**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and chart review, the facility failed to maintain a clean, home-like environment for one resident, Resident #49, out of thirty-five residents in the survey sample, as well as for one of four units (300 unit) in the facility. The findings include: 1. Resident #49 (R49) did not have her personal items and clothing returned after a room change. R49 was admitted to the facility with diagnoses that included paraplegia, hypertension, gastroesophageal reflux disease, gastric ulcer, diabetes, COPD (chronic obstructive pulmonary disease), polyneuropathy, major depression disorder and anemia. The minimum data set (MDS) dated [DATE] assessed R49 as cognitively intact and to require the extensive assistance of two people for bed mobility, transfers, dressing and hygiene. On 7/10/23 at 12:00 p.m., R49 was interviewed about quality of life/care in the facility. R49 stated during this interview that she moved rooms a couple of months ago and many of her personal items were missing and had not been brought to her new room. R49 stated, They lost all my personal items. R49 stated missing items included clothing, shoes, cosmetics, facial creams, family pictures and a purse. R49 stated the social worker was aware that she was missing the items and she had received no follow up about when the items would be returned. Resident #49 stated she did not want to lose her items, especially her family pictures, and that she wanted to wear some of her summer clothes. On 7/11/12 at 1:35 p.m., the certified nurses' aide (CNA #1) caring for R49 was interviewed. CNA #1 stated the resident moved from another floor and her personal items were packed in storage. CNA #1 stated the resident preferred to wear a gown in bed but wanted clothes on when she went to activities and/or appointments. CNA #1 was not sure if the resident was missing clothing or other personal items. On 7/11/23 at 1:37 p.m., accompanied by the registered nurse unit manager (RN #3) and with R49's permission, the resident's room, dresser and closet were inspected. Several plastic containers beside the bed stored crafts and paper/pens but no clothing or pictures. There was one pair of sweatpants, a shirt, socks and a pair of shoes on top of the plastic containers. There were two fleece sweatsuits in the dresser. There were no other clothing or personal items in the dresser or in the resident's closet. The resident's cosmetics, creams and pictures were not located in the room. No summer clothing items were found other than the set on top of the plastic container. RN #3 was interviewed at this time about R49's belongings. RN #3 stated that R49's move from another floor was initially planned to be temporary because the room required maintenance/repair. RN #3 stated that R49's items and clothing were packed and placed in storage. RN #3 stated that R49 decided to stay in the new room. When questioned regarding R49's personal items not being returned, RN #3 stated Somebody has dropped the ball. On 7/11/23 at 3:45 p.m., the maintenance director (other staff #2) was interviewed about R49's belongings. The maintenance director stated that the resident moved floors due to renovations of the previous room. The maintenance director stated that R49 .had too much stuff and that most of the items were packed and placed in storage. The maintenance director stated that R49 was told when she moved that only the things she needed would be brought to the new room to reduce the clutter. The maintenance director stated R49's items were not lost but were packed in the storage room. The maintenance director stated the social worker was aware and he thought the family was going to assist the resident with selecting items for the new room. On 7/12/23 at 9:53 a.m., the social worker (other staff #5) was interviewed about R49's clothing and personal items. The social worker stated the resident had lots of items. The social worker stated prior to the room change, she had a conversation with R49 about not taking all the items to the new room. The social worker stated R49 had about .ten boxes of stuff. The social worker stated that R49 had some of her things in the new room and the problem was going through the boxes with her to get out what she wanted and/or needed. Resident #49's clinical record documented the resident moved to the current floor on 5/2/23. This finding was reviewed with the administrator and director of nursing during a meeting on 7/11/23 at 4:30 p.m. 2. The 300 unit was observed to have several areas of persistant concern. Findings include: Observation on 07/10/23 at 2:37 PM, on 07/11/23 at 4:17 PM, and 07/12/23 at 10:33 AM revealed that the plastic base board was loose and fell off the wall in a 5-foot area in room [ROOM NUMBER]A's bathroom. The wall behind the base board was disintegrating. Observation on 07/10/23 at 2:28 PM, 07/11/23 at 7:50 AM and 4:17 PM and on 07/12/23 at 10:33 AM revealed that the upholstered seats on five of five wooden chairs in the TV lounge on the 3rd floor were soiled with white and brown substances. Three of the chair seats were soiled with what appeared to be a large, dried spot in the center of the seats. Observation on 07/10/23 at 2:28 PM, 07/11/23 at 7:50 AM and 4:17 PM and on 07/12/23 at 10:33 AM revealed a build up of brown substance on the floor around the base of the toilet in room [ROOM NUMBER]'s bathroom. On 07/12/23 at 10:33 AM, the Administrator, Maintenance Director and Housekeeping Director were present during each of the observations, and verified the findings. They stated that they were not aware of the environmental issues. Review of the undated facility policy titled Maintenance and Housekeeping stated, .the facility's maintenance and housekeeping departments will work to provide a safe, clean, comfortable, and homelike environment

Based on interviews, record review, and policy review, the facility failed to ensure an allegation of abuse was reported to the Administrator and to the State Agency within two hours of the allegation being reported to facility staff. This involved one resident (R)84) in the sample of 35 residents. Findings include: During an interview on 07/10/23 at 12:30 PM, R84 stated that a male aide was rough with her during perineal care and had cursed at her. When asked if he hurt her, R84 stated he hurt her bottom. R84 stated it had occurred on the 3:00 PM to 11:00 PM shift and it has been ongoing. At 12:32 PM, the Unit Manager/Registered Nurse (RN)3 entered R84's room. R84 told the Unit Manager that the male aide on the evening shift was rough with her, that she did not want him caring for her, and that she preferred to have a female aide. On 07/10/23 at 3:22 PM, the resident was asked by the surveyor if she knew who was assigned to care for her on the 3:00 PM to 11:00 PM shift that evening. R84 answered that the same male aide had been assigned to her, and she was not happy about it. At 3:23 PM, Licensed Practical Nurse (LPN)2 was queried about which nursing assistants were assigned on the second shift. LPN2 stated that certified nursing assistant (CNA) 2 and CNA 3. CNA 2 met the description provided by R84 earlier. At 3:25 PM, CNA 2 and CNA 3 were both asked what residents they were assigned to, and both stated CNA 2 was assigned to care for R84. CNA 2 stated R84 was on his routine assignment. On 07/10/23 at 3:28 PM, the Unit Manager/RN 3 was asked what R84 had reported when she entered R84's room. RN 3 stated that R84 had reported that a male aide on the evening shift was rough during perineal care, she did not want him caring for her, and that she requested a female care giver. RN 3 stated that she was going to make sure R84 had a female CNA, however she had not yet gotten around to it. When questioned further, RN 3 stated that she had not told the Administrator what R84 had reported to her. During an interview on 07/10/23 at 4:06 PM, the Director of Nursing (DON) and the Administrator stated they had just been informed at 3:30 PM by RN 3 of R84's allegation that a male nursing assistant had been rough during peri care. The Administrator stated that RN3 told her she was looking into it and trying to figure out which male nursing assistant, since there were two male nurse aides working the 3:00 PM to the 11:00 PM shift. The Administrator stated that a resident stating an aide was rough during perineal care would be considered as abuse. The Administrator stated she had not been told about it until 3:30 PM after the surveyor queried RN 3 about it. Interview on 07/10/23 at 4:33 PM, the RN 3 was interviewed with the Administrator present. RN 3 stated that at 12:30 PM, R84 told her CNA 2 was rough and she wanted a female aide. RN 3 stated that she did not report it to the Administrator because she did not consider it to be abuse and she was attempting to figure out which male nursing assistant R84 was talking about. Review of R84's electronic medical record (EMR) under the Minimum Data Set (MDS) tab revealed R84's significant change MDS with an Assessment Reference Date (ARD) of 06/09/23 indicated R84 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating she was cognitively intact and required extensive assistance of one person for toilet use and personal hygiene. Review of a progress note under the progress note tab of the EMR written by Unit Manager/RN3 dated 07/10/23 at 5:10 PM revealed, Resident reports that the assigned male 3-11 CNA [certified nurse aide] is rough when providing peri care, causing soreness to her perineum, head to toe assessment performed no redness or excoriation noted to perineum no discoloration or bruises observed, denies discomfort at time of assessment. Review of the facility's policy titled, Regency Care of Arlington Resident Abuse dated 05/03/17 revealed the facility's definition of abuse included .causing physical pain or injury. The policy stated, . reported allegations or suspected abuse must be reported to the Administrator, other officials in accordance with State law, and the State Survey and Certification agency within 2 hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure three of three residents and their representatives (Resident (R) 358, R84 and R135) reviewed for facility initiated emergent hospital transfer were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to adversely affect the residents and their Resident Representatives (RR) by not having the knowledge of where and why a resident was being transferred, and/or how to appeal the transfer, if desired, as well as preventing the State LTC Ombudsman from identifying inappropriate discharges. Findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA) dated 2022 provided by the Administrator, revealed the facility will provide a notice of transfer to the resident and representative as indicated. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman. 1. Review of R358's Diagnosis tab in the electronic medical record (EMR) revealed R358 was admitted on [DATE] with a non-operable fracture of the left humerus, fusion of the cervical spine, and a history of falling. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/23 revealed R358 had a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating no cognitive impairment. Review of a nursing progress note dated 05/29/23 at 9:10 AM revealed R358 was sent to the hospital's emergency department (ED) due to an unwitnessed fall during the night. Review of R358's EMR revealed no documentation that a written notice of transfer/discharge was sent to R358, R358's responsible party, or the Ombudsman. 2. Review of R135's Diagnosis tab in the EMR revealed R135 was admitted [DATE] with diagnoses of hypertensive chronic kidney disease, Type II Diabetes Mellitus, and generalized muscle weakness. Review of R135's admission MDS with an ARD of 01/13/23 revealed a BIMS of 09, indicating moderate cognitive impairment. Review of a nursing progress note dated 03/14/23 at 8:16 PM revealed R135 was sent to the hospital's ED due to an unwitnessed fall with head injury. Review of R135's EMR revealed no documentation that a written notice of transfer/discharge was sent to R135, R135's responsible party, or the Ombudsman. 3. Interview on 07/13/23 at 2:53 PM, R84 stated that she was sent to the hospital not too long ago because her knee was swollen, and she was sick. When asked if she received a written transfer notice, she stated that she could not remember. Review of R84's EMR Diagnosis tab revealed diagnoses of Methicillin Resistant Staphylococcus Aureus (MRSA) and inflammatory reaction due to internal left knee prosthesis. Review of R84's significant change MDS with an ARD of 06/09/23 revealed a BIMS score of 13 out of 15 indicating R84 was cognitively intact. Review of a nursing progress note dated 05/14/29 at 11:48 PM, indicated resident had emesis with coffee ground color. The doctor was notified, and the resident was sent to the hospital ED for evaluation. Review of a nursing progress note dated 05/15/23 at 6:39 AM indicated the resident was admitted to the hospital with a diagnosis of sepsis. Review of R84's EMR revealed no documentation that a written notice of transfer/discharge was sent to R84, R84's responsible party, or the Ombudsman. During an interview on 07/12/23 at 10:50 AM, the Administrator revealed that the facility did not provide written transfer notices or contact the Ombudsman concerning emergent transfers of the residents to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of facility policy, the facility failed to ensure three of three residents (Resident (R) 358, R84 and R135) reviewed for facility initiated emergent transfer to the hospital and/or their Resident Representative (RR) received a written bed hold notice that included all required information from a sample of 35 residents. This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization. Findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA) dated 2022 provided by the Administrator, revealed that the facility will provide the facility's bed hold policy to the resident and representative as indicated. Review of the facility's policy titled, Bed Hold Notice Upon Transfer dated 2022 provided by the Administrator, revealed: 1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and /or the resident representative written information that specifies: a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility. b. The reserve bed payment policy in the state plan policy, if any. c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed. d. Conditions upon which the resident would return to the facility: o the resident requires the services which the facility provides. o the resident is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. 2. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan. Review of a facility policy titled, Regency Care of Arlington - BED HOLD POLICY AND PROCEDURE provided by the Administrator revealed, Federal Law Requires that this statement be given to each resident upon discharge for a hospitalization or a therapeutic leave. 1. Review of R358's Diagnosis tab in the electronic medical record (EMR) revealed R358 was admitted on [DATE] with a non-operable fracture of the left humerus, fusion of the cervical spine, and a history of falling. Review R358's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/23 revealed R358 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive impairment. Review of a nursing progress note dated 05/29/23 at 9:10 AM revealed R358 was sent to the hospital's emergency department (ED) due to an unwitnessed fall during the night. 2. Review of R135's Diagnosis tab of the EMR revealed that R135 was admitted on [DATE] with hypertensive chronic kidney disease, Type II Diabetes Mellitus, and generalized muscle weakness. Review of R135's admission MDS with an ARD of 01/13/23 for R135 revealed he had a BIMS of 09 out of 15, indicating moderate cognitive impairment. Review of a nursing progress note dated 03/14/23 at 8:16 PM revealed R135 was sent to the hospital's ED due to an unwitnessed fall. Review of R135's EMR revealed no documentation of a written notice of bed hold being sent to the R135 and/or R135's responsible party. 3. Interview on 07/13/23 at 2:53 PM, R84 stated she was sent to the hospital not too long ago because her knee was swollen, and she was sick. When asked if she received a written bed hold notice, she stated not that she could remember. Review of R84's EMR under the medical diagnosis revealed her diagnosis included Methicillin Resistant Staphylococcus Aureus (MRSA) and inflammatory reaction due to internal left knee prosthesis. Review of R84's significant change MDS assessment with an ARD of 06/09/23 revealed R84 had a BIMS score of 13 out of 15 indicating she was cognitively intact. Review of a nursing progress note dated 05/14/29 at 11:48 PM stated R84 had coffee ground colored emesis. The doctor was notified, and R84 was sent to the hospital's ED for evaluation. Review of a nursing progress note dated 05/15/23 at 6:39 AM stated the resident was admitted to the hospital with a diagnosis of sepsis. Review of R84's EMR revealed no documentation that a written notice of bed hold was sent to R84 and/or R84's responsible party. During an interview on 07/12/23 at 10:50 AM, the Administrator revealed that the facility did not provide written bed hold notices to the residents and/or their representatives with emergent transfers to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for two of thirty-five residents in the survey sample (Residents #129 and #359). The findings include: 1. Resident #129's MDS dated [DATE] failed to accurately assess the resident's actual dental problems. Resident #129 (R129) was admitted to the facility with diagnoses that included quadriplegia, respiratory failure, neurogenic bladder, anemia, anxiety, history of pulmonary embolism, pressure ulcers and depression. The minimum data set (MDS) dated [DATE] assessed R129 as cognitively intact. On 7/10/23 at 3:15 p.m., R129 was interviewed about quality of care in the facility. R129 stated during this interview that she was missing all but her front upper teeth and that she had tooth decay. R129 then displayed her front teeth. The teeth were dark around the edges with broken, jagged surfaces. R129 was missing the upper back and lower teeth. Resident #129's clinical record documented an oral assessment dated [DATE] indicating that R129 had broken, decayed, and missing teeth. Section L0200 of R129's MDS dated [DATE] documented that the resident had no dental problems. The category to indicate obvious or likely cavities or broken natural teeth was not marked. Item Z. was erroneously marked indicating no oral/dental problems. On 7/12/23 at 8:00 a.m., the registered nurse MDS coordinator (RN #4) was interviewed about R129's MDS assessment indicating no dental problems. RN #4 reviewed the clinical record and stated the resident's oral assessment completed on 6/13/23 indicated broken, decayed teeth. RN #4 stated the 7/5/23 MDS should have indicated that R129's broken, decayed, and missing teeth. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual on pages L-1 and L-2 documents regarding oral/dental assessment, .This item is intended to record any dental problems present in the 7-day look-back period .Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen . (1) This finding was reviewed with the administrator and director of nursing during a meeting on 7/12/23 at 12:45 p.m. (1) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, Centers for Medicare & Medicaid Services, Revised October 2019. 2. Review of R359's electronic medical record (EMR) discharge return not anticipated Minimum Data Set (MDS)with an Assessment Reference Date (ARD) of 01/13/23 in the MDS tab revealed the MDS was coded that R359 did not have any pressure ulcers at the time of discharge under section M. Review of R359's Specialty Physician Wound Evaluation and Management Summary dated 01/11/23 under the Miscellaneous tab of the EMR revealed R359 had an unstageable necrosis pressure wound measuring 5.7 centimeter (CM) by 6 cm by 0.1 cm. During an interview on 07/11/23 at 2:15 PM, the MDS was reviewed with the Assistant Director of Nursing (ADON), who verified R359 had the pressure ulcer on 01/13/13 when she was discharged from the facility. The ADON verified that the discharge MDS was inaccurately coded for pressure ulcers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to develop care plan interventions for one resident (Resident #3) from a sample of 35 residents. Resident #3 (R3) had physician's orders for care of his suprapubic catheter site but no interventions were care planned for this device. This failure has the potential for the resident not to receive the proper care of his catheter. Findings include: Review of the facility's policy titled Comprehensive Care Plans with an October 2022 revision date reads in part, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment. During an observation of morning care on 07/11/23 at 10:30AM, R3 was observed to have a suprapubic catheter draining cloudy urine with heavy sediment to a bedside bag. R3 did not have a dressing covering the suprapubic catheter site. Review of R3's admission Record located in the electronic medical records (EMR) under Medical Diagnosis tab revealed R3 was admitted to the facility on [DATE]. Review of R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/23 located in R3's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated severe cognitive impairment. This MDS further assessed R3 to be dependent on the staff for all activities of daily living, as well as having a suprapubic catheter. Review R3's July 2023 Physicians Orders in the resident's EMR under the Orders tab revealed orders to clean the suprapubic catheter site with wound cleanser and apply dry dressing daily on 11-7 shift. Review of R3's Care Plan with a revision date of 06/02/23, located in the resident's EMR under the Care Plan, revealed the interventions for the resident's suprapubic catheter included the following: position catheter bag and tubing below the level of the bladder; check tubing for kinks each shift; monitor and document intake and output as per facility policy; monitor for signs and symptoms of discomfort on urination; monitor and document discomfort due to catheter; monitor and report any signs or symptoms of urinary tract infection. However, the interventions did not include the physician's order to clean the catheter site and cover it with a dressing. During an interview on 07/12/23 at 08:38 AM, the Unit Manager Registered Nurse (RN)5 revealed that all nurses were responsible for developing and updating the resident's care plans with interventions. RN 5 stated that she developed the care plan interventions for R3's suprapubic catheter. RN 5 further stated that interventions should have included the physicians' orders to cleanse the catheter site and cover it with dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to provide appropriate suprapubic catheter care and handling for one resident (Resident # 3) from a sample of 35 residents. This failure increases the potential for R3 to develop recurring urinary tract infections (UTIs) or other complications. Findings include: Review of the facility's policy titled Catheter Care-Suprapubic dated October 2022 reads in part .Ensure drainage bag is located below the level of the bladder to discourage backflow of urine .Suprapubic catheter care will be performed every shift and as needed by nursing personnel. Observation on 07/11/23 at 10:30AM revealed R3 receiving morning care. R3 was positioned on his back in bed. The catheter tubing was secured to R3's right thigh area with a leg strap. The catheter site did not have a dressing covering it. Certified Nursing Assistant (CNA) 6 and CNA8 were providing care to this resident. CNA 6 held the catheter drainage bag above the level of R3's bladder and then proceeded to empty the drainage bag, placing the drainage bag in the bed with the resident. However, there was still cloudy urine with sediment present in the tubing, which backed towards R3's bladder. After CNA8 wiped the suprapubic catheter, R3 was turned from side to side to clean his buttocks. While turning the resident, the drainage bag fell to the floor and remained there until the CNAs had completed R3's care and positioned him on his back again. Review of R3's admission Record located in the electronic medical records (EMR) under Medical Diagnosis tab revealed R3 was admitted to the facility on [DATE] with the diagnosis of sepsis. Review of R3's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/23 located in the resident's EMR located under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated R3 was severely cognitively impaired. This MDS also assessed R3 as being dependent on the staff for all activities of daily living, as well as having a suprapubic catheter. Review of R3's Physicians Orders for the month of July located in the EMR under the Orders tab revealed orders to clean the suprapubic catheter site with wound cleanser and apply dry dressing daily on 11-7 shift. Review of R3's Urinalysis and Urine Culture Report located in the EMR under the Results tab revealed a urinalysis and urine culture report dated 06/28/23, which identified a urinary tract infection of proteus mirabilis - carbapenem resistant organism. This pathogen is common cause of cather-associated infections and can quickly progress into infections of the kidneys & blood stream.(1) During an interview on 07/11/23 at 11:00 AM, CNA 8 stated that she had been trained to empty the catheter drainage bag before placing it in the bed with the resident. CNA 8 stated that she was not aware there was still urine in the tubing, potentially backing into the resident's bladder. CNA8 stated the urine backing into the resident's bladder could lead to reoccurring UTIs. CNA8 stated she was aware the drainage bag had fallen to the floor and the resident should receive a new drainage bag. During an interview on 07/11/23 at 11:10 AM,CNA 6 stated that he knows to empty the drainage bag before placing it in the bed with the resident, but did not see the urine that remained in the tubing. Interview on 07/11/23 at 11:27 AM, the Assistant Director of Nursing (ADON) and Unit Manager Registered Nurse (RN)5 stated that staff should have ensured the urine was completely drained from the tubing and the bag before placing the bag in the bed with the resident while turning. Both agreed that the urine backing up into the resident's bladder can contribute to reoccurring UTIs. When questioned further, neither the ADON nor RN 5 were aware of the active physicians' order to clean R3's suprapubic catheter site with wound cleanser and apply dry dressing daily on 11-7 shift. 1. National Institutes of Health https://www.ncbi.nlm.gov>articles>PMC4638163

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of facility policy, the facility failed to ensure that one resident (Resident #3) from a sampled 35 residents was properly positioned while receiving gastrostomy tube feeding. This failure has the potential for the resident to develop aspiration problems from the tube feeding. Finding include: Review of the facility's policy titled Care and Treatment of Feeding Tube dated October 2022 reads in part The resident's plan of care will direct staff regarding proper positioning of the resident consistent with the resident's individual needs. Review of the facility's policy titled Flushing a Feeding Tube dated October 2022 reads in part Prevent aspiration risk by keeping the head of bed elevated at a minimum of 30 degrees. Observation on 07/11/23 at 10:30AM of morning care revealed R3 in bed with the head of the bed (HOB) elevated less than 20 degrees, with the tube feeding infusing. While providing care the two Certified Nursing Assistants (CNA)6 and CNA 8 lowered the head of the R3's bed. R3's tube feeding continued to infuse while in this lower position. While in the lower position, R3 coughed a couple of times and the ventilator alarm sounded. The Respiratory Therapist entered the room and elevated R3s head to 35 degrees and suctioned the resident. Review of R3's admission Record located in the electronic medical records (EMR) under Medical Diagnosis tab revealed R3 was admitted to the facility on [DATE] with the following diagnoses of sepsis, acute and chronic respiratory failure, ventilator dependent, and dysphagia. Review of R3's admission Minimum Data Set (MDS) with an Assessment Reference Date of 05/12/23 located under the MDS tab revealed a Brief Interview for Mental Status score of zero out of 15, indicating severely impaired cognition. This MDS assessed R3 to be dependent on staff for all activities of daily living, as well as requiring enteral feeding through a gastrostomy to maintain his nutritional status. Review of R3's July 2023 Physicians Orders located under the Orders tab revealed .Always elevate HOB 30-45 degrees when in bed every shift. May interrupt tube feeding for medication administration and nursing care as needed. Review of R3's Care Plan with a revision date 6/2/23 located under the Care Plans tab revealed that the interventions for the tube feeding included to keep HOB elevated 30-45 degrees during tube feed administration. During an interview on 07/11/23 at 11:00 AM, CNA8 revealed that she was not sure of how many degrees the HOB should be when a resident is receiving tube feeding. When questioned further, CNA8 then stated she thought it should not be any lower than 35 degrees. Then she stated that she did not feel the HOB was that low. During an interview on 07/11/23 at 11:10 AM, CNA 6 revealed that he did not know what position the head of bed should be in for residents receiving tube feeding. During an interview on 07/11/23 at 11:27 AM, the Assistant Director of Nursing (DON) revealed that residents receiving tube feedings should have the HOB elevated at between 35 to 45 degrees. The DON also stated that when the CNA's were providing care to the residents on tube feeding, they are expected to notify the nurse so the tube feeding can be put on hold, until the care is completed. During an interview of 07/12/23 at 08:38 AM, the Unit Manager Registered Nurse (RN)5 revealed that any resident receiving tube feeding should have the HOB elevated at all times. RN 5 further stated that it is an expectation for the CNAs to notify the nurse when giving care, so the tube feeding can be held during the care.

2. Resident #91 was given Vitamin C 500 milligrams (mg) instead of physician ordered combination medication of iron and Vitamin C medication. The Findings Include: On 09/27/22 at 9:00 AM a medication pass and pour observation was conducted. License practical nurse (LPN) #1 began pulling medications out of the medication cart for Resident #91 and handing the medications to this surveyor to document. One of the medications pulled from the medication cart was Vitamin C 500 MG. LPN #1 dispensed the Vitamin C into the medication cup and gave it to Resident #91. Physician's orders were then reviewed to verify accuracy of medications given. There was a physician's order to give Iron-Vitamin C Tablet 65-125 MG (a combination medication) for anemia. On 7/11/23 at 9:21 AM LPN #1 was interviewed regarding the discrepancy. LPN #1 reviewed the order and then looked in the medication cart for the proper medication but could not find it. LPN #1 verbalized that she thought she had given the correct medication and thought that it was only a Vitamin C tablet. On 7/11/23 at 4:29 PM the above information was presented to the director of nursing (DON) and administrator. No other information was presented prior to exit on 7/12/23. Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed two errors out of thirty-four opportunities resulting in a 5.8% error rate. The findings include: 1. On 7/11/23 at 8:00 a.m., a medication pass observation was conducted with licensed practical nurse (LPN #2) administering medications to Resident #134 (R134). Included in the medications administered to R134 was Senna Plus 8.6/50 milligrams (mg). R134's clinical record documented a physician's order dated 6/19/23 for Senna 8.6 mg once per day for bowel management. R134 had no order for the Senna Plus 8.6/50 mg administered during the observed medication pass. On 7/11/23 at 9:25 a.m., LPN #2 was interviewed about the Senna Plus administered to R134. LPN #2 reviewed the orders and stated the order was for plain Senna and not Senna Plus, which included a stool softener. LPN #2 stated both senna products were from house stock and were available in the medication cart. This finding was reviewed with the administrator and director of nursing during a meeting on 7/11/23 at 4:30 p.m. with no further information provided about the medication error prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, review of facility policies, the facility failed to ensure food was stored, prepared, and maintained in accordance with professional standards for food service safety. a sanitary manner. This failure had the potential to affect 136 of 155 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's policy titled, Food Safety Requirements dated 2023 revealed . food should be labeled and dated. Foods should be used by its use-by date or discarded. Review of the facility's policy titled, Date Marking for Food Safety dated 2023 revealed . food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening the food shall be responsible for dating the food item when it is opened. Review of the facility's policy titled, Use and Storage of Food Brought in by Family and Visitors dated 2023 revealed . food items brought in by family or visitors must be labeled with content and dated. The facility will store the food in the nourishment refrigerator and food not consumed within three days will be thrown away. 1. Observation on 07/10/23 at 11:41 AM of the refrigerator in the fifth-floor kitchenette with the Dietary Manager (DM) revealed the following food items in the refrigerator were either not labeled, not dated, or were past the use-by date: A 12-ounce Styrofoam cup of a white substance A dinner plate of fruit that was loosely covered with plastic wrap and appeared to be half eaten. An open 8-ounce container of milk Two 1.5-quart containers of melted churned ice cream. The ice cream containers were in a plastic style grocery bag. A plastic container of what appeared to be Chinese food. A plastic container of rice. A brown substance wrapped in aluminum foil. A container of chicken rice and green beans which appeared to be partially eaten. An open container of Lyons brand nectar thick water with a use-by date of 06/28/23. Three unopened containers of Lyons brand nectar thick liquid with use-by date of 06/28/23. A half-gallon plastic container of tea. A plastic container of unidentified food. The DM was present and verified each of these findings. The DM stated that they should have been dated, labeled, and discarded within 72 hours of opening and/or placing them in the refrigerator. The DM also stated that the refrigerator was supposed to be used only for resident food items. 2. Observation on 07/10/23 at 12:00 PM, the fourth-floor refrigerator contained two 32-ounce containers of nectar thick water with a use by date of 04/02/23 and one 32 ounce-container of honey thick water with a use by date of 01/04/23. The DM verified the observation and stated that the items should have been discarded after the use by date. 3. Observation on 07/10/23 at 12:05 PM of the third-floor resident refrigerator/freezer located in the third-floor kitchenette contained the following undated, unlabeled food items: A plastic quart size container of an unidentified food item. The container had no name or date. There was a one-inch area of green furry mold on the top of the food item. A quart size bag of grapes. A container of rice and meat with R122's name written on it. The container was covered in foil and was not dated. Mold was growing on the top of the food. The bottom of the refrigerator was soiled with a brown substance. The freezer located over the refrigerator contained: A glass container of a red substance and two containers of food with no name or date. A 4-ounce container of yogurt with a use by date of 05/23/23. A paper on the front of the refrigerator directed staff to date and label all food items with resident's names and that all food would be discarded after 72 hours. The DM was present and verified each of these findings. The DM stated that the items should have been dated, labeled, and discarded within 72 hours of opening and/or placing them in the refrigerator. The DM again stated that the refrigerator was supposed to be used only for resident food items. 4. Observation on 07/10/23 at 11:30 AM and on 07/11/23 at 12:32 PM the following items were observed being stored on a shelf under the food preparation counter in the dietary department: A one-half full 32-ounce bottle of lemon juice. A one-half full 5-pound bottle of Teriyaki glaze. A gallon jug of [NAME] maple syrup. The jug had been opened; was three-fourths full; and had a best by date of 12/18/22. A gallon jug of [NAME] Choice soy sauce. The container only had about one cup of soy sauce left in it. None of the items were dated with the date they were opened. Review of the manufacturer's instructions on each of the products stated to Refrigerate after opening. On 07/11/23 at 12:32 PM, the DM and [NAME] 1 verified each of the products had been opened and partially used; none of the products were dated with the date they were opened; each of the products were supposed to be refrigerated after being opened; and the maple syrup was past its best by date. The DM and Cook1 stated they had never put the food products in the refrigerator after they were opened because they were not aware that they needed to be refrigerated. The DM stated the items should have been dated with the date they were opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Facility staff failed to ensure infection control practices were followed while assisting a resident who was on contact isolation. On 7/11/23 at 8:10 AM a hospitality aide (Other Staff, OS #1) donned a gown and gloves and entered room [ROOM NUMBER]. A sign was posted on the door instructing staff and visitors of contact isolation and proper personal protective equipment needed. The sign also instructed to discard gown and gloves before exiting the room. The Resident in room [ROOM NUMBER], identified as Resident #34, was on contact isolation due to CRE (Carbapenem-resistant enterobacteriaceae), a bacterial infection. Approximately 5 minutes later, OS #1 came out of room [ROOM NUMBER] wearing the same gown, went across the hallway to room [ROOM NUMBER] to help another resident with a breakfast tray, then removed the gown, and put it into the trash can. On 7/11/23 at 8:27 AM, OS #1 was interviewed regarding wearing a gown from one room to another. OS #1 said that the gown is supposed to be removed prior to exiting the room, but had gotten in a hurry and did not take the gown off. On 7/11/23 at 4:29 PM, the above finding was presented to the administrator and director of nursing (DON). The DON verbalized that the facility has been doing a lot of education with infection control issues and OS #1 should have disposed of the gown before leaving the room. No other information was presented prior to exit conference on 7/12/23. Based on observation, interview, record review, and review of facility policy, the facility failed to ensure proper hand hygiene during meal service for 12 residents (R) from a sample of 35 residents. Staff failed to perform hand hygiene when passing meal trays to R63, R75, R86, R103, R122, R133, R409, R411, R412, R413, 414, and R415. Staff handled residents' food without wearing gloves. The facility also failed to post the correct signage for personal protective equipment (PPE) for two residents of six residents on transmission-based precautions. (R3 and R139). The facility also failed to ensure that the posted precautions were followed for one of six residents on transmission-based precautions (Resident #34). These combined failures have the potential to widely transmit infectious agents and increase the risk of facility-acquired infections. Finding include: 1. Staff failed to perform hand hygiene when passing meal trays. Review of the facility's undated policy titled Serving a Meal reads in part Perform hand hygiene prior to passing the first tray .Place the tray on the dining table or over bed table if the resident eats in their room .Avoid handling unwrapped food with bare hands .Perform additional hand hygiene after touching items in the resident's room or if hands become visibly soiled . Observation of breakfast on 07/11/23 at 07:39 AM on the fifth floor revealed the Assistant Director of Nursing (ADON) announcing the arrival of the breakfast cart on the unit. Certified Nursing Assistant (CNA)5 pulled out a tray and went R411's room and arranged the meal tray on the overbed table for the resident. CNA5 left the room and went to the meal cart without performing hand hygiene and pulled out another tray. CNA5 took this tray to R409's room and placed the tray on the overbed table. The CNA5 moved the overbed table so the resident could reach her food. CNA5 left the room without performing hand hygiene and went to the coffee cart to obtain coffee and condiments for R133. CNA 5 left the resident's room and made a phone call to the kitchen for a resident's request. Without performing hand hygiene, the CNA5 returned to the meal cart and pulled a tray for R415 and set up the tray on the resident's overbed table. CNA5 left the resident's room again without performing hand hygiene and removed a tray from the meal cart, added a cup of coffee, condiments, and entered R413's room. CNA5 arranged the resident's meal tray and bed covers. CNA 6 was observed in R414's room setting up the meal tray and came directly out of the room without performing hand hygiene. CNA5 requested CNA6's assistance in repositioning R412 in bed. Neither CNAs performed hand hygiene before or after assisting R412 in bed. Both CNAs walked past sanitizer wall units and bottles of hand sanitizer on the medication and treatment carts; and the coffee cart without utilizing any of the units. Both CNAs returned to the meal cart. CNA5 pulled a tray for R86, took it to her room, and set up the tray on the resident's overbed table. CNA5 left R86's room without performing hand hygiene. CNA6, without performing hand hygiene, removed a meal try for R63, took it to her room, and set it up to feed the resident. CNA6 was then observed tearing the breakfast bagel into small pieces with his bare hands. During an interview on 07/11/23 at 08:03 AM, CNA5 stated that she has been taught to perform hand hygiene after serving every two trays. When questioned further, CNA5 then changed her answer to performing hand hygiene after every tray. CNA admitted that she had not performed any hand hygiene during the meal service. Interview on 07/11/23 at 08:08 AM, CNA 6 stated that he sanitized his hands at the start of meal service and performed hand hygiene in the residents' rooms that he served trays. During an interview on 07/11/23 at 09:51 AM, the Assistant Director of Nursing (ADON)/Infection Control Preventionist stated that the issue of hand hygiene has been addressed in several meetings. The ADON stated that it is an expectation that staff will perform hand hygiene when passing each tray each. During an interview on 07/12/23 at 10:15 AM, with the ADON and the Infection Control Preventionist 7(in orientation), the ADON stated that she had observed CN6 and CNA5 not performing hand hygiene while passing trays. The ADON stated that she had reminded both employees that they should perform hand hygiene after passing each tray. The ADON stated that she instructed the two CNAs to pass this onto the other employees. The ADON also stated that even after reminding CNA 6 to perform hand hygiene, he failed to do so. 2. Staff failed to wear gloves before directly touching resident's food. Review of the facility's undated policy titled Serving a Meal reads in part Perform hand hygiene prior to passing the first tray .Place the tray on the dining table or over bed table if the resident eats in their room .Avoid handling unwrapped food with bare hands .Perform additional hand hygiene after touching items in the resident's room or if hands become visibly soiled . Observation on 07/11/23 at 8:04 AM, CNA4 was assisting R122 with setting up his food tray on the overbed table. At 8:06 AM, after assisting R122, CNA4 went over to R75's tray and picked up the resident's bagel with her bare hands, tearing the bagel into smaller pieces. At 8:15 AM, CNA4 picked up R103's bagel and tore it into smaller pieces with her bare hands. CNA4 was not observed to wash her hands between assisting any of the residents with their trays or before touching the bagels with her bare hands. At 8:16 AM, CNA4 was observed handling R122's straw with her bare hands. On 07/11/23 at 8:16 AM, when asked if she had washed her hands and/or wore gloves prior to touching the residents' food with her bare hands, CNA4 stated that she had not. On 07/11/23 at 4:45 PM, the observations were shared with the Director of Nursing (DON) who stated that CNA 4 should have used utensils to cut up the resident's food or should have worn gloves when she touched the food. 3. The facility failed to post the correct signage for isolation precautions. Review of the facility's policy titled Transmission Based Precautions' dated 07/25/18 reads in part Contact isolations precautions - healthcare personnel caring for resident wears gloves and gowns. Droplet Precautions - healthcare personnel must wear a mask for close contact with infectious resident . Observation during the initial tour on 07/11/23 at 11:41 revealed R3's signage on the door indicated that droplet and contact precautions were to be observed, directing that staff must wear gowns, gloves, mask, face shield/goggles. Observation on 07/11/23 at 10:30AM revealed CNA 6 and CNA8 in the R3's room wearing face mask, gown, and gloves. They were not wearing face shield/goggles as posted on R3's door. Review of R3's Physicians Orders for the month of July 2023 located under Orders tab revealed orders for contact isolation for multidrug resistant organisms. During an interview on 07/11/23 at 11:00 AM, CNA8 revealed that she had not looked at the sign posted on the door. CNA8 stated that she thought she needed just the mask, gown, and gloves. During the facility tour on 07/11/23 at 11:41AM, R139's door was observed to have signage posted for contact isolation precautions, directing staff to perform hand hygiene before entering and when leaving the room. The signage also directed that staff must put on gloves and gown before entering the room and discard before exiting the room, as well as stating, Do not wear the same gown and gloves for the care of more than one resident. Observation on 07/10/23 at 12:19 PM revealed a CNA8 entering R139's room without donning any PPE. The CNA wore an N95 face mask on her arm. CNA8 arranged R139's bed sheets, removed a pair of discarded gloves from the dresser and tossed them in the trash can. CNA8 exited R139's room and donned a pair of gloves, returned to the resident's room without donning any PPE, and removed the trash from R139's room. CNA8 emptied the trash can to the resident's room and removed her gloves. CNA8 failed to perform hand hygiene before going to the next resident's room. Review of R139's Physicians Orders for the month of July 2023 located in R139's EMR under the Orders revealed orders for contact isolation precautions: Staff to wear gown, gloves, and mask when in resident's room. During an interview on 07/10/23 at 1:30 PM, CNA 8 stated she was only pulling the trash from the resident's room and did not think she needed to wear the PPE when emptying the trash. Reminded CNA8 that she was observed at the R139's bedside adjusting his linen. CNA8 then acknowledged that she failed to perform hand hygiene before going to the next resident. Interview and tour on 07/11/23 at 12:30 PM with the Unit Manager Registered Nurse (RN)5 revealed that R3's isolation signage was incorrect. According to RN5, R3 should be on contact isolation precautions, not droplet precautions adding that staff should wear gowns and gloves. RN5 then stated that R139 was also on contact isolation precautions, adding that CNA8 should have worn PPE when entering R139's room. Interview on 07/12/23 at 10:30 AM with the Assistant Director of Nursing (ADON) and Infection Control Preventionist (ICP)7 revealed currently all the residents on the fifth floor were on contact isolation precautions. The ADON stated all the staff on the fifth floor had received training regarding the types of isolation precautions. The ADON stated the Unit Manager was responsible for ensuring the correct signage was posted on the resident's door and ensuring the staff was adhering to the directions. The ADON then stated that she did not realize the incorrect signage was posted for R3 and that staff were not following isolation precautions for R139.

Based on Resident interview, staff interview and clinical record review, the facility failed to develop a care plan for one of 29 resident's. Resident #82 did not have a care plan for vision. The Findings Include: Diagnoses for Resident #82 included: Malignant neoplasm of bladder, anxiety, adult failure to thrive, and unspecified dementia. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 7/26/22. Resident #82's cognitive score was a 13 indicating cognitively intact. On 8/30/22 at 10:06 AM an interview was conducted with Resident #82. During the conversation Resident #82 verbalized she liked reading but her glasses were broke and said no one has done anything about it (glasses were sitting on Resident #82's dresser, the ear pieces were broken off). On 8/30/22 Resident #82's clinical record was reviewed. Section B1000 (Vision) of Resident #82's most recent MDS documented Resident #82's vision was adequate and no corrective lenses were needed. Resident #82's care plan was also reviewed and revealed no documentation of a care plan for vision. On 8/30/22 at 2:16 PM the MDS coordinator (registered nurse, RN #2) was asked about the concern regarding vision listed on the MDS as not needing glasses and vision was adequate. RN #2 verbalized that he filled out the sections and gets information from the chart and interviews with family and Resident's, but would look into it. On 8/31/22 at 8:16 AM, RN #2 verbalized after reviewing Resident #82's admission MDS he realized a mistake had been made on the MDS regarding vision and that resident #82 needed glasses. RN #2 was asked, if vision would have been triggered on the MDS as needing glasses and vision was inadequate, should a care plan be developed. RN #2 verbalized a care plan would have been put in place for a resident needing glasses. On 8/31/22 at 12:15 PM the above information was presented to the administrator and director of nursing (DON). No other information was presented prior to exit conference on 8/31/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #133 was admitted to the facility with diagnoses that included long-term use of insulin, insomnia, osteoarthritis, GERD, stage 5 chronic kidney disease requiring dialysis, hyperlipidemia, anemia, and muscle weakness. The discharge minimum data set (MDS) dated [DATE] documented Under Section A that Resident #133 discharge to an acute hospital. On [DATE], Resident #133's closed clinical record was reviewed. Observed in the clinical record was the Discharge Summary and Discharge Plan/Instructions dated [DATE], both documented that Resident #133 discharged to home on [DATE]. A progress note dated [DATE] documented Resident #133 discharged to home on [DATE] at 11:15 a.m. Resident #133's discharge MDS was reviewed and documented that the resident discharged on [DATE]. The MDS documented the discharged was planned and the resident's return was not anticipated. The discharge MDS documented that the resident discharge to an acute care hospital. On [DATE] at 6:10 p.m., the MDS Coordinator (RN #2) was interviewed regarding Resident #133's discharge location. RN #2 stated the resident discharged to home. RN #2 was asked to review the MDS for accuracy of the resident's discharge location. RN #2 reviewed the discharge MDS and stated it was coded in error, that Resident #133 did not discharge to the hospital, and the resident was planned discharge to home. On [DATE] at 12:14 p.m., the above findings were reviewed during a meeting with the administrator & DON. 3. Resident #131 was admitted to the facility with the following diagnoses including but not limited to: Chronic respiratory failure, heart failure, diabetes mellitus, gastrostomy, tracheostomy, dependence on ventilator, mediastinal b-cell lymphoma, heart failure, rib fractures and COPD. The admission MDS with an ARD of [DATE], assessed Resident #131 as cognitively intact with a summary score of 13. Resident #131 was added to the survey sample a closed record with a discharge disposition of Death in Facility. The clinical record was reviewed on [DATE] at approximately 3:00 p.m. The following note was written [DATE]: [DATE] 01:22 (a.m.) Respiratory Therapy Progress Not .Called to pt's room at approximately 2310 (11:10 p.m.) by CNA (certified nursing assistant) who said pt was requesting to see respiratory. Pt indicated that he was having trouble breathing. Airway assessed, and trach noted to be partially out of stoma. Before I could advance the trach tube further into place, the resident reached up and pulled his trach tube out. Attempted several times unsuccessfully to reinsert trach using obturator and correct position. 9-1-1 was immediately called after several unsuccessful attempts of reinsertion of trach tube. Trachea appeared to have blockage which would not allow for insertion. Began bagging pt with stoma mask. Additional attempts made to pass tracheostomy tube, but again unsuccessfully. Began bagging pt with stoma mask again. Pt became unresponsive during this process, and CPR (cardio pulmonary resuscitation) was initiated. CPR was continued until the EMTs (emergency medical transports) arrived and took over the resuscitation process. During a meeting with the DON (director of nursing) and the administrator on [DATE] at approximately 12:15 p.m. Resident #131's death in the facility was discussed. The administrator stated, He didn't die here .he died at the hospital. The administrator was informed that since the patient was transferred out to the hospital his MDS discharge status should have been, Acute hospital, not deceased . She agreed. The discharge documentation from the hospital was presented at approximately 1:00 p.m. and included: .Patient presented in cardiac arrest .bedside ultrasound showed no organized cardiac activity. Patient was declared dead at 12:42 (a.m.) No further information was obtained prior to the exit conference on [DATE]. Based on staff interview and clinical record review, the facility failed to ensure an accurate MDS (minimum data set) assessment for three of 18 resident's in the survey sample. 1. Resident #82's MDS section B (vision) and section H (Bladder and Bowel) was coded incorrectly. 2. Resident #133's MDS section A (discharge) was coded incorrectly. 3. Resident #131's MDS section A (discharge) was coded incorrectly. The Findings Include: 1. Diagnoses for Resident #82 included: Malignant neoplasm of bladder, anxiety, adult failure to thrive, and unspecified dementia. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of [DATE]. Resident #82's cognitive score was a 13 indicating cognitively intact. On [DATE] at 10:06 AM an interview was conducted with Resident #82. During the conversation Resident #82 verbalized she liked reading but her glasses were broke and said no one has done anything about it (glasses were sitting on Resident #82's dresser, the ear pieces were broken off). Also during the interview Resident #82 was asked if she had a catheter in place (as documentation indicated Resident #82 had a catheter). Resident #82 verbalized that she has never had a catheter. On [DATE] Resident #82's clinical record was reviewed. Section B1000 (Vision) of Resident #82's most recent MDS documented Resident #82's vision was adequate and no corrective lenses were needed. Also, section H0100 (Bladder and Bowel documented Resident #82 had an indwelling catheter. On [DATE] at 2:16 PM the MDS coordinator (registered nurse, RN #2) was asked about the concerns regarding vision and catheter that were listed on the MDS. RN #2 verbalized that he filled out the sections and gets information from the chart and interviews with family and Resident's, but would look into it. On [DATE] at 8:16 AM, RN #2 verbalized after reviewing Resident #82's admission MDS he realized a mistake had been made on the MDS regarding vision and catheter. RN #2 went onto say Resident #82 does need glasses and Resident #82 never had a catheter. On [DATE] at 12:15 PM the above information was presented to the administrator and director of nursing (DON). No other information was presented prior to exit conference on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident #107 was admitted to the facility with diagnoses that included: hyperlipidemia, presence of pacemaker, anemia, stage 5 chronic kidney disease - requiring dialysis, muscle weakness, urinary tract infection, and afib. The most recent minimum data set (MDS) dated [DATE] was the 5-day admission assessment and assessed Resident #107 as moderately impaired for daily decision making with a score of 12 out of 15. Resident #107's clinical record was reviewed. Observed on the order summary report was the following order: DNR (do not resuscitate). Order Date [DATE]. Resident #107's clinical record included a copy of a DNR form signed on [DATE]. Resident #107's care plans included the following focus area with goals and interventions: Resident identified Advanced Directives are Full Code. Date Initiated: [DATE]. On [DATE] at 6:10 p.m., the MDS Coordinator (RN #2) was interviewed regarding Resident #107's care plans. RN #2 reviewed Resident #107's clinical record and stated the advance directive/code status care plan should have been reviewed and revised to reflect the change from Full Code to DNR. On [DATE] at 12:14 p.m., the above findings were reviewed during a meeting with the administrator & DON. 6. Resident #8 was admitted to the facility with diagnoses that included: dependence on renal dialysis, anxiety disorder, dysphagia, long-term use of anticoagulant, dysphagia, anemia, hypercalcemia, depression, hypertensive heart, and acute embolism and thrombosis of right internal jugular vein. The most recent readmission assessment dated [DATE] assessed Resident #8 as alert and oriented times 4. On [DATE], Resident #8 clinical record was reviewed. Observed on the care plans was the following focus area with goals and interventions, The resident is on anticoagulant therapy r/t (related to) Right internal jugular vein thrombosis (RIJ DVT) and right basilic vein thrombosis. Date Initiated: [DATE]. Revised: [DATE]. Resident #8's orders were reviewed and documented the following order: Heparin Sodium (Porcine) Solution 5000 Unit/ML Inject 5000 unit subcutaneously every 12 hours for clotting prevention for 1 week. Start Date: [DATE]. End Date: [DATE]. Resident #8's medication administration record (MAR) was reviewed for the period of [DATE] through [DATE]. The MARS documented Resident #8 received the Heparin as ordered for one week, ending on [DATE]. On [DATE] at 8:26 a.m., the MDS Coordinator (RN #2) was interviewed regarding Resident #8's care plans. RN #2 reviewed Resident #8's clinical record and stated the anticoagulant care plan should have been resolved since the Heparin order was completed in June. On [DATE] at 12:14 p.m., the above findings were reviewed during a meeting with the administrator & DON. On [DATE] at 12:14 p.m., during a meeting with the administrator and DON concerns with care plans was discussed. The administrator stated, the IDT (interdisciplinary team) meets daily and discusses any changes with the residents. The care plans are pulled up at that time and should be reviewed and revised daily at that time instead of waiting until the care plan meeting. This keeps everyone updated on the plan of care . 3. Resident #118 was admitted to the facility with the following diagnoses, including but not limited to: Unspecified convulsions, chronic pain, left above knee amputation, peripheral vascular disease and COPD (chronic obstructive pulmonary disease) A quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE], assessed Resident #118 as cognitively intact with a summary score of 15. Resident #118's clinical record was reviewed on [DATE] at approximately 10:00 a.m. A focus area, Resident is a smoker was observed with interventions that included, but were not limited to: Instruct resident about smoking risks, Instruct resident about facility policy on smoking, observe clothing and skin for signs of cigarette burns. At approximately 10:30 a.m., the administrator was asked if any residents in the facility were allowed to smoke. She stated, No, we do not allow smoking here. She was informed that Resident #118's care plan listed him as a smoker. She stated, That is incorrect. Resident #118 was interviewed on [DATE] at approximately 10:45 a.m. He was asked about smoking. He stated, I don't smoke anymore, I have COPD and had to quit. I did the patch .smoking is a hard habit to break. The above information was discussed during a meeting with the DON (director of nursing) and the administrator on [DATE] at approximately 12:15 p.m. They were asked who updates the care plans. The administrator stated, (Name of MDS) we meet every morning for an IDT (interdisciplinary team) meeting we discuss everything, that is the time for MDS to update the care plan. She was asked if the nurses also updated the care plans. She stated, No, it should be done in real time by MDS in the morning meeting. She was told about the interventions for smoking on Resident #118's care plan. She stated, We know we have a problem with care plans .that should have been updated. No further information was obtained prior to the exit conference on [DATE]. 4. Resident #131 was admitted to the facility with the following diagnoses including but not limited to: Chronic respiratory failure, heart failure, diabetes mellitus, gastrostomy, tracheostomy, dependence on ventilator, mediastinal b-cell lymphoma, heart failure, rib fractures and COPD. The admission MDS with an ARD of [DATE], assessed Resident #131 as cognitively intact with a summary score of 13. The clinical record was reviewed on [DATE] at approximately 3:00 p.m. The following note was written [DATE]: [DATE] 01:22 (a.m.) Respiratory Therapy Progress Not .Called to pt's room at approximately 2310 (11:10 p.m.) by CNA (certified nursing assistant) who said pt was requesting to see respiratory. Pt indicated that he was having trouble breathing. Airway assessed, and trach noted to be partially out of stoma. Before I could advance the trach tube further into place, the resident reached up and pulled his trach tube out. Attempted several times unsuccessfully to reinsert trach using obturator and correct position. 9-1-1 was immediately called after several unsuccessful attempts of reinsertion of trach tube. Trachea appeared to have blockage which would not allow for insertion. Began bagging pt with stoma mask. Additional attempts made to pass tracheostomy tube, but again unsuccessfully. Began bagging pt with stoma mask again. Pt became unresponsive during this process, and CPR (cardio pulmonary resuscitation) was initiated. CPR was continued until the EMTs (emergency medical transports) arrived and took over the resuscitation process. The care plan was reviewed. A focus area: The resident has a tracheostomy r/t (related to) respiratory failure. One of the interventions listed was: TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. The director of respiratory services was interviewed on [DATE] at 5:30 p.m. He was asked about the incident. He stated, (Name of resident) had mobility in his hands he would reposition the vent and the trach. OS (other staff) #3 a respiratory therapist that had worked with Resident #131 earlier in the shift of the night his trach tube cam out was interviewed at 6:20 p.m. She stated that Resident #131 Messed with is trach .he moved it to the right and to the left .we told him the importance of leaving it alone. She was asked if hemostats were used to reopen the stoma if a trach came out as the care plan directed. She stated, No, we don't do that. On [DATE] at 07:40 a.m., OS #2 the therapist who attempted to reinsert the trach was interviewed. She stated, When I got in there he had his hands on his trach .I got his hands down and tried to get it back in but I couldn't get it in, it was blocked .I bagged him and suctioned him, and still couldn't get it in. She was asked if she had used hemostats per the care plan to try to reopen the stoma. She stated, We don't do that. She was asked if Resident #131 moved his trach around. She stated, Yes, he was constantly, moving and fiddling with it .we tried to explain to him that it was his lifeline. She was asked what was normally done if residents moved their trachs around or touched them frequently. She stated, We talk to the nurses, they may need a PRN (as needed) to relax them. sometimes a psych consult. She was asked if she had spoken with any of the nurses, she stated, No. On [DATE] at approximately 8:20 a.m., the MDS nurse who created Resident #131's care plan was interviewed. He was asked about the intervention for the use of hemostats to reopen the stoma in the event the trach tube came out. He explained that he had a library of interventions in the computer system to choose from when doing care plans. He stated, that respiratory therapy should review the care plans to make sure they were okay. He was asked why there were no interventions regarding Resident #131 moving his trach around. He stated, I was unaware of that. He was asked if he had been aware would that have been care planned. He stated, Yes. The director of respiratory services was interviewed at approximately 9:00 a.m. and was asked if he had reviewed the care plan. He stated, Yes. He was asked if hemostats were used to reopen the stoma if the tube was coughed out as the care plan directed. He looked at the intervention and stated, No, we don't do that. I missed that on the care plan. That part should have been marked out. Concerns were voiced to him that the intervention regarding the use of hemostats had not been reviewed and revised/removed from the care plan, nor had the respiratory therapists communicated to the MDS nurse or documented in the clinical record, that Resident #131 was moving his trach tube around so interventions could be put into place. The policy on care plans was requested and contained the following: An interdisciplinary plan of care will be established for every resident and updated in accordance with stated and federal regulatory requirements and on an as needed basis . The above information was discussed with the DON and the administrator in a meeting on [DATE] at approximately 12:15 p.m. The administrator stated the care plan should have been updated. No further information was obtained prior to the exit conference on [DATE]. Based on staff interview, clinical record review and facility document review, the facility staff failed to review and revise the CCP (comprehensive care plan) for six of 29 residents in the survey sample, Resident #47, #97, #118, #131, #107 and #8. 1.) The facility staff failed to update Resident #47's care plan related to snacks and an AV (arteriovenous) fistula (no longer in use). 2.) The facility failed to update Resident #97's care plan related to trach care interventions for dislodgement of a tracheotomy tube. 3.) Resident #118's care plan was not reviewed and revised to remove the focus area, Resident is a smoker. 4.) Resident #131's care plan was not reviewed and revised to include his repositioning of his tracheotomy tube, nor was the care plan revised to delete the use of hemostats to open up the stoma in the event the tube was coughed out. 5). Resident #107's CCP was not reviewed & revised for code status change. 6.) Resident #8's CCP was not reviewed & revised for discontinuation of anticoagulant medication. Findings include: 1.) Resident #47's diagnoses included, but were not limited to: end stage renal disease (recent kidney transplant), metabolic encephalopathy, cardiovascular and coagulation disease, high blood pressure, enlarged prostate, constipation, reflux disease, dementia without behaviors, insomnia, major depression, and arteriovenous fistula (no longer used). The resident's most recent full MDS (minimum data set) was a significant change assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. The resident triggered in the CAAS (care area assessment summary) section of this MDS for nutrition. On [DATE] at approximately 9:30 AM, the resident was interviewed and stated that he has lost weight, but has a good appetite. The resident was eating corn flakes and stated that he likes to 'indulge' in eating them, he really enjoyed them. The resident stated that staff do not bring him snacks and that he wants to eat. The resident stated that his brother had brought the corn flakes to him. The resident also stated that he had just had a kidney transplant, which may have contributed to some of the weight loss that he was in the hospital for 2 weeks. The resident stated that he was happy and doing well, was no longer receiving dialysis, and was hoping to be able to get rid of his fistula (AV fistula located in the resident's left arm) and eventually go home. The resident's physician's orders were reviewed and documented, SNACKS TID [three times a day] three times a day @ 10AM, 2PM, & 8PM Active [DATE] . The physician orders did not document any information regarding the AV fistula. The resident's CCP was then reviewed and the physician ordered TID snacks (intervention for weight loss) was not located on the care plan. The resident's CCP did not mention and/or address the resident's AV fistula that was still in place, but no longer in use. The resident's TARS (treatment administration records) were reviewed, it was documented by staff initials that the resident was getting the snacks TID. There was no information on the resident's MARs/TARs (medication/treatment administration records) regarding the resident's AV fistula. On [DATE] at 8:47 AM, the MDS coordinator/care planner (MDSCC) was interviewed regarding the above information. The MDSCC stated that the RD (registered dietitian) is supposed to update the care plans regarding nutrition. The MDSCC did not have an answer regarding the resident's AV fistula. On [DATE] at approximately 9:00 AM, the RD was interviewed and stated that she will include interventions, but that is typically added by the MDSCC and stated that the snacks should have been included on the resident's care plan. On [DATE] at approximately 11:45 AM, the DON (director of nursing) and the administrator were made aware of above regarding Resident #47's CCP. The administrator stated that 'it doesn't work that way' as far as the RD updating the care plan, that is actually done by the MDSCC. The concern regarding the resident not having a care plan for the AV fistula was also shared. The DON stated that the resident should have a care plan for the fistula that was no longer in use (since the kidney transplant). No further information and/or documentation was provided prior to the exit conference on [DATE]. 2.) Resident #97's diagnoses included, but were not limited to: atrial fibrillation, diabetes mellitus, and sudden cardiac arrest now with tracheotomy and ventilator dependent. The most recent full MDS was a significant change assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15 indicating the resident was intact for daily decision making skills. The resident was assessed as having a trach and ventilator on this MDS. The resident was observed on [DATE] and [DATE]. The resident was not interviewable. The resident's trach care was observed on [DATE] at approximately 10:00 AM with RT (respiratory therapist) #2. RT #2 explained the procedure during the observation of Resident #97's care for suctioning, inner canula change and total care of the tracheotomy tube and what should happen if the resident's tube is dislodged. There was no mention of hemostats and no hemostats were observed at the bedside. The resident's physician orders and CCP were then reviewed. The resident's physician's orders did not have any information regarding hemostats. The resident's CCP was reviewed for trach/ventilator care and documented, .TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. If tube is coughed out, open stoma with hemostat. If tube cannot be reinserted, monitor/document for signs of respiratory distress. If able to breathe spontaneously, elevate HOB 45 degrees and stay with resident. Obtain medical help IMMEDIATELY . On [DATE] at approximately 5:30 PM RT #2 was interviewed with the survey team. RT #2 explained that they do not use hemostats and wasn't sure why that information was on the resident's care plan. On [DATE] at approximately 8:45 AM, the MDSCC was interviewed regarding Resident # 97's care plan for trach/vent care. The MDSCC could not provide an answer to where that particular intervention came from and then stated that he has a library to pick interventions from for trach/vent care and that must have been selected for this resident (even though hemostats are not used at this facility and did not apply to this resident). The MDSCC was made aware that the care plan was not specific to this resident and was generalized, not customized for this particular resident. On [DATE] at approximately 11:45 AM, the DON and administrator were made aware of the above information and findings. The DON and administrator both stated that they are aware they have a problems with MDS and care plans. No further information and/or documentation was provided prior to the exit conference on [DATE].

Based on facility document review, clinical records review and staff interview, the facility staff failed to ensure the infection prevention and control program (IPCP) antibiotic stewardship included antibiotic use protocols and an accurate system for monitoring antibiotic use. Findings include: On 08/31/22, the facility's antibiotic stewardship book/program was reviewed. The book/program did not consistently identify the type of infection, the antibiotic used, did not identify the specific organism, did not include the date of infection, specific symptoms and/or means of confirming infection prior to the prescribing and/or administering antibiotics. There was not a way to confirm the antibiotic prescribed was for the correct indication, dose, and duration to appropriately treat the resident. The antibiotic stewardship program for antibiotic use protocol(s) did not address antibiotic prescribing practices (i.e., documentation of the indication, dose, and duration of the antibiotic; review of laboratory reports to determine if the antibiotic is indicated or needs to be adjusted; an infection assessment tool or management algorithm is used when prescribing) and a system to monitor antibiotic use (i.e., antibiotic use reports, antibiotic resistance reports) were not found in the information provided by the administrator. The administrator stated that they do not currently have an IPCP preventionist at this time and stated that she has been gone since June 24th and that they recently hired someone for that role, but the person has not actually worked and was supposed to start on Monday (August 29th), but had not started yet. The administrator stated that the previous DON (director of nursing) had left approximately 2-3 weeks and that the new/current DON has been at the facility for approximately 2 weeks. The administrator stated that she knew the program was lacking as the information was not being input into the system. The administrator was asked for a policy on antibiotic stewardship. The policy was presented and reviewed and documented, .Antibiotic Stewardship Program .implement an Antibiotic Stewardship Program .optimize treatment of infections while reducing the adverse events associated with antibiotic use .includes antibiotic protocols and a system to monitor antibiotic use .complete an SBAR .lab testing .uses the (CDC's NHSN surveillance definitions) to define infections .Loeb minimum criteria are used to determine whether or not to treat an infection with antibiotics .monitoring .shall be reviewed for appropriateness .random audits .antibiotic use shall be measured by .monthly prevalence, antibiotic starts . The administrator was made aware that the policy provided does not match the antibiotic stewardship program, that there no evidence of SBAR, lab testing, surveillance, and/or any criteria/algorithm for indications of use/necessity. No further information and/or documentation was provided prior to the exit conference on 08/31/22 to evidence that the facility had an effective and accurate antibiotic stewardship program in place.

Based on staff interview and facility document review, the facility staff failed to ensure at least one staff member was designated as the infection preventionist who is responsible for the facility's IPCP (infection prevention and control program). Findings include: On 08/31/22 at approximately 7:30 AM, the facility's IPCP/antibiotic stewardship program was reviewed. The program presented did not consistently identify the type of infection, did not identify the specific organism, did not identify the antibiotic used/prescribed, did not include the date of infection, specific symptoms and/or means of confirming infection prior to the prescribing and/or administering antibiotics to residents. On 08/31/22 at approximately 9:30 AM, the administrator stated that they do not currently have an IPCP preventionist at this time and stated that she (infection preventionist) has been gone since June 24th and that they have not had anyone in that role, but did recently hire someone for that role. The administrator stated that the person has not actually worked yet and was supposed to start on Monday (August 29th), but had not started yet. The administrator stated that the previous DON (director of nursing) had left approximately 2-3 weeks ago and that the new/current DON has been at the facility for approximately 2 weeks. The administrator stated that she knew the program was lacking as the information was not being input into the system for the infection control program. The administrator was asked for a policy on antibiotic stewardship. The policy was presented and reviewed and documented, .Antibiotic Stewardship Program .implement an Antibiotic Stewardship Program .the infection preventionist, with oversight from the DON, serves as the leader of the .program .DON serves backup . The administrator stated that the current DON had pretty much, just got here to the facility and has not been in that role. No further information and/or documentation was provided prior to the exit conference on 08/31/22 to evidence that the facility had a designated infection control preventionist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and during the course of a complaint investigation, the facility staff failed to develop and implement a baseline care plan for for dialysis within 48 hours of admission for one of 39 residents (Resident #170). Findings include: Resident #170 was originally admitted to the facility on [DATE]. The resident was discharged from the facility on 07/01/19, with another readmission to the facility on [DATE]. The most current MDS (minimum data set) during that time was the resident's discharge return anticipated MDS dated [DATE]. This MDS documented that the resident's cognitive status as having no short term or long term memory impairment and no issues with daily decision making skills. The resident was assessed as receiving dialysis services in Section O. (Special Treatments) J. Dialysis while not a resident and while a resident in the last 14 days. During the closed clinical record review, the resident's care plan was reviewed. The care plan did not have any information regarding dialysis care and treatment, nor any interventions for the care and treatment of the resident's dialysis access, until 07/01/19 (the day the resident was discharged to the hospital), three days after the resident's admission. On 02/27/20 at approximately 10:30 AM, the DON (director of nursing), the ADON (assistant director of nursing) and the SW (social worker) were made aware that Resident #170's initial baseline care plan could not be located. The ADON stated that it was included in the regular care plan. The facility staff were made aware that Resident #170 did not have anything listed in care plan regarding dialysis until 07/01/19, three days after the resident's original admission. On 02/27/20 at 12:30 PM, the DON stated that she looked and there was no initial baseline care plan regarding dialysis that was developed within 48 hours of admission. No further information and/or documentation was presented prior to the exit conference on 02/27/20 to evidence that a baseline care plan for dialysis had been developed and implemented for Resident #170 within 48 hours of admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medication pass and pour observation, staff interview, clinical record review, and in the course of a complaint investigation, facility staff failed to follow physician orders for two of 39 residents in the survey sample, Resident #83 for dressing changes and skin integrity assessments, and Resident #156 for administration of Senna; and failed to ensure Resident #170 received dialysis care and services to prevent hospitalization. Findings included: 1. Resident #83 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Lymphedema, Non-pressure Chronic Ulcers, Dementia with Behaviors, and Chronic Embolism of right lower extremity. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/14/2020. Resident #83 was assessed as cognitively intact with a total cognitive score of 15 out of 15. Resident #83's physician orders were reviewed on 02/25/2020 at approximately 2:00 p.m. Included in the physician order sheet (POS) dated February 2020 was, .Cleanse right lower extremity with wound cleaner, pat dry and apply Adaptic dressing Q [every] day and evening shift and PRN [as needed] .Wash left lower extremity with soap and water, pat dry apply 2 layer compression Q Tuesday and Friday . On 02/25/2020 at 2:15 p.m. LPN #1 (licensed practical nurse) was observed changing the dressings to Resident #83's bilateral lower extremities. The old dressings were removed, the left lower extremity (LLE) was cleaned with NS (normal saline), patted dry with 4x4's (gauze), wrapped with a cotton covering and self adherent wrap tape (Coban). The right lower extremity (RLE) was cleaned with NS, patted dry with 4x4's, covered with adaptic, ABD's, and secured with rolled gauze and tape. The LLE presented as red, but without any open wounds. The RLE presented as red, very edematous, with open ulcers of various sizes, and serosanguinous drainage. LPN #1 was interviewed regarding wound assessments and measurements for the open ulcers on Resident #83's RLE. LPN #1 stated, Open areas are measured on admission, any new wounds, or changed wounds. We do not measure his wounds. He is not seen by the wound doctor here. He goes out to the wound clinic every week and they send recommendations back to the facility. Resident #83 had only two weekly skin observations on 02/17/2020 and 02/24/2020. They both included, Does the resident have current skin issues, marked as yes .Any new skin issues identified, 02/17/2020 - yes .small open area to the back and 02/24/2020 - no. Wound clinic notes dated 11/19/19, 12/03/19, 01/07/20, and 01/29/20 were reviewed. All notes included wound and dressing change recommendations, but no wound measurements or descriptions. Infectious disease (ID) notes dated 11/19/2019, 12/03/2019, 01/07/2020, and 01/29/2020 were reviewed. These were the only notes that included wound descriptions and measurements. The 11/19/19 and 12/03/19 notes identified a Leg Right; Lower boxed measurement and Leg Left; Lower boxed measurement. There were minimal changes in the wound measurements. ID Note dated 01/07/2020 showed increased measurements for the right leg and minimal changes to the left leg. A new site was identified on the left dorsal foot, biopsy site. ID note dated 01/29/2020 showed no change to the right lower extremity measurements, left lower extremity wound was healed, and minimal change to the left dorsal foot, biopsy site. Wound measurements and descriptions were sporadic without any set days for wound evaluations and assessments. There were no wound measurements or detailed assessments from the facility. The Medical Director was interviewed on 02/26/2020 at 5:35 p.m. The Medical Director stated, He does have lymphedema .The ulcers are a complication of his lymphedema. I am not sure what happened with his wound/skin notes. They are usually really good. His left leg is much smaller than his right. I'm sure it is atrophied from the constant wraps and his inability to walk. I believe he is being followed by [Name] facility wound doctor now. The DON (director of nursing) was interviewed on 02/26/2020 at approximately 6:35 p.m and stated Our wound nurse [RN-registered nurse] has been off. She will be back next week. I would expect for any wounds to be measured weekly and with any change in condition. The DON stated on 02/27/2020 at approximately 10:30 a.m., [Name] Resident #83 is not followed by the facility wound doctor, but he will be. He is here right now if you would like to speak to him. No further information was received prior to the exit conference. 2. The medication pass and pour observation was conducted 02/26/2020 at 9:00 a.m. with LPN #8. During this observation Resident #156 was administered Senna 8.6mg (milligrams) po (orally). The medication pass and pour observation was reconciled to Resident #156's physician orders on 02/27/2020 at approximately 8:00 a.m. Resident #156's physician order was for Sennosides/Docusate Sodium Tablet 8.6-50 mg Give 1 tablet by mouth two times a day for bowel regime. Hold for loose stools. LPN #8 was interviewed at 8:20 a.m. on 02/27/2020. LPN #8 pulled the bottle of Senna 8.6mg from the medication cart and stated, This is the regular one. This is what she gets. LPN #8 pulled the physician order up on her computer. The order was written as above. LPN #8 stated, I want to call and clarify the order with the doctor. LPN #8 also called central supply and requested a bottle of Senna-S be brought to the floor. There was none on her medication cart. Central supply brought a bottle of Senna-S to LPN #8. LPN #7, Unit Manager, approached us comparing the two medication bottles. LPN #7 verified the physician order and stated, She should be getting Senna-S. The one with the Senna and Colace. The Administrator and DON (director of nursing) were informed of the above during a meeting with the survey team on 02/27/2020 at approximately 11:30 a.m. 2. Resident #170 was originally admitted to the facility on [DATE]. The resident was discharged from the facility on 07/01/19 and then readmitted to the facility on [DATE]. The most current MDS (minimum data set) for that time frame was the resident's DCRA (discharge return anticipated) MDS dated [DATE]. This MDS documented the resident's cognitive status as, having no short term or long term memory impairment and no issues with daily decision making skills. The resident was assessed as receiving dialysis services in Section O. (Special Treatments) J. Dialysis while not a resident and while a resident in the last 14 days. Resident #170 was admitted to the facility on [DATE] and discharged on 07/01/19 due to critical laboratory results. Resident #170 did not receive any dialysis treatments during that time, as a result the resident was admitted to the hospital to be dialyzed. Resident #170 returned to the facility on [DATE]. During the closed clinical record review, the resident's admission [DATE]) Plan of Care (POC) was reviewed. This POC did not have any information regarding dialysis care and treatment, nor any interventions for the care and treatment of the resident's dialysis access, until 07/01/19 (the day the resident was discharged to the hospital). Resident #170's admission assessment dated [DATE] was reviewed and documented, .06/28/19 2:50 PM .Spanish .admitted from .with discharge diagnosis of hypoglycemia .HTN [high blood pressure], DM [diabetes mellitus], ESRD [end stage renal disease], PVD [peripheral vascular disease], Full Code, dialysis Tuesdays, Thursdays, and Saturdays. Dialysis site on left upper arm .able to make needs known . Resident #170's physician admission orders included an order for: Dialysis at [name of long term care facility] on Tuesdays, Thursdays, and Saturdays [Order Date: 06/29/19] . The resident's nursing notes were then reviewed. The nursing notes revealed the following: 06/28/19 2:50 PM .calm and cooperative .balance is unsteady .non ambulatory .skilled services: Dialysis . 07/02/19 11:20 AM .resident was sent to [initials of hospital] for dialysis, critical lab value MD [medical doctor] aware, new order to send resident to [initial of hospital] dialysis with copies of lab results . 07/02/19 00:20 AM .Resident was sent [initials of hospital] for dialysis, critical lab value MD (medical doctor) aware, new order to send resident to [initials of hospital] dialysis with copies of lab results . 07/02/29 6:03 AM .Resident was discharged to the hospital on [DATE] just after 11 PM as per 11-7 nurse. Call placed to [hospital]. She was admitted to Unit [number] . The critical lab results dated 07/01/19 and timed 7:26 PM documented, . creatinine, serum 10.2 HP [HIGH PANIC] .notified with 'PANIC RESULTS' on 07/01/19 at 8:18 PM The resident's hospital Discharge summary dated [DATE] documented, .Discharge Summary Date of Service: 07/05/19 1:11 PM .admission Date: 07/02/19 discharge date : [DATE] .Consultation: Nephrology .oriented to person, place and time .left AV (arteriovenous) fistula .Discharge Diagnoses: end stage renal disease on hemodialysis; metabolic derangements, hyperkalemia, .weakness .diabetes .hypertension .anemia of chronic disease .History and Hospital Course: .hypertension, hyperlipidemia, hyponatremia, diabetes mellitus, peripheral vascular disease, ESRD on HD [hemodialysis] Tuesday/Thursday/Saturday .anemia, history of CHF [congestive heart failure] (per records) presenting for metabolic derangements after missing hemodialysis .Most likely presentation is to missed hemodialysis sessions, patient states that she was unable to have this performed at [name of LTC facility], unsure as to why. Nephrology consulted, appreciated recommendations. Continued with hemodialysis as per T/Th/S schedule; hyperkalemia improved after hemodialysis .Patient discharged back to [name of LTC facility] . On 02/27/20 at 8:00 AM, the dialysis administrator and assistant administrator were interviewed regarding Resident #170. The dialysis staff stated that the admissions department or nursing will bring the orders for the new dialysis patient down to them. The dialysis staff stated that they did not get any orders or any paperwork for Resident #170 until 07/05/19 (the resident's second admission) and the dialysis staff stated that Resident #170 was dialyzed the following day, which was on Thursday. The dialysis administrator stated that when a dialysis patient misses one dialysis treatment the patient's mortality rate increases three times. The dialysis administrator stated, If the patient misses two treatments the patient starts going into fluid overload and becomes uremic, the patient will start swelling all over, even their head will look large, you can tell, there a lot of physical changes that you can see and mental status changes occur, it is very serious. On 02/27/20 at 8:15 AM, the admissions director was interviewed regarding Resident #170. The director stated that prior to admission, the facility will determine if they have a bed and a dialysis chair for the new admission and then they admit the resident. The director stated that paperwork can come via fax or with the resident and then that paperwork is put together and taken to our dialysis onsite. The admission director stated that he didn't know what happened with Resident #170, and wasn't sure why Resident #170 didn't get dialysis here and had to be sent out. The admission director stated that they are in the office Monday through Friday from 8-4:30 PM and stated that he is on call on the weekends and occasionally will come into the facility to check the fax machine. The admission director stated that after hours if he comes in the office and something has come through, he will give it to the receptionist to take to the dialysis department. The admission director stated that if he doesn't come in the office then it waits until Monday. On 02/27/20 at approximately 11:00 AM, the administrator, DON (director of nursing) and the ADON (assistant director of nursing) were made aware of concerns regarding the above information. The DON stated that is why Resident #170 went out, was to have dialysis, and stated that we didn't do it at the facility. The DON stated that Resident #170 had dialysis on Thursday prior to admission and stated that she would get that information. On 02/27/20 at 12:15 PM, the DON presented the resident's dialysis results for 06/27/19 (Thursday), which documented the resident ended the dialysis session at 11:30 PM on 06/27/19. No further information and/or documentation was presented prior to the exit conference on 02/27/20 to evidence that the facility staff provided care and services to prevent hospitalization for Resident #170. This is a complaint deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review, the facility staff failed to ensure one of 39 residents (Resident #25) received necessary treatment and services to promote healing and prevent infection during a pressure ulcer dressing change. Findings include: Resident #25 was admitted to the facility on [DATE]. Diagnoses for Resident #25 included, but were not limited to: DM (diabetes mellitus), history of stroke with right side hemiparesis and hemiplegia, end stage renal disease (hemodialysis dependent), heart failure, high blood pressure, and kidney transplant failure. The most current, completed full MDS (minimum data set) was a 14 day admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. On 02/25/20 PM at 3:25 PM, a dressing change on Resident #25's stage 4 sacral pressure ulcer was observed. LPN (Licensed Practical Nurse) #1 and #2 gathered supplies and entered the room. The LPNs washed their hands and donned gloves and prepared the resident for the dressing change. LPN #1 prepared the dressing supplies and LPN #2 rolled the resident on her left side and then back, and slid the resident's pants down. LPN #2 then rolled the resident again to her left side, the resident's brief was in place and the back of the brief was visibly soiled from the resident's sacral wound dressing. LPN #2 unfastened the brief and pulled it back, exposing the saturated sacral dressing. LPN #1 removed the saturated dressing and disposed of it in the trash can. LPN #1 removed the gloves and disposed of them. LPN #1 then went to box of gloves, reached in and donned another pair of gloves. LPN #1 did not wash or sanitizer her hands. LPN #1 then picked up a 4x4 gauze, squirted normal saline on it, wiped the wound, disposed of the gauze, turned and picked up another 4x4 gauze, picked up the normal saline and squirted it on the 4x4 and wiped the wound a second time. LPN #1 again turned picked up more 4x4 gauze, picked up the normal saline and squirted the gauze, wiped the resident's wound a third time, and then removed those gloves. LPN #1 again donned new gloves, but did not wash or sanitize her hands. LPN #1 turned and picked up a q-tip, dipped it into the santyl and applied it to the wound, then took another q-tip, dipped it into the santyl and applied it to the wound. LPN #1 then took a dressing and applied it to the resident's sacrum. LPN #2 then took the resident's unfastened brief and re-taped it and covered the resident back up. LPN #1 and LPN #2 then washed their hands and left the room. At approximately 3:50 PM, both LPNs were made aware of concerns with glove changing and lack of hand washing during the dressing change and were made aware of concerns that the resident's soiled brief was not changed. LPN #2 stated, We were about to do that. The LPNs were asked to present a policy on dressing changes. On 02/26/20, the Clean Dressing Change policy was reviewed and documented, .policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross contamination .wash hands and put on gloves .remove the existing dressing .remove gloves .discard .wash hands and put on clean gloves .cleanse wound as ordered taking care not to contaminate other skin surfaces .pat dry .wash hands and put on clean gloves .apply topical ointments .dress wound .discard disposable items and gloves .wash hands .return resident to comfortable position . The Wound Treatment Guidelines policy was then reviewed, .promote wound healing .dressing changes may be provided outside the frequency parameters in certain situations: feces has seeped underneath dressing .dislodged .the dressing is soiled other, or is wet . The DON (director of nursing) and the administrator were made aware of the above observation on 02/27/19 at 10:00 AM. No further information and/or documentation was presented prior to the exit conference on 02/27/20 at 1:00 PM to evidence that facility staff provided pressure ulcer care and treatment to promote wound healing and prevent infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On [DATE] at 03:30 PM, on a medication cart located on the forth floor was observed. Two containers of Advair were observed. One Advair container was opened on [DATE], and the other container did not have an open date. The label on both containers instructed to discard 30 days after opening. Neither was labeled with a discard date. LPN (licensed practical nurse) #5 was interviewed at this time. After reviewing the labels LPN #5 stated that both Advair containers should have been discarded within 30 days after being opened, and since there was no open date on one of the Advair containers, it should be discarded also. An insert inside the Advair box read in part Safely throw away [Advair] in the trash 1 month after you open the foil pouch [ .]. On [DATE] at 06:36 PM, the above information was brought to the attention of the director of nursing (DON) and administrator during an end of day staff meeting. A policy titled Labeling of Medications and Biological's read in part Any medication label that is soiled, incomplete, illegible, worn or makeshift must be returned [ .]. No other information regarding this concern was provided prior to exit conference on [DATE]. Based on observation, facility document review and staff interview, the facility staff failed to properly store and label medications and biologicals on two of four nursing units. On unit 2, two insulin pens were not labeled from the pharmacy; one multi-use vial of tuberculin PPD (purified protein derivative) solution opened greater than 30 days was available for use; and one multi-use vial of tuberculin PPD solution was without an opened date. Expired Advair was available for administration on a fourth floor medication cart. The findings include: On [DATE] at 8:12 a.m., accompanied by the licensed practical nurse unit manager (LPN #7) the medication storage refrigerator was inspected on unit two. Stored in the refrigerator was a multi-use vial of tuberculin PPD solution opened for greater than 30 days (opened on [DATE]). Another vial of tuberculin PPD solution was opened with no indication of when opened. LPN #7 was interviewed at the time of the observation about the storage of the opened tuberculin solution. LPN #7 stated she thought the tuberculin solution was good until the manufacturer's date printed on the label. LPN #7 was not sure about how long to keep the vials after opening. On [DATE] at 8:24 a.m., accompanied by registered nurse (RN) #1, medications on a unit two cart were inspected. Stored on the cart were two Lantus Solostar insulin pens (100 units/milliliter) without pharmacy labels. One pen was in a plastic bag and the other pen was in the cart drawer. The plastic bag had a pharmacy label for a current resident but the pen had no pharmacy label indicating a resident name, physician name or dosage. The other pen stored in the drawer had no pharmacy label with any resident identification. RN #1 was interviewed at this time about the unlabeled insulin pens. RN #1 stated both pens were provided by their back-up pharmacy. RN #1 did not know why the pens were not labeled. On [DATE] at 6:40 p.m., the director of nursing (DON) was interviewed about the stored tuberculin solution and unlabeled insulin pens on unit two. The DON stated the tuberculin PPD solution was supposed to be used within 30 days after opening. The DON stated nurses were to label all multi-use vials with the date opened. The DON stated all medications were supposed to be labeled by pharmacy with prescribing information that included a resident name, dose and physician. The facility's policy titled Labeling of Medications and Biologicals (2019) documented, All medications and biologicals will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices .Any medication label that is soiled, incomplete, illegible, worn, or makeshift must be returned and replaced by the issuing pharmacy .Labels for individual drug containers must include .The resident's name .prescribing physician's name .medication name .prescribed dose .prescription number .date the drug was dispensed This policy also documented on page 2, Labels for multi-use vials must include .the date the vial was initially opened or accessed (needle-punctured) .All opened or accessed vials should be discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial .Only the issuing pharmacy may place a drug label on a medication container . Storage instructions for tuberculin PPD solution include, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. (1) These findings were reviewed with the administrator and director of nursing during a meeting on [DATE] at 6:15 p.m. (1) Aplisol (tuberculin purified protein derivative) - FDA prescribing information, side effects and uses. Drugs.com. [DATE]. https://www.drugs.com/pro/aplisol.html

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for two of 39 in the survey sample, Resident #54 and Resident #14. Resident #54's clinical record inaccurately documented the resident as receiving hospice when the resident had been discharged from hospice, and there was no physician's order for the dialysis. Resident #14's name was incorrect. The findings include: 1. Resident #54 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease - requiring hemodialysis, type II diabetes, Parkinson's Disease, contracture, muscle weakness, chronic obstructive pulmonary disease (COPD), and depression. The minimum data set (MDS) dated [DATE] which was a quarterly assessment assessed Resident #54 as cognitively intact for daily decision making with a score of 15 out 15. On 02/25/20 during the initial tour, Resident #54 was interviewed regarding the quality of care and life while residing at the facility. Resident #54 was asked if she was receiving dialysis services. Resident #54 replied, yes I go to dialysis on Monday, Wednesday, and Friday and last week I had the dialysis catheter replaced. Resident #54's clinical record was reviewed on 02/25/20. Observed on the physician's orders was the following: Resident admitted [name of hospice provider] with terminal diagnosis of Parkinson. Order Date: 09/27/18 .OBSERVED EXTERNAL HEMODIALYSIS CATHETER EVERY 2 HOURS FOR SIGNS OF COMPLICATIONS .Order Date: 11/09/2018. Start Date: 11/09/2018. A physician order for dialysis was not located in the clinical record, only the order for observing the hemodialysis catheter was observed. Observed in the clinical record was a following note: 02/9/19 14:48 Health Status Note: Resident alert and oriented x3 was discharged from hospice consult . Observed in the clinical record was the following hospice note: 02/8/19 Time In: 1:00 Time Out: 1:45. Pt. (patient) d/c (discharged ) from hospice . On 02/26/20 at 9:03 a.m., the fourth floor unit manager where Resident #54 resided, LPN (licensed practical nurse) #1, was interviewed regarding if Resident #54 was receiving hospice and dialysis services. LPN #1 stated, no I don't believe she is receiving hospice services. She graduated from hospice, but I will verify and let you know. She does receive dialysis on Monday, Wednesday and Friday. On 02/26/20 at 3:15 p.m., LPN #1 stated, I spoke with the social worker and [Resident #54] is no longer receiving hospice services. LPN #1 was asked to review the current physician orders which included an order for hospice. LPN #1 stated it was an oversight the hospice order was not discontinued. LPN #1 continued and stated I am not sure why there is no dialysis order, but [Resident #54] does go to dialysis three days a week. The above findings were reviewed with the administrator, director of nursing (DON), assistant director of nursing (ADON) and the administrator in training during a meeting on 02/26/20 at 6:35 p.m. The ADON stated, she [Resident #54] was readmitted and it is possible the order was accidentally dropped during her readmission, but she [Resident #54] does go to dialysis three days a week. No additional information was received by the survey team prior to exit on 02/27/20 at 1:00 p.m. 2. Resident # 14 in the survey sample was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, senile degeneration of the brain, adult failure to thrive, restlessness and agitation, altered mental status, and shortness of breath. According to the most recent Minimum Data Set (MDS), Quarterly review, with an Assessment Reference Date (ARD) of 11/22/19, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 01 out of 15. According to a review of Resident # 14's Electronic Health Record, an Entry Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/15/2019, and an admission MDS, with an ARD of 11/22/2019, had the resident's first and last names interchanged. On a Quarterly MDS with an ARD of 2/22/2020, the resident's name was listed correctly, but the first name was misspelled. At approximately 10:30 a.m. on 2/26/2020, the Social Worker familiar with Resident # 14 was asked to verify the resident's name. According to the Social Worker, the resident's name as it appeared on the Entry MDS dated [DATE], and the admission MDS dated [DATE], was the correct name. The Social Worker went on to say that, I usually call her Ms. (resident's first name), just because it's easier to pronounce. At 9:20 a.m. on 2/27/2020, the Social Worker stated she was wrong when she said the resident's name on the Entry and admission MDS's was correct. The Social Worker said the names were in fact reversed, that the name listed as the first name was the resident's last name, and the name listed as the last name was the resident's first name The findings were discussed at an end of day meeting held at 5:00 p.m. on 2/26/2020, that included the Administrator, Director of Nursing, and the survey team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, facility staff failed to follow infection control practices for three of 39 residents; Resident #83 and Resident #25 during dressing changes, and Resident #166 contact isolation precautions. Findings included: 1. Resident #83 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Lymphedema, Non-pressure Chronic Ulcers, Dementia with Behaviors, and Chronic Embolism of right lower extremity. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/14/2020. Resident #83 was assessed as cognitively intact with a total cognitive score of 15 out of 15. Resident #83's physician orders were reviewed on 02/25/2020 at approximately 2:00 p.m. Included in the physician order sheet (POS) dated February 2020 was, .Cleanse right lower extremity with wound cleaner, pat dry and apply Adaptic dressing Q [every] day and evening shift and PRN [as needed] .Wash left lower extremity with soap and water, pat dry apply 2 layer compression Q Tuesday and Friday . On 02/25/2020 at 2:15 p.m. LPN #1 (licensed practical nurse) was observed changing the dressings to Resident #83's bilateral lower extremities. LPN #2 was observed washing her hands for approximately five seconds, turned the water off with her bare, wet hand, then dried with a paper towel. LPN #2 applied gloves and removed Resident #83's old dressings. She removed her soiled gloves and repeated hand washing as stated above. LPN #1 washed her hands and assembled her dressing change supplies. LPN #1 applied a pair of clean gloves and cleaned the left lower extremity (LLE) with NS (normal saline), patted dry with 4x4 gauze, changed gloves without washing her hands or using hand sanitizer, wrapped the LLE with a cotton covering and self adherent wrap tape (Coban). She removed her soiled gloves and replaced them with a clean pair. No hand washing or hand sanitizer was observed. LPN #1 cleaned the right lower extremity (RLE) with NS, patted dry with 4x4 guaze, again changed her gloves without washing her hands or using hand sanitizer, covered the wounds with adaptic, ABD's, and secured with rolled gauze and tape. LPN #2 was observed removing and replacing her gloves three more times during this dressing change process without washing her hands or using hand sanitizer. LPN #1 was interviewed at 2:45 p.m. regarding hand washing during dressing changes. LPN #1 stated, I wash my hands when I enter the room. I change gloves after removing a dressing, after cleaning wounds, and after applying a dressing. I wash my hands if they get soiled. I wash at the beginning and the end and if they get soiled. I only use hand sanitizer if I am not doing wound care. I am not sure about hand washing or use of hand sanitizer with glove changes. LPN #2 was interviewed at 2:50 p.m. regarding hand washing during dressing changes. LPN #2 stated, I would have to go check. I am not sure. The facility policy for clean dressing changes was requested and received on 02/25/2020 at 4:10 p.m. Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination .7. Wash hands and put on clean gloves .9 .remove existing dressing .10. Remove gloves .11. Wash hands and put on clean gloves. 12. Cleanse wound as ordered .14. Wash hands and put on clean gloves .16. Secure dressing .17. Discard disposable items and gloves into appropriate trash receptacle and wash hands . The Administrator and DON (director of nursing) were informed of the above findings during a meeting with the survey team on 02/26/2020 at approximately 6:35 p.m. No further information was received prior to the exit conference.3. Resident #166 was admitted to the facility on [DATE]. Diagnoses for Resident #166 included; Pneumonia, chronic obstructive pulmonary disease, chronic kidney disease, diabetes, and left sided hemaplegia hemiparesis. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 02/14/20. Resident #166 was assessed with a cognitive score of 14 indicating cognatively intact. A sign outside of Resident #166's room indicated that Resident #166 was on contact isolation and instructed anyone entering the room that a gown, gloves and mask was to be worn. On 02/25/20 at 9:00 AM, while interviewing Resident #166, a certified nursing assistant (CNA #1) came into Resident #166's isolation room without gowning, gloving or putting on a mask, took Resident #166's breakfast tray and left the room. CNA #1 then returned to Resident #166's room and put on gloves and gown and cleaned Resident #166's face. On 02/25/20 at 9:27 AM, CNA #1 was interviewed regarding the above observation. CNA #1 stated she thought that contact isolation precautions were just for when you touch the Resident, but did not consider that Resident #166 was also touching the tray that she also touched. The current physician orders were reviewed. An order dated 2/13/20 documented, please maintain Contact Isolation. On 02/25/20 at 10:06 AM, license practical nurse (LPN) #1 was interviewed concerning the observation. LPN #1 stated that CNA #1 should have gowned up and deposed of the tray in a seperate container. On 02/26/20 at 6:36 PM, the above information was presented to the director of nursing (DON) and administrator. The DON stated staff should be putting on PPE (personal protective equipment) prior to entering the room. No other information was presented prior to exit conference on 2/27/20 2. Resident #25 was admitted to the facility on [DATE]. Diagnoses for Resident #25 included, but were not limited to: DM (diabetes mellitus), history of stroke with right side hemiparesis and hemiplegia, end stage renal disease (hemodialysis dependent), heart failure, high blood pressure, and kidney transplant failure. The most current, completed full MDS (minimum data set) was a 14 day admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 15, indicating the resident was intact for daily decision making skills. On 02/25/20 PM at 3:25 PM, a dressing change on Resident #25's stage 4 sacral pressure ulcer was observed. LPN (Licensed Practical Nurse) #1 and #2 gathered supplies and entered the room. The LPNs washed their hands and donned gloves and prepared the resident for the dressing change. LPN #1 prepared the dressing supplies and LPN #2 rolled the resident on her left side and then back, and slid the resident's pants down. LPN #2 then rolled the resident again to her left side, the resident's brief was in place and the back of the brief was visibly soiled from the resident's sacral wound dressing. LPN #2 unfastened the brief and pulled it back, exposing the saturated sacral dressing. LPN #1 removed the saturated dressing and disposed of it in the trash can. LPN #1 removed the gloves and disposed of them. LPN #1 then went to box of gloves, reached in and donned another pair of gloves. LPN #1 did not wash or sanitizer her hands. LPN #1 then picked up a 4x4 gauze, squirted normal saline on it, wiped the wound, disposed of the gauze, turned and picked up another 4x4 gauze, picked up the normal saline and squirted it on the 4x4 and wiped the wound a second time. LPN #1 again turned picked up more 4x4 gauze, picked up the normal saline and squirted the gauze, wiped the resident's wound a third time, and then removed those gloves. LPN #1 again donned new gloves, but did not wash or sanitize her hands. LPN #1 turned and picked up a q-tip, dipped it into the santyl and applied it to the wound, then took another q-tip, dipped it into the santyl and applied it to the wound. LPN #1 then took a dressing and applied it to the resident's sacrum. LPN #2 then took the resident's unfastened brief and re-taped it and covered the resident back up. LPN #1 and LPN #2 then washed their hands and left the room. At approximately 3:50 PM, both LPNs were made aware of concerns with glove changing and lack of hand washing during the dressing change and were made aware of concerns that the resident's soiled brief was not changed. LPN #2 stated, We were about to do that. The LPNs were asked to present a policy on dressing changes. On 02/26/20, the Clean Dressing Change policy was reviewed and documented, .policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross contamination .wash hands and put on gloves .remove the existing dressing .remove gloves .discard .wash hands and put on clean gloves .cleanse wound as ordered taking care not to contaminate other skin surfaces .pat dry .wash hands and put on clean gloves .apply topical ointments .dress wound .discard disposable items and gloves .wash hands .return resident to comfortable position . The Wound Treatment Guidelines policy was then reviewed, .promote wound healing .dressing changes may be provided outside the frequency parameters in certain situations: feces has seeped underneath dressing .dislodged .the dressing is soiled other, or is wet . The DON (director of nursing) and the administrator were made aware of the above observation on 02/27/19 at 10:00 AM. No further information and/or documentation was presented prior to the exit conference on 02/27/20 at 1:00 PM to evidence that facility staff implemented infection control standards to prevent infection during a dressing change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, and staff interview, the facility staff failed for one of 37 residents in the survey sample, Resident # 36, to implement the plan of care. Resident # 36, who had a diagnosis of Huntington's, had a care plan intervention to add padding to the walls of the resident's room that was not implemented. The findings were: Resident # 36 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included anemia, Non-Alzheimer's dementia, Huntington's disease, seizure disorder, anxiety disorder, depression, psychotic disorder, schizophrenia, and mood disorder. According to the most recent MDS, Quarterly review, with an ARD of 12/7/19, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 00 out of 15. During the orientation tour at 8:30 a.m. on 2/25/2020, the resident's room was noted to have two twin size mattresses, both covered with sheets, placed side-by-side on the floor. There was a pillow on one of the mattresses, and the call bell was laying on the other mattress. Resident # 36's care plan included the following problem, The resident is at risk for falls r/t (related to) impaired mobility, unsteady gait and Dx (diagnosis) Huntington disease and increased chorea. The goal for the problem was, The resident will be free of fall related injury through next review date. Included as an intervention to the stated problem was the following, Place mattress on the floor as needed and pad walls for safety and prevent injury from chorea activity. The date the intervention was added to the care plan was listed as 8/25/19. Following review of the resident's care plan, a second observation of the room was made. There was no padding on the walls of the resident's room. During observation of the noon meal in the third floor Dining Room on 2/26/2020, LPN # 3 (Licensed Practical Nurse), the Unit Manager on the third floor, was asked about the wall padding in Resident # 36's room. There is none, LPN # 3 said. They (administration) have been talking about it. The findings were discussed at an end of day meeting held at 5:00 p.m. on 2/26/2020, that included the Administrator, Director of Nursing, and the survey team. The Administrator, who has only been in the position for approximately six months, was unaware of the care plan intervention for wall padding. The Director of Nursing offered no explanation as to why padding had not been added to the walls of Resident # 36's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #91 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, paralytic syndrome, cerebrovascular disease, hyperlipidemia, type II diabetes, and chronic kidney disease. The most recent minimum data set (MDS) assessment dated [DATE] which was a significant change assessment, assessed Resident #91 as severely impaired for daily decision making, having long and short term memory problems with inattention continuously present. Resident #91's clinical record was reviewed on 02/25/20. Observed was the following note: 1/28/2020 18:46 Nutrition/Dietary Note .Diet CCHO (consistent carbohydrate diet), Regular. Upgraded by Speech therapist from Pureed to Regular-CCHO portion controlled to promote BG (blood glucose) control . A review of the physician's orders documented the following: CCHO diet, Regular texture, Thin consistency. Order Date 01/17/2020. Start Date 01/17/2020. A review of Resident #91's care plan documented the following focus area: Resident's diet is puree and thickened liquids. Date Initiated 01/07/2020. Revised on 01/09/2020 Interventions: Puree diet and thickened liquids. Date Initiated 01/09/2020. Created on: 01/09/2020. Signed by LPN #1. On 02/26/2020 at 8:20 a.m., Resident #91 was observed in his room lying in bed. Resident #91 was interviewed regarding if he ate breakfast this morning and he stated yes, I had oatmeal and it was good. On 02/26/2020 at 8:37 a.m., the licensed practical nurse (LPN #4) was interviewed regarding what type of diet Resident #91 ordered. LPN #4 provided a copy of the breakfast meal ticket which documented CCHO, Regular Diet. On 02/26/2020 at 3:15 p.m., the fourth floor unit manager (LPN #1) where Resident #91 resided was interviewed regarding the care plan documented the resident was ordered a pureed diet. LPN #1 reviewed Resident #91's orders and care plans. LPN #1 stated it was a mistake the care plan was not updated to reflect the change. The above findings were reviewed with the administrator, director of nursing (DON), assistant director of nursing (ADON) and the administrator in training during a meeting on 02/26/20 at 6:35 p.m. No additional information was received by the survey team prior to exit on 02/27/20 at 1:00 p.m. Based on observation, resident interview, staff interview, facility document review, and clinical record review, facility staff failed to review and revise comprehensive care plans (CCP) for three of 39 residents in the survey sample, Residents #83, #111, and #91. Resident #83 for skin integrity, Resident #111 for a PICC (peripherally inserted central catheter) line and Contact Isolation and Resident #91 for dietary orders. Findings included: 1. Resident #83 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to: Lymphedema, Non-pressure Chronic Ulcers, Dementia with Behaviors, and Chronic Embolism of right lower extremity. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/14/2020. Resident #83 was assessed as cognitively intact with a total cognitive score of 15 out of 15. Resident #83's physician orders were reviewed on 02/25/2020 at approximately 2:00 p.m. Included in the orders was dressing change orders for bid (twice daily) dressing changes for the right lower extremity (RLE) and twice weekly dressing changes for the left lower extremity (LLE). Dressing changes to Resident #83's bilateral lower extremities was observed on 02/25/2020 at 2:15 p.m. The LLE presented as red, but without any open wounds. The RLE presented as red, edematous, with several open ulcers of various size, and serosanguinous drainage. Resident #83's CCP was reviewed on 02/26/2020 at 4:00 p.m. The CCP included, .Resident skin is intact. Resident has dry flaky skin to upper bilateral extremities and dry flaky skin to BLE .Revision on: 11/12/2019 .Cleanse right lower extremity with soap and water, pat dry and apply adaptic dressing covered with roll gauze Q [every] Tuesday and Friday, and PRN [as needed] .Revision on: 01/21/2020 .Gentamicin Sulfate Ointment 0.1%. Apply to right lower extremity .Revision on: 11/20/2019 .Wash left lower extremity with soap and water, pat dry apply dermaseptin cream q [every] shift and prn .Revision on: 01/21/2020 . The CCP did not match the current physician orders, and the skin observed during the wound care was not intact on the RLE. The unit manager for Unit #2 was interviewed 02/26/2020 at 4:30 p.m. regarding care plan updates. LPN #7 (licensed practical nurse) stated, It should have been updated as the physician orders for wound care were changed. The Administrator and DON (director of nursing) were informed of the above during a meeting with the survey team on 02/26/2020 at approximately 6:35 p.m. 2. Resident #111 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, peripheral venous insufficiency, depression, osteomyelitis in left foot, diabetes, methicillin resistant staphylococcus aureus infection, cerebrovascular disease, heart failure, chronic kidney disease, atrial fibrillation and insomnia. The minimum data set (MDS) dated [DATE] assessed Resident #111 as cognitively intact. Resident #111's clinical record documented a physician's order dated 2/4/20 for Vancomycin solution 750 mg (milligrams) to be administered intravenously twice per day for treatment of osteomyelitis in the left foot via a PICC (peripherally inserted central catheter). The record also documented physician orders dated 1/21/20 for use of Heparin solution (10 units/milliliter) to flush the right arm PICC two times a day to maintain patency. Resident #111's clinical record documented the resident was placed on contact precautions at the time of admission due to the infected wound on the left foot. The physician discontinued contact precautions on 1/21/20. Resident #111's plan of care (revised 2/4/20) was not updated to include problems, goals and/or interventions regarding the resident's PICC. The care plan documented the resident received intravenous antibiotic therapy for treatment of osteomyelitis but made no mention of the PICC. The care plan documented the resident was on contact precautions with gowns, masks and gloves required by staff, family and caregivers entering his room when precautions were discontinued 1/21/20. On 2/26/20 at 2:10 p.m., the licensed practical nurse (LPN #7) unit manager was interviewed about Resident #111's plan of care. LPN #7 stated the care plan should have been updated to include care and interventions regarding the PICC. LPN #7 stated the contact precautions were discontinued by the physician on 1/21/20 and should have been removed from the care plan. These findings were reviewed with the administrator and director of nursing during a meeting on 2/26/20 at 6:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, facility staff failed to provide showers for one of 39 residents in the survey sample, Resident #107. Findings included: Resident #107 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Diabetes, Peripheral Vascular Disease (PVD), Left AKA (above knee amputation), and Right BKA (below knee amputation. The most recent MDS (minimum data sheet) was a quarterly assessment with an ARD (assessment reference date) of 02/20/2020. Resident #107 was assessed as moderately impaired in his cognitive status with a total cognitive score of 12 out of 15. Resident #107 was interviewed on 02/25/2020 at 10:50 a.m. The resident was lying in the bed, alert and oriented, with his Bipap in place over his nose. Resident #107 was asked about getting showers. Resident #107 stated Huh, I get a shower about once, every other week. I give myself a bed bath the rest of the time. The staff give me my supplies and water. I like to get a shower, but the staff don't always ask me. Shower records for Resident #107 were requested on 02/26/2020 at 4:00 p.m. Shower records were received on 02/27/2020 at 10:00 a.m. Shower documentation showed Resident #107 received a shower on 01/22/2020, refused a shower on 01/29/2020, and received a shower on 02/05/2020, 02/12/2020, 02/19/2020. There was nothing documented on the shower record for 01/18/2020, 01/25/2020, 02/01/2020, 02/02/2020 and 02/22/2020 (all Saturdays), evidencing that Resident #107 received or refused showers on those days. The DON (director of nursing) was interviewed on 02/27/2020 at 10:00 a.m. Resident #107's scheduled shower days were Wednesday and Saturday per the DON. CNA (certified nursing assistant) #3 and #4 (who worked on the unit where Resident #107 lived) were both interviewed on 02/27/2020 at approximately 10:30 a.m regarding missed showers. They stated, Sometimes he refuses and then sometimes we are short staffed on the weekends. The Administrator and DON (director of nursing) were informed of the above during a meeting with the survey team 02/27/2020 at approximately 11:30 a.m. No further information was provided prior to the exit conference.

Based on individual resident interview, resident group interview, staff interview, facility document review, and in the course of a compliant investigation, the facility staff failed to respond to call bells in a timely manner for 9 out 39 residents in the survey sample, Resident #s 152, 69, 121, 130, 151, 139, 76, 2, 117. Residents and the resident group council reported lengthy call bell response with waiting between 15 to 30 minutes and up to 2 hours for staff response. The findings include: On 2/25/20 at 9:00 a.m., Resident #152 was interviewed about sufficient staffing and call bell response. Resident #152 stated call bell response on his unit was slow and he waited at times up to an hour for staff response. Resident #152 stated call bell response was worse on the night (11:00 p.m. to 7:00 a.m.) shift. Resident #152 stated he did not think they had enough staff to get to everyone when needed. On 2/25/20 at 9:15 a.m., Resident #69 was interviewed about staffing and call bell response. Resident #69 stated his roommate frequently activated the call bell and had extended wait times for response, sometimes up to 30 minutes. Resident #69 stated he frequently went to the nursing desk and requested help because staff did not respond promptly to the call bell. On 2/25/20 at 10:38 a.m., Resident #130 was interviewed about staffing and call bell response time. Resident #130 stated call bell response time was slow and she waited at times 30 - 45 minutes for staff response. Resident #130 stated she did not think there was enough staff to help out on all shifts. On 02/25/0 at 11:58 a.m., Resident #121 was interviewed about staffing and call bell response time. Resident #121 stated call bell response time was slow and the wait was between 30 minutes and one hour. Resident #121 stated he has to use a slide board and sometimes he would have to get out of bed an go to the nurses station for assistance. A resident council group meeting was conducted on 02/26/20 at 11:00 AM. Five out of five residents' (Resident #'s 151, 139, 76, 2, and 117) agreed and stated that staff were slow to respond to call bells. Resident #151 stated that it can and has taken up to two hours. The remaining residents stated that it was usually 30 minutes or greater, but on average it took 15 to 30 minutes. Resident #2 stated that when you need someone or have to use the bathroom, that amount of time seems like forever. Resident #76 stated that they are typically short on the weekend. The above findings were reviewed with the administrator, director of nursing (DON), assistant director of nursing (ADON) and the administrator in training during a meeting on 02/26/20 at 6:35 p.m A review of the resident council group meeting minutes for the months of November 2019, December 2019, and January 2020 all documented the resident council discussing call light response times and certified nursing assistant (CNA) shortages with the facility administrator. The meeting minutes documented the administrator was discussing the call light response times withe the director of nursing (DON) and informed the residents of an upcoming hiring fair to address the CNA shortages. CNA (certified nursing assistant) #3 and #4 were both interviewed on 02/27/2020 at approximately 10:30 a.m regarding providing resident showers. They stated, .sometimes we are short staffed on the weekends. On 02/27/20 at 11:25, the DON was interviewed regarding call bell response time. The DON stated staff are inserviced on responding to the light in 12 minutes even if they can't provide the service for the resident they should at least respond and get the appropriate staff member. No additional information was received by the survey team prior to exit on 02/27/20 at 1:00 p.m. This is a complaint deficiency.

Based on observation and staff interview, the facility failed to ensure proper handling techniques while serving food from the steam table on one of 4 units, unit #4; and failed to ensure expired yogurt, orange juice, and flavored water was not available for distribution in the main kitchen. The findings Include: 1. On 02/25/20 at 08:31 AM, dietary aide (Other Staff, OS #4) was observed plating toast, bacon, boiled eggs directly with gloved hands. OS #4 was also observed touching the side of his face. OS #4 was interviewed at this time and stated he didn't know where the utensils were to handle the food, turned to another staff member and asked if they could call the kitchen to get some utensils. OS #4 then asked the surveyor if he could continue using his gloved hands to plate food. OS #4 was told he could not tell OS #4 what he should be doing. OS #4 then received tongs and began using them for the bacon but continued to use gloved hands for toast and boiled eggs. On 02/26/20 at 07:48 AM, the dietary manager (OS #2 ) was interviewed. OS #2 stated dietary assistant should be using utensils to handle food and shouldn't be touching other things that may not be clean while serving. OS #2 stated that he would reeducate OS #4. On 02/26/20 at 06:36 PM the above information was presented during a meeting with the director of nursing and administrator. No other information was presented prior to exit conference on 2/27/20.2. During a tour of the main Kitchen at 8:20 a.m. on 2/25/2020, the following food items in the walk-in cooler were found to have expired use-by dates: One case of 48, four ounce individual cups of Lite & Fit Yogurt with a use-by date of 2/24/2020. Five 46 ounce cartons of Ready Care Thickened Lemon Flavored Water with a use-by date of 2/21/2020. Twenty-one 4 ounce individual cups of Ready Care Thickened Orange Juice with a use-by date of 2/4/20. The Food Services Manager and the Assistant Food Services Manager were present during the observations and confirmed the findings. The findings were discussed at an end of day meeting held at 5:00 p.m. on 2/26/2020, that included the Administrator, Director of Nursing, and the survey team.