**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote resident self-determination through support of resident choice for 1 of 19 residents reviewed for resident rights. (Resident #64) The facility did not assist Resident #64 out of bed as often has he preferred. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Findings included: Record review of Resident 64's face sheet dated 03/18/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #64 had diagnoses which included hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body, affecting muscles and motor function), acquired absence of left leg above the knee, and depression. Record review of Resident #64's quarterly MDS assessment dated [DATE], indicated he had a BIMS score of 10, which indicated she had moderate cognitive impairment. Resident #64 was totally dependent on staff for most ADLs. The MDS indicated Resident #64 was totally dependent for chair/bed-to-chair transfers. Record review of Resident #64's Care Plan last revised 02/10/25 reflected Resident #64 had a behavioral problem. The care plan indicated, .I also want up out of bed as soon as possible then I want right back in bed . Record review of Progress Notes dated 02/17/2025 - 03/17/2025 did not indicate that offers were made to assist Resident #64 out of bed or that the resident had refused to get out of bed. During an observation and interview on 03/17/25 at 9:48 a.m., Resident #64 was in bed. He said staff would not let him get up out of bed. He said he would like to be gotten up every day. He said he had asked to get up every day and staff told him they were too busy. He said he had asked staff to be gotten up earlier in the day on 03/17/25. During an observation on 03/18/25 at 8:20 a.m., Resident #64 said he had already asked to get out of bed on 03/18/25. He said he was never gotten up out of bed on 03/17/25. During an observation on 03/18/25 at 10:09 a.m., Resident #64 was in the bed. During an observation and interview on 03/18/25 at 1:32 p.m., Resident #64 was in bed. He said he had not been gotten out of bed all day. He said he would love to get up out of bed. During an interview on 03/18/25 at 2:07 p.m., CNA R said Resident #64 got out of bed every now and then. She said sometimes he did refuse to get out of bed. She said he had not asked to get up. She said when he finished eating, he told her to just lay him back that he just wanted to lay there and then told her bye. During an interview on 03/19/25 at 10:03 a.m., CNA B said Resident #64 did normally ask to get out of bed. She said if they offered to get him up there were certain times he did not want to get out of bed. She said staying in bed could cause bed sores and no social life. She said they had to honor the rights of the residents. During an interview on 03/19/25 at 10:05 a.m., CNA S said Resident #64 was not gotten up because by the time he was dressed he would be agitated, had started cussing them and did not want to get up. She said it was not that they did not want to get him up. It was just that by the time they offered he did not want to be gotten up. She said staying in bed all of the time could cause depression. During an interview on 03/19/25 at 10:23 a.m., LVN M said staff should be offering all residents to get out of bed. She said Resident #64 could be difficult but that he should be gotten out of bed if he wanted to be gotten up. She said it might even help with some of his behaviors. She said being in bed could cause skin breakdown, cause emotional and mental issues and depression. She said staying in bed could also cause residents to lose mobility and they were not getting stimulation physically or mentally. During an interview on 03/19/25 at 12:56 p.m., the DON She said Resident #64 refused to get out of bed quite a bit. She said if he was offered, 8 times out of 10 he would say no. She said she would expect staff to offer to get residents up and gotten out of bed if they choose. She said residents not being gotten up could cause psychosocial problems. During an interview on 03/19/25 at 1:23 p.m., the Administrator said staff needed to be educated to go to Resident #64 and ask what his preference was for each day. If his preference was to get out of bed, he needed to be gotten out of bed. He said not being gotten up could lead to pressure ulcers and just overall lack of breakdown of their spiritual moral. He said that would be the resident just not having a choice and bring down their moral. Record review of an undated EXCERPT - Operations Manual, Section 7 - Quality of Life provided by the facility indicated, .make choices about aspects of life in the community significant to them .A resident has the right to (a) Resident and receive services in the community with reasonable accommodation of individual needs and preferences .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 19 residents reviewed for assessments. (Resident #48) The facility failed to ensure Resident #48's MDS dated [DATE], was coded for receiving an anticonvulsant medication (help treat and prevent seizures). The facility failed to ensure Resident #48's MDS dated [DATE], was coded for receiving a hypoglycemic medication (used to lower blood sugar levels in individuals with diabetes). These failures could place residents at risk of not having individual needs met. Findings included: Record review of Resident #48's face sheet dated 3/18/25 indicated Resident #48 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #48 had diagnoses including Type 2 diabetes (is a chronic condition in which the body does not use insulin properly or does not produce enough insulin) and multiple sclerosis (is a disease that causes breakdown of the protective covering of nerves). Record review of Resident #48's quarterly MDS assessment dated [DATE] indicated Resident #48 was understood and had the ability to understand others. Resident #48 had a BIMS score of 13 which indicated an intact cognition. Resident #48 MDS did not reflect use of an anticonvulsant or hypoglycemic medications used during the last 7 days. Record review of Resident #48's care plan dated 02/10/25 indicated: *Resident #48 had diabetes mellitus with potential for abnormal blood sugar levels, poor wound healing, and pain. Resident #48 took Ozempic to help regulate blood sugars and to assist with weight loss. Intervention included diabetes medication as ordered by doctor. *Resident #48 is on over the counter medication related to insomnia (is when you don't get enough quality sleep,). Intervention included administer over the counter medication per the Medical Doctor orders. Record review of Resident #48's consolidated physician order dated 2/1/25 indicated: *Gabapentin (is in a class of medications called anticonvulsants) Capsule 300mg, give 1 capsule by mouth at bedtime for insomnia. Started on 12/11/24. *Ozempic (is an anti-diabetic medication used for the treatment of type 2 diabetes and an anti-obesity medication used for long-term weight management) Subcutaneous Solution Pen-Injector 2mg/3ml (Semaglutide), inject 0.25mg subcutaneously in the morning every 7 days related to Type 2 diabetes mellitus. Started on 1/24/25. *Ozempic Subcutaneous Solution Pen-Injector 2mg/3ml (Semaglutide), inject 0.5mg subcutaneously in the morning every 7 days related to Type 2 diabetes mellitus. Started on 2/21/25. Record review of Resident #48's MAR dated 2/1/25-2/28/25 indicated: *Gabapentin Capsule 300mg, give 1 capsule by mouth at bedtime for insomnia. Started on 12/11/24. Resident #48 received 27 of 28 scheduled doses. *Ozempic Subcutaneous Solution Pen-Injector 2mg/3ml (Semaglutide), inject 0.25mg subcutaneously in the morning every 7 days related to Type 2 diabetes mellitus. Started on 1/24/25. Resident #48 received 2 of 2 scheduled doses. *Ozempic Subcutaneous Solution Pen-Injector 2mg/3ml (Semaglutide), inject 0.5mg subcutaneously in the morning every 7 days related to Type 2 diabetes mellitus. Started on 2/21/25. Resident #48 received 2 of 2 scheduled doses. During an interview on 3/19/25 at 9:09 a.m., the MDS Coordinator said she had been employed at the facility for 2 years. She said she was responsible for MDSs and care plans. She said she coded Ozempic as an injection on the MDS assessments. She said she did not know if Ozempic was also supposed to be coded as a hypoglycemic medication. She said she associated Gabapentin being used for nerve pain not as an anticonvulsant. She said Gabapentin was an anticonvulsant medication. She said on the MDS assessment, medication section stated, pharmacological classification, not how it is used. She said it was important for the resident MDS assessment to be accurately coded so the medical doctors knew what medications the resident was on. She said it was also not good or ethical for a resident to have an inaccurate MDS assessment. She said the Corporate MDS coordinator oversaw her completed MDS assessments. She said the MDS Coordinator completed audits all the time. During an interview on 3/19/25 at 2:15 p.m., the DON said the MDS Coordinator was responsible for the resident's MDS assessment. She said the Corporate MDS Coordinator oversaw the MDS coordinator. She said Resident #48's Gabapentin should have been coded as an anticonvulsant and Ozempic as a hypoglycemic. She said the resident's MDS assessment should have all the accurate information. She said the resident's MDS should have accurate information because it affected the resident's insurance and reimbursement. During an interview on 3/19/25 at 3:23 p.m., the Administrator with the VP of Operations present, said the MDS Coordinator was responsible for MDSs. He said the DON signed the MDS assessments verifying the accuracy. He said he expected medications to be coded by the drug classifications. He said an inaccurate MDS assessment could be detrimental to the resident. He said it affected the resident's insurance and reimbursement. The VP of Operations said it affected the resident's assessment. The VP of Operations said the Corporate MDS Coordinator oversaw the facility MDS Coordinator as a support staff member. During an interview on 3/19/25 at 4:22 p.m., the Corporate MDS Coordinator said she was responsible for the facility's MDS Coordinator training on the regulation requirement. She said she spot checked MDS assessments weekly and sometimes more often. She said Gabapentin should have been coded as an anticonvulsant and Ozempic as a hypoglycemic medication. She said accurate MDS assessments were important because they painted a picture of the resident. She said in the case of Resident #48's inaccurate MDS assessment, it did not negatively affect the resident just the MDS assessment. She said MDS assessments were important because they affected the facility's quality measures, care plans, and informed staff on how to take care of the resident. Record review of an undated facility's Minimum Data Set Process policy indicated .the long tern care facility follows CMs requires per RAI as a policy the facility completes as MDS and codes the Minimum Data Set (MDS) per the RAI manual and coding is based upon clinical assessments, interviews, interventions, etc .Responsible Disciplines: IDT members .the RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 4 residents reviewed for ADLs (Residents #246 and Resident #18.) The facility did not change the adult brief for Resident #246 in a timely manner leaving her in a urine-soaked brief. The facility failed to shave Resident #18 facial hair. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. The findings were: 1. Record review of Resident #246's Face sheet dated 3/17/2022 indicated the resident was a 74 year- old female who admitted to the facility on [DATE] with diagnoses of Chronic Obtrusive Pulmonary Disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs, leading to breathing difficulties), Cerebral Infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die), and Muscle Weakness (decreased ability of muscles to contract and generate force). Record review of Resident #246's MDS assessment, dated 3/11/2025, indicated the resident had a BIMS score 12 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #246 was dependent with all activities of daily living (ADL). The MDS indicated Resident #246 was on oxygen. Record review of Resident #246's Care Plan indicated the resident required maximal assistance with her ADLs. During an interview on 3/17/25 at 10:29 a.m. Resident # 246 said that staff do not want to change you if you were wet. She said her brief is wet right now. She said that she had pushed her call light button earlier this morning and a CNA, whom she did not know their name, came in and turned the call light button off and said they would come back later. She said she is red, chaffed, and uncomfortable. She said it takes the CNAs hours to change her. During an interview on 3/18/25 at 8:27 a.m. Resident # 246 said she was wet again and had not been changed in hours. She said that she pushed her call light button and CNA B came into her room, turned off her call light, said she would come back later after she picked up the breakfast tray to change her. She said this CNA never came back. During an interview and observation on 3/18/25 at 8:19 a.m., CNA B said she knew Resident # 246 was wet as she had pushed her call light earlier. She said she would go back later to change her because she was picking up breakfast trays to take back to the kitchen. CNA left to continue picking up trays. 2. Record review of Resident #18's Face sheet dated 3/17/2023 indicated the resident was a 78 year- old female who admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die), Anemia (a condition where the body does not have enough healthy red blood cells or hemoglobin), Hyperlipidemia (a condition characterized by high levels of fats (lipids) in the blood, including cholesterol and triglycerides). Record review of Resident #18's MDS assessment, dated 1/13/2025, indicated the resident had a BIMS score 10 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #18 was dependent with all activities of daily living (ADL). Record review of Resident #18's Care Plan indicated the resident required maximal assistance with her ADLs. During an interview and observation on 3/17/25 at 9:43 a.m., Resident #18 was observed with chin hairs that were approximately 2 inches long. She said she did not know how long it had been since she was shaven. She said she would like to be shaved. She said it bothered her that she had facial hair. During an observation on 3/19/2025 at 8:32 a.m., Resident #18 had yet to be shaved. Her facial hair was still approximately 2 inches long. During an interview on 3/19/25 at 8:36 a.m. CNA C said she was not sure if Resident #18 was care planned for refusal of care. She said she believes that Resident #18 refuses care. She said that she has not asked or tried to shave Resident #18. She said that it was the responsibility of CNAs to shave residents who are dependent for care. During an interview on 3/19/2025 at 1:13 p.m., the Director of Nurses said that residents dependent on care who are not resistive to care should have their activities of daily living taken care of by the appropriate staff. She said that CNAs should ensure that residents are shaved. She said that residents who need their adult briefs changed should not be left in wet briefs for a long period of time . She said that it is the responsibility of CNAs to ensure that residents are not left in wet briefs for prolong periods. She said that picking up lunch trays was not a valid excuse to delay changing a resident's wet brief. During an interview on 3/19/25 at 1:40 p.m., the Administrator said residents dependent for their ADLs should not have to wait for care for prolong periods. He said it was the responsibility of CNAs to ensure that resident's facial hair kept cut and briefs are changed in a timely manner. He said that residents would be at risk if they were left in wet briefs. Review of the facility policy and procedure on Activities of Daily Living (ADL), Supporting revised March 2018 revealed that the purpose of Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene, bathing, dressing, grooming, and oral care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who had a urinary catheter received appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 5 residents reviewed for catheter care. (Resident #24) The facility failed to drain urine from Resident #24's urinary catheter bag. The facility failed to keep Resident #24's urinary catheter bag off the floor. These failures could place residents at risk for the spread of urinary tract infections, making the residents high risk for pain, confusion and sepsis (infections that spread to the blood) from severe urinary tract infections. Findings included: Record review of a face sheet dated 03/18/25 revealed Resident #24 was [AGE] years old and was admitted on [DATE] with diagnoses including multiple sclerosis (a chronic, autoimmune disease that affects the central nervous system (brain and spinal cord), flaccid neuropathic bladder (a condition where the bladder muscles do not contract properly, leading to difficulty or inability to urinate), and muscle weakness. Record review of an Order Summary Report for Resident #24 dated 03/18/24 indicated an order for suprapubic catheter (a thin, flexible tube inserted directly into the bladder through a small incision in the lower abdomen, just above the pubic bone. It is used to drain urine from the bladder when a person is unable to urinate normally) care every shift and as needed every 12 hours as needed for catheter care with a start date of 01/04/25. There was no end date. There was an order for suprapubic catheter care every shift and as needed one time a day with a start date of 01/04/25. There was no end date. Record review of the most recent MDS dated [DATE] indicated Resident #24 indicated a BIMS of 13 which indicated intact cognition. The MDS indicated Resident #24 had an indwelling catheter. Record review of a care plan last revised on 01/18/25 indicated Resident #24 had a suprapubic catheter related to neuropathic bladder. There was an intervention to check that the catheter was stabilized/anchored using a leg strap/stabilizer. Record review of a Nursing Medication Administration Record for March 2025 indicated an order for suprapubic catheter care every shift and as needed. The nursing MAR indicated the resident had not received any as needed catheter care. During an observation and interview on 03/17/25 at 10:06 a.m., Resident #24's catheter bag was laying on the floor. The bag was completely full, and urine had backed up into the tubing approximately 6 inches. The urine extended beyond the 2000 milliliter measure on the bag and had a bloated appearance. An attempt was made to hang the bag on to the bed frame. The bag fell back into the floor. The bag was so heavy it straightened out the plastic hooks used to hang the bag. Resident #24 said she did not know the bag was full or on the floor. She said she would call for assistance to empty the bag. During an interview on 03/17/25 at 10:12 a.m., CNA R said Resident #24's catheter bag was laying on the floor. She said it should have been hanging on the side of the bed. She said the bag was excessively full. She said it should have been emptied every shift. She said it should have been emptied by the night shift. She said the bag laying in the floor could cause cross contamination and infection. She said the urine could back up into Resident #24 and cause infections. During an interview on 03/19/25 at 10:23 a.m., LVN M said urinary catheter bags should be emptied every shift. She said CNAs could empty the catheter bags, but they should tell the nurse what the output was. She said catheter care was documented on the Treatment Administration Record. She said she normally Resident #24 had 800 milliliters to 1000 milliliters output of urine per shift. She said she did not feel like it had been emptied for it to have been completely full and backed up into the tubing. She said, maybe that is why she has been having bladder spasms. She said if urine backed up into the tubing, it was a major cause of urinary tract infections and discomfort for the patient. She said it could cause bladder distention also. During an interview on 03/19/25 at 12:56 p.m., the DON said urine catheter bag orders usually said they should be emptied every shift and as needed. She said she would have expected for Resident #24's bag to have been emptied on the previous shift. She said you were looking at a urinary tract infections at the very least. She said a catheter bag not being emptied could also cause kidney issues and bladder issues. During an interview on 03/19/25 at 1:23 p.m., the Administrator said he expected catheter bags to be checked frequently. He said this is a huge deal to make sure catheter bags were emptied and definitely not laying in the middle of the floor. He said a negative outcome could be an infection. Record review of a Catheter Care, Urinary facility policy dated 09/2014 indicated, .The purpose of this procedure is to prevent catheter-associated urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor .Empty the drainage bag regularly .Empty the collection bag at least every eight (8) hours .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the appropriate treatment and services to prevent complications was provided for 2 of 3 residents reviewed for feeding tube management. (Resident #47 and Resident #52) The facility failed to ensure Resident #47 and Resident #52 had a physician order for the volume, frequency, and type of flush to administer via the feeding tube. The facility failed to ensure Resident #47 and Resident #52 had a physician order on the frequency of cleaning and the care of the site on the feeding tube. The facility failed to ensure Resident #47 and Resident #52 had a physician order on the frequency of residual checks (assess the rate of gastric emptying) for the feeding tube. The facility failed to ensure Resident #47 and Resident #52 had a physician order on the frequency of checking placement for the feeding tube. These failures placed residents at risk for clogged tubing, trapped air, vomiting, and aspiration. Findings included: Record review of Resident #47's face sheet dated 3/18/25 indicated Resident #47 was a [AGE] year-old female admitted on [DATE]. Resident #47 had diagnoses including severe protein-calorie malnutrition (is a condition caused by an inadequate intake of protein and calories, leading to a deficiency in essential nutrients and impacting body composition and function), gastrostomy status (is the placement of a feeding tube through the skin and the stomach wall), and dysphagia (difficulty swallowing). Record review of Resident #47's admission MDS assessment dated [DATE] indicated Resident #47 was understood and had the ability to understand others. Resident #47 had a BIMS score of 11 which indicated moderate cognitive impairment. Resident #47 had received parenteral feeding (is a medical procedure that provides nutrients directly into the bloodstream through a catheter inserted into a vein) while not a resident of this facility but within the last 7 days. Resident #47 had received during the entire 7 days, fifty-one percent or more proportion of total calories through parenteral or tube feeding (is a method of providing nutrition and fluids directly into the stomach or small intestine through a tube). Record review of Resident #47's care plan dated 2/10/25 indicated Resident #47 had a gastrostomy tube. Intervention included Resident #47 was dependent with tube feeding and water flushes. Record review of Resident #47's consolidated physician order dated 3/18/25 indicated Isosource 1.5 nocturnal feeds at 50ml/hr with water flushes at 50ml/hr times 12 hours at bedtime. Started on 2/11/25. Resident #47's consolidated physician order did not reflect the volume, frequency, and type of flush to administer before and after feeding, the frequency of cleaning, the frequency of residual checks, and the frequency of checking placement. During an interview on 3/17/25 at 10:22 a.m., Resident #47 said she was on tube feedings. She said she had irritable bowel syndrome and the tubing feeding sometimes caused diarrhea. She said yesterday (3/16/25) they tried to start the feeding tubing but she refused. Record review of Resident #52's face sheet dated 3/18/25 indicated Resident #52 was a [AGE] year-old male and admitted on [DATE] and readmitted on [DATE]. Resident #52 had diagnoses including dysphagia (difficulty swallowing), feeding difficulties, and dementia (is a general term for a decline in mental ability severe enough to interfere with daily life). Record review of Resident #52's quarterly MDS assessment dated [DATE] indicated Resident #52 was rarely/never understood and rarely/never had the ability to understand others. Resident #52 had no speech. Resident #52 had short-and-long term memory problems and severely impaired cognitive skills. Record review of Resident #52's care plan dated 3/17/25 indicated Resident #52 required tube feeding related to weight loss. Intervention included check for tube placement and gastric contents/residual volume per facility protocol and record. Record review of Resident #52's consolidated physician order dated 03/18/25 indicated: *Nothing by Mouth diet. Started on 3/17/25. *Jevity 1.5 at 20ml times 24 hours then increase by 10ml every 24 hours as tolerated for goal of 60ml continuously daily. Every shift 60ml continuously times 24 hours. Started on 3/19/25. Resident #52's consolidated physician order did not reflect the volume, frequency, and type of flush to administer before and after feeding, the frequency of cleaning, the frequency of residual checks, and the frequency of checking placement. During an interview on 3/19/25 at 12:51 p.m., LVN K said she had worked at the facility for almost 2 years. She said she primarily worked the hall Resident #47 and Resident #52 resided on. She said the admitting nurse was responsible for obtaining feeding tube orders if the resident's hospital discharge did not have any. She said the resident with feeding tubes should have residual checks, cleaning orders, and verifying placement orders. She said residual checks should be done before and after medications were given and before tube feedings were started. She said it was important to clean the gastrostomy site to prevent infections. She said it was important to check the resident's residual to make sure the stomach was emptying. She said it was important to have physician orders because some staff may come through and not follow best nursing practices. She said the facility used agency staffing and they may not follow or know the facility's policy of tube feeding. During an interview on 3/19/25 at 2:15 p.m., the DON said the admit nurse was responsible for obtaining physician orders for a resident with a feeding tube. She said nursing management was responsible for ensuring the nurses obtained physician orders. She said it was important to have physician orders for residual checks and flushing to maintain accuracy of the resident's electronic medical record. She said the resident could experience patency issues if physician orders were not in place. She said the facility also had standing orders that could have been put in place. She said nursing management was supposed to audit the resident's physician order the day after admission to ensure accuracy. During an interview on 3/19/25 at 3:23 p.m., the Administrator, with the VP of Operations present, said the nurses were responsible for obtaining physician orders for a resident with a feeding tube. He said he knew if the resident did not have cleaning orders, it placed the resident at risk for infections. He said the DON was responsible for ensuring the nursing staff obtained physician orders. Record review of a facility's Administering Medications through an Enteral Tube policy revised on 11/2018 indicated .the purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .verify that there is a physician's order for this procedure .administer each medication separately and flush between medications .equipment and supplies .purified warm water for diluting medications . purified warm water for flushing .stethoscope .verify placement of feeding tube .stop feeding and flush tubing with at least 15ml warm purified water (or prescribed amount) .dilute crushed (powdered) medication with at least 30ml purified water (or prescribed amount) .if administering more than one medication, flush with 15ml warm purified water (or prescribed amount) between medications .when the last of the medication begins to drain from the tubing, flush the tubing with 15ml of warm purified water (or prescribed amount) . Record review of https://www.ncbi.nlm.nih.gov/books/NBK593216/ was accessed on 3/24/25 and indicated .after the initial verification of the tube placement by x-ray, it is possible for the tube to migrate out of position due to the patient coughing, vomiting, and moving .for this reason, the nurse must routinely check tube placement before every use .the area of tube insertion should be assessed daily for signs of pressure damage .cleansing is typically performed using gauze moistened with water or saline and then allowed to air dry .the health care provider writes the order for the enteral nutrition .amount and frequency of free water flushes .measurement of gastric residual volume .aspirate stomach contents through the tube .it has traditionally been used to assess aspiration risk with associated intervention such as slowing or stopping the enteral feeding .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 5 residents (Resident #22) reviewed for unnecessary medications. The facility failed to ensure Resident #22 did not received Nitrofurantoin Macrocrystal (is used to treat urinary tract infections (is a bacterial infection in the urinary system)) for prophylactic use. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections (happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them). Findings included: Record review of Resident #22's face sheet dated 3/18/25 indicated Resident #22 was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #22 had diagnoses including neuromuscular dysfunction of bladder (occurs when the nerves controlling bladder function are damaged, leading to difficulties in bladder control and emptying) and chronic kidney disease, stage 3 (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood). Record review of Resident #22's quarterly MDS assessment dated [DATE] indicated Resident #22 was understood and had the ability to understand others. Resident #22 had a BIMS score of 04 which indicated severe cognitive impairment. Resident #22 required substantial/maximal assistance for toileting hygiene. Resident #22 had an indwelling catheter. Resident #22 had frequent bowel incontinence. Resident #22 had received an antibiotic during the last 7 days of the assessment period. Record review of Resident #22's care plan dated 3/4/25 indicated Resident #22 was on antibiotic therapy prophylactic. Intervention included administer antibiotic medications as ordered by the physician. Monitor/document side effects and effectiveness every shift. Record review of Resident #22's consolidated physician order dated 3/18/25 indicated Nitrofurantoin Macrocrystal Oral Capsule 50mg, give 1 capsule by mouth in the morning for prophylactic. Started on 12/17/24. Record review of Resident #22's MAR dated 3/1/25-3/31/25 indicated Nitrofurantoin Macrocrystal Oral Capsule 50mg, give 1 capsule by mouth in the morning for prophylactic. Started on 12/17/24. Resident #22 received 18 out of 18 doses. During an interview on 3/19/25 at 10:27 a.m., ADON H, the Infection Control Preventionist, said she had been the ADON at the facility since June 2024. She said MD U prescribed Resident #22 prophylactic antibiotic. She said MD U prescribed the prophylactic antibiotic because Resident #22 had constant urinary tract infections with an indwelling catheter. She said Resident #22 only displayed altered mental status when she had urinary tract infections. She said Resident #22 antibiotic use did not met McGeer criteria (a set of clinical guidelines used to identify and diagnose healthcare-associated infections (HAIs) in long-term care facilities). She said before the facility prescribed Resident #22 a prophylactic antibiotic, they tried encouraging fluids, flushing her indwelling catheter, and prescribed an over-the-counter medication. She said Resident #22 was being followed by a urologist (is a medical doctor who specializes in the diagnosis and treatment of diseases and conditions of the urinary tract and the reproductive system) and the urologist was aware Resident #22 was on a prophylactic antibiotic. She said typically the facility prescribed probiotics when a resident was on long term antibiotic use. She said Resident #22 was not on a probiotic. She said she did not know why a probiotic was not started on Resident #22. She said she was not the ICP when Resident #22 started prophylactic antibiotics. She said Resident #22 had not shown a decrease in urinary tract infection while being on a prophylactic antibiotic. She said Resident #22's last hospital admission in January 2025 was for a urinary tract infection. She said she was responsible for consulting the prescribing medical doctor about Resident #22's prophylactic antibiotic use not preventing urinary tract infections. She said MD U wanted Resident #22 to see the urologist for the reoccurring urinary tract infections. She said the family decided against seeing the urologist and placed Resident #22 on hospice due to her declining health. She said hospice continued Resident #22's prophylactic antibiotic after she was their service. She said she let hospice with the family input, decide which medications to continue and discontinue. She said antibiotics were supposed to be prescribed for short periods of time. She said long term antibiotic use took away the resident's normal flora which was why probiotic were important. She said when the resident's normal flora and good bacteria was removed, it could cause more illnesses. During an interview on 3/19/25 at 12:51 p.m., LVN K said it was not recommended for residents to be on an antibiotic without an infection. She said being on antibiotic without an infection could cause super bugs (are bacteria that have developed resistance to multiple antibiotics, making them difficult or impossible to treat). She said the resident was also taking a medication not needed. She said the ADONs were responsible for monitoring resident's antibiotic use. During an interview on 3/19/25 at 2:15 p.m., the DON said the facility followed the physician order related to Resident #22 prophylactic antibiotic use. She said the facility followed the McGeer criteria for antibiotic use. She said Resident #22's prophylactic antibiotic use did not met the McGeer criteria. She said prophylactic antibiotic use increased antibiotic resistance. She said it was not realistic to always met McGeer criteria when prescribing antibiotics. She said Resident #22 had frequent urinary tract infection. She said Resident #22 was on hospice so the facility let them decide the continued use of the antibiotic. She said Nitrofurantoin was normally prescribed to help relieve urine tract infection symptoms not really to treat the infection. She said antibiotic use created adverse responses which was not what the facility wanted. During an interview on 3/19/25 at 3:23 p.m., the Administrator, with the VP of Operations present, said the ICP was responsible for antibiotic use. He said he expected nursing staff and management to follow the facility's policy. He said prophylactic antibiotic use placed residents at risk for not treating the right organism and infections. Record review of a facility's Infection Prevention and Control Program policy revised 8/2016 indicated .antibiotic stewardship .culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities .medical criteria and standardized definitions of infections are used to help recognize and manage infections .antibiotic usage is evaluated and practitioners are provided feedback on reviews .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 29 residents (Resident # 20) reviewed for infection control practices. 1. The facility failed to ensure LVN O applied enhanced barrier precautions while providing medication administration to Resident # 20 on 3/18/2025 at 1:18 PM. These failures could place residents at risk of cross-contamination and infections leading to illness. Findings included: Record review of Resident #20's Face sheet dated 3/19/2025 indicated the resident was a 49-year- old male who was readmitted to the facility on [DATE] with diagnoses of cerebral palsy (a group of conditions that affect movement and posture), Dysphagia (a term for difficulty swallowing), Aphasia (a disorder that affects how you communicate, usually after a stroke or head injury), Epilepsy (a brain disorder that causes recurring, unprovoked seizures), gastroparesis (a condition that affects the normal spontaneous movement of the muscles in your stomach), and gastrostomy (a feeding tube inserted into the stomach through the abdomen). Record review of Resident #20's MDS assessment, dated 2/1/2025, indicated the resident was rarely and never understood. The MDS also indicated Resident #20 was dependent with all activities of daily living (ADL). Record review of Resident #20's Care plan initiated on 4/24/2024, indicated Resident #20 required tube feedings related to dysphagia and was nothing by mouth. Resident #20's care plan initiated on 12/6/2024 indicated he was on enhanced barrier precautions related to risk for multidrug-resistant organism (MDRO) due to indwelling medical device feeding tube. Interventions included Enhanced barrier precautions to be utilized during ADL's including but not limited to dressing, bathing, transferring, providing hygiene, changing linens/briefs or when toileting, caring for indwelling medical device and wound care of chronic wounds. During an observation on 3/18/2025 at 1:49 PM, LVN O was observed administering medication for Resident #20 via peg tube. LVN I was not wearing proper personal protective equipment while checking placement and administering routine medication. During an interview on 3/18/2025 at 1:49 PM LVN O said she forgot to put on her protective personal equipment (PPE) prior to administering medication via peg tube. LVN O said she was sorry, and she was supposed to wear PPE while administering Resident #20's medication. LVN O said personal protective equipment should be worn while administering medication via a resident's peg tube. She said the facility had plenty of PPE to provide care. LVN O said infection control was responsible for ensuring PPE was worn. LVN O said wearing PPE protected her from the resident. LVN O said she was an agency nurse and did not work at the facility often. LVN O said she had been educated on EBP and PPE. During an interview on 3/19/2025 at 8:36 AM, CNA P said she had been in-serviced on Enhanced barrier precautions and personal protective equipment (PPE). CNA P said EBP were used to prevent cross-contamination and the facility had plenty of PPE. CNA P said the nurses were responsible for ensuring proper PPE was worn. She said if she observed another staff member not wearing proper PPE, she would correct the staff and teach them to wear PPE. During an interview on 3/19/2025 at 8:56 AM, LVN M said anytime a staff provided a resident care such as residents with dialysis port, foley catheter, Peg tube and wounds, EBP precautions should be adhered to, and PPE would be worn. LVN M said PPE should be worn while administering medications with a resident on a feeding tube. She said the PPE would be disposed of prior to exiting the resident's room and the nurse should wash their hands. LVN M said she had been in-serviced on PPE and EBP. She said it was to protect the resident and staff. LVN M said medical devices on residents place them at higher risk for infection and prevents potential splashes on staff. She said she would remind staff if she observed them providing care to a resident while not wearing proper PPE and report to the DON. LVN M said the charge nurse, ADON, and DON were responsible for ensuring staff were wearing proper PPE while providing care. During an interview on 3/19/2025 at 11:30 AM, LVN N said residents who have a foley catheter, g-tubes, covid, IV and wounds require enhanced barrier precautions and PPE. She said proper PPE was important to prevent cross-contamination. LVN N said staff entering the resident's room was responsible for wearing PPE. LVN N said she had been in-serviced on PPE and EBP. She said she would tell staff to start over and wear proper PPE if she observed they were not following proper procedures. During an interview on 3/19/2025 at 1:14 PM, ADON H said all staff had been in-serviced on enhanced barrier precautions (EBP). She said resident who had foley catheters, peg-tubes and wounds required EBP and PPE. She said PPE should be worn when providing direct care with gown and gloves. She said wearing proper PPE was included in administering medications to Resident #20 who had a peg-tube. ADON H said the facility had plenty of PPE to provide care. She said the facility would educate staff who was identified to not properly wearing PPE with residents on EBP. ADON H said the nurses were responsible for ensuring staff was wearing proper PPE. During an interview on 3/19/2025 at 2:05 PM, the DON said the facility had in-serviced staff of enhanced barrier precautions (EBP). She said the facility had plenty of PPE for the staff to provide care. The DON said she expected her staff to report other staff not wearing the proper PPE. She said multidrug-resistant organisms could spread, which was the whole point of wearing proper PPE. During an interview on 3/19/2025 at 2:21 PM, the Administrator said he expected the nurses and staff to adhere to the enhanced barrier precautions for each resident and was knowledgeable about the signs posted on the resident's door. He said the facility had plenty of PPE. The Administrator said the DON was responsible for ensuring staff were wearing proper PPE while providing direct care. He said he would expect staff to report other staff members who were not adhering to the enhanced barrier precautions. The Administrator said it puts the staff at risk for contracting what the resident has and passing it on to other staff and an outbreak could occur. Record review of a policy titled Infection Prevention and control program revised on August 2016 indicated .infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2.elements of the infection prevention and control program consist of coordination and oversight, policies and procedure, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Record review of Centers for Disease Control (CDC) titled 'Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated June 2021 indicated .Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee charted to provide advice and guidance to the Centers for Disease Control Executive Summary .1. (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality .2. Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resident organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated for resident with any of the following: a. wounds or indwelling medical devices, regardless of MDRO colonization status, b. infection of colonization with MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment and the availability of PPE and hand hygiene supplies at the point of care. Background .Resident in skilled nursing facilities were disproportionately affected by multidrug-resistant organism (MDRO).Resident to resident pathogen transmission in skilled nursing facilities occurs .Residents who have complex medical needs .In 2019, CDC introduced a new approach to the use of personal protective equipment called Enhanced Barrier Precautions (EBP). This new approach recommends gown and glove use for certain residents during specific high-contact resident care activities associated with MDRO transmission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate the use of an antibiotic for 1 of 2 residents reviewed antibiotic use. (Resident #47) The facility failed to ensure Resident #47 received the appropriate antibiotic to treat her urinary tract infection on 2/22/25. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections. Findings included: Record review of Resident #47's face sheet dated 3/18/25 indicated Resident #47 was a [AGE] year-old female admitted on [DATE]. Resident #47 had diagnosis including urinary tract infection (is a bacterial infection in the urinary system), severe sepsis (is a serious condition in which the body responds improperly to an infection) with septic shock (a widespread infection causing organ failure and dangerously low blood pressure), and neuromuscular dysfunction of bladder (the nerves that carry messages back and forth between the bladder and the spinal cord and brain don't work the way they should). Record review of Resident #47's admission MDS assessment dated [DATE] indicated Resident #47 was understood and had the ability to understand others. Resident #47 had a BIMS score of 11 which indicated moderate cognitive impairment. Resident #47 required substantial/maximal assistance for toileting hygiene. Resident #47 had an indwelling catheter. Resident #47 always had bowel continence. Record review of Resident #47's care plan dated 2/4/25 indicated Resident #47 had an indwelling catheter. Intervention included monitor/record/report to MD signs and symptoms of a urinary tract infection. Record review of Resident #47's consolidated physician order dated 2/24/25 indicated Cipro (is used to treat bacterial infections in many different parts of the body) Oral Tablet 500mg (Ciprofloxacin HCl), give 1 tablet by mouth two times a day for UTI for 7 days. Started on 2/24/25. Record review of Resident #47's MAR dated 2/1/25-2/28/25 which indicated Cipro Oral Tablet 500mg (Ciprofloxacin HCl), give 1 tablet by mouth two times a day for UTI for 7 days. Started on 2/24/25. Resident #47 received 10 out of 10 scheduled doses. Record review of Resident #47's MAR dated 3/1/25-3/31/25 which indicated Cipro Oral Tablet 500mg (Ciprofloxacin HCl), give 1 tablet by mouth two times a day for UTI for 7 days. Started on 2/24/25. Resident #47 received 4 out of 4 scheduled doses. Record review of Resident #47's progress notes dated 1/1/25-3/18/25 indicated: *On 2/22/25 at 2:42 p.m. by LVN F, .Resident #47 noted with supra catheter leaking .MD notified new order to send to emergency room to replace catheter . *On 2/22/25 at 3:46 p.m. by LVN F, .Returned from emergency room for catheter change .new orders received for Cipro 500mg one tablet by mouth twice a day times 7 days for treatment of UTI . Record review of Resident #47's hospital urine culture (is a laboratory test that analyzes a urine sample to detect and identify bacteria or other microorganisms that may be causing a urinary tract infection (UTI)) dated 2/22/25 indicated .greater than 100,000 CFU/ml Proteus Mirabilis (is a Gram-negative bacterium that is a common cause of urinary tract infections (UTIs)) .susceptibility (is used to determine which antimicrobials will inhibit the growth of the bacteria) .Ciprofloxacin . resistant . During an interview and observation on 3/17/25 at 10:22 a.m., Resident #47 was lying in bed with a hospital gown on. Resident #47 said she had a suprapubic catheter, pressure ulcer, and feeding tube. She said she had several urinary tract infections, but currently did not have one. Resident #47 had a catheter bag hang on the side of bed. Resident #47's catheter bag had a moderate amount of light amber colored urine. During an interview on 3/19/25 at 10:27 a.m., ADON H, the ICP, said the physician was responsible to ensure the residents were treated with an antibiotic susceptible to the organism growing. She said on 2/22/25, Resident #47 returned to facility from the emergency room with an order for Cipro. She said the facility had to wait on the hospital urinalysis with culture and sensitivity results to be released. She said Resident #47's culture and sensitivity results came back a few days later and showed Ciprofloxacin (Cipro) was resistant to proteus mirabilis. She said she did not know if the physician was aware of the culture and sensitivity results. She said she was responsible for contacting the physician if a resident was prescribed an antibiotic that was resistant to the current treatment. She said she was aware Resident #47 was on an antibiotic resistant to the organism growing in her urine. She said she did not contact MD V about Resident #47's culture and sensitivity results because MD V was not open to conversation related to her prescribed treatments. She said she it was important for a resident to be on a susceptible antibiotic so the organism could be treated. She said if not, then the resident was basically taking an antibiotic for nothing. She said it placed the resident at risk for delayed treatment which could result in sepsis. During an interview on 3/19/25 at 12:51 p.m., LVN K said the nursing staff should notify the physician if a resident was on an antibiotic resistant to the organism. She said being on the correct antibiotic was important to get rid of the organism. She said if a resident's UTI was not treated with the right antibiotic, it could affect the resident's mind and make them sicker. She said she was not aware Resident #47 had been on a resistant antibiotic in March 2025. During an interview on 3/19/25 at 1:37 p.m., NP J, the NP for MD V's office, said MD V was out of town. She said she could only review what the facility had sent by fax to the office. She said the facility could have contact MD V about Resident #47's results by phone or text messages. She said she did not see any communication, by fax, related to Resident #22's culture and sensitivity results from 2/22/25. She said normally if a resident was on a resistant antibiotic, they would change the prescribed antibiotic to a susceptible antibiotic. She said it was important to treat the organism with a susceptible antibiotic because the resident could become more susceptible to antibiotic resistance. During an interview on 3/19/25 at 2:15 p.m., the DON said the physician was responsible to ensure the residents were treated with an antibiotic susceptible to the organism. She said the staff member who received Resident #47's culture and sensitivity result were responsible for contacting the physician. She said there was no documentation in Resident #47's progress notes related to MD V being notified about the culture and sensitivity results from 2/22/25. She said it was important for the prescribed antibiotic to treat the organism growing. She said it was for completion of care. She said the DON was responsible for ensuring nursing staff contacted the physician related to culture and sensitivity results. During an interview on 3/19/25 at 3:23 p.m., the Administrator, with the VP of Operations present, said the nurses were responsible for contacting the physician about urinalysis results. He said the nurses should also follow up with the doctor if new results arrived and a new order was needed. He said Resident #47 was medicated for something that was not going to work. The VP of Operations said Resident #47 was not going to get better if she was given an antibiotic not susceptible to her urinary tract infection. He said the DON and/or ICP were responsible for ensuring nursing staff contacted the physician related to culture and sensitivity results. Record review of a facility's Antibiotic Stewardship policy revised 12/2016 indicated .antibiotics will be prescribed and administered to residents under the guidance of the community's antibiotic stewardship program .the purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our resident .when a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 19 (Resident #64, Resident #74 and Resident #76) residents reviewed for call lights. The facility failed to ensure call lights were within reach while Resident #64, Resident #74 and Resident #76 were in bed. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings included: 1. Record review of Resident 64's face sheet dated 03/18/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #64 had diagnoses which included hemiplegia (paralysis of one side of the body), hemiparesis (weakness on one side of the body, affecting muscles and motor function), acquired absence of left leg above the knee, and depression. Record review of Resident #64's quarterly MDS assessment dated [DATE], indicated he had a BIMS score of 10, which indicated she had moderate cognitive impairment. Resident #64 was totally dependent on staff for most ADLs. The MDS indicated Resident #64 was totally dependent for chair/bed-to-chair transfers. The MDS indicated Resident #64 was always incontinent of bowel and bladder. Record review of Resident #64's Care Plan last revised 02/10/25 reflected the resident had an ADL self-care performance deficit with an intervention to encourage the resident to use bell to call for assistance. During an observation and interview on 03/17/25 at 9:48 a.m., Resident #64 said he did not have a call button. He said he had to holler when he did not have his call bell. Resident #64's call light draped over the foot of the bed. He said he was unable reach it. He said, once it is down there it is gone. 2. Record review of Resident #74's face sheet dated 03/18/25 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #74 had diagnoses which included anxiety, depression, stroke and hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body, affecting muscles and motor function). Record review of Resident #74's a quarterly MDS assessment dated [DATE], indicated he had a BIMs score of 11, which indicated he had moderate cognitive impairment. Resident #74 required substantial/maximal assistance for with ADLs. The MDS indicated Resident #74 was always incontinent of bladder and bowel. The MDS indicated Resident #74 required substantial/maximal assistance with chair/bed-to-chair transfers. Record review of Resident #74's Care Plan last revised 02/21/25 reflected the resident had an ADL self-care performance deficit with an intervention to encourage the resident to use bell to call for assistance. The care plan indicated Resident #74 was at risk for falls. During an observation and interview on 03/17/25 at 10:32 a.m., Resident #74's call light was draped over head of bed. He said he could not reach the call light. He said, I have to holler nurse, but they don't like that. During an observation on 03/18/25 at 8:24 a.m., Resident #74 was asleep in the bed. The call light was on the floor under the edge of the head of the bed. 3. Record review of Resident #76's face sheet dated 03/18/25 indicated she was [AGE] years old and admitted to the facility on [DATE]. Resident #76 had diagnoses which included morbid obesity, diabetes, stroke and hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body, affecting muscles and motor function). Record review of Resident #76's quarterly MDS assessment dated [DATE], indicated he had a BIMs score of 10, which indicated he had moderate cognitive impairment. Resident #76 required substantial/maximal for most ADLs including chair/bed-to-chair transfers. The MDS indicated Resident #76 was always incontinent of bladder and bowel. Record review of Resident #76's Care Plan last updated 01/29/25 reflected Resident #76 had an ADL self-care performance deficit with an intervention to encourage the resident to use bell to call for assistance. The care plan reflected Resident #76 was at risk for falls. During an observation and interview on 03/17/25 at 10:12 a.m., Resident #76's call light was on floor under the side of the bed. She said she could reach the call light. She said sometimes she had to holler and sometimes she tried to sit up to get it. During an observation and interview on 03/19/25 at 8:15 a.m., Resident #76 was in bed eating breakfast. Her call light was draped over the foot of her bed. She said she could not reach the call light if she needed it. During an interview on 03/19/25 at 10:03 a.m., CNA B said call lights should been to where residents could always reach them. She said all care givers were responsible for making sure residents have their call lights. She said not having a call light could lead to a fall risk or the resident might have an emergency. During an interview on 03/19/25 at 10:23 a.m., LVN M said everybody was responsible for making sure residents had their call lights. She said ultimately the CNAs provided care and they should be checking to make sure residents had call lights. She said a resident not having a call light did not have any way to call staff for help. She said it could cause them to try to get up and cause them to fall. During an interview on 03/19/25 at 12:56 p.m., the DON said CNAs and floor staff were responsible for making sure resident could reach their call lights. She then said everyone was responsible for keeping call lights in reach of residents. She said she would have expected for the residents to have had their call lights. She said a resident not having a call light might need something and not be able to get to staff. During an interview on 03/19/25 at 1:23 p.m., the Administrator said he just had in-serviced staff on call lights about making sure the call lights were visible and within reach . He said the call lights should be attached to the pillow or clothes so the residents could respond in a time of need. He said he would have expected each of the resident to have had their call light within reach. Record review of an In-Service Training Report for RNs, LVNs, and CNA dated 02/25/25 at 4:15 p.m. reflected, Please make sure (when you are doing rounds) that CALL LIGHTS are easily in reach and are clipped onto linens/night clothes/etc. Too many families (and) residents are complaining that the CALL LIGHT is not reachable. If you need clips - Let someone know . The In-Service was signed by 34 staff members. Record review of an Answering the Call Light facility policy dated 03/2021 indicated, .The purpose of this procedure is to ensure timely responses to the resident's requests and needs .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . Record review of an undated Certified Nurse Aide Standards of Clinical Practice facility policy indicated, .The CNA answer call lights promptly and assists residents as required and checks for call light in reach prior to leaving the room .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 5 of 11 residents (Resident #42, Resident #246, Resident #16, Resident #9, and Resident #33) reviewed for respiratory care and services. The facility failed to properly store Resident #246's Nasal Cannula. The facility failed to change the dirty filters for Resident #16. The facility failed to ensure Resident #42's oxygen concentrator was set at 2 LPM, as ordered by the physician. The facility failed to ensure Resident #9's oxygen concentrator filter was without white fuzzy particles. The facility failed to ensure Resident #33's oxygen concentrator filter was without white fuzzy particles. This failure could place residents at risk for developing respiratory complications. Findings included: 1. Record review of Resident #246's face sheet dated 3/17/2022 indicated the resident was a 74 year- old female who admitted to the facility on [DATE] with diagnoses of Chronic Obtrusive Pulmonary Disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs, leading to breathing difficulties), Cerebral Infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to die), and Muscle Weakness (decreased ability of muscles to contract and generate force). Record review of Resident #246's MDS assessment, dated 3/11/2025, indicated the resident had a BIMS score 12 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #246 was dependent with all activities of daily living (ADL). The MDS indicated Resident #246 was on oxygen. Record review of Resident #246's Care Plan indicated the resident had a problem initiated on 3/4/2024. The resident has oxygen therapy regarding their diagnosis of Chronic Obtrusive Pulmonary Disease . During an interview and observation on 3/17/24 at 10:29 a.m., Resident #246's nasal cannula was laying in the trashcan. Resident #246 said that she did not place her nasal cannula in the trashcan and that a nurse that was in there who just made her bed must have placed it in the trashcan while she was making her bed. She said that she would never place her cannula in the trashcan because it would go into her nose when she got into bed again. During an interview on 3/19/25 at 10:44 a.m., CNA C said that residents nasal canula should be stored in a bag when it was not in use. She said that if a resident's cannula was lying in a trashcan, it could place the resident at risk of infection. She said it was the responsibility of CNAs and nurses to ensure that cannula is stored properly . 2. Record review of Resident #16's face sheet dated 2/04/2022 indicated the resident was a 67-year- old female who admitted to the facility on [DATE] with diagnoses of Chronic Obtrusive Pulmonary Disease (a group of lung diseases that cause ongoing inflammation and damage to the airways and air sacs in the lungs, leading to breathing difficulties), Schizoaffective Disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), and Heart Failure (a condition in which the heart cannot pump enough blood to meet the body's needs). Record review of Resident #16's MDS assessment, dated 3/6/2025, indicated the resident had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS indicated Resident #16 was on oxygen. Record review of Resident #16's Care Plan indicated the resident had a problem initiated on 4/11/2024. The resident has oxygen therapy regarding their diagnosis of Chronic Obtrusive Pulmonary Disease. During an interview and observation on 3/17/25 at 10:44 a.m., Resident #16's oxygen concentrator was covered in a thin layer of dust. The external filter had a thick layer of dust that when touched became airborne. Resident #16 was asked about her filter but she did not give a valid response to the question asked. 3. Record review of Resident #42's face sheet dated 3/18/2025 indicated the resident was a 81-year- old male who admitted to the facility on [DATE] with diagnoses of acute gastritis with bleeding ( an inflammation of the lining of the stomach), gastrointestinal hemorrhage (a sign of bleeding in the digestive tract), Hypertensive heart disease with heart failure (a condition caused by prolong high blood pressure which can lead to heart failure) and urinary calculus (harden deposits of minerals that form in the kidney and cause pain as they pass through the urinary tract). Record review of Resident #42's MDS assessment, dated 3/7/2025, indicated the resident had a BIMS score 9 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #42 was dependent with all activities of daily living (ADL). The MDS indicated Resident #42 was on oxygen. Record review of Resident #42's Care Plan created on 2/21/2025 indicated the resident had little to no activity involvement due to disinterest, immobility and physical limitations. The care plan revised on 3/18/2025 indicated the resident wanted his RP to manage talking with physicians, staff members and nurses about care. Interventions included to administer medications as ordered and monitor and document effects and effectiveness. The care plan did not indicate Resident #42 was on oxygen. Record review of Resident #42's MAR dated 3/1/2025-3/31/2025 indicated the resident was on 2 liters via nasal cannula continuously every shift starting on 3/16/2025. The Physician's order was initiated on 3/16/2025 indicated Resident #42 was prescribed 2 liters via nasal cannula continuously every shift. During an interview and observation on 3/17/2025 at 11:14 AM, Resident #42 said he was not feeling well, and RP was at bedside. The RP said the resident recently returned from the hospital. The RP was concerned Resident #42 was sleeping too much. Observed Resident #42's oxygen setting on 5 liters of oxygen. During an interview and observation on 3/17/2025 at 3:43 PM, Resident #42 continued to have oxygen setting on 5 liters. The RP said she had not adjusted the oxygen settings. During an interview on 3/17/2025 at 3:45 PM, LVN T said the resident was supposed to be on 2 liters of oxygen and returned to his room and corrected the setting. She said she was not sure why the resident was on 5 liters. She said she tries to check the setting as she reviews the residents MAR and makes her rounds. She said she had just recently disconnected resident from the oxygen tank to the concentrator. During an interview on 3/19/2025 at 8:56 AM, LVN M said the nursing staff changed the oxygen tubing and dated weekly. LVN said the nurses were responsible for ensuring the settings were correct and educating the resident and family on proper placement, keeping the tubing above the level of the water, not dropping the tubing on the floor and monitoring areas behind the ears for sores. LVN said the staff educate the resident and family on not adjusting the oxygen settings and follow the physician orders. LVN said we educate residents with respiratory issues such as COPD (a group of lung diseases that block airflow and make it difficult to breathe) that increasing the oxygen setting could cause other risk such as increasing CO2 retention and causing an exacerbation of their Chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe). LVN said it was the responsibility of the nurses to ensure the oxygen was on the correct settings every shift. During an interview on 3/19/2025 at 11:30 AM, LVN N said the nursing staff should be checking the oxygen settings every shift. LVN N said if she observed a resident on 5 liters and the order was for 2 liters, she would make the adjustment to correct. She said she had never had any issues with residents on oxygen. LVN N said the nurses were responsible for ensuring the orders were followed and the family or resident should not be adjusting their own oxygen. During an interview on 3/19/2025 at 12:00 PM, the RP said she had never touched the oxygen concentrator or adjusted the oxygen settings. She said she saw when LVN M returned to the room and adjusted the setting. During an interview on 3/19/2025 at 1:14 PM, ADON H said the nurses should be checking to make sure how many liters of oxygen were ordered and checking the resident's oxygen saturations. She said if a resident's oxygen were set too low, it could cause complications and she was not sure what would happen if the setting were too high. ADON H said every shift, the nurses check to ensure the oxygen was on the correct liters ordered. ADON H said the staff made Angel rounds and assigned to a hall and they checked to make sure the tubing was changed, and the oxygen were on the correct settings. ADON H said she did not know why Resident #42's oxygen was set on 5 liters. She said when she made rounds, Resident #42 was on his oxygen tank and not the concentrator. 4. Record review of Resident #9's face sheet dated 3/18/25 indicated Resident #9 was a [AGE] year-old female admitted on [DATE] and readmitted on [DATE]. Resident #9 had diagnoses including cerebral palsy (is a group of conditions that affect movement and posture) and hypertensive heart disease with heart failure (is a condition where chronic high blood pressure (hypertension) damages the heart muscle, leading to heart failure). Record review of Resident #9's quarterly MDS assessment dated [DATE] indicated Resident #9 was understood and had the ability to understand others. Resident #9 had a BIMS score of 15 which indicated intact cognition. Resident #9 MDS assessment did not indicated oxygen therapy. Record review of Resident #9's care plan dated 3/3/35 indicated Resident #9 was on oxygen therapy related to ineffective gas exchange. Intervention included oxygen settings per medical doctor orders. Record review of Resident #9's consolidated physician orders dated 3/18/25 indicated: *Check oxygen filter for placement and cleanliness, every night shift, every Sunday. Start date of 12/29/24. *Oxygen at 2-4 liters via nasal cannula as needed every 12 hours if saturation less than 88%. Start date 10/13/24. Record review of Resident #9's MAR dated 3/1/25-3/31/25 indicated check oxygen filter for placement and cleanliness, every night shift, every Sunday. Start date of 12/29/24. The MAR indicated administration on 3/16/25 (LVN E). During an observation on 3/17/25 at 11:41 a.m., Resident #9 was lying in her bed with a nasal cannula connected to an oxygen concentrator. Resident #9's oxygen concentrator filter had a thick, moderate amount of white, fuzzy particles. Resident #9 said staff changed her nasal cannula tubing once a week. She said she did not know about the oxygen filter. During an observation on 3/18/25 at 8:47 a.m., Resident #9 was lying in her bed with a nasal cannula connected to an oxygen concentrator. Resident #9's oxygen concentrator filter had a thick, moderate amount of white, fuzzy particles. 5. Record review of Resident #33's face sheet dated 3/18/25 indicated Resident #33 was a [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. Resident #33 had diagnoses including acute respiratory failure (is a life-threatening condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low blood oxygen levels (hypoxemia) and/or high carbon dioxide levels (hypercapnia)) and chronic obstructive pulmonary disease (is an ongoing lung condition caused by damage to the lungs). Record review of Resident #33's quarterly MDS assessment dated [DATE] indicated Resident #33 was usually understood and usually had the ability to understand others. Resident #33 had a BIMS score of 9 which indicated moderate cognitive impairment. Resident #33 had oxygen therapy within the last 14 days. Record review of Resident #33's care plan dated 02/24/25 indicated Resident #33 had oxygen therapy related to history of respiratory failure and chronic obstructive pulmonary disease. Intervention included oxygen settings per medical doctor orders. Record review of Resident #33's consolidated physician order dated 3/18/25 indicated: *Oxygen at 2 liters via nasal cannula continuous every shift. Start date of 12/27/24. *Check oxygen filter for placement and cleanliness, every night shift, every Sunday. Start date of 12/29/24. Record review of Resident #33's MAR dated 3/1/25-3/31/25 indicated check oxygen filter for placement and cleanliness, every night shift, every Sunday. Start date of 12/29/24. The MAR indicated administration on 3/16/25 (LVN E). During an observation on 03/17/25 at 9:41 a.m., Resident #33 was lying in bed with a nasal cannula connected to an oxygen concentrator. Resident #33's oxygen concentrator filter had a small amount of white, fuzzy particles. During an observation on 3/18/25 at 8:19 a.m., Resident #33 was lying in bed with a nasal cannula connected to an oxygen concentrator. Resident #33's oxygen concentrator filter had a small amount of white, fuzzy particles. On 3/19/25 at 12:15 p.m., call placed to LVN E and was unable to leave a message. During an interview on 3/19/25 at 12:51 p.m., LVN K said the nurses who worked on Sunday nights were responsible for cleaning oxygen filters. She said the facility also had staff assigned to complete angel rounds in the resident's room. She said angel rounds were done every morning. She said during angel rounds the assigned staff looked at the oxygen setups and other things. She said Resident #33's oxygen filter did not look as if it was cleaned last Sunday night. She said it was important for a resident's oxygen filter not to have white fuzzy particles because it was respiratory equipment. She said an unclean oxygen filter could cause a bunch of problems. She said an unclean filter could cause sickness and affect the resident's overall health. During an interview on 3/19/25 at 1:23 p.m., the Director of Nurses said that it is the responsibility of nurses to ensure that nasal cannula is stored properly when not in use. She said that cannula should not be left hanging in a trashcan. She said that resident filters are replaced by nursing staff, and they are kept clean by nursing staff. She said there was a risk of a respiratory infection if cannula is not stored properly, and concentrators are not kept clean. During an interview on 3/19/25 at 1:40 p.m., the Administrator said that nasal cannula should be stored properly and not left in a trashcan. He said that their concentrators should be cleaned, and filters changed. He said residents could be placed at risk of a respiratory infection if proper protocol was not followed. During an interview on 3/19/2025 at 2:05 PM, the DON said the nurses were responsible for ensuring orders were followed. She said the oxygen should be care planned. The DON said she spoke with the RP and she reported she turned up the oxygen concentrator. The DON said Resident #42 could have had respiratory issues. During an interview on 3/19/2025 at 2:21 PM, the ADM said he expected the nurses to check the orders and oxygen daily. The ADM said he expected the family and resident to be educated on oxygen care. The ADM said too much oxygen could cause light headedness or dizziness. The ADM said the nurses were responsible for checking the oxygen settings and orders. During an interview on 3/19/25 at 3:15 p.m., the DON said the nurses were responsible for the external oxygen filters and maintenance was responsible for the internal. She said oxygen filters were supposed to be cleaned weekly. She said the oxygen filters on concentrators were supposed to draw in the particles, in the resident's environment. She said if the oxygen filter had white fuzzy particles, then it was doing its job. She said it was important the oxygen filter to be clean to maintain airflow to the resident. She said if the resident's oxygen filter was not cleaned weekly, it could decrease the air flow. During an interview on 3/19/25 at 3:23 p.m., the Administrator with the VP of Operations present said he had been employed at the facility for thirteen months. The VP of Operations said the external filter on the oxygen concentrator was assigned to the nursing staff. The VP of Operations said the facility had daily angel rounds who also were supposed to check the oxygen filters. The VP of Operations said the internal filters were assigned to the Maintenance staff. The VP of Operations said he was not sure how often the internal filters were cleaned by Maintenance. The VP of Operations said he believed Maintenance were supposed to clean the internal filters monthly. The Administrator said the external filters should be cleaned as needed. The Administrator said oxygen filters should be cleaned because it affected the resident's breathing. The Administrator said he was responsible to ensure the nursing staff, assigned angel round employees, and maintenance staff cleaned the resident's oxygen concentrator filters. Review of a facility policy titled Oxygen undated indicated Purpose .A resident will receive oxygen therapy when ordered by a physician. The resident's disease, physical condition, and age will help determine the most appropriate method of administration. Responsible Disciplines .Licensed Nursing, Attending physician, FNP .Procedure .1. Assess the resident's room to determine if the environment is safe for oxygen administration. 2. Post an oxygen precaution No smoking sign on the resident's door.3. Obtain physician orders for oxygen administration .Orders should include following .oxygen source .method of delivery .flow rate .oxygen saturation monitoring parameters .4. Assess the resident's condition .5. Monitor the resident's response to oxygen .Check pulse oximetry 6. Monitor for signs of hypoxemia .a. level of consciousness .pulse oximetry .vital signs .skin and mucous membrane .breathing patterns .dyspnea .cyanosis, cool .7. Observe the resident's skin .Documentation: Place documentation in the resident's EMR Administration Record (TAR) .date and time of oxygen administration .type of delivery///oxygen flow rate .residents vital signs, skin

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review of Resident #47's face sheet dated [DATE] indicated Resident #47 was a [AGE] year-old female admitted on [DATE]. Resident #47 had diagnosis including hypotension. Record review of Resident #47's admission MDS assessment dated [DATE] indicated Resident #47 was understood and had the ability to understand others. Resident #47 had a BIMS score of 11 which indicated moderate cognitive impairment. Record review of Resident #47's care plan dated [DATE] did not reflect the diagnoses of hypotension and use of Midodrine. Record review of Resident #47's consolidated physician order dated [DATE] indicated Midodrine HCl Oral Tablet 5mg, give 1 tablet by mouth three times a day related to Hypotension. One tab in morning, one tab at noon, and one tab in the evening. Started on [DATE]. Resident #47's consolidated physician order did not reflect hold blood pressure parameters. Record review of Resident #47's MAR dated [DATE]-[DATE] indicated Midodrine HCl Oral Tablet 5mg, give 1 tablet by mouth three times a day related to Hypotension. One tab in morning, one tab at noon, and one tab in the evening. Started on [DATE]. Resident #47 received 30 of 52 doses. Resident #47 had 13 doses held for parameters not me. Resident #47's MAR did not reflect hold blood pressure parameters. During an interview on [DATE] at 12:51 p.m., LVN K said the nurse who put the order in should get the hold parameters. She said the ADONs were supposed to monitor medication orders. She said without hold parameters if a resident's blood pressure was low it could bottom out. She said if the resident's blood pressure was high it could increase the blood pressure. She said if a resident was administered a blood pressure medication and the hold parameters were not followed, it could cause the need for more medication or being sent out to the hospital. LVN K reviewed Resident #47's Midodrine order and said it did not have blood pressure hold parameters. During an interview on [DATE] at 2:15 p.m., the DON said the admit nurse or whoever received the physician order should have also obtained hold parameters. She said Resident #47's Midodrine order should also have hold parameters orders. She said it depended on the physician, what hold parameters were ordered to follow. She said if resident received a medication for hypotension but was not hypotensive, they could become hypertensive (is a condition where the force of blood against artery walls is consistently too high). She said nursing management, through chart audits, should ensure the nursing staff obtained hold blood pressure parameters. During an interview on [DATE] at 3:23 p.m., the Administrator, with the VP of Operations present, said the physicians decide the hold parameters for the resident's medications. He said the nurses should contact the physician for hold parameters orders. He said if a resident received a medication to increase their blood pressure but it was not needed, they could experience increased blood pressure. He said with the increased blood pressure they could have a stroke or heart attack. He said the DON should ensure the nursing staff obtained hold blood pressure parameters. Review of a facility policy titled Storage of Medications Revised on [DATE] indicated .all drugs and biologicals in a safe, secure and orderly manner. 1. Drugs and biologicals used in the community are stored in a locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2.are stored in the packaging, containers, or other dispensing systems in which they were received .3.nursing staff is responsible for maintaining medication storage and preparation .4.discontinue, outdated or deteriorated drugs . Record review of a facility's Administering Medications policy revised 04/2019 indicated .medications are administered in a safe and time manner, and as prescribed .the director of nursing services supervises and directs all personnel who administer medications and/or have related functions .the following information is checked/verified for each resident prior to administering medication .vital signs . Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage rooms and to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 19 residents (Resident #50 and Resident #47) reviewed for medications storage and pharmacy services. 1. The facility failed to remove expired over the counter medications from the Medication Storage room. 2. The facility failed to ensure narcotic counts were accurate for Resident # 50's Belsomra 10 mg (medication used for insomnia) for medication cart on Hall 100 at shift change on [DATE]. 3. The facility failed to ensure Resident #47 Midodrine (is used to treat low blood pressure (hypotension)) had hold blood pressure (is the force exerted by blood against the walls of your arteries as it circulates through your body) parameters orders. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications and inaccurate drug administration. Findings included: Record review of Resident # 50's Face sheet dated [DATE] indicated the resident was a 68-year- old male who readmitted to the facility on [DATE] with diagnoses of Hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side (a complete paralysis or weakness affecting one side of the body after a stroke due to the damage to the brains motor pathway), recurrent depression (a pattern of repeated episodes of major depressive disorder), Hypertensive heart disease with heart failure (prolonged high blood pressure that causes the heart to work harder, leading to weakened heart muscle and reduced pumping ability), and convulsions (a rapid, involuntary muscle contraction that causes uncontrollable shaking and limb movement). Record review of Resident #50's MDS assessment, dated [DATE], indicated the resident had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #50 required supervision with personal hygiene and ADL's. Record review of Resident #50's Care Plan created on [DATE] indicated the resident was taking an antidepressant medication for depression. Interventions included monitoring, documenting, and reporting adverse reactions to antidepressant therapy such as changes in behavior, mood, cognition, hallucinations, social isolation, withdrawal, decline in ADL ability, continence, constipation, diarrhea, gait changes, rigid muscles, balance problems, movement problems, tremors and insomnia. Record review of Resident # 50's MAR dated [DATE]-[DATE] indicated he was ordered Belsomra 10 mg (a medication used to treat insomnia) was started on [DATE]. During medication cart review on [DATE] at 10:00 AM, Resident # 50 had documented on the narcotic sheet to have 3 tablets remaining. LVN O pulled Belsomra 10 mg packet out for a narcotic count and Resident #50 had 4 tablets of medication left. LVN O said she did the counts that morning and did not identify the off count. She said the medication must have been signed out and not given. She said she did not know why the counts were off and she did not work last night. During an interview on [DATE] at 10:03 AM, the DON said she was going to check the EMR, and she requested LVN O to notify the Physician. During an interview on [DATE] at 12:00PM, the DON said she had investigated the narcotic counts, and it was determined the night shift nurse failed to administer the medication on [DATE]. The DON notified Resident #50 of the medication error, notified the Physician, and completed an incident report. The DON provided documentation that she would begin monitoring narcotic counts beginning on [DATE], 3 times weekly for 90 days. The DON completed an in-service with the 3 nurses responsible for medication counts on the Rights of Medication Administration and controlled substances and narcotic counts. The nurse who was responsible for administering the medication indicated on the in-service he may have forgotten to pop the pill out but signed it out in the narcotic book and electronic medical record. During an observation on [DATE] at 3:10 PM, this surveyor reviewed the storage room and found the following medications: Lorazepam 2 mg/ml 3 vials with dated expirations (2 vials) expired on [DATE] and (1 Vial) expired on [DATE] for Resident # 52. The medication was in the refrigerator under double lock and key. Potassium 99 mg tablets 2-bottles had expired [DATE]. The DON said she was responsible for removing the expired Lorazepam vials from the refrigerator. She said Resident #52 was on the medication for seizures and he was currently well controlled with oral medications. The DON said she was going to notify the Physician. The DON said she had just returned from vacation and had not removed the medication. The DON said central supply was responsible for stocking and removing expired over the counter medications. Review of an in-service dated [DATE] subject Handoff/Narcotic Counts indicated the DON discussed proper hand off of medication cart keys and narcotic counts at shift change. The DON indicated 2 nurses are to count narcotics and compare them to the narcotic book. She noted keys should not change hands until the counts were confirmed to be accurate. The DON indicated for any discrepancies, the DON and MD must be notified so an investigation could be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 5 of 29 residents (Residents #29, #39, #42, #55, and #84) reviewed for storage of medication. 1. The facility failed to securely store Resident #29's Benadryl and Neosporin cream found at her bedside table on 3/17/2025. 2. The facility failed to securely store Resident # 39's Systane eye drops found at her bedside table on 3/17/2025. 3. The facility failed to securely store Resident #42's Oxymetazoline HCL 0.05% (nasal decongestant) and a powdery substance in a medication cup located on beside table on 3/17/2025. 4. The facility failed to securely store Resident # 84's Visine eye drops located on her bedside table on 3/17/2025. 5. The facility failed to securely store over the counter medications for Resident #55. These failures could place residents at risk for adverse reactions to medications or overdose. Findings included: 1. Record review of Resident #29's Face sheet dated 3/19/2025 indicated the resident was a 90-year- old female who readmitted to the facility on [DATE] with diagnoses of Alzheimer's disease (a type of dementia that affects memory, thinking and behavior) Hypertension (a condition that affects the bodies arteries due to the force of the blood pushing against the artery walls is consistently too high), and Hyperlipidemia (a condition of high cholesterol or fats in the blood). Record review of Resident #29's MDS assessment, dated 1/22/2025, indicated the resident had a BIMS score of 10 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #29 required supervision with bathing and supervision with dressing upper and lower body. Record review of Resident #29's Care Plan created on 10/28/2024 indicated the resident had ADL self-care performance deficits related to activity intolerance, Alzheimer's, Dementia, and impaired balance. The care plan initiated on 1/28/2025 indicated resident was on over the counter medication that she could keep at her bedside and was able to pass her self-administration test. Interventions included Resident #29 could administer over the counter medications per MD orders. During an interview and observation on 3/17/2025 at 9:39 AM, Resident #29 had Benadryl cream and Neosporin on her bedside table. Resident #29 said the staff were aware she had medication in her room. Resident #29 said she applies the medications on her skin if she gets a rash. She denied any current rashes. 2. Record review of Resident #39's Face sheet dated 3/19/2025 indicated the resident was a 94-year- old female who admitted to the facility on [DATE] with diagnoses of collapsed vertebra (a thick oval segment of bone that makes up the front of a vertebra becomes compressed and loses its normal height) , wedge compression fracture of lumbar vertebra (a type of compression fracture occurs when one side of your vertebrae collapses) and hypertensive heart disease with heart failure (a condition caused by prolong high blood pressure which can lead to heart failure). Record review of Resident #39's MDS assessment, dated 2/18/2025, indicated the resident had a BIMS score of 9 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #39 was dependent bathing, dressing and personal hygiene. Record review of Resident #39's MAR dated 3/1/2025-3/31/2025, indicated the resident did not have an order for Systane lubricant eye drops. During an observation on 3/17/2025 at 2:59 PM, Resident #39 observed to have eye drops Systane lubricant eye drops on the bedside table. 3. Record review of Resident #42's Face sheet dated 3/18/2025 indicated the resident was a 81-year- old male who admitted to the facility on [DATE] with diagnoses of acute gastritis with bleeding ( an inflammation of the lining of the stomach), gastrointestinal hemorrhage (a sign of bleeding in the digestive tract), Hypertensive heart disease with heart failure (a condition caused by prolong high blood pressure which can lead to heart failure) and urinary calculus (harden deposits of minerals that form in the kidney and cause pain as they pass through the urinary tract). Record review of Resident #42's MDS assessment, dated 3/7/2025, indicated the resident had a BIMS score 9 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #42 was dependent with all activities of daily living (ADL). Record review of Resident #42's Care Plan created on 2/21/2025 indicated the resident had little to no activity involvement due to disinterest, immobility and physical limitations. The care plan revised on 3/18/2025 indicated the resident wanted his RP to handle talking with physicians, staff members and nurses about care. Interventions included to administer medications as ordered and monitor and document effects and effectiveness. The care plan did not indicate Resident #42 was assessed for self-administering medication. Record review of Resident #42's MAR dated 3/1/2025-3/31/2025 indicated the resident was oxygen pm 3/16/2025 at 2 liters and no nasal spray was ordered. During an interview and observation on 3/17/2025 at 11:14 AM, Resident #42 said he was not feeling well, and RP was at bedside. The RP said the resident recently returned from the hospital. The RP was concerned Resident #42 was sleeping too much. During an interview and observation on 3/17/2025 at 3:43 PM, Resident #42 had a medication cup sitting behind a bag located on the nightstand. The medication cup observed to have a white powdery substance in the cup, a nasal spray Oxymetazoline HCL 0.05% (nasal decongestant) was observed in his tissue box located on his bedside table. The RP said she had brought in the medication to use for him. The RP said she did not make the staff aware she brought the medication but was in plain view. During an interview on 3/17/2025 at 3:45 PM, LVN T said she could not identify the white powdery substance in the medication cup. She felt the medication in the cup was Nystatin powder and must have been left in the room and she forgot to remove it from his room. She said the resident could had taken the nystatin powder by mouth causing him an adverse reaction. She said it was a small mistake. 4. Record review of Resident #84's Face sheet dated 3/18/2025 indicated the resident was a 79-year- old female who admitted to the facility on [DATE] with diagnoses of nonalcoholic steatohepatitis (a liver problem that affects people who drink little to no alcohol), Dysphagia (a condition with difficulty swallowing food or liquid), paralysis of vocal cords and larynx (a condition where the muscles that control the vocal cords lose their ability to function properly), severe protein-calorie malnutrition (a condition when the body does not get enough protein and calories) and gastrostomy (a feeding tube inserted into the stomach through the abdomen). Record review of Resident #84's MDS assessment, dated 3/3/2025, indicated the resident had a BIMS score of 2 which indicated the resident had severe cognitive impairment. The MDS also indicated Resident #84 was dependent with all activities of daily living (ADL). Record review of Resident #84's Care Plan created on 9/26/2024 indicated the resident had impaired cognitive function and impaired thought processes with difficulty making decisions. The interventions included administering medications as ordered and to monitor and document side effects for effectiveness. There was no care plan indicating resident was able to self-administer medications. Record review of Resident #84's MAR dated 1/3/2025 indicated Resident #84 had an order for artificial tears ophthalmic solution 0.5-0.6 % to instill 2 drops in both eyes every 8 hours as needed for dry eyes. During an observation and interview on 3/17/2025 at 2:39 PM, Resident # 84 observed to have Visine eye drops located on her bedside table. Resident #84 had difficulty speaking due to her diagnosis of paralysis of her vocal cords and was difficult to understand. During an interview on 3/19/2025 at 9:17 AM, CNA P said residents should not have over the counter medications in their room. CNA P said she would remove an over the counter (OTC) medication and notify the nurse. She said the over the counter (OTC) medications should be locked up and no residents should have medications in their room. The CNA P said the nurses were responsible for ensuring medications are put up. During an interview on 3/19/2025 at 8:56 AM, LVN M said the nursing staff should never leave medications in a resident's room. LVN M said over-the-counter medications that are self-administered should be care planned and an assessment for self-administration would determine if a resident was able to self-administer the medications. LVN M said the residents should not have nasal sprays, Neosporin, Benadryl cream, medication cups with medications in their rooms without an order and if they are able to self-administer. LVN M said if a resident was capable and had completed an assessment, the medication could not be sitting out in the open and should be stored in a drawer. LVN M said the facility had some dressers that locked. LVN M said the medication could get in the wrong hands and a person could have an adverse reaction or a fatal reaction. She said the nurses were responsible for ensuring medications were properly stored and were not expired. LVN M said the nurses should educate the resident and families on medications brought in the facility and there should be an order on the MAR. LVN M said if another staff member observed a medication in the room, then they needed to report it to the nurse and then follow the chain of command. During an interview on 3/19/2025 at 11:30 AM, LVN N said residents should not have over the counter eye drops, nasal sprays, ointments unless they had an assessment indicating they can self-administer medications. LVN N said there should be an order for the medication and care planned. LVN N said the medication should be store in a lock box in the resident room. She said she expected the CNAs to report any OTC medications observed in a resident's room. LVN N said the resident could have an allergic reaction to the medication. LVN N said the nurses were responsible for medications and putting in the orders. During an interview on 3/19/2025 at 1:14 PM, ADON H said residents were not able to have medications at bedside. She said the residents must have a self-administration assessment and an order for the medication. ADON H said Resident # 29 did not have an order for Benadryl or Neosporin. The ADON H said Resident #29 did have a self-administration assessment completed but was not specific to what medications she could self-administer. ADON H said the following residents did not have an order or self-administration assessment completed: Resident #39- no order for eye drops. Resident #42- no order for nasal sprays. Resident #84- no order for eye drops. ADON H said Resident #42 did not have orders to crush his medications and thought the white powdery substance could have been his nystatin powder. She said it could cause damage if a resident took the white powdery substance by mouth making him sick. ADON H said medications left in a resident's room could cause harm to others and make them sick if taken. She said medications were allowed in a resident's room and should be stored in a drawer so others would not get it. ADON H said the DON was the nurse who completed the self-administration assessments. The ADON H said the nurses should make sure the medications were being stored out of reach of other residents. ADON H said the facility makes Angel rounds and they would put the medications in a drawer if identified. During an interview on 3/19/2025 at 2:05 PM, the DON said residents were allowed to have medications at bedside with the proper medications and orders. The DON said the medications should be out of plain view. The DON said depending on the medication, a visitor or other resident could have an adverse effect if obtained. The DON said the facility would have to call poison control if consumed. The DON said the nurses were responsible for ensuring medications were properly stored and not expired. During an interview on 3/19/2025 at 2:21 PM, the ADM said residents could have bedside medications. The ADM said the resident should be cognizant of the usage of the medications. He said there should be an assessment that was performed to determine if a resident was able to self-administer. The ADM said he thought the social worker was responsible for making sure the self-administration assessments were completed. The ADM said a resident should have an order for the medication. The ADM said the DON was responsible for ensuring OTC medications have an order. The ADM said the nursing staff were responsible for making sure the medications were properly stored. The ADM said if a resident or visitor obtained medications that were not prescribed to them or expired, it could be detrimental including death. 5. Record review of the face sheet 1/06/2020 indicated Resident #55 was [AGE] years old and was admitted on [DATE] with diagnoses including Senile Degeneration of Brain (a group of conditions that cause a progressive decline in cognitive function, memory, and behavior), Alzheimer's Disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and reasoning skills, eventually leading to the inability to perform daily task), Hyperlipidemia (a condition characterized by high levels of fats (lipids) in the blood). Record review of the MDS dated [DATE] indicated Resident #55 was understood and understood others. The MDS indicated a BIMS score of 02 indicating Resident #55 was severely cognitively impaired. Record review of a care plan revised on 04/05/24 indicated Resident #55 had an ADL self-care performance deficit related to activity intolerance and impaired balance. During an observation and interview on 3/17/25 at 10:18 a.m. it was observed that a bottle of skin cleanser (chlorhexidine gluconate) was observed in the resident's bathroom on top of the medicine cabinet. Resident #55 is unable to answer questions due to cognitive decline. During an interview on 3/19/25 at 8:28 a.m. RN A said that any medication or skin cleanser is not allowed in a resident's room as it should be secured. She said it could be dangerous if a resident swallowed chlorhexidine gluconate. During an interview on 3/19/2025 at 1:13 p.m., the Director of Nurses said that antimicrobial antiseptic skin cleansing products should not be left in a resident's room. She said that it was the responsibility of all staff to ensure that prohibited items are not in resident's rooms. She said that she would have to call poison control if a resident ingested this type of chemical and she does not know the risk. During an interview on 3/19/25 at 1:40 p.m., the Administrator said prohibited chemicals are not allowed to be left in a resident's room. He said that residents could place themselves at risk for poisoning themselves. He said it was the responsibility of all staff to ensure that prohibited items are not left in a resident's room. ADM. Review of a facility policy titled Self-administration of Medications undated, indicated Purpose .Each resident has the right to self-administer medications . The interdisciplinary team evaluates each resident who expresses wishes to self-administer medications to determine if the resident is safe to do so, and if so, provides the education and monitoring necessary to provide safe administration. Guidelines .1. When admitted , alert residents shall be informed of their rights to self-administer medications. 2.the clinical team perform an assessment to the competence .3.nurse is to interview the resident .4.a decision should be made by the IDT members as to whether the resident is a candidate for self-administration .5.the nurse is to obtain a physician's order for self-administering .6.nurse, medication aide is still to verify consumption of medication and document on the medication administration record .7.Storage of self-administered medications should comply with state and federal requirements .a. if medication the resident is requesting is an OTC this should be noted and can be stored in resident room in a drawer out of site .8.error if made by the resident self-administering medications, the nurse and IDT may review the resident's ability . Review of a facility policy titled Storage of Medications Revised on November 2020 indicated .all drugs and biologicals in a safe, secure and orderly manner. 1. Drugs and biologicals used in the community are stored in a locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. 2.are stored in the packaging, containers, or other dispensing systems in which they were received .3.nursing staff is responsible for maintaining medication storage and preparation .4.discontinue, outdated or deteriorated drugs .6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, for 1 of 4 halls (Hall 200) reviewed for a homelike environment. The facility failed to ensure Hall 200's armed exit door near the designated smoke area and laundry, was functioning correctly and not alarming on 3/17/25 and 3/18/25. This failure could place residents at risk for diminished quality of life in an environment that is not homelike. Findings included: During an observation on 3/17/25 at 11:11 a.m., the Hall 200 exit door was entered by a staff member. The Hall 200 exit door shut behind the staff member. The Hall 200 exit door started alarming. The staff member who entered the exit door was partially down the hall when the Hall 200 door alarmed. A housekeeping staff member securely shut the exit door previously entered by another staff member. The Hall 200 exit door stopped alarming. During an interview on 3/17/25 at 11:41 a.m., Anonymous Resident (AR) #1 said the Hall 200 exit door alarmed all day and night. AR #1 said the alarm was annoying and interrupted his/her sleep. During an interview on 3/17/25 at 4:15 p.m., Anonymous Resident #2 said Hall 200 was very loud. AR #2 said the exit door alarming got on his/her nerves. During an observation on 3/18/25 at 8:49 a.m., the Hall 200 exit door alarmed after a staff member entered the exit door. The staff member who entered the exit door was partially down the hall when the Hall 200 door alarmed. Another staff member securely shut the exit door previously entered by another staff member. The Hall 200 exit door stopped alarming. During an observation on 3/18/25 at 9:03 a.m., the Hall 200 exit door alarmed after a staff member exited the door. Another staff member securely shut the exit door previously exited by another staff member. The Hall 200 exit door stopped alarming. During an interview on 3/18/25 at 1:27 p.m., Anonymous Resident #3 said the Hall 200 exit door was the general smoking area used mostly by the staff. AR #3 said the alarm went off all the time. AR #3 said the weather changes made the exit door alarm more. AR #3 said the alarm had gone off for at least 10 minutes before someone stopped it. AR #3 said the residents who ate their meals on the hall, had to stop eating to turn off the alarm on the exit door. AR #3 said the alarm on the exit door interrupted his/her sleep and meals. During an interview on 3/19/25 at 10:00 a.m., CNA G said she had worked at the facility on and off for 10 years. She said she primarily worked the 200 hall. She said the facility fixed the Hall 200 exit door sometime last week. She said when staff went out of the door, the magnet did not latch and caused a loud beeping noise. She said a lot of the resident from room [ROOM NUMBER]-224 complained about the loud beeping noise. She said the loud beeping noise, from the door not latching good, had been going on since at least February 2025. She said when she came back full time to the facility in February 2025, the 200 hall exit door alarmed excessively. She said staff had been instructed to make sure the exit door was completely shut. She said a lot of staff said they were not going to make sure it was closed because maintenance needed to fix it. She said the exit door excessively alarmed all times of day and night. She said the excessive alarming probably affected the resident's sleep. During an observation on 3/19/25 at 10:25 a.m., a staff member exited the Hall 200 exit door. When the exited door closed, a motor sound was heard then a latching noise. The Hall 200 door did not alarm. During an interview on 3/19/25 at 12:51 p.m., LVN K said the Hall 200 exit door near the smoking area had been alarming a lot for about a year. She said it was the excessive beep noise was terrible and she felt bad for the residents. She said staff had been told to make sure the exit door was completely closed. She said a lot of the resident had complained about the exit door alarming excessively. She said the excessive alarming affected the resident's mood and sleep. During an interview on 3/19/25 at 2:10 p.m., the Maintenance Supervisor L said the Hall 200 exit door had intermittent issues for the last 4 months. He said about 4 months ago, one of the ADONs reported to him the maglock (is a locking device that consists of an electromagnet and an armature plate) was ripped off the door. He said after that incident, the 200 hall exit door started excessively alarming. He said he tried to fix the door himself several times. He said he also tried to adjust the door several times. He said the 200 hall exit door was not locking causing it to alarm. He said when the exit door alarmed excessively, it was all the time, day, and night. He said he only knew of one resident complaining about the excessive alarming. He said the facility had called out to a company to look at the exit door. He said the company came out last Friday (3/14/25) and Wednesday (3/19/25) to look at the 200 hall exit door. He said the door was completely fixed now. During an interview on 3/19/25 at 2:15 p.m., the DON said a company was just at the facility fixing the 200 hall exit door. She said she knew at a period of time, the exit door had issues. She said no residents had complained to her about the excessive alarming. She said the noise level would be loud and disruptive if the Hall 200 exit door was excessively alarming. She said the facility tried to provide the resident a homelike environment, but there was going to be noise. During an interview on 3/19/25 at 3:23 p.m., the Administrator, with the VP of Operations present, said the facility had an issue with the Hall 200 exit door alarming excessively. He said the issue with the Hall 200 exit door had not been for a long period. He said the Maintenance staff were aware of the issue and attempted to fix it. He said there was a period of trial and error trying to get the exit door to stop excessively alarming. He said the staff were instructed to secure the exit door. He said the resident did complain about the excessive alarming. Record review of an undated facility Quality Assurance and Performance Improvement policy which indicated .the community is designed, constructed, equipped, and maintained to protect the health and safety of resident .the accommodation's facilities are expected to make to satisfy the needs of its residents .sound .of particular concern to comfortable sound levels is the resident's control over unwanted noise .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to allow residents to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the family for 1 of 1 (Resident #1) residents reviewed for the right to access copies of records. The facility failed to provide medical records for Resident #1 to her attorney within two working days of a request on 07/31/2024. This failure could place residents at risk by causing a negative health impact due to not having continuity of care. Findings included: Record review of a face sheet dated 9/16/2024 indicated Resident #1 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of paroxysmal atrial fibrillation (irregular often rapid heart rate that causes poor blood flow), dementia with behavioral disturbance (impaired concentration, apathy, anxiety, and agitation), and asthma (cough, wheeze, shortness of breath and chest tightness). Record review of a the annual comprehensive MDS dated [DATE] indicated Resident #1 was usually understood, and usually understood others. The MDS indicated Resident #1's BIMS was a 12 indicating moderate cognitive impairment. Record review of a discharge MDS dated [DATE] indicated Resident #1 discharged from the facility and return was not anticipated. Record review of a certified mail receipt dated 7/31/2024 indicated the facility's Receptionist signed a receipt of a medical records request from a law firm regarding Resident #1. Record review of a formal letter records request for Resident #1's attorney dated 7/29/2024 indicated, enclosed please find an authorization for the release of protected health information. Please provide [Resident #1's] records electronically within 48 hours of receiving this notice. The formal request also included a signed release form from the power of attorney. During an interview on 9/16/2024 at 11:33 a.m., HR said she had worked at the facility for 3 years. She said on 7/31/2024 the Receptionist for the facility had signed for the medical records request via certified mail , and then put it in the mail area on the counter in the front office. She said on 7/31/2024 she had gone through the mail and saw the request and it did not look like a typical medical records request; it had looked like a subpoena. She said she had contacted corporate HR to see how the request should have been handled. She said corporate advised her that the previous owner was responsible for those records. She said Resident #1 was not a resident of the current owner of the building and had discharged from the facility prior to the current owner taking over ownership of the facility on 12/1/2022. She said she had contacted the Previous Owner who then came and picked up the certified mail medical records request on 8/2/2024. She said to her knowledge the facility had not received any other correspondence from the law firm. She said the facility did not send any medical records to the law firm. During an interview on 9/16/2024 at 1:31 p.m., the Paralegal indicated the firm had requested medical records on July 29, 2024, and the facility had signed a certified mail receipt on 7/31/2024. The Paralegal said they had not received any medical records since the request was made. The Paralegal said the firm had received a phone call on 8/02/2024 at 4:02 PM from an Attorney Friend of the previous owner of the facility. The Attorney Friend indicated he was not representing the Previous Owner but was trying to help as a friend. The Attorney Friend indicated the Previous Owner was not ignoring the request for medical records, but it may take longer than the 48 hours requested in the letter. During an interview on 9/16/2024 at 2:19 p.m., the Administrator said when a request was received the request was sent to the corporate level for processing. The Administrator said when there was a delay in sending the medical records there could be a delay of a resolution. During an attempted interview on 9/17/2024 at 2:39 p.m. the Surveyor called and left a voicemail for the Previous Owner. The Surveyor had not received a return call by the time of exit. During an interview on 9/18/2024 at 8:39 a.m. after exit, the Surveyor received a return call from the Previous Owner who said that she had received a notice from the facility of the medical records request. She said on 8/02/2024 she went to the facility and picked up the medical records request. She said she called an Attorney Friend of hers who then reached out to the law firm that was requesting the records and let them know the request had been received. She said she had not contracted the services of the Attorney Friend, but the Attorney Friend was trying to help her and advised her not to send any records to the law firm. She said the Attorney Friend advised her to notify her insurance company and to let them handle the situation. She said she was advised from the insurance company to just wait and see what happens due to the statute of limitations would run out on 11/30/2024. She said she had not sent any of the requested records to the law firm as of 9/18/2024. She said she could send the requested medical records by the end of the day on 9/18/2024 if the law firm still needed them. She said she had never been sued before and was not sure how to handle the situation but said the facility did the right thing by reaching out to her for the medical records. She said she did not contact the law firm to advise them that she was the previous owner and that she had the requested medical records. Record review of an Record Requests policy, undated, revealed: Residents or their authorized legal representatives have the right to access and obtain copies of their records. * Upon the request and two working days' advance notice to the community, the resident or their authorized legal representative per state requirements has the right to purchase photocopies of the records or any portions therein. The community requires a written request for copies as a cost per state copy fees may apply. 1. The community will notify the company medical records oversight designee, the Administrator and DON of the request, to review the legal right to access and approval prior to the release of any clinical records. 6. If the request is accepted and is for a copy of records, a bill for copying services may be sent. The records will then be provided to the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who need respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences, for 3 of 11 residents (Residents #1, Resident #2, and Resident #3) reviewed for respiratory care. The facility failed to ensure Residents #1, #2 and #3's oxygen tubing and humidifier bottle was changed and dated as ordered. These failures could place residents at risk for upper respiratory infections and worsening of their physical condition. The findings included: Resident #1's cannula tubing was not changed as ordered, the concentrator water bottle was dated 06/09/2024 and was empty. Resident #2's cannula tubing was not changed as ordered, the concentrator water bottle was dated 06/19/2024. Resident #3's canula tubing was not changed as ordered, the concentrator water bottle was dated 06/20/2024. Record review of Resident #1's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses to include, pneumonitis due to inhalation of food and vomit, sepsis, unspecified organism, respiratory failure unspecified, unspecified, whether with hypoxia or hypercapnia, morbid (severe) obesity due to excess calories, hypertensive heart disease with heart failure, anxiety disorder due to known physiological condition and generalized anxiety disorder. Review of Resident #1's most recent MDS, dated [DATE], indicated she had a BIMS (Brief Interview for Mental Status) score of 15. Record review of Resident #1's comprehensive care plan, revision date of 4/01/2024, revealed the resident required oxygen therapy related to ineffective gas exchange. Record review of Resident #1's physician orders for June 2024 revealed the following: - Change and date oxygen tubing/humidifier bottle every week on Sunday, with order date 9/10/23 and no end date. - O2 (oxygen) at 2 to 4 liters per minute via nasal cannula continuous, every shift, with order date 1/29/24 and no end date. Record review of Resident #2's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses to include heart failure, unspecified, schizoaffective disorder, unspecified, other recurrent depressive disorders, other specified anxiety disorders, insomnia, unspecified sarcopenia and obstructive sleep apnea, adult. Review of Resident #2's most recent MDS, dated [DATE], indicated she had a BIMS (Brief Interview for Mental Status) score of 15. Record review of Resident #2's comprehensive care plan, revision date 4/11/2024 revealed the resident required oxygen therapy related to ineffective gas exchange. Record review of Resident #2's physician orders for June 2024 revealed the following: - Change and date oxygen tubing/humidifier bottle every week on Sunday, with order date 9/10/23 and no end date. - O2 (oxygen) at 2 to 4 liters per minute via nasal cannula continuous, every shift, with order date 1/29/24 and no end date. Record review of Resident #3's face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure, unspecified whether with hypoxia or hypercapnia, chronic obstructive pulmonary disease, unspecified, type 2 diabetes, mellitus with other specified complication, morbid (sever) obesity due to excess calories hypertensive heart disease with heart failure and depression, unspecified. Review of Resident #3's most recent MDS, dated [DATE], indicated he was not able to complete the BIMS (Brief Interview for Mental Status) interview. Record review of Resident #3's comprehensive care plan, revision date 7/01/2024 revealed the resident required oxygen therapy related to sleep apnea and COPD. Record review of Resident #3's physician orders for June 2024 revealed the following: - Clean oxygen concentrator filter weekly, ever Sunday, with order date 6/02/2024 and no end date. - O2 (oxygen) at 2 to 4 liters per minute via nasal cannula continuous, every shift, with order date 5/30/24 and no end date. During observation and interview on 6/26/24 at 11:32 p.m., Resident #1 was lying in bed on her back, talking to a visitor. Resident #1's oxygen concentrator was on, the nasal cannula was in her nostrils. The cannula tubing and the humidifier bottle was dated 6/9/2024. The humidifier was noted to be empty, she said the bottle had been empty for several days. During observation and interview on 6/26/24 at 12:15 p.m., Resident #2 was in bed, on her personal phone. The oxygen concentrator was on and the cannula was in her nostrils. She said her tubing had not been changed in 3 weeks, the tubing and the humidifier bottle was dated 6/19/24. She said she told the Social Worker and a nurse about her cannula tubing not being changed but nothing had been done. She said she could not remember the nurse's name. During observation and interview on 6/26/24 at 12:54 p.m., Resident #3 was in his room, sitting in his wheelchair, viewing his cell phone. He said he was treated good. Resident #3's concentrator was not operating, and the cannula tubing was not in his nostrils. He said he had no idea when the cannula tubing was last changed. The cannula tubing and humidifier bottle was dated 6/20/24. During interview with RN A on 6/26/24 at 1:55 p.m., she said no, the cannula tubing had not been changed out for the resident #3. She said the cannula tubing should have been changed every Sunday night, but they don't have the supplies. She said, if the cannula tubing is not changed on Sunday night, she'll change it while doing rounds on Monday, but she could not change them because there were no supplies. She said the tubing and the humidifier bottle came as one piece and would be changed at the same time. During interview with LVN B on 6/26/24 at 2:17 p.m., she said the cannula tubing should be change every Sunday. She said a night nurse on the 6:00 p.m. - 6:00 a.m. shift should change the cannula tubing and the humidifier bottle. She said it did not get done because there were no supplies. She said the medical records person used to order supplies, but she was not sure who order supplies now. During interview with RN C, on 6/26/24 at 2:25 p.m., she said the cannula tubing and the humidifier bottle is supposed to be change once per week, usually Sunday night. She said the cannula and the humidifier was usually changed by the RN on Sunday and they should have been dated when changed. She said she was not sure who orders supplies. She said if the cannula tubing is not changed and no water is in the humidifier, a resident could experience drying in the nostrils, bleeding in the nose and respiratory infection. During interview with the DON, on 06/26/24 at 2:39 p.m., she said the cannula tubing and humidifier bottle should be changed on Sunday night, by the nurses. She said they did not have the supplies, they were ordered, and she thought the supplies would have come in. She said the cannula tubing and humidifier bottles, came as one piece, therefore the staff could not change them out separately. She said the person who ordered supplies was new to the role and that may have contributed to the supply shortage. During interview with the ADM, on 6/26/24 at 2:52 p.m., he said the person who does medical records has now taken on the role of ordering supplies and is relatively new to the role. He said she was out for a few days, and he was trying to get supplies ordered. He said he ordered supplies on 6/20/24 but the order was not filled. He said he placed a second order for cannula tubing and water bottles and that order should be in on 6/27/24. The ADM provided an order slip placed to a medical supplier, which confirmed an order was placed on 06/25/2024, for cannula tubing and prefill water humidifier bottles. During interview with the Social Worker on 6/27/24 at 2:52 p.m., she said Resident #2 talked to her all the time and they had recently talked but Resident #2 had never mentioned anything about her oxygen concentrator. She said Resident #2 usually talked about other things, her brother, or her wife, but never said anything about her oxygen concentrator. Review of a facility policy titled: Oxygen Concentrator & Other Respiratory Equipment, with a revised date of February 2024, revealed: Steps in the Procedure .8. Check water level of any pre-filled bottle and replace when empty or at 7 day schedule/shift. Change oxygen cannula and tubing every seven (7) days or as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for 1 of 3 residents (Resident # 58) reviewed for dignity. The facility failed to ensure Resident # 58's urinary drainage bag had a dignity/privacy cover. This failure could place residents in the facility at risk for a diminished quality of life, loss of dignity and self-worth. Findings: Record review of an admission Record dated 1/30/2024 for Resident #58 indicated she admitted to the facility on 3/17.2022 and was [AGE] years old with diagnoses of Chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body), Asthma (narrow airways that make it difficult to breathe), type 2 diabetes, COPD (group of lung diseases that make it difficult to breathe) and neuromuscular dysfunction of bladder (loss of control over the bladder). Record review of a Quarterly/Medicare 5 Day MDS assessment dated [DATE] for Resident #58 indicated she did not have any iimpairments in thinking with a BIMS score of 14. The MDS reflected she had an indwelling catheter. Record review of a care plan for Resident #58 dated 12/14/2023 with a revision on 1/25/2024 indicated she had an indwelling catheter related to urine retention. Record review of an active physician order summary report dated 1/29/2024 indicated foley catheter care every shift and as needed with an order date of 12/14/2023. During an observation and interview on 1/30/2024 at 9:51 AM, revealed Resident #58 was up in a power chair in the hallway, fFoley catheter was present and hanging on the side of the chair without a privacy bag. Resident #58 said she was going to therapy. Other residents and staff were observed in the hallway. During an interview on 1/30/2024 at 4:10 PM, LVN F said the nurses were responsible for placing privacy bags on the drainage bag for foley catheters. She said she saw Resident #58 going up the hallway without a cover on her drainage bag earlier. She said the resident should have had a privacy cover over the bag before leaving the room. She said it could be an invasion of a resident's privacy if they did not have a cover on it. During an interview on 1/31/2024 at 11:09 AM, the DON and Administrator said nursing staff were responsible for making sure the foley catheter bags were covered at all times. She said she was made aware of Resident #58 being out of her room without a privacy cover over her foley drainage bag. She said Resident #58 was able to transfer herself and would take the privacy cover off at times. She said if she had a foley catheter she would not want anyone to see the drainage bag being uncovered with urine in it. She said going forward, the residents would be educated along with staff to ensure catheter bags would have privacy covers. The Administrator said when residents were out of their rooms and had a foley catheter, they should have a privacy bag. Record review of a facility policy-undated titled Urinary Catheter Policy indicated, .The purpose of this policy is to prevent catheter-associated urinary tract infections. Nursing is to ensure; privacy bag shall always be in place unless care is being provided. Nursing staff shall remind/educate residents who are able to provide self-care that privacy bag should be in place. Nursing staff shall assist with the task as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents had the right to a safe, clean, comfortable and homelike environment for 2 of 17 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) reviewed for homelike environment. The facility failed to ensure the walls in rooms [ROOM NUMBERS] were free from holes. The facility failed to ensure the walls in room [ROOM NUMBER] were kept clean. These failures could place residents at risk for diminished quality of life due to the lack of a well- kept and clean environment. Findings: During initial rounds and observations on 01/29/24 at 9:40 am revealed room [ROOM NUMBER] had a hole in the sheet rock measuring approximately one foot by one foot on the wall next Resident #3's bed and had splatters of a thick brown and tan substance on the same wall. Resident #3 did not have anything to say about the wall. During initial rounds and observations on 01/29/24 at 10:52 am revealed room [ROOM NUMBER] had a hole in the sheetrock behind the head of Resident #24's bed near the floor measuring approximately two feet by one foot . Resident #24 did not have anything to say about the hole in the wall. During an interview on 1/29/2024 at 11:02 am LVN D stated that if there was an issue with something being broken or holes in the wall it should be reported to maintenance or put in the maintenance logbook. She stated she worked as an agency nurse and was not aware of the issues in rooms [ROOM NUMBERS]. She stated that if rooms were not cleaned it could cause infections and holes could be a danger to residents. During an interview on 1/30/2024 at 8:11 am the Maintenance Director stated anytime there was a hole in the wall the staff would either tell him directly or place in the maintenance logbook . He stated he was not aware of the holes in the sheetrock in rooms [ROOM NUMBERS] but he would address the issue and begin the repair. He stated he did not see a risk to the residents for the damaged walls, but it was not pretty to have holes in the walls. During an interview on 1/30/2024 at 8:28 am HSK H stated she had been in housekeeping for 6 months. She stated that every room should be deep cleaned at least two times a week and that included cleaning the walls in the room. She stated she cleaned the rooms on the 100 hall and had not noticed room [ROOM NUMBER]'s wall being that dirty. She stated she had not cleaned the walls in room [ROOM NUMBER] in many weeks. She stated if walls were left dirty it could cause the resident to get sick or be embarrassed that they were dirty. During an interview on 1/30/2024 at 8:35 am the Housekeeping Supervisor stated he had been the supervisor for 7 years. He stated he expected the housekeepers to clean the entire room including the walls at least weekly and more often if needed when soiled or dirty. He stated if rooms were not kept clean it could cause infections. During an interview on 01/31/24 at 1:41 pm the Administrator stated that the maintenance and housekeeping supervisors were responsible for the physical environment of the facility, but it was all staffs responsibility to report issues when they were found. She stated she expected the facility process to be followed for keeping the building in good repair and clean. Record review of an undated facility guideline titled Physical Environment indicated, .ensure the community environment is safe, functional, sanitary, and comfortable for residents . Record review of an undated facility document titled Notification of Maintenance regarding new issues or concerns indicated, .as part of the ongoing preventative maintenance program this facility shall keep a log/book with any equipment or room concerns regarding repairs. Any issues are followed up by the maintenance or designee and documented . Record review of a facility policy titled Cleaning and Disinfecting Resident's Rooms dated 1/2024 indicated, .walls, blinds, and window curtains in resident areas will be cleaned when surfaces are visibly contaminated or soiled. Example: deep cleaning every 2 weeks .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 6 residents (Resident #62) reviewed for MDS assessment accuracy. The facility did not accurately document Resident #62's oxygen therapy on the quarterly MDS dated [DATE]. This failure could place residents at risk of not receiving care and services to meet their needs. Findings: Record review of a facility face sheet indicated Resident #62 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of mild cognitive impairment. During an observation and interview on 1/29/24 at 9:55 am Resident #62 had an oxygen concentrator next to her bed. She stated she used the oxygen every night when she was sleeping. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #62 had a BIMS of 09 indicating moderate cognitive impairment. MDS assessment did no capture oxygen therapy. Record review of comprehensive care plan dated of 11/10/2023 did not indicate Resident #62 required oxygen therapy. Record review of a consolidated physician's order list indicated no orders for oxygen therapy or changing and cleaning respiratory equipment and supplies. During an interview on 1/29/24 at 3:45 pm the MDS coordinator stated she had been completing MDS assessments and care plans for 22 years. She stated she was responsible for completing comprehensive assessments through the MDS assessment and care plans. She stated if a resident was receiving oxygen therapy there should have been an order, the use would have been captured on the MDS and the care plan would reflect need for oxygen with interventions and goals. She stated if the resident's orders were not accurate, she would not have known to mark oxygen use on the MDS and updated the care plan. Stated when she visits with the resident, she picked up in resident care needs like oxygen use. She stated she was not aware Resident #62 used oxygen at night. She stated if the MDS assessment and care plan was not accurate the resident needs would not be reflected, and delay of care could occur. During an interview on 1/29/24 at 3:48 pm the DON stated the MDS nurse was responsible completing an accurate comprehensive assessment on each resident. She stated if the orders were not accurate the MDS assessment and care plan would not be accurate and could affect resident care. The DON stated there was no policy for MDS accuracy and they followed the RAI manual. She stated she expected all residents care needs were accurately reported in the MDS assessment and the care plan to reflect resident care needs. During an interview on 01/31/24 at 1:41 pm the Administrator stated the MDS coordinator was responsible for the accuracy of the comprehensive assessment of each resident and the IDT was responsible for reviewing the assessment before transmission. She stated she expected assessment data to be accurate and reflect all care needs of the resident to prevent resident care issues. The Administrator stated there was not a policy for MDS accuracy and the facility followed the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 10 residents (Resident #8, Resident #16) reviewed for ADL's. The facility failed to ensure Resident #8's and Resident #16's nails were kept clean. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings: 1. Record review of a facility face sheet indicated Resident #8 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #8 had a BIMS of 00 indicating severe cognitive impairment and was dependent on staff for all ADL care. Record review of a comprehensive care plan dated 2/23/2023 indicated Resident #8 had a self-care ADL deficit and was totally dependent on staff for personal hygiene. During an observation on 01/29/24 at 9:39 AM revealed Resident # 8's fingernails had a black substance under them. During an observation on 1/30/2024 at 7:58 am revealed Resident # 8's fingernails had a black substance under them. She was unable to verbalize who or when they were last cleaned. During an interview on 01/30/24 at 12:03 PM CNA K stated she worked at the facility through an agency staffing company but had been a CNA for 29 years. She stated the CNAs were responsible for checking and cleaning residents' nails and care should be performed daily. She stated she gave Resident #8 a bed bath earlier that day and should have cleaned her nails. She stated if nails were left unclean it could lead to infections. 2. Record review of a facility face sheet indicated Resident #16 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #8 had a BIMS of 06 indicating severe cognitive impairment and was dependent on staff for personal hygiene. Record review of a comprehensive care plan dated 2/15/2023 indicated Resident #8 had a self-care ADL deficit and was dependent on staff for personal hygiene. During an observation and interview on 01/29/24 at 9:40 am revealed Resident # 16's fingernails on both hands had a thick black substance under them. Resident #16 stated the staff were cleaning her fingernails but stopped. During an observation on 01/29/24 at 4:32 PM revealed Resident #16 was sitting up in bed eating a cracker and the black substance remained under her fingernails. During an observation and interview on 1/30/2024 at 7:55 am revealed Resident #16 was in the bed eating breakfast. Her fingernails on both hands continued to have a dark thick black substance under them. She stated she did not remember the last time they were cleaned or when her shower/bath days were. She stated her nails were nasty and she wanted them cleaned. During an interview 01/30/24 at 11:43 am CNA G stated she had been a CNA at the facility for 11 years. She stated she had provided care to Resident #16 on 1/29/2024 and 1/30/2024 and had given Resident #16 a bath this morning, 1/30/2024. She stated the CNAs were responsible for nail care and nails should be cleaned when the resident received a bath. She stated if a resident's nails were left uncleaned it could cause infections. During an interview on 01/31/24 at 1:39 pm the DON stated the CNAs were responsible for providing personal hygiene and care, but all staff were responsible for recognizing a care need and ensuring resident care was performed. She stated if dependent residents did not receive ADL care it could affect them negatively and she expected all residents to receive all care needed daily. During an interview on 01/31/24 at 1:41 pm the Administrator stated that the nursing staff were responsible for resident personal care and hygiene, but the DON was overall responsible for oversight of the nursing department. She stated if resident personal care was not completed it could affect resident condition and expected all dependent residents to receive all ADL care they needed daily. Record review of an undated facility policy titled Routine Resident Care indicated, .Residents should receive necessary assistance to maintain good grooming and personal hygiene. 3. Nail care should be encouraged as needed and as allowed by the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure and 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 for 1 of 6 ( Resident #70) residents reviewed for pharmaceutical services, in that: Resident #70's medications (Systane ultra pf lubricant eye drops, Pataday once daily relief eye allergy solution, and Systane lubricant eye drops and a bottle of ninety soft gel capsules of PreserVision eye supplements) were found on the bedside table with no attached labels for use. These deficient practices could place residents at risk of not receiving the intended therapeutic effect of the medications resulting in exacerbation of the resident's condition and disease process. Findings included: During a record review physician order summary dated January 2024 for Resident #70 indicated she was [AGE] years old with diagnosis of colostomy and muscle weakness with an admission date of 08/01/13. Resident #70 Physician orders indicated no current orders for preservision eye vitamins, Systane ultra pf lubricant eye drops, Pataday once daily relief eye allergy solution, and Sysytane lubricant eye drops. During a record review of Resident #70's MDS dated [DATE] indicated she was cognitively intact with a BIMS score of 15. During an interview and observation on 01/29/24 at 11:00 AM Resident #70 said she had recently gone to the eye doctor and was given medications for her eyes. Resident #70 said the nurses put her eye drops in, but she keeps them at her bedside. Resident #70 showed this surveyor three vials of unlabeled eye drops, including Systane ultra pf lubricant eye drops, Pataday once daily relief eye allergy solution, and Systane lubricant eye drops and an unlabeled bottle of ninety soft gel capsules of PreserVision eye supplements. During an interview on 01/29/24 at 11:45 AM the DON said that resident #70 could not keep her drops at bedside without an MD order and an assessment for safe medication administration. She said she would remove the eye drops and the interdisciplinary would have to decide if it was appropriate for her to have medications in her room. She said if the resident was unable to safely administer her eye drops it could cause an eye infection or under dosing and overdosing of the vitamins at bedside. Interview with on 01/30/24 RN B she said she removed the medication when the DON made her aware the resident could not have these items at bedside and notified resident #70's daughter that she could not have medications at bedside. RN B said the risk to the resident was inappropriate medication administration due to no labels on the drops and infection due to contamination of the eye drops if they were allowed to stay in the resident's room. During an interview on 1/31/24 at 11:00 AM, CNA A said they she has worked at the facility 24 years and was aware that resident #70 had eye drops and vitamins at bedside, she said resident #70 should not have any medications at bedside and going forward she would tell the nurse or DON if she found medications at bedside. She said the residents might take too many pills or not use the medications correctly. During an interview on 1/31/23 at 2:00 PM the Administrator said that resident #70 could not self-medicate without an assessment and an order from his medical doctor. The administrator said the medication had been removed. She said that the DON and ADON were responsible for ensuring medications were administered according to regulation. The administrator said there was a risk to the resident for infection or incorrect dosages. The administrator said that the staff would be Inserviced for safe administration of medication to ensure this problem is corrected. Review of a Nursing Services policy and procedure for long term care 2001 Med pass Revised April 2019 Administering Medications, policy statement: Medications are administered in a safe and timely manner, and as prescribed .28. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary team, has determined that they have the decision-making capacity to do so safely.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective training program for 1 of 15 employees (CNA O) new and existing staff reviewed for training. The facility failed to ensure CNA O was trained on fall prevention on hire. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings include: Record review of CNA O's personnel file indicated she was hired at the facility on 9/6/2023 and there was no documented evidence the aide completed training on fall prevention on hire. During an interview on 1/31/2024 at 8:47 AM, HR said she had been employed at the facility for 2 years and was responsible for payroll, orientation of new employees and on boarding of new hires along with ensuring they had the required trainings. She said she ensured the trainings were completed and corporate sets up the curriculum with online training. She said all staff should be getting trainings annually and on hire and was not aware that CNA O did not receive training on falls on hire. She said corporate added fall prevention training to the online training program yesterday, 1/30/2024. She said the last time staff at the facilty received training on fall prevention was on 8/4/2023. She said December 2022 the facility had a change in ownership, and they were completing their trainings on paper but have since transitioned to online training. She said if not trained on falls, there could be an increase in falls with the residents. She said going forward, she would ensure the staff received the required trainings and would conduct an audit monthly. During an interview on 1/31/2024 at 11:09 AM, the Administrator said the facility utilized an online training program and staff received the required trainings on hire during orientation, monthly and as needed when things came up. She said corporate assigned the trainings and she would ensure staff received trainings. Record review of an In-Service Training Program dated April 2019 indicated, .The Director of Human Resources and the Director of Clinical Services are responsible for developing the company's in-service training plan for each year and for assigning all mandatory annual in-service training to associates provided via the Company's computer based in-servicing program .

Based on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 1 of 15 employees (LVN N) reviewed for training, in that: The facility failed to ensure required education was provided on the rights of the resident and responsibilities of a facility to properly care for its residents was conducted by LVN N annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of LVN N's personnel file revealed he was hired on 6/17/2020 and had not completed annual training on rights of the resident and responsibilities of a facility to properly care for its residents. The last time he received training on resident rights was on 7/2/2022. During an interview on 1/31/2024 at 8:47 AM, HR said she had been employed at the facility for 2 years and was responsible for payroll, orientation of new employees and on boarding of new hires along with ensuring they had the required trainings. She said she ensured the trainings were completed and corporate sets up the curriculum with online training. She said all staff should be getting trainings annually and on hire and was not aware that LVN N did not receive the annual resident rights training. She said corporate added the resident rights trainings to the online training program on yesterday 1/30/2024. She said December 2022 the facility had a change in ownership, and they were completing their trainings on paper but have since transitioned to online training. She said if not trained on resident rights, staff would not know what was included in resident rights and residents could be at risk for a lot of things to happen. She said going forward she would ensure the staff received the required trainings and would conduct an audit monthly. During an interview on 1/31/2024 at 11:09 AM, the Administrator said the facility utilized an online training program and staff received the required trainings on hire during orientation, monthly and as needed when things came up. She said corporate assigned the trainings and she would ensure staff received trainings. Record review of an In-Service Training Program dated April 2019 indicated, .The Director of Human Resources and the Director of Clinical Services are responsible for developing the company's in-service training plan for each year and for assigning all mandatory annual in-service training to associates provided via the Company's computer based in-servicing program .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 4 of 18 residents (Residents #3, #7, #58 and #65) reviewed for care plans. The facility failed to care plan the use of oxygen therapy for Resident #3. The facility failed care plan the use of oxygen therapy for Resident #7. The facility failed to care plan the use of oxygen therapy for Resident #58. The facility failed to care plan the use of oxygen therapy for Resident #65. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: 1. Record review of a facility face sheet indicated Resident #3 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #3 had a BIMS of 05 indicating severe cognitive impairment and required oxygen therapy. Record review of comprehensive care plan with revision date of 8/29/2023 indicated Resident #3 had COPD (chronic obstructive pulmonary disease that affects breathing) but no intervention for oxygen therapy. Record review of a consolidated physician's order list for Resident #3 indicated an order on 09/06/2023 to change/date oxygen tubing and humidifier bottle, clean filter and outside of concentrator weekly on Sunday. There was no order for oxygen therapy. During an observation and interview on 01/29/24 at 10:12 am revealed Resident # 3 had oxygen on at t 2 liters via nasal cannula. Resident #3 stated she wore her oxygen all the time and had for a long time. During an observation on 1/30/2024 at 8:06 am revealed Resident # 3 had oxygen on in place [NAME] nasal cannula. 2. Record review of an admission Record for Resident #7 dated 1/30/2024 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Iron deficiency anemia (body does not produce enough iron to produce oxygen in the blood), chronic ischemic heart disease (heart weakening caused by reduced blood flow to the heart), hypertensive heart disease with heart failure (high blood pressure in the heart) and age related osteoporosis (brittle, bone disease). Record review of a Modification of admission MDS dated [DATE] for Resident #7 indicated she had a BIMS score of 6. She had special treatments, procedures and programs that included oxygen therapy while a resident. Record review of a physician order summary report dated 1/30/2024 for Resident #7 indicated she had an order for oxygen on 2 Liters per nasal cannula continuous with a start date of 11/17/2023. Record review of a care plan dated 1/30/2024 for Resident #7 indicated she had oxygen therapy related to ineffective gas exchange with interventions of oxygen setting O2 via nasal cannula that was added on 1/30/2024. During an observation and interview on 1/29/2024 at 9:45 AM, revealed Resident #7 was up in a wheelchair and said she was going to therapy. She had on portable oxygen that was at the back of her wheelchair. During an observation and interview on 1/30/2024 at 9:10 AM, revealed Resident #7 was sitting up in a wheelchair in her room and using portable oxygen. She said when she was in the room, in bed, she used the concentrator and was on oxygen all the time. 3. Record review of an admission Record dated 1/30/2024 for Resident #58 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Chronic respiratory failure (not enough oxygen or too much carbon dioxide in the body), Asthma (narrowed airways that make it difficult to breathe), type 2 diabetes, and COPD (a group of lung diseases that make it difficult to breathe). Record review of a Quarterly/Medicare 5 Day MDS assessment dated [DATE] for Resident #58 indicated she had a BIMS score of 14. The MDS reflected for Special treatments, procedures and programs indicated on admission and while a resident she received oxygen therapy. Record review of a care plan dated 1/30/2024 for Resident #58 indicated she had oxygen therapy related to ineffective gas exchange with diagnoses of COPD with interventions for oxygen settings O2 via nasal cannula that was added on 1/30/2024. Record review of active physician's orders for Resident #58 dated 1/29/2024 indicated an order to change and date oxygen tubing/humidifier bottle and clean concentrator filter. Clean outside of concentrator weekly and prn with disinfectant every night shift Sunday with a start date of 9/10/2023. During an observation and interview on 1/29/2024 at 10:17 am, revealed in the room of Resident #58 who was in bed and awake was on oxygen at 2.5 Liters/min. She said used oxygen all the time. 4. Record review of the facility face sheet indicated Resident #65 admitted [DATE], was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (the lungs inability to exchange oxygen and carbon dioxide in the blood), morbid obesity and muscle weakness. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #65 was cognitively intact with a BIMS of 14. The assessment, section O indicated the resident received oxygen. Record review of a care plan updated 2/11/23 through current date indicated Resident #65 had no interventions for oxygen therapy. Record review of active physician orders for Resident #65 did not indicate an order for administration of oxygen During an observation on 01/29/24 at 10:45 a.m., revealed Resident #38 was lying in bed watching television. Oxygen via nasal cannula at 2.5 L/min portable concentrator was in use. During an interview on 01/29/24 3:27 PM LVN D stated she worked at the facility as needed through an agency staffing company. She stated the care plan was updated by the MDS nurse and oxygen should be on the care plan. She stated if care plans were not accurate it could affect resident care and coordination of services. During an interview on 1/29/24 at 3:34 pm LVN F stated she had been an LVN for 24 years. She stated the care plan was entered and updated by the MDS nurse. She stated if the care plan was not accurate it could cause care delivery issues. During an interview on 1/29/24 at 3:45 pm the MDS coordinator stated she had been completing MDS' and care plans for 22 years. She stated she was responsible for completing and revising the residents' care plans. She stated if a resident was receiving oxygen therapy the care plan should reflect the need for oxygen with interventions and goals. She stated if care plans were not accurate the resident needs would not be reflected, and delay of care could occur. During an interview on 1/29/24 at 3:48 pm the DON stated the MDS nurse was responsible for care plan completion and revision. DON stated there was no policy for care plans and they followed the RAI manual for care plan completion. She stated she expected all resident care plan were accurate to reflect resident care needs. During an interview on 1/31/2024 at 11:09 AM, the Administrator said the MDS coordinator was responsible for revising care plans along with the IDT members who had access to the care plans also. She said residents could be at risk of no continuum of care and everyone not being on the same page. Record review of an undated facility policy titled Care Plan Process indicated, .the facility IDT team utilizes the CMS requirements of RAI as policy for reviewing and revising care plans. Residents preferences and goals may change throughout their stay and changes should be reflected in the comprehensive care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 10 of 13 residents reviewed for respiratory care (Residents #3, #50, #62, #65, #43, #7, #25, #58, #66 and #21). 1.The facility failed to ensure Resident #3's had an order for oxygen, the humidifier and tubing for the oxygen concentrator were dated and the filter was clean and free of dust buildup. 2.The facility failed to ensure Resident #50's oxygen concentrator had an external filter and was free of dust buildup. 3.The facility failed to ensure Resident #62's had an order for oxygen, the oxygen tubing was changed per the facility's policy and the concentrator filter was free of dust buildup. 4.The facility did not obtain orders for Resident #65's oxygen. 5.The facility did not clean the oxygen concentrator filter as ordered for Resident #43. 6. The facility failed to ensure the internal filter of Resident #7's oxygen concentrator was free of dust buildup. 7. The facility failed to ensure Resident #25 had an order for oxygen and the external filter was free of dust buildup. 8. The facility did not obtain an order for Resident #58's oxygen administration and did not ensure the oxygen concentrator was free of dust buildup. 9. The facility did not obtain an order for Resident #66's oxygen administration. 10. The facility did not obtain an order for Resident #21's oxygen administration. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators and exacerbation of respiratory distress. Findings included: 1. Record review of a facility face sheet indicated Resident #3 was a [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #3 had a BIMS of 05 indicating severe cognitive impairment and required oxygen therapy. Record review of comprehensive care plan with revision date of 8/29/2023 indicated Resident #3 had COPD (chronic obstructive pulmonary disease that affects breathing) but no intervention for oxygen therapy. Record review of a consolidated physician's order list for Resident #3 indicated an order on 09/06/2023 to change/date oxygen tubing and humidifier bottle, clean filter and outside of concentrator weekly on Sunday. There was no order for oxygen therapy. During an observation and interview on 01/29/24 at 10:12 am revealed Resident # 3 had oxygen on at 2 liters via nasal cannula. The oxygen concentrator filter had thick buildup of dust. The oxygen tubing and humidified water bottle were not dated. Resident #3 stated she wore her oxygen all the time and had for a long time. She was not sure on who or when her oxygen supplies were changed or when the concentrator was cleaned. During an observation on 1/30/2024 at 8:06 am Resident # 3's oxygen concentrator filter continued to have thick dust buildup and resident had oxygen in place via nasal cannula. 2. Record review of a facility face sheet indicated Resident #50 was a [AGE] year-old male and admitted to the facility on [DATE] with diagnosis of hemiplegia (paralysis to one side). Record review of a quarterly MDS assessment dated [DATE] indicted Resident #50 had a BIMS of 12 indicating moderate cognitive impairment and required oxygen therapy. Record review of comprehensive care plan with revision date of 9/15/2023 indicated Resident #50 required oxygen therapy. Record review of a consolidated physician's order list I for Resident #50 indicated an order on 09/06/2023 to change/date oxygen tubing and humidifier bottle, clean filter and outside of concentrator weekly on Sunday. During an observation and interview on 01/29/24 at 10:41 am revealed Resident #50 had an oxygen concentrator with no external filter. The internal filter had thick layers of dust buildup. Resident #50 stated no one cleaned the oxygen filters and the concentrator had not had an outside filter in some time. He stated he had different concentrators but had the current oxygen concentrator since October 2023. 3. Record review of a facility face sheet indicated Resident #62 was an [AGE] year-old female and admitted to the facility on [DATE] with diagnosis of mild cognitive impairment. During an observation and interview on 1/29/24 at 9:55 am revealed Resident # 62 had an oxygen concentrator next to her bed. She stated she used the oxygen every night when she was sleeping. The oxygen tubing was not dated, and she stated she tended to her oxygen and changed the tubing when needed. The internal filter was observed with buildup of a black residue on filter and the resident stated no one had changed or cleaned the filter since her admission in November 2023. Record review of a quarterly MDS assessment dated [DATE] indicted Resident #62 had a BIMS of 09 indicating moderate cognitive impairment. The MDS assessment did not reflect oxygen therapy use. Record review of comprehensive care plan dated of 11/10/2023 did not indicate Resident #62 required oxygen therapy. Record review of a consolidated physician's order list indicated no orders for oxygen therapy or changing and cleaning respiratory equipment and supplies. 4. Record review of the physician orders dated January 2024 indicated Resident #65, admitted [DATE], was [AGE] years old with diagnoses of chronic obstructive pulmonary disease (the lungs inability to exchange oxygen and carbon dioxide in the blood), morbid obesity and muscle weakness. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #65 was cognitively intact with a BIMS of 14. The assessment, section O indicated the resident received oxygen. Record review of a care plan updated 2/11/23 through current date indicated Resident #65 had no interventions for oxygen therapy. Record review of active physician orders for Resident #65 indicated there was no documentation on the physician orders for administration of oxygen. During observation and interviews on 01/29/23 at 10:45 a.m., revealed Resident #38 was lying in bed watching television. Oxygen via nasal cannula at 2.5 L/min portable concentrator was in use, and the nasal cannula was dated 12/04/23 Resident #38 said she did not know when her tubing was last changed, and she was unable to see the concentrator beside her bed. 5. Record review of the physician orders dated January 2024 indicated Resident #43, admitted [DATE], was [AGE] years old with diagnoses of acute respiratory failure, with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions). Orders included oxygen at 2 L/min per nasal cannula, an order dated 9/10/23 to change the filter and clean, change and date oxygen tubing/humidifier bottle, clean the concentrator filter and clean the outside of concentrator weekly and PRN with disinfectant, night shift every Sunday. Record review of the most recent quarterly MDS dated [DATE] indicated Resident #43 had a BIMs of 7 out of a total score of 15 indicating the resident had severe cognitive impairment. Record review of care plans for Resident #43 indicated oxygen therapy with interventions. During observation on 01/29/24 at 10:00 a.m., revealed Resident #43 was sleeping in a reclining chair with oxygen infusing at 2 L/min via nasal cannula via a concentrator at bedside. The concentrator filter was built up with a thick grey dust underneath it was black foam. The oxygen tubing and humidifier was dated 1/28/24. 6. Record review of an admission Record for Resident #7 dated 1/30/2024 indicated she was [AGE] years old with diagnosis of Iron deficiency anemia (decreased iron in the blood that carries oxygen), chronic ischemic heart disease (heart weakening caused by reduced blood flow to your heart), hypertensive heart disease with heart failure (high blood pressure in the heart) and age-related osteoporosis (brittle, bone disease). Record review of a Modification of admission MDS dated [DATE] for Resident #7 indicated she had severe impairment in thinking with a BIMS score of 6. She had special treatments, procedures and programs that included oxygen therapy while a resident. Record review of a care plan dated 1/30/2024 for Resident #7 indicated she had oxygen therapy related to ineffective gas exchange with interventions of oxygen setting O2 via nasal cannula. Record review of a physician order summary report dated 1/30/2024 for Resident #7 indicated she had an order for O2 on 2L via nasal cannula continuous with a start date of 11/17/2023 During an observation and interview on 1/29/2024 at 9:45 AM revealed in the room of Resident #7, the resident was present sitting up in a wheelchair and said she was going to therapy. The oxygen concentrator had internal filters with about an inch of dust noted. During an observation and interview on 1/30/2024 at 9:10 AM revealed in the room of Resident #7, the oxygen concentrator still had a lot of dust inside on the filters. Resident #7 was sitting up in a wheelchair on portable oxygen and said when she was in the room in bed, she used the concentrator and was on oxygen all the time. She said she had never seen any staff clean the filters. 7. Record review of an admission Record dated 1/30/2024 for Resident #25 indicated she admitted to the facility on [DATE] and discharged on 1/23/2024 to the hospital and was [AGE] years old with diagnosis of encephalopathy (disease that affects the brain), type 2 diabetes, hypertensive heart disease with heart failure (high blood pressure in the heart), COPD (group of lung diseases that make it difficult to breathe) and GERD (acid reflux). Record review of a nurse progress noted dated 1/23/2024 by LVN P at 11:15 am for Resident #25 indicated, Resident returned from therapy sob noted. O2 sat at 81%. O2 increase to 3 L per nasal cannula. O2 sat up to 84%. Pulse running between 61 and 64. New order to transfer to ER for eval and treatment. Unable to reach granddaughter message left. EMs notified. Resident transferred to ER via stretcher. Personal belongings left in room. Record review of active physician orders for Resident #25 dated 1/30/2024 indicated she did not have an order for oxygen or as needed use. During an observation on 1/29/2024 at 9:30 AM, revealed Resident #25 still in the hospital and an oxygen concentrator was present with an external filter with a lot of dust buildup. 8. Record review of an admission Record dated 1/30/2024 for Resident #58 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of chronic respiratory failure (airways become narrow and damaged), Asthma (airways become inflamed, narrow and swell), type 2 diabetes, and COPD (group of lung disease that make it difficult to breathe). Record review of a Quarterly/Medicare 5 Day MDS assessment dated [DATE] for Resident #58 indicated she did not have any impairment in thinking with a BIMS score of 14. Special treatments, procedures and programs indicated on admission and while a resident she received oxygen therapy. Record review of active physician orders for Resident #58 dated 1/29/2024 indicated an order to change and date oxygen tubing/humidifier bottle and clean concentrator filter. Clean outside of concentrator weekly and prn with disinfectant every night shift Sunday with a start date of 9/10/2023. There was no order for oxygen administration. Record review of a care plan dated 1/30/2024 for Resident #58 indicated she had oxygen therapy related to ineffective gas exchange with diagnoses of COPD with interventions for oxygen settings O2 via nasal cannula. During an observation and interview on 1/29/2024 at 10:17 am, revealed in the room of Resident #58, the resident was in bed awake with oxygen on at 2.5 Liters/min. The filter was clean, but the concentrator was dirty with dust buildup. She said the tubing was changed last night and she used oxygen all the time. During an observation on 1/30/2024 at 9:32 AM, in the room of Resident #58 revealed the oxygen concentrator was still dirty with dust buildup. 9. Record review of an admission Record dated 1/30/2024 for Resident #66 indicated he admitted to the facility on [DATE] with diagnoses of unspecified fracture of left leg (broken leg), hypertensive heart disease with heart failure (high blood pressure in the heart), COPD (group of lung disease that make it difficult to breathe), and Type 2 diabetes. Record review of an admission MDS dated [DATE] indicated Resident #66 did not have an impairment in thinking with a BIMS score of 14 and had special treatments, procedures and programs that included oxygen therapy as a resident within the last 14 days. Record review of a care plan for Resident #66 dated 1/18/2024 indicated he had oxygen therapy related to ineffective gas exchange. Record review of active physician orders dated 1/19/2024 indicated Resident #66 did not have order for oxygen administration. During an observation and interview on 1/29/2024 at 9:55 AM revealed in the room of Resident #66, the resident was in bed on oxygen via nasal cannula at 3 L/min. The Resident said he had been at the facility for 2 weeks and was on oxygen all the time. 10. Record review of an admission Record dated 1/31/2024 for Resident #21 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of sarcopenia (loss of muscle tissue as part of the aging process), heart failure and obstructive sleep apnea. Record review of an MDS dated [DATE] for Resident #21 revealed the resident was coded as using oxygen. Record review of a care plan for Resident #21 dated 1/19/2024 indicated oxygen use. The Care Plan initiated on 9/5/2023 included oxygen use. Record review of doctors' orders dated 1/29/2024 indicatedthat Resident #21 did not have an order for oxygen. During an observation and interview on 1/29/2024 at 10:45 AM, revealed Resident #21 said she had been at the facility for 5 years. She said she needed a new oxygen concentrator. She stated that if I the settings on the concentrator were more than 2 liters it would beep She stated that they did not change oxygen tubing regularly because they ran out of tubing. She said she needed a new concentrator, but they did not have enough to replace hers. During an interview on 01/29/2024 at 10:46, LVN D stated she was an agency nurse and worked prn at the facility for 3 years. She stated oxygen tubing was changed by the nurse every Sunday. She stated the outside filter should be cleaned weekly but was unsure who checked and changed the internal filter. She stated if the filters were not kept clean it could lead to infections. During an interview on 01/29/2024 3:27 PM, LVN D stated she worked at the facility as needed through an agency staffing company. She stated that a resident that used oxygen should have an order for the oxygen to include the flow rate and frequency of use as well as an order to change tubing and clean filters. She stated if resident orders were not accurate it could affect resident care and coordination of services. During an interview on 1/29/2024 at 3:34 pm, LVN F stated she had been an LVN for 24 years. She stated the nurses were responsible for ensuring the orders were accurate and if a resident required oxygen there should be an order. She stated by not having an order it could affect resident care. She the night nurses were responsible for changing and cleaning the oxygen tubing and filters. She stated she was not aware there was an internal filter but felt that every filter should be checked, cleaned, and changed as needed to prevent infection or oxygen delivery issues. During an interview on 1/29/2024 at 3:42 pm, the DON stated the charge nurses were responsible for changing the oxygen tubing and cleaning the filters weekly. She stated she was not aware of who was to replace the internal filter or how often it should be replaced. She stated by not doing so could cause oxygen delivery issues or infections. She stated there was no policy or procedure for cleaning or replacing the internal filters. During an interview on 1/29/2024 at 3:48 pm, the DON stated the charge nurse was responsible for entering the orders, but she was responsible for checking orders periodically for accuracy. She stated if the orders were not accurate the MDS assessment and care plan would not be accurate and could affect resident care. During an interview on 1/30/2024 at 8:11 am the Maintenance Director stated he was not aware that the oxygen concentrators required the internal filter to be changed. He stated previously the oxygen company maintained the concentrators however in the last year the concentrators became the property of the facility, and he was now responsible for the maintenance and filter changes. He stated there was not a system in place previously but now he had started a log of each concentrator and would be replacing all the filters. During an interview on 1/31/2024 at 11:09 AM, the Administrator said nursing was responsible for cleaning the oxygen concentrators, changing the tubing and bottles every Sunday and as needed. She stated the DON was to oversee that the nursing staff were following the respiratory care policy and expected respiratory equipment to be cleaned and changed weekly. She stated she expected all resident orders to be accurate and reflect resident care needs to prevent adverse event from occurring. She said going forward she would do a follow up plan to ensure the tasks were done on Sundays. She said she would have the DON or designee do an audit to check that they were done. She said residents could be at risk for inadequate air flow if the concentrators were not cleaned and infections. Record review of a facility policy with a revised date of November 2022 titled Oxygen Concentrator and other Respiratory Equipment indicated, .distilled water used in respiratory treatment must be dated and initialed when opened and discarded after 24 hours, change the oxygen cannula and tubing every 7 days, wash filters for oxygen concentrators every 7 days . Record review of an undated facility policy titled Oxygen Administration indicated, a resident will receive oxygen therapy when ordered by a physician

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #38) and 2 of 6 staff (CNA E and CNA L) reviewed for infection control. CNA E failed to perform proper hand hygiene during meal service on 1/29/2024. CNA L failed to perform proper hand hygiene while providing incontinent care to Resident #38 on 01/30/2024. These failures could place residents at risk of exposure to communicable diseases and infections. Findings: 1. During an observation on 1/29/2024 between 12:33 pm and 12:43 pm revealed CNA E was passing the meal trays for the lunch meal. She was observed entering room [ROOM NUMBER] setting up the resident tray by opening containers and cutting up food, adjusting the resident in the bed and then returned to the hall. CNA E obtained another tray from the cart and entered room [ROOM NUMBER]. CNA E set up the tray by opening containers and cutting food, adjusted the resident by use of the bed remote then returned to the hall for another tray. CNA E obtained another tray from the cart and entered room [ROOM NUMBER]. She set up the tray by opening containers and cutting up food and then propped the resident with pillows. She exited room [ROOM NUMBER] and did not wash or sanitize her hands before, during, or after meal service and between resident care. During an interview on 1/29/24 at 12:44 pm, CNA E stated she had been a CNA for 2 years and had been trained on passing meal trays. She stated she should have performed hand hygiene between residents to prevent spread of infection. During an interview on 01/29/24 at 3:27 PM, LVN D stated that she was an agency nurse and had worked at the facility 3 years. She stated that in between resident care hand hygiene should always occur to prevent the spread of infection. During an interview on 1/29/24 at 3:42 pm the DON stated that all staff were responsible for hand hygiene and had been trained on when to perform hand hygiene. She stated if staff were not performing appropriate hand hygiene it could cause infections and expected all staff to properly clean their hands to protect the residents. 2. Record review of an admission Record dated 1/30/2024 for Resident #38 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of COPD (group of lung diseases that make it difficult to breathe), Type 2 diabetes, GERD (acid reflux disease) and hypertension. Record review of an Annual MDS assessment dated [DATE] for Resident #38 indicated she did not have any impairment in thinking with a BIMS score of 15. She was frequently incontinent of bladder and always incontinent of bowel. Record review of a care plan dated 2/14/2023 for Resident #38 indicated she had an ADL performance deficit related to dementia, fatigue, limited mobility with interventions the was totally dependent on one staff for incontinent care. She had bladder incontinence with interventions to check every two hours and as required for incontinence. During an observation on 1/30/2024 at 9:54 AM, CNA L provided incontinent care to Resident #38 with the assistance of CNA M. Both washed their hands in the bathroom and applied gloves. CNA L opened the brief on Resident #38 and pulled it down between her thighs, CNA M assisted with positioning and holding. CNA L wiped Resident #38's perineal area from front to back using 3 different wipes and placed them in the trash. CNA M rolled Resident #38 onto her left side and CNA L wiped Resident #38's buttocks from front to back and placed the wipes in the trash. CNA L removed the brief and placed it in the trash. CNA L placed a clean brief underneath Resident #38's buttocks and brief was secured and then removed her gloves and placed them in the trash without washing or sanitizing her hands and placed clean gloves on. CNA M removed her gloves and placed them in the trash and sanitized her hands. CNA L placed a mechanical lift sling underneath her buttocks. CNA L and CNA M both transferred Resident #38 using the mechanical lift from her bed to her power chair. During an interview on 1/30/2024 at 10:12 AM, CNA L said she had been employed at the facility for 6 months and worked 6a-6p on hall 200 where Resident #38 resided. She said during the incontinent care provided to Resident#38, she should have sanitized her hands between gloves changes and changed her gloves when going from dirty to clean. She said Resident #38 was joking with them both as always and she did not realize her mistakes until after the care was provided. She said she had not been checked off for competency skills check with any of the nursing staff. She said residents could get an infection of any kind if staff did not wash or sanitize their hands between glove changes or change their gloves. Record review of a competency check off for CNA L dated 8/16/2023 indicated she had a competency review with the DON which showed proficiency in hand washing. During an interview on 1/31/2024 at 11:09 AM, the DON said between the ADON and charge nurses they conducted skills check offs with staff on hire, annually and as needed if they noticed any concerns. She said staff should be washing or sanitizing their hands any time they were dirty, and before and after glove changes. She said CNA L had a check off on hire. She said going forward she would reeducate the nurses and aides on infection control and hand hygiene. She said residents could be at risk of infections. During an interview on 1/31/2024 at 11:09 AM, the Administrator said she expected all staff to follow infection control practices. She said going forward she would ensure all staff were educated on hand hygiene and residents could be at risk of infections if staff did not follow infection control practices. Record review of a facility handwashing skills form dated 9/11/2019 indicated, .handwashing should be done at the following times: b. before and after caring for each resident . Record review of a facility policy titled Standard Precautions Infection Control undated indicated, .All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand Hygiene after touching blood, body fluids, secretions, excretions, contaminated items; before and after removing ppe .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 1 resident (Resident #46) reviewed for resident rights. The facility failed to ensure CNA G properly stored her pumped breast milk in a facility approved storage freezer instead of Resident #46's personal refrigerator. These deficient practices could place residents at risk of not being treated with respect and dignity and having their choices honored. Findings Include: During an interview and observation on [DATE] at 09:29 AM, 1 store-bought lansinoh breastmilk storage bag was observed in the door of Resident #46's personal refrigerator with a white fluid inside. There was no name or date on the bag. Resident #46 stated that somebody kept putting that stuff (breastmilk bag with white fluid) in her refrigerator. On the same day at 03:15pm, there were 3 store-bought lansinoh breast milk storage bags in the door of the same refrigerator with a white fluid inside, also with no name or date labeled on bag. During an interview on [DATE] at 03:21 PM with administrator, she stated that housekeeping was responsible for cleaning the residents' personal refrigerators. She also said that she was unaware of any staff members that were currently pumping. During an interview on [DATE] at 03:25 PM, with DON, she stated that they do offer breastfeeding staff a place to pump and store their milk. She also stated that she was unaware of any staff that were currently pumping. During an interview on [DATE] at 03:34 PM, with CNA G, she stated that she worked for agency and stated that she was trying to put it up quickly so that she could help another aide with a resident on a lift. She also stated that she is now aware that the facility provides a refrigerator for pumping staff members. During an interview on [DATE] at 08:50 am with DON, she stated that going forward, she would in-service all staff on pumping and storing breastmilk so that they were aware of the facility policy on pumping and storing. She also stated that she wanted the staff to feel comfortable enough to come to them and ask if they need somewhere to pump and store. She also said that she was aware that there was a risk of certain viral illnesses if resident #46 were to have ingested it, or if any other resident had wandered in and drank it. She stated that some residents were like toddlers and did not know what they were doing. During an interview on [DATE] at 09:45am with administrator, she stated that going forward she would expect her staff to know that storing their breast milk in a resident's personal refrigerator was not acceptable, and they should know that the facility offered staff a room to pump with a storage freezer available. She also said that she had spoken to the director of the agency and that he would be in servicing all the agency staff on this. She said that she was not aware of any risk of illnesses related to the ingestion of breast milk. Record review of quarterly MDS dated [DATE] for Resident #46 revealed a BIMS score of 10, and reveals that resident was independent with locomotion once in chair, and was able to eat and drink independently. Record review of face sheet dated [DATE] for Resident #46 revealed that she was a [AGE] year-old female originally admitted to the facility [DATE] and subsequently readmitted on [DATE] with diagnoses including: personal history of traumatic brain injury, noninfective gastroenteritis and colitis, gastrointestinal hemorrhage, mild cognitive impairment, acute kidney failure, diabetes mellitus, and dementia. Reference article Transmission of Infectious Diseases Through Breast Milk and Breastfeeding states .the concern is about viral pathogens, known to be blood-borne pathogens, which have been identified in breast milk and include but are not limited to hepatitis B virus (HBV), hepatitis C virus (HCV), cytomegalovirus (CMV), [NAME] Nile virus, human T-cell lymphocytic virus (HTLV), and HIV . Citation: [NAME], RM. Transmission of Infectious Diseases Through Breast Milk and Breastfeeding. Breastfeeding. 2011; 406-473. DOI:10.1016/B978-1-4377-0788-5.10013-6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152307/#__ffn_sectitle Found on National Library of Medicine website. According to CDC.gov, . Ebola virus disease is spread through direct contact with blood and other bodily fluids including urine, saliva, sweat, feces, vomit, breast milk, and semen, of a person who is sick with or has died from EVD . and .HIV is a virus that attacks the body's immune system and is spread through certain body fluids, including breast milk . .Breast milk transmission of maternal viral infection is well established for CMV and HIV-1 . Citation: Stiehm ER, [NAME] MA. Breast milk transmission of viral disease. Adv Nutr Res. 2001;10:105-22. doi: 10.1007/978-1-4615-0661-4_5. PMID: 11795036. https://pubmed.ncbi.nlm.nih.gov/11795036/ Record review of facility policy titled Resident Refrigerators dated [DATE], stated .it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators . Record review of facility titled Expressing Breast Milk, undated, states .provide access to a freezer to store expressed milk. (A freezer is located in the employee breakroom) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident had an environment that was free from accident hazards for 2 of 34 residents (Resident #37 and Resident #49) reviewed for accidents, hazards, and supervision in that: Resident #37 had a personal microwave in her room that was not allowed by the facility. Resident #49 had a personal microwave in her room that was not allowed by the facility. These failures could place residents at risk of injuries and contribute to avoidable accidents. The findings were: 1. Record review of a Face Sheet for Resident #37 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebral palsy (a brain disability that causes weakness and problems with using the muscles), acute on chronic diastolic congestive heart failure (heart not able to pump effectively), vitamin d deficiency (not enough vitamin d in the body), type 2 diabetes, and osteoporosis (thin, brittle bones). Record review of a Care Plan for Resident #37 dated 8/15/2022 indicated an ADL functional/rehabilitation potential and she required staff assistance x2 Cna's for ADLs such as transfers, bed mobility, toileting and extensive to total assist with ADL's. An approach for staff to assist with all ADL's due to her being unable to perform independently. Record review of a Quarterly MDS dated [DATE] for Resident #37 indicated she did not have any impairment with thinking and had a BIMS score of 15. Her functional status indicated she required total dependence with bed mobility, dressing, toilet use and personal hygiene. During an observation and interview on 10/17/2022 at 10:34 AM, Resident #37 said she had been at the facility for 4 1/2 years and loved it there. A personal microwave was observed in her room on top of a refrigerator. During an interview on 10/17/2022 at 2:05 PM, the Administrator said the facility does not allow residents to have microwaves in their rooms. During an interview on 10/17/2022 at 3:12 PM, Resident #37 said she has had her microwave since she was admitted to the facility. She said maintenance and the Administrator were aware of it being in her room. She said the staff would use it and warm up foods for her when she wanted. During an observation and interview on 10/18/2022 at 9:18 AM in Resident #37's room the personal microwave was not present, and she said the night nurse removed it last night 10/17/2022 and was told she couldn't have it. 2. Record review of a Face Sheet dated 10/19/2022 for Resident #49 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of Type 2 diabetes, COPD (a group of lung diseases), osteoporosis (brittle bones), and hypertension. Record review of a Care Plan for Resident #49 dated 8/16/2022 indicated an ADL functional/rehabilitation potential of staff assistance x2 Cna's for ADLs such as transfers. Record review of a Quarterly MDS dated [DATE] for Resident #49 indicated no impairment in thinking with a BIMS score of 15. She was totally dependent with bed mobility, transfers, dressing, and toilet use with 2-person physical assist. She required supervision with eating and set up help only. During an interview and observation on 10/17/2022 at 10:48 AM, Resident #49 said she had been at the facility for 10 years and a personal microwave was observed in her room. During an interview on 10/18/2022 at 2:30 PM, Resident #49 said her microwave was removed from her room last night 10/17/2022 by the night nurse. She said the nurse told her that state said she could not have the microwave in her room. She said she has had the microwave since she was admitted to the facility 10 years ago. During an interview on 10/18/2022 at 4:10 PM, the Administrator said she didn't know Resident #37 and Resident # 49 had microwaves in their rooms. She said she had been employed at the facility for 2 1/2 years and shortly after she started work at the facility, majority of the residents had personal microwaves and she had them all removed. She said the facility did not have anyone checking the resident's room routinely such as ambassador rounds. She said the microwaves were a potential for a fire hazard or burns and that's why she got rid of them shortly after her employment started. She said facility staff removed the microwave from Resident #31's room yesterday 10/17/2022. Record review of a facility policy titled Microwave Oven Policy with a revised date of 7/22/2021 indicated, .It is the policy of .not to permit personal microwaves in resident's rooms. Microwave related incidents have the potential to cause injury, fires, burns and even death .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 3 of 4 CNAs (CNA E, CNA H and CNA I) observed for incontinent care. CNA E did not provide proper incontinent care for Resident #50 and wiped from the anal area toward the urethral area (back to front). CNA H and CNA I did not wash or sanitize their hands when changing gloves while performing incontinent care for Resident #31. This failure could place residents at risk for bacterial infections from improper incontinent care. Findings include: 1. Record review of the face sheet dated 10/19/22 indicated that Resident #50 was a [AGE] year-old female originally admitted to the facility on [DATE], and subsequently readmitted on [DATE] with diagnoses including: Congestive Heart Failure, adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, Chronic obstructive pulmonary disease, Repeated falls, osteoarthritis, unspecified site, Alzheimer's disease, and hypertension. Record review of the quarterly MDS dated [DATE] indicated that Resident #50 had a BIMS score of 9, which indicated moderate cognitive impairment. She was totally dependent for bed mobility and toileting and required extensive assist with personal hygiene. She was always incontinent of bowel and bladder. During an observation of incontinent care on 10/19/22 at 09:54 AM, CNA E and CNA F were performing incontinent care on Resident #50. CNA E wiped Resident #50 from the anal area towards the urethral area (back to front) when performing care to perineal area. CNA E and CNA F were performing incontinent care due to urinary incontinence. During an interview with CNA E on 10/19/22 at 10:42 AM, she said she had been employed at the facility for 4 years. She stated that she must have been nervous being watched while performing care, but that she knew to wipe from front to back. She said that this could cause residents to develop an infection. During an interview on 10/19/2022 at 10:23 AM, the DON said the staff were in-serviced annually and prn on incontinent care. She said a resident could be at risk for infections if staff wiped back to front. 2. Record review of a Face Sheet dated 10/19/2022 for Resident #31 indicated he admitted to the facility on [DATE] and was [AGE] years old. His diagnoses included cerebral palsy (a brain disability that causes weakness and problems with using the muscles), aphasia (not able to understand or speak), gastroparesis (delayed stomach emptying), epilepsy (seizure disorder), profound intellectual disabilities (severe learning disability), GERD (gastroesophageal reflux disorder) and gastrostomy status (feeding tube in the stomach). Record review of a Care Plan dated 8/9/2022 for Resident #31 indicated he had urinary incontinence with an approach to provide incontinence care after each incontinent episode. Record review of a Quarterly MDS dated [DATE] for Resident #31 indicated he was rarely/never understood. He required total dependence with two-person physical assist with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. He was always incontinent of bowel and bladder. During an observation on 10/18/2022 at 10:40 AM Resident # 31 's room revealed, CNA H and CNA I were present to provide incontinent care. Both CNA's washed their hands in the bathroom in Resident #31's room and applied gloves. CNA H and CNA I positioned Resident #31 in bed and pulled down his brief. CNA H removed a wipe from a container and cleaned his penis in a circulation motion. CNA H placed the wipe in the trash along with her gloves and applied gloves to her hands without washing or sanitizing them. CNA H removed another wipe and wiped his perineal area on his right side from top to bottom. CNA I used a wipe and wiped his perineal area on his left side from top to bottom. CNA H and CNA I both placed their wipes and gloves in the trash and, applied gloves to both hands without washing or sanitizing their hands. Resident #31 was rolled to his left side by CNA I and CNA H, CNA H took a wipe from the container and wiped his buttocks from front to back using a total of 4 wipes. CNA H placed the wipes in the trash along with her gloves. CNA H applied gloves to her hands without washing or sanitizing them and placed a pad and brief underneath Resident #31's buttocks. Resident #31 was rolled to his right side by CNA I and the soiled brief and under-pad was removed and placed in the trash bag and the new padding and brief were put in place. CNA H and CNA I rolled Resident #31 onto his back, brief was pulled up and secured. Both CNA H and CNA removed their gloves and placed them in the trash. Resident #31 was repositioned in bed with head elevated. Both CNA H and CNA I washed their hands in the bathroom. During an interview on 10/18/2022 at 10:50 AM, CNA H and CNA I both said they were agency staff who worked in the facility as needed. When they were asked if they would have done anything differently with the incontinent care provided to Resident #31, both said they should have washed or sanitized their hands with each glove change. Both said they had received in-service training at the facility on infection control, hand washing and hygiene. Both said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. During an interview on 10/19/2022 at 10:23 AM, the DON said facility staff should change gloves at least one time during incontinent care when going from clean to dirty. She said staff could sanitize their hands between glove changes instead of washing their hands. She said the staff were in-serviced annually and prn on infection control. She said whatever staffing agency the facility used was responsible for skills checkoffs and they relied on the agency staffing to provide the training. She said if there was a problem with agency staffing staff then the staff would be in-serviced at the facility on whatever topics. She said a resident could be at risk for infections if staff did not wash or sanitize their hands between gloves changes. Record review of facility procedure guide titled Incontinent care for the female resident, undated, stated .Thoroughly cleanse perineal area - wiping front to back - using a clean area of the washcloth for each stroke . Record review of the facility's policy titled Infection Prevention and Control Program dated 1/25/21 stated .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . Record review of a facility policy undated on Hand Hygiene indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. 6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 18 residents (Resident #66) observed for respiratory care and services in that: Resident #66 was oxygen dependent with oxygen in place and nasal cannula tubing was dated 09/09/2022. This failure could place residents who receive respiratory care and services at risk of developing respiratory infections and complications. The Findings were: Record review of the face sheet dated 10/18/2022 indicated Resident # 66 was admitted on [DATE] with diagnoses of amputation requiring after care, infection of surgical area, and chronic obstructive pulmonary disease (lung disease). Record review of the physician order dated 3/27/2022 for Resident #66 indicated oxygen per nasal cannula 2 to 4 liters per min continuously. Record review of an MDS dated [DATE] revealed a of BIMS of 11 indicating moderately impaired cognition, and Resident #66 used oxygen daily. Record review of the Comprehensive care plan dated 10/17/2022 indicated Resident #66 required oxygen therapy. During an observation and interview on 10/17/22 at 1:00 pm, Resident #66 was up in her wheelchair with oxygen per nasal cannula in place. The nasal cannula tubing was dated 9/9/2022. When asked, Resident #66 stated she wore her oxygen at all times. During an observation and interview on 10/17/2022 at 1:05 pm, LVN A stated the tubing should have been changed. LVN A removed the outdated nasal cannula and applied new oxygen cannula for Resident #66. LVN A stated oxygen tubing should be changed weekly because of risk for infection. During an interview on 10/18/22 at 1:34 PM, LVN B stated that oxygen tubing was to be changed every Sunday evening on night shift. The medication record will show that it has been done and the tubing was dated to reflect the date it was changed. LVN B stated she received training regarding the oxygen policy. LVN B stated the risk could be infection if it was not changed. LVN B also stated Resident # 66 does wear her oxygen daily at all times. During an interview on 10/18/22 at 1:42 PM, LVN C stated oxygen tubing should be changed weekly, usually on Sundays and as needed. The tubing was then dated so they know if has been done. LVN C stated she tried to check her residents when she was working to make sure oxygen tubing has been changed. LVN C stated if tubing has not been changed, she will change it herself. LVN C stated she was knowledgeable on oxygen use and care from working in the nursing home. LVN C stated she was an agency nurse and has worked at the facility almost one year. LVN C stated the risk could be infection, and improper dispensing of oxygen due to wear and tear of the tubing. During an interview on 10/18/22 at 1:47 PM, LVN D stated she was an agency nurse and worked at the facility since March 2022. LVN D stated she was knowledgeable on changing out oxygen tubing and tubing should be changed weekly and as needed. LVN D stated at this facility it was usually on Sunday night. LVN D stated she has not worked night shift. LVN D stated she looks at her resident's oxygen tanks to make sure the tubing has been changed. LVN D stated the risk could be infection and oxygen may not deliver at the correct flow. During an interview on 10/18/22 at 1:53 PM, the DON stated oxygen tubing was changed once a week and prn. The charge nurses on night shift were responsible for changing out the tubing and all nurses are responsible for overseeing that oxygen tubing is within date. The DON stated the nurse then signs off on the MAR that it has been done. The DON stated she was responsible for monitoring. The DON stated the risk to the resident could be infection control. The DON stated she would retrain the staff on the policy and make sure that all oxygen tubing was changed weekly and as needed. During an interview on 10/18/22 at 1:56 PM, the ADMIN stated she will do more training with nursing staff and will make sure to check behind to see that all tubing was changed per their policy and procedure. Record review of undated policy titled Oxygen administration indicated .Section 5 other infection control measures include, change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .