**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 a right to be treated with respect and dignity for 1 of 6 residents (Resident #66) reviewed for dignity. The facility failed to promote resident independence and dignity while dining when staff stood over Resident #66 while assisting them to eat on 01/07/25. This failure could have compromised residents' independence and dignity for those who require feeding assistance. Findings included: Record review of Resident #66's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female with an admission date of 07/05/24. Resident #66 had diagnoses which included Alzheimer's (a type of brain disorder that causes problems with memory, thinking, and behavior), difficulty in walking, muscle weakness, cognitive communication deficit, and osteoporosis (a condition when bone strength weakens and is susceptible to fracture). Resident #66's BIMS score was left blank. The MDS indicated the resident started speech-language and audiology services therapy on 12/09/24 for 4 days a week. Record review of Resident #66's care plan dated last revised 11/20/24 reflected she had a nutritional problem or potential nutritional problem related to disease process and ADL self-care performance deficit. In an observation on 01/07/25 at 01:05 PM Resident #66 was being assisted with her lunch tray by a SLP who was standing over Resident #66 the entire duration of assistance. In an interview on 01/07/25 at 01:20 PM with the SLP she stated she had worked at the facility since September of 2024. She stated that she was conducting an evaluation on Resident #66 due to a recent weight loss. She stated Resident #66 had poor attention span, could feed herself but may require assistance, and she was checking for Dysphasia (a language disorder that affects the ability to produce and understand spoken language). When asked if the SLP had been trained on how to provide feeding assistance she stated Yes, I am sure there was something in the LMS trainings but was unable to recall if she was supposed to sit or stand next to a resident when providing assistance. In an interview on 01/07/25 at 2:15 PM with the DOR she stated she had worked at the facility for 3 years. When asked what her expectation was for feeding assistance, she stated that she would need to be notified by nursing that certain signs were occurring so that an SLP could evaluate the residents' cognition and swallowing. She stated that normally CNA's assist residents with feeding, but it would not be out of the ordinary that SLP's would be available and/or assisting. The expectation would be for the SLP to be seated next to the resident while providing assistance, and they were informed that they should be sitting for respect purposes, but this was not necessarily talked about for the evaluations. Review of the facility's Feeding checklist for training staff revealed The following table lists the steps that are expected of you in order to feed an individual. The table also provides rationales that explain why you perform some of these steps. The use of this content is for educational purposes only and should only be used as a guide in performing the below skill, subject to the terms and conditions of the Master Services Agreement. no instruction for the employee being trained, to sit next to residents while providing feeding assistance was listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to coordinate assessments with the PASARR program for 1 of 8 Residents (Resident #63) reviewed for PASARR services. 1. The SW failed to assess Resident #63, based on his behaviors, for a referral for PASARR services. 2. The MDSC failed to refer Resident #63 for a Level II PASARR Evaluation by the local LIDDA. This failure placed residents in the facility at risk for exclusion for PASARR Services. Findings Included: RR or Resident #63's AR, dated 1/10/2025, reflected an [AGE] year-old male, who admitted to the facility on [DATE]. RR of Resident #63's Medical Diagnosis, downloaded from PCC on 1/10/2025, reflected Resident #63 was diagnosed with Depression, Unspecified (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life) and Schizophrenia, Unspecified (which was a chronic mental illness that affected a person's thoughts, feelings, and behavior.) RR of Resident #63's BIMS Score assessment, administered on 1/10/2025, reflected a score of 6, which indicated the resident had severe cognitive impairment. RR of Resident #63's CP reflected a Focus area for impaired cognition or impaired thought, initiated on 12/6/2024, R/T disease process. The Goal, revised on 12/29/2024, indicated the resident was supposed to maintain their current level of functioning through 3/5/2025. The Intervention, initiated on 12/6/2024, delegated nursing home to engage in simple structured activities that avoid overly demanding tasks; a Focus area for psychotropic medication, unknown date of initiation, R/T Schizophrenia. The Goal, initiated on 12/13/2024, indicated the resident would not have reactions to antipsychotic drug therapy (Seroquel 25 MG). Antipsychotic was discontinued on 12/19/2024 / Replaced with Anti-Anxiety Drug Therapy (Hydroxyzine 25 MG) The Intervention, initiated on 12/13/2024, delegated nursing home staff to check blood pressure monthly. RR of Resident #63's P-1, located in PCC, reflected a document sent from Resident #63's referring entity. The document was dated 12/5/2024. Page 4 of 12 indicated resident did not have evidence of an MI, ID, or DD. RR of Resident #63's P-1, located in Simple, reflected a document sent from Resident #63's referring entity. The document was dated 12/5/2024. Page 3 of 8 indicated resident did have evidence of an MI. Interview and observation on 1/7/2025 at 12:14 PM with Resident #63 revealed him in bed in his room. He was able to respond to questions, clean, and appropriately dressed. He was new to the facility and stated it was rough getting used to the routine. It was hard remembering who provided which services. Interview and RR on 01/10/25 at 10:56 AM with the SW, revealed that she was the facility designee to collaborate with residents and their PASARR eligibility/referrals. Based on Resident #1's P-1, located in PCC, Resident #63 presented to the facility on [DATE] with a negative P-1, meaning he did not have evidence of a MI, ID, or DD. The SW stated she had spent time with Resident #63, who had exhibited changes in his alertness, orientation, mood, and cognition. She was unaware Resident #63 had diagnosis of Depression, Unspecified and Schizophrenia, Unspecified. Had she been aware of his mental health diagnosis, she would have had him re-assessed by a medical provider and then referred him to the LIDDA for the P-2 evaluation as needed. However, she had not discovered the mental health diagnosis; she had not referred the resident for mental health services; she had not referred the resident for a P-2 evaluation. RR of the resident medical records in PCC did not reveal a P-2 or referral to the LIDDA. Interview and observation on 1/10/25 at 1:21 PM with the MDSC revealed she was the MDSC at the facility until last week, 1/2/2025. She was responsible, along with the SW, for residents and their PASARR eligibility/referrals. She had been trained as an MDSC at the facility, taken on-line training, and completed the classes for CMAC (Certified MDS Assessment Certification.) The facility followed the guidelines in the RAI for PASSAR processing. Observation of the MDSC revealed her search Simple, a 3rd party data base with HHSC and PASARR, for a P-2 for the LIDDA for Resident #63. Instead of a P-2 for the LIDDA, a P-1 was found. The P-1 found in Simple, was different from the P-1 that was found in PCC. The P-1 found in Simple reflected Resident #63 did have evidence of a MI. Based on the P-1 in simple. The MDSC stated, I just did not see it and there should have been a P-2 submitted for the LIDDA. RR of Simple did not reveal a P-2 for Resident #63. Residents who qualified for PASARR services were available to receive NFSS services, such as PT/OT/ST/DME. Residents who were qualified for, but did not receive NFSS services, were placed at risk for a decrease in options for quality of care. Since she had been removed from her position, CMDSC M and CMDSC N oversaw the MDS/PASARR entries. She was unaware of any support structure in place to catch errors in the PASARR process. Interview on 1/10/25 at 2:23 PM with the ADM stated that the SW and the MDSC were responsible for the residents' PASARR eligibility/referrals to the LIDDA. The facility followed the guidelines of the PASARR division. Residents, who benefitted for PASARR services, were eligible for benefit's such, as DME, assistance post DC from the facility with housing, and therapeutic services. Residents who were eligible, but not afforded the opportunity, risked the loss of services provided through the PASRR program. Safeguards in place to ensure residents get linked to PASARR services were team meetings, MDSC checks, morning meetings, and corporate resource personal. In a situation where there were two conflicting P-1s for a resident, the ADM stated the document in Simple would have taken precedence over the one found in PCC. The failure for the SW to assess the resident for MI and make the appropriate referral, along with the MDSC's failure to retrieve the P-1 from Simple, was a process failure. The staff members responsible for the PASARR eligibility/referrals were the SW and the MDSC. RR of the CMS RAI Version 3.0 Manual, dated 10/2024, reflected: Referral for Level II Resident Review Evaluations is required for individuals previously identified by PASRR to have MI, ID, or a related condition in the following circumstances: Referral for Level II Resident Review Evaluations is also required for individuals who may not have previously been identified by PASARR to have MI, ID, or a related condition in the following circumstances: 1. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a diagnosis of mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan furnishing services to attain, or maintain, the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #30) reviewed for comprehensive care plans. The facility failed to care plan Resident #30's high risk of elopement. This failure placed resident at risk of their needs having gone unmet. Findings included: Record review of Resident #30's quarterly MDS assessment dated [DATE], reflected the resident was a [AGE] year-old male with an admission date of 09/24/23. Resident #30 had diagnoses which included Parkinson's Disease (a neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems), cognitive communication deficit (impairment in thought organization, attention, memory, and safety awareness), hallucinations, and anxiety. The MDS reflected the resident had a BIMS score of 07, which indicated the resident had severe cognitive impairment. Record review of Resident #30's elopement/wandering evaluation dated 10/23/2024 reflected a score of 14, indicating the resident was a high risk of elopement. Record review of Resident #30's care plan dated last revised on 10/13/24 reflected no interventions for elopement or wandering. In an observation on 01/07/25 at 10:53 AM resident #30 was standing in his room watching television. In an interview on 01/08/25 at 01:58 PM with the DON she stated the MDS Coordinator was responsible for creating the care plan. She stated there had recently been a change in the MDS Coordinator because the previous MDS person at the facility did not work out for them, and the DON did not see where Resident 30 had been care planned for elopement. In an interview on 01/10/25 at 10:04 AM with the MDSR she stated that she had held that position since about 2019. She stated she worked as an MDS resource for multiple facilities. She stated that if a resident had any risk of elopement, the resident should be care planned for elopement interventions. Record review of facility policy titled Care and Treatment, Care Planning dated reviewed on 08/2015 reflected, It is the policy of this facility that the interdisciplinary team shall develop a comprehensive care plan for each resident. A comprehensive care plan is developed within seven days of completion of the resident minimum data set.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 Residents (Resident #3) reviewed for respiratory care. The facility failed to place Resident #3's oxygen tubing in a bag when not in use. This failure could place residents at risk of not receiving appropriate respiratory care. The findings were: Resident #3 Record review of Resident #3's undated face sheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses of Heart Failure, Acute upper Respiratory Infection, Obstructive Sleep Apnea, and Shortness of Breath. Record review of Resident #3s care plan dated 03/31/2022 reflected she had Chronic Obstructive Pulmonary Disease (a group of lung diseases that make it difficult to breath) her Goal was to be free of signs and symptoms of respiratory infections through review date. Interventions included to give oxygen therapy as ordered by the physician. Record review of Resident #3's quarterly MDS dated [DATE] reflected she had a BIMS score of 15 indicating she was cognitively intact. Record review of Resident #3's physicians' orders summary dated 01/08/2025 reflected an order to change oxygen tubing and humidifier bottle, clean filter weekly as needed if equipment is used, every night shift, every Sunday. Keep tubing inside plastic bag when not in use dated 04/22/2021. In an observation and interview on 01/07/25 at 11:49 AM Resident #3s oxygen tubing was laying on top of her concentrator out of the bag and not dated. Resident #3 stated for the most part the nurses changed her oxygen tubing weekly. She stated occasionally she got sick and required her oxygen machine due to her respiratory disease. She stated she liked for it to be clean. In an interview on 01/10/25 at 01:25 PM LVN A stated oxygen tubing was supposed to be changed weekly. She stated the tubing should be in a bag when not in use. She stated the nurses had been instructed on changing the tubing and keeping it covered by the DON. She stated there was a physician's order in the computer to change the tubing. Night shift nursing staff were responsible for changing the tubing on Sundays. The risk to residents for having dirty oxygen tubing included respiratory infection. In an interview on 01/10/25 at 1:31 PM the DON stated staff were educated by the DON, ADON and LVN resource team. The DON stated if a resident had respiratory equipment tubing it should have been bagged, even if it was used as needed it should be bagged. She stated negative effects for residents having unbagged oxygen tubing could include respiratory infections. She stated staff were instructed to remove oxygen equipment in rooms if not used. The DON stated the department heads do angel room rounds every morning to monitor for things that could negatively affect the resident. Record review of facility policy titled Oxygen Equipment dated 05/2017 reflected It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner and to use disposable prefilled humidifiers, tubing, masks, and cannulas for residents receiving oxygen. The equipment is to be discarded after use. The facility will maintain clean tanks, connectors, and concentrators. When oxygen mask or cannula is temporarily not being used it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 (Resident #26) of 6 residents reviewed for pharmacy services. The facility failed to obtain a stop date for Resident #26's Cipro (an antibiotic used to treat an acute infection) started on 01/01/2025. These failures could place residents at risk of side effects (gastrointestinal upset, multiple drug resistant infections) related to long term antibiotic use. Findings included: Record review of Resident #26's undated face sheet reflected he was a [AGE] year-old male admitted on [DATE] with diagnoses of neuromuscular dysfunction of the bladder (the nerves and muscles that control the bladder aren't working properly), hypertension (elevated blood pressure), legal blindness, and personal history of malignant neoplasm of brain (history of brain cancer). Record review of Resident #26's quarterly MDS dated [DATE] reflected he had short term memory problems. His cognitive skills for daily decision making were severely impaired. The MDS reflected Resident #26 required an indwelling catheter. Record review of Resident #26's care plan dated 01/01/2025 reflected he had a urinary tract infection. The care plan reflected he had started Cipro 500mg active date 01/01/2025 to 01/06/2025. The goal reflected the urinary tract infection will resolve without complications by the review date. Interventions included to give antibiotic therapy as ordered, monitor/document for side effects and effectiveness. Record review of infection surveillance assessment dated [DATE] reflected Resident #26 had a urinary tract infection with an indwelling catheter. He had purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate. The assessment reflected Resident #26 had started Cipro oral tablet 500mg 1 tablet by mouth two times a day for UTI for 5 days. Record review of the progress notes for Resident #26 dated 01/01/2025 reflected he had swelling to penis, small amount of pus noted with no noted odor to area, doctor and RP were notified and a new order for Cipro 500mg, BID x 7 days for UTI and discharge was obtained. The progress note was signed by the DON. Record review of the infection surveillance assessment dated [DATE] reflected Resident #26 had a urinary tract infection with an indwelling catheter. He had other infection of epididymitis (an infection or inflammation of the testis). The assessment reflected Resident #26 had started Levofloxacin Oral (an antibiotic used to treat infection) Tablet 500 MG to start on 01/03/2025, Give 500 mg by mouth one time a day for Bilateral epididymitis (inflammation of the testis) until 01/10/2025. Record review of Resident #26's Physicians order summary dated 01/08/2025 reflected an order for Cipro Oral Tablet 500 MG (Ciprofloxacin HCl an antibiotic), Give 1 tablet by mouth two times a day for UTI, monitor swelling to penis, dated 01/01/2025. The order did not contain a stop date /duration for antibiotic therapy. Record review of Resident #26's Physicians order summary dated 01/08/2025 reflected an order for Levofloxacin Oral (an antibiotic used to treat infection) Tablet 500 MG to start on 01/03/2025, Give 500 mg by mouth one time a day for Bilateral epididymitis (inflammation of the testis) until 01/10/2025. Record review of Resident #26 Medication Administration Record dated 01/08/2025 reflected resident had received 14 doses of Cipro 500mg starting 01/01/2025. Record review of Resident #26 Medication Administration Record dated 01/08/2025 reflected resident had received Levofloxacin Oral Tablet 500 MG (Levofloxacin) Give 500 mg by mouth one time a day for 6 doses. In an interview on 01/10/2025 at 1:25 PM LVN A stated there should be a stop date on all antibiotic orders used for short term treatment of acute infections. She stated the nurses should have clarified the order with doctor. She stated nurses were instructed to get the stop dates on any short-term medications by in-services monthly given by don. LVN A stated she was unsure why a stop date was not obtained at the time of order for the Cipro order. She stated she was unsure what the negative effects of long-term use of Cipro could be, but she could find out the information. In an interview on 01/10/25 at 1:31 PM the DON stated the Cipro for Resident #26 should have been for 5 to 7 days only. She stated the nurses were instructed to obtain a stop date for all antibiotics used for treatment of acute infections at the time of the order being received. She stated the DON and ADON were responsible for the review of orders daily. She stated they review daily for acute changes in residents' condition by looking at daily reports, review electronic medical records dashboard, and clarifying with the doctors for stop dates. The DON stated negative effects for residents that use long term antibiotic could lead to antibiotic resistant infections or intestinal infections. In an interview on 01/10/25 at 1:53 PM the PA stated Cipro for Resident should have been for 7 days. She stated the staff should have obtained a stop date at time the order was given. She stated the Levofloxacin Oral Tablet 500 MG (Levofloxacin) 1 po q day ordered on 1/3/24 was ordered by another practitioner. She stated it was not protocol to have two antibiotics at the same time. She stated the facility should have stopped the cipro once the Levofloxacin order was received. She stated the Levofloxacin was ordered when the urine culture came back. The PA stated orders were given by encrypted text messages services. The orders were given to the DON or nurses. She stated she did not see any negative effects for Resident #26 being on the cipro for the time he was on it. She stated she would have caught the error at his next visit she sees the resident weekly. Record review of facility policy titled Unnecessary Drugs dated 04/2012 and last revised on 11/12/2015 reflected It is the policy of this facility that each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug us any drug when used: For excessive duration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 (Resident #75) of 6 residents reviewed for infection control. CNA C and NA D failed to wash their hands and change their gloves when removing a soiled brief and placing a clean brief during peri care for Resident #75. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #75s undated face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of acute respiratory failure, age-related physical debility, and chronic obstructive pulmonary disease (a group of lung diseases that make it difficult to breath). Record review of Resident #75's care plan dated 01/02/25 reflected she had bowel and bladder incontinence related to physical dependence with ADL and cognitive deficit related to new surroundings. Her goal was to remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included: incontinent checks as required, wash rinse and dry perineum, and change clothing as needed after incontinent episodes. Goals also included to monitor for signs and symptoms of urinary tract infection including pain, burning, blood, cloudiness, no output, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, and changing behavior. Record review of Resident #75's MDS dated [DATE], reflected she had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also indicated that Resident #75 was always incontinent of urine and bowel. Resident #75 required substantial/maximal assistance indicating the helper does more than half the effort with toileting hygiene. In an observation on 01/07/25 at 3:18 PM of Peri Care on Resident #75 CNA C and NA D Did not wash hands or use alcohol-based hand sanitizer when changing gloves while removing a soiled brief and application of a clean brief. In an interview on 01/07/25 at 3:42 PM NA D stated she was trained on Infection control through Inservice and in meetings by the DON. She stated staff were trained to wash hands or use ABH each time they removed their gloves. She stated risk to residents for not cleansing hands between gloving could spreading of infections. In an interview on 01/07/25 at 3:50 PM CNA C stated she would normally use her ABH or wash her hands after removing her gloves. She stated it just slipped her mind. She stated she has been visually checked off on peri care twice in the last 6 by her DON. CNA stated the Risk to residents for not changing her gloves would be urinary tract infections. In an interview on 01/10/25 at 1:31 PM the DON stated her expectation was for staff to hand sanitize before and after gloving. She stated staff were educated by the DON, ADON and LVN resource team. The CNAs perform visual check offs on peri care and teaching upon hire and quarterly. She stated the negative effects for staff not washing their hands between glove changes could possibly be the spreading of infection. Record review of facility policy titled Hand Hygiene dated 05/2007 and revised 10/2022 reflected to use an alcohol-based hand rub containing at least 62%; or, alternatively, soap and (antimicrobial or non-antimicrobial) and water for the following situations: After removing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 medication carts and 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure the medication cart and medication room was locked and medications were secure and not accessible to other staff, resident, or visitors while unattended by MA on 01/08/2025. This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles. Findings included: Observation on 01/08/2025 at 9:02 MA B left the medication cart unlocked outside of room [ROOM NUMBER] in the hallway with the keys on top of the cart while she washed hands inside of the restroom and obtained gloves to administer eye drops. Observation on 01/08/25 at 9:05 AM the facility's only medication storage room was unlocked, and no facility staff were present. In an interview on 01/08/2025 at 9:30AM MA B stated she should never walk away from the cart leaving it open with keys on top. She stated she had been trained to never walk away from an unlocked medication cart. She stated she was sidetracked looking for large gloves. MA B stated the negative effects for leaving the cart unlocked could be a resident may take the keys, other could have access to the medications in the cart. MA B stated she had been visually checked off on med pass monthly with the Pharmacist and DON. In an interview on 01/08/25 at 9:17 AM with the DON she stated the medication storage room was supposed to be locked and that another staff member thought the door locked automatically as the doorknob was recently replaced. In an interview on 01/10/25 at 1:31 PM the DON stated it was her expectation for the medication assistants and Nurses to lock the medication cart when unattended. She stated the staff had been instructed to never leave the keys on top of the cart, always keep the keys on their person, and keep the cart locked. She stated the DON and ADON make rounds frequently and monitor staff as well as instruct them through in-services and when they are checked off visually on medication pass. She stated potential negative effects for the leaving the medication cart open could be missing medications, possible drug diversion. Review of the facility's Medication Access and Storage/Drug Destruction Policy revealed: It is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety and sanitation in the facility's only kitchen. The facility failed to ensure all expired pantry items were discarded. This failure could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. Findings include: Observation of the kitchen pantry on 01/07/2025 at 10:28 AM revealed: 1 large container of Italian Seasoning with Rec 12/11/23, open 12/11/23 Ex 12/2024 written in black permanent marker on the side. 1 large container of Parsley Flakes with R 12/11/23 Ex 6/11/24 written in black permanent marker on the side. 1 container of Ground Cumin Seeds with Rec 10-30-23 Ex 10-30-2024 written in black permanent marker on the side. 1 container of Ground Turmeric with R 11/27/23 Ex 11/27/24 written in black permanent marker on the side. 1 container of Curry Powder with R 11/27/23 E 5/27/24 written in black permanent marker on the side. Interview with the DM on 01/07/25 at 10:34 AM revealed that employees who received the food delivery would label the items received with the received date, date of opening, and expiration date based off the open date if a use by date was not printed on the product. Interview with the ADM on 01/10/25 at 11:00 AM revealed the facility kitchen follows guidance from the TFER. Review of the FDA 2022 Food Code revealed, 3-501.18 Disposition of Ready-to-Eat, Time/Temperature Control for Safety Food o Food held beyond its labeled use-by or expiration date, or past the allowed storage time for safety reasons, must be discarded. 3-302.12 Food Storage Containers Identified with Common Name of Food o This section indirectly reinforces the importance of proper labeling and identifying food to avoid usage of expired or unsafe items. 3-701.11 Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food o This section states that food that is unsafe, adulterated, or not honestly presented must be discarded. Expired food often falls into this category if it is deemed unsafe. 3-306.14 Return of Food to Prevent Contamination o This section implies that food returned or deemed unfit for service should be discarded to avoid risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for one (Resident #2) of 2 residents reviewed for resident rights. The facility nurse failed to assist Resident #2 with obtaining ambulance transport to the emergency department when Resident #2 asked, so he was forced to dial 911 for assistance. This failure could place residents at risk of not being able to determine their own need for emergency assistance which could lead to decreased self-worth, dignity and delay access to emergency services that could lead to deterioration of health. Findings included: Record review of Resident #2's undated face sheet, printed on 01/31/24, revealed that he was a [AGE] year-old male first admitted to the facility on [DATE] with diagnoses that included type II diabetes, stroke (blood clot in brain), body mass index of 40 - 44.9 (morbid obesity), and hypertension. Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS of 14, which indicated he was cognitively intact. Further review revealed he had clear speech, was understood in his ability to express ideas and wants, and has the ability to understand others. Further review revealed he did not reject care, have behavioral symptoms, nor did he wander. Record review of Resident #2's undated care plan revealed no documentation that Resident #2 had behaviors nor did it reveal any intervention or planning related to calling for emergency services. Record review of the police department call log printed 01/29/24 revealed Resident #2 called 911 on 01/26/24 at 8:46 pm and reported he had fluid on his heart and had a cough and runny nose and he requested transport to the emergency department. The dispatcher advised Resident #2 speak with the nurse to arrange transport, but to call back if he did not get assistance. Further review revealed Resident #2 called back to 911 on 01/26/24 at 9:22 pm and said he spoke to the nurse and nothing had been done; an ambulance transported Resident #2 to the emergency department. During an interview on 01/30/24 at 12:57 pm Resident #2 stated that he was told from his chest x-ray on 01/24/24 that he had fluid buildup on his heart and on 01/26/24 he was having difficulty breathing and wanted to go to the hospital for evaluation. He said he called 911 from his cell phone and they told him to tell the nurse to arrange transport and if the nurse would not, to call 911 back. Resident #2 stated that he told an aide and a nurse that he wanted to go to the emergency room and he was told they could not help him with that. Resident #2 then called 911 back because nobody helped him and he was taken to the emergency room by ambulance and diagnosed with influenza (flu). During an interview on 01/30/24 at 4:00 pm with hospital RN Director of Emergency Services revealed Resident #2 was brought to the emergency room on [DATE] and was put in the room at 10:12 pm with complaint of cough and shortness of breath and had a runny nose and was positive for Influenza A. Resident #2 had a chest x-ray that was negative for infiltrates (signs of pneumonia). During an interview on 01/30/24 at 1:15 pm with the DON she said Resident #2 told the nurse he wanted to go to the hospital and she started an assessment of Resident #2 and while she was assessing Resident #2 emergency personnel entered the building to transport Resident #2. She stated that Resident #2 only called 911 one time that evening. She also stated Resident #2 had a history of calling 911. Record review of Resident #2's progress notes from 01/29/23 to 01/30/24 revealed no reference to him calling 911. During an interview on 01/31/24 at 2:05 pm with Confidential Emergency Personnel they stated they got to the facility on [DATE] at 9:34 pm and did not see staff on the way to Resident #2's room. They said Resident #2 stated he was having trouble breathing and had a cough for 2 days; he did not appear in obvious distress. Confidential Emergency Personnel stated that they went to find staff as none were on the hall and found staff on the opposite side of the building and staff denied knowledge of Resident #2's desire to be taken to the hospital but said they could not stop him. Staff did not offer demographics and report to the Emergency Personnel but were printing it when it was requested; Resident #2 was transferred to the stretcher, vitals were checked and oxygen was applied because his oxygen was 93% (he was given 2 liters/minute). Resident #2 was taken to the emergency room. During an interview on 01/30/24 at 1:20 pm with the ADM she said that residents have the right to go to the hospital and her expectation was that family and resident requests for transfer to the hospital be respected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident #32 and Resident #51) of 2 residents reviewed for wound care. The facility failed to provide wound care as ordered for Resident #32. The facility failed to document wound care for Resident #32 and Resident #51. These failures could place residents at risk of worsening pressure injuries. Findings included: Resident #32: A record review of Resident #32's face sheet dated 11/15/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dysphagia (difficulty swallowing), repeated falls, hypertension (high blood pressure), hyperlipidemia (high cholesterol), and cognitive communication deficit (problems with communication). A record review of Resident #32's MDS assessment dated [DATE] reflected a BIMS of 12, which indicated moderately impaired cognition. A record review of Resident #32's care plan last revised on 10/02/2023 reflected she had an unstageable DTI on her left heel . Interventions included nursing staff were to follow facility protocol for treatment of injury. A record review of Resident #32's physician order dated 10/10/2023 reflected an order to cleanse open area to left buttocks with normal saline, apply calcium alginate, collagen powder and dressing daily until healed. A record review of Resident #32's physician order dated 10/24/2023 reflected an order to cleanse with NS, pat dry, apply povidone iodine topical (topical anti-infective) liberally and keep her unstageable DTI to left heel covered with a dry dressing for wound protection three times a day. A record review of Resident #32's physician order dated 11/02/2023 reflected an order to cleanse with NS, pat dry, apply calcium alginate, collagenase (topical medication used for removing damaged skin to allow for wound healing and growth of health skin) and cover her unstageable DTI to left heel daily and PRN. A record review of Resident #32's physician order dated 11/08/2023 reflected an order to cleans with NS, pat dry, apply povidone-iodine (topical anti-infective), Kerlix wrap (woven gauze) and tape her unstageable DTI to left heel two times a day for wound care. A record review of Resident #32's TAR dated November 2023 reflected the following: Treatments for daily wound care to her left buttocks were not documented on 11/02/2023, 11/05/2023, and 11/08/2023. Treatments for daily wound care three times a day were not documented one of three shifts on 11/01/2023 and on 11/02/2023, respectively. Treatments for daily wound care to her left heel were not documented on 11/05/2023 and 11/08/2023. Treatments for twice daily wound care to her left heel were not documented on the evening shift on 11/09/2023, nor on the day or evening shifts on 11/13/2023 and 11/14/2023. A record review of Resident #32's progress notes dated 10/17/2023-11/14/2023 reflected no documented wound care. During an observation and interview on 11/13/2023 at 10:55 a.m., Resident #32 was observed sitting in her wheelchair in her room with her heel bandaged and dated 11/12/2023. Resident #32 stated sometimes it gets changed and sometimes it does not and that the Wound Care Physician wanted wound care to happen more than it had been happening. Resident #32 stated the facility was short-staffed and they tried the best they could. During an interview on 11/15/2023 at 3:43 p.m., LVN D stated she did wound care for Resident #32 that day, 11/15/2023, but she did not do it on Tuesday 11/14/2023. LVN D stated no wound care did not get done for Resident #32 on 11/14/2023 either because the Wound Care Physician usually came on Mondays and we were waiting on him to come. LVN D stated LVN E also did treatments on the 600-hall where Resident #32 and Resident #51 resided. LVN D stated possibly wound care was not done if no one signed off on it on the TAR. LVN D stated wound care did not get done Monday because the Wound Care Physician did not come to the facility. LVN D stated yes there was a lot going on and maybe it got missed. LVN D stated there were a lot of falls on Monday 11/13/2023 and Tuesday 11/14/2023, and they were moving a lot of residents to different rooms. LVN D stated the facility did not have a wound care/treatment nurse and I wish we did. LVN D stated we need one because we have a lot of bumps. Resident #51: A record review of Resident #51's face sheet dated 11/15/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of cerebral infarction (stroke), cardiomegaly (enlarged heart), hemiplegia and hemiparesis (paralysis of one side of the body), stage 4 pressure ulcer of sacral region, hyperlipidemia (high cholesterol), major depressive disorder (depression), hypertension (high blood pressure), heart failure, and atrial fibrillation (irregular heartbeat). A record review of Resident #51's MDS assessment dated [DATE] reflected a BIMS of 14, which indicated minimally impaired cognition. A record review of Resident #51's care plan last revised on 11/08/2023 reflected she had a stage 4 pressure ulcer to her sacrum. Interventions included nursing staff were to administer treatment as ordered and follow facility policies/protocols for the prevention/treatment of skin breakdown. A record review of Resident #51's physician order dated 10/24/2023 reflected an order to cleanse her state 4 sacral pressure injury with wound cleanser, pat dry, apply calcium alginate, cover with superabsorbent silicone dressing daily. A record review of Resident #51's physician order dated 11/02/2023 reflected an order to cleanse her stage 4 sacral pressure injury with wound cleanser, pat dry, apply calcium alginate, apply collagen powder, and cover with superabsorbent silicone dressing daily and PRN. A record review of Resident #51's TAR dated November 2023 reflected treatments for wound care to her stage 4 sacral pressure injury were not documented on 11/01/2023, 11/02/2023, 11/04/2023, 11/05/2023, 11/13/2023 and 11/15/2023. A record review of Resident #51's progress notes dated 10/16/2023-11/15/2023 reflected no documented wound care. During an observation and interview on 11/14/2023 at 11:07 a.m., Resident #51 stated she got her wounds from the hospital because her doctor told her she had not been repositioned for five weeks. Resident #51 stated the facility did wound care and voiced no concerns. During an interview on 11/15/2023 at 3:03 p.m. the DON stated she started working at the facility in mid-October of 2023. An interview was attempted with LVN E on 11/15/2023 at 3:53 p.m. but contact with LVN E was unsuccessful. During an observation and interview on 11/15/2023 at 4:31 p.m., LVN D was asked where wound care might be documented if not on the TAR, LVN D turned away and did not answer. During an interview on 11/15/2023 at 4:32 p.m., the DON stated it was her expectation that nursing staff followed wound care orders. The DON stated staff were supposed to click off and document wound care but if you don't see it clicked off, you can go to the patient and see if the wound care was done. The DON stated, some nurses don't click off on it. The DON said floor nurses were responsible for doing wound care and yes they had enough time. The DON stated there were not that many wounds and there was enough time. The DON stated staff were trained on wound care through in person demonstrations and in-service trainings. The DON stated all nurses were aware they needed to do wound care. The DON stated, if it's a trend, we would pick up on it. When asked how not following orders and documenting wound care could affect wounds, the DON stated, I would have to see the orders and said it depended on the type of wound dressing and the actual wound the DON stated if it were stable or eschar (slough or piece of dead tissue that is cast off from the surface of the skin) only, it can stay on a couple days. A record review of the facility's policy titled Wound Care & Treatment Guidelines dated May 2007 reflected the following: POLICY: It is the policy of this facility to provide excellent wound care to promote healing. PROCEDURES: 13. Documentation of the treatment should be completed. A record review of the facility's policy titled Physician Orders dated October 2022 reflected the following: POLICY: It is the policy of this facility that drugs and treatments shall be administered/carried out upon the order of a person duly licensed and authorized to prescribe such drugs and treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately notify her authority, the resident representative when there was a significant change for 1 of 1 residents (Resident #166) reviewed for notification of changes. The facility failed to notify Resident #166's responsible party on 08/14/2023, 08/26/2023, 11/04/2023, 11/13/2023, /1/2023, and 02/05/2023, when new adjustments to medication regimen were made. This failure could place residents who experience a change in condition at risk of responsible party not being informed in care decisions. Findings include: Record review of Resident #166's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE], with a principal diagnosis of Cerebral palsy (Neuromuscular deficit), and secondary diagnosis of bipolar disorder. CR#1 was discharged on 07/29/2023. Record review of Resident #166's MDS, dated [DATE], revealed the resident had a BIMS score of 10 in Section C. Section I revealed R#1 was triggered for cerebral palsy. Section I revealed that R#1 was triggered for psychotic disorder, bipolar disorder, and depression. Section E triggered R#1 for potential indicators of psychosis which included delusions. Record Review of Resident #166's care plan dated 12/09/2023 reported resident to have a potential for a psychological well-being problem related the anxiety and abuse allegation. Intervention listed for R#1 were to increase communication between family about care including explaining all medications. Record Review of Resident #166's medication list per admission record dated 07/22/2022 revealed: -Gabapentin 300mg -Tizanidine 4mg -1 capsule PO TID -2 tablets PO TID -Nortel 1/35 - 28 day 1 tablet PO QD [active pills only] -Atorvastatin 10mg 1 tablet PO Q HS -Quetiapine 100mg 1 tablet PO Q HS -Midodrine 5mg 1 tablet PO TID -Calcium+ D 600/400 1 tablet PO BID -Oivalproex 500mg 1 tablet PO BID -Pantoprazole 40mg 1 tablet PO BID -Spironolactone 25mg 1 tablet PO Q AM -Multivitamins 1 tablet PO QAM -Escitalopram 10mg + 20mg (total 30mg) 1 tablet each PO Q AM -Folic Acid 1mg 1 tablet PO Q AM -Furosemide 40mg 1 tablet PO QAM, and -Levothyroxine 100mcg 1 tablet PO Q AM before food or other meds. Record review of psych service initial assessment note dated 08/26/2022 reported Staff requested visit to assess mental status, mood and to review/manage psych meds. Assessment revealed resident had negative and intrusive thoughts towards herself. The Nurse Practitioner (NP) recommended the following dose adjustment for Resident #166: Prazosin 1 mg Capsule /QHS for night terrors. Record review of psych service subsequent assessment note dated 12/31/2022 reported chief complaint of staff requesting visit due to recurring psychosis and aggression Resident #166 displayed to other residents. The Nurse Practitioner (NP) recommended the following dose adjustment for Resident #166: 175 mg PO daily. The reason for dose change was due to ineffective therapy. Record Review of medication order for Resident #166 reported: -08/14/2023 - Ambien - 5 mg Tablet give 1 tablet at bedtime for insomnia. -08/26/23 - Prazosin HCL 1 mg capsule -Give 1 mg at bedtime for night. -11/04/2022- Loperamide 2 mg tablet Give 2 tablets PRN for Diarrhea. -11/12/2023 - Seroquel 25 mg added per day for psychosis. DC'd 12/31/2023. -12/31/2023 - Seroquel 50 mg added per day for psychosis. -02/05/2023 - Milk of Magnesia Suspension 400 mg/ 5 ml, give 30 ml per day prn for constipation. Interview with FM #1 dated 11/14/2023 at 3:56 PM revealed she had conflicts with the care that was provided toward Resident #166. Resident #166's family member stated that R31 had a mind of a 3-year-old and needed staff to communicate to her any changes in her therapy so she can decide if it is necessary. Resident #166's family member stated that staff including management were not communicating to her the adjustments that were being med to Resident #166 medications. Resident #166's family member stated she was first made aware of the medications Resident #166 was on when Resident #166 discharged from the facility and her medication list was different from when she admitted to the facility. Resident #166's family member stated that she would not have had Resident #166 on the medications regimen she was on had she known about it. Interview with Medical Records Supervisor (MRS) dated 11/14/2023 at 12:55 PM revealed the following: upon being asked for medication list of Resident #166 she responded that it was in the EMR. MRS stated that as soon as the records get uploaded the DON is supposed to communicate with physician which meds should be continued or discontinued and/or other adjustments that need to be made. Interview with Nurse Practitioner (NP) dated 11/14/2023 at 01:42 PM revealed that Resident #166 was ordered Seroquel for severe paranoia. NP stated Resident #166 would sometimes report signs and symptoms of auditory hallucinations. NP stated that she saw Resident #166 on 11/12/23. NP stated she added 25 mg Seroquel daily because Resident #166 was verbally and physically abusive to other residents.NP stated she witnessed physical assaults and asked about it and it was confirmed with staff. NP stated she increased another dose of Seroquel because staff called in stating resident was continuing with her aggressive behavior. NP stated Resident #166 had night terrors. told me of them. She stated she would have nightmares. I am not the one who gave her Ambien. I believe Ambien is what she came in with. I don't think the medication adjustment had a role in her going to her hospital. She was attention seeking. I felt it was needed for her to be on those medications but if there was no change in her condition, I would have taken the medication off. NP Stated that residents RP was supposed to be communicated by nursing so that they are aware of what medications Resident #166 is on. Interview with LVN C and LVN D on 11/20/2023 at 4:30 PM revealed that Nurses are supposed to communicate every new order and dose adjustment to residents and/or responsible parties (RP). LVN D stated that upon reaching out to family members it is the facility job to document in the progress notes that they communicated to RP. When asked why Resident #166's family member was not communicated to LVN C and D stated that this occurred long ago and that the nurses who were working with Resident #166 are no longer here. LVN C and LVN D stated that RP need aware of adjustments of order because that's their right to know what medications they will approve to be ordered by the doctor. Interview with LVN C and LVN D on 11/20/2023 at 4:30 PM revealed that Nurses are supposed to communicate every new order and dose adjustment to residents and/or responsible parties (RP). LVN D stated that upon reaching out to family members it is the facility job to document in the progress notes that they communicated to RP. When asked why Resident #166's family member was not communicated to LVN C and D stated that this occurred long ago and that the nurses who were working with Resident #166 are no longer here. LVN C and LVN D stated that RP need aware of adjustments of order because that's their right to know what medications they will approve to be ordered by the doctor. Record review of Resident #CR#1's undated care plan, revealed: Focus: [CR #1] has left inner ankle wound x2. Goal: [CR#1] will maintain or develop clean and intact skin by the review date. Interventions: Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Provide treatment per physician order. Specialty mattress to bed. Pressure reduction mattress. Turn and reposition per facility protocol and PRN. Use a draw sheet or lifting device to move resident. In a phone interview with RP for CR#1 on 08/01/2023 at 11am, she said that facility did not notify her that CR#1 had a wound to her foot. She said she observed the wound on 07/29/2023 while visiting. In an interview with LVN A on 08/02/2023 at 12:39pm, she said she first saw CR#1 had two wounds to her left ankle on 07/24/2023. She said she worked at the facility for 3 months. She said when a new wound was identified the appearance should be documented. She said the primary doctor, wound care doctor, and family should be notified. She said the Treatment Nurse, ADON, and DON are to be notified. She said she notified Physician C on 07/24/2023. She said she did not notify the family or primary doctor after the wound was identified. She said she did not notify the ADON or DON when the wound was identified. She said she did not document the appearance of the wound observation in a progress note, skin assessment, or SBAR when the wound was assessed on 07/24/2023. She said she did not complete the tasks which caused a delay in CR#1's treatment. In an interview with DON on 08/01/2023 at 1:49pm, she said that she started at the facility on 07/26/2023. She said that when a wound is identified the nurse should document the appearance, notified the physician, wound care doctor, family, and DON. She said that if the DON is not available the ADON should be notified. She said that on 07/26/2023 the floor nurse assigned to CR#1 brought to her attention that resident had a wound to left ankle that had not been there when previously worked. She said that she instructed the floor nurse to notified primary doctor, wound care doctor, and family. She said that she reviewed progress notes completed by LVN A who identified the wound initially on 07/24/23. She said that LVN A documented that she notified the wound care doctor but not the family or DON. She said that LVN A did not notify the ADON or DON at the time that CR#1 had a wound identified. She said that LVN A did not follow up on treatment orders after CR#1 was assessed by the wound care doctor on 07/24/2023. She said that because she did not complete the tasks CR#1's treatment was delayed. She said that LVN A did not follow the facilities protocol, and she will receive disciplinary action. Record review of facility policy, Change in a Residents Condition or Status dated February 2021 read in part, .4. Unless otherwise instructed by the resident, a nurse will notify the residents 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 observation, interview and record review, the facility failed to incorporate recommendations from the PASARR level II determination and the PASSARR evaluation report into a resident's assessment, care planning, and transitions of care for 2 (Resident #1 and Resident #167) of 16 residents reviewed for PASARR. 1. The facility failed to initiate ILS, HC and specialized services in a timely manner for Resident #1 2. The facility failed to initiate a PE for Resident #167. These failures could place residents at risk of receiving eligible services late. Finding included: 1. A record review of Resident #1's face sheet reflected a [AGE] year-old female admitted on [DATE] with diagnoses of moderate intellectual disabilities, cognitive communication deficit (problem with communication), depression and anxiety. A record review of Resident #1's MDS assessment dated [DATE] reflected a BIMS of 00, which indicated severely impaired cognition. A record review of Resident #1's care plan last revised on 11/05/2023 reflected she had a PASARR positive diagnosis of moderate intellectual disabilities and received PASARR level II services. Interventions included IDT meetings were to be completed as required. Resident #1's care plan also reflected she was at risk for a communication problem related to cognitive impairment/primary Spanish speaking. Interventions included communication techniques to enhance interaction. A record review of a document titled Copy of May 2023 PASRR Compliance call report dated May 2023 reflected the following: Resident #1 had IDD, her first IDT meeting was held on 4/25/2023 and she required specialized OT, PT and ST. The MDS Coordinator as well as the Administrator were contacted on 8/25/2023 and the facility had a due date of 8/29/2023 to submit the NFSS form in the LTC portal. Resident #1's NFSS form had not been submitted in the LTC portal by the due date and had been denied. A record review of [NAME] on 11/10/2023 reflected a complaint intake submitted on 9/26/2023 which reflected the following: Attached is the spreadsheet of nursing facilities (NFs) that have been contacted by staff within the HHSC PASRR Unit. These NFs were informed that per §19.2407(i)7(A) they have failed to provide a specialized service for a PASRR positive resident as agreed to during that resident's interdisciplinary team (IDT) meeting. The resident has not received a Medicaid service as a result of the following: The NF was notified and instructed to submit a NFSS Request by a specific deadline, but failed to do so. The NFSS Request submittal by the NF was denied and there was not a follow up submittal to ensure the request was approved to provide specialized services for PASRR for the resident. A record review of Resident #1's document titled PASRR Comprehensive Service Plan (PCSP) Form dated 4/25/2023 reflected her Medicaid eligibility was confirmed, she had IDD only, and IDT reviewed and discussed all specialized services and supports and agreed upon the following- PT, OT, ST, ILS, HC. During an observation and interview on 11/13/2023 at 12:51 p.m., Resident #1 was observed sitting on her bed eating lunch. Resident #1 was non-interviewable and did not speak when spoken to. During an interview on 11/14/2023 at 3:33 p.m., HC B stated Resident #1 was on her caseload and at the time of her initial IDT meeting on 4/25/2023, her Medicaid was still pending and that caused a delay in getting her services. HC B sated the NFSS was a form/document which proved services recommended by PASARR were received by a resident from the nursing facility. During an interview on 11/15/2023 at 9:19 a.m., the ADOR stated Resident #1 was evaluated for PT, OT and ST on 4/11/2023, 4/12/2023 and 4/21/2023 respectively. During an interview on 11/15/2023 at 9:26 a.m., the DOR stated Resident #1 started receiving specialized habilitative OT, ST and PT under PASARR on 10/22/2023. The DOR stated Resident #1 had received services before, it was just the payer source that changed. During an interview on 11/15/2023 at 9:49 a.m., the MDS Coordinator stated there were issues with Resident #1's Medicaid eligibility. During an interview on 11/15/2023 at 9:55 a.m., the BOM stated Resident #1 had Medicaid when she was admitted but there was an issue with her Medicaid number or her social security number. The BOM stated one of the numbers was off by five numbers. The BOM stated when the facility's previous Admissions Coordinator entered in Resident #1's demographic information into their electronic health record system incorrectly, and then herself or the MDS Coordinator entered in that information into their LTC platform. The BOM stated when her or the MDS Coordinator gather information from their electronic health records system, if any information in incorrect, it gives an error. The BOM stated, we got bounced back and forth and those forms were held up for quite some time. The BOM stated it was not an issue with Medicaid getting Resident #1 approved, it was an issue with incorrect information being entered. During an interview on 11/15/2023 at 10:09 a.m., the MDS Coordinator stated the forms sat there forever for Resident #1 and around August, there were changes that needed to be made. The MDS Coordinator stated, I honestly don't know what happened. During an interview on 11/15/2023 at 12:15 pm., the Habilitation Supervisor stated Resident #1's enrollment meeting for PASARR was in September of 2023 so that meant she finally had nursing facility Medicaid. The Habilitation Supervisor stated PASARR had sent in a referral to get ILS started for Resident #1 and when the trainer went to the facility on 9/27/2023, the LSW and MDS Coordinator pretty much turned away the skills trainer because Resident #1 spoke Spanish. The Habilitation Supervisor stated the goal was for Resident #1 to communicate in English, the trainer could have seen Resident #1 since this time period, but she did not have full access to that documentation. During an interview on 11/15/2023 at 1:42 p.m., HC B stated she had full access to any ILS notes, and she did not see any record of Resident #1 having received ILS visits. HC B stated Resident #1 began habilitation coordination services on 9/06/2023. During an interview on 11/15/2023 at 2:20 p.m., the Administrator stated she would need to pull the policy to see what it reflected for initiating PASARR services recommended through the IDT meeting. The Administrator stated the MDS Coordinator monitored the process to ensure compliance by meeting with HC A and HC B, but it was an IDT approach. The Administrator stated if one were to look into their platform, one could see a request with services still pending for Resident #1. The Administrator stated, there is something that happened with her [Resident #1's] Medicaid ID #. When asked how a delay in receiving PASARR service could affect residents, the Administrator stated family had not complained. The Administrator stated PASARR was put into place to make sure residents with ID, MI, and DD would not continue to decline. During an interview on 11/15/2023 at 5:03 p.m., the Habilitation Supervisor stated Resident #1 missed her quarterly meeting in July of 2023 due to her nursing facility Medicaid not being approved. The Habilitation Supervisor stated the difference between therapy services through Medicare and PASARR was that with Medicare, a resident had to have and show progress through rehabilitation, and with PASARR, there are no limits. The Habilitation Supervisor stated the skills training they agreed upon in the IDT meeting in April of 2023 was for Resident #1 to learn simple words in English to communicate with staff. The MDS Coordinator stated that by not learning these skills to communicate with staff, it could affect communication and quality of life. The Habilitation Supervisor stated that with habilitation coordinator, we monitor all services, not only what's offered through PASARR and all of that was missed. The Habilitation Supervisor stated oh yeah it could cause a delay if a resident's social security number or Medicaid number were off. 2. Review of Resident #167's Face Sheet dated 11/15/23 revealed Resident #02 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy (a chronic (long-lasting) health condition that affects how a person's ability to move and maintain balance and posture), and secondary disorder including bipolar disorder (Mental illness including emotional swings) and Schizophrenia (serious mental illness involving altered states of perception). Review of Resident #167's MDS dated [DATE] revealed in Section C (Brief Interview for Mental Status (BIMS).), C0500 (BIMS Summary Score.), revealed a BIMS score of 15. Section E ((Behavior).), C0200 (Behavioral Symptom - Presence & Frequency), revealed that verbal behavioral symptoms directed toward others occurred daily with Resident #167. Review of Resident #167''s MDS dated [DATE] revealed in Section N (Medications), N0410 (Medications), revealed Resident #167 received an antipsychotic in the previous 5 days. Review of Resident #167's PASRR Level I screening, completed on 3/24/2023, by the hospital. Section C PASRR Screen questions C0100 asks is there evidence or an indicator this individual has Mental Illness? The answer was 1. Section C PASRR Screen questions C0200 asks is there evidence or an indicator this individual has Mental Disability? The answer was 1. Section C PASRR Screen questions C0300 asks is there evidence or an indicator this individual has Developmental Disability other than an intellectual ability? the answer was 1. Review of Resident #167''s Comprehensive Care Plan dated 05/23 revealed Resident #167 had documented for being at risk for impaired cognitive function/dementia or impaired thought process r/dt cerebral palsy/bipolar disorder/schizophrenia. Interventions included were PASSAR Level 2 Recommendations. Review of Resident #167's Progress note revealed R#02 dated 03/30/23 had documented for being at risk for impaired cognitive function/dementia or impaired thought process r/dt cerebral palsy/bipolar disorder/schizophrenia. Interventions included were PASSAR Level 2 Recommendations. Interview on 11/15/23 at 2:45 p.m. with the MDS Coordinator revealed that there was no meeting set up for Resident #167 PASSAR services. MDS Coordinator stated she does not know why Resident #167 did not get her Level 2 completed, she was out on vacation during the time and somehow there was no follow up on setting the meeting up. MDS Coordinator stated she was not sure if there was an actual system with how to set PASSARR care meetings. MDS Coordinator stated that normally she would get emails from Lake Regional which is a PASSAR services and as a team staffing works with Lakes Regional for coordinating the meeting. MDS Coordinator stated that by not receiving PASSAR services the facility would not know what type of services Resident #167 would require which can affect her quality of care. Interview on 11/15/23 at 3:00 p.m. the Administrator revealed MDS nurse is the coordinator for PASSAR services. Administrator stated that community center was responsible for working with her on the IDT meeting. The Administrator stated that during the PASSAR meeting everything was documented on the form PCSP (PASSAR Comprehensive Service Plan). Administrator stated if a PASSAR Level 2 was not done Resident #167's would be at risk for not receiving services that they need. Administrator stated that a meeting should have been done according to facilities policy. Interview on 11/15/23 at 4:00 p.m. with HC A stated she had a PASSAR Evaluation (PE) done on Resident #167 on 05/05/23. HC A is positive for Intellectual Disabilities and that there was no PCSP documented in her records. HC A stated that the nursing facility are responsible for doing the annual PCSP, but an IDT meeting was supposed to be coordinated with both PASSAR and Nursing Facility. HC A stated that if a Level 2 is not done a delay in individual services would occur for the resident. Interview on 11/15/23 at 4:50 p.m. with the Habilitation Supervisor revealed that a PE was done and forwarded to the Nursing Facility on 05/09th through email. HS stated she did not get a response and set a follow up email on 05/15/23. HS stated a meeting was set up when Resident #167's mother was available, but the nursing home overlooked that she had an appointment the same time. HS stated that she reminded staff it was state requirement for Resident #167 to have a PASSAR meeting set up. HS stated on 05/30/23 she received an emergency email stating that Resident #167 needed to have a meeting set up since she was discharging early to her home, but the IDT meeting never happened. HS stated that the meeting is important because we and the nursing staff go over all the services to determine what would be best for Resident #167. A record review of the facility's undated policy titled PASRR POLICY AND PROCEDURE reflected the following: Policy: The facility will designate an individual to follow up on ALL residents have received a PASRR Level I screening. If Facility serves a resident with a positive PASRR Level I screening, the facility MUST have obtained A PASRR Level II evaluation from the Local Authority or have a documented attempts to follow up with the Local Authority to obtain the PASRR Level II evaluation. C. Coordinate with the local authority to ensure that the individual is properly assessed for any specialized services recommended in the Level II evaluation as being needed when a determination of ID, DD, or MI is made. (Under 40 TAC Chapter 19, the NF is responsible for assessing the individual for PT, OT, and ST needs and for Durable Medical Equipment. F. Provide nursing facility specialized services agreed to in the IDT meeting within 30 days after IDT meeting. G. Coordinate and cooperate with the LIDDA/LMHA Service Planning Team (SPT) If specialized services are assigned, the NF MUST: A. Certify that they can provide, arrange for, or support services recommended in the Level II evaluation. B. Document the roles and responsibility of the NF in carrying out that specialized service in the Comprehensive care plan. C. Provide training to NF staff on their roles and responsibilities in ensuring that the specialized service is provided. D. Document in the individual's clinical record that the specialized service is provided consistent with the care plan

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to maintain an infection prevention and control program that must include, at a minimum, written standards, policies, and procedures for the program which included standard and transmission-based precautions to be followed to prevent spread of infections for 1 of 8 residents (Resident #7) reviewed for infection control practices, and 5 of 8 staff (CNA G, DON, ADOR, Medical Records Supervisor, and MA F) reviewed for infection control practices. 1) The Medical Records Supervisor and CNA G failed to don and doff PPE prior to entering Resident #7's, who was on contact precautions, room. 2) The facility failed to ensure 4 of 9 staff were tested for tuberculosis upon hire/ re-hire. These failures could place residents at risk for infection. Findings included: 1) A record review of Resident #7's face sheet dated 11/15/2023 reflected an [AGE] year-old female admitted on [DATE] with diagnoses of sepsis (infection of the blood stream), muscle weakness, dysphagia (difficulty swallowing), pneumonia, type 2 diabetes (uncontrolled blood sugar), hyperlipidemia (high cholesterol), and COPD. A record review of Resident #7's MDS assessment dated [DATE] reflected she had not yet been assessed for a BIMS score. A record review of Resident #7's care plan last revised on 11/09/2023 reflected she had Shingles and was to be on contact isolation. A record review of the Resident #7's physician orders reflected an active order dated 11/09/2023 for her to be on contact isolation. An observation on 11/13/2023 at 9:00 a.m. revealed Resident #7's room had no contact precautions sign on her door or PPE bin outside her room. An observation of 600-hall on 11/13/23 at 12:55 p.m. revealed a nurse put a red sign on the door that read stop check with nurse before entering. An observation on 11/13/2023 12:59 p.m. revealed CNA G entered Resident #7's room with a meal tray without donning PPE. An observation on 11/13/2023 at 1:07 p.m. revealed the Medical Records Supervisor medical records supervisor was putting a white sign on Resident #7's door that read contact isolation. An observation on 11/13/2023 at t 1:20 p.m. revealed the Medical Records Supervisor entered Resident #7's room with no PPE. During an interview on 11/13/2023 at 1:02 p.m., CNA G stated she did not know what kind of precautions Resident #7 was on. CNA G said she believed they started today with precautions but she was not sure because she was on a different hall yesterday (11/12/2023). CNA G said she asked her nurse and was told standard precautions. CNA G stated when she asked what she needed to wear, she was told to 'wear gloves and a mask if not providing direct care but to wear gloves, mask, and gown if providing direct care.' During an interview on 11/13/23 at 1:25 p.m. with Medical Records Supervisor, she said Resident #7 had been on isolation for about a week and knew it was due to shingles. The Medical Records Supervisor said she was told by nurses to suit up every single time she went into the room no matter what. During an interview on 11/15/2023 at 2:45 p.m., the DON stated the policy on contact precautions/isolation depended on the disease process. The DON stated some infections like shingles, isolation time would vary depending on symptoms or signs of active lesions. The DON said the expectation for anyone on contact isolation was for them to have contact isolation signage on the door and a PPE bin outside the door stocked with gowns and gloves. The DON said PPE was to be put on prior to entering a contact isolation room. The DON said staff were trained on infection control practices during annual in-services and all current staff were up to date on training. The DON stated herself along with the help of charge nurses monitored for infection control compliance in the building. When asked what the potential negative outcome to residents would be if policy was not followed, the DON said infections could spread. A record review of the facility's policy titled Infection Prevention and Control Program dated October 2022 reflected the following: Policy The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Goals o Decrease the risk of infection to residents and personnel. Recognize infection control practices while providing care. o Identify and correct problems relating to infection control. o Ensure compliance with state and federal regulations related to infection control o Promote individual resident's rights and well-being while trying to prevent and control the spread of infection. o Monitor personnel health and safety. Scope of the Infection Control and Prevention Program: The infection prevention and control program is comprehensive in that it addresses detection, prevention and control of infections among residents and personnel. (Personnel covers staff, volunteers, visitors, and other individuals providing services under a contractual agreement). 3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. a. Facility personnel with a communicable disease or infected skin lesion will not directly contact. residents or their food, if direct contact could transmit the disease; and b. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. c. Validation of the personnel infection prevention and control practices are monitored by the infection preventionist through skills competency evaluation such as observation of hand hygiene. A record review of the facility's policy titled IPCP Standard and Transmission-Based Precautions dated October 2022 reflected the following: Policy It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. In Long Term Care (LTC), it is appropriate to individualize decisions regarding resident placement (shared or private), balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. It is therefore appropriate to use the least. restrictive approach possible that adequately protects the resident and others. Maintaining isolation longer than necessary may adversely affect psychosocial well-being. Where possible, the goal is to isolate the organism, not the resident. Transmission-Based Precautions are the second tier of basic infection control and used in addition to Standard Precautions for patients who are or may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. Procedure 1. Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include: a. Proper selection and use of PPE, such as gowns, gloves, facemasks, respirators, and eye protection i. Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated). b. Hand hygiene; c. Safe injection practices; d. Respiratory hygiene and cough etiquette; e. Environmental cleaning and disinfection; and f. Reprocessing of reusable medical equipment. 2. Contact Precautions (Transmission-Based Precautions or TBP) are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment (e.g. MDROs). Note: Contact precautions/isolation are required for the patients with MDROs with: o Draining wounds or secretions/excretions that cannot be covered and contained, o Acute diarrhea, or o Ongoing transmission within the unit or facility a. Room Placement: i. Residents on Contact Precautions should be restricted to their rooms and restricted from participation in group activities; Exception is for medically necessary care. ii. Contact Precautions are generally intended to be time limited and, when implemented, should include a plan for discontinuation or de-escalation due to room restrictions. iii. When private rooms are not available, some residents (e.g., residents with the same pathogen) may be cohorted or per an alternative risk-based approach. Room placement decisions are made balancing risks to other patients. b. Personal protective equipment (PPE): i. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. ii. [NAME] PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens. 6. Implementation: a. The facility will implement a system to alert staff, residents and visitors that a resident is on TBP. i. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. b. Make PPE, including gowns and gloves, available immediately outside of the resident 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. Provide education to residents and visitors as needed. The facility's policy titled IPCP Standard and Transmission-Based Precautions dated October 2022 also reflected gloves and gown were to be used with any room entry into a resident room on contact precautions. 2) A record review of the DON's personnel file reflected she was hired on 10/09/2023 and was not screened and tested for TB. A record review of the ADOR's personnel file reflected she was hired on 1/09/2023 and was not screened and tested for TB. A record review of the Medical Records Supervisor's personnel file reflected she was hired on 10/13/2023 and was not screened and tested for TB. A record review of MA F's personnel file reflected she was rehired on 10/18/2023 and was not screened and tested for TB. During an interview on 11/14/2023 at 3:45 p.m., the HR Manager with the HR Manager stated TB tests were performed on site as needed. The HR Manager stated if staff members arrived with a prior test, they would accept it. The HR Manager stated they tried to ensure testing for TB was done within the first two weeks of hire. During an interview on 11/15/2023 at 2:45 p.m., the DON stated in regard to the facility's policy on new hires, employees should be tested upon hire. The DON stated if staff brought a prior test from a facility they were previously employed with, then that would be accepted. The DON stated screening assessments were done annually, but that did not include an actual TB test. The DON stated the annual screening processing was composed of a signs and symptoms questionnaire. The DON said the HR Manager monitored the TB screening process. The DON said no there would not be a negative outcome to residents if staff were not up to date with TB screening and testing. The DON stated if staff came from other facilities, they have been tested. The DON said a screening was fine and they did not need to be tested upon hire for TB. A record review of the facility's undated policy titled Personnel Requirements - TB reflected the following: POLICY It is the policy of this facility to ensure Personnel meet state and federal regulatory requirements for employment. PROCEDURE: All staff and volunteers who work in the facility: 1. Will have documented upon hire and screening annually, as evidence of freedom from pulmonary tuberculosis. The following are acceptable: a. A report of a negative Mantoux skin test administered within six months of submitting the report, b. A written physician's statement dated within six months of submitting the statement, indicating freedom from pulmonary tuberculosis.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for sanitation. The facility failed to ensure all food items were sealed and properly covered. CK H failed to wash and sanitize the food processor in between uses. DA I failed to wash her hands after handling trash and prior to beginning a food preparation activity. The Dietary Supervisor failed to ensure the dish machine was operating at the proper temperature for ware washing. These failures could place residents at risk of foodborne illness. Findings included: Observations of the kitchen's walk-in refrigerator on 11/13/2023 from 9:02 a.m. through 9:04 a.m. revealed the following: -At 9:02 a.m., the walk-in refrigerator contained a bag of opened tortillas inside a resealable bag which was not completely sealed and open to outside air. -At 9:03 a.m., the walk-in refrigerator contained two containers of red potatoes dated 11/13/2023, uncovered and with ice on top. -At 9:04 a.m., the walk-in refrigerator contained an opened bag of shredded cheddar cheese dated 11/12/2023 which was not sealed off to open air. During an observation on 11/13/2023 at 11:32 a.m., CK H pureed sauerkraut in a blender, washed off the lid and proceeded to puree hot dogs. CK H did not wash or sanitize the blender. During an observation on 11/13/2023 at 11:35 a.m., CK H finished pureeing hot dogs, rinsed the blender blade and lid and proceeded to puree cornbread. CK H did not wash or sanitize the blender. During an observation on 11/13/2023 at 11:40 a.m., DA I was observed wearing gloves. DA I picked up an item off the floor, touched the trash can lid, discarded items and proceeded to bag cornbread without changing gloves or washing her hands. During an observation on 11/13/2023 at 11:44 a.m., CK H finished pureeing cornbread, rinsed the blender, blade and lid under running water, and proceeded to mechanicalize sausage. CK H did not wash or sanitize the blender. During an interview on 11/14/2023 at 11:35 a.m., CK H stated the blended needed to be washed and sanitized between each pureed item and there was no excuse, he just forgot. During an observation and interview on 11/14/2023 at 2:15 p.m., the Dietary Supervisor was observed washing dishes using the dish machine. The Dietary Supervisor measured the water using a digital thermometer during the wash and rinse cycles, and the water reached a maximum of 113.6 degrees Fahrenheit. The Dietary Supervisor stated it was supposed to be at 120 degree Fahrenheit and she would call their technician to fix it. During an interview on 11/14/2023 at 2:35 p.m., the Administrator stated the facility adhered to the TFER which had adopted the FDA Food Code for food storage guidelines. The Administrator stated she would look for a policy on the dish machine and ware washing but this was not provided before exit. During an observation and interview on 11/14/2023 at 2:42 p.m., the Maintenance Supervisor was observed on the floor in the kitchen, working on the dish machine. The Dietary Supervisor stated the Maintenance Supervisor was checking the hot water heater. During an interview on 11/14/2023 at 2:43 p.m., the RD stated the dish machine should operate at 120 degrees Fahrenheit and was a low temperature machine which utilized chemicals to sanitize. The RD stated foods needed to be closed with a fitted lid or sealable bag. The RD stated she expected staff to wash their hands between every task and they needed to wash their hands before going back to a food preparation activity. The RD stated staff should wash the blender between pureeing every food item to prevent cross contamination and allergies. The RD stated the Dietary Supervisor trained staff on food storage and sanitation through hands on training. The RD stated she followed up with in-services throughout the year. The RD stated CK H and DA I were new employees. The RD stated the Dietary Supervisor was there daily, so she monitored those policies and procedures daily and the RD audited once monthly. The RD stated if food storage and sanitation policies were not followed, there could be infection control issues or foodborne illness. During an interview on 11/15/2023 at 2:19 p.m., the Administrator stated yes staff should wash hands after picking up trash and before preparing a food item. The Administrator stated the dish machine should run at 120 degrees Fahrenheit and the blender should be washed and sanitized between blending food items. The Administrator stated food items in the walk-in refrigerator should be covered so there was no air exposure. The Administrator stated the Dietary Supervisor monitored the kitchen in these areas throughout every shift by looking at logs and working with staff to make sure they were doing what they were supposed to be doing. The Administrator stated dietary staff were trained upon hired and received in-services from the Dietary Supervisor. The Administrator stated if policies were not followed, there could be potential infection control issues. A record review of the 2017 FDA Food Code reflected the following: FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in packages, covered containers, or wrappings 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning. 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than 49°C (120°F).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident#21) reviewed for quality of life in that: - Resident #21 was receiving oxygen therapy at 3LPM without humidification resulting in nose feeling dry frequently. - Facility did not have signage posted stating oxygen in use posted on doorway to Resident #21's room. -Resident 21's saline humidification was dated for longer than the facility policy of 7 days. -Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were left exposed to debris when not in use. -Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were not dated. These failures could place residents who required continuous oxygen therapy and could result in decreased quality of life and a decline in health. Findings included: Record review of admission record revealed Resident #21 was a [AGE] year-old male admitted to facility 5/6/22 and to hospice on 7/13/22 with respiratory diagnosis: Pneumonia, Acute systolic Heart Failure, Chronic Obstructive Pulmonary Disease with (Acute) exacerbation, Obstructive Sleep Apnea, and Pleural Effusion. Record review revealed Resident #21's physician order dated 5/7/22 to notify MD if bloody nose persists. Record review revealed Resident #21's physician order dated 6/10/22 for Eliquis 2.5mg an anticoagulant that can cause increased risk for bleeding. Record review revealed Resident #21's physician order dated 6/3/22 for continuous oxygen at 3 LPM. Record review revealed oxygen policy stating oxygen tubing and humidification is to be changed weekly. In an observation on 09/13/22 at 10:49 AM revealed Resident #21's oxygen concentrator running at 3LPM. The nasal canula was draped over the oxygen concentrator and not bagged. The nasal canula was dated 9/5/22 and connected to an empty sterile saline bottle dated 8/29/22. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. There was no signage posted on the door going into his room [ROOM NUMBER]A stating oxygen in use. In an observation on 09/14/22 09:49 AM of Resident # 21, revealed he was sitting in a chair next to his bed with the nasal canula in his nose and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. The nebulizer mask and tubing were not dated. There was no plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. There was no signage posted on the door going into his room stating oxygen in use. In an observation on 09/14/22 at 1:00 PM revealed 12 portable oxygen cannisters were delivered to the nursing station. In an observation on 09/14/22 at 2:42 PM of Resident # 21, revealed he was not in his room. The oxygen tubing was not connected. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. The nebulizer mask and tubing were not dated. There was no plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. There was no signage posted on the door going into his room stating oxygen in use. Resident was sitting in dining room connected to a portable oxygen canister. In an observation on 9/15/22 at 9:33 AM revealed Resident #21 was sitting in chair next to his bed with nasal canula on the floor and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. There was no signage posted on the door going into his room stating oxygen in use. In an observation and interview on 09/13/22 at 11:00 AM with Resident # 21, revealed he was sitting in the dining room without his oxygen. He said he used his oxygen throughout the day and night if he was in his room. He stated he did not have oxygen available to him when he was outside of his room. He stated there were times when he felt short of breath without oxygen. He stated his nose felt dry frequently since he started oxygen therapy. He stated he would stop activities in dining room and go back to his room when he felt short of breath. He said he had not reported this to anyone. In an interview on 09/14/22 09:39 AM with [NAME] LVN she stated sterile saline for oxygen therapy, nasal canula, nebulizer tubing, and nebulizer mask should be changed out weekly and dated. She then changed the oxygen tubing and sterile saline. She said the nurses on overnight were responsible for changing and labeling tubing and humidification saline on Sunday nights. She stated Resident #21 always put on and took off nasal canula on his own when in his room. She reported he had not told her he was short of breath. In an interview on 09/14/22 09:49 AM with Resident # 21, he said he had double pneumonia not long ago and thought he was going to die. He said he had always put his own oxygen on and off and used nebulizer on his own. He said he did not change the setting on concentrator himself and left it running at all times. He said he had never been instructed by the facility to put the oxygen tubing or nebulizer tubing and mask in a bag. He stated he did not realize his saline humidifier attached to the oxygen concentrator was empty and his nose felt dry frequently from oxygen. In an interview on 09/14/22 at 3:42 PM the DON stated she was not aware of a policy stating each resident room where oxygen was being used should have a no smoking oxygen in use sign posted outside the door. In an interview on 9/15/22 at 9:33 AM with LVN 1, she said oxygen or nebulizer tubing lying on the floor, draped over oxygen concentrator, or on top of bedside table was putting resident at risk for infection. She stated the tubing and mask should be stored in a bag when not in use. She stated she was aware the facility had put up no smoking oxygen in use signs outside the rooms of residents receiving oxygen therapy today. She stated she had been trained on infection control through in-services frequently. In an interview on 09/15/22 at 9:38 AM, the ADON stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. She stated she had been trained on infection control through in-services once since started 2 months ago. In an interview on 09/15/22 at 9:42 AM, the DON stated oxygen tubing and the nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection She stated she had put up no smoking oxygen in use signs outside the rooms of residents receiving oxygen therapy today. She stated she had been trained on infection control through in-services frequently. In an interview on 09/15/22 at 10:22 AM, the ADMIN stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. Record review revealed Oxygen Concentrator policy dated 05/2017 to include equipment required, No Smoking signs outside the resident's room. Record review revealed oxygen policy dated 05/2017 stating oxygen tubing and humidification is to be changed weekly.

Based on observation, interview, and the facility failed to ensure food and equipment were prepared under sanitary conditions consistent with professional standards for all residents receiving meals at facility of practice in that: A. Food in pantry, refrigerator, and freezer were not labeled with open date or expiration date. - Food prep areas were left not sanitized after usage. - Disposable utensils, cups, bowls and kitchen pots and pans were stored uncovered exposing inside to dust and debris. - Baking pans were stored on shelf with visible dried food debris. - Floors in kitchen were unclean and sticky. - Juice dispenser machine and area were unclean. B. Cook1 did not utilize hygienic practices when handling food - Cook1 did not properly wash hands with soap and water to prevent cross-contamination. - The dishwasher was seen multiple times in kitchen with mask not covering her nose while food was being prepared. These failures could affect all the residents identified for frequently or occasionally receiving meals in the facility and could place residents who ate from the kitchen at risk of food borne illnesses. Findings included: In the initial observation of the kitchen on 9/13/22 at 9:12 AM, boxes were left open exposing plastic utensils, plastic lids, paper bowls and plastic cups. Pots and pans were stored leaving insides exposed to debris. Food debris could be seen on food prep table, food storage shelving, cookware storage, and bakeware storage areas. Juice dispenser machine was unclean with a visible buildup of dried juice inside drink dispenser nozzle and storage hanger for nozzle. Cabinet under drink dispenser was visibly unclean with a dry sticky substance and visible dirt. Food items unlabeled in the dry storage, fridge and freezer were unlabeled included wheat bread, hot dog buns, buttermilk biscuits, sugar cookies, butter packets, grated parmesan cheese, American cheese slices, Neufchatel cheese, maraschino cherries, snowflake coconut, and shredded carrots. In observation of the kitchen on 9/13/22 at 2:12 PM, boxes were left open exposing plastic utensils, plastic lids, paper bowls and plastic cups. Pots and pans were stored leaving insides exposed to debris. Food debris could be seen on food prep table, food storage shelving, cookware storage, and bakeware storage areas. Cabinet under drink dispenser was visibly unclean with a dry sticky substance and visible dirt. Food items unlabeled in the dry storage, fridge and freezer were unlabeled included wheat bread, hot dog buns, buttermilk biscuits, sugar cookies, butter packets, grated parmesan cheese, American cheese slices, Neufchatel cheese, maraschino cherries, snowflake coconut, and shredded carrots. In observation of the kitchen on 9/14/22 at 9:15 AM boxes were left open exposing plastic utensils, plastic lids, paper bowls and plastic cups. Pots and pans were stored leaving insides exposed to debris. Food debris could be seen on food prep table, food storage shelving, cookware storage, and bakeware storage areas. Cabinet under drink dispenser was visibly unclean with a dry sticky substance and visible dirt. Food items unlabeled in the dry storage, fridge and freezer were unlabeled included wheat bread, hot dog buns, buttermilk biscuits, sugar cookies, butter packets, grated parmesan cheese, American cheese slices, Neufchatel cheese, maraschino cherries, snowflake coconut, and shredded carrots. In observation of the kitchen on 9/14/22 at 10:45 AM boxes were left open exposing plastic utensils, plastic lids, paper bowls and plastic cups. Pots and pans were stored leaving insides exposed to debris. Food debris could be seen on food prep table, food storage shelving, cookware storage, and bakeware storage areas. Cabinet under drink dispenser was visibly unclean with a dry sticky substance and visible dirt. Food items unlabeled in the dry storage, fridge and freezer were unlabeled included wheat bread, hot dog buns, buttermilk biscuits, sugar cookies, butter packets, grated parmesan cheese, American cheese slices, Neufchatel cheese, maraschino cherries, snowflake coconut, and shredded carrots. In an interview on 9/13/22 at 9:25 AM with the dietary manager, he stated he was responsible for monitoring and maintaining for everything in the kitchen. He was aware the food was not labeled with open or expiration dates. He stated he had ordered stickers to be used for labeling, but they had not arrived. He stated he was not aware the kitchen was unclean until surveyor pointed out findings. He stated the juice machine nozzles were to be soaked every night and it appeared they had not been cleaned last night. He acknowledged the juice dispenser machine cabinet appeared unclean. He acknowledged the food debris left on food prep table, and the baking pans, utensils, cups, and bowls being exposed to dust and debris. He stated he was aware these findings could put the residents at risk for illness. In an interview on 9/14/22 at 11:13 AM with Admin and Dietary manager, they both stated they were aware the cleanliness of the kitchen needed to be addressed and had professional cleaners scheduled to come into facility overnight tonight to deep clean. The Dietary Manager stated he was in the process of labeling all the food properly and had already begun discarding anything that was already opened without a date. No kitchen policies were available since previous dietary manager resigned 4 months ago. - Finding included: In an observation on 9/13/22 at 9:12 AM the dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 09/13/22 at 10:49 AM oxygen concentrator was running at 3LPM. The nasal canula was draped over oxygen concentrator and not bagged. The nasal canula was dated 9/5/22 connected to an empty sterile saline bottle dated 8/29/22. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/13/22 at 11:15 AM dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 9/13/22 at 3:10 PM the dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 9/14/22 at 9:32 AM the dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 09/14/22 09:49 AM Resident # 21, was sitting in chair next to bed with nasal canula in nose and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/14/22 at 11:32 AM the dishwasher was seen in the kitchen with mask not covering her nose while food was being prepared. In an observation on 09/15/22 at 8:55 AM Cook1 was seen with face mask not covering her nose while she was placing rolls on a baking sheet for lunch. She took her gloved hand pulled mask up over her nose when she saw surveyor. She used the same gloved hand used to move mask to reach into box of frozen rolls and placed them on baking sheet. She then changed gloves without washing hands before continuing to place rolls on baking sheet again. In an interview on 9/13/22 at 11:15 AM the dishwasher stated she knew the face mask was to cover her mouth and nose. She stated leaving her mouth or nose uncovered while in kitchen around food could increase resident risk of infection. In an interview on 09/15/22 at 8:55 AM Cook1 stated she stated she knew the mask was to be covering her nose to prevent the spread of Covid and that is why she pulled mask up after seeing surveyor. She said she knew she was supposed to change gloves after touching her mask and that is why she changed them after seeing surveyor. She said she knew she was supposed to wash hands in between glove changes but forgot. She said she knew all of these actions could lead to increased risk of infection for residents. In an interview on 09/15/22 at 9:02 AM dietary manager stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. He stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. In an interview on 9/15/22 at 9:33 AM with LVN 1 she stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. In an interview on 09/15/22 at 9:38 AM ADON stated a face mask should always worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. In an interview on 09/15/22 at 9:42 AM DON stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. In an interview on 09/15/22 at 10:22 AM ADMIN stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. Record review revealed hand washing policy stating gloves should be changed anytime they become contaminated, and hands should be washed in between gloves being changed. Record review revealed Covid-19 Mask Policy updated 12/31/2021 to include staff shall wear well-fitting mask at all times in resident care areas. The mask should cover both nose and mouth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were left exposed to debris when not in use. -Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were not dated. -Resident 21's saline humidification was dated for longer than the facility policy of 7 days. - The dishwasher was seen multiple times in kitchen with mask not covering her nose while food was being prepared. Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 5 of 6 residents (Resident # 42, Resident 44, Resident # 21,Resident # 45 and Resident # 27) reviewed for wound care, use of wrist blood pressure monitor , incontinence care, oxygen therapy and all residents eating meals at facility for infection control in that: a) LVN-S did not wash her hands before and after wound assessment and care on Resident # 44 and Resident # 42. LVN-S operated the bed remote without changing the contaminated gloves. b) MA-H did not sanitize the wrist blood pressure monitor after using it on Resident # 21 and before and after using on Resident #45 c) CNA-D and CNA- W handled clean items with contaminated gloves while providing incontinent care on Resident # 27. d) Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were left exposed to debris when not in use. e) Resident 21's oxygen tubing, nebulizer tubing, and nebulizer mask were not dated. f) Resident 21's saline humidification was dated for longer than the facility policy of 7 days. These failures could place the residents at risk for infection. This deficient practice could affect (CENSUS) residents identified for frequently or occasionally receiving meals in the facility and Resident #21 receiving oxygen therapy. Findings included: Review of Resident # 44's medical record reflected a [AGE] year-old man admitted on [DATE]. His diagnoses included Urinary tract infection, Mood disorder due to known physiological condition, MRSA, Type 2 Diabetes Mellitus, Dementia with behavioral disturbance and Aphasia. Review of Resident # 42's medical record reflected a [AGE] year-old woman admitted on [DATE]. Her diagnoses included Unspecified Dementia, Muscle Weakness (generalized), Dysphagia(difficulty swallowing), oral phase, Other abnormalities of gait and mobility, Cognitive Communication Deficit, Hyperlipidemia (too many fat in blood), Depression, Encephalopathy (a disease in which the functioning of the brain is affected by agents like virus or toxins), Cerebral infarction(stroke), Pressure Ulcer of Right Hip, Stage 3 , Pressure Ulcer of left heel, unstageable , Pressure ulcer of other site, unstageable, Pressure ulcer of other site, stage and Osteoarthritis(wear and tear of joints). During an observation on 09/14/2022 at 3.45 pm, the wound nurse LVN-S and LVN-L performed wound assessment on Resident#42 while LVN-L was holding the electronic tablet for Dr-C. LVN-S was assisting DR-C who was on the video call on the electronic tablet for assessing the wounds of the residents in the facility remotely. LVN-S then assessed the ulcers situated on Resident #42's right hip area and right knee by touching and then measuring them with disposable wound measuring strip. After the completion of the assessment LVN-S without changing the contaminated gloves operated the remote control of Resident#42's bed to adjust the height. After that, LVN-S removed the gloves and sanitized her hands with hand sanitizer. She then without washing her hands moved on to Resident# 44. The surveyor stopped her with the intention to avoid the risk of spreading infections if any, when LVN-S about to perform the wound assessment on Resident #44 without washing hands. During the interview on 9/14/22 at 4:00pm LVN-S stated that per her understanding handwashing was not necessary if hand sanitizer was used. LVN-L said she was not aware that washing hand was mandatory before and after wound care. LVN-S and LVN-L did not respond when the surveyor showed the facility's infection control policy and protocol stating washing hands before and after wound care was necessary. Review of the facility policy 'Licensed Nurse procedures, Subject: Dressing, clean revised on 05/2007 stated . Procedures: (3). Place red plastic bag near foot of bed to receive the soiled dressing. (4). Wash hands and apply gloves, (5). Open dressing pack, (6). Pour prescribed solution onto gauze to be used for cleaning, (7). Remove soiled dressing and discard in red plastic bag, (8). Remove old adhesive with adhesive remover, taking care not to get solution into wound, (9). Wash hands and apply clean gloves, . (13). Assist resident to comfortable position. (14). Place call light within reach and instruct resident to call for assistance, if needed, (15). Wash hands. Review of Resident # 21's medical record reflected a [AGE] year-old man admitted on [DATE]. His diagnoses included Pneumonia, unspecified organism, Heart Failure, COPD, Dysphagia (difficulty swallowing), Unspecified, muscle weakness (generalized), Unsteadiness on feet, Cognitive Communication Deficit, Heart Failure, Chronic Kidney Disease, Type 2 diabetes mellitus, Unspecified Dementia, Myocardial Infarction (Heart attack), Cerebral Infarction(stroke), Acute Kidney Failure and Mass and Lump, unspecified lower limb Review of Resident # 45's medical record reflected a [AGE] year-old woman admitted on [DATE]. Her diagnoses included Cerebral Palsy (disorder that affects ability to move and maintain balance and posture), Schizoaffective Disorder, bipolar type(a type of mental disorder), Hyperlipidemia(too many fat in blood), unspecified, Mild Intellectual Disabilities, Major Depressive Disorder and Generalized anxiety disorder. An observation of taking blood pressure using a wrist blood pressure monitor on 09/14/2022 beginning at 9:00 am, revealed MA-H did not sanitize the wrist blood pressure cuff after using it on Resident #21 and before and after using it on Resident #45 until the surveyor asked her about it. During the interview on 09/14/2022 at 9:20 am, MA-H stated that per the facility sanitation policies and procedure for hand and equipment sanitization, all the healthcare providers should sanitize their hands as well as reusable medical equipment after the use. She said that it was a mistake from her side and will remember not to repeat the same mistake in the future. Review of the facility's policy Cleaning and disinfection of resident-care items and equipment' dated 01/ 2022 it was stated c. non-critical items are those that come in contact with intact skin but not mucous membranes. 1. non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers . d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscope, durable medical equipment) . 3. Durable medical equipment (DME)must be cleaned and disinfected before reuse by another resident 4. Reusable resident care equipment will be decontaminated and /or sterilized between residents according to manufacturer's instructions Review of Resident # 27's medical record reflected a [AGE] year-old woman initially admitted on [DATE] and admitted recently on 06/28/2016. Her diagnoses included Vascular Dementia without behavioral disturbance, Essential (primary) Hypertension, Hyperlipidemia (too many fat in blood), unspecified pain in unspecified joint, Dysphagia (Difficulty swallowing), Primary Osteoarthritis (wear and tear of joints), Cognitive communication deficit, Pain in right ankle and joints, Unsteadiness on feet, and Parkinson's disease (A brain disorder causes unintended or uncontrollable movements). During an observation on 9/14/22 at 12:00pm, CNA D and CNA W provided incontinent care to Resident # 27. CNA- D and CNA -W entered Resident #27's room and donned gloves after washing their hands. CNA-D removed Resident #27's brief which was soaked with urine. CNA D cleaned resident's perineal area, removed soiled gloves, and applied hand sanitizer. She donned new pair of gloves from her scrub's pocket. She turned the resident to the left side with the help of CNA W and cleaned the back of Resident #27. CNA D applied cream at the back and perineal area and then picked up a new diaper without changing the gloves. She removed the disposable liner that was under Resident # 27 and gave to CNA W to dispose. After the disposal, with the same gloves CNA W pulled back the blanket on Resident # 27 and tidied up the bed. Both the CNAs removed the gloves and washed their hands before leaving the room During an interview on 09/13/2022 at 11:10 a.m., CNA -D and CNA -W said they thought they were doing the peri care correctly. CNA- D said she did not remember using the unclean gloves for handling clean items. They said they understood the mistakes and the importance of correct incontinent care practices to control the infections. An interview on 09/15/2022 at 9:00 am with the DON revealed that her expectation was that the nursing staff follow facility policy/procedure for washing the hands before and after wound care, handwashing/sanitization and clean techniques while providing perineal care. She said sanitizing after the use of reusable medical equipment was also important to minimize the spread of infectious diseases. The DON added that they have infection control training annually and in services on regular intervals related to infection control (Eg. Hand washing). The facility identifies deficiencies in infection control practices through direct observations. In services provided to the relevant staff members when any deficiencies identified. The DON who had the role of IP was responsible for overseeing infection control Review of a current facility policy on 09/15/2022 titled Infection control: prevention and control program: Handwashing/Hand Hygiene revised 09/2017 stated, This facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the Handwashing/Hand Hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents ., c. Before preparing or handling medications , g. Before handling clean or soiled dressings, gauze pads, etc. h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin .k. After handling used dressings, contaminated equipment, etc. l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves . Review of the website, https://www.cdc.gov/handhygiene/providers/guideline.html, dated 01/30/2020, the Center for Disease Control (CDC) recommended the following for hand hygiene: Hand Hygiene Guidance The Core Infection Prevention and Control Practices for Safe Care Delivery in All Healthcare Settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. In an observation on 9/13/22 at 9:12 AM revealed the dishwasher was in the kitchen with mask not covering her nose while cook was preparing food. In an observation on 09/13/22 at 10:49 AM Resident #21's oxygen concentrator was running at 3LPM. The nasal canula was draped over oxygen concentrator and not bagged. The nasal canula was dated 9/5/22 and connected to an empty sterile saline bottle dated 8/29/22. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/13/22 at 11:15 AM the dishwasher was in the kitchen with mask not covering her nose while food was being prepared by cook. In an observation on 9/13/22 at 3:10 PM the dishwasher was in the kitchen with mask not covering her nose while food was being prepared by cook. In an observation on 9/14/22 at 9:32 AM the dishwasher was in the kitchen with mask not covering her nose while food was being prepared by cook. In an observation on 09/14/22 at 09:49 AM revealed Resident # 21sitting in chair next to his bed with nasal canula in nose and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/14/22 at 11:32 AM the dishwasher was in the kitchen with mask not covering her nose while food was being prepared by cook. In an observation on 09/14/22 at 2:42 PM revealed Resident # 21, was not in his room. Oxygen tubing was not connected. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an observation on 9/15/22 at 9:33 AM Resident #21 was sitting in chair next to bed with nasal canula on the floor and oxygen concentrator running at 3LPM. The nebulizer machine was sitting on top of the bedside table and the nebulizer mask was not in a bag. Nebulizer mask and tubing were not dated. There was no Plastic bag at the bedside to store the nebulizer mask/tubing or oxygen tubing while not in use. In an interview on 9/13/22 at 11:15 AM, the dishwasher stated she knew the face mask was to cover her mouth and nose and did not have a reason mask was not worn properly. She stated leaving her mouth or nose uncovered while in kitchen around food could increase resident risk of infection. In an interview on 09/14/22 at 09:59 AM, LVN 1 stated sterile saline for oxygen therapy, nasal canula, nebulizer tubing, and nebulizer mask should be changed out weekly by overnight nurse on Sunday. In an interview on 09/14/22 at 09:49 AM with Resident # 21, he said he puts his own oxygen on and off and uses nebulizer on his own. He said he had never been instructed to put tubing in bag. He stated his nose felt dry frequently from oxygen. In an interview on 9/15/22 at 9:33 AM with LVN 1, she said tubing lying on the floor, draped over oxygen concentrator, or on top of bedside table was putting resident at risk for infection. She stated the tubing and mask should be stored in a bag when not in use. She stated a face mask should always be worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. She stated she had been trained on infection control through in-services frequently. In an interview on 09/15/22 at 9:38 AM the ADON stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. She stated a face mask should be worn over nose and mouth at all times while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. She stated she had been trained on infection control through in-services once since started 2 months ago. She said the nurses on overnight were responsible for changing and labeling tubing and humidification saline on Sunday nights to reduce risk for infection to resident. In an interview on 09/15/22 at 9:42 AM, the DON stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. She stated a face mask should always worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. She stated she had been trained on infection control through in-services frequently and trained staff herself. She said the nurses on overnight were responsible for changing and labeling tubing and humidification saline on Sunday nights to reduce risk for infection to resident. In an interview on 09/15/22 at 10:22 AM, the ADMIN stated oxygen tubing and nebulizer mask should be stored in a bag when not in use. She stated leaving oxygen tubing and nebulizer mask uncovered could put resident at risk for infection. She stated a face mask should always worn over nose and mouth while in facility to prevent the spread of Covid. She stated hands should be washed if face mask was touched, in between residents, and each time gloves were changed. She stated she had been trained on infection control through in-services frequently. Record review of the oxygen equipment policy dated 05/2017 stated in section C.1) Tubing should be replaced every week. 2) Masks should be replaced every week. 3) Cannulas should be replaced every week. D.) When mask or cannula is temporarily no being used, it will be covered loosely to prevent contamination from airborne microorganisms. It will not be covered tightly. Record review of the oxygen equipment policy 05/2017 stated in section 2. Nebulizer Equipment procedures A.) Nebulizer equipment generates aerosols small enough to be readily deposited in the lungs. Careful technique is required to prevent infecting the resident. D.) Daily dismantle entire breathing assembly including all hoses, wash with warm soapy water, rinse well and ensure parts are dry, including inside of hoses. F.) Store, clean and dry until next use. Record review of admission record revealed Resident #21 was a [AGE] year-old male admitted to facility 5/6/22 and to hospice on 7/13/22 with respiratory diagnosis: Pneumonia, Acute systolic Heart Failure, Chronic Obstructive Pulmonary Disease with (Acute) exacerbation, Obstructive Sleep Apnea, and Pleural Effusion