**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #6, #14, and #22) reviewed for care plans in that: Resident #6 did not have a care plan in place for fall risk. Resident #14 did not have a care plan in place for dehydration or hand rolls. Resident #22 did not have a comprehensive care plan. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #6's Resident Face Sheet, dated 12/5/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including unspecified dementia, and Diabetes Mellitus with Diabetic Neuropathy (nerve damage causing people to not feel their extremities). Review of Resident #6's Quarterly MDS Assessment, dated 10/23/24 revealed: She had a mental status of 3 of 15 (indicating severe cognitive impairment) with signs of delirium to include disorganized thinking that fluctuated. She needed substantial assistance for transferring to chair to bed. She took the following high-risk medications: anti-anxiety, anti-depressant, opioid. Review of Resident #6's Significant Change MDS, dated [DATE], revealed the Care Area Assessment triggered area: Falls. In the column indicating if it was care planned the facility documented they care planned for falls. Review of Resident #6's electronic record, including the care plan revealed no care plan for falls. Review of Resident #14's Resident Face Sheet, dated 12/5/24, revealed he was a [AGE] year-old male admitted to the facility 10/21/20 with diagnoses including stroke and paralysis of both sides. Review of Resident #14's Significant Change MDS Assessment, dated 11/5/24 revealed: Cognitive statuswas unable to be assessed. Range of Motion impairment was noted of the upper and lower extremities on both sides. He was completely dependent for all ADL's. Review of Resident #14's Care Plan and electronic record revealed no care plan for dehydration and the hand rolls. Observation on 12/3/24 at 3:27 PM revealed Resident #14 was in bed, the head of his bed was raised, he had an air mattress and was hooked to a feeding tube. His hands were severely contracted (curled in and unable to be straightened) and he had hand rolls (rolled up dry wash cloths in them to absorb sweat and keep the contracture from getting worse). Observation on 12/5/24 at 9:48 AM revealed Resident #14 was in bed with the hand rolls in place. Interview on 12/5/24 at 9:52 AM LVN A stated the first thing she did in the morning was make sure Resident #14's hands were clean, and the hand rolls were in place. Review of Resident #22's Face Sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, high blood pressure, high cholesterol, gastroesophageal reflux disease, pain, edema (swelling to the lower extremities), and history of blood clots. Review of Resident #22's Quarterly MDS, dated [DATE] revealed: She scored 2 of 15 on a mental status exam indicating severe cognitive impairment. She displayed wandering behaviors 1 to 3 days during the look back period. She required moderate assistance to total dependence for all ADL's. She had active diagnoses of Alzheimer's disease, dementia, coronary artery disease, high blood pressure, high cholesterol, stroke, and anxiety disorder. She had 2 or more falls without injury reported since the last assessment. She was at risk of developing pressure ulcers. She received an antipsychotic medication and a diuretic medication. She was on hospice services. Review of Resident #22's medication orders, dated 12/05/24, revealed the following orders: Alprazolam 0.25mg give 1 tablet by mouth every 4 hours as needed for anxiety/agitation (Order Date 8/23/24) Amantadine HCl 100mg give 1 capsule by mouth daily (Order Date 8/5/24) Amlodipine 10mg give 1 tablet by mouth daily (Order Date 8/5/24) Furosemide 20mg give 1 tablet by mouth daily as needed for edema (Order Date 8/5/24) Polyethylene glycol 17 grams/dose give 17 grams mixed in 8 ounces of beverage of choice by mouth daily (Order Date 8/5/24) Quetiapine 25mg give 1 tablet by mouth twice daily (Order Date 8/27/24) Levothyroxine 100mcg give 1 tablet by mouth daily (Order Date 8/5/24) Acetaminophen 325mg give 2 tablets by mouth every 6 hours as needed for pain (Order Date 8/8/24) Vitamin D3 25mcg give 1 tablet by mouth daily (Order Date 8/8/24) Review of Resident #22's electronic health record revealed no comprehensive care plan in place. In an interview on 12/05/24 06:03 PM with the Administrator and the DON, the DON stated that Resident #22 was admitted in August 2024 and had a full care plan in the old system that should have transferred into the new system. The Administrator stated that some things did not transfer from the old EMR system, and it was being addressed as it was discovered. The DON stated that Resident #6 should have had a care plan for falls due to her history of falls. The DON stated that an audit had been done in November 2024 for all residents with recent falls to ensure that care plans were in place and Resident #6 was overlooked because she had not had any recent falls. The DON stated that Resident #14 should have had a care plan or intervention under his skin care plan regarding his hand contractures and hand rolls/pads. The DON stated that the ADON for LTC was responsible for starting and maintaining care plans for all residents. (The ADON was not present for an interview at the time of survey.) The DON stated that she expected care plans to be done within the required time frame and that care plans reflected the needs and wants of each resident. She stated that she expected any special needs, such as AFO's, low bed and mats next bed to be addressed in care plans. The DON stated that the purpose of the care plan was to outline needs so that anyone who looked at any resident's care plan would know how to take care of the resident. The DON stated that CAAs did not automatically trigger a care plan in the EMR system and that the care plan had to be built based on assessment and knowledge of each resident. She stated that the nurses had a whole library of care area templates to choose from when creating a care plan. The DON stated the nurses did some training on how to do care plans in the new system. The Administrator stated that she expected care plans to be completed in the correct time frame and so that anyone who looked at the care plan should be able to understand the care of the resident. The Administrator stated that the care plan should have a clear view of what tasks/care nurses were responsible for, what tasks/care CNAs were responsible for, dietary or nutritional needs, and any special situations present for the resident. The Administrator stated that DON audited care plans especially since changing to the new EMR on 10/01/24. The Administrator stated that Resident #22 had been stable with no falls, no infections, and no new diagnoses, so there had been no reason to audit her care plan. DON stated that if a resident falls or had an infection, she looked at the resident's care plan to make sure it was current and updated it if needed. The Administrator stated that the DON looked at the entire care plan during her audits. The DON stated the facility held weekly IDT meeting to discuss every resident - weight, skin, falls, about all changes. The Administrator and the DON both stated that all resident information was supposed to transition into the new EMR system, and some things did not, which they believe was the reason for the failure. The DON stated that the facility did not have a policy regarding care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included locked secured medications, the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 3 medication carts (Rehab hall and secured unit medication carts), 1 of 2 medication rooms (Secured unit medication room) and to maintain locked medication cabinets for 4 of 60 rooms (Residents #9, #10, #28, #94) reviewed for medication storage. The medication cart used for the secured unit had an insulin pen that had been opened and placed into use but had no open date on it. The medication cart used for the rehab hall had 2 insulin vials that had been opened and placed into use but had no open dates on them. The secured unit medication room had opened Tuberculin (TB) vial that had expired. (Tuberculin is used to test for Tuberculosis in the body, Tuberculosis is a contagious infection caused by bacteria that mainly affects the lungs). The medication cabinets for 4 of 60 rooms (Residents #9, #10, #28, #94) were unlocked and unsupervised. The failures could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications and could place residents at risk for drug diversion or accidental ingestion. Findings include: INSULIN AND EXPIRED TB During an observation and interview on 12/04/24 at 02:38 PM revealed the medication room in the secure unit was inspected with LVN A present. There was a small refrigerator that contained a vial of Tuberculin that had an open date of 10/30/24 and the box indicated to discard 30 days after opening. LVN A said she was not aware the TB solution had already expired. LVN A said as far as she knew it was each nurse's responsibility to remove any expired medications from the refrigerator. LVN A said if someone received a test with that expired TB solution it could lead to false readings. During an observation and interview on 12/04/24 at 05:39 PM revealed the medication cart in the rehab hall was inspected with LVN B present. Inside the cart were 2 insulin vials that had been opened and placed into use and had no open date written on them. The insulin boxes and vials indicated Discard unused portion 28 days after first opening, Use within 28 days after initial use. LVN B said she had not opened the insulin vials and had no idea who had done that. LVN B said whenever she opened an insulin vial she dated them and as far as she knew every nurse was responsible for dating the insulin when they opened it. LVN B said if an expired insulin was administered to a resident it might not be as effective and lower the resident's blood sugar. During an observation and interview on 12/05/24 at 11:04 AM revealed the medication cart in the secure unit was inspected with LVN A present. Inside the cart was an insulin pen that had been opened and placed into use but had no open date written on it. The insulin pen indicated that it was good for 28 days after being opened. LVN A said she was not aware of the insulin pen not being dated. LVN A said she would always date the insulin pens when she opened them so that they would know when to dispose of them. LVN A said if the insulin pens were not dated and if used after 28 days it could lead to resident's sugar not being lowered and the insulin could have lost its potency. During an interview on 12/05/24 at 05:32 PM the DON was made aware of the opened and undated insulin medications and also the expired TB vial in the medication room. The DON said it was expected for the nursing staff to date the insulin and TB medications when they were opened. The DON said the nursing staff was supposed to date it because those medications were usually good for only 30 days. The DON said they did random audits of the medication rooms and medications carts but not at all times. The DON said if staff administered expired insulin or TB test that could lead to not being as effective. The DON said the failure occurred because the nursing staff did not date the insulins or removed the expired TB from the medication room. During an interview on 12/05/24 at 05:48 PM the Administrator was made aware of the opened and undated insulin medications and also the expired TB vial in the medication room. The Administrator said she expected for the nursing staff to have applied standard nursing practices such as following nursing guidelines they were taught in nursing school. The Administrator said if the staff administered an expired medication it may or may have a negative outcome. The Administrator said the failure because the nurses that open the insulins failed to date the vials and pen and they also failed to remove the expired TB vial from the medication room. During an interview on 12/05/24 at 06:02 PM the DON said they did not have a specific policy or any current training in regard to dating medication when opened. UNLOCKED MEDICATION CABINETS Review of Resident #9's Resident Face Sheet, dated 12/5/24, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, hypertension (high blood pressure), hypothyroidism (low thyroid levels), Arthritis, Anxiety, Allergies, incontinence, constipation, and dermatitis. Review of Resident #9's Quarterly MDS Assessment, dated 10/11/24, revealed: She had long and short-term memory impairment with moderately impaired decision-making skills. She showed signs of delirium that included disorganized thinking that fluctuated. Triggered medications included an anti-anxiety and a diuretic. Review of Resident #9's Care Plan, last revised 9/25/24, revealed: Problem: History of elevated Blood pressure and needs medication to keep it controlled. Goal: Blood pressures within normal range for resident Approaches included: Administer antihypertensive medication as ordered. Problem: Pain. Will not show decline in mobility due to pain not controlled. Goal: Remain comfortable as disease progresses. Approaches included: Administer pain medications as ordered. Takes acetaminophen twice a day routinely. Problem: Psychosocial Wellbeing, Depression: Chronic. Goal: Depression will not increase as evidenced by participation in activities, leaving room, and absence of crying and making statements that she is depressed. Approaches included: Assess effectiveness of anti-depressant medication therapy. Review of Resident #9's Continuity of Care Document, dated 12/5/24, revealed ordered medications: Benazepril 40 mg tablet, once a day for Hypertension. Citalopram 10 mg, once a day for anxiety Donepezil 10mg , once a day for dementia Hydrochlorothiazide 12.5mg capsule once a day for hypertension. Observation on 12/3/24 at 3:51 p.m. revealed Resident #9's resident room open, the medication cabinet in her room was closed but did not lock. Resident #9 was out of her room. Inside the cabinet were cards of: Memantine 28 mg Benazepril 40 mg Hydrochlorothiazide 12.5mg capsules Citalopram 10mg Donepezil 10mg tablets And a box of Albuterol Sulfate. Interview on 12/4/24 at 12:50 p.m. LVN A stated she never checked the door to the medication cabinets, she put the key in, and the doors unlocked. LVN A was shown Resident #9's cabinet and stated Oh goodness. LVN A said she switched to the cabinet the medications were currently in because the other cabinet in the room required to be slammed and she (LVN A) did not want to scare Resident #9 like that. LVN A stated she guessed as the charge nurse she was responsible for monitoring the doors. LVN A said there were 4 nurses who passed medications: herself, another day shift nurse, and two night shift nurses. LVN A stated she never checked the cabinets to see if they locked before now; she just assumed they would lock. LVN A stated, It's like the gun cabinet; you can bet I will be double checking now. LVN A stated she never received an in-service about checking to make sure the cabinets were [NAME]. LVN A added Why would we? It's a lock; it's supposed to lock. Review of Resident #10's Face Sheet revealed she was an [AGE] year-old female admitted to the facility 6/18/20 with diagnoses including Alzheimer's disease, generalized anxiety disorder, protein-calorie malnutrition, constipation, pain, nausea, and diarrhea. Review of Resident #10's Annual MDS assessment dated [DATE] revealed: She had long and short-term memory impairment with severely impaired decision-making skills. She showed signs of delirium that included continuous inattention. Review of Resident #10's Continuity of Care Document, dated 12/5/24, revealed the following orders: Lactulose 10grams/15ml give 30ml by mouth three times a day as needed for constipation (Order Date 10/26/23) Lactulose 10grams/15ml give 30ml three times a day for constipation (Order Date 12/5/24) Observation on 12/03/24 at 4:00 pm revealed Resident #10's door open and the built-in medication cabinet in Resident #10's room was unlocked. One 32-ounce bottle of Lactulose (liquid laxative) was observed in the unlocked medication cabinet. Resident #10 was not in the room at the time of the observation. Review of Resident #28's Resident Face Sheet, dated 12/5/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis including Pseudomonas (having the pneumonia virus), anemia (low iron), pressure ulcer of the left hip (bed sore), tachycardia (unstable heart rhythm), altered mental status, dementia, pain, allergies, arthritis, hypertension (high blood pressure), hyperlipidemia (high cholesterol), Diabetes. Review of Resident #28's 11/17/24 admission MDS, dated [DATE], revealed: He had long and short-term memory problems with severely impaired cognitive ability. He showed signs of delirium including inattention and disorganized thinking that were continuously present. Triggered medications included anti-anxiety, and opioid medication. Review of Resident #28's Care Plan, initiated 11/26/24, revealed: Category: Pain: Chronic pain due to arthritis and general aches and pains. Goal: Will voice or show relieve or reduction in pain within one hour after receiving intervention for pain. Approaches included: Administer scheduled ibuprofen and monitor effects. Category: Hyper/Hypoglycemia (high and low blood sugar) Goal: Will remain free of complications from hyper or hypoglycemia Approaches included: Administer Metformin as ordered, hold if Capillary Blood Glucose is below 140. Review of Resident #28's Continuity of Care Document, dated 12/5/24, revealed orders for: Diclofenac Sodium 1% gel Four times a day Ibuprofen 600 mg tablets every 6 hours Hyoscyamine sulfate 0.125 mg tablet every 4 hours as needed Metformin 500 mg once a day hold for blood glucose level less than 140. Vitamin B1 100mg tablet once a day Loratadine 10mg once a day Observation of Resident #28's room on 12/4/24 at 11:20 AM revealed Resident #28 in bed asleep. Resident #28's door was open. The medication cabinet in Resident #28's room came open. In Resident #28's medicine cabinet were: 2 boxes of Diclofenac Sodium 1% gel Four times a day Ibuprofen 600 mg tablets every 6 hours Hyoscyamine sulfate 0.125 mg tablet every 4 hours as needed Metformin 500 mg once a day hold for blood glucose level less than 140. Vitamin B1 100mg tablet once a day Loratadine 10mg once a day Review of Resident #94's Resident Face Sheet, dated 12/5/24, revealed she was an 81-year-femaled admitted to the facility on [DATE] with diagnoses including hypokalemia (low potassium), hypertension (high blood pressure), hyperlipidemia (high cholesterol), hypothyroidism (low thyroid), hypo-somality (sleeps too much), edema (swelling, usually to lower extremities), allergies, and respiratory failure (difficulty breathing). Review of Resident #94's Care plan, updated 10/16/24, revealed: Problem: Nutritional Status: At risk in nutrition/hydration due to needs for assist with meal intake, risk for weight changes due to edema and diuretic use. Goal: Will encourage at least 75% of meal and offer fluids regularly Approaches included: Administer sodium and diuretic medication daily as ordered. Problem: Sleep: Difficulty with insomnia. Goal: Will be able to sleep 6 - 8 hours at night. Approaches included: Assess effectiveness of medication therapy Melatonin. Review of Resident #94's Continuity of Care Document, dated 12/5/24, revealed orders: Fexofenadine 180 mg -pseudoephedrine 240mg once a day Amlodipine 10mg once a day Digoxin 0.125mg once a day. Furosemide 20mg twice a day Gabapentin 100mg 2 capsules three times a day Levothyroxine 100 mcg tablet once daily Melatonin 3 mg tablet at bedtime Montelukast sodium 10mg once day Potassium Chloride 20 meq tablet, 5 tablets to equal 100 meq three times a day. Simvastatin 20 mg at bedtime Sodium Chloride 1,000 2 tablets twice a day Rivaroxaban 20mg at bedtime Observation on 12/04/24 on 12:01 PM revealed Resident #94 in the dining room. The door to the room was open the medication cabinet in her room was completely open with the work ledge down. All medications were easily accessible to people passing by. Medications included: Montelukast sodium -10 mg Vitamin D-1 Amlodipine desolate 10mg Levothyroxine 10mg in am Digoxin 0.125 mg Furosemide 20 mg bid Gabapentin 100mg Rivaroxaban 20 mg Simvastatin 20 mg Sodium chloride 1,000 mg Potassium 20 meq Iron tab ferrous sulfate 65 mg Melatonin 3 mg Fexofenadine 180 mg -pseudoephedrine 240mg Interview and observation on 12/4/24 at 12:35 PM, LVN C said she did not have trouble keeping cabinets locked. She said only the nurses had keys. LVN C was shown Resident #94's cabinet. LVN C said she just did not lock it behind her because she was in a rush. LVN C explained she gave Resident #94 their meds, closed the door and forgot to lock the cabinet because she was busy taking Resident #94 to the dining room. LVN C was shown Resident #28's medicine cabinet that was unlocked. LVN C stated the cabinets were supposed to be locked. LVN C stated they closed and should lock automatically. LVN C said she covered all medications on that cottage (20 rooms) and no one had orders to self-medicate. LVN C attempted to show that the cabinet closed automatically and admitted the cabinet did not lock automatically and she had to push the door closed and lock the door with the key. Interview on 12/4/24 at 1:18 p.m. the DON and Administrator were informed of the cabinets that were unlocked and unattended. The DON stated she had never found a medication cabinet unlocked when she had the occasion to have the medication keys. The DON said she did not know why they would be unlocked, and it was brand new information to her. The Administrator added the Maintenance Department did not check the cabinet doors in the rooms to ensure they locked. The DON said she would rather nursing staff did that because of the medication. The DON said the nurses must not be pushing hard enough on the doors. The DON said there was no in-services on locking the cabinets because there did not need to be one until now. The Administrator and DON both said there was no policy about unlocked medication cabinets when a policy was asked for.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's four of four kitchens. The facility failed to ensure milk was not used or discarded by the use by date in 2 of 4 kitchens. The rehabilitation kitchen drawer had an accumulation of food debris in the drawers. The juice reservoirs under the juice dispensers of 2 of 4 kitchens were not clean and beginning to have white mold growing in the bottom. The rehabilitation kitchen refrigerator had fruits that were fuzzy with mold. Food was unlabeled in 2 of 4 kitchens. The handwashing sinks did not have trash cans that did not require staff to touch them in order to prevent re-contamination of hands in 2 of 4 hands. Dishes were stored face up in 1 of 4 kitchens. Hand hygiene was not performed when indicated by staff in 1 of 4 kitchens. Dirty rags were not kept separate from clean rags in 1 of 4 kitchens. These failures could affect residents who received meals prepared from the kitchens at risk for food borne illness and cross contamination. Findings included: Observation of the facility's main kitchen (Younger Unit) on 12/3/24 at 9:33 a.m. revealed a half-used gallon of milk that had a best by date of 11/28/24. [NAME] D stated Oh that's expired milk, took the milk and dumped it down the sink. Observation of the rehabilitation kitchen on 12/3/24 at 10:05 a.m. revealed: - a drawer of individual serving saltine crackers that had a multitude of crumbs - the refrigerator had a container of unlabeled, unlabeled container of berries that was fuzzy with grey mold. - the reservoir beneath the juice containers had some grey circular mold flecks beginning to grow through it. Observation of the [NAME] Cottage kitchen on 12/3/24 at 10:30 a.m. revealed: One of two handwashing sinks blocked by an empty milk crate. The other handwashing sink had a flip-lid trash can for paper towels. Interview on 12/3/24 at 10:45 a.m. Universal Aide E was asked about the flip-top trash can and said there was a foot-pedal type trash can by the blocked hand-washing sink. Universal Aide E asked why that was an issue. The surveyor washed their hands slowly throwing out the paper towel pushing the flip-lid down to dispose of the paper towel. Universal Aide E said Oh, that's cross contamination! Observation of the [NAME] Cottage Kitchen on 12/3/24 at 10:49 a.m. revealed: -The juice dispenser reservoir had an accumulation of juice and was beginning to have white spots of mold in it. -The resident refrigerator unlabeled (no resident name on it) with a best-by date of 11/22/24 -The facility refrigerator had a gallon of milk with a best by date of 11/28/24. -The hand washing sink trash can had a flip top lid and no paper towels available. -Serving platters and coffee carafes were stored face up (open to air contamination) -In the second refrigerator was a bowl of unlabeled, undated peaches and a bag of shredded cheese. -Universal Aide F rinsed some dirty dishes, took off gloves and did not perform hand hygiene. The aide left to get a resident some iced-tea. - Under the sink was a stack of clean rags folded neatly. Immediately next to it was a stack of used rags (visible stains) touching the clean rags. In an interview on 12/5/24 at 1:37 p.m. Aide F stated she worked at the facility for 3 years and always worked at the cottages. Aide F stated she worked in the kitchen and was responsible for cooking breakfast and serving lunch. Aide F stated everyone was responsible for making sure the kitchen was clean and there was no set cleaning schedule and the aides got to it if they could. Aide F stated [NAME] Cottage did not have a dedicated cook like [NAME] Cottage did, but they would lose an aide if they did dedicate someone to the kitchen full time. Aide F stated the cook, or the coordinator was responsible for checking to see that foods were not expired and that things were labeled. Aide F said all dishes were supposed to be stored face down. Aide F said she did not know when the peaches were put in the bowl since she did not see them, but they made after 12/1/24. Aide F stated they were trained to wash their hands or perform hand hygiene before and after all resident care or when they changed their gloves. She stated the surveyor probably caught her at a busy time and she did not perform hand hygiene. Interview on 12/5/24 at 2:35 p.m. the Administrator, with the DON present, stated housekeeping was responsible for cleaning out the drawers in the rehabilitation kitchen but the aides or the ADON were responsible for ensuring the reservoir was empty and clean. The DON stated there was no policy it was just to follow regulation and she did not remember the last in-service but there was an all-skills fair on 4/12/24 that all staff had to go to that covered hand hygiene and food handling. The DON added they facility also used a computer-based computer program that also covered hand-hygiene. The DON and Administrator stated they were mad because they made sure all the hand washing sinks in the cottages had a foot pedal trash can for handwashing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Residents #18) reviewed for indwelling catheters. The facility failed to ensure Resident #18's indwelling catheter was secured to prevent pulling or tugging. The facility failed to ensure CNA B performed urinary catheter care for Resident #18 during incontinent care. These failures could place residents at risk for discomfort, urethral trauma and urinary tract infections. Findings included: Record review of Resident #18's face sheet dated 11/15/2023 indicated he was admitted to the facility on [DATE] with diagnoses of retention of urine and Alzheimer's disease. He was [AGE] years of age. Record review of Resident #18's physician order report for the month of November 2023 indicated in part: Foley catheter care (Q = every) shift. Start date 03/29/2017. Record review of Resident #18's care plan dated 04/18/2023 indicated in part: Care plan description - urinary catheter : Indwelling due to urinary retention. Care plan goal: will reduce the risk of infection. Interventions; Assess color, clarity and character of urine, assess for acute behavioral changes that may indicate UTI. Catheter care every shift. Monitor catheter tubing for kinks or twists in tubing. Record review of Resident #18's MDS dated [DATE] indicated in part: Cognitive skills for daily decision making = Severely impaired-never/rarely made decisions. Appliances: indwelling catheter. Bowel continence = Always incontinent. During an observation on 11/14/23 at 09:50 AM Resident #18 was in bed resting and had a urinary catheter which hung on the side of the bed. The urinary catheter tube was not secured to the resident's leg. The resident was not able to state if the catheter had caused him any discomfort due to his cognitive status. During and observation and interview on 11/14/23 beginning at 11:45 AM CNA B and CNA C performed incontinent and urinary catheter care for Resident #18. CNA B put some gloves on and undid the resident's brief and performed catheter care. CNA B took some wipes and wiped the resident's penis with front to back motions. CNA B did not cleanse the catheter tubing that entered the resident's penis. Both CNAs then turned the resident on his side and CNA B wiped the resident's bottom as he had a bowel movement. CNA B then disposed of the soiled brief and pad, removed her gloves and fastened a new brief to the resident. Both CNAs then dressed the resident and got him out of bed with the use of the mechanical lift. CNAs B and CNA C said they had never seen the catheter secured to his leg. During an interview on 11/15/23 at 01:52 PM ADON A said she recalled Resident #18 having his catheter anchored to his leg at times but did not know why he no longer had it. The ADON said the reason it was anchored to his leg was to prevent the catheter from tugging or injury to his urethra. During an interview on 11/16/23 at 10:02 AM LVN D said she did not recall Resident #18 having his catheter anchored as she did not believe the resident would pull on the catheter and staff were careful not to pull on it when they assisted the resident. The LVN said that but now the resident did have his catheter secured to prevent any issues. During an interview on 11/16/23 at 02:58 PM CNA B said she had gotten nervous and forgot to cleanse the catheter tubing during the incontinent care she performed for Resident #18. CNA B said she had been trained on how to properly perform catheter care but again she got nervous during the procedure and forgot to wipe the catheter tubing. During an interview on 11/16/23 at 03:47 PM ADON A said she expected for staff to clean from the meatus up to the catheter tube and from dirty to clean during catheter care. The ADON was made aware of the observation of the catheter care performed by CNA B. The ADON said if the catheter care was not done correctly it could lead to infections. The ADON said she believed the failure occurred because the CNA got nervous and forgot her steps. The ADON said they had just initiated the catheter leg strap this morning 11/16/23 to prevent tugging and pulling on Resident #18's penis. The ADON said the CNAs received in-services and computer training on how to perform catheter care. During an interview on 11/16/23 at 04:14 PM the DON was made aware of an observation of Resident #18's urinary catheter not being secured to his leg. The DON said if a resident was mobile then it would be good to have a leg strap that secured the catheter to prevent it from being tugged. The DON said if the catheter was not secured it could become dislodged. The DON said the staff received training such as in-services and computer training regarding catheter care. The DON said Resident #18 now had a leg strap in place. The DON was made aware of an observation of Resident #18's urinary catheter care. The DON said it was her expectation for the staff to clean the meatus around the penis and then wipe the catheter tubing as well. The DON said if the care was not cone correctly it could lead to an infection. The DON said the failure probably occurred because the CNA got nervous and forgot the steps. The DON said she would do rounds to monitor staff and conducted in-services to include computer training regarding catheter care. During an interview on 11/16/23 at 04:15 PM the Administrator was made aware of an observation of Resident #18's urinary catheter not being secured to his leg and the catheter care performed by the CNA. The Administrator said she was not a nurse and agreed with the DON's answers regarding the catheter not being secured and the catheter care performed by the CNA. Record review of the document provided by the facility on 11/16/23 and titled Catheter and perineal care and dated 2022 indicated in part: Following proper perineal and catheter care procedures can prevent contamination that can lead to urinary tract infections. This course discusses how to perform perineal care and catheter care. It also discusses how to empty a catheter drainage bag. Male catheter care: Using your non-dominant hand retract the foreskin if it is not already retracted. Hold the penis just below the head and use two fingers of the same to grasp the catheter to grasp the catheter to secure it. Remove the excess water from a cloth, apply soap and wash around the meatus using a circular motion and use a clean area of the washcloth with each stroke. Set the used washcloth on the disposable pad on the table. Take another washcloth from the basin and remove excess water. Apply soap to the cloth . Cleanse the catheter working your way down from the meatus about 4 inches or farther if needed. Avoid tugging the catheter Set the used cloth on the disposable pad on the table and get a clean cloth, then remove excess water and rinse the meatus in the same manner used to cleanse it. Use a clean area of the washcloth for each stroke. Set the used cloth on the waterproof pad on the table. Take the last washcloth and remove excess water. Rinse the catheter from the insertion site downward at least 4 inches. Return the foreskin to its natural position and gently pat with a dry towel. Follow post procedure instructions. Replace the catheter in the leg strap. Secure the catheter to the individual's leg using a leg strap to prevent pulling or tugging. The catheter and tubing must be free from kinks to allow the urine to drain safely. Review of the online the CDC website - According to the CDC website document, dated 2012, indicated in part: Indwelling Urinary Catheter Insertion and Maintenance. Catheter securement devices act as an anchor to prevent tugging and pulling which can cause irritation and inflammation. When catheters are not secured in male patients, the tugging and pulling can cause pressure sores on the penis tip. Properly secure catheters to prevent movement and urethral traction. Reference. https://www.cdc.gov/infectioncontrol/pdf/strive/CAUTI104-508.pdf Review of the online the CDC website - According to the CDC website document, dated 06/06/2019, indicated in part: Guideline For Prevention Of Catheter-Associated Urinary Tract Infections 2009. Proper Techniques for Urinary Catheter Insertion. Properly secure indwelling catheters after insertion to prevent movement and urethral traction. Reference. https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed treat each resident with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two of five residents (Residents #31, #32) and two unsampled residents (Residents #3 and #10) reviewed for treatment with respect and dignity. CNA E was on her cell phone and tapped her fingers on Resident # 32's wheelchair arm. CNAF stood while feeding Resident #31 and #10. This failure placed residents at risk of feeling embarrassed, infantilized, dehumanized, or stigmatized due to their need for assisted dining. Findings included: Review of Resident #31's Face Sheet, dated 11/15/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included diabetes, weight loss. Review of Resident #31's Quarterly MDS assessment dated [DATE] revealed (an 11/9/23 quarterly MDS assessment was in progress): He had long- and short-term memory loss and had severely impaired decision-making skills (indicating he was not interview-able). He needed extensive assistance from staff for ADLs. Review of Resident #32's Face Sheet, dated 11/15/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (progressive disease affecting the resident's memory and ability to perform basic functions), psychotic disorder with hallucinations due to known physiological conditions (they see or hear things that are not there). Review of Resident #32's Annual MDS Assessment, dated 9/27/23, revealed: She had short- and long-term memory impairment with severely impaired decision-making skills (indicating she was not interviewable). She was totally dependent on staff for all ADLs. Observation on 11/15/23 at 11:39 AM revealed CNA E stood while trying to feed Resident #3 but then walked around and crouched to talk to unidentified Resident #6. At 11:45 AM CNA E sat next to Resident #32, CNA E took her cell phone out of her pocket and tapped her fingers on Resident #32's wheelchair arms in a sequential fashion. Observation on 11/16/23 at 9:42 AM revealed CNA F stood while feeding Resident #31. CNA F turned and fed unsampled resident #10 while standing. Interview on 11/16/23 at 09:45 AM LVN G stated her expectation for staff while feeding residents was, they needed to speak and visit with the residents. LVN G said she did not prefer them standing except for Resident #3 who you could sometimes sneak in a bite if you said, here trying this, give her a bite and walk away. LVN G said some staff had to stand while feeding Resident #32 because she was so tall the staff had to support her head. LVN G said cell phone use depended on the aide. LVN G stated she did not agree with staff texting but did not mind staff playing music on their phones. LVN G said she monitored by looking over the window into the dining room from the nurses' station. LVN G said she would wait and get the aides by themselves because she did not like being called out in front of someone else. Interview 11/16/23 04:34 PM the DON stated the expectation for staff feeding dependent residents was for them to do it. The DON said she expected staff to sit with residents and feed the residents at the resident's speed and the staff did not need to be on their phone. The DON said standing was ok in certain circumstances. The DON elaborated that there was one resident who would gaze up so to make eye contact, the staff would have to stand to feed the resident. The DON said the computer training program had trained on resident rights in the last year but did not know if it specifically covered feeding or being on the phone. Interview on 11/16/23 at 05:15 PM the DON said the last in person in-service on cell phone use was done prior to the last annual survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 3 of 9 residents (Residents #19, #31 and #32) whose records were reviewed for assessments after significant change. The facility failed to complete a comprehensive MDS assessment after Resident #19, Resident #31 and Resident #32 developed pressure ulcers. These failures placed residents at risk of having assessments that do not reflect significant changes in their conditions and need for additional care/treatment. The findings included: Review of Resident #19's Face Sheet, dated 11/16/23, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including pulmonary embolism, acute kidney failure, dementia, chronic obstructive pulmonary disease, heart failure, high blood pressure, anemia, and depression. Review of Resident #19's most recent MDS Assessment, dated 10/11/23 revealed: He scored a 3 on his mental status exam, indicating severe cognitive impairment. He required substantial to maximal assistance with all ADLs and used a wheelchair for mobility. He had no documented pressure ulcers at the time of the assessment. Review of Resident #19's Physician's Orders for November 2023 revealed the following orders: Apply medi-honey to buttocks, cover with foam border dressing every day and PRN (start date 10/22/23) Multivitamin 1 tablet by mouth every day (start date 11/15/23) Push Powder in 8oz beverage of choice to aid in wound healing twice a day (start date 11/13/23) Vitamin C 500mg 1 by mouth twice a day (start date 11/15/23) Air mattress every shift (start date 11/13/23) Turn every 2 hours (start date 9/23/23) Right buttocks wound care: clean with normal saline/wound cleanser, pat dry, apply Santyl to eschar, cover with padded dressing every day and PRN (start date 11/13/23) Review of Resident #19's Care Plan, most recent revision date 11/14/23, revealed: Care Plan Description: Pressure Ulcer, Stage 2 (start date 10/30/23) Goal: Ulcer will heal Interventions: Repositioning - two person assist to avoid skin friction/shearing; Refer to dietician for evaluation of current nutritional status, provide supplemental nutritional support; Perform wound care as ordered; Mechanical lift to avoid skin friction/shearing; Full skin evaluation with bath/shower; Float heals off the bed; encourage good nutritional intake; Provide pressure reducing surfaces on bed and chair; Assess wound healing weekly; Assess skin daily with routine care; Administer pain medication prior to initiating treatment Review of Resident #31's Face Sheet, dated 11/15/23, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included diabetes, weight loss , kidney disease disorders of the skin of subcutaneous tissue, and skin cancer. Review of Resident #31's Quarterly MDS assessment dated [DATE] revealed (an 11/9/23 quarterly MDS assessment was in progress): He had long- and short-term memory loss and had severely impaired decision-making skills (indicating he was not interview-able). He needed extensive assistance from staff for ADLs. There were no identified skin issues. Review of Resident #31's November 2023 Physician's Orders, printed 11/15/23, revealed: Order dated 10/5/23 Cleanse Stage II to left inner buttock with wound cleanser, apply hydrocolloid dressing and change every three days and as needed if soiled until healed. Review of Resident #31's Care Plan, dated 5/23/23, revealed: Resident #31 had a history of pressure ulcer and skin issues., he moves his heels against bed sheets frequently, at high risk for further break down. The goal was Remain free from skin break down. Identified interventions included: perform wound care as ordered, asses changes in skin status that indicate worsening of pressure ulcer and notify the physician, keep skin clean and dry, provide pressure reducing surfaces on bed and chair, repositioning assist to avoid friction/shearing/contact with other body part or objects, monitor for signs of infection or spreading, provide incontinent care as needed, apply moisture barrier to peri area as indicated, turn and reposition every two hours, keep heels off bed, may have heel boots to relieve pressure, stage II area to left inner buttock apply treatment as ordered, monitor skin weekly if area is not improving notify hospice/doctor, administer vitamins per dietary consultant recommendations to promote healing. Review of Resident #32's Face Sheet, dated 11/15/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, psychotic disorder with hallucinations due to known physiological conditions, and stage III of the sacral region (tail bone). Review of Resident #32's Annual MDS Assessment, dated 9/27/23, revealed: She had short- and long-term memory impairment with severely impaired decision-making skills (indicating she was not interviewable). She was totally dependent on staff for all ADLs. She had no identified pressure injuries. Review of Resident #32's Care Plan for Pressure Ulcer, Stage 2 to Coccyx, started 10/2/23, revealed: Care Plan Goal: Area will remail free of infection with interventions including perform wound care as ordered, assess changes in skin status that indicate worsening of pressure ulcer and notify the physician, reposition every two hours off back as much as possible, encourage nutritional intake provide protein supplement if intake less than 50%, and administer vitamins per dietary consultant recommendations. Review of Resident #32's Physician's Orders for November 2023 revealed: Cleanse Stage II to coccyx and right side of coccyx with wound cleanser, pat dry and apply hydrocolloid dressing every three days and as needed if soiled, dated 10/2/23. In an interview on 11/16/23 at 5:04 PM, the MDS Coordinator stated that a Significant Change MDS was required when a resident had 2 or more changes in their care, significant weight loss, and when a resident started on or went off hospice. She stated that a significant change assessment could be done with only 1 change if the IDT (Interdisciplinary Team) agreed. She stated that the IDT's decision-making process was normally based on the severity of the diagnosis. When asked if the development of new pressure ulcer required a significant change assessment, she stated that she thought it still required a change in level of care for 2 care areas, but she would have to look at the CMS (Centers for Medicare and Medicaid Services) resident assessment tool to be certain. The MDS Coordinator logged onto the CMS RAI (Resident Assessment Instrument) guide during the interview to double check and she stated that, according to the tool, Resident #19, Resident #31, and Resident #32 all should have had significant change assessments done when they developed pressure ulcers. She stated that she was not notified by the nursing staff that those residents had new pressure ulcers. The MDS Coordinator stated that she was made aware of changes with the residents primarily by the ADONs via email. She stated that skin issues were not addressed during the morning meeting unless a new skin tear or bruise was identified. In an interview on 11/16/23 at 5:33 PM, ADON A stated that she was not aware that the MDS Coordinator needed to be notified when a resident developed a pressure ulcer. She stated that when a CNA charted a new skin issue it alerted the nurse to follow up, and the way the nurse charted should alert her (MDS Coordinator). ADON A stated that when she was informed of a new pressure ulcer by staff, she would send a text message to the DON and the Administrator to let them know. She stated that the weekend RN did skin checks for the residents, but she was not aware if they notified the MDS Coordinator of their findings. In an interview on 11/16/23 at 5:58 PM, the DON and Administrator were informed that significant change MDS assessments had not been completed for Residents #19, #31, and #32. Neither was able to offer any further information regarding why the significant change assessments were not done. The facility did not have a policy regarding resident assessment per the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 9 residents (Residents #17, #19, and #32) reviewed for care plans in that: Resident #17 did not have a care plan in place for fall risk. Resident #19 did not have a care plan in place for skin integrity risk, bipolar disorder, or psychotropic medication use. Resident #32 did not have a care plan in place for an indwelling catheter. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #17's Face Sheet, dated 11/16/23, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Parkinson's disease, Lewy Body dementia, high blood pressure, generalized osteoarthritis, and pain. Review of Resident #17's Annual MDS Assessment, dated 4/20/23, revealed: Fall risk CAA triggered and to be added to care plan. Review of Resident #17's Care Plan, most recent revision date 10/25/23, revealed no fall risk care plan. Review of Resident #17's Quarterly MDS Assessment, dated 11/2/23, revealed: He had short-term and long-term memory loss, and severely impaired decision-making skills (indicating he was not interviewable). He had behavioral symptoms not directed towards others which occurred less than daily. He required maximum assistance and was dependent on staff for all ADLs except for eating. He used a wheelchair for mobility. He had no reported falls in the previous 6 months. He received antipsychotic medication, antidepressant medication, opioid medication, and antiplatelet medication. Review of Resident #17's Physician's Orders for November 2023 revealed: Quetiapine 12.5mg by mouth every night - give ½ of 25mg tablet (start date 5/9/32) Tylenol with codeine #3, 1 tablet by mouth three times a day as needed for breakthrough pain (2/16/19) Cymbalta 60mg 1 capsule by mouth daily (start date 5/16/17) Metoprolol succinate ER 50mg 1 tablet by mouth daily (start date 2/15/22) Memantine 10mg tablet by mouth twice a day (start date 10/20/17) Carbidopa-Levodopa 25-250mg 1 tablet by mouth four times a day before meals and at bedtime (start date 6/23/17) Neurontin 600mg 1 by mouth every evening (start date 2/16/19) Trazodone 50mg 1 tablet by mouth at bedtime (start date 11/4/19) Neurontin 300mg 1 by mouth every morning and noon (start date 4/2/19) MS Contin ER 15mg tablet give 1 by mouth every 12 hours, hold for lethargy (start date 2/9/23) Review of Resident #19's Face Sheet, dated 11/16/23, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including pulmonary embolism, acute kidney failure, dementia, chronic obstructive pulmonary disease, heart failure, high blood pressure, anemia, and depression. Review of Resident #19's most recent MDS Assessment, dated 10/11/23 revealed: He scored a 3 on his mental status exam, indicating severe cognitive impairment. He required substantial to maximal assistance with all ADLs and used a wheelchair for mobility. He had no documented pressure ulcers at the time of the assessment (10/11/23). He was taking an antipsychotic medication and a hypnotic medication. Review of Resident #19's Physician's Orders for November 2023 revealed the following orders: Temazepam 15mg give 1 by mouth at bedtime PRN (start date 9/15/23) Quetiapine fumarate 25mg give two (50mg) by mouth daily (start date 9/15/23) Offload heels while in bed every shift (start date 11/13/23) Air mattress every shift (start date 11/13/23) Monitor right heel every shift and PRN for openings and report to ADON (start date 11/13/23) Monitor left heel every shift and PRN for openings and report to ADON (start date 11/13/23) Turn every 2 hours (start date 9/23/23) Review of Resident #19's Care Plan, most recent revision date 11/14/23, revealed no care plan for skin integrity, bipolar disorder , or his use of psychotropic medication. Review of Resident #32's Face Sheet, dated 11/15/23, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, psychotic disorder with hallucinations due to known physiological conditions, neurogenic disorder of the bladder, and stage III pressure ulcer of the sacral region (tail bone). Review of Resident #32's Annual MDS Assessment, dated 9/27/23, revealed: She had short- and long-term memory impairment with severely impaired decision-making skills (indicating she was not interviewable). She was totally dependent on staff for all ADLs. She had an indwelling catheter. Review of Resident #32's Care Plan, most recent revision date 11/2/23, revealed no care plan for indwelling catheter use. Review of Resident #32's Physician's Orders for November 2023 revealed: Foley catheter care every shift (start date 9/21/22) Foley output every shift (start date 9/21/22) Continue foley catheter 20 French change every month and as needed (start date 12/27/22) In an interview on 11/16/23 at 5:04 PM, the MDS Coordinator stated that she was responsible for creating care plans for the skilled residents and the ADONs were responsible for creating care plans for the rest of the residents. She stated that if a CAA was triggered during an assessment, a care plan should automatically be created. She stated that she was not aware if the new system generated care plans based on the MDS or if the care plans had to be done manually. In an interview on 11/16/23 at 5:33 PM ADON A stated that she was responsible for care plans for all the rehab and long-term care residents. She stated that she would expect a care plan to address admitting diagnosis and other pertinent diagnoses, psychotropic medication, pain and pain medication, pressure ulcers, consent for psychotropic medication, code status, dietary changes, antibiotics, lab work, fall risk, catheter care. When asked if a pressure ulcer care plan would override a skin integrity care plan, she stated she would have both because if the sore heals the resident would still be at risk. She stated that any type of preventative care, air mattress, moon boots things like that should be care planned. ADON A stated that she had to manually add everything into the computer program when something needed to be care planned. She stated that if a CAA triggered, she would add it on the care plan. She stated she did not have an answer as to why there were no care plans for Resident #17 for fall risk, Resident #19 for skin integrity, depression, or psychotropic medication use, or Resident #32 for her catheter. In an interview on 11/16/23 at 5:58 PM the DON stated that all resident care plans had been redone recently and she was not surprised that some were missed. She stated that she would not expect a skin integrity care plan and a pressure ulcer care plan for the same resident because it was apples to apples and apples to oranges even though they would have different interventions. She stated that psychotropic medications, depression, catheters, and fall risk would require care plans. On review of care plans with surveyor, she acknowledged that Residents #17, #19, and #32 were missing care plans. The DON stated that the facility did not have a policy regarding care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents have the right to formulate an advanced directive for 4 of 11 residents (Resident #16, #17, #23, and #86) reviewed for advance directives, in that: The facility failed to obtain a valid Out-of-Hospital Do Not Resuscitate (OOHDNR) form for Residents #16, #17, #23 and #86. This deficient practice could place residents at-risk of having their end of life wishes dishonored, and of having cardiopulmonary resuscitation (CPR) performed against their wishes. The findings were: Record review of the facility's undated document titled admission Agreement revealed a document titled Resident/family consent for cardiopulmonary resuscitation. There was no OOH-DNR document or explanations on how to obtain one found in the agreement. Review of the Resident/Family Consent for Cardio-Pulmonary Resuscitation form , undated, revealed: This Care Center requests that a written signature of the Elder be obtained in advance regarding the desire for cardiopulmonary (CPR) in the event of an extreme emergency. CPR is the initiation of life saving measures for an individual who has had the sudden cessation of cardia and/or respiratory function. These procedures include the artificial respiration (oxygen) and chest compressions. These procedures will artificially enable the heart to keep pumping as well as aerate the lungs. If the Elder is mentally or physically unable to make this decision and the physician documents this, then a Responsible Party can be assigned as durable Power of Attorney for Health Care. Please note that CPR constitutes an extraordinary measure that can be a life saving procedure. Possible effects of these procedures may be some forms of brain damage due to the absence of oxygen reaching the brain. Other side effects can be damage to internal organs or broken ribs. Often these procedures are successful and will allow the patient life saving time until they can make it to the hospital. We ask that you mark ONE of the decisions below, accompanied by your signature and date. If you have further questions, please contact your attending physician. This statement will remain in effect as long as the resident remains a resident of this facility or until we receive a written and signed notice of revocation from you. (box) I understand that CPR constitutes an extraordinary measure and SHOULD NOT be done on this resident. However, I wish that essential life support interventions such as oxygen, nutrition, hydration, and certain medications for the relief of pain be administered to maintain the resident's comfort. (box) I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in case of extreme emergency. Resident #16 Review of Resident #16's Face Sheet dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, hypertension (high blood pressure), Diabetes (fluctuating blood sugar), abnormal weight loss, pain, glaucoma, and presence of cardiac pacemaker. The face sheet indicated he was a DNR. Review of Resident #16's Quarterly MDS Assessment, dated [DATE], revealed Resident #16 had: -long- and short-term memory loss and had moderately impaired decision-making skills. - needed assistance of one staff for ADLs, except locomotion and eating which he needed supervision. - used a walker. - was frequently incontinent of bladder and occasionally incontinent of bowel. - was on scheduled pain medication and reported not experiencing any pain; - had two or more falls with no injury; - triggered medications included insulin injections for 7 of 7 days; an antidepressant for 7 of 7 days; and was an anticoagulant for 7 of 7 days. Review of Resident #16's Advanced Directive care plan started [DATE] documented: Need: Resident has the following Advanced Directives on record : Do Not Resuscitate (DNR) *Date of physician's order for DNR ___ Goal: Resident's Advanced Directives are in effect, and their wishes and directions will be carried out in accordance with their advanced directives on an ongoing basis through next review date. If the resident's heart stops or if they stop breathing, CPR will not be initiated in honor with their DNR wishes. Identified Approaches included: discuss advanced Directives with the resident and/or appointed health care representative. An Advanced directive can be revoked or changed if the resident and/or appointed health care representative changes their mind about the medical care they want delivered. Advise resident and/or appointed health care representative to provide copies to the facility and any updated Advanced Directives. For DNR Status verify presence of pink DNR on resident's chart, certify presence of physician's order for DNR, place residents name on DNR lists hanging in the facility's common places. Review of Resident #16's Physician Orders for [DATE] revealed the facility had him coded as a Do Not Resuscitate (DNR). Review of the admission paperwork completed on [DATE] documented the Responsible Party signed the Resident/Family Consent for Cardiopulmonary Resuscitation. Review of Resident #16's admission paperwork showed his primary physician signed the Certificate of Incapacity (facility form) on [DATE]. Interview on [DATE] at 11:55 AM, LVN F stated Resident #16's DNR paperwork should be at the front of chart. She flipped through chart for OOHDNR and was unable to find one. She stated she would ask ADON H if the OOH was not filed yet because they were way behind on the filing. She stated she and the other charge nurse worked with the family forever to get them to make up their mind for the OOHDNR. Interview on [DATE] at 12:04 PM, LVN H stated the family wanted a copy of the OOHDNR and they didn't put it back in the clinical record. She said ADON H was looking for it. Follow-up interview on [DATE] at 9:10 AM, LVN H stated the facility was unable to find Resident #16's OOHDNR so they started a new one yesterday ([DATE]). Interview on [DATE] at 9:29 AM, LVN H stated she and the evening nurse worked months to get the family to accept that Resident #16 was declining and sign the OOHDNR. She stated they convinced the family to go to the social worker. She said she was told the family signed the OOHDNR in the wrong place and the actual OOHDNR was in a folder. LVN H said the OOHDNR did her no good in a folder because if she had to send Resident #16 out she would have been standing there with the Resident/Family Consent for Cardio Pulmonary Resuscitation while the Emergency Medication Technicians waiting on her trying to explain Resident #16 had a OOHDNR. She stated without the OOHDNR the EMTs would not be able to respect Resident #16 wishes. Interview on [DATE] at 10:42 AM, ADON H stated she had more problems with getting the OOHDNR than anything. She said in Resident #16's case the Responsible Party signed the form in the wrong place. ADON H stated she did not know why the social worker did not catch the error. Resident #17 Review of Resident #17's Face Sheet, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, restlessness and agitation, hypertension, chronic pain, and need for assistance with personal care. Her Face Sheet indicated she was a DNR. Review of Resident #17's Care Plan dated [DATE] revealed, in part, Elder has a terminal illness with a prognosis of six months or less; place copy of advanced directive on the chart, For DNR status: verify presence of PINK DNR on resident's chart, verify presence of physicians order for DNR, place resident's name on DNR lists hanging in the facility common places. Review of Resident #17's Quarterly MDS assessment, dated [DATE], revealed: Her cognitive status was not assessed. She had no symptoms of delirium. She sometimes understood others and sometimes was understood. She had unclear speech. She had physical behaviors 1 to 3 out of 7 days. She had verbal behaviors 1 to 3 out of 7 days. She had other behaviors 4 to 6 out of 7 days. She required extensive assistance with most ADLs, was totally dependent for bathing, and required limited assistance with eating. She used a wheelchair for locomotion. She was always incontinent of bowel and bladder. She had a condition or chronic disease that might result in a life expectancy of less than 6 months. She received antianxiety medication 7 out of 7 days. Review of Resident #17's clinical record revealed no OOHDNR. Resident #23 Review of Resident #23's Face Sheet, dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, hypertension, anxiety disorder, hypokalemia (low potassium), insomnia, chronic kidney disease, Type 2 diabetes mellitus, and pain. His Face Sheet indicated he was a DNR. Review of Resident #23's Care Plan dated [DATE], revealed, in part, DNR; For DNR status: verify presence of PINK DNR on resident's chart, verify presence of physicians order for DNR, place resident's name on DNR lists hanging in the facility common places. Review of Resident #23's Quarterly MDS assessment, dated [DATE], revealed: He scored a 3 out of 15 on his mental status exam (indicating severe cognitive impairment). He exhibited physical behavioral symptoms directed at others 1 to 3 of 7 days. He refused care 1 to 3 of 7 days. He had wandering behavior 4 to 6 of 7 days. He required extensive assistance with dressing, toileting, and personal hygiene. He required one person assistance for all other ADLs. He used a rolling walker to ambulate. He was frequently incontinent of bladder and always incontinent of bowel. He received antianxiety medication 7 of 7 days. Review of Resident #23's clinical record revealed no OOHDNR. Resident #86 Review of Resident #86's Face Sheet, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, urinary tract infections, pain, psychotic disorder with hallucinations, anxiety, hypertension, and neuropathy. The face sheet identified she was on hospice and was a DNR. Review of Resident #86's Physician's Orders for [DATE] revealed she was on hospice and was identified as a Do Not Resuscitate. Resident #86's admission MDS assessment, dated [DATE], revealed Cognitive ability was not assessed. She was totally dependent on one or two staff for all ADL's. She used a wheelchair. She had a catheter. Pain was not assessed. She was identified as having less than 6 months to live. Triggering medications included an antipsychotic for 7 of 7 days, an antianxiety medication for 6 of 7 days, an antidepressant for 7 of 7 days, and antibiotic for 7 of 7 days. Review of Resident #86 care plan documented a care plan for a DNR that included approaches that included Date of Physician Order for DNR __ Interview on [DATE] at 12:58 p.m., ADON H looked through Resident #86's clinical record and confirmed she did not have an OOHDNR. She stated Resident #86 was admitted to the facility two weeks ago. ADON H stated the Hospice company stated they would get one so she guessed Resident #86 was a full code on hospice for about a year prior to her admission. Interview on [DATE] at 12:13 p.m., the Administrator said the facility used the Resident/Family Consent for Cardiopulmonary Resuscitation in place of a DNR. She stated the form covered the facility for what happened in the facility but would not cover the facility if they needed to send a resident to the emergency room or something. Interview on [DATE] at 12:27 p.m., LVN F said she was not comfortable with the Family Consent for Cardio-Pulmonary Resuscitation. She said in the event of finding a resident not breathing she would send the resident out to the ER. She said she worked with a family for two months to sign a OOHDNR because she was not comfortable with that form. LVN F said as a nurse she would not accept the consent form in place of an OOHDNR. She said she did not know the facility's policy for DNRs and had not received any in-services about it because we know as a nurse. Interview on [DATE] at 12:58 p.m., ADON H stated the family consent was what the facility used. She said as a nurse working the floor, if that was all the resident had they had to send the resident to the emergency room and treat them as a full code. She said unless the resident signed the OOHDNR on admission, they facility would have to send out the OOHDNR to be signed by the doctor. ADON H stated she did not know how long the process took because she did not keep up with it. ADON H stated surveyor would have to ask the DON what the policy was and how long the process should take. She said the social worker was responsible for keeping up with the OOHDNR but the facility was between social workers right now and had a designee. She said they had been without one for at least six months. Interview on [DATE] at 1:41 p.m., the SSD stated she was designated to be the SSD until the facility found a full-time social worker. She stated she did a lot of OOHDNR on the rehab side of the facility but had not been doing much on the long-term side unless the facility brought it to her attention. The SSD said she did not check to see if a resident's code status was consistent through all the lists and records. She stated one doctor came about once a week and that was when he would sign the OOHDNR. She said there was not an initial timeframe for how long it took to get it signed, it just depended on the doctor. She said the facility had a cheat sheet for who was what code status, and she went by the in-house list. The SSD said she would not have any idea how many residents an OOHDRN had signed because she did not check them. She said the only list she checked was on the rehab side. Interview on [DATE] at 2:36 PM, the DON said the facility went through on admission and asked family what their advanced directive was at that time. She said as a nurse working the floor, she would be comfortable accepting the Family Consent form in place of an OOHDNR. The DON stated the facility had not trained nurses on OOHDNRs. She said the nurses had multiple places to check for code status including the crash cart, the pink or yellow sheet at the front of the resident's file, the physician's order and/or face sheet on the computer, on the 24-hour report. She stated the consent was only in-house and an OOHDNR would go with the EMT. She said if it came down to brass tacks the EMTs would have to perform CPR on the resident. The DON said the facility had no policy on DNR/CPR. She said she had not in-serviced the nurses because as nurses they all know. The DON said she checked approximately a month ago to make sure the code lists were consistently documented

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests, and the physical, mental, and psychosocial well-being of 5 of 6 residents reviewed for activities. (Residents #7, #19, #20, #23, and #86). Residents on the Younger Unit were not provided with activities that matched the cognitive or psychosocial level for Residents #7, #19, #20, #23, and #86. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being. The findings included: Resident #7 Review of Resident #7's Face Sheet dated 10/05/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbances, heart disease, hypertension, hypothyroidism (low thyroid), major depressive disorder, anxiety disorder, hypokalemia (low potassium), hyperlipidemia (high cholesterol), insomnia, and chronic pain. Review of Resident #7's Quarterly MDS assessment, dated 6/20/22, revealed: She scored a 0 out of 15 on her mental status exam (indicating severe cognitive impairment). She exhibited wandering behaviors 4 to 6 of 7 days. She needed extensive to total assistance for all ADLs but was able to feed herself with only setup assistance. She was always incontinent of bowel and bladder. She used a wheelchair for locomotion. She received antipsychotic medication 7 of 7 days. She received antianxiety medication 7 of 7 days. She received antidepressant medication 7 of 7 days. Activities were not addressed. Resident #19 Review of Resident #19's Face Sheet, dated 10/5/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disorder, hypertension, pain, abnormal weight loss, mood disorder (mild depression), convulsions, hyperlipidemia (high cholesterol), and anxiety. The face sheet indicated she was [NAME] Catholic. Review of Resident #19's Quarterly MDS assessment, dated 8/17/22, revealed: Cognitive abilities/Mental Status Exam was not assessed. She showed no signs of delirium. She needed supervision of staff for transfers, walking and eating. She needed assistance of one staff for all other ADLs. She was frequently incontinent of bladder and continent of bowel. She had no pain and no falls. Trigger medications was an antidepressant for 7 of 7 days. Review of Resident #19's Annual MDS assessment, dated 5/17/22, revealed: She had long- and short-term memory impairment with modified independent decision-making skills. It was very important to the resident to listen to her preferred music, to do things with groups of people, to do her favorite activities, to go outside, and to participate in religious activities. Resident #20 Review of Resident #20's Face Sheet, dated 10/5/22, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, above the knee amputation, hyperlipidemia, blindness in the left eye, arthritis, depression, pain, neuropathy (nerve pain), anxiety, and mood disorder. Review of Resident #20's Quarterly MDS Assessment, dated 8/17/22, revealed: She scored a 5 of 15 on her mental status exam (indicating severe cognitive impairment). She needed assistance of one staff for all ADLs. She used a wheelchair. She was frequently incontinent of bowel and bladder. She had no pain and no falls. Triggering medications included an antidepressant for 7 of 7 days and an anxiety for 7 of 7 days. Review of Resident #20's Annual MDS Assessment, dated 7/7/22, revealed it was very important for her to listen to her preferred music, to do her favorite activities, and participate in religious practices. Resident #23 Review of Resident #23's Face Sheet, dated 10/05/22, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, hypertension, anxiety disorder, hypokalemia (low potassium), insomnia, Type 2 diabetes mellitus, and pain. Review of Resident #23's Quarterly MDS assessment, dated 8/22/22, revealed: He scored a 3 out of 15 on his mental status exam (indicating severe cognitive impairment). He exhibited physical behavioral symptoms directed at others 1 to 3 of 7 days. He refused care 1 to 3 of 7 days. He had wandering behavior 4 to 6 of 7 days. He required extensive assistance with dressing, toileting, and personal hygiene. He required one person assistance for all other ADLs. He used a rolling walker to ambulate. He was frequently incontinent of bladder and always incontinent of bowel. He received antianxiety medication 7 of 7 days. Activities were not addressed. Resident #86 Review of Resident #86's Face Sheet, dated 10/5/22, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, urinary tract infections, pain, psychotic disorder with hallucinations, anxiety, hypertension, and neuropathy. Resident #86's admission MDS assessment, dated 9/27/22, revealed Cognitive ability was not assessed. She was totally dependent on one or two staff for all ADL's. She used a wheelchair. She had a catheter. Pain was not assessed. She was identified as having less than 6 months to live. Triggering medications included an antipsychotic for 7 of 7 days, an antianxiety medication for 6 of 7 days, an antidepressant for 7 of 7 days, and antibiotic for 7 of 7 days. Observations on the Younger Unit 10/3/22 at 10:51 a.m. through 12:35 p.m., showed no activities occurred. The noon meal was observed from 11:43 a.m. - 12:35 p.m., the staff were observed passing food but there were no other resident interaction, there was no music playing and there was nothing to do. At 12:00 p.m. the residents who were able to eat independently were getting restless and were playing with the cloth items in reach (clothes protector, napkins) by folding them; the independently mobile residents began to try to wander off and the dependent residents had increase hand wringing or other repetitive motions. At 12:11 p.m. Resident #26 (non-sampled) started yelling out can we go now, when staff tried to correct her she responded well, lets go!. Resident #8 (not sampled) pushed herself backwards with her feet repetitively trying to tip her wheelchair over. At 12:19 p.m. Resident #7 (not sampled) started sorting her silverware and licking her butterknife. Staff snatched it out of her hands telling her she could not have the butterknife but could have the fork and spoon. When Resident #7's table mate was served lunch, she immediately started to reach over to grab it. Observation on the Younger Unit on 10/5/22 between 9:08 a.m. and 10:48 a.m., showed no activates occurring on the unit. After the morning meal, residents were parked in front of the television and left to sit there. Observation of the [NAME] unit during the same time revealed the residents were getting manicures outside). Observation on 10/5/22 between 12:44 p.m. and 2:00 p.m. showed no activities on the Younger Unit. Interview on 10/05/22 at 1:35 PM, LVN F stated there were no scheduled activities for the Younger Unit. She stated sometimes they had eating popcorn as a group activity and there was bible study on Thursday nights, but generally there was nothing else offered. She stated the staff normally parked the residents in front of the television and left them. LVN F stated the residents on the Younger Unit were viewed as though they weren't missing out by not having activities due to their cognitive statuses. She stated she believed the lack of activities was due to budget and the facility not having enough staff. Interview on 10/05/22 at 2:53 PM, the DON stated the Younger Unit had an activity calendar. She stated there was a staffing issue right now and the facility was trying to fill the scheduling holes right now. She said the CNA Coordinator was usually responsible for doing activities on the Younger Unit but was working the floor as a CNA that week. The Administrator said the unit did a lot of music and memory activities and the residents liked it. They both said the activities did not get done every day. The DON stated the facility had a Chaplain that did a bible study with the residents and if he was unavailable, then Resident #23 used to be a minister and he would do it. The Administrator stated that the CNAs would do circles with the residents which was when the staff would sit around and talk with the residents about an event. The Administrator added visitors would come and do impromptu stuff with the residents like play music. The Administrator and DON agreed it had not been a good week for Activities on the Younger Unit due to staffing. The DON stated the residents would sometimes play with baby dolls and on the weekends, they did a movie with a projector with movie type of snacks. The DON said when the CNA Coordinator could be at the facility during the day activities would usually get done, but she was currently working on the rehab unit . Observation and interview on 10/05/22 at 3:10 PM, revealed CNA G playing music and interacting with 9 residents in the dining room. CNA G stated they had music and dancing every day around 3PM when they could. She stated that the residents liked music and didn't like having to leave the unit or go outside because they got anxious. She stated she was a neighborhood coordinator but had been working in the kitchen and on the floor because facility had been short staffed. Interview on 10/05/22 at 4:04 PM, the Activity Director stated she believed there were activities happening on the Younger Unit but there were not as many as there could have been because the campus had large scale outdoor activities planned for the week and the residents on Younger Unit would not have enjoyed attending them. She stated that each unit was supposed to have a neighborhood coordinator that was responsible for planning activities for each unit, but that currently there was not enough staff to accommodate it. The Activity Director stated the neighborhood coordinator for the Younger Unit was working in the kitchen and as direct care due to staff shortages. She stated she would have to look at the activity calendar for the Younger Unit to see what changes could be made in the future. She stated that she was unaware there were not activities for the residents in the mornings in the Younger Unit. Interview on 10/05/22 at 6:00 PM, the DON stated the facility did not have a policy regarding activities. She stated all staff received training online related to activities for residents with the diagnosis of Alzheimer's/dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 of 8 (Resident #2, #189, #191 and #195) reviewed for infection control in that: a) Resident # 189's oxygen nasal cannula tubing was not stored in plastic bag and labeled with date changed, and initials according to orders. b) Resident # 191's oxygen nasal cannula tubing was not stored in plastic bag and labeled with date changed, and initials according to orders. c) Resident # 195's oxygen nasal cannula tubing was not stored in plastic bag and labeled with date changed, and initials according to orders. d) CNA A wiped Resident #2's vaginal area with back to front motion and then applied her brief while wearing soiled gloves. This failure could place residents at risk of respiratory infections, cross contamination and spread of infections. Findings included: INCONTINENT CARE: Record review of Resident #2's admission record dated 05/12/22 indicated she was admitted to the facility on [DATE] with diagnoses of osteoarthritis (joint disease) and pain. She was [AGE] years of age. Record review of Resident #2's MDS dated [DATE] indicated in part: Cognitive Patterns - Cognitive skills of daily decision making = moderately impaired- decisions poor; cues/supervision required. Bladder and Bowel: Urinary Continence =. e. Always incontinent. Bowel Continence = 3. Always incontinent. Record review of Resident #2's care plan dated 10/04/22 indicated in part: Problem/Need: Incontinent of bowel and bladder. Goal and target date: Will be clean, dry and comfortable in between incontinent episodes over the next 90 days. Approaches: Administer peri-care after each incontinent episode. During an observation on 10/03/22 at 11:29 AM, CNA A performed incontinent care for Resident #2. CNA A took some wet wipes and wiped the residents vaginal area a couple of times with a back to front wiping motion. The resident was turned on her right side and the CNA proceeded to clean the residents rectum. The resident had a bowel movement also. While still wearing the same gloves CNA A proceeded to apply the new brief on the resident. During an interview on 10/05/2022 at 12:48 PM, CNA A said the way to wipe the resident's peri-area was with a front to back motion. CNA A said during incontinent care with Resident #2 she had become very nervous and wiped in the wrong direction which was back to front. CNA A said she knew she was supposed to change her gloves prior to applying the clean brief. CNA A said she was so nervous she forgot to change them prior to applying the new brief on the resident. CNA A said wiping from back to front could lead to UTI's and not changing her gloves could lead to cross contamination. CNA A said she received training on those tasks regularly. During a telephone interview on 10/05/22 at 09:46 AM, the nurse aide instructor said she did skills training with skills with the CNAs such as how to wash their hands, glove changing and discuss how to wipe the residents during incontinent care. The instructor said they monitored the CNAs by conducting in-services. The instructor said she was responsible for training the staff on incontinent care and infection control procedures. The instructor said when CNAs performed incontinent care they were supposed to wipe away from the urethra and to wipe from front to back. The instructor said if the staff wiped from back to front that could lead to a risk of infections such as a UTIs. The instructor said staff were trained to change their gloves after they performed the incontinent care and when going from dirty to clean. The instructor said the staff were supposed to don new gloves to place the new brief on the resident to prevent cross contamination. The nurse aide instructor said she believed the failure occurred because the nurse aide got nervous and forgot her steps. During an interview on 10/05/22 at 04:56 PM, the Administrator and DON said the nurse aide instructor would do in-services with CNAs regarding incontinent care and that the DON would also do trainings. The DON said the aides were supposed to wipe from front to back so the residents would not get UTIs. The DON said the aides were supposed to change their gloves when going from dirty to clean to prevent cross contamination. The DON and Administrator said they believed the failure occurred because the CNA got nervous and forgot the correct steps. NASAL CANNULA TUBING: Record review of Resident # 189's face sheet revealed admission date of 10/01/2022 with diagnoses of pseudoaneurysm (blood vessel wall is injured and the leaking blood collects in the surrounding tissue), left basilar atelectasis (partial collapse of your lungs), acute hypoxemia respiratory failure (you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal). The resident was [AGE] years of age. Record review of Resident #189's care plan dated 10/01/2022 indicated, in part: Interventions: oxygen 1 Liter per minute via nasal cannula, as needed. Record review of Resident #189's medication profile dated 10/01/2022 indicated in part: Oxygen via nasal cannula at 1 liter per minute, as needed. Record review of Resident #191's face sheet revealed admission date of 09/28/2022 with diagnoses of Congestive Heart Failure (heart muscle doesn't pump blood as well as it should), hypoxemia (abnormally low concentration of oxygen in the blood), Acute Upper Respiratory Infection, Cough. She was [AGE] years of age. Record review of Resident #191's medication profile dated 09/28/2022 indicated in part: Oxygen 1 liter per minute via nasal cannula, as needed. Record review of Resident # 195's face sheet revealed admission date of 09/30/2022 with diagnoses of Chronic obstructive pulmonary disease (group of diseases that cause airflow blockage and breathing-related problems). She was [AGE] years of age. Record review of Resident #195's care plan dated 09/30/2022 indicated, in part: Interventions: oxygen via nasal cannula, as needed, 2 liters per minute for COPD. Record review of Resident #189's medication profile dated 09/30/2022 indicated in part: Oxygen 2 liters per minute via nasal cannula, as needed. During an observation on 10/3/22, 10/4/22 and 10/5/22 Resident #195's oxygen tubing was not in plastic bag when not in use. During an interview and observation on 10/05/2022 at 09:55 AM, Resident #195's oxygen tubing revealed the cannula and tubing hanging on the recliner and nebulizer mask on bedside table while not being used. Resident #195 was in the wheelchair, oxygen tank attached to wheelchair and oxygen tubing and cannula hanging on oxygen tank. There were no plastic bags to store oxygen tubing, cannula and mask while not in use. CNA E stated that oxygen tubing is supposed to be in a clear plastic bag when not in use. CNA E stated she would get plastic bags to bag them all up. During an observation on 10/3/22, 10/4/22 and 10/5/22 Resident #189's oxygen tubing was not in a plastic bag when not in use. During an interview on 10/05/2022 at 09:40AM, revealed Resident #189's oxygen tubing and cannula lying on an unmade bed. The wheelchair in the resident's room revealed the oxygen tubing and cannula in the wheelchair seat while not in use. No plastic bags to store the oxygen tubing and cannula were observed while they were not in use. During observations on 10/3/22, 10/4/22 and 10/5/22 Resident #191's oxygen tubing was not stored in plastic bag when not in use. During an interview and observation on 10/05/22 at 09:45AM, Resident #191's oxygen tubing and cannula was hanging from oxygen concentrator and not in use. There was no plastic bag in the room to store oxygen tubing and cannula and mask while they were not in use. During an interview on 10/05/2022 at 10:08 AM, LVN D stated that all residents with oxygen should have plastic bags for the oxygen tubing when not in use. LVN D stated when residents are admitted to the facility with oxygen ordered, staff should place a plastic bag in the room for storing the oxygen tubing when it is not being used. LVN D stated that she will get bags for the residents now. During an interview on 10/05/2022 at 11:30 AM, the DON stated the facility had no policies for oxygen tubing storage and she was aware of Residents #189, #191, and #195 not having storage bags for oxygen tubing this morning but stated it has been fixed now. Record review of the facility's document titled Infection control-personal protective equipment and dated 3/15/2020 indicated in part: Facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to residents, visitors and other staff. Gloves: wear gloves when direct contact with blood, body fluids, mucous membrane, non-intact skin, or potentially contaminated surfaces or equipment is anticipated.