**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, 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 32 residents (Resident #98) reviewed for dignity issues: The facility did not place a urinary catheter drainage bag in a privacy bag to screen/cover it from view for Resident #98 on 03/06/2025 and 03/07/2025. This failure placed residents in the facility, with urinary catheters, at risk of feeling uncomfortable or embarrassed and decreased privacy. Findings included: Record review of Resident #98's admission Record dated 03/7/2025, a [AGE] year-old male with an admission date of 11/08/2024, with diagnoses that included the following: Osteomyelitis (a bone infection that happens when bacterial or fungal infections spread from other parts of your body into bone marrow); Pathological fracture (when force or impact didn't cause the break to happen, instead, an underlying disease leaves bones weak) , left femur (thigh bone); Bed confinement status (unable to tolerate any activity out of bed ); Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems); and hydronephrosis (when urine backs up into one or both of the kidneys). Record review of Resident #98's Physician Orders, undated, revealed: Foley Catheter: Provide catheter care every shift Every Shift; Foley Catheter: Output every shift Every Shift; Foley catheter: Size 16 French Diagnosis: Neurogenic Bladder. During an observation on 03/6/20/25 at 1:30 PM Resident #98 was lying in bed with the room door open. Resident #98 had an indwelling urinary catheter drainage bag on the left side of the bed, facing the door. The urinary catheter drainage bag was visible through the open door and not in a privacy bag. The urinary catheter drainage bag was observed to contain urine. During a follow-up observation and interview 03/7/20/25 at 9:30 AM Resident #98 was lying in bed, with the room door open. Resident #98's urinary catheter bag was on the left side of the bed, facing the door. The urinary catheter drainage bag was again visible through the open door and not in a privacy bag. Resident #98 stated he could not recall the urinary catheter drainage bag ever being in a privacy bag. Resident #98 stated he was not aware it was possible to place it in a privacy bag, and he stated he would prefer the privacy bag. During an interview on 03/07/2025 at 3:57 PM the DON stated it was the facility's policy to always provide a privacy bag for a resident's urinary catheter drainage bag, unless the resident specifically requested to not have one. The DON stated she was not aware of any residents at the facility who had requested to not have the privacy bag. The DON stated it was the charge nurse on each shift's responsibility to ensure each resident had a privacy bag on their urinary catheter drainage bag. The DON stated the charge nurse on each shift should have been monitoring this during their daily rounds and when they provided catheter care for the resident. The DON stated this was trained to nursing staff upon hire as well as during regular in-service trainings. The DON stated a resident not being provided a privacy bag for their urinary catheter drainage bag could make a resident feel their dignity and privacy were violated if they did not want anyone to know they had a catheter. During an interview on 03/07/2025 at 4:09 PM the ADM stated it was the facility's policy to provide a privacy bag for a resident's urinary catheter drainage bag, and they should have always been covered. The ADM stated if a residents urinary catheter drainage bag was left uncovered, it was because someone overlooked it, because there was no reason the privacy bag should not be used. The ADM stated any nursing staff could have placed the privacy bag, as needed. The ADM stated all nursing staff were responsible for ensuring the privacy bags were provided and they should have seen this when they were providing care and treatment to the resident. The ADM stated the nursing management team and the ADM were responsible for ensuring privacy bags were always used. The ADM stated nursing staff received regular training by the nurse management team regarding catheter care and dignity. The ADM stated if the privacy bag was not used for a resident's urinary catheter drainage bag, this could affect the resident's dignity. During an interview on 03/07/2025 at 5:00 PM the ADON stated she worked on the floor as a charge nurse regularly. The ADON stated all urinary catheter drainage bags should be placed in a privacy bag. The ADON stated all nursing staff were responsible for ensuring a resident's urinary catheter drainage bag was placed in a privacy bag, and this should be monitored on each shift by the charge nurse. The ADON stated if a resident's urinary catheter drainage bag was not placed in a privacy bag, it could have caused a dignity issue for the resident. Record review facility policy titled Dignity, revised February 2021, revealed the following: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 of 32 residents (Resident #2,) reviewed for Respiratory Care. 1. The facility failed to follow physician's orders indicating Resident #2's oxygen humidification bottle should be monitored every shift and replaced or refilled as needed on 03/05/2025. 2. The facility failed to follow physician's orders indicating Resident #2's nasal cannula and oxygen tubing should be changed weekly on 03/05/2025 and 03/06/2025. These deficient practices have the potential to affect residents by placing them at an increased risk of respiratory infection, respiratory distress, and a diminished quality of life. Findings include: Resident #2 Record review of Resident #2's face sheet dated 03/07/2025 revealed a [AGE] year-old male with an admission date of 01/19/2023 and included the following diagnoses: Acute respiratory failure with hypoxia (when the respiratory system cannot adequately provide oxygen to the body); Other pulmonary embolism without acute cor pulmonale (condition where there is a blockage in the pulmonary artery due to a blood clot in the lungs), Acute upper respiratory infection, unspecified (viruses and bacteria that infect the respiratory tract), Extended spectrum beta lactamase (enzymes that confer resistance to most beta-lactam antibiotics), Shortness of breath, Unspecified diastolic (congestive) heart failure (when the heart does not relax properly between beats), and Essential (primary) hypertension (high blood pressure). Record Review of Resident #2's Care Plan, dated 01/29/2025, revealed the following: The Diagnosis included: Acute respiratory failure with hypoxia, Acute upper respiratory infection, unspecified; A Problem area that stated, Category: Diagnosis with a Goal that stated, Long Term Goal Target Date: 05/01/2025 No Complications and an Approach area that stated, Oxygen therapy/O2 Sats as ordered- AS NEEDED. Record Review of Resident #2's current Physician Orders, undated, revealed the following: Nasal Cannula(Continuous):O2 @ (1-3 __)L/Min, Special Instructions: To keep Oxygen sats greater than 90%, Every Shift, dated 01/21/2025; Change oxygen tubing, Cannula/Mask once a week. Once A Day on Sun Eve 06:00 PM - 06:00 AM, dated 07/21/2023; Monitor oxygen Humidification Bottle every shift. Replace or Refill as required. Every Shift, dated 07/21/2023. During observation and interview on 03/05/2025 at 10:43 AM Resident #2's nasal cannula, oxygen tubing, and oxygen humidification bottle had no date to indicate when they were last changed. Additionally, the oxygen humidification bottle was empty and contained no water. Resident #2 stated Resident #2 could not recall when the oxygen tubing and nasal cannula had been replaced last and stated they were not changed weekly. Resident #2 stated the oxygen humidification bottle was empty all the time, and staff had to be reminded to replace it often. During an observation and interview on 03/06/2025 at 12:20 PM Resident #2's oxygen humidification bottle contained water but had no date indicating when it had been replaced or refilled. Resident #2's nasal cannula and oxygen tubing still contained no date. Resident #2 stated there was a new humidification bottle replaced by a nursing staff on this date, but, he stated, they did not replace the oxygen tubing or nasal cannula. Resident #2 stated Resident #2's nose became dry when the oxygen humidification bottle was empty, and it was preferred by Resident #2 for it to contain water as it became uncomfortable for Resident #2 when it was empty. During an interview on 03/07/2025 at 3:57 PM the DON stated it was the facility's procedure for residents' oxygen tubing to be changed every Sunday evening by nursing staff. The DON stated it was the facility's policy that oxygen tubing be bagged and dated with the date the tubing was changed. The DON stated all residents' oxygen tubing should have contained the date it was last changed, and there should not be an exception to this. The DON stated oxygen humidification bottles should have water in them at all times, especially if ordered by a physician for the resident. The DON stated the purpose of the humidification bottles were to provide humidification to the residents; oxygen as the oxygen can be dry, causing dryness to the resident. The DON stated some residents prefer their oxygen without humidification, but some residents prefer their oxygen with humidification. The DON stated if the residents' order stated they should have a humidification bottle, it should have been maintained to prevent the oxygen from being administered without humidification. The DON stated it was her expectation that the bottle was not empty for any longer than it would take for the bottle to be replaced, and it should have been replaced as soon as possible. The DON stated it was the charge nurse's responsibility to ensure this was monitored on each shift. The DON stated nursing staff were trained upon hire and received regular training in-services regarding residents' oxygen, as recently as last month (February). The DON stated if a resident's oxygen tubing was not changed regularly, it could potentially have caused a respiratory infection. The DON stated oxygen would still function properly without a humidification bottle; however, if it was empty it could cause dryness to the resident's sinuses or possible complications if the resident had COPD (Chronic Obstructive Pulmonary Disease). During an interview on 03/07/2025 at 4:09 PM the ADM stated he believed it was the facility's policy for residents' oxygen tubing to be changed once a week. The ADM stated this was done by charge nurses. The ADM stated he was unsure how often residents' oxygen humidification bottle should be changed, and he referred to the DON for the specific timeframe. The ADM stated the nurse management team was responsible for ensuring oxygen tubing and oxygen humidification bottles were changed, as required, as well as monitoring this on each shift. The ADM stated the ADM and the nurse management team were ultimately responsible for ensuring it was done. The ADM stated he was not certain what the specific purpose of the oxygen humidification bottles was, but he thought it could possibly lead to dryness if the bottles were not maintained. The ADM stated it was his expectation that nursing staff monitored oxygen humidification bottles on each shift and changed out oxygen tubing as required. The ADM stated nursing staff received regular in-service trainings by the nurse management staff pertaining to resident's oxygen use. The ADM stated if oxygen tubing was not changed out regularly, this could lead to some type of infection for the residents. During an interview on 03/07/2025 at 5:00 PM the ADON stated she worked on the floor as a charge nurse regularly. The ADON stated all residents' oxygen tubing should have been dated with the date it was changed, with no exceptions. The ADON stated oxygen tubing and oxygen humidification bottles were changed weekly on Sunday evenings, or more often as needed. The ADON stated only nurses could change the oxygen tubing and humidification bottles, but any nursing staff could have monitored these items to determine if they needed to be replaced or if they were missing a date and reported this back to the nurse. The ADON stated all nursing staff received regular in-service training regarding residents' oxygen needs. The ADON stated if a resident's oxygen humidification bottle was empty, it could cause dryness to the resident's nose which could cause discomfort to the resident. The ADON stated if a resident's oxygen tubing was not changed out as required, this could have caused an infection for the resident as the oxygen tubing can become dirty and breakdown. Record review facility policy titled Oxygen Administration, dated February 2025 revealed the following: Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. 1. Oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. 2. Personnel authorized to initiate oxygen therapy include physicians, RNs, LVNs, and respiratory therapists. 5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: b. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. c. Change humidifier bottle when empty, every 72 hours or per facility policy, or as recommended by the manufacturer. Use only sterile water for humidification. d. Oxygen tubing will be changed weekly or as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to change gloves and wash hands while preparing snack sandwiches on 03/05/2025 at 11:15 AM. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During an observation on 03/05/25 at 11:15 AM DA A was preparing sandwiches on prep table. DA A had gloves on. DA A left the prep table with gloves on and walked to the dry storage room. DA A returned to prep table with same gloves on and opened bag of potato chips and using gloves hand put potato chips in Styrofoam container with sandwich. DA A put right gloved hand into pocket to get sharpie marker. DA A wrote on Styrofoam container and placed marker back in pocket. DA A left prep table with gloves on and went into DM office. DA A returned to prep table with same gloves on and being preparing sandwiches placing them on cookie sheet lined with wax paper. DA A left prep table with gloves on and went to refrigerator. DA A returned to prep table with same gloves on and began placing sandwiches in plastic bag. DA A placed gloved hand in pocket for sharpie marker and hand to DA B. DA A left prep table with gloves on and walked to the dishwashing area with DA C and placed right gloved hand on DA C right shoulder. DA A returned to prep table with same gloves on and continued placing sandwiches in bags. During an interview on 03/06/25 at 10:45 AM with the DA A, she stated she should have changed her gloves and washed her hands anytime she left the prep table or changed task. She stated she had been trained on proper hand hygiene and when to change her gloves. She stated she had no reason for not changing her gloves. She stated the potential negative outcome could be cross contamination. During an interview on 03/07/25 01:55 PM with the DM, she stated gloves should have been changed and hands washed anytime staff leave the prep table, place hands in pockets or change a task. She stated all staff have been trained. She stated she was responsible for monitoring staff and training staff. She stated she expects staff to follow policy and procedure when preparing food. She stated the potential negative outcome could be bacteria on food and cross contamination. During an interview on 03/07/25 at 02:01 PM with the ADM, he stated gloves should have been change and hands washed when DA left the prep table and placed her hand in her pocket. He stated not changing gloves and not washing hands was a problem. He stated he was responsible for monitoring and training dietary staff. He stated the potential negative outcome could be cross contamination and a resident could get sick. Record review of the facility policy, titled Handwashing, undated reflected the following: Objective: Use proper hand washing technique to keep hands and exposed portions of the arms clean. Procedure: . Employees should wash their hands: . After visiting resident rooms, when re-entering the kitchen, and prior to any food production. During food preparation, as often as necessary to prevent cross contamination when changing tasks . After engaging in any other activity that may contaminate the hands . Glove Use: . Change gloves any time the team member completes a task . Change gloves after touching an unsanitized item or surface or when gloves are soiled or torn .

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 19 of 22 confidential residents. The facility failed on 03/07/2025 to ensure 19 of 22 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews and Record Review during Resident Council on, 03/06/2025 at 10:30am, 19 of 22 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Nineteen Residents attended the meeting, the 19 Residents in attendance had all been Residents of the facility for 6 plus months. Record Review of the facility Grievance policy on 3/07/2025 at 2:33pm; according to the facilities' Grievance policy a copy of the Grievance/Complaint procedure should be posted in a prominent location. Observed prominent postings on 3/07/2025 at 3:17pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available and there was no access to submit a Grievance anonymously. Interview with the ADM on 3/07/2025 at 1:35pm; the ADM stated he was the Grievance Officer for the facility. The ADM stated he was responsible for the review of Grievances and assign them to department heads. The ADM stated the Grievance form was kept at the Nurses' Station and in the ADM's office. The ADM stated the Residents cannot obtain a Grievance form without asking the ADM or the SW for the form. The ADM stated staff completed Grievance forms for Residents, Residents do not ask for forms and complete them on their own. The ADM stated there was no procedure for Residents to submit Grievances anonymously. The ADM stated the facility has 72 hours to resolve Grievances once they were submitted. The ADM stated he assigned the Grievance to the appropriate department, that department addresses the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the Grievance form and the completed form was submitted to the ADM for review. The ADM stated completed Grievance forms were kept in a notebook. The ADM stated he monitored the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated he will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated he was responsible for ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance procedure and it was not being discussed in Resident Council. Grievance Policy Record Review of the Grievance Policy last updated in 2023. Policy Statement: All grievances filed with the facility will be investigated and corrective actions will be taken to resolve the grievance. Policy Interpretation and Implementation: 1. The facility will make available information on how to file a grievance available to residents, family, and staff. 2. The Administrator or designed will assign the responsibility of investigating the grievance. 3. Each Resident grievance form will include the date and time and details of the grievance. 4. The Administrator or designee will record and maintain all grievances in the Grievance Log. 5. The Resident Grievance form will be filed with the Administrator or designee and the resolution will be identified within three working days of the concern. 6. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 3 working days of the filing of the grievance. 7. If during the investigation abuse, neglect, misappropriation and/or injuries of unknown source are identified, the facility will refer to the Abuse Policy. a. Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and b. Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievances for period of no less than 3 years from the issuance of the grievance decision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 4 of 6 residents (Resident #2, Resident #63, Resident #71, and Resident #86) and 3 of 3 staff (LVN E, CNA H, CNA I) reviewed for infection control. 1. CNA H failed to follow policy and procedure for handwashing while providing peri care for Resident #2, during observations of peri care on 03/06/2025 at 1:42 PM. 2. LVN E failed to follow policy and procedure for handwashing while providing wound care for Resident #63, during observations of wound care on 03/05/2025 at 11:33 AM. 3. CNA I failed to follow policy and procedure for handwashing while providing peri care for Resident #71, during observations of peri care on 03/05/2025 at 10:50 A. 4, LVN E failed to follow policy and procedure for handwashing while providing wound care for Resident #86, during observations of wound care on 03/07/2025 at 11:01 AM. These failures could place residents at risk for spread of infection and cross contamination. Findings included: 1. Record review of Resident #2s face sheet undated revealed a [AGE] year-old male with an original admission date of 01/19/2023 and a readmission date of 04/23/24 with the following diagnoses: Partial intestinal obstruction (something blocking the intestines), Herpes viral infection , Urinary tract infection, Herpes viral vesicular dermatitis (a skin infection caused by herpes simplex type 1), Severe sepsis with septic shock, Bacteremia (the presence of viable bacteria in the bloodstream), Methicillin resistant Staphylococcus aureus infection (a type of staph bacteria that is resistant to many antibiotics), Infection and inflammatory reaction due to indwelling urethral catheter, Benign prostatic hyperplasia with lower urinary tract symptoms (prostate gland enlargement), obstructive and reflux uropathy (when urine cannot drain through the urinary tract), Shortness of breath, Acute embolism and thrombosis of deep veins of left lower extremity (blood clot), Cellulitis of left upper limb (potentially serious bacterial skin infection). Record review of Resident #2's admission MDS dated [DATE] revealed a BIMS score listed as 14 meaning cognitive intact. The MDS under Bowel and Bladder listed Resident #2 as having an indwelling catheter and urinary catheter was listed as a 9 meaning not rated. Under bowel continence Resident #2 was listed as a 0 meaning always continent. Record review of Resident #2's Care Plan dated 09/24/24, revealed that Resident #2 was listed as Enhanced Barrier Precautions with the interventions of staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type. requiring a dressing, device care or use (central line, urinary catheter, feeding tube, trach care). Record review of Resident #2's Care Plan dated 07/16/24, revealed that Resident #2 was listed as having indwelling catheter. Record review of Resident #2's Care Plan dated 07/16/24, revealed that Resident #2 was listed as being at risk for urinary tract infection. Record review of Resident #2's Care Plan dated 07/16/24, revealed that Resident #2 was listed as Resident #2 was bowel incontinent. During an observation on 03/06/2025 at 1:42 PM, CNA H prepared to provide peri care to Resident #2. CNA H did not wash hands or use hand sanitizer prior to gathering peri care supplies. CNA H placed on a yellow gown, face mask, and face shield. CNA H washed her hands for 10 seconds with soap and friction before rinsing under water. CNA H used a clean paper towel to dry her hands. CNA H used a separate clean paper towel to turn off the water faucet. CNA H placed on a pair of clean disposable gloves. CNA H shut the resident's door and closed the privacy curtain completely. CNA H removed her gloves and disposed of them in the trash. CNA H used hand sanitizer and placed on a new pair of clean disposable gloves. CNA H put a towel on the bedside table to provide a barrier for the peri care supplies. CNA H removed her gloves and disposed of them in the trash. CNA H had used hand sanitizer and put on a pair of clean disposable gloves. CNA H prepared Resident #2 for peri care by removing the pillows under legs, wedges, blankets, raise the bed, removing Resident #2's pants, and provided privacy with a towel. CNA H placed a clean towel underneath Resident #2. CNA H removed gloves and disposed of them in the trash. CNA H put on hand sanitizer and placed on a clean pair of disposable gloves. CNA H used a clean wipe to clean the catheter tubing going from the insertion site downward away from insertion site, while holding the tubing in place. CNA disposed of the wipe in the trash. CNA H repeated this step four times. CNA H completed all steps of peri care for a male. CNA H covered Resident #2 with a towel. CNA H removed her gloves and discarded in the trash. CNA H used hand sanitizer and put on a pair of clean disposable gloves. CNA H asked Resident #2 to turn on his side so that she could clean the backside of the resident. CNA did not clean the right side of the buttock, just the left side and the anus area. CNA H removed gloves and disposed of them in the trash. CNA H used hand sanitizer. CNA H put on a clean pair of disposable gloves. CNA H used blue tape to tape the catheter tubing to the resident's leg. CNA H completely dressed the resident. CNA H gathered dirty towels and placed in the bag. CNA H gathered all trash and gathered in the bag. CNA H removed dirty gloves and disposed in the trash. CNA H used hand sanitizer and placed on clean gloves. CNA H used the urinal to empty the catheter bag and then used a clean wipe to wipe the urinal spout and shut the spout. CNA H emptied the urinal in the toilet and flushed. CNA H did not rinse out the urinal before placing the urinal on the nightstand. CNA H removed dirty gloves and discarded in the trash. CNA H used hand sanitizer and put on clean disposable gloves. CNA H took and disposed of all of the trash in the resident's room. CNA H used hand sanitizer and put on clean gloves. CNA H wet a paper towel with water and wiped down the bedside table. CNA H removed dirty gloves and disposed of them in trash. CNA H washed her hands for 29 seconds with soap before rinsing her hands. CNA H used three clean paper towels to dry her hands and then disposed of them in the trash. CNA H used a clean paper towel to turn off the faucet. During an interview on 03/06/2025 at 3:37 PM, CNA H stated that she had training for hand washing through in-services, monthly and competency checks every other week. CNA H stated that the policy says to wash hands for 30-60 seconds. CNA H stated that she got nervous being watched and knows that she had messed up a few times. CNA H stated that the negative potential outcome of not washing hands as the policy stated could cause the spread of infection and cross contamination. 2. Record review of Resident #63s face sheet undated revealed a [AGE] year-old male with an original admission date of 02/11/2022 and a readmission date of 07/12/24 with the following diagnoses: Nontraumatic intracerebral hemorrhage in hemisphere (most commonly results in hypertensive damage in blood vessel walls), Type 2 diabetes mellitus, Pressure ulcer of sacral region, stage 4, Acute kidney failure, Urinary tract infection, hyperlipidemia (high levels of fat particles in the blood), Methicillin resistant Staphylococcus aureus infection (a type of staph bacteria that is resistant to many antibiotics), Overactive bladder (a problem with bladder function that causes sudden need to urinate), Hyperkalemia (high potassium), Hypertension (high blood pressure), Elevated white blood cell count, Cholecystitis (gallbladder inflammation), Anemia (iron deficiency), Morbid (severe) obesity due to excess calories, Abnormal posture, need for assistance with personal care, Pressure ulcer of sacral region, Sepsis, chronic kidney disease, Tachycardia (fast heart rate), Muscle wasting and atrophy. Record review of Resident #63's quarterly MDS dated [DATE] revealed a BIMS score listed as 15 meaning Resident #63 had cognitively intact. Under skin conditions in the MDS, Resident #63 was listed as being a risk of developing a pressure ulcer and listed Resident #63 as having one pressure ulcer upon admission at a stage four. Record review of Resident #63's Care Plan dated 06/06/23, revealed that Resident #63 was listed as enhanced barrier precautions due to a wound and a suprapubic catheter. Record review of Resident #63's Care Plan dated 06/06/23, revealed that Resident #63 was listed as having a has a pressure ulcer to Sacrum. Resident #63 was at risk for further breakdown r/t incontinence, decreased mobility and Diabetes. Record review of Resident #63's Physician Orders dated 02/13/2025, revealed: wound treatment order for sacrum, cleanse with normal saline/ wound cleanser, collagen, calcium alginate, cover with silicone absorbent dressing. During an observation on 03/05/2025 at 11:33 AM, LVN E put on hand sanitizer and pair of clean disposable gloves to prep wound care supplies of several pairs of disposable gloves, wax paper on bedside table, 4 x 4 bordered bandage, plastic cup with gauze and normal saline, several gauze pads (dry), calcium alginate, collagen, and bordered dressing, green pad, and trash bag. LVN E disposed of gloves in the trash. LVN E used hand sanitizer and put on a pair of clean disposable gloves. LVN E cut pieces of calcium alginate and collagen and placed on the supply table. LVN E placed a clear trash bag over the clean supplies. LVN E disposed of gloves in the trash. LVN E put on hand sanitizer. LVN E put on yellow gown and clean disposable gloves for enhanced barrier precautions. LVN E set up supplies next to resident and provided privacy. LVN E removed disposable gloves and discarded in the trash. LVN E turned on water faucet to wash hands. LVN E put one squirt of soap in hands and for six seconds before rinsing hands under water. LVN E used clean dry paper towel to dry hands. LVN E used a clean paper towel to turn off the faucet. LVN E put on pair clean disposable gloves. LVN E removed Resident #63 blanket, raised bed, provided privacy, removed pillows from under legs, unfastened the front end of resident's brief. LVN E turned Resident #63 on the side to the left. LVN E removed gloves and disposed in the trash. LVN E washed hands with soap for five seconds before rinsing under water. LVN E used a clean dry paper towel to dry hands and disposed in the trash. LVN E used a clean paper towel to turn off the water faucet and disposed in the trash. LVN E put on pair clean disposable gloves. LVN E placed a blue pad under Resident #63. LVN E placed resident on left side. LVN E removed gloves and disposed in the trash. LVN E washed hands for four seconds with soap before rinsing under water. LVN E used a clean dry paper towel to dry hands and disposed in the trash. LVN E used a clean dry paper towel to turn off the water faucet. LVN E used gauze with normal saline to clean wound from inside, outward wound with one swipe, and discarded of gauze. LVN E removed gloves and disposed in the trash. LVN E washed hands with soap without lathering with and immediately rinsing underneath the water for three seconds. LVN E used a clean paper towel to dry hands and discarded in the trash. LVN E used a clean paper towel to turn off faucet. LVN E used dry gauze to pat dry wound one time per gauze and discarded in the trash. LVN E removed gloves and discarded in the trash. LVN E washed hands for five seconds with soap before rinsing under water. LVN E used a clean paper towel to dry hands and discarded in the trash. LVN E used a clean paper towel to turn off the water faucet and discarded in the trash. LVN E put on clean disposable gloves. LVN E put the collagen and calcium alginate on the wound. LVN E placed the bandage with date and initials on the wound. LVN E fastened Resident #63's brief and pulled up pants. LVN E covered resident with blanket. LVN E gathered trash and discarded in the biohazard trash. LVN E removed gloves and discarded them in trash. LVN E had ran out of soap in the resident's bathroom. LVN E went to the meeting room to wash hands. LVN E washed hands with soap for three seconds before rinsing under water. LVN E used a clean dry paper towel to dry hands and discarded paper towel in the trash. LVN E used a clean paper towel to turn off the water faucet and disposed in the trash. During an interview on 03/06/2025 at 5:00 PM, LVN E stated that policy stated that she should wash her hands with soap for 20 seconds before rinsing. LVN E stated that she did not know why she did not wash hands for the 20 seconds that policy stated. LVN E stated that she had been trained in hand washing through in-services, monthly. LVN E stated that she had competency checks completed, monthly. LVN E stated that it is the responsibility of the DON to oversee the training. LVN E stated that the negative potential outcome of not following the handwashing policy could be a risk for infection and the spread of germs. 3. Record review of Resident #71s face sheet undated revealed a [AGE] year-old female with an admission date of 03/23/25 with the following diagnoses: Alzheimer's disease, muscle weakness, hyperlipidemia (high levels of fat particles in the blood), depression, high blood pressure, atrioventricular block (a heart rhythm disorder), tubule-interstitial nephritis (kidney condition that causes swelling in the spaces between the kidney tubules which can impair kidney function). Record review of Resident #71's admission MDS dated [DATE] revealed a BIMS score listed as 3 meaning cognitive impairment. The MDS under functional abilities for toileting (The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment), listed Resident #71 as a 3 meaning: Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Resident #71 was listed under bowel and bladder as being always incontinent for bowel and bladder. Record review of Resident #71's Care Plan dated 08/13/24, revealed that Resident #71 was listed as being at risk for Pressure Ulcer Development due to occasional episodes of incontinence. Record review of Resident #71's Care Plan dated 08/13/24, revealed that Resident #71 was listed as being occasionally incontinent and require assistance at times with incontinent care. Record review of Resident #71's Care Plan dated 08/13/24, revealed that Resident #71 was listed as needing assistance with ADL's. During an observation on 03/05/2025 at 10:50 AM, CNA I put on hand sanitizer in the hallway and gathered peri care supplies that included: clear trash bag, two towels. CNA I went into resident's room and shut the door. CNA I washed hands with soap for nine seconds before rinsing under water. CNA I used a clean paper towel to dry hands and disposed in the trash. CNA I used a clean paper towel to turn off the faucet and disposed in the trash. CNA I put on clean gloves and shut the middle privacy curtain and shut the blinds; however, the blinds were pulled up a quarter of the way from the bottom and were not shut. CNA I uncovered resident and unfastened her brief. CNA I provided peri care to the front area. CNA I removed gloves and disposed in the trash. CNA I washed hands with soap for nine seconds before rinsing under water. CNA I used a clean paper towel to dry hands and disposed in the trash. CNA I used a clean paper towel to turn off the faucet and dispose in the trash. CNA I put on clean gloves and turned Resident #71 to the left side to clean the backside of the resident. CNA I put a clean brief on Resident #71, laid her back, and fastened brief. CNA I gathered all trash. CNA I removed gloves and disposed in trash. CNA I took all of the trash that had been gathered from the resident's room and disposed in the trash. CNA I did not wash her hands. During an interview on 03/05/2025 at 3:25 PM, CNA I stated that the hand washing policy stated that she should wash her hands for twenty seconds. CNA I stated that she did not wash her hands at the end because she had forgotten to do it when she went to throw the trash. CNA I stated that she had been trained in hand washing through competency checks with the educator, two to three times a month. CNA I stated that policy stated that she should wash her hands before, during, and after peri care. CNA I stated that she did not do that because she was nervous. CNA I stated that the negative potential outcome of not following the hand washing policy would have been the spread of germs and infections. CNA I stated that the resident's need to be clean. 4. Record review of Resident #86's face sheet undated revealed a [AGE] year-old female with an original admission date of 06/14/2025 and a readmission date of 06/20/25 with the following diagnoses: Multiple sclerosis, Urinary tract infection, Elevated urine levels of drugs, medicaments and biological substances, osteomyelitis (inflammation of the bone caused by infection), Pressure ulcer of heel, Elevated white blood cell count, Obstructive and reflux uropathy (when urine cannot drain through the urinary tract), Hyperglycemia (high blood sugar), Tachycardia (fast heart rate), acid reflux, Hypotension (low blood pressure), Calculus of kidney (hard deposit that forms in the kidneys), Muscle weakness, high blood pressure, Pressure ulcer of left buttock, stage 4, retention of urine (difficulty of urinating and completely emptying the bladder), reduced mobility, Need for assistance with personal care, Pressure-induced deep tissue damage, Hypothyroidism (a condition which the thyroid does not produce enough thyroid hormone), Polyneuropathy (peripheral nerve disorder that causes multiple nerves to malfunction simultaneously), Paraplegia (affects all or part of the trunk, legs, and pelvic organs). Record review of Resident #86's Care Plan dated 10/08/24, revealed that Resident #86 was listed as enhanced barrier precautions due to a wound. Record review of Resident #86's Care Plan start date of 10/08/24 and edited on 02/26/2025, revealed that Resident #86 had a pressure ulcer to left buttocks. Record review of Resident #86's Care Plan start date of 10/08/24 and edited on 02/26/2025, revealed that Resident #86 had a pressure ulcer to right buttocks. Record review of Resident #86's Care Plan start date of 10/08/24 and edited on 02/26/2025, revealed that Resident #86 was at risk for further breakdown or new pressure ulcer due to bedfast / mobility. During an observation on 03/07/2025 at 11:01 AM, LVN E washed hands with soap for eight seconds before rinsing under water. LVN E used clean paper towel to dry hands and disposed in the trash. LVN E used a clean paper towel to turn off the faucet and disposed in the trash. LVN E used hand sanitizer. LVN E put a clear trash bag over the bedside table. LVN E put on clean gloves and gathered supplies of handful of gauze pads in clear plastic cup with normal saline, disposable gloves. LVN E removed gloves and discarded in the trash. LVN E used hand sanitizer and put on clean disposable gloves. LVN E grabbed silicone absorbent dressing (6 x 6), calcium alginate, collagen. LVN E removed gloves and discarded in the trash. LVN E used hand sanitizer. LVN E put on clean pair of disposable gloves. LVN E grabbed blue pad and used a clear plastic bag to cover the supplies. LVN E removed gloves and disposed in the trash. LVN E pushed the bedside table into the resident's room. LVN E washed her hands by putting soap in her hands and rubbing together without lathering and immediately rinsing for three seconds. LVN E left resident's room to put on yellow gown and gloves for PPE. LVN E went back into resident's room, shut the door, and pulled the privacy curtain. LVN E removed gloves and disposed in the trash. LVN E washed hands for three seconds, with soap, before rinsing under running water. LVN E used clean paper towel to dry hands and discarded in the trash. LVN E used a clean paper towel to turn off water faucet and disposed in the trash. LVN E put on clean pair of disposable gloves. LVN E removed pillows from under resident's feet and behind her back. Resident #86 did not have a bandage on. LVN E stated that the bandage must have come off during the shower. Wound was open in a portion of the wound and entire wound was approximately 6 X 3. LVN E disposed of gloves in the trash. LVN E washed hands with soap for two seconds and then rinsed under running water. LVN E used a clean paper towel to dry hands and disposed in the trash. LVN E used a clean paper towel to turn off faucet and disposed in the trash. LVN E put on pair of clean disposable gloves. LVN E used gauze with normal saline to clean the inner open part of the wound and discarded in trash. LVN E disposed of gloves in the trash. LVN E washed hands with soap for seven seconds before rinsing under running water. LVN E used a clean paper towel to dry her hands and disposed in the trash. LVN E used a clean paper towel to turn off the faucet and disposed in the trash. LVN E used a clean gauze with normal saline to clean the other side of the inner wound and discarded in the trash. LVN E disposed of gloves in the trash. LVN E washed hands with soap for five seconds before rinsing under running water. LVN E used a clean paper towel to dry hands and disposed of paper towel in the trash. LVN E used a clean paper towel to turn off water faucet and dispose in the trash. LVN E used dry gauze to pat dry the wound and disposed in the trash. LVN E put on clean pair of disposable gloves. LVN E put calcium alginate on two parts of the wound. LVN E covered the wound with the bandage that was dated and initialed. LVN E removed blue pad and disposed in the trash. LVN E laid resident back, fastened her brief, pulled up her pants, and covered her with a blanket. LVN E gathered trash and disposed of trash in biohazard bag. LVN E removed all PPE and disposed in biohazard bag. LVN E washed hands with soap without lathering and immediately rinsing under water. LVN E used a clean paper towel to dry hands and disposed in the trash. LVN E used a clean paper towel to turn off faucet and disposed in the trash. During an interview on 03/07/2025 at 3;27 PM, The DON and the Administrator were interviewed together. The DON stated that the nurse educator provides training with competency checks a couple times a month for hand washing. The DON stated that as per policy the staff should properly wash their hands with soap and water, after using hand sanitizer three times. The DON stated she expects the staff to follow the policy for peri care, wound care, and hand washing. The DON stated that the negative potential outcome would be increase in infections. The Administrator stated it would be the responsibility of the Administrator to oversee the training and infection control. The Administrator stated, It's always the Administrator. Record review of the facility-provided policy titled, Hand Hygiene, undated, revealed: Objective: Use proper hand washing techniques to keep hands and exposed portions of the arms clean. Procedure: Employees should wash their hands: Before starting work, after visiting resident rooms, and after engaging in any other activity that may contaminate the hands. Handwashing Technique: Turn on warm water. Rinse hands under clean, warm running water. Apply soap. Rub all surfaces of the hands and fingers together vigorously with friction for at least 15 to 20 seconds, giving particular attention to the area under the fingernails, between the fingers/ fingertips, and surfaces of the hands. Rinse under clean, warm running water. Leave water running, dry hands with paper towel. Cloth towels are not permitted to dry hands and do not use apron or uniform. Avoid recontamination of hands and arms by using a paper towel, when turning off hand sink faucets or touching the handle of a restroom door. Discard used paper towels in step trash can. Glove use: Always wash hands before putting on a new pair of gloves. Change gloves any time the team member completes a task. Change gloves after touching an un-sanitized surface or when gloves are soiled or torn. Gloves and hand sanitizers do not replace handwashing with soap and water. Remember, using gloves is not a substitute for proper handwashing with soap and water. Record review of the facility-provided policy titled, Enhanced Barrier Precautions, date revised on 1/20/2023, revealed: Policy Statement: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistance organisms. 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. b. PPE for enhanced barrier precautions is only necessary when performing high contact care activities and ma does not need to be donned prior to entering the resident's room. c. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. e. The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. f. Provide education to residents and visitors. g. Do not restrict room placement or out of room activities due to enhanced barrier precautions. 4. High contact resident care activities include: a. dressing c. transferring d. providing hygiene. e. changing linens. f. changing briefs or assisting with toileting. g. device care or use; central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. h. Wound care: any skin opening requiring a dressing. 9. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at a higher risk. Record review of the facility-provided policy titled, Perineal Care, date revised 01/20/2023, revealed: Policy Statement: Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. Steps in the Procedure: 1. Introduce self to the resident and explain that will be provided. 2. Provide privacy; (pull curtain, and close door) 3. Perform hand hygiene and don gloves. 4. Arrange the supplies so that they can easily be reached. 5. Adjust bedding to resident's comfort and provide dignity during care. 6. Remove clothing enough to perform peri-care. Avoid unnecessary exposure of the resident's body. 7. Remove the soiled clothing, linens, and brief. Place items in the proper receptacle. 8. Encourage the resident to participate in care as able. 9. Provide the steps to peri care for either male or female. 10. Dry area thoroughly. 11. Discard disposable. 12. Remove gloves and discard into designated container. 13. Perform hand hygiene. 14. Reposition bed covers. Make the resident comfortable. 15. Place the call light within easy reach for the resident. 16. Perform hand hygiene. Record review of the facility-provided policy titled, Infection Control Plan, dated July 2024, revealed: Infection Control: The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. 5. Written standards, policies, and procedures for the program include but are not limited to: f. The hand hygiene procedures to be followed by staff involved in direct resident contact. Record review of the Centers for Disease Control website (www.cdc.gov) article titled Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, revealed: Know how to wash hands with soap and water. 3. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Record review of the facility-provided policy titled, Wound Care, date revised 2022, revealed: Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Steps in the Procedure: 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Perform hand hygiene. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on clean gloves. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. 6. Put on clean gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 residents (Residents #2 and #3) reviewed for infection control. 1. CNA A failed to utilize proper hand hygiene during incontinence care for Resident #2 2. CNA B failed to utilize proper hand hygiene during incontinence care for Resident # 3. These failures could place residents at risk for infection and cross contamination. Findings include: 1. Record review of Resident #2's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had a history of Dementia (impaired ability to remember), generalized anxiety disorder, and hypertension (high blood pressure). Record review of Resident #2's MDS dated [DATE], Section C Cognitive patterns revealed Resident #2 had a BIMs score of 08 which indicated the resident had moderate cognitive impairment. MDS Section H- bladder and bowel revealed the resident was always incontinent of bladder and always incontinent of bowel. Record review of Resident #2's care plan dated 4/23/24 revealed the resident had urinary incontinence and required the use of briefs. During an observation on 6/26/2024 at 9:41 PM, revealed CNA A donned (put on) clean gloves after washing her hands with soap and water. CNA A cleaned Resident #2's peri area with wet wipes, doffed (took off) her gloves, and donned new gloves. No hand hygiene was utilized between the glove change. CNA A removed Resident #2's soiled brief, cleaned the resident with wet wipes, and doffed her gloves. No hand hygiene was performed prior to donning new gloves. CNA A secured Resident #2's clean brief, adjusted Resident #2 in bed, and doffed her gloves. CNA A did not perform hand hygiene prior to exiting Resident #2's room. Record review of Resident #3's undated face sheet revealed a [AGE] year-old male, admitted to the facility on [DATE]. Resident #3 had a history of COPD (chronic obstructive pulmonary disorder, obstructive airflow), hypertension (high blood pressure), atrial fibrillation (heart arrythmia), and cognitive communication deficit. Record review of Resident #3's MDS dated [DATE] Section C- Cognitive patterns revealed Resident #3 had a BIMs score of 10, which indicated Resident #3 had moderate cognitive impairment. MDS Section H- bladder and bowel revealed resident was always incontinent of bladder and always incontinent of bowel. Record review of Resident #3's care plan dated 3/26/24 revealed resident had urinary incontinence and required the use of briefs. During an observation on 6/26/2024 at 10:00 PM, revealed CNA B donned gloves to provide incontinence care to Resident #3. No hand hygiene was performed prior to donning gloves. CNA B unfastened Resident #3's brief, cleaned the resident with wet wipes, and assisted the resident to turning to Resident #3's left side. CNA B cleaned Resident #3's bowel movement, discarded the dirty wet wipes and brief. While still wearing the same gloves, CNA B walked to Resident #3's closet, opened the doors, removed a clean brief from the closet and walked back to complete incontinence care. CNA B placed a clean brief under the resident, turned Resident #3 on his back and fastened the brief. CNA B utilized Resident #3's remote to lower the head of the bed, and adjusted Resident #3 in bed to his comfort. CNA B doffed his dirty gloves and discarded them in the trash can. CNA B removed the dirty trash from Resident #3's room and exited the room. No hand hygiene was utilized by CNA B before care, during care, or after incontinence care. During an interview with CNA B on 6/26/24 at 10:16 PM, he stated he had been at the facility for the past 2 months and a CNA for three years. He stated he did not know who the infection preventionist was and he did not remember the last training on infection control. He stated he had been trained on infection control during his CNA Program and at a different facility. He stated the negative outcomes of not utilizing infection control was spreading diseases to residents. He stated the best practice for infection control was handwashing. He stated he thought he changed his gloves at least one time during the incontinence care. He stated he should have changed his gloves and performed had hygiene before touching anything else in the room. During an interview with CNA A on 6/26/24 at 10:35 PM, she stated she did not know who the infection preventionist was. She stated she had training on infection prevention and the last in-service was November of 2023. She stated the negative outcomes of not utilizing infection control is spreading infection and passing it on to other people. CNA A stated she was nervous and forgot to use hand sanitizer between glove changes. During an interview with the ADM on 6/27/24 at 11:14AM, he stated the ADON was responsible for training on infection control and the ADON was the infection preventionist. He stated that walking rounds were conducted to monitor for infection control, and hand hygiene. He stated they also monitored for increased infection rate and the amount of UTI's (urinary tract infections) to monitor infection control. He stated his expectation of staff was to follow the regulation of infection prevention and wash hands after every resident contact. He stated the negative outcomes of not utilizing infection control was sepsis (a serious condition in which the body responds improperly to an infection), infection, UTI's, ill residents and cross contamination. He stated he was not aware of the staff not utilizing proper infection prevention technique. During an interview with the DON on 6/27/24 at 11:21AM, she stated the ADON was the infection preventionist. She stated the educator and charge nurses help with training. She stated audits are conducted on peri-care, resident charts, and monthly antibiotic monitoring with QAPI to monitor infection rates, and infection control. She stated they conduct hand hygiene audits as well to monitor for infection prevention. She stated her expectation of staff is for them to wash their hands prior to entering a resident room, before touching a resident, when removing gloves, any incontinence care and to utilize proper PPE (personal protective equipment). She stated the negative outcome of not utilizing proper infection control is sepsis, passing infection to other residents or passing infections to staff. She stated she was not aware of staff not utilizing proper infection control or prevention technique. During an interview with the ADON on 6/27/24 at 11:35 AM. She stated she was the infection preventionist. She stated staff training is conducted between the ADON, DON and the educator. She stated they have a checklist that is followed, and they will bring staff in to perform hand hygiene and provide feedback as needed. She stated for night shift, she will come in around 5pm and monitor handwashing for evening staff as well. She stated her expectation of staff was for them to wash their hands between residents, and utilize frequent handwashing as needed . She stated the negative outcome of not utilizing infection control and prevention was risk of UTI's, spreading infection and viruses. She stated she was not aware of staff not utilizing proper infection control practices. During an interview with LVN A on 6/27/24 at 11:49AM, she stated the ADON was the infection preventionist. She stated she was the educator and does training as an ongoing daily practice. She stated her expectation of staff was for them to follow policy, procedure, and hand hygiene practices. She stated the risk of not utilizing proper infection control and prevention was risk of infection, increasing infection rates and cross contamination. She stated she was not aware of staff not utilizing proper infection control and prevention technique. Record review of facility policy titled Employee training on Infection Control, last revised on January 2022, revealed: The facility shall provide staff with appropriate information and instruction about infection control through various means including initial orientation and ongoing training programs . 1. All staff and personnel will complete orientation and training on preventing the transmission of healthcare associated infections. 2. The infection preventionist and administrator will identify those disciplines or individuals who need task- or job- specific infection control training beyond that provided by initial orientation or policies and procedures. Record review of facility policy titled Handwashing/Hand Hygiene, last revised on 1/20/2023 revealed: This facility considers hand hygiene the primary needs to prevent the spread of infection . 1. All personnel should value their hand washing campaign and procedures to help prevent the spread of infection to other personnel resident and visitors. 5. Hand hygiene must be performed prior to donning and after doffing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the resident had the right to be free from neglect for 1 of 1 resident (Resident #64), reviewed for neglect when LVN D failed to provide incontinent care services to Resident #64 in a timely manner. LVN D neglected Resident #64 by failing to provide incontinent care when Resident #64 had a bowel movement during wound care when LVN D was aware of R#64's bowel incontinent episode. This failure could affect all residents by placing them at risk of abuse neglect, skin breakdown, mental anguish, emotion distress, infections, and possible serious harm. Findings include: Record Review of Resident #64's face sheet revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with a readmit date of 09/07/2023 with the following diagnoses of: type 2 diabetes with neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), pressure ulcer of the sacral region (stage 4), acute kidney failure, overactive bladder, hyperkalemia (high potassium), neuromuscular dysfunction of the bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem. This nerve damage can be the result of diseases such as multiple sclerosis (MS), Parkinson's disease or diabetes), direct infection of left knee in infectious and parasitic diseases, Methicillin resistant Staphylococcus aures (MRSA, high blood pressure, cholecystitis (inflammation of the gallbladder), elevated white blood count, depression, paraplegia (paralysis of the legs and lower body), acid reflux, constipation, muscle wasting and atrophy, muscle weakness, osteomyelitis of vertebra (vertebral infection), tachycardia (fast heart rate), myositis ( a rare group of diseases characterized by inflamed muscles, which can cause prolonged muscle fatigue and weakness). , . Record review of Resident #64's annual Minimum Data Set (MDS) dated [DATE] documented that Resident #64 was understood and had a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. On the MDS Resident #64 was listed as total dependent with upper and lower body limitation and needing extensive assistance for toilet use and personal hygiene. Resident #64 is listed as bowel incontinence and need maximal assistance with toileting and personal hygiene. Resident #64 was listed as having a stage 4 pressure ulcer. Record Review of Resident #64 Care plan dated for 12/21/2023, revealed: Resident #63 has bowel incontinence, a pressure ulcer to the sacrum, and was at risk for functional decline with no interventions listed. During an observation on 02/21/2024 at 9:45 am of wound care with LVN D for Resident #63, revealed: (observation of wound care) LVN D provided wound care and as she had Resident #64 turned to the right side to finish wound care and bandage, he began to have a bowel movement. LVN D identified that the resident was having a bowel movement and proceeded in laying Resident #64 on his back and covered him up. LVN D stated to Resident #64 that she would get someone to clean him up and left the room. LVN D stated that she had told CNA A to clean up Resident #64. During an observation on 02/21/2024 at 10:18 am of Resident #64, he stated to Surveyor 1 that he had not been cleaned yet. Observation of Resident #64 lying in bed in the same position as when LVN D had left him with being covered with a blanket. Observed Resident #64 laying in a large amount of BM. During an observation on 02/21/2024 at 11:26 am of Resident #64, he stated to Surveyor 1 that he had not been cleaned yet. Observation of Resident #64 lying in bed in the same position as when (9:45 am) LVN D had left him with being covered with a blanket. Observed Resident #64 laying in a large amount of BM. During an observation on 02/21/2024 at 12:10 PM of Resident #64, he stated that CNA A had just changed him a few minutes prior at approximately 12:00 pm. Observed Resident #64 with clean brief. During an interview with LVN D on 02/22/2024 at 3:25 PM. LVN D stated that she had told CNA A to clean Resident #63 up after wound care was completed. LVN D stated that she did not know if State was going to want to watch any more wound care observations. LVN D stated she can provide incontinent care for residents and should have just cleaned up Resident #63. LVN D stated that she had been trained in neglect. LVN D stated that the training consisted of in-services and are held approximately every month. LVN D stated that the negative potential outcome for not providing incontinent care is skin breakdown, more wounds or neglect. During an interview with CNA A on 02/22/2024 at 3:40 PM. CNA A stated that no one had told her that Resident #63 needed to be cleaned up. CNA A stated that she normally makes her rounds every 2 hours unless the resident needs it before that. CNA A stated that if she had known she would have cleaned Resident #63 up. CNA A stated that she had been trained in neglect and the facility will usually hold an in-service approximately every other week. CNA A stated that the negative potential outcome for leaving a resident dirty is skin break down and makes the resident feel dirty. During an interview with Resident #64 on 02/22/2024 at 4:15 PM. Resident #64 stated that it took a while for someone to go clean him up. Resident #64 stated that the CNA went to clean him up, but it took a long time for someone to go clean him up. Resident #64 stated that him being left like that makes him feel dirty, uncomfortable, embarrassed, and helpless. Resident #64 stated that it makes him think that the staff do not want to help him. Resident #64 stated who wants to be left like that. Resident #64 stated that he is not able to clean himself up or he would have done it himself. Resident #63 stated that he would like to have seen them clean him up a little quicker instead of waiting for over and hour to do it. Resident #63 stated that if they were the ones who had to lay in that they would have wanted someone to clean them up quicker also but because it is not them laying in it, they are not in a hurry. During an interview with LVN F on 02/21/2024 at 4:37 PM. LVN F stated that she does believe that CNA A changed Resident #64. LVN F stated that she was the charge nurse on the hall in question. LVN F stated that she was not aware of LVN D leaving Resident #64 laying in feces for over an hour. LVN F stated that she would have expected LVN D to clean Resident #64 and that she is very capable of providing incontinent care. LVN F stated that she does not understand why LVN D would just leave Resident #64 like that and expect someone else to clean him when she could have just cleaned him right then and it would have been taken care of. LVN F stated that the facility does provide in-services on neglect about every other week or so. LVN F stated that the negative potential outcome for leaving a resident laying in feces for a period of time could be skin break down or worsening of wounds. During an interview with DON on 2/22/24 at 3:35PM stated was not aware of the situation that occurred with Resident #64 being left in his bowel movement for over an hour. DON stated all nurses have the ability to provide resident care, including the treatment nurses. She stated she would discuss with the educator on addressing the concerns. During an interview with Administrator on 2/22/24 at 3:35PM, he stated staff has been trained on providing dignity during incontinence care and wound care. He stated training occurs initially on hire, and quarterly and in-services as needed. He stated the ADM is the abuse coordinator. He stated the last training was the beginning of February 2024. He stated he ADM, and the educator, are responsible for the training. He stated the negative consequences of abuse, neglect, and exploitation are that the resident may have a negative reaction and hurt the resident physically, mentally, and emotionally. Administrator stated an example of neglect is not checking on your patients in a timely manner and ignoring resident care. He stated he was not aware of the resident being left in his own bowel movement and his expectation of all nursing staff is to provide care if it is within their scope. He stated that situation should never have happened, and he would address the situation. Record review of a facility document titled, Abuse, Neglect, and Exploitation, date not provided, revealed: Policy Statement: The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. Policy Interpretation and Implementation: 1. The facility will develop and implement written policies and procedures that: A). Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Prevention of Abuse, Neglect, and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B). Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents care needs and behavioral symptoms. G). Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur. Identification of Abuse, Neglect, and Exploitation: B). Possible indicators of abuse included, but are not limited to: 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning, and positioning. Record review of a facility document titled, Abuse Prevention Program, date revised 1/9/2023, revealed: Policy Statements: 1. The Administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures in accordance with the Elder Justice Act. 2. Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. 5. Our Center will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately. 7. All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies. 9. All occurrences of abuse, neglect, mistreatment, injuries of unknown source and theft or misappropriation of resident property will be analyzed b the Quality Assurance and Performance Improvement (QAPI) Committee to determine if system changes need to be made. Policy Interpretation and Implementation: As part of the resident abuse prevention program, the Administrator will: 3. Develop and Implement policies and procedures to aid our Center in preventing abuse, neglect, or mistreatment of our residents. CMS defines the following: 2. Neglect: as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Reporting: 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the Center Administrator or his/her designee, to the following personas or agencies required; a). The Stated licensing/certification agency responsible for surveying/licensing the Center, b). The Resident's Representative of Record. 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately. Record Review of facility provided in-service, labeled, Abuse/Neglect/Misappropriation, dated 1/26/2024, revealed: Topic: Patients have the right to live in a safe environment and free of any abuse/neglect. It is all staff responsibility to identify and report any abuse, neglect, or misappropriation. Patients have the right to have personal belongings secured. Types of abuse are physical, mental, verbal, sexual, neglect, and financial. It is all staff responsibility to identify and report any abuse/neglect/misappropriation immediately to the Administrator who is the abuse preventionist. Signed and dated by 38 staff members. In-Service states: All residents must be free from abuse and neglect, and it is everyone's responsibility to be able to identify what abuse/neglect is, report abuse/neglect in a timely and appropriate manner with no fear of reprisal, know to whom to report their knowledge of abuse/neglect. The Administrator is the Abuse preventionist/coordinator. All reports of abuse, neglect, exploitation, misappropriation, mistreatment, and injuries of unknown source will be reported to local, state, and federal agencies. Neglect: harming someone because services were not given or not given right. You report abuse as soon as it is brought to your attention. You report to the Abuse Coordinator/Preventionist immediately. Administrator and/or DON. If in doubt, report. Record Review of facility provided in-service, labeled, Resident Rights, dated Revised in February 2021, revealed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a). a dignified existence. b). be treated with respect, kindness, and dignity. c). be free from abuse, neglect, misappropriation of property, and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 2 of 2 resident for dignity and catheter care (Resident #64 and Resident #106); in that: 1. The facility failed to ensure respect and dignity to Resident #64 by LVN D knowingly leaving him lying in feces for over an hour, when he had a bowel movement during wound care. 2. The facility failed to place catheter tubing off the floor and place a cover on the catheter. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings include: Record Review of Resident #64's face sheet revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with a readmit date of 09/07/2023 with the following diagnoses of: type 2 diabetes with neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet), pressure ulcer of the sacral region (stage 4), acute kidney failure, overactive bladder, hyperkalemia (high potassium), neuromuscular dysfunction of the bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem. This nerve damage can be the result of diseases such as multiple sclerosis (MS), Parkinson's disease or diabetes), direct infection of left knee in infectious and parasitic diseases, Methicillin resistant Staphylococcus aures (MRSA, high blood pressure, cholecystitis (inflammation of the gallbladder), elevated white blood count, depression, paraplegia (paralysis of the legs and lower body), acid reflux, constipation, muscle wasting and atrophy, muscle weakness, osteomyelitis of vertebra (vertebral infection), tachycardia (fast heart rate), myositis ( a rare group of diseases characterized by inflamed muscles, which can cause prolonged muscle fatigue and weakness). , . Record review of Resident #64's annual Minimum Data Set (MDS) dated [DATE] documented that Resident #64 was understood and had a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. Record Review of Resident #64 Care plan dated for 12/19/2023, revealed: Resident #64 was at risk of psychosocial well-being (the state of mental, emotional, and social health of an individual). No interventions listed. During an observation on 02/21/2024 at 9:45 am of wound care with LVN D for Resident #64, revealed: (observation of wound care) LVN D provided wound care and as she had Resident #64 turned to the right side to finish wound care and bandage, he began to have a bowel movement. LVN D identified that the resident was having a bowel movement and proceeded in laying Resident #64 on his back and covered him up. LVN D stated to Resident #64 that she would get someone to clean him up and left the room. LVN D stated that she had told CNA A to clean up Resident #64. During an observation on 02/21/2024 at 10:18 am of Resident #64, he stated to Surveyor 1 that he had not been cleaned yet. Observation of Resident #64 lying in bed in the same position as when LVN D had left him with being covered with a blanket. Observed Resident #64 laying in a large amount of feces. During an Observation on 02/21/2024 at 11:26 am of Resident #64, he stated to Surveyor 1 that he had not been cleaned yet. Observation of Resident #64 lying in bed in the same position as when LVN D had left him with being covered with a blanket. Observed Resident #64 laying in a large amount of feces. During an Observation on 02/21/2024 at 12:10 PM of Resident #64, he stated that CNA A had just changed him a few minutes prior at approximately 12:00 pm. Observed Resident #64 with clean brief. During an interview with LVN D on 02/22/2024 at 3:25 PM. LVN D stated that she had told CNA A to clean Resident #64 up after wound care was completed. LVN D stated that she did not know if State was going to want to watch any more wound care observations. LVN D stated she can provide incontinent care for residents and should have just cleaned up Resident #64. LVN D stated that she had been trained in dignity and. LVN D stated that the training consisted of in-services and are held approximately every month. LVN D stated that the negative potential outcome for not providing incontinent care was skin breakdown, more wounds or neglect and feeling helpless. During an interview with CNA A on 02/22/2024 at 3:40 PM. CNA A stated that no one had told her that Resident #64 needed to be cleaned up. CNA A stated that she normally makes her rounds every 2 hours unless the resident needs it before that. CNA A stated that if she had known she would have cleaned Resident #64 up. CNA A stated that she had been trained in dignity and the facility will usually hold an in-service approximately every other week. CNA A stated that the negative potential outcome for leaving a resident dirty was skin break down and makes the resident feel dirty. During an interview with Resident #64 on 02/22/2024 at 4:15 PM. Resident #64 stated that it took a while for someone to go clean him up. Resident #64 stated that the CNA went to clean him up, but it took a long time for someone to go clean him up. Resident #64 stated that him being left like that makes him feel dirty, uncomfortable, embarrassed, and helpless. Resident #64 stated, I don't like it, it makes me feel bad. Resident #64 stated that it makes him think that the staff do not want to help him. Resident #64 stated who wants to be left like that. Resident #64 stated that he was not able to clean himself up or he would have done it himself. Resident #64 stated that he would like to have seen them clean him up a little quicker instead of waiting for over and hour to do it. Resident #63 stated that if they were the ones who had to lay in that they would have wanted someone to clean them up quicker also but because it was not them laying in it, they are not in a hurry. During an interview with LVN F on 02/21/2024 at 4:37 PM. LVN F stated that she does believe that CNA A changed Resident #64. LVN F stated that she was the charge nurse on the hall in question. LVN F stated that she was not aware of LVN D leaving Resident #64 laying in feces for over an hour. LVN F stated that she would have expected LVN D to clean Resident #64 and that she is very capable of providing incontinent care. LVN F stated that she does not understand why LVN D would just leave Resident #64 like that and expect someone else to clean him when she could have just cleaned him right then and it would have been taken care of. LVN F stated that the facility does provide in-services about every other week or so. LVN F stated that the negative potential outcome for leaving a resident laying in feces for a period of time could be skin break down or worsening of wounds and would make him possible feel embarrassed. During an Interview with DON on 2/22/24 at 3:35PM stated was not aware of the situation that occurred with Resident #64 being left in his bowel movement for over an hour. DON stated all nurses have the ability to provide resident care, including the treatment nurses. She stated she would discuss with the educator on addressing the concerns. . During an Interview with Administrator on 2/22/24 at 3:35PM, he stated staff has been trained on providing dignity during incontinence care and wound care. He stated training occurs initially on hire, and quarterly and in-services as needed. He stated the last training was the beginning of February 2024. He stated he and the educator, are responsible for the training. He stated the negative consequences of dignity are the resident may have a negative reaction and hurt the resident physically, mentally, and emotionally. He stated he was not aware of the resident being left in his own bowel movement and his expectation of all nursing staff is to provide care if it is within their scope. He stated that situation should never have happened, and he would address the situation. Record Review of Resident #106's face sheet revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE] with a readmit date of 09/07/2023 with the following diagnoses of: Type 2 diabetes mellitus, Pressure ulcer stage 4, Acute kidney failure, Overactive bladder, bacterial pneumonia, Hypertension (high blood pressure) Retention of urine, Elevated white blood cell count, Depression, unspecified, Anemia, unspecified, Paraplegia, acid reflux, Muscle wasting and atrophy. Record review of Resident #106's annual Minimum Data Set (MDS) dated [DATE] documented that Resident #106 was understood and had a BIMS (Brief Interview for Mental Status) score of 10, which indicated moderately impaired. In an observation and interview on 02/20/24 at 10:11 AM, Resident #106's catheter tubing was laying on the floor with no privacy bag present.? Resident #106 stated he has had UTI's in the past and was sure if he had one at this time, they took labs this morning.? In an observation on 02/20/24 at 1:09 PM, Resident #106's catheter tubing was laying on the floor with no privacy bag present. In an observation on 02/20/24 at 6:30 PM, Resident #106's catheter tubing was laying on the floor with no privacy bag present.? In an observation on 02/21/24 at 7:15 AM, Resident #106's catheter tubing was laying on the floor with no privacy bag present. In an observation on 02/21/24 at 5:00 PM, Resident #106's catheter tubing was laying on the floor with no privacy bag present. In an observation on 02/22/ at 9:20 AM, Resident #106's catheter tubing was laying on the floor with no privacy bag present.? In an interview on 02/22/24 at 4:20 PM, DON stated the catheter should be below the bladder, with a privacy bag, free from any tangles, not a full bag, and the bag or the tubing should not be on the floor.? DON stated that can contribute to infections in the kidneys and bladder. Record Review of facility provided in-service, labeled, Resident Rights, dated Revised in February 2021, revealed: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a). a dignified existence. b). be treated with respect, kindness, and dignity. c). be free from abuse, neglect, misappropriation of property, and exploitation. Record review of Catheter Care dated 2023. Policy: It is the policy of this facility to ensure that residents with indwelling catheter receive appropriate catheter care and maintain their dignity and privacy when indwelling catheter are in use: Policy Explanation: 1. Catheter care will be performed every shift and a s needed by nursing personnel. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 3. Privacy will be changed out when soiled, with a catheter change or as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for 3 of 3 residents (Resident #102, #106, and #276) reviewed for privacy issues in that: 1. Housekeeper failed to knock and introduce herself prior to entering Resident #276 room. 2. NA failed to provide privacy by not pulling curtain all the way for Resident #102 during perineal care. 3. LVN E failed to pull the privacy curtain while providing wound care for Resident #102. 4. LVN G failed to pull the privacy curtain while providing wound care for Resident #106. This failure could cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by. Findings include: Record Review of Resident #102 face sheet dated 2/22/2024 reveals a [AGE] year-old female, originally admitted on [DATE] with a primary diagnosis of fracture of shaft on left tibia, reduced mobility, thrombocytopenia (low platelet level), high blood pressure, heart failure, pleural effusion (buildup of fluid between the tissues that line the lungs and the chest), acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), muscle weakness, chronic kidney failure. Record review of resident #102 MDS with a date of 11/23/2023, reveals a BIMS score of 14 which indicates resident is cognitively intact. During observation of NA providing perineal care of Resident #102 and not pulling the privacy curtain to provide privacy on 2/21/2024 at 2:55 PM. NA was observed providing perineal care for Resident #102 and not pulling the privacy curtain and other staff came to the resident door and opening the door after knocking, but no curtain to provide privacy for the resident. Interview with NA on 2/21/2024 at 3:00 PM. stated that she should have known better to not pull the curtain. NA stated that she was caught off guard and should have pulled the curtain. NA stated that she had been trained in providing privacy. NA stated that they had in-services and they are held approximately monthly. NA stated that the negative potential outcome for not providing residents privacy was that they could be exposed and make them feel violated. During an observation with LVN E on 2/21/2024 at 3:18 PM. during wound care with LVN E for Resident #102, she failed to pull the privacy curtain during wound care. LVN E went through the entire process of wound care without providing privacy by pulling the privacy curtain while she went out of the room twice and came back into resident room. Another unidentified staff member came into the resident room and had opened the door during wound care. During an interview with the LVN E on 2/22/2024 at 2:15 PM. stated that she forgot to pull the privacy curtain. LVN E stated that she had been trained in providing privacy through in-services usually weekly. LVN E stated that the negative potential outcome of not providing privacy would be that the resident could be exposed. Record Review of Resident #106 face sheet dated 2/22/2024 reveals a [AGE] year-old male, originally admitted on [DATE] with a diagnosis of: insomnia, depression, high blood pressure, pressure ulcer, anemia, urinary tract infection, retention of urine, altered mental status, hyperlipidemia (high levels of fat particles in the blood, cachexia (a general state of ill health involving weight loss and muscle loss), hyperhidrosis (excessive sweating), osteomyelitis (inflammation of bone caused by infection generally in the legs, arms, or spine), sepsis (a life-threatening complication of an infection), hydronephrosis (excess fluid in thee kidney due to a backup of urine), neuromuscular dysfunction of bladder. Record review of resident #106 MDS with a date of 2/1/2024, reveals a BIMS score of 10 which indicates resident is moderately impaired. Observation made during wound care for Resident #106 for LVN G on 2/21/2024 at 11:18 AM. LVN G failed to pull the privacy curtain when providing wound care for Resident #106. Resident #106 roommate had gone to the restroom which was on Resident #106 side of the room and the curtain was not pulled, allowing Resident #106 roommate to observe the bare backside of Resident #106 as well as the residents open wound. Interview with LVN G on 02/22/2024 at 11:52 AM. LVN G stated that she had forgot to pull the curtain before providing wound care. LVN G stated that she had been trained in privacy through in-services monthly. She stated that the negative potential outcome is exposing the resident and they may be embarrassed. . During an observation of housekeeper on 02/22/2024 at 2:15 PM of housekeeper entering Resident #276's room without knocking or introducing herself. Housekeeper did not acknowledge Resident #276. Housekeeper walked in resident room, stood there for some time, and then just walked out. During this time Surveyor 1 was in the room trying to interview and had to stop the interview through the interruption. During an Interview with housekeeper on 02/22/2024 at 2:18 PM. Housekeeper stated that she had been trained in knocking on resident's doors before entering by in-services. She stated that training had been monthly. She stated that they also do verbal training by one on one with the administrator. She stated that she knows that she should have knocked on Resident #276. She stated that the negative potential outcome of not knocking and introducing herself to residents was that it could make them sad, they may be confused, and scared. During an Interview with Resident #276 on 2/22/24 at 2:26 PM. He stated that he would prefer that the staff would knock before entering because he may be trying to get dressed. He stated that it makes him feel as if he cannot have any privacy or be worried if he were trying to get dressed. He stated that he does not like that the staff will just walk in his room like that. During an Interview with Administrator on 2/22/24 at 3:35PM, he stated staff has been trained on providing privacy and dignity during incontinence care and wound care. He stated training occurs initially on hire, and quarterly. He stated the negative potential outcome of not providing privacy could be embarrassment and loss of dignity for the resident. He stated his expectation of staff when providing any sort of care is to close the door, pull the curtain between roommates, and prevent anyone from entering during care. He stated staff not knocking on the residents' doors before entering can affect the resident's privacy. He stated, We wouldn't want someone to barge into our homes. During an Interview with DON on 02/22/2024 at 3:45 PM, she stated that the negative consequences for not providing privacy for residents is emotional distress, lack of self-confidence, and depression. She stated that her expectations regarding knocking is that all staff should knock prior to entering any room. She stated that her expectations for providing privacy while providing care is to make sure resident has privacy by pulling the curtain, have family step out if they are in there, and close the door and perform care. She stated that staff is trained in providing privacy weekly. Record Review of facility policy, labeled, Resident Rights Guidelines for All Nursing Procedures, date Revised October 2010, revealed: Purpose: To prove guidelines for resident rights while caring for the resident. Preparation: 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: b). Resident dignity and respect. General Guidelines: 1. For any procedure that involves direct resident care, follow these steps: a). Knock and gain permission before entering the resident's room. f). Close the room entrance door and provide for the resident's privacy. Record Review of facility in-service, provided on 02/22/2024, labeled, Privacy, dated on 02/06/2024, revealed: Topic: Before working with a patient, we must inform patient what we are doing. Introduce self-when entering a patient room. Always ask about comfort and provide privacy. Signed and dated by 16 staff members.

Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were accurately acquired, received, dispensed, and administered in accordance with currently accepted professional standards for 2 of 3 medication carts (Wildflower Cart A and B) , 2 of 2 medication rooms (Wildflower Med room A and Rapid med room B) and 1 of 1 treatment cart (Treatment cart A) reviewed. 1. The facility failed to ensure that all medical supplies stored in Cart A were not past their expiration date. 2. The facility failed to ensure that all medication stored in Cart B were not past their expiration date. 3. The facility failed to ensure that all medication stored in Medication room A were not past their expiration date. 4. The facility failed to ensure that all treatment supplies and medication in Treatment Cart A were not past their expiration date. 5. The facility failed to ensure all medical supplies in Medication room B were not past their expiration date. These failures placed all residents at risk of harm or decline in health due to lack of potency of medications and expired medical supplies. The findings included: During an observation of Medication Cart A on 2/21/2024 at 07:45 AM, it revealed a bottle of hand sanitizer with an expiration date of 6/2022. During an observation of Medication Cart B on 2/21/2024 at 8:10 AM it revealed a bottle of One-Daily multi-vitamin with an expiration date of 8/2023 and Geri-Lanta regular strength antacid and anti-gas, with expiration date of 9/2023 and an open date of 12/21/2023. During an observation Medication Room A on 2/21/2024 at 8:15 AM revealed a Sore throat Spray- Phenol 1.4% with expiration date of 1/24. During an interview with LVN A on 2/21/24 at 07:50 AM she stated risk of having expired hand sanitizer stocked in the cart, was the hand sanitizer being ineffective. She stated the medication carts should be checked daily for expired medication and it was all the nurse's job to check the carts. She stated there was a non-resident task that appears for the nurses on their electronic charting system, and it requires medication carts to be cleaned and organized daily. She stated she has been trained on keeping the carts clean but is not sure when her last training was. She stated the ADON is responsible for the training. During an interview with LVN C on 2/21/24 at 8:20 AM she stated expired medications should not be kept in the medication carts and should be disposed of appropriately. She stated medication carts are checked every month. She stated the risk of using expired medication was the medications not working effectively. She stated they are trained to a check the medication carts and medication rooms frequently, and her last training was 2 months ago. She states LVN B and ADON are responsible for training. During an observation of Treatment Cart A on 2/21/24 at 11:00 AM, it revealed a debridement kit (specially curated sets of instruments designed to remove dead tissue, foreign material, and bacteria from wounds) with an expiration date of 12/31/2020, vitamin A&D ointment with an expiration date of 5/2022, wound closure strips with an expiration date of 11/14/2019 and a culture swab (Used to find infections in open wounds or on burn injuries) with an expiration date of 12/31/2022. During an interview with LVN D the Wound Care Nurse on 2/21/24 at 11:10 AM, she stated her infection preventionist was the ADON. She stated she has been trained on checking the treatment cart and her last training was 2/2024. She stated the risk of utilizing expired wound care items was the items being contaminated. She states she checks the treatment cart monthly per her facility policy. During an observation of Medication Room B on 2/21/2024 at 11:15 AM it revealed 23 Red top lab tubes (utilized for blood serology and chemistry testing) with an expiration date of 2023-12-04. During an interview with LVN E on 2/21/2024 at 11:19AM she stated all the nurses are responsible for ensuring equipment and medication are up to date in the medication room. She stated negative consequences of utilizing expired lab tubes could be inaccurate results of lab work. She stated the ADON was responsible for her training. During an interview with ADM on 2/22/2024 at 2:45 PM, he stated medication carts, treatment carts and medication rooms are checked twice a month and are checked for expired medication and expired medical supplies. The ADM stated the negative consequences of utilizing expired medication and medical supplies could be debilitating the resident's health. He stated staff are trained on medication storage on hire, quarterly and annually. He stated the DON is responsible for training. During an interview with the DON on 2/22/2024 at 2:54 PM, she stated all medication carts should be checked at the beginning of each shift. She stated the negative consequences of not checking medication carts could be giving the wrong medication to a resident and any adverse event. She stated medication rooms and treatment carts are checked weekly. She stated any nurse who utilizes the medication carts, treatment carts and medication rooms are responsible for ensuring everything is up to date. She stated the ADON or DON check the carts, and medication rooms weekly. She stated staff are trained on medication storage annually and as needed. She stated LVN B was responsible for the training. During an interview with LVN B, (the educator) on 2/22/24 at 3:12 PM, stated staff are trained on medication storage as needed. She stated she conducts in-services that educated staff on keeping the carts and medication rooms clean, checking medication expiration dates, checking the carts for loose pills, and counting controlled medications. She stated all carts should be checked each shift and it is the responsibility of the nurse who is assuming care of that cart to check that they have a working cart with no expired medication or supplies. Record Review of policy titled Storage of Medications with a revision date of November 2020 revealed . The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4 Discontinued, outdate, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 3 medication carts (Sunflower cart C), and 1 of 2 medication rooms (Rapid med room B) reviewed. 1. The facility failed to ensure proper temperature documentation of the refrigerator in Medication room B. 2. The facility failed to ensure all medication in Medication Cart C were properly labeled. These failures placed all residents at risk of harm or decline in health due to lack of medication labeling, and inadequate temperature monitoring. The findings include: During an observation of Medication Room B on 2/21/2024 at 11:15 AM it revealed the medication storage refrigerator in Medication room B had a temperature log dated 12/2023. The last checked temperature on 12/5/2023 with a logged temperature of 39 degrees Fahrenheit. Record review of documentation labeled Temperature Log for Refrigerator-Fahrenheit dated 12/23 revealed a logged temperature for dates 12/1/23, 12/4/23, and 12/5/2023. No documentation for 12/2/23, 12/3/23, or 12/6/23-2/21/24 were completed. During an interview with LVN E on 2/21/2024 at 11:19AM she stated all the nurses are responsible for ensuring medical equipment and temperature logs are up to date. She stated refrigerator temperatures should be checked daily. She stated the ADON is responsible for her training. During an Observation of Medication Cart C on 2/21/2024 at 12:10 PM it revealed an unlabeled loose blue pill between medication packets. The unlabeled blue pill was taken to the DON by LVN F. The DON was able to identify the pill as sertraline 50mg. During an interview with LVN F on 2/21/2024 at 12:20 PM she stated she checks the medication cart weekly. She stated all the nurses, ADON and DON are responsible for ensuring the medication carts are clean and organized. She states she has been trained on keeping the medication carts clean and her last training was 9 months ago upon hire. She stated the risk of medication not being labeled is giving a resident the wrong medication. During an interview with ADM on 2/22/2024 at 2:45 PM, he stated medication carts, treatment carts and medication rooms are checked twice a month for cleanliness. The ADM stated the medication refrigerators should be checked daily and the temperatures logged. He stated the charge nurses are responsible for checking the temperatures. He stated staff are trained on medication storage on hire, quarterly and annually. He stated the DON is responsible for training. During an interview with the DON on 2/22/2024 at 2:54 PM, she stated all medication carts should be checked at the beginning of each shift. She stated the negative consequences of not checking medication carts could be giving the wrong medication to a resident and any adverse event. She stated medication rooms and treatment carts are checked weekly. She stated any nurse who utilizes the medication carts, treatment carts and medication rooms are responsible for ensuring everything is up to date. She stated the ADON or DON check the carts, and medication rooms weekly. She stated medication refrigerators for medication storages should be checked daily by the charge nurse and temperatures documented. She stated all refrigerators are checked weekly by DON or ADON. She stated staff are trained on medication storage annually and as needed. She stated LVN B is responsible for the training. During an interview with LVN B, the educator on 2/22/24 at 3:12 PM, she stated staff are trained on medication storage as needed. She stated she conducts in-services that educated staff on keeping the carts and medication rooms clean, checking medication dates, checking the carts for loose pills, and counting controlled medications. She stated all carts should be checked each shift and it is the responsibility of the nurse who is assuming care of that cart to check that they have a working cart. Record Review of policy titled Medication Storage in the Facility with an effective date of 6/2/2022 revealed . Policy: Medications and biologicals are stored safely, securely, and properly: C. All medications dispensed by pharmacy are stored in the container with the pharmacy label. Temperature . E. The facility should maintain a temperature log in the storage area to record temperatures at least once a day. Record Review of policy titled Storage of Medications with a revision date of November 2020 revealed: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and attractive for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable and attractive for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (2/21/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews 9 of 32 residents voiced concerns related to food palatability and appearance. One Resident stated that the food it's crap to me. She stated she did not like the flavor and texture. Another Resident stated the food was horrible. It's cold it has no flavor, and the squash was mushy. It floats on the plate . Yet another Resident had concerns with food palatability. She stated, I don't like the food. One Resident said the presentation of the food was not good and did not look good. He stated that his family brings him food. Another Resident stated he had issues with the flavor/seasoning of the foods. He stated, the eggs are salty, and they need pepper. Two residents stated the food was not good at all. Another Resident stated the food was horrible, and the food in general did not taste good. In another confidential interview, a Resident stated the food was so bad, they did not eat any of it; they have a man come by every day to bring them something to eat. The Resident stated they eat about one meal day, what the guy brings him. The Resident stated they cannot afford to continue to have food brought in from the outside. The Resident showed a picture of what was on the plate for lunch, scoop a mash potatoes and bowl of something that the resident could not identify. The following interviews and observations were made during a kitchen tour on 2/21/24 that began at 11:41 AM and concluded at 1:05 PM: During an interview on 2/21/24 at 11:41 AM the Dietary Manager was informed of a request for a test tray. On 2/21/24 at 11:43 AM temperatures were taken on the steam table by the Dietary Manager with the following results: Pork patty 189°F and several of the pork patties in the pan had a dark and dry appearance. Black Eyed Peas, 198°F Cauliflower 177.4°F. Gravy 186.9°F. Cheese sauce 163.2°F. Fortified potatoes 176.4°F. Ground pork patty 174°F and had a dark dry appearance. Puréed bread 151°F. Puréed cauliflower 176°F. Purée pork patty 170°F. Purée black-eyed peas 162.5°F and had a coarse appearance. Meat pie 156°F. Corn muffin room temperature Meal service started on 2/21/24 at 12:00 PM. The last tray was prepared for the center hall section cart #1 at 12:16 PM and left the kitchen at 12:17 PM. They started center cart section cart #2 at 12:17 PM and the last tray was prepared at 12:28 PM and cart #2 left the kitchen at 12:29 PM. Preparation started for the hall 300 rapid recovery cart at 12:28 PM and the last tray was prepared at 12:49 PM. On 2/21/24 at 12:42 PM, a puréed meal tray was prepared for Resident #55 . The purée was flat on the plate, and he received puréed pork, puréed, black-eyed peas, puréed bread, and the purée. Cauliflower was placed on top of the puréed bread on the three-section plate. The foods were all tan colored on the plate. The tray was prepared by Dietary staff A. The hall 300 cart left at 12:50 PM. Tray preparation started for hall cart 100/200 at 12:50 PM. On 2/21/24 at 12:54 PM the purée tray was prepared for Resident #33 and the foods were flat on the plate and the plate had an overall beige/tan color. The resident was served puréed bread, puréed, cauliflower, puréed, pork patty, purée black-eyed peas and gravy. The last tray was prepared for the 100/200 hall at 1:02 PM. Preparation for the test trays started at 1:02 PM and ended at 1:04 PM. The cart left the kitchen at 1:05 PM and got to the unit at 1:06 PM. On 2/21/22 at 1:08 PM the DON began serving the trays off the cart for cart 100/200. Another staff member started to serve at 1:09 p.m. and another two staff members assisted in passing trays at 1:11 PM. Resident #99 was the last individual served from the cart at 1:20 PM and he began to eat at 1:21 PM. The test tray arrived for testing on 1:22 PM. The test tray temperatures were taken, and testing began at 1:23 PM. with the following results: Ground pork 115°F Did not have a pork type flavor and had poor flavoring. Pork patty with gravy 125°F had very poor flavor, very little pork flavor to it and had an old type of dry taste. Purée cauliflower 125°F poor appearance - flat on the plate. Puréed bread 120°F poor appearance - flat on the plate. Purée, black-eyed peas 125°F poor appearance - flat on the plate. Puréed pork patty 122°F texture not smooth and had a grainy texture. Poor appearance - flat on the plate. Six of 12 foods sampled had poor flavor, texture and or appearance issues. The colors of the foods were all brown, tan or beige and the purée appearance was flat and not in a purée form. On 2/22/24 at 2:00 PM an interview was conducted with the Dietary Manager regarding palatability issues with the food. She stated staff were ordering pork chops and changed to the pork patty. Staff had changed (Food) vendors. She stated they would remove the pork patty from the menu. She added staff had added beef broth to the puréed pork. She also stated they were having problems with the pork chop texture and that's why we went to the pork patty. She stated the pork was not a great meat and that some of their menus did have the same colors of food. She stated, staff add seasoning, and we asked the dietitian to change out food in order to improve food palatability. She stated staff could have added parsley and onions to make the food more attractive looking. She stated she was responsible for ensuring foods were palatable. She added residents would not eat the food and would not get the nutrition from the meal if foods were not palatable and attractive. She stated some residents were vocal individually about the foods and she had attended the resident council meetings. On 2/22/24 at 5:06 PM an interview was conducted with the Administrator regarding palatability of the foods. He stated palatability was subjective but if he received a number of residents that said the same thing about the food, he would have a problem with the menu. He added the food vendor was new to this are. He stated he expected the food presentation to have, garnishes, and added color. He stated he had talk to residents about this issue. He stated he was ultimately responsible for the palatability of the food. He stated resident could feel like they were eating in jail and would have a reduced confidence in what we do here, if foods were not palatable. Record review of the Resident Council Meeting Agenda, Meeting Date: 2/15/24 revealed the following documentation, . 12. Dietary Concerns: resident said dietary is bringing trays to the hall and residents say food does not taste that great .They said trays sit for a while . Food Correct Temp. Residents say food needs to be warmer . Record review of the Resident Council Meeting Agenda, Meeting Date: 1/3/24, revealed the following documentation, . 12. Dietary Concerns. Residents aren't happy with the food; they serve food cold . Food is making residents sick . Residents say they need a new cook . Food Correct Temp. breakfast is cold. Other meals cold on Sunflower and they have no microwave to heat food up . Record review of the facility's, policy titled Food and Nutrition Services, revised September 2021, revealed the following documentation, Policy Statement. Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation. 1. The multidisciplinary staff, including nursing staff, the attending physician, and the dietitian will assess each residents' nutritional needs, food likes, dislikes, and eating habits, as well as physical, functional and psychosocial factors that affect eating and nutritional intake and utilization. 2. Resident center diet and nutritional plan will be based on this assessment. 3. Meals and/or nutritional supplements will be provided at schedule mealtimes, and in accordance with the resident's medication requirements . 6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the dietary staff so that a new food tray can be issued .

**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 to help prevent the development and transmission of communicable diseases and infections for 4 of 4 of Residents (Resident #52, #61, #72, and #102) observed for infection control for 4 0f 8 resident's reviewed for infection control practices (Resident #52, #61, #72, and #102). 1. CNA A failed to wash her hands before, during, and after incontinent care of Resident #52. 2. LVN E failed to wash her hands properly. She turned on water, placed soap on hands, and immediately started washing hands under running water and not allowing soap to lather. LVN E used a dirty paper towel to turn off the faucet after wound care for Resident #102. 3. NA failed to wash her hands before, during, and after incontinent care for Resident #102. 4. LVN A did not sanitize the blood pressure cuff before or after use on Resident #61. 5. LVN A entered resident #72 room without washing her hands. LVN A placed blood pressure cuff on resident, without cleaning the blood pressure cuff prior to use or after use. LVN A exited Resident #72's room without washing her hands and began prepping Resident #72 medications. These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Resident #52: Record Review of Resident #52's face sheet reveals a [AGE] year-old female, originally admitted on [DATE] and readmitted on [DATE] with a diagnosis of dementia, anxiety, muscle weakness, dysphagia, fractured hip, depression, acute bronchitis, hyperkalemia (high potassium), insomnia, type 2 diabetes, vitamin D deficiency, acid reflux, atherosclerotic heart disease (buildup of cholesterol plaque in the walls of arteries causing obstruction of blood flow), anemia. Record review of resident #52 MDS with a date of 11/06/2023, reveals a BIMS score of 06 which indicates Resident #52 is severely cognitively impaired. Record review of Resident #52's care plan dated 02/06/2024 revealed a risk for pressure ulcers with occasional incontinence and need of assist with some or part of ADLs with interventions listed as: keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry and wrinkle free. Record review of Resident #52's care plan dated 02/06/2024 revealed a risk of urinary incontinence with occasional bladder weakness with the interventions of provide incontinence care after each incontinent episode. Report any signs of skin breakdown. During an observation with CNA A for perineal care for Resident #52 on 2/22/2024 at 9:47 AM. CNA A failed to wash her hands after walking into Resident #52's room to provide perineal care but put on clean gloves. CNA A closed Resident #52's door and curtain and removed blanket. CNA A removed dirty brief, rolled it up under Resident #52 and then grabbed a clean brief and opened it up and laid it at the bottom of the bed. CNA A used the one swipe per wipe method starting from left to right and then center of the vagina. CNA A turned Resident #52 to the right on her side and then realized she needed to grab bedding supplies to change the bed. CNA A laid Resident #52 on her back and covered her up and then took gloves off and disposed of them. CNA A went to the hall area to grab bedding supplies and failed to wash hands. CNA A failed to wash hands the entire process of perineal care. CNA A put on clean gloves. CNA A changed bedding while Resident #52 was in the bed. Once the bedding was changed, CNA A turned Resident #52 to the right and proceeded in finish cleaning her using the one swipe per wipe method starting from center buttocks, left side, and then right side. CNA A disposed of all trash in the clear trash bag. CNA A placed on clean brief and put clean pants on Resident #52. CNA A then disposed of gloves in the clear trash bag, took the trash with her out of the room. During an interview with the CNA A on 2/22/2024 at 10:04 AM. CNA A stated that she had been trained in infection control practices by in-services, once a week. CNA A stated that she should have washed her hands before, during, and after resident care. CNA A stated that she was not sure why she did not wash her hands. CNA A stated that the negative potential outcome for not washing hands before, during, and after resident care was that residents could get sick and it could transfers bacteria. Resident #61: Record Review of Resident #61 face sheet dated 2/22/2024 reveals a [AGE] year-old male, originally admitted on [DATE] with a primary diagnosis of Alcoholic Cirrhosis of the liver with ascites (kidneys have mild to moderate damage in which fluid collects in spaces within your abdomen). Record review revealed a history of chronic kidney disease stage III, Viral hepatis C (an infection caused by a virus that attacks the liver and leads to inflammation), muscle weakness, hypertension (high blood pressure) and Atrial Fibrillation (an irregular and often very rapid heart rhythm). Record review of resident #61 MDS with a date of 1/12/2024, reveals a BIMS score of 15 which indicates resident was cognitively intact. Record review of Resident #61's physician's orders revealed an order for amlodipine 5mg once a day for HTN with a start date of 2/2/2025. Record review of Resident #61's care plan dated 12/19/2023 revealed a risk for cardiac complications related to AFIB and HTN. Care plan goal was for resident to not have any complications. Record review revealed interventions to assess heart rate, blood pressure, and respiratory. During an observation of Medication administration with LVN A on 2/21/24 at 07:25 PM for Resident #61. LVN A was observed placing a blood pressure cuff on Resident #61. LVN A did not washing her hands prior to placing the cuff or after removing the blood pressure cuff. LVN A did not sanitize the blood pressure cuff before or after use on Resident #61. LVN A prepared medication for Resident #61 and administered the medication. No handwashing prior to preparing the medication, before administering the medication or after medication administration, was observed. Resident #72: Record review of resident #72s face sheet dated 2/22/24, revealed [AGE] year-old male admitted on [DATE] with a primary diagnosis of Cerebral Infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). Record review revealed a medical history of anxiety, vascular dementia (Brain damage caused by multiple strokes), depression, hypotension (low blood pressure) and insomnia (sleep disorder). Record review of resident #72's MDS dated [DATE] revealed a BIMS score of 12, which indicates moderate cognitive impairment. Record Review of resident #72s physician orders revealed midodrine (used to treat low blood pressure) tablet 5 mg with special instructions: hold for systolic great than 135 or a diastolic greater than 90. Record Review of resident #72's care plan with a date of 1/9/2024 revealed a goal to maintain blood pressure between 140 systolic and 80 diastolic. During an observation of medication administration with LVN A on 2/21/24 at 07:35 AM with Resident #72. LVN A entered Resident #72 room without washing her hands. LVN A placed blood pressure cuff on resident, without cleaning the blood pressure cuff prior to use or after use. LVN A exited resident #72's room without washing her hands and began prepping Resident #72 medication. Surveyor 2 intervened and requested nurse LVN A to wash her hands as this was an infection control risk. During an interview with LVN A on 2/21/24 at 07:50 AM, she stated she has been trained on infection prevention. She stated her last training was two weeks ago. LVN A stated handwashing should occur between residents, before starting medication and after administering medication. LVN A stated blood pressure cuff should be cleaned in between resident use. She stated the possible negative outcomes of not washing her hands or utilizing proper infection prevention practices is cross contamination of bacteria. She stated LVN B, the educator, oversees her training. Resident #102: Record Review of Resident #102 face sheet dated 2/22/2024 reveals a [AGE] year-old male, originally admitted on [DATE] with a primary diagnosis of fracture of shaft on left tibia, reduced mobility, thrombocytopenia (low platelet level), high blood pressure, heart failure, pleural effusion (buildup of fluid between the tissues that line the lungs and the chest), acute respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), muscle weakness, chronic kidney failure. Record review of resident #102 MDS with a date of 11/23/2023, reveals a BIMS score of 14 which indicates resident is cognitively intact. Record review of Resident #102's care plan dated 02/13/2024 revealed a risk for stage 3 pressure ulcer development due to incontinence and need of assist with mobility and was admitted with pressure ulcers but at risk of worsening, incontinent episodes of bowel and bladder and at risk of skin breakdown, Resident #102 had pressure ulcers to left and right heel and coccyx. During an observation with NA on 02/21/2024 at 2:42 PM. NA failed to wash hands before perineal care or between dirty and clean. NA put on clean gloves and removed wet brief. NA used one wipe per swipe starting from the center of the vagina and then from left side and then right side. NA placed the dirty wipe in the opened dirty brief. NA then turned Resident #102 to the right side and proceeded in cleaning the buttock area using one wipe per swipe starting from the center of the buttock, then right side and then left side. NA discarded of dirty wipes by placing them in the dirty open brief. NA took off dirty gloves and put on clean gloves and then placed on clean brief. NA completed perineal care and proceeded in washing hands. NA put soap in hands and washed hands for 9 seconds and rinsed. NA used two paper towels and dried both hands and then used thee dirty paper towel to turn off the faucet. During an interview with the NA on 2/21/2024 at 2:59 PM. NA stated that she did understand where she went wrong but was really nervous and does not like being in the spotlight. NA stated, I knew better and should have washed my hands. NA stated she had been trained in infection control practices through in-services about every month. NA stated that the negative potential outcome for not properly washing your hands or washing your hands at all was the spread of germs and infections. During an observation with LVN E on 2/21/2024 at PM. LVN E first knocked on door and explained to Resident #102 that she would be providing wound care. LVN E went to sink and washed hands. LVN E turned on the water, put soap in her hands, and then immediately put her hands under the water while rubbing her hands together and did not let the soap lather. LVN E grabbed a paper towel and dried one hand, grabbed another paper towel and dried the other hand but used the dirty paper towel to turn off faucet. LVN E placed on clean gloves and then used purple wipes to wipe off tray for supplies. LVN E allowed for some time for the tray to dry and then removed gloves and disposed. LVN E used purple wipes to clean Resident #102 bedside table and discarded of used purple wipes. LVN E placed on clean gloves without washing hands after using purple wipes. LVN E used wax paper to line the tray to set up supplies (6 clear cups, sodium chloride solution, 2 long q-tips, manuka honey, calcium alginate, adhesive foam dressing, skin prep, island dressing, alginate). LVN E removed gloves, used hand sanitizer, and put on clean gloves. NA helped LVN E turn Resident #102 to the right on her side. LVN E added sodium chloride on the dry gauze in the clear plastic cups. LVN E opened the packages of the foam dressing and laid on the supply table, opened the packages of the q-tips and laid on thee supply table, LVN E removed gloves and disposed and placed on clean gloves. LVN E placed drape underneath Resident #102. LVN E removed gloves and discarded, used hand sanitizer, and placed on clean gloves. LVN E used 1 wet gauze starting at the wound on the coccyx, one swipe with half circle, grabbed a clean gauze and proceeded on the other half of the wound, working her way with the same steps from inner to outer wound. LVN E used dry gauze to pat dry two times with two different dry gauze. LVN E removed dirty gloves, discarded in the trash, used hand sanitizer, and placed on clean gloves. LVN E put manuka honey on wound with long q-tip and discarded. LVN E put calcium alginate on wound and added the foam dressing, initialed and dated. LVN E removed dirty gloves used hand sanitizer and put on clean gloves. LVN E pulled Resident #102's pants up and placed blanket on her. LVN E removed dirty gloves and discarded in designated trash. LVN E went to sink to wash hands. LVN E turned on the water, put soap in her hands, and immediately started washing her hands underneath the water and not allowing hands to lather. LVN E grabbed a paper towel and dried one hand, grabbed another clean paper towel and dried the other hand. LVN E used the dirty paper towel to turn off the faucet. During an interview with the LVN E on 2/22/2024 at 2:15 PM. LVN E stated that she does understand where she went wrong and was just nervous. LVN E stated that she had been trained in infection control practices with in-services and competency checks. LVN E stated that competency checks are every few months and in-services are approximately held weekly. LVN E stated that the negative potential outcome for not providing hand washing while providing care was the spread of infection. During an interview with the LVN F on 2/22/2024 at 10:36 AM. LVN F stated that she had been the charge nurse. LVN F stated that she expects staff to wash their hands before, during, and after resident care, before preparing medications, any contact with residents, while serving food, and after using the restroom. LVN F stated that staff had been trained in infection control practices by in-services and skills checks and that is approximately every other week but just had an in-service the day prior on 2/21/2024 for hand washing. LVN F stated that the negative potential outcome for not providing infection control practices was cross contamination and the spread of infections quickly. During an interview with the DON on 2/22/2024 at 11:55 AM. DON stated that she expects staff to wash their hands and use hand sanitizer before, during, and after resident care. DON stated that the facility does provide training for infection control practices in the form of in-services and competency checks monthly. DON stated that they choose staff members randomly until all staff have completed training and that was completed quarterly. DON stated that the negative potential outcome for not using infection control practices was the spread of infections. During an interview with ADM on 2/22/2024 at 2:45 PM, stated the ADON was the infection preventionist. He stated staff are trained on handwashing and infection prevention upon hire, quarterly and annually. He stated his expectations of staff when administering medication was for staff to wash their hands using soap and water. He stated the blood pressure cuffs should be sanitized between each resident. He stated negative consequences of not utilizing proper infection control practices was cross contamination and spreading germs. During an interview with the DON on 2/22/2024 at 2:50PM, stated the ADON was the infection preventionist. She stated all staff have been trained on hand washing. The DON stated training occurs quarterly and twice a month. She stated her expectation of staff during medication administration is to use hand sanitizer or wash their hands with soap and water. The DON stated all blood pressure cuffs should be cleaned before use, after use and they should be allowed to dry completely before being utilized again. The DON stated the negative consequences of not utilizing proper infection prevention is the widespread of any pathogens. Record review of facility policy titled, Handwashing/ Hand Hygiene, date Revised1/20/2023 revealed: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretations: 1. All personnel shall follow the handwashing / hand hygiene procedures to help prevent the spread of infections to other personnel, residents , and visitors. 2. Residents, family members, and/or visitors will be encouraged to practice hand hygiene throughout the facility. 3. Wash hands with soap and water, when hands are visibly soiled and after contact with resident with an infectious diagnosis. 4. Use an alcohol-based hand rub containing at least 60% to 93% ethanol alcohol or isopropyl alcohol. 5. Hand hygiene must be preformed prior to donning and after donning gloves. 6. Hand hygiene is the final step after removing and disposing of personal protective equipment. Procedure: Washing Hands: 1. Wet hands first with water, then apply soap. 2. Lather your hands by rubbing them together with the soap. Lather the back of your hands between your fingers and under the nails. 3. Scrub your hands for at least 20 seconds. 4. Rinse your hands well under clean, running water. 5. Dry your hands using a clean towel and use a towel to turn off the faucet. Using Alcohol-Based Hand Rubs: 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry. Record review of facility policy titled, Administering Medications, date Revised April 2019 revealed: 21. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Record review of facility policy titled, Cleansing and Disinfection of Resident-Care Items and Equipment, date Revised October 2018 revealed: Policy Statement: Resident care equipment, including reusable items and durable medical equipment will be cleansed and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens standard. Policy Interpretation and Implementation: C). Non-Critical items; are those that come in contact with intact skin but not mucous membranes. 1). Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computer. 2). Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). D). Reusable items are cleansed and disinfected or sterilized between residents (stethoscopes, durable medical equipment). 3. Durable medical equipment (DME) must be cleansed and disinfected before reuse by another resident. 4. Reusable resident care equipment will be documented and/ or sterilized between residents according to manufactures instructions. 5. Only equipment that is designated reusable shall be used by more than one resident. 7. Intermediate and low-level disinfectants for non-critical items include: a). Ethyl or isopropyl alcohol b). Sodium hypochlorite c). Phenolic germicidal detergents d). Iodophor germicidal detergents e). Quaternary ammonium germicidal detergents (low-level disinfection only). Record review of facility policy titled, Wound Care, date Revised June 2023 revealed: Purpose: The purpose of this procedure is to provide for the care of wounds to promote healing. Steps in the Procedure: 2. Perform hand hygiene 5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. 13. Discard disposable items into the designated container. Discard all soiled laundry, linens, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Perform hand hygiene. 16. Sanitize overbed table. 18. Sanitize scissors 19. Perform hand hygiene Record review of facility policy titled, Perineal Care, date Revised 01/20/ 2023 revealed: Steps in the Procedure: 3. Performa hand hygiene and don gloves. 13. Perform hand hygiene 16. Perform hand hygeine For a Female Resdient; 13. Perform hand hygiene Record review of facility in-services titled, Infection Control, dated 02/21/2024 revealed: Topic: Infection Control: Hand hygiene must be completed before or during patient care any time we go from dirty to clean we must perform hand hygiene, when in doubt wash hands. This is the single most important thing to prevent spreading infection. Any reusable supplies are to be cleaned in between patients. 20 staff members signed and date. Record review of facility Competency Validation for LVN C titled, Hand Hygiene Competency Validation, dated 2/21/2024 revealed: Hand Hygiene with Soap and Water: 1. Checks that sink areas are supplied with soap and paper towels. 2. Turns on faucet and regulates water temperature. 3. Wets hands and supplies enough soap to cover all surfaces of hands. 4. Vigorously rubs hands for at least 20 seconds including palms, back of hands, between fingers, and wrists. 5. Rinses thoroughly keeping fingertips pointed down. 6. Dries hands and wrists thoroughly with paper towels. 7. Discards paper towel in wastebasket. 8. Uses paper towel to turn off faucet to prevent contamination to clean hands. Hand Hygiene with ABHR: 1. Applies enough product to adequately cover all surfaces of hands. 2. Rubs hands including palms, back of hands, between fingers until all surfaces dry. Record review of facility Competency Validation for CNA C titled, Hand Hygiene Competency Validation, dated 2/22/2024 revealed: Hand Hygiene with Soap and Water: 1. Checks that sink areas are supplied with soap and paper towels. 2. Turns on faucet and regulates water temperature. 3. Wets hands and supplies enough soap to cover all surfaces of hands. 4. Vigorously rubs hands for at least 20 seconds including palms, back of hands, between fingers, and wrists. 5. Rinses thoroughly keeping fingertips pointed down. 6. Dries hands and wrists thoroughly with paper towels. 7. Discards paper towel in wastebasket. 8. Uses paper towel to turn off faucet to prevent contamination to clean hands. Hand Hygiene with ABHR: 1. Applies enough product to adequately cover all surfaces of hands. 2. Rubs hands including palms, back of hands, between fingers until all surfaces dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to notify, consistent with his or her authority, the resident representative(s) for 2 of 6 sampled residents (Resident #1 and Resident #4) when there was a significant change. LVN A failed to document notification of Family Member A or Family Member B when Resident #1 developed new open areas on his skin. LVN B and LVN A failed to document notification of Resident #4's Family Member C when he had a change of condition, and new orders were received. This deficient practice had the potential to place residents at risk for not having their family or legal representative notified when having a change of condition. The findings include: Resident #1 Record review of Resident #1's undated facesheet revealed a [AGE] year-old male that was admitted to the facility on [DATE] with the following diagnosis of hemiparesis (muscular weakness) following cerebral infarction (disrupted blood flow to the brain) affecting right dominant side, nontraumatic intracerebral hemorrhage (spontaneous bleeding in the brain), shortness of breath, dysphagia (difficulty swallowing, cognitive communication deficit (difficulty with thinking and how someone uses language), hypertension (high blood pressure), atherosclerotic heart disease of native coronary artery (buildup of plaque inside the artery walls, that slows down the flow of blood), paroxysmal atrial fibrillation (rapid erratic heart rate begins suddenly and then stops on its own within seven days), chronic systolic congestive heart failure (the hearts left ventricle or bottom chamber is weak and cannot contract to produce enough pressure to push blood into circulation), and type 2 diabetes mellitus (the body does not produce enough insulin, or it resists insulin). Record review of MDS assessment summary, dated [DATE], documented Resident #1' BIMS as 12 (moderately impaired), required extensive assistance of two staff members for bed mobility, transfers, and toileting, extensive assistance of one staff member for eating, feeding tube, one pressure ulcer that was unstageable, pressure reducing device for bed, pressure injury/ulcer care, applications of non-surgical dressings, and application of ointments or medication. Record review of Resident #1's care plan dated [DATE] revealed: Problem start date: [DATE]: Pressure Ulcer/Injury-resident at risk for pressure ulcer development. Goal date of [DATE]: Prevent/heal pressure sores and skin breakdown. Approaches documented: follow facility skin care protocol, pressure reducing mattress, report to charge nurse any redness or skin breakdown immediately, and turn every two hours and as needed (prn). Record review of Resident Progress Note dated [DATE] at 4:56 PM, LVN A was made aware Resident #1 had an open area to his right buttock. The Nurse Practitioner (NP) was notified with new orders received. LVN A documented the NP would also assess Resident #1's wound on her visit/wound rounds on Thursday, [DATE]. There was no supporting documentation that Resident #1's family was notified about the open area. Record review of Facility Wound Summary Report for [DATE],revealed the following: * [DATE] at 4:01 PM Resident #1 had a pressure ulcer to coccyx measuring 9 cm x 11 cm. *[DATE] at 5:01 PM documentation revealed Resident #1 had an unspecified ulcer to right buttock, not measured. Record review of physician order dated [DATE] revealed to treat open area to right buttock and coccyx by cleaning with normal saline or wound cleanser, apply med honey and calcium alginate, and cover with adhesive foam. During a phone interview on [DATE] at 12:25 PM with Resident #1's Family Member B, revealed that she was not notified about her the residents pressure ulcer. Family Member B reported she did not know about the pressure ulcer until the day Resident #1 was sent to the hospital on [DATE], when she saw a dressing on Resident #1's right buttock. Family Member B stated she did not know about the pressure area on the coccyx. During a phone interview on [DATE] at 5:52 AM LVN A stated she would notify the family and the physician if a resident developed a new pressure ulcer. LVN A stated she documented the notifications in the resident progress notes if she called the family she would document it, but if she told them in person, probably not. During an interview on [DATE] at 1:15 PM with LVN A she reported she had talked to Resident #1's Family Member A, on several occasions when she was at the facility, and reported that Family Member A would ask how the wounds were doing, but LVN A stated she did not document it. Interview on [DATE] at 9:55 AM with the DON revealed that her expectations for a change of condition, was to notify her so she can do her own assessment of the resident, and for them to notify the physician and the family member or responsible party of the residents change in condition. The DON stated a change in condition included a change in ADL's, a new medication or reaction, altered mental status, a new pressure ulcer, or anything that is out of the ordinary care of that resident. The DON stated she expected staff to document the change and notifications in the progress notes. During an interview on [DATE] at 12:44 PM with the ADM, revealed his expectations for a change of condition, is to notify the DON, the physician, and the family member or responsible party and to document the change and notifications in the progress notes. Resident #4 Record Review of Resident #4's undated facesheet reveals a [AGE] year old male admitted to the facility on [DATE], with a readmission date of [DATE]. Resident #4 had the following diagnosis of atherosclerotic heart disease of native coronary artery (buildup of plaque inside the artery walls, that slows down the flow of blood), constipation (fewer than three stools a week, or has difficult bowel movements), bacterial pneumonia (infection of lungs by certain bacteria), acquired absence of limb, post COVID-19 condition (includes fatigue, fever, or difficulty breathing or shortness of breath, and cough), chronic obstructive pulmonary disease (condition that blocks airflow and makes it difficult to breath), cognitive communication deficit (difficulty with thinking and how someone uses language), traumatic subdural hemorrhage with loss of consciousness of unspecified duration (caused by a traumatic head injury, such as a blow to the head, or fall), alcohol dependence, type 2 diabetes mellitus (the body does not produce enough insulin, or it resists insulin), diabetic polyneuropathy (affects multiple peripheral sensory and motor nerves that branch out from the spinal cord into the arms, hands, legs, and feet), heart failure (the heart does not pump blood as well as it should), peripheral vascular disease (any condition that affects your circulatory system, or system of blood vessels), diabetic chronic kidney disease (disease of the kidneys leading to renal failure), hyperlipidemia (blood has to many fats such as cholesterol and triglycerides), restless legs syndrome (irresistible urge to move the legs, typically in the evenings), insomnia (trouble falling or staying asleep), phantom limb syndrome with pain (condition where there is sensations in a limb that does not exist), secondary vitreoretinal degeneration of right eye (gradual changes in the structure and function of the clear gel-like substance that is in the eye and retina that can be caused by trauma, infection, or inflammation), hypertension (high blood pressure), benign prostatic hyperplasia with lower urinary tract symptoms (a condition in men in which the prostate gland is enlarged causing blockage of urine flow out of the bladder). Record review of Resident #4's MDS assessments revealed on [DATE], there was a Discharge with Return Anticipated. Resident was readmitted to the facility with entry date on [DATE]. Death in facility MDS assessment dated [DATE]. Record review of Resident #4's Care plan dated [DATE] revealed: Problem Start Date: [DATE] ADL Functional/Rehab Potential - I need assist with ADL's. Approach Start Date: [DATE] Ambulation/Transferring - Extensive assist of 1-2. Bathing/Hygiene - Total assist of one. Dressing/Grooming - Extensive assist of 1-2. Eating - Supervision/Set up. Wheelchair for mobility. Record review of Resident #4's Resident Progress Notes dated [DATE] at 1:30 PM revealed that LVN B requested the DON to assess the resident. Upon assessment, the DON obtained vital signs that were within normal limits. Resident #4 was oriented only to self; resident reported the year as 1933 and that he was in Mexico City. Resident #4 reported he was not in pain at this time. Resident #4 had a busted blood vessel in his right eye and a tremor to his right hand. DON reported her findings to LVN B and requested for her to call to send the resident out. Record review of Resident #4's Resident Progress Notes dated [DATE] at 1:55 PM revealed that LVN B documented that Resident #4 is very confused, right inner eye is blood shot red, and resident has a new tremor to right hand. Vital signs are within normal limits, oxygen saturation reading 76%. LVN B started order prn (as needed) oxygen at 4 liters per minute via nasal cannula and oxygen saturations increased to 96%. Resident #4 is scheduled for dialysis in the morning at 10:00 AM. LVN B notified NP on [DATE] and received new orders to collect CBC, CMP, BNP, chest x-ray, and to swab resident for the flu and COVID. Report the results to NP as soon as possible. There is no documentation of LVN B notifying Resident #4's family of the new orders, or of Resident #4's change of condition. Record review of Resident #4's Resident Progress Notes dated [DATE] at 9:49 PM revealed that LVN A documented that she had received the chest x-ray, and she sent the results to the NP. The NP gave new orders for Rocephin 1 gram IM (intramuscular) injection for 5 days after hemodialysis (HD) and to give Resident #4 a now dose of Lasix 40 mg, and then change Resident #4's Lasix orders to 120 mg on non - HD days and to change the morning dose to non- HD days only, and handheld nebulizer (HHN) of DuoNeb's four times a day (QID) for 5 days. LVN A documented that she had administered Resident #4's initial dose of Rocephin. There is no documentation of LVN A notifying Resident #4's family member of new orders or of Resident #4's change of condition. Record review of physician orders dated [DATE] revealed to collect portable 2V chest x-ray stat, due to SOB to r/o illness, due to resident confined to a nursing home. Lasix 80 mg, administer 2 tabs to equal 180 mg oral. Ceftriaxone 1 gram (reconstituted solution) 1 gram injection. Ipratrupuim-albuterol solution for nebulation 0.5-3 mg (2,5 mg) base 3 ml, adminsiter one vial; inhalation for post-COVID conditon. During an interview on [DATE] at 3:50 PM with the Physical Therapist (PT) revealed that she went to evaluate Resident #4 on the afternoon of Monday, [DATE] and that Resident #4 was very confused and was struggling to breath. The PT stated that Resident #4's oxygen saturation was low, so she let LVN B know that they needed an oxygen concentrator. Oxygen was started at 3 to 5 liters of oxygen per minute, and reported Resident #4's oxygen saturation level went up to the 90's via nasal cannula. The PT reported that Resident #4 was up in the wheelchair, but his oxygen saturations would still dip down, even with the oxygen. The PT reported that she did notice that one of his eyes were red. The PT stated when she came to work with Resident #4 on Tuesday, [DATE] she was told that Resident #4 had expired that morning. During an interview on [DATE] at 1:15 PM with LVN A revealed that she did not notify family regarding Resident #4 because there was no change in his condition during her 12-hour shift. LVN A stated that she checked on Resident #4 frequently throughout the night and there was no change. LVN A stated she faxed the chest x-ray orders to the NP when she received it. Then LVN A received orders from the NP to give Rocephin and Lasix, then to monitor Resident #4 throughout the night, and she was told that the Physician Assistant (PA) would be at the facility in the morning. LVN A stated she followed the orders. During an interview on [DATE] at 3:00 PM with the CMA regarding Resident #4, revealed that the last time she saw him was on [DATE] and Resident #4 was breathing shallow and did not look good. The CMA stated that LVN B notified the provider and received new orders, and she thought LVN B had tried to call Resident #4's family member. The CMA revealed that a change of condition needed to be reported immediately to the charge nurse, so the resident could be evaluated. During an interview on [DATE] at 3:07 PM with CNA C revealed that on Monday, [DATE] that Resident #4 was not himself. CNA C reported that Resident #4 was not eating, and that therapy had tried to work with him, but they had to put him back in bed because he was too weak. CNA C stated that she knew the physician was notified, and she thought LVN B had tried calling the daughter. CNA C stated that she would report any change of condition to her charge nurse immediately, because any little change could be something big. During an interview on [DATE] at 3:17 PM with CNA D revealed on [DATE] Resident #4 was having trouble breathing, so she notified LVN B who went to assess him. CNA D then reported that the DON went into assess him as well. CNA D reported that LVN B notified the physician, and thought she tried calling the daughter. CNA D stated that she did notify the charge nurse when she noticed a change in condition. CNA D stated it was important to report a change of condition immediately, because the resident could have a UTI, dehydration, or something else that needed to be checked on. During an interview on [DATE] at 3:37 PM with LVN B revealed when Resident #4 was noted to have a change of condition, that she notified the physician and received orders for labs and a chest x-ray. LVN B reported that Resident #4 did not want to go back to the hospital. LVN B stated she called Family Member C on two different occasions but did not get an answer. LVN B stated she did not feel comfortable with leaving a message, and stated that she thought that when Family Member C saw the facility number she would call back. LVN B stated she did not document her attempts of contacting Family member C. LVN B stated that when Resident #4 returned back to the facility from dialysis on Saturday, [DATE], she noticed that his right eye was red. LVN B reported when Resident #4 returned it was close to change of shift, so she reported to LVN A and asked her to look at his eye. During an interview on [DATE] at 4:25 PM with the ADON, she reported that that she did call and talk to Family Member C on [DATE] when Resident #4 was readmitted from the hospital. ADON stated that it was important to quickly assess a resident that is noted to have a change of condition, to keep them from getting worse. During an interview on [DATE] at 4:30 PM, the DON stated going forward, the next time she assessed a resident for a change of condition, that she would not only report to the charge nurse, but she would also document her findings and notify the family or responsible party as well. Record review of a facility policy titled, Change in a Resident's Condition or Status, revised [DATE] documented the following: Policy Statement: Our facility promptly notifies the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status(e.g., changes in the level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation: 3. The nurse/designee will notify the resident's representative when: b. there is a significant change in the resident's physical, mental, or psychosocial status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 11 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 received his Metformin for 14 days after admission to the facility. This failure could place residents at risk of complications from deterioration in health, increased blood sugar levels, extended recoveries, hospitalizations. Findings include: Record review of Resident #1's clinical record revealed a 68 year-year-old male who was admitted to the facility on [DATE] with diagnoses which included, Type 2 diabetes mellitus with ketoacidosis without coma (high levels of sugar in the blood), metabolic encephalopathy ( a problem in the brain caused by chemical imbalances in the blood), acute kidney failure (kidneys suddenly become unable to filter waste products from your blood), autistic disorder (a developmental disability caused by differences in the brain, Type 2 diabetes mellitus with unspecified complications (high levels of sugar in the blood). Record review of Resident #1's admission MDS, completed 03/14/2023, revealed a BIMS of 3, which indicated he had sever impairment. Record review or Resident #1's Hospital Discharge Orders dated 03/07/2023 revealed the following: Metformin 500mg tablet morning. This medication is used to treat Type 2 diabetes, a condition where the body does not make enough insulin. Record review of Resident#1, MAR indicated metformin 500mg tablet morning was not in orders from 03/07/2023 until 03/23/2023. Record Review of Resident #1's physician orders revealed metformin 500mg tablet morning was not on the orders from 3/7/2023 through 3/23/2023. During an interview on 03/23/2023 at 12:55 PM, the DON stated Resident #1 had admitted to the facility around 6-7PM on 03/07/2023 with six pages of admitting orders. He stated that the last two pages of the admitting orders had the admitting medications on them, and the last medication listed was the metformin 500mg tablet to be given mornings. He stated the facility had an agency nurse that was working that day and was the admitting nurse for Resident #1. He stated that the admitting nurse should have done a medication reconciliation to ensure all medication were entered. He stated then the admitting nurse should have sent the medication orders to the NP for approval, then the following day the ADON's should have verified the admitting orders with the current orders entered in the system for any errors. He stated then he will check the orders and update the care plan. He stated he verified with the ADON's that the medications were not reviewed and stated, we missed it. During an interview on 03/23/2023 at 2:15 PM. ADON A stated that Resident #1 did admit to the facility on [DATE] in the evening. She stated that the next morning when she came to work, she had several residents that needed to move rooms for various reasons, and she was busy moving residents. She stated, she was not making excuses she dropped the ball that she would normally check the orders but didn't. She stated she did call the admitting nurse (LVN C) for Resident #1 and she (LVN C) told her that alerts had popped up so she did not put all the medication in she wanted to call the NP to verify however something else happened so she didn't get that done. During an interview on 03/23/2023 at 2:24 PM ADON B stated that she had been told by the DON that morning of 03/23/2023, that all the medications were entered for Resident #1 except the metformin when he admitted . She stated that on 03/08/2023 when she arrived at work there were several residents needing to be moved and that she and ADON A, started moving the residents and, that no one followed up on the admit for Resident #1. During an interview on 03/23/2023 at 2:45 PM LVN C stated she was the admitting nurse for Resident #1, she stated she thought she entered all the admitting medications for Resident #1 but that she had a very busy night with another resident and was distracted. She stated the process for a new admission was to send the admitting orders and the reconciled orders to NP for verification of accuracy. LVN C stated she was not sure how she verified them with the NP, that she might have called her over the phone. Record review the facility policy Reconciliation of Medication on admission dated 2001 Revised July 2017 reveled the following: Purpose: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation: 1. Gather the information needed to reconcile the medication list: B. Discharge summary from referring facility. 2. Find a quiet place that is free from distractions. General Guidelines: 1. Medication reconciliation is the process of comparing pre-discharge medications to post dis-charge medications by creating an accurate list of both prescription and over the counter medications that include the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points of care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications that residents need and has been taking continue to be administered without interruption. In the correct dosages and routes, during the admission/transfer process. 3. Medication Reconciliation helps to ensure that all medications, routes and dosages have been accurately communicated to the attending physician and care team. Steps in Procedure: 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 4. List the does, route, and frequency for all medications 5. Review the list carefully to determine if there are discrepancies/conflicts

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents highest practicable physical, mental, and psychosocial needs for 6 of 27 residents (Residents #46, #79, #100, #102, #103 and #104) reviewed for care plans. Resident #46 did not have a care plan for visual, urinary incontinence, pressure ulcer risk and psychotropic drug use. Resident #79 did not have a care plan for urinary incontinence and pressure ulcer risk. Resident #100 did not have a care plan for urinary incontinence, psychosocial well-being, pressure ulcer risk and psychotropic drug use. Resident #102 did not have a care plan for urinary incontinence and pressure ulcer risk. Resident #103 did not have a care plan for urinary incontinence, psychosocial well-being, pressure ulcer risk and psychotropic drug use. Resident #104 did not have a care plan for pressure ulcer risk. These failures could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Resident #46 Record review of Resident #46's undated admission record revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include acute respiratory failure with hypoxia (low oxygen in the body), depression, hypertension (high blood pressure), obesity, difficulty in walking, muscle weakness and lack of coordination. Record review of Resident #46's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 04, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 03. Visual Function 06. Urinary Incontinence and Indwelling Catheter 16. Pressure Ulcer 17. Psychotropic Drug Use Section B B1000 - Vision Ability to see in adequate light: 2 - Moderately impaired - limited vision, not able to see newspaper headlines but can identify objects Section H H0300 Urinary Continence: 3 - Always incontinent (no episodes of continent voiding) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Section N Medications N0410. Medication Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days. A. Antipsychotic - given the last 7 days C. Antidepressant - given the last 7 days Record review of Resident #46's care plan, dated 01/02/23, revealed no care plans for vision, urinary, pressure ulcers or psychotropic drug use. Resident #79 Record review of Resident #79's undated admission record revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include pneumonia (lung infection), congestive heart failure, edema (swelling), hypotension (low blood pressure), stage 4 (severe) kidney failure, stage 2 pressure ulcer of sacral region (area between lower back and tailbone), and muscle weakness. Record review of Resident #79's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence and Indwelling Catheter 16. Pressure Ulcer Section H H0300 Urinary Continence: 1 - Occasionally incontinent (less than 7 episodes of incontinence) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M0210. Unhealed Pressure Ulcers/Injuries Does this resident have one or more unhealed pressure ulcers/injuries? Coded 1 = Yes M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage B. Stage 2 1. Number of Stage 2 pressure ulcers - Coded 1 = number of ulcers 2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - Coded 1 = number of ulcers M1200. Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed E. Pressure ulcer/injury care Record review of Resident #79's care plan, dated 12/06/22, revealed no care plans for urinary and pressure ulcers risks. Resident #100 Record review of Resident #100's undated admission record revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include stroke, depression, diabetes (high blood sugar), hypertension (high blood pressure), chronic obstructive pulmonary disease (lung disease) and muscle weakness. Record review of Resident #100's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence and Indwelling Catheter 07. Psychosocial Well-Being 16. Pressure Ulcer 17. Psychotropic Drug Use Section D - Mood D0200. Resident Mood Interview (PHQ-9) A. Little interest or pleasure in doing things 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) B. Felling down, depressed, or hopeless 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 1 = 2-6 days (several days) D. Felling tired or having little energy 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 1 = 2-6 days (several days) D0300 Total Severity Score Add score for all frequency responses in Column 2 - 04 = mild depression Section N Section N Medications N0410. Medication Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days. C. Antidepressant - given the last 7 days Section H H0300 Urinary Continence: 3 - Always incontinent (no episodes of continent voiding) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M1200 Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed Record review of Resident #100's care plan, dated 12/19/22, revealed no care plan for urinary, psychosocial well-being, pressure ulcer risk or psychotropic drug use. Resident #102 Record review of Resident #102's undated admission record revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include stroke, muscle spasms and diabetes (high blood sugar). Record review of Resident #102's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence and Indwelling Catheter 16. Pressure Ulcer Section H H0300 Urinary Continence: 1 - Occasionally incontinent (less than 7 episodes of incontinence) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M1200 Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed Record review of Resident #102's care plan, dated 12/14/22, revealed no care plan for urinary and pressure ulcer risk. Resident #103 Record review of Resident #103's undated admission record revealed a [AGE] year-old-male was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include major depressive disorder (depression), anxiety, repeated falls, weakness, hypertension (high blood pressure), congestive heart failure (fluid around the heart) and pain. Record review of Resident #103's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: 06. Urinary Incontinence and Indwelling Catheter 07. Psychosocial Well-Being 16. Pressure Ulcer 17. Psychotropic Drug Use Section D - Mood D0200. Resident Mood Interview (PHQ-9) A. Little interest or pleasure in doing things 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) B. Felling down, depressed, or hopeless 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) C. Trouble falling or staying asleep, or sleeping too much 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) D. Felling tired or having little energy 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 1 = 2-6 days (several days) F. Feeling bad about yourself - or that you are a failure or have let yourself or your family down 1. Symptom Presence - 1 = yes 2. Symptom Frequency - 2 = 7-11 days (half or more of the days) D0300 Total Severity Score Add score for all frequency responses in Column 2 - 10 = severe depression Section N Section N Medications N0410. Medication Received Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days. C. Antidepressant - given the last 7 days Section H H0300 Urinary Continence: 2 - Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M1200 Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed Record review of Resident #103's care plan, dated 12/20/22, revealed no care plans for urinary, psychosocial well-being, pressure ulcer risk or psychotropic drug use. Resident #104 Record review of Resident #104's undated admission record revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include mild intellectual disabilities, pneumonia, and history of COVID-19 (Coronavirus). Record review of Resident #104's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: 16. Pressure Ulcer Section M Skin Conditions M0150. Risk of pressure ulcers/injuries: Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes M1200 Skin and Ulcer/Injury Treatments B. Pressure reducing device for bed Record review of Resident #104's care plan, dated 01/03/23, revealed no care plan for pressure ulcer risk. Interviewed LVN A and LVN B on 01/05/23 at 10:30 AM, LVN B stated they are both responsible for care planning triggered care areas on the MDS . LVN A reviewed Resident #102's care plan and stated she did not see a care plan for urinary incontinence, or pressure ulcer risks . LVN B reviewed the care plan for Resident #46's and stated she did not see a care plan for visual, urinary incontinence, pressure ulcer risks or psychotropic drug use. LVN A reviewed the care plan for Resident #79's and stated she did not see a care plan for urinary incontinence or pressure ulcers. LVN A reviewed the care plan for Resident #100's and stated she did not see a care plan for urinary incontinence, psychosocial well-being, pressure ulcer risks or psychotropic drug use. LVN B reviewed the care plan for Resident #103's and stated she did not see a care plan for urinary incontinence, psychosocial well-being, pressure ulcer risks or psychotropic drug use. LVN A reviewed the care plan for Resident #104's and stated she did not see a care plan for pressure ulcer risks. LVN B stated missed care areas were triggered for Residents #46, #79, #100, #102, #103 and #104 in section V of the MDS and should have been care planned. The LVN B stated care plans are developed using triggered care areas in section C of the MDS and anything brought up in the daily meeting. LVN B stated the ADON's and the DON care plan acute care issues and the wound care nurse and activities care plan wounds and activities. LVN B stated They are behind on care plans and are trying to get them all updated. LVN B stated the care plan is used to notify staff what is going on with the residents. LVN B stated everyone uses the care plan. LVN B stated if triggered care areas were not care planned staff would not know how to handle a specific care area for the resident. LVN A stated it could cause harm or an incident to happen to the resident. LVN B stated there was no system in place to monitor care plans. LVN B stated she has been trained on care plans in the past. LVN A stated she was trained by LVN B on how to complete and develop a care plan. Interviewed the DON on 01/05/23 at 10:45 AM, he stated the MDS nurses are responsible for care planning triggered care areas on the MDS. The DON reviewed the care plans for Residents #46, #79, #100, #102, #103 and #104 and stated the triggered care areas were not care planned. He stated care plans are developed by using admission for baseline, diagnoses and medication and triggered care areas on the MDS . He stated there is no reason the triggered care areas would not be care planned. He stated the care plan is a guide on how to treat and care for the residents. He stated all staff use the care plans. He stated, Missing care areas that triggered on the MDS that are not care planned could cause residents to miss out on care and their needs not being met. He stated he did not know why the triggered care areas were not care planned but would find out. He stated he is not aware of any system in place to monitor care plans. He stated his expectation of what should be in the care plan is care areas that triggered, special needs and anything to meet residents' needs. He stated he is not sure if the MDS nurses have been to special training, but they do have a corporate MDS nurse support. Interviewed the Admin on 01/05/23 at 11:08 AM, he stated the MDS nurses are responsible for care plans. When asked if there was a reason triggered care areas would not be care planned, he stated Not that I know of. He stated the care plan is used to ensure proper care for each resident. He stated if the care plan is not complete, staff would not be aware of the care needed for that resident. Record review the facility policy titled Care Area Assessments with revision date 11/2019, revealed: Policy statement Care Area Assessment (CAAs) are used to help analyze data obtained from the MDS and to develop individualized care plans. Policy interpretation and implementation 1. Triggered care areas are evaluated by the end disciplinary team to determine the underlying causes, potential consequences and relationships to other triggered care areas. 2. The Care Area Assessments (CAAs) process consists of the following steps: a. Identify areas of concern triggered on the MDS: (1) This can be done using software or by manually using the CAT logic tables in the RAI User's Manual. b. Review the triggered CAA's by doing an in-depth, resident-specific assessment of the triggered condition. (1) History taking; (2) Physical assessment; (3) Gathering of relevant information (labs, test, etc); and (4) Sequencing of clinically significant events. c. Define the problem(s): (1) Identify the functional, physical, and or behavioral implications of the problem(s); (2) Identify the relationships between risk factors, triggers and problems; (3) Distinguish between causes and consequences; and (4) Look for common causes and consequences; and d. Make decisions about the care plan: (1) Determine whether the problem(s) need intervention; (2) Evaluate the resident's goals, wishes, strengths and needs; (3) Design intervention's goals, wishes, strengths and needs; (4) Establish which items need further assessment or additional review. e. Document interventions on the care plan: (1) Include specific interventions, including those that address common cause of multiple issues; and (2) Include recommendations for monitoring and follow-up timeframes. 4. CAA Documentation explains the basis for the care plan. The documentation should include: a. Causes and contributing factors for the triggered care areas; i. Completion of section V of the MDS. Record review the facility policy titled Care Plans, Comprehensive Person-Centered with revision date 12/2020, revealed: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally competent and trauma informed. Policy Interpretation and Implementation 1. the Interdisciplinary Team (IDT), in conjunction with resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a through analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will; g. Incorporate identified problem areas; 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 1 medication cart reviewed. The facility failed to ensure that the keys to the medication cart were kept secured when staff left them on the desk, and that controlled medications were not counted in accordance with their policy resulting in four Fentanyl Pain Patches missing. This failure could place residents at risk of having missed doses of their pian medication and/or lead to possible harm or drug diversion. Finding included: During an interview on [DATE] at 10:30AM, MA-A stated she had worked with LVN-B on [DATE] and they had counted the medication cart that morning around 7:15AM after arriving for her day shift starting at 7:00AM, and all controlled medications were accounted for. MA-A stated when she left for lunch later that day, she handed the medication cart keys over to LVN-B and they did not count the cart at that time. MA-A stated she had been trained by the facility, that anytime the medication cart keys were exchanged staff would need to count the cart. MA-A stated she was not sure why they did not count the cart at that time they just did not. MA-A stated she had never had any issues with missing medications before and that is why it was easy to hand off the keys without counting. MA-A stated when she returned from her lunch break, around 3:30PM, LVN-C informed her that LVN-B had an emergency and had left the facility without counting the medication cart with LVN-C. MA-A stated LVN-C told her they would need to go and count the medication cart. MA-A stated while counting the medication cart with LVN-C that something was not correct with the cart and medications. MA-A stated she had noticed a box of Fentanyl patches were missing along with the narcotic count sheet for that medication. MA-A stated she knew the box of Fentanyl Patches had arrived at the facility on [DATE] and one patch had been used out of the box on [DATE] which left four Fentanyl pain patches in the box. MA-A stated she told LVN-C that a box of Fentanyl was missing, and the narcotic count sheet log was missing for the Fentanyl. MA-A stated that LVN-C told her she would notify LVN-D of the missing medications since LVN-D was the administrative nurse on-call. During an interview on [DATE] at 5:25AM, LVN-C stated she had worked the morning shift on [DATE] the day of the incident. LVN-C stated she was not working on the station where the Fentanyl went missing, she was working different station. LVN-C stated LVN-B and MA-A were working on the station where the incident happened. LVN-C stated later in the afternoon she received a call from LVN-D asking her to go count the medication cart with LVN-B because LVN-B reported she had a family emergency and had to leave, and the MA-A was on break. LVN-C stated she went to that station and did not see LVN-B and she called LVN-D to let her know she could not find LVN-B to count. LVN-C stated LVN-D informed her that LVN-B called and reported she counted the medication cart with LVN-E before leaving. LVN-C stated she had a bad feeling because of the way LVN-B had left the facility and did not count the medication cart with her. LVN-C stated she spoke with LVN-E to make sure the medication cart had been counted and that LVN-E had the keys to the cart. LVN-C stated LVN-E told her she did not count the cart with LVN-B and that LVN-B walked up and threw the keys on the desk at the nurse's station and stated she had to go and that LVN-B walked out of the facility. LVN-C stated when MA-A returned to the facility from break they counted the medication cart and MA-A noticed the box of Fentanyl with four patches was missing from the cart along with the narcotic count sheet from the book. LVN-C stated she notified LVN-D at that time of the missing Fentanyl patches. During an interview on [DATE] at 7:35AM, LVN-D stated she was the nurse on call for that weekend and had received a call on [DATE] around 3:15 to 3:30PM from LVN-B that she had a family emergency and needed to leave work. LVN-D stated she informed LVN-B to count the medication cart with LVN-C before leaving work. LVN-D stated she received a call from LVN-C stating she could not find LVN-B to count the medication cart. LVN-D stated she informed LVN-C that LVN-B called her and told her she gave the keys to LVN-E but did not count the medication cart with LVN-E because MA-A had the keys and had been in the medication cart that morning. LVN-D stated when she arrived at the facility on [DATE] at approximately 3:45-3:50 PM, LVN-C told her there was a problem with the medication cart and four Fentanyl patches were missing along with the narcotic count sheet. LVN-D stated she looked in all medication carts and the medication room and could not locate the Fentanyl patches or the narcotic count sheet. LVN-D stated she notified the DON of the missing Fentanyl patches, and he came to the facility. LNV-D stated hospice services were notified of the missing Fentanyl patches since the hospice physician was the ordering physician. LVN-D stated hospice informed her they would replace the missing medication if the resident needed them replaced as long as the facility provided a police report. LVN-D stated the facility did not need to have the medication replaced as the resident expired the evening on [DATE] and did not miss any doses of the medication. During an interview on [DATE] at 8:25AM, LVN-E stated that on [DATE] around 3:45 PM she was sitting at the nurse's station and LVN-B walked up and threw the keys on the desk and said she had a family emergency and had to leave, and LVN-D was on her way, then LVN-B walked out of the facility. LVN-E stated she sent LVN-D a text about the incident and at the same time LVN-C walked up and asked if she counted the medication cart with LVN-B. LVN-E stated she told LVN-C, no she did not give me time she walked up threw the keys on the desk and said she had to leave. LVN-E stated she never touched the keys and LVN-C took the keys from the desk. During an interview on [DATE] at 6:20AM, the DON stated he had learned of the incident with the missing Fentanyl patches on [DATE] that he received a call from LVN-D letting him know of the missing Fentanyl patches and that MA-A had given the keys to LVN-B when she left for her lunch break, and they did not count the medication cart. The DON stated LVN-D informed him that LVN-B had called LVN-D saying she had an emergency and needed to leave work and did not count the medication cart with any of the LVNs in the building just left the keys and left work. The DON stated he told LVN-D he would head to the facility to help try and locate the missing Fentanyl. The DON stated while on his way to the facility he called LVN-B and let her know Fentanyl patches were missing and per the facility's policy she would need to return to work and help locate the missing medication and that she would also need to be drug tested. DON stated LVN-B stated she would not be returning, and several staff had access to the medication cart with the exchange of the keys and the cart not being counted. DON stated he notified the local police department of the missing Fentanyl patches. The DON stated he completed the self-report for the missing medication. The DON stated he completed his investigation and did not have evidence that LVN-B had taken the missing Fentanyl patches. The DON stated he did have MA-A and LVN-E drug tested and both were negative, he also in-serviced staff on [DATE] regarding counting narcotics. Record review of facility in-service dated [DATE] reflected staff must count narcotics when arriving for their shift, when going on lunch breaks and returning, if giving the keys to someone else, when your shift ends with oncoming staff. Record review of shipping manifest from PharMerica documented date [DATE] dispense to station 3, Fentanyl 75 MCG/HR Patch Quantity 5.000 each. Record review of Facility Interview Worksheet dated [DATE] for MA-A documented [MA-A] counted narcotics in the morning at 7:15AM. There was one box of Fentanyl in the narc box and there were four patches in the box. When [LVN-C] and I counted at 3:50PM the box was missing along with the narc sheet. I failed to count out the cart when I went on break around 2:15PM, I gave my keys to [LVN-B] at that time. When I returned from break [LVN-B] was gone from the facility for an emergency. Record review of the facility policy: Medication Storage, Controlled Medication Storage dated [DATE] revealed: 4.2 Controlled Medication Storage Policy Medications included in the Drug enforcement administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. Procedures 6. At each shift change or when keys are surrendered, a physical inventory of all scheduled two, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substance accountability record or verification of controlled substances count report. The nursing care center may elect to count all controlled medications at shift change.