR's. She said the system for ensuring all advance directives were correctly documented in the EHR was that when the CN receives the completed OOH-DNR form, she makes a copy of it, and puts the copy in a designated folder that they all refer to and would update the resident's advance directive in the EHR. She said then she puts the original copy of the OOH-DNR in the Business Office mailbox who scans and uploads the advance directive into the EHR documents section, and then the original OOH-DNR would be filed in the resident's physical paper chart. She said the business office staff only uploads the OOH-DNR electronic file into the EHR, however they do not update the advance directive status in the EHR. She verified resident #6's OOH-DNR form was not uploaded into the EHR and the EHR also shows the resident's advance directive was listed as full code in the Care Plan, physician orders, and face sheet. She said she does not know why the advance directive in the EHR was incorrect for Resident #6. She said she was trained to look for advance directives in the resident's EHR and to call 911 in the event of a medical emergency. She said she was not aware the advance directive for Resident #6 had changed to DNR status. She said the potential negative outcome of the incorrect advance directive being in the EHR was that nursing staff may respond incorrectly when a resident has a medical emergency and could either cause an injury by administering CPR to a resident with DNR orders or a resident with an advance directive of full code status could die because they did not receive CPR, and that would be negligent on their part. She said there were times that a person can sustain injuries such as bruising and broken bones during the process of receiving CPR and those injuries would be unnecessary for residents who have an advance directive of DNR. During an interview on [DATE] at 4:20 PM, LVN B said that she's the Charge Nurse (CN) for all residents that live on Hall 3, which includes Resident #6 and Resident #13. She said she has worked at the facility for a total of 14 years. She said in the event of a medical emergency she would first refer to the resident's physical paper chart to look for their advance directive. She verified the EHR shows Resident #13's advance directive was listed as full code. She said the business office staff scan and upload the OOH-DNR forms into the EHR for all residents. She said the business office staff scan upload the OOH-DNR form into the EHR and then nursing staff enter the advance directive status of either full code or DNR status in the EHR during the resident's initial admission. She said she was only responsible for updating the advance directives on residents that were returning from the hospital. She said during the readmission process, if she was given an OOH-DNR form, she would update the advance directive status in the EHR, then she would put the original form in the business office staff mailbox, who would then scan and upload the document into the EHR, then or original OOH-DNR form would be filed in the physical paper chart. She said she does not know if Resident #13's OOH-DNR was completed during the initial admission or if it was completed during a readmission. She said that she does not know why Resident #13's advance directive listed in the EHR was incorrect. She said she was aware that resident #13's advance directive was DNR. She said she was trained that on the same day the resident was readmitted in the facility while she is completing the readmission process in the EHR record that she must update the advance directive on the same day of the readmission. She said she was concerned that the advance directive in the EHR was incorrect. She said this was a concern because if staff only refer to the EHR when looking for the resident's advance directive during a medical emergency, then this would show that Resident #13 was a full code and then the staff would respond incorrectly by administering CPR to the resident. She said she was also concerned because once staff start administering CPR on a resident, they cannot stop until a doctor instructs them to stop, even if it was later discovered during that process that the resident's advance directive was DNR. She said a potential negative outcome of the advance directive being incorrect in either the EHR or the physical paper chart was that staff would respond incorrectly and possibly administer CPR on a DNR resident or not administer CPR on a full code resident and that resident could die. She said another potential negative outcome of this was that in both scenarios they and/or the facility would be at risk of facing a lawsuit and other legal consequences. During an interview on [DATE] at 12:30 PM, the DON said she has worked at the facility for 27 years. She said she believes staff would first look in the physical paper chart and then refer to the EHR on the front screen of the resident when trying to locate a resident's advance directive. She said her expectation was for staff to document and/or update a resident's advance directive in the EHR immediately when the completed OOH-DNR form was received from the physician. She said the advance directive should be documented on the physician orders and the care plan in both the EHR and physical paper chart. She said advance directives should be changed if the physician instructs them to change it or if a resident request it to be changed. She said she was not aware that advance directives documented in the EHR and physical paper chart for Resident #6 and Resident #13 were incorrect until she was notified by her staff that the surveyor brought it to their attention, which has since been corrected. She said the system for them to ensure advance directives were correct was that during the initial admission processing of a resident, the business manager scans the OOH-DNR form into the EHR if it has been completed correctly, then the CN writes an order to update the advance directive, then the advance directive status was updated in the EHR. She said then the OOH-DNR form gets filed in the resident's physical paper chart. She said the CN was responsible to update or enter advance directives into the EHR for residents during both the initial admission as well as readmission process. She said the orders for Resident #6 and Resident #13 did not get written by the CN, which was why their advance directives were incorrect. She said staff were trained that the business manager scans the OOH-DNR form into the EHR if it has been completed correctly, and then the CN writes an order to update the advance directive, and then the CN updates the advance directive in the EHR. She said herself, the ADON, and the ADM were responsible for training staff. She said the facility policy for advance directives was that the CN writes the order to update the advance directive in the EHR as soon as the OOH-DNR form was received from the physician and verified that it was filled out correctly. She said potential negative outcomes of advance directives being incorrect in the EHR and/or the physical paper chart were that a resident with a full code advance directive would not get CPR when they were supposed to or a resident with a DNR advance directive would receive CPR when they were not supposed to. During an interview on [DATE] at 12:45 PM, the ADM said she has worked at the facility for 11 months. She said staff would look in the EHR first when trying to locate a resident's advance directive in the event of a medical emergency. She said her expectation was for staff to upload the OOH-DNR form and update the advance directive in the EHR immediately once they have verified the form was received and filled out correctly by the physician. She said the OOH-DNR form must be uploaded in the documents section in the EHR and then the original must be filed in the resident's physical paper chart. She said the advance directive status must also be documented in nurse progress notes and the report log. She said she was not aware that advance directives documented in the EHR and physical paper chart for Resident #6 and Resident #13 were incorrect until she was notified by her staff that the surveyor brought it to their attention. She said the system in place to ensure advance directives were documented correctly was that the business office manager uploads the OOH-DNR form into the EHR, then it was sent to the ADON or DON, who then document the advance directive in the EHR, and then file the OOH-DNR form in the resident's physical paper chart. She said herself, the ADON, and the DON were responsible for training staff. She said the facility policy was that the DON notifies the physician of the advance directives so the orders can be documented in the resident's record and care plan, then the resident's wishes were communicated to staff. She said facility policy also stated the OOH-DNR form was uploaded and documented in the EHR as well as in the resident's care plan and then the Inter-disciplinary Team must be notified of any changes to a resident's advance directive. She said a potential negative outcome of the advance directive being incorrect on the face sheet, care plan, EHR, physical paper chart, and physician orders was that staff would not be respecting resident rights if they were to respond incorrectly during a medical emergency. She said a resident with an advance directive of DNR should not receive CPR and a resident that was full code should receive CPR. She said responding incorrectly could result in an unnecessary and preventable death to a resident who was full code or injuries and unnecessary health problems to a resident that was DNR. Record review of the facility policy, Advance Directive, Revised [DATE], revealed the following documentation: Applicability: this policy sets forth the procedures relating to Advance Directives Policy Statement The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members, and/or his or her legal representative about the existence of any written advance directives. If the Resident Has an Advance Directive 1. If the resident or the resident's representative has executed one or more advanced directive(s) or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DNS) or designee notifies the attending physician of advanced directives (or changes in advanced directives) so that appropriate orders can be documented in the resident's medical record and plan of care. a. The attending physician is not required to write orders for which he or she has an ethical or conscientious objection. 3. The resident's wishes are communicated to the resident's direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the resident's wishes in care planning meetings. 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive. a. Facility staff are not required to provide care that conflicts with an advance directive. b. Facility staff are not required to implement an advance directive if state law allows the provider to conscientiously object. 8. Changes or revocations of the directive must be submitted in writing to the administrator. The administrator may require new documents if changes are extensive. The interdisciplinary team will be informed of the changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan. 9. The nurse supervisor is required to inform emergency medical personnel of residents advance directive regarding treatment options and provide such personnel with a copy of the advance directive or physician orders for life sustaining treatment (POLST) when transfer from the facility via ambulance or means is made. Record review of the facility policy, Do Not Resuscitate (DNR) Order, Revised [DATE], revealed the following documentation: Applicability: this policy sets forth the procedures relating to DNR's Policy Statement Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet and maintained in the resident's medical record. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record. 5. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. a. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. b. Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet. c. The attending physician must be informed of the resident's request to cease the DNR order. 8. Inquiries concerning do not resuscitate orders/requests should be referred to the administrator, director of nursing services, or the social services director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 Resident (Resident #30) reviewed for incontinent care, in that: Resident #30 was observed to have a 16 french silicone foley catheter and had physician orders for a 14 french coude (slightly bent) catheter. This failure could affect residents by placing them at increased risk of discomfort, skin ulcerations and improper medical treatment. Findings include: Record review of face sheet for Resident #30, dated 01/17/24, revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: lobar pneumonia (infection in one of the sections (lobes) of the lung), constipation (bowel movement problems) and retention of urine (urination problems). Review of Resident #30's physician orders, undated, revealed an order for: Change 14 French Coude catheter q(every) monthly on the 12th, with a start date of 02/12/23. Review of Resident #30's comprehensive MDS, dated [DATE] revealed Resident #30 had a BIMS score of 08 which indicated the resident's cognition was moderately impaired. The MDS also revealed Resident #30 had an indwelling catheter. Record review of Resident #30's Comprehensive Care Plan dated 01/17/24 revealed the resident had an intervention to change the foley catheter monthly, with a start date of 07/21/23. During an observation on 01/17/24 at 1:09 PM, Resident #30 was receiving incontinent care and it was noted that Resident #30's foley catheter was a 16 French silicone catheter. During an interview on 01/18/24 at 8:42 AM, LVN B confirmed that Resident #30's current foley catheter was a 16 French silicone catheter and his physician orders are for a 14 French Coude catheter. LVN B stated she did not know why Resident #30 had the wrong size catheter in, as she did not do it. LVN B stated the catheter was probably from a kit from the hospital and that was the size catheter available in the kit. LVN B stated she has been trained to insert the same size catheter as ordered by the physician. LVN B stated it was unknown what the potential negative outcome to the resident could be, but it may cause some problems. During an interview on 01/18/24 at 9:00 AM, the DON stated the nurses are trained to follow physician orders. The DON stated she did not know why Resident #30 had the wrong size catheter inserted because she did not do it. The DON stated the charge nurses, and she is responsible for ensuring physician orders are being followed. The DON stated the potential negative outcome to the resident could be he was not getting what he was supposed to have. During an interview on 01/18/24 at 9:07 AM, the ADM stated the charge nurses, the DON and the ADON are all responsible for ensuring physician orders are being followed. The ADM stated she did not know why Resident #30 had the wrong size catheter inserted. The ADM stated the potential negative outcome to the resident was the catheter could not work properly or could cause harm to his health. During an interview on 01/18/24 at 10:03 AM, the DON stated the facility did not have a policy related to following physician orders for indwelling catheters.

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 1 out of 48 days (12/25/23) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following day: 12/25/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster dated 01/16/24 revealed there were three RNs employed at the facility. Record review time sheet for the DON dated 01/16/24 revealed no hours worked for 12/25/23. Record review time sheet for RN A dated 01/16/24 revealed no hours worked for 12/25/23. Record review time sheet for RN B dated 01/16/24 revealed no hours worked for 12/25/23. During an interview on 01/18/24 at 8:42 AM, the DON she stated she works Monday through Friday 08:00 AM to 05:00 PM. The DON stated she did not work on 12/25/23 because she was off for vacation. The DON stated she did not know why the facility did not have RN coverage as the ADM is the one who schedules for RN coverage. The DON stated it was unknown what the potential negative outcome could be because they are close to the hospital if they needed help. During an interview on 01/18/24 at 8:07 AM, the ADM stated she did not know why the facility did not have RN coverage for 12/25/23. The ADM stated maybe agency was scheduled and did not show up, she was not sure. The ADM stated the potential negative outcome to the residents could be RN responsibilities could not be performed and it was detrimental to the residents. During an interview on 01/18/24 at 12:45 PM, the ADM stated the facility did not have a policy regarding RN coverage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 in 1 of 1 kitchen reviewed for dietary services. 1)The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions. 2) The facility failed to ensure foods were not beyond manufacturer's use dates. 3) The facility failed to ensure foods were in sound condition. 4) The facility failed to ensure food were accurately dated and labeled. 5) The facility failed to protect foods from potential contamination. 6) The facility failed to ensure staff used good hygienic practices. 7) The facility failed to ensure staff facial hair was restrained, and 8) The facility failed to ensure sanitizer levels were maintained at manufacturer's recommended levels. These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observations were made during a kitchen tour on 1/16/24 that began at 1:08 pm and concluded at 1:45 PM: Chemical storage room had chemicals stored above and on the same shelves with insulated lids in boxes and boxes of silverware. The chemicals that were on the shelf were Spray Glass Cleaner, ProForce Sanitizer, and Dyna Force Foaming Decarbonate Oven and Grill Cleaner. These chemicals were stored on the top shelf of the rack and the insulated lids were below it. The documentation on the Dyna Force Foaming Decarbonate Oven and Grill Cleaner was, .Causes severe skin burns and eye damage. There were spray bottles of Monogram Glass Cleaner was stored on the shelf next to boxes of silverware. The documentation on the spray bottles was .Not for use on food contact surfaces . There was another rack in the chemical storage room that had Break Up Oven and Grill Cleaner labeled, . Causes severe skin burns and eye damage . and an aerosol can of Lysol Foam Cleaner that stated, . Caution: causes moderate eye damage . stored on the shelves. These items were stored on the shelf with food containers, above boxes of plates and containers of salt and pepper shakers. The walk-in refrigerator had thawed vanilla Mighty Shakes that had the date of 12-6 marked on the box. There was another box of chocolate Mighty Shakes that was thawed and had a date on the box of 12-12. Documentation on the Mighty Shakes cartons revealed the following, Store frozen. Thaw at below 40°F. Use thawed product within 14 days. Keep refrigerated. In the walk-in refrigerator, there was a box of 16 Yoplait strawberry banana yogurt, 4-ounce containers that was labeled, Use by 16 [DATE]. Observation of the pantry revealed there was one #10 can (6 lbs. 9 oz.) of California sliced yellow cling peaches that had a large dent on the side that caused a large bent the rim. The can was stored in the can rack with other in-use cans of food. - The following interviews and observations were made during a kitchen tour on 1/16/24 that began at 4:35 PM and concluded at 6:07 PM: On 1/16/24 at 4:40 PM temperatures were taken on the steam table by Dietary staff C. While taking the temperature of the purée chicken salad, Dietary staff C cleaned the thermometer probe and then held it with her bare fingers to take the temperature. Temperatures were taken with a dial thermometer. Dietary staff B was observed handling the soiled side dishwashing sprayer and cleaning dishes. She then went directly and put away clean utensils without washing her hands between the soiled and clean operations. Puréed tomato soup was 110°F and served with a 4-ounce ladle. The surveyor asked at 4:59 PM if they had calibrated the thermometers. During an interview with the Dietary Manager on 1/16/24 at 4:59 PM, he stated, he checked the calibration of the dial thermometers last week and had requested the purchase of a digital thermometer. The facility dial thermometers were checked in comparison to the surveyor's digital thermometer in ice water. The surveyor's digital thermometer was 32.5°F and the facility's #1 dial thermometer was 23°F. The surveyor's digital thermometer read 32.7°F and the facility's #2 dial thermometer registered at 29°F. The Dietary Manager tested the quaternary sanitizer in the wiping cloth bucket, and it tested at 50 ppm with the quaternary test strips. On 1/16/24 at 5:16 PM an observation and interview were conducted. The Dietary Manager tested the quaternary sanitizer dispensed from the three compartment sink and it tested at 100 ppm. He stated the quaternary level needed to be adjusted up. Observation of the quaternary sanitizer used, Ecolab ProForce Sanitizer, stated 1 ounce per gallon of water should give the appropriate level of sanitizer. No active level was stated on the container. During an interview on 1/16/24 at 5:27 PM, the Dietary Manager stated, the online information about the ProForce Sanitizer stated the active level for the quaternary sanitizer should be 200 ppm. There was a red bucket of wiping cloth quaternary sanitizer stored on the cart shelf with plates and insulated bottoms for plates at the steam table. This bucket of sanitizer was also stored above and with Styrofoam bowls. On 1/16/24 at 5:55 PM the Dietary Manager was in the kitchen with no beard restraint. - The following observations were made during a kitchen tour on 1/17/24 that began at 9:21 AM and concluded at 9:45 AM: The processor pot exterior tube was soiled with food debris. Dietary staff B was observed handling soil silverware in the dishwasher area then going directly to put away clean cups. Shed did not wash your hands between the soiled and the clean operations. The Dietary Manager was in the kitchen without a beard restraint. Dietary staff A was observed holding a container lid against her shirt, then covering the stewed vegetable container with the lid. On 1/17/24 at 9:37 AM an interview was conducted with Dietary staff B. She stated that she had not been told she needed to wash her hands between the soiled and clean operations when washing dishes. She stated that she had worked in the facility for 10 years. The walk-in refrigerator had thawed vanilla Mighty Shakes that had the date of 12-6 marked on the box. There was another box of chocolate Mighty Shakes that was thawed and had a date on the box of 12-12. Documentation on the Mighty Shakes cartons revealed the following, Store frozen. Thaw at below 40°F. Use thawed product within 14 days. Keep refrigerated. There were now 12 Yoplait strawberry banana yogurt containers in a box that was labeled Use by 16 [DATE]. The cleaners and chemicals were still stored above and with food equipment on racks as observed on 1/16/24 at 1:08 PM in the chemical storage room. - The following interviews and observations were made during a kitchen tour on 1/17/24 that began at 11:03 AM and concluded at 11:41 AM: Dietary staff A was observed puréeing foods. She placed broccoli in the processor, and then adjusted the blade with her bare hand. She then puréed the food with an unknown amount of thicker. As she was pureeing the food, she covered the hole in the lid with a paper towel with her hand. She then continued to purée, then placed the purée in a pan. The Dietary Manager was in the kitchen and had no beard restraint on. Dietary staff A took the processor parts to the dishwasher to wash. After washing, she dried the parts with a paper towel and handled the blade with her bare hands as she dried the parts. She then assembled the processor parts, added tartar sauce and fish fillets and then puréed the mixture. She opened the processor lid, then closed it and rubbed her nose and face with her bare hand. She continued to purée the mixture. She then poured the purée in a pan, and as she was pouring the mixture in a pan, she took the blade out with her bare hand, and she scraped more purée into the pan from the processor pot and blade. On 1/18/24 at 9:33 AM an interview was conducted with the Dietary Manager regarding issues found in the dietary department. He stated as far as checking the dates on foods, he and another employee he was training was responsible. Regarding the dates on the boxes of shakes, he stated that the date marked on the boxes was the receive date most likely the date thawed. He added he was changing the policy to label foods when they were received, and the use dates. He stated the plan was to move the plates and cups to another rack. He further stated that the dishwashing vendor had not returned his call and at this time staff were using the quaternary sanitizer but mixing it manually. He stated the issues observed in the kitchen were due to a lack of training. He stated he planned to start in-services every two weeks. He added that he had conducted in-services. He stated he was also working on dietary related policies. He stated he expected staff to perform the correct dietary procedures. He stated the Dietary Manager and staff were responsible for ensuring that dietary sanitation procedures were conducted correctly. He stated the observed dietary sanitation issues could affect the nutrition and well-being of residents and could affect them emotionally. On 1/18/24 at 9:58 AM an interview was conducted with the Administrator regarding dietary sanitation issues found in the facility. She stated the dietary sanitation issues observed occurred due to human error and staff overlooking those things. She stated Dietary Manager and Administrator were responsible for ensuring dietary sanitation procedures were carried out correctly. She stated resident health could be in jeopardy, definitely with the outdated foods, as a result of the dietary sanitation issues observed. She added she expected staff to follow policy. Record review of the Dietary Staff Meeting Minutes dated 12/6/23, revealed a subject covered in the meeting were dates and labels. Those attending the meeting were Dietary staff A, B and C. Record review of the 3 Compartment Sink Log (chemical sanitation) for January 2024 revealed the following documentation, . Quaternary value should be 200 ppm. Sanitize temperature should be 75-120°F . Record review of the online Ecolab Proforce Sanitizer label revealed the following documentation, ProForce Sanitizer is an effective sanitizer at 200 PPM active quaternary for use on food contact surfaces in 500 PPM hard water. Record review of the facility policy, titled Chapter 3: Food, Production and Food, Safety, 3-22, 2023, revealed the following documentation, Policy and Procedure Manual. Food Storage. Policy: sufficient storage facilities will be provided to keep foods, safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure. 4. Chemicals must be clearly labeled, kept in original containers, when possible, kept in a locked area and stored away from food. 13. Refrigerated food storage. f. All foods should be covered, labeled and dated and routinely, monitored to assure that foods (including leftovers) will be consumed by their use by dates, or (where applicable) or discarded. h. Refrigerated food should be stored upon delivery and careful rotation procedures should be followed . Record review of the facility policy, titled Chapter 3: Food, Production and Food Safety, 3-32, 2023, revealed the following documentation, Policy and Procedure Manual. Resource: Taking Accurate Temperatures. Choosing a Thermometer. Start with an accurately calibrated thermometer that is in good working condition. There are many types of thermometers available. Check state regulations for more specific guidelines. Calibrating The Thermometer. For all thermometers, follow the manufacturer's directions for calibration. Taking Accurate Temperatures Using Metal Stem Thermometers. 1. To take temperatures, a clean, rinsed, sanitized and air-dried thermometer that is the metal stem type, numerically, scaled and accurate to plus or -2°F is needed. Record review of the facility policy titled Chapter 4: Sanitation and Infection Control, 4-1, 2023, revealed the following documentation, Policy and Procedure Manual. Food, Safety, and Sanitation. Policy: all local, state and federal standards and regulations will be followed to assure as safe and sanitary food and nutrition services department. Procedures . 2. Employees. a. All staff will be in good health, will practice, good personal hygiene and will use safe food handling practices. c. Employees are required to have their hairstyle so that it does not touch the collar, and to wear clean aprons, clothes, and closed toed shoes. [NAME] nets are required when facial hair is visible. d. Employees will wash their hands just before they start to work in the kitchen, and after smoking, sneezing, using the restroom, handling, poisonous compound, or dirty dishes, and touching face, hair, other people, or surfaces, or items with potential for contamination. Record review of the facility policy titled Chapter 4: Sanitation and Infection Control, 4-4, 2023, revealed the following documentation, Policy and Procedure Manual. Employee Hygiene for Food Safety. Policy: all food and nutrition services employees will practice good personal hygiene and safe food handling procedures. Procedure: all employees will 1. Wear hair restraint, (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. 2. Wash hands before handling food, using posted handwashing procedures. 7. Avoid touching mouth or face while preparing food (and wash hands if contaminated) . Record review of the facility policy titled Chapter 4: Sanitation and Infection Control, 4-8, 2023, revealed the following documentation, Policy and Procedure Manual. Handwashing. Policy: employees will wash their hands as frequently as needed throughout the day, using proper handwashing, procedures . Procedure: hands and exposed portions of arms, (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation. 1. When to wash hands. f. After handling solid equipment are utensils. g. During food preparation, as often is necessary to remove soil or contamination and prevent cross contamination when changing tasks. j. After engaging in other activities, that contaminate the hands .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 5 of 24 residents (Residents #17, #28, #34, #39, and #41) reviewed for advanced directives. 1. The facility failed to ensure Residents #17, #28, #34, and #39's Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms were correctly filled out or not missing required information. 2. The facility failed to ensure Residents #17 and #41had the required or correct DNR physician order. 3. The facility failed to ensure Resident #17's OOH-DNR and care plan advanced directives were consistent. 4. The facility failed to ensure Resident #41's OOH-DNR and physician orders were consistent. These failures could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Record review of Resident #17's undated face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include fracture of the left femur (thigh bone), edema (swelling), and hypertension (high blood pressure). Record review of Resident #17's physician order summary dated 10/17/22 revealed no order related to code status or advanced directive. Record review of Resident #17's care plan, dated 10/18/22, revealed a care plan for Full Code. Record review of Resident #17's Out of Hospital Do Not Resuscitate form dated 07/21//22 revealed under Physician's Statement revealed no license number, date, or printed name. Record review of Resident #28's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Type 2 Diabetes, need for assistance with personal care, major depressive disorder, and hypertension (high blood pressure). Record review of Resident #28's physician order summary, dated 10/10/22, revealed an order Do Not Resuscitate - DNR dated 10/10/22. Record review of Resident #28's care plan, dated 06/09/22, revealed care plan for Advance Care Plan: No CPR, Hospice Care. Record review of Resident #28's Out of Hospital Do Not Resuscitate form dated 08/04/20 revealed under Physician's Statement revealed no information. Under F. Directive by two physicians, the attending physician's signature is filled out and the date, but no printed name or license number is provided, nor is a second physician's information provided. Record review of Resident #34's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (memory loss) , bilateral cataract (clouding of eye lens in both eyes), difficulty walking, anxiety, major depressive disorder, and hypertension (high blood pressure). Record review of Resident #34's physician order summary, dated 10/06/22, revealed an order Do Not Resuscitate - DNR dated 10/23/19. Record review of Resident #34's care plan, dated 11/11/21, revealed care plan for Advance Care Plan: No CPR. Record review of Resident #34's Out of Hospital Do Not Resuscitate form dated 10/23/19 revealed under Physician's Statement revealed no license number, date or printed name. Furthermore, the date of birth for the resident was marked 11/04/19218. Record review of Resident #39's (dated 11/28/22) face sheet revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include acute kidney failure, insomnia( problems falling and staying asleep), depression and obesity. Record review of Resident 39's physician order summary dated for November 2022 revealed an order ADC: Do Not Resuscitate - DNR dated 11/03/22. Record review of Resident #39's care plan, dated 02/06/22, revealed care plan for DNR started 2/16/22. Record review of Resident #39's Out of Hospital Do Not Resuscitate form dated (undated) revealed under Physician's Statement revealed no date. Record review of another copy provided of Resident #39's Out of Hospital Do Not Resuscitate form dated (undated) revealed under Physician's Statement revealed no date, license #, printed name or signature. Under directive by two physicians there is one signature (not the same physician signature from the first document). There was no notary or witness signatures. Record review of Resident #41's face sheet revealed an [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include achalasia cardia (rare disorder that causes food to collect in the mouth and causes difficulty in swallowing) and Parkinson's ( central nervous system disease). Record review of Resident #41's physician order summary dated for the month of November 2022 revealed an order ADC: Full Code dated 10/13/22. Record review of Resident #41's care plan, dated 10/26/22, revealed a care plan for DNR that started 10/25/22. Record review of Resident #41's Out of Hospital Do Not Resuscitate form dated 10/12/21 revealed the form was completed correctly. During an interview on 11/30/22 at 10:00 AM, the Administrator said a DNR is a do not resuscitate order, and the business office manager was responsible for initiating the process upon admission. She said the business office manager would get the signatures from the Resident, family, and witness and send the document to the physician. She said that she was taught that once the physician signs it, then the document is valid. She said with the physician's signature and the presence of the second page, it was safe to place it in the resident's chart. She said she expected the DNR to be placed in the chart once it is complete in its entirety. She said that the DON and the Administrator are ultimately responsible for ensuring that the DNRs are complete. When asked what makes a DNR valid, she said that the out-of-hospital DNR order is effective with signatures. When asked for clarification, she said that the form must be completed in its entirety. When asked about the physician's order, she said the actual paper copy is an order. When asked why some of the residents have a separate order vs. some do not, she said that it is her expectation for the facility to be consistent and that all residents have both but that the staff should be looking at the paper copy, not the physician order. When told that both nurses interviewed reported that they checked the order first, she said she was now aware of an issue with the system. She said she was not aware that there were incomplete DNRs. When asked about multiple versions being in different areas of the facility (electronic medical record, green binder in ADON office, and the physical chart at the nurses' station), she said that this results in the incompletion of the DNR process. She said there was no specific reason why the DNRs were not complete. When asked what would be a negative outcome for an incomplete DNR, she initially said none, but when asked for clarification, she said she did not believe that there would be a negative outcome because her staff would still do CPR if they knew that this was the wishes of the resident. During an interview on 11/30/22 at 10:08 AM, the DON stated DNR means do not resuscitate. She said that she and the Administrator were ultimately responsible for completing the resident DNRs. She stated that the process for a DNR is usually initiated upon admission. She said the business office manager starts the process and obtains the signature from the resident and the notary. She said the document was sent to the physician for a signature. Once the physician signs it, it is scanned and physically placed in the chart. She said the following made a DNR valid in their facility: Signature, physician signature, and date, witness signatures and dates or notary. She said the DNR should be located in the residents' medical record. She said there are 27 residents that wish to have an active directive of do not resuscitate. She said she was unaware there were residents whose DNR paperwork was incomplete. When asked why there were multiple versions of the incomplete DNRs in the facility and how this may affect the resident, she said that this result is incompletion. When asked what she meant by this, she said that the system for DNRs in the facility is incomplete and that there were multiple versions because the DNRs were not being updated. She said there was no specific reason why the DNR was not completed correctly. She initially said there was no adverse outcome to the resident DNR not being completed in its entirety but then said that the resident may not get their wishes for end a life carried out. She said her expectation is for the DNR form to be completed correctly. During an interview on 11/30/22 at 10:10 AM, the ADON said a DNR was a piece of paper that tells others that you do not want to be resuscitated. She said that the BOM initiates the DNR process upon admission. She said that she is responsible for DNRs at the facility but that the Medical Doctor (MD) is responsible for ensuring the form is completed correctly according to Health and Human Services. She said that the MD signature is what makes the DNR valid. She responded yes when asked if there was no separate order for the DNR and whether the paper copy was valid. She said the medical staff uses the DNR. She clarified that only the nurses do CPR at the facility. She said the DNR could be found in either the electronic medical record or the paper chart of the green binder in her office. When asked what the outcome of having multiple versions in multiple places in the facility is, she said that she believed that having multiple versions was necessary and that them not being all correct and updated was her failure. When asked if there was a particular reason why the DNRs were not updated and completed correctly, she said that she did not review them or ask anyone else to review them before filing them in the residents' chart. She said generally, the Administrator would review the DNR before she would process it. She said recently, when the DNR was given to her; she would not check for anything but the MD signature. When asked about the negative outcome of not having the form completed correctly, her response was that if medical staff see a DNR on a resident's chart, they will not perform CPR regardless of whether the date is on there. During an interview on 11/30/22 at 10:33 AM, LVN C stated if a resident coded (cardiac arrest) that, her first place of reference was to check the doctor's orders. She said if the resident did not have a physician order for DNR, she would administer CPR as that person would be considered a full code. She said that if they administered the wrong end-of-life wishes, she would be upset if she was brought back, but if it was a resident that was the opposite, the resident would not know, but the family might be upset to learn that CPR was not administered. During an interview on 11/30/22 at 10:45 AM, RN A said that if a resident coded (cardiac arrest), she would check the orders and then proceed to check the chart. She said that she was taught to always look at the orders. She said when checking the chart, she checked to ensure that the appropriate signatures are there. She said if she saw that not all appropriate signatures were there, she would start CPR. She said the DNR is not complete without all appropriate signatures. She said if the right end-of-life wishes are not carried out, this could upset the family. Record review of the facility policy, Do Not Resuscitate (DNR) Order, Revised April 2017, revealed the following documentation: Applicability: this policy sets forth the procedures relating to DNRs Policy Statement Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Policy Interpretation and Implementation: 1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. 2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record. 6. The interdisciplinary care planning team will review advance directives with the resident during a quarterly care planning session to determine if the resident wishes to make changes in such directives. Record Review of the Instructions For Issuing An OOH-DNR Order (Undated) revealed the following: INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE: The Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) Order on reverse side complies with Health and Safety Code (HSC), Chapter 166 for use by qualified persons or their authorized representatives to direct health care professionals to forgo resuscitation attempts and to permit the person to have a natural death with peace and dignity. This Order does NOT affect the provision of other emergency care, including comfort care. APPLICABILITY: This OOH-DNR Order applies to health care professionals in out-of-hospital settings, including physicians' offices, hospital clinics and emergency departments. IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section A - If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C. Section D - If the person is incompetent and his/her attending physician has seen evidence of the person's previously issued proper directive to physicians or observed the person competently issue an OOH-DNR Order in a nonwritten manner, the physician may execute the Order on behalf of the person by signing and dating it in Section D. Section E - If the person is a minor (less than [AGE] years of age), who has been diagnosed by a physician as suffering from a terminal or irreversible condition, then the minor's parents, legal guardian, or managing conservator may execute the OOH-DNR Order by signing and dating it in Section E. Section F - If an adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, proxy, or available qualified relative to act on his/her behalf, then the attending physician may execute the OOH-DNR Order by signing and dating it in Section F with concurrence of a second physician (signing it in Section F) who is not involved in the treatment of the person or who is not a representative of the ethics or medical committee of the health care facility in which the person is a patient. In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. REVOCATION: An OOH-DNR Order may be revoked at ANY time by the person, person's authorized representative, or physician who executed the order. Revocation can be by verbal communication to responding health care professionals, destruction of the OOH-DNR Order, or removal of all OOH-DNR identification devices from the person. AUTOMATIC REVOCATION: An OOH-DNR Order is automatically revoked for a person known to be pregnant or in the case of unnatural or suspicious circumstances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 8 of 18 residents (Residents #4, #12, #15,#17, #18,#34, #36, and #39) reviewed for care plans as follows: 1. Resident #4 did not have a care plan for visual function. 2. Resident #12 did not have a care plan for communication pattern. 3. Resident #15 did not have a care plan for urinary incontinence and dental care. 4. Resident #17 did not have a care plan for visual function. 5. Resident #18 did not have a care plan for visual function. 6. Resident #34 did not have a care plan for visual function. 7. Resident #36 did not have a care plan for cognitive loss, visual function and communication. 8. Resident #39 did not have a care plan for visual function, urinary incontinence, and pressure ulcer. These failures could place residents at risk of not receiving the care required to meet their needs. Findings include: 1. Record review of Resident #4's (dated 11/28/22) face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia, dizziness, and psychotic disorder with delusions. Record review of Resident #4's care plan, dated 11/13/22, revealed no care plan for vision impairment. Record review of Resident #4's annual Minimum Data Set assessment, dated 10/26/22, revealed: The Brief Interview for Mental Status score was 0 out of 15, which indicated the resident's cognition was severely impaired. The Care Area Assessment (CAA) Summary triggered for visual function. Resident #4's vision was indicated as impaired. The resident can see large print, but not regular print in newspapers or books. 2. Record review of Resident #12's (11/28/22) face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include gastro-esophageal reflux disease (risk of stomach acid going back and forth between the mouth and stomach), cirrhosis of the liver( chronic liver damage), and chest pains. Record review of Resident #12's care plan, dated 10/03/22, revealed no care plan for communication. Record review of Resident #12's admission Minimum Data Set assessment, dated 09/26/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was cognitively intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 04. Communication Section B Hearing, Speech, Vision B0600 Speech Clarity-Enter Code: 0 - Clear Speech - distinct intelligible words. B0700 Make Self Understood-Enter Code: 0 - Understood B0800 Ability To Understand Others-Enter Code: 0 - Understands - clear comprehension. 3. Record review of Resident #17's undated face sheet revealed an [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include fracture of the left femur (thigh bone), edema (swelling), and hypertension (high blood pressure). Record review of Resident #17's care plan, dated 10/18/22, revealed no care plan for vision impairment. Record review of Resident #17's annual Minimum Data Set assessment, dated 07/27/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was cognitively intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. Section B 1200. Corrective Lenses 1. Yes 4. Record review of Resident #15's undated face sheet revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia, schizophrenia, and insomnia. Record review of Resident #15's care plan, dated 07/14/22, revealed no care plan for urinary incontinence and dental care. Record review of Resident #15's annual Minimum Data Set assessment, dated 07/07/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was moderately intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 06. Urinary 15. Dental Care Section H Bladder and Bowel H0300 Urinary Incontinence-Enter Code: 01- Occasionally incontinent - less than seven episodes of incontinence Section L Oral/Dental Status L0200 Dental The following were checked: Obvious or likely cavity or broken natural teeth Mouth or facial pain, discomfort or difficulty chewing. 5. Record review of Resident #18's undated face sheet revealed an [AGE] year-old-male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's disease, unsteadiness on feet, heart failure (chronic heart condition), and hypertension (high blood pressure). Record review of Resident #18's annual Minimum Data Set assessment, dated 02/20/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. Record review of Resident #18's care plan, dated 02/27/22, revealed no care plan for vision. 6. Record review of Resident #34's undated face sheet revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, bilateral cataract(clouded eye lens in both eyes), difficulty walking, anxiety, major depressive disorder, and hypertension (high blood pressure). Record review of Resident #34's annual Minimum Data Set assessment, dated 11/03/22, revealed: Section C Brief Interview for Mental Status score revealed a score of 06, which indicated the resident's cognition was severe cognitively impairment. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. Section B 1200. Corrective Lenses Yes Record review of Resident #34's care plan, dated 11/11/21, revealed no care plan for vision. 7. Record review of Resident #36's (dated 11/28/22) face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dementia, muscle weakness, and major depressive disorder. Record review of Resident #36's care plan, dated 12/14/21, revealed no care plan for cognitive loss, visual function, and communication. Record review of Resident #36's annual Minimum Data Set assessment, dated 12/07/21, revealed: Section C Brief Interview for Mental Status score revealed a score of 5, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Cognitive Loss 03. Visual Function 04. Communication Section B Hearing, Speech and Vision B0200 Hearing -Enter Code: 1 - Minimal Difficulty - difficulty in some environments B0700 Make Self Understood -Enter Code: 1 - Usually understood- difficulty communicating some words or finishing thoughts but is able if prompted or given time. B0800 Ability To Understand Others-Enter Code: 1 - Usually Understands - misses some part/intent of message but comprehends most conversations. B1000 Vision -Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. 8. Record review of Resident #39's (dated 11/28/22) face sheet revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include acute kidney failure, insomnia, depression and obesity. Record review of Resident #39's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 10, which indicated the resident's cognition was moderately intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 06. Urinary Incontinence 16. Pressure Ulcer Section B Hearing, Speech and Vision B0200 Hearing -Enter Code: 1 - Minimal Difficulty - difficulty in some environments. B0800 Ability to Understand Others -Enter Code: 1 - Usually Understands- missies some part/intent of message but comprehends most conversation. B1000 Vision -Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. B1200 Corrective lenses-Enter Code: 1 - Yes Section H Bladder and Bowel H0300 Urinary Continence -Enter Code: 1 - Occasionally Incontinent- less than 7 episodes of incontinence. Section M Skin Conditions M0150. Risk of Pressure Ulcer/Injuries -Enter Code: 1 - Yes Record review of Resident #39's care plan, dated 02/16/22, revealed no care plan for vision impairment, urinary incontinence, and pressure ulcer. 9. During an interview on 11/30/22 at 09:18 AM, the MDS Coordinator revealed that she had obtained all the information for the MDS assessment from the resident charts, orders, diagnoses, and facility kiosks that nursing staff document in and from her observations. She said that she had been trained to do MDS assessments and that if a resident triggered for a care area in section V, it was accurate to her knowledge. She said if any of the information appears to be incorrect or inconsistent with the resident or the previous assessment, she follows up with further steps, such as asking staff so that her assessments are correct to meet the needs of the Resident. She said all CAAs should be addressed if triggered because if the area is not addressed, the residents' area of concern could become a more significant problem for the Resident, or the care plan will be missed. Regarding the specific care areas for each Resident, she stated the following was pertinent regarding each Resident: Resident #4's vision has declined, and she takes eyedrops throughout the day. She said that sometimes there is a build-up in her eyes that staff needs to clean and monitor. She said the Resident does well after you tell her where her items are that are sat directly in front of her. She said because of her eyesight, she needs verbal prompts. Resident #12, when initially admitted , had difficulty communicating, but since then, she has improved. However, she said although she has improved, staff need to know to slow down when speaking with her and allow her time to say what she needs to say. She said staff should also know that the Resident often will repeat herself. Resident #15 does well with going to the restroom, but sometimes holds her urine and then has accidents. She said this Resident prefers to wear a pull-up, which may be good information for the staff to know so that they stay within her preferences. She said Resident #15 does have dental issues and will rush through brushing her teeth. Staff should know this to encourage dental hygiene and know ahead of time that she might be reluctant. Resident #17 wears glasses, and if she wears her glasses, her vision is not too bad. However, she said staff would need to know that she has glasses and potentially how to care for them. She said Resident #18 vision is good, but regarding activities, staff should know that he needs the large print crossword puzzles. Resident #34 does wear glasses and needs verbal prompts because of her vision. Resident #36 wears glasses. She said the resident would place her glasses on the floor, and staff should know this to look for them and encourage her to wear them. Resident #39 does have visual issues and uses eye drops. Staff should know to look for redness and swelling. She said Resident #39 wears glasses and sometimes will not use them when utilizing her tablet. She said staff should know that things should be within reach for her visual impairment. She also said Resident #39 sometimes would have small accidents and pee on herself a little. She said this is because the resident moves slowly. She said Resident #39 would sometimes walk backward to the restroom. She said it would be beneficial for staff to know this because staff would be aware and check on frequently as the resident sometimes waits until she has gone to the restroom to pull the call light, and this is after she has made an accident. She said although the resident does not have a pressure ulcer, she is at risk. She sometimes said the resident would not get up if she had frequent incontinence, which could increase the risk of pressure ulcers. She said if the staff did not know, the resident could be at risk for a pressure ulcer. During an interview on 11/30/22 at 10:00 AM, the Administrator said the DON was responsible for care plans. She said the care plan is for nursing staff to provide the plan of care for the resident's individual needs. She said the MDS and section V determine what goes into a care plan. She said she expects the care plan to be individualized and that the triggered areas on the MDS should be care planned for each resident. She said she was unaware there were missing care plans for the identified residents. She said there is a system put in place to monitor care plans as they review them quarterly, annually, and any time there is a change of condition with the resident. When asked what the negative outcome for a resident is if they triggered for visual, communication, urinary, pressure ulcer, cognitive loss, and dental care, she said that the outcome would be the same for all the residents meaning that the resident would not receive the care that they need. She said there was no particular reason why the care plans were incomplete. During an interview on 11/30/22 at 10:08 AM, the DON stated she was responsible for completing care plans for the facility. She stated the care plan was used for taking care of the residents, and the nursing staff utilizes the care plan. She said that she uses the MDS and section V of the MDS to determine what goes in the care plan. She said that her expectation is for the care plan to be individualized and for the triggered areas from the MDS to care planned. She said she was unaware that the residents were missing care plans and did not know until the surveyor's intervention. She said that she has been trained on how to do care plans and did not have a particular reason why the care plans were not completed, except that it was just an error on her part. She said she reviews care plans on a quarterly and annual basis. When asked what the specific negative outcome would be for the residents missing visual, communication, urinary, pressure ulcer, cognitive loss, and dental care, she said that the outcome would be the same, meaning that the residents could potentially not receive the care that they need. Record review of the facility policy Care Plans, Comprehensive Person-Centered, Revised November 2019, revealed the following documentation: Applicability: this policy sets forth the procedures relating to developing a comprehensive, person-centered care plan. Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the Resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: #8. The comprehensive, person-centered care plan will: (a.) Include measurable objectives and time frames; (b.) Describe the services that are to be furnished to attain or maintain the Residents highest practicable physical, mental, and psychosocial well-being. (c.) Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. (k.) Reflect treatment goal, timetables and objectives in measurable outcomes; #10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the Resident, are the endpoint of an interdisciplinary process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Infection Control FACILITY Medication Administration Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for three of three residents (Residents #30, #35, and #37) reviewed for wound care/infection control. LVN A failed to perform hand hygiene while performing wound care for Residents #30 and #37. LVN B failed to perform hand hygiene while performing wound care for Resident #35. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #37 Record review of admission record for Resident #37 dated 11/29//22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include displaced fracture of left femur (broken leg bone), type 2 diabetes mellitus (blood sugar), anxiety, and depression. Record review of active physician orders for Resident #37 for November 2022 revealed the following order: Start date: 11/29/22 - Cleanse coccyx with skin integrity. Mix collagen with sodium chloride to a paste. Pack mixture into wound and apply dressing. Record review of Comprehensive Assessment for Resident #37 dated 11/29/22 revealed Section M Skin Conditions: M0100 Determination of Pressure Ulcer/Injury Risk: A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, M0210 Unhealed Pressure ulcers/injuries: 1. Yes Record review of care plan for Resident #37 dated 04/11/22 revealed Focus: Skin Integrity, Goal: Pressure area will have no signs of deterioration and will show signs of healing in the next 90 days. Intervention: Cleanse pressure injury to coccyx with wound cleanser; mix collagen with sodium chloride to form a paste and apply to wound and cover with a dressing for Nursing staff. During an observation of wound care on 11/29/22 at 9:40 AM, LVN B provided wound care for Resident #37. LVN B did not change gloves or perform hand hygiene after removing the dirty dressing. LVN B then cleansed the wound and applied the new dressing to the wound bed. LVN B took the bottle of skin integrity from Treatment cart into Resident #37's room with no barrier used. LVN B then returned the skin integrity to the Treatment cart after wound care was provided to Resident #37. The bottle of skin integrity was not cleaned. During an interview with LVN B on 11/29/22 at 1:01 PM, LVN B stated she had not received specific training regarding wound care and hand hygiene at the facility. LVN B stated she should have cleaned the bottle of skin integrity before returning to the cart. LVN B stated she didn't think about the risks of infection to the residents due to improper glove changes and hand hygiene. LVN B stated the ADON checked up on the nurses, but she did not remember the last time she had been in-serviced regarding wound care. Resident # 30 Record review of admission record for Resident #30 dated 11/29/22 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include dementia (cognitive loss), repeated falls, congestive heart failure (fluid around heart), and fracture of left humerus (broken arm). Record review of active physician orders for Resident #30 for November 2022 revealed the following order: Start date: 11/14/22 - Cleanse right heel with skin integrity. Mix collagen with sodium chloride to a paste. Pack mixture into wound and apply dressing. Record review of Comprehensive Assessment for Resident #30 dated 11/29/22 revealed Section M Skin Conditions: M0100 Determination of Pressure Ulcer/Injury Risk: A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device, M0210 Unhealed Pressure ulcers/injuries: 1. Yes. Record review of Resident #30's care plan dated 07/06/22 revealed Focus: Skin Integrity, Goal: I will maintain good skin integrity evidenced by no new red or broken areas to my skin in the next 90 days. Intervention: Cleanse pressure injury to right heel with wound cleanser, mix collagen with sodium chloride into a paste and apply to wound and cover with a dressing every day and PRN. During an observation of wound care on 11/29/22 at 9:52 AM, LVN B provided wound care for Resident #30. LVN B did not change gloves or perform hand hygiene after removing the dirty dressing. LVN B then cleansed the wound and applied the new dressing to the wound bed. LVN B took the bottle of skin integrity from Treatment cart into Resident #30's room with no barrier used. LVN B then returned the skin integrity to the Treatment cart after wound care was provided to Resident #30. The bottle of skin integrity was not cleaned. During an interview with LVN B on 11/29/22 at 1:05 PM, LVN B stated she had not received specific training regarding wound care and hand hygiene at the facility. LVN B stated she didn't think about the risks of infection to the residents due to improper glove changes and hand hygiene. LVN B stated the ADON checked up on the nurses, but she does not remember the last time she had been in-serviced regarding wound care. Resident #35 Record review of admission record for Resident #35 dated 11/29/22 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include dehydration, peripheral vascular disease (poor blood circulation), hypertension (high blood pressure), and dementia (cognitive loss). Record review of active physician orders for Resident #35 for November 2022 revealed the following order: Start date: 11/26/22 - Cleanse [NAME] x 2 to coccyx with skin integrity. Apply Anasept and collagen and cover with dressing every day and PRN. Record review of Comprehensive Assessment for Resident #35 dated 11/29/22 revealed Section M Skin Conditions: M0100 Determination of Pressure Ulcer/Injury Risk: B. Formal assessment instrument/tool, M0150 Risk of Pressure ulcers/injuries: 1. Yes. Record review of Resident #35's care plan dated 07/06/22 revealed Focus: Skin Integrity, Goal: I will maintain good skin integrity evidenced by no new red or broken areas to my skin in the next 90 days. Intervention: Cleanse pressure injury x3 to coccyx with wound cleanser, apply Anasept and collagen and cover with a dressing every day and PRN. During an observation of wound care on 11/29/22 at 11:45 AM, LVN A provided wound care for Resident #35. LVN A did not change gloves or perform hand hygiene after removing the dirty dressing. LVN A then cleansed the wound and applied the new dressing to the wound bed. LVN A took the bottle of skin integrity from Treatment cart into Resident #35's. The bottle of skin integrity was grabbed with dirty gloves to spray directly onto wound bed. LVN A then returned the skin integrity to the Treatment cart after wound care was provided to Resident #35. The bottle of skin integrity was not cleaned. During an interview with LVN A on 11/29/22 at 2:15 PM, LVN B was asked about glove changes and hand hygiene during wound care for Resident #35. LVN A stated she was taught to change gloves only when going from one sore to another sore on the same resident. LVN A stated she had not been trained to change gloves after removing the dirty dressing and before applying the clean one. LVN A stated the residents were at risk of spreading infections and germs due to improper glove changes and hand hygiene. LVN A stated the ADON monitors the staff once a year on competencies and she cannot remember the last time hers was done, but she knows it was done in the year of 2022. During an interview on 11/29/22 at 2:30 PM, the ADON stated she expected the nurses to change gloves after removing the dirty dressing. The ADON stated she expected the skin integrity bottle to be dedicated to the residents' room or used at the treatment cart and not taken into the resident's room. The ADON stated the nurses made the mistake out of habit and the residents were at risk of cross-contamination. The ADON stated she did skills competencies once a year with staff and monitored them frequently on the floors. During an interview on 11/30/22 at 9:21 AM, the DON stated she expected the nursing staff to use a barrier when providing wound care to the residents. The DON stated she expected a barrier to be used if the skin integrity bottles were going into resident rooms from the treatment cart or for the skin integrity bottle to stay at the treatment cart. The DON stated she expected the nursing staff to change gloves and perform hand hygiene after removing the dirty dressing. The DON stated the residents were at risk of infections spreading or unhealing wounds. The DON stated the nurses were probable nervous and forgot. The DON stated the ADON monitored the nurses for infection control but does not know how often it is done. Interview on 11/29/22 at 3:15 PM, the ADON stated the facility did not have a policy specific to glove changes. Record review of Competency review for LVN B performed on 04/08/22 revealed: On 04/08/22, LVN B was observed performing proper handwashing based on facility policy and procedure. Yes. On 04/08/22, LVN B was observed performing a treatment based on facility policy and procedure. Yes. Record review of Competency review for LVN A performed on 04/08/22 revealed: On 04/08/22, LVN A was observed performing proper handwashing based on facility policy and procedure. Yes. On 04/08/22, LVN A was observed performing a treatment based on facility policy and procedure. Yes. Record review of facility's policy titled Wound Care; revision October 2010 revealed: Steps in Procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. .4. Put on exam gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves Record review of the facility's policy titled Infection Prevention and Control revised October 2010 revealed: Purpose: To establish and maintain an effective Infection Prevention and control program designed to minimize and help prevent infections.