**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop a comprehensive person-centered care plan for 2 of 18 sampled residents (R46 and R60). The facility did not develop a care plan for R46 and R60 for respiratory care. Findings: The facility policy titled, COMPREHENSIVE PERSON-CENTERED CARE PLANNING reviewed 05/15/24, states in part: .Policy Interpretation and Implementation 1) The interdisciplinary team (IDT), in conjunction with the resident and representative and/or family, develops and implements a comprehensive, person-centered care plan for each resident . 3) The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . Example 1 R46 was admitted on [DATE] with diagnoses of pneumonitis (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath and fatigue), sepsis, acute bronchitis, acute respiratory failure with hypoxia (is a below-normal level of oxygen in your blood). R46 had doctor's orders that include budesonide for acute respiratory failure with hypoxia. Albuterol nebulizer as needed for shortness of breath. Mucus relief tablet for cough. R46 had a progress note in the medical chart dated 04/14/2024 titled Infection Note. Note text: Resident is receiving antibiotic for aspiration pneumonia with no adverse effects noted. Resident also receiving budesonide nebulizer treatment in conjunction with albuterol nebulizer treatment, both scheduled. Lungs auscultate faint inspiratory wheezes prior to nebulizer, resolved post nebulizer, occasional throat clearing, cough noted. Does not appear short of breath, oxygen saturation was 92% on room air. On 07/17/24 at 9:36 AM, Surveyor asked Director of Nursing (DON) B for a comprehensive care plan regarding R46's respiratory care. On 07/17/24 at 9:53 AM, DON B provided Discharge summary dated [DATE] care plan General Nutrition & Hydration. No care plan found that was specific to respiratory cares provided. Example 2 R60 was admitted on [DATE] with diagnoses of Respiratory Syncytial Virus (RSV causes infections of the lungs and respiratory tract), acute bronchiolitis due to RSV, acute respiratory failure with hypoxia, dependence on supplemental oxygen. R60 had doctor's orders that included albuterol nebulizer for shortness of breath. Guaifenesin as needed for a cough. Oxygen every shift for shortness of breath. On 07/17/24 at 8:47 AM, Surveyor was unable to find a respiratory care plan and asked DON B to provide this. On 07/17/24 at 9:37 AM, Surveyor interviewed DON B. DON B informed Surveyor that there was no comprehensive respiratory care plan on the resident, but we are starting one now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure care plans were reviewed and revised to reflect changes in care for 2 of 18 residents (R45 and R6). According to the Resident Assessment Instrument, The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving. The facility policy entitled Comprehensive Person-Centered Care Planning and last reviewed on 05/15/24 with a Policy Statement: A comprehensive person-centered care plan that includes measurable objectives and goal dates to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident Section 12 of policy stated, The interdisciplinary team reviews and updates the care plan: a. When there has been a significant change in the resident's condition b. When the desired outcome is not met. c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly, in conjunction with the required quarterly MDS assessment. Example 1 R45 was admitted to the facility on [DATE] with a diagnosis of retention of urine and has an indwelling urinary catheter since admission. R45's care plan revised on 06/05/24 states for toilet use resident does have an indwelling foley catheter (chronic), dependent upon staff for catheter management. On 07/15/24 at 9:42 AM, Surveyor interviewed R45 regarding management of catheter. R45 stated independence with emptying urinary bag and reports to staff the amount of urine emptied from bag each time. R44 confirmed preference managing the catheter independently. On 07/17/24 at 11:26 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding management of catheter. CNA D confirmed R45 usually manages catheter on own as is a very private person and doesn't like assistance. On 07/18/24 at 9:00 AM, Surveyor interview Director of Nursing (DON) B, who stated R45 was admitted with catheter and has always managed it independently and confirmed the care plan does not reflect current approaches accurately. Example 2 R45's care plan for fall risk was revised on 06/05/24 with an intervention of assuring call light is within reach. On 07/15/24 at 9:43 AM, Surveyor interviewed R45 stating recently having a fall, but was not aware of any interventions put into place to prevent further falls. On 07/17/24 at 12:06 PM, Surveyor reviewed R45's medical record and noted the care plan was not revised to reflect interventions: On 05/08/24 at 11:15 PM, R45 had a fall investigation that determined the root cause was due to R45 wearing socks. An intervention was documented to have R45 wear gripper socks. On 7/9/24 at 2:57 AM, R45 had a fall investigation that determined the root cause was due to R45 attempting to go to bathroom as felt catheter leg bag was full. An intervention was documented to have staff do frequent checks of catheter bag. On 07/18/24 at 9:00 AM, Surveyor interview DON B, who confirmed the care plan does not reflect current interventions accurately. Example 3 R6 was admitted to facility on 10/09/23 with diagnosis of unspecified dementia and reduced mobility. R6's care plan problem for moderate risk for falls revised on 05/30/24, states current interventions of ensuring clear pathways in room and hall, ensure call light within reach and ensure personal items are within reach. On 07/15/24 at 10:14 AM, Surveyor observed a sign hanging on walker stating, Take me with you, an alarm on bed and an alarm on wheelchair to alert staff of self-transfers. On 07/17/24 at 10:38 AM, Surveyor interviewed Licensed Practical Nurse (LPN) E regarding R6's current fall interventions that were observed. Surveyor asked where to locate them in the care plan. LPN E pulled up R6's record and confirmed inability to locate current interventions of alarms and reminder sign on R6's care plan. On 07/17/24 at 10:49 AM, Surveyor interviewed DON B who stated DON B was not aware that current interventions were not accurately documented in care plans.

Based on observation, record review and interview, the facility did not implement enhanced barrier precautions consistent with current infection control standards of practice for 1 of 3 residents reviewed on enhanced barrier precautions (R29). This is evidenced by: Surveyor requested and reviewed the facility policy titled Infection Prevention and Control dated as most recently reviewed on 2/20/2023. The policy in part read: Standards of Practice: Centers of Disease Control (CDC) Association for Professionals in Infection Control (APIC) Enhanced Barrier Precautions Implementation of Personal Protective Equipment in Nursing Homes to Prevent the Spread of Novel or Targeted Multi-Drug-resistant Organisms (MDRO's) updated: July 29, 2019. Enhanced Barrier Precautions expands the use of PPE beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include . Wound Care: any skin opening requiring a dressing. Surveyor reviewed R29's record and noted: R29's diagnosis included: 3/12/24: Encounter for orthopedic aftercare following surgical amputation 3/12/24 Acquired absence of right leg below knee R29's medical record directs staff on isolation as follows: Onset: 3/12/24 Enhanced Barrier Precautions PPE Requirements: Gloves and Gowns Route of Transmission: Direct Contact On 7/16/24 at 10:29 AM, Surveyor observed Registered Nurse (RN) C enter R29's room without gown or gloves. Surveyor observed a Personal Protective Equipment (PPE) cart outside R29's room. The room door had signage that read STOP: Transmission Based Precautions: Contact Precautions with Gown, Gloves and may come out of room boxes checked. The PPE cart outside R29's room had a sign that read Gloves and Gowns ONLY. The PPE cart contained gloves, gowns, garbage bags, face masks and Sani-hands wipes. RN C placed gauze, tape and scissors on a towel placed on R29's foot of the bed. RN C cut the tape with scissors, performed hand hygiene and donned gloves. RN C did not don a gown. RN removed tape and dressing from R29's lower leg/stump. RN C then dampened the incision with saline, removed gloves, performed hand hygiene when done wiping stump. No redness with 2 open areas on top of stump. RN C was not wearing a gown with direct contact with R29. Surveyor asked RN C what precautions R29 is on and what should be worn for direct contact/wound treatment. RN C indicated R29 is on Enhanced Barrier precautions/contact precautions. RN C then said, Oh shucks I was yapping too much and didn't put on a gown. RN C then stepped out of room to PPE cart and donned a gown. RN C expressed it is required for her to don a gown and gloves before any direct contact with R29 as part of enhanced barrier precautions/contact precautions and she should have donned a gown prior to any contact with R29. RN C was observed completing the remainder of R29's wound care with expected enhanced barrier precautions. On 07/16/24 at 2:50 PM, Surveyor interviewed Director of Nursing (DON) B about R29's incisional wounds and expected precautions for any staff contact with R29. DON B expressed R29 has areas on the incision line which are chronic and non-healing. The areas have no infection. The areas were last cultured on 5/14/24 with no growth noted. R29 is on enhanced barrier precautions with the expectation to wear gown and gloves with any close contact with her including wound care to keep area free of infection. RN C should have donned gown and gloves prior to any direct contact with resident per the facility policy and standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 5 R25 had an error in Section N0415, wherein the use of a high-risk drug class of an antipsychotic use was not identified as being taken. R25 was admitted to the facility on [DATE] with a diagnosis of adjustment disorder with depressed mood. On 07/17/24 at 8:04 AM, Surveyor reviewed R25's physician orders which indicated a physician order dated 03/29/23 for Aripiprazole (an antipsychotic) 10 mg one time daily for antidepressant augmentation with a gradual dose reduction on 04/12/24 to Aripiprazole 5mg one time daily for antidepressant augmentation. On 07/18/24 at 9:22 AM, Surveyor reviewed R25's annual MDS dated [DATE] and a quarterly MDS completed on 06/29/24 which were not coded accurately identifying R25 receives an antipsychotic. On 07/17/24 at 2:29 PM, Surveyor interviewed DON B, asking about the inaccurate MDS entries. DON B stated the expectation would be that a resident on an antipsychotic be accurately coded on the MDS. Based on staff interview and record review, the facility did not accurately code Minimum Data Set (MDS) 3.0 assessments for 4 residents (R) (R43, R25, R35 and R34) of 18 sampled residents. Findings: The facility's policy titled, COMPREHENSIVE ASSESSMENTS reviewed 4/18/2024, states in part: . 7. A significant error is an error in an assessment where: a. The resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care; and b. The error has not been corrected via submission of a more recent assessment. 8. A significant error differs from a significant change because it reflects incorrect coding of the MDS and NOT an actual significant change in the resident's health status. Example 1 R43 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) unable to complete or assess. Diagnoses included dementia, psychotic disorder, and anxiety. R43 was marked for no Preadmission Screening and Resident Review (PASARR) level II with diagnosis. On 07/15/24 at 10:55 AM, Surveyor asked Director of Nursing (DON) B for R43's PASARR level II and was this was readily provided to Surveyor. The MDS indicator in the Long Term Care Survey Process (LTCSP) program showed no PASSAR level II. Review of the annual MDS dated [DATE] is the last MDS that addresses section 1500 Preadmission SCREENING AND RESIDENT REVIEW. The MDS section 1500 has No checked. On 07/15/24 at 11:13 AM, MDS Coordinator, MDSC F, who works remotely, returned phone call to Surveyor. Surveyor informed MDSC F that the MDS has under section 1500 marked No, that there is no PASARR level II completed. MDSC F acknowledged the MDS was coded inaccurately. Example 2 R35 was admitted on [DATE] with a BIMS of 15 and diagnoses of schizoaffective disorder (mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder) and anxiety. R35 had an admission 5-day MDS dated [DATE] with section 1500 marked No, for completion of PASARR level II with diagnosis. Surveyor reviewed the medical record and noted that R35 has a PASARR level II completed. Example 3 R34 was admitted on [DATE] with a BIMS of 15 and diagnoses of schizoaffective disorder, anxiety, and depression with an annual MDS date 04/10/24 under section 1500 marked No, for completion of PASARR level II. Surveyor reviewed the medical record and noted a PASARR level II was completed. Example 4 R25 was admitted on [DATE] with a BIMS of 15 (indicating normal cognitive function) on the annual MDS dated [DATE]. R25 had diagnoses of bipolar II, anxiety, and depression. On 07/15/24 at 12:55 PM, Surveyor reviewed medical chart for R25 and found the annual MDS dated [DATE] has under section 1500 marked No for completion of PASARR level II with diagnosis. Surveyor reviewed the medical record and noted the PASARR level II was completed. On 07/16/24 at 1:38 PM, Surveyor interviewed DON B asking why R25, R35, and R34 were incorrectly coded on the MDS for no PASARR level II being completed. DON B informed Surveyor this information is incorrect and will be given to MDS coordinator for correction. On 07/18/24 at 7:53 AM, Surveyor noted in the medical chart that R43, R25, R35 and R34 have a 'Sig. Change' in process for this correction.

Based on interview and record review, the facility did not ensure that 1 of 3 residents reviewed for falls had adequate supervision and assistance to prevent accidents. A thorough fall investigation was not completed to determine staff used a mechanical lift with 1 assist for (R1), This is evidenced by: Surveyor reviewed facility's undated policy titled Falls - Clinical Protocol, which read in part: 2. LPN's [Licensed Practical Nurse] should alert the supervisor (RN). The nurse will complete an assessment .5. Incident Scene Investigation (ISI) tool completed by staff who found resident, or who was present at the time - as completely as possible and as soon as possible but definitely before that person shift ends .7. If an LPN is the charge nurse, supervisor (RN) should review and follow up LPN documentation with their assessment of any problems or injuries . Review of facility's undated policy titled Safe Resident handling, read in part: Ready Stand (Mechanical Lift) - 2 caregivers . Surveyor reviewed R1's medical record. R1's diagnoses include hypertension, orthostatic hypotension, and Alzheimer's disease. Review of Minimum Data Set (MDS) 11/24/23 quarterly assessment documented R1 having Brief Interview of Mental Status score of 8. A score of 8 is identified as having moderate cognitive impairment. R1 requires substantial/maximum assistance of staff for transfers. Review of R1's comprehensive care plans document on 11/29/23 R1 transfers with assist of one. R1's current resident care card documents transfers with a 4 wheeled walker and gait belt with assist of 2. Additional instructions: May use e-z stand PRN [as needed]. Alert nurse to changes in ability. Surveyor reviewed R1's interdisciplinary notes documented on 12/20/23 at 6:52 p.m. by LPN C. R1 was transferred to emergency department for chest pain/angina pectoris and vitals of pulse 72, respiratory rate 22 and blood pressure 222/114. The interdisciplinary notes did not document a description of events that occurred prior to the transfer to the hospital. On 12/21/23, the notes document R1 returned from the emergency department at 7:30 a.m. with diagnoses of vasovagal syncope, and chest pain. The emergency nurse reports all vitals, labs, and EKG at hospital are within normal limits. On 01/08/24 at 12:02 p.m., Surveyor interviewed Registered Nurse (RN) D, asking if any incidents occurred with a resident fall from an e-z stand lift and how many staff are to assist. RN D indicated no current incidents of a resident falling from a mechanical lift and two staff are to assist with any type of mechanical lift. Surveyor asked about R1's return to facility on 12/20/23 and if this was related to a fall. RN D indicated it sounds like a fall and could not fully recall. RN D could not locate documentation of an investigation for R1's incident. At 12:12 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) E. CNA E indicated a fall occurred a while ago and did not recall when and indicated two staff are to assist with all lift transfers. On 01/08/24 at 2:50 p.m., Surveyor interviewed LPN C and Director of Nursing (DON) B, asking about the events that occurred prior to R1 being transferred to the emergency room. LPN C indicated being called over the radio to R1's room. CNA F said R1 was unresponsive in the lift and while in the e-z stand CNA F lowered R1 to the floor. LPN C indicated only CNA F was in the room when LPN C arrived. LPN C indicated R1 is a pivot transfer or assist of two with e-z stand transfer depending on his ability. Surveyor asked if any incident reports were written about the transfer to the floor from the e-z stand lift by one CNA. LPN C indicated only the documentation about being transferred to the emergency room. DON B indicated no other reports were written and the incident should have been written in the interdisciplinary notes. Surveyor asked DON B if lowering to the floor is considered a fall. DON B indicated lowering a resident to the floor is considered a fall and an investigation should have taken place. DON B indicated having no knowledge until today that CNA F was the only one using the lift and R1 being transferred to the floor from the lift as no investigation had been completed. On 01/08/24 at 3:25 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A, asking about staff reporting of a fall. NHA A indicated it is expected a change in plane is considered a fall and should be reported, investigated, and reviewed by the interdisciplinary team. The RN that was called to R1's room should have recognized this as a fall and completed further documentation. Surveyor asked if the RN completed any assessment documentation about the incident. NHA A and DON B indicated there was no documentation from RN G. NHA A indicated it is expected the RN complete documentation of an assessment if an LPN collected the data. On 01/08/24 at 3:46 p.m., Surveyor interviewed RN G, asking about the events that occurred with R1 on 12/20/23. RN G indicated being called to R1's room by LPN C. R1 was on the floor and complained of chest pain and told LPN C to send R1 to the emergency room. In the room was the mechanical lift and wheelchair. RN G indicated knowing he was lowered from the floor from the lift and should be considered a fall. RN G indicated not knowing CNA F was the only aide transferring R1 in the lift. RN G stated RN G should have started a fall investigation and should have signed off on LPN C's charting. On 01/09/24 at 10:51 a.m., Surveyor had a phone interview with Social Worker (SW) H about CNA F not following the care plan. SW H indicated after finding out yesterday of neglect when the CNA F did not follow the care plan for two staff assist with the transfer the facility will be filing a misconduct report to the State Agency.

Based on observation, interview and record review the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) received necessary services to maintain good nutrition for 2 of 3 sampled residents (R37 and R65). R37 prefers to eat in his room and requires staff assistance. Staff did not provide a breakfast tray or assistance for R37. R65 was not assisted with meal while repeatedly making attempts to reach food bowls that were placed out of her reach. This is evidenced by: Example 1 R37 was admitted to facility on 1/29/20. Diagnoses include right side paralysis after stroke, major depressive disorder, type 2 diabetes with insulin use, and dehydration. R37's care plan, dated 6/15/23, indicated R37 has a self-care deficit requiring assist of 1:1 with eating, staff to encourage intake. R37 chooses to have meals in his room, staff to provide relaxed mealtime environment, offer alternatives, and record intake. Record revealed few weights have been taken over the last year due to R37's refusals. R37 has had a -9.62% weight loss; 1/3/23 weight #151.8, 7/11/23 weight #137.2. On 02/01/23, staff performed Heimlich maneuver on R37 due to a choking incident. Speech Therapy (ST) referral was made. ST recommendation for soft diet with regular liquids and supervision during meals due to R37's refusals to get out of bed to eat. 07/17/23, continuous observation, 3 hours and 51 minutes: -7:00 AM, Surveyor observed R37 lying in his bed sleeping. -8:00 AM, Surveyor observed R37 lying in his bed sleeping. Meal cart arrived to dining room. Surveyor observed staff serving and providing meal assistance in the dining room. -9:33 AM, Surveyor observed R37 lying in his bed sleeping, R37 has not been offered or received a meal tray. Surveyor observed meal carts returned to kitchen. Surveyor interviewed Certified Nursing Assistant (CNA) F. CNA F reported that she has not had a chance to assist R37 yet and she does not think that anyone else has assisted him either. CNA F stated that residents can have a grab and go breakfast, consisting of oatmeal, boiled eggs, or yogurt. -9:47 AM, Surveyor observed R37 lying in his bed sleeping, Surveyor asked R37 if he had breakfast this morning and he replied that he would have something. -10:51 AM, Surveyor observed R37 lying in his bed sleeping. Surveyor observed CNA meal intake sheets on nurses' desk by Licensed Practical Nurse (LPN) G. Surveyor asked LPN G if she could confirm R37's breakfast intake. Surveyor observed LPN G reviewed intake sheets and R37's intake was not documented. LPN G stated she would have to ask staff. Surveyor observed LPN G ask the following staff if they had assisted R37 with breakfast. Paid Feeding Assistants H, J and K, and CNAs F and I. All staff replied that they had not assisted R37 with breakfast meal. Surveyor reviewed R37's meal intake sheet for the previous week, completed by CNAs. There was no documentation of meal intake for supper on 7/9, supper on 7/10, supper on 7/11, and breakfast on 7/15. Surveyor reviewed electronic version of meal intake documentation for the previous week, which was not consistent with CNA documentation. Documentation indicated 70% supper on 7/9, 50% supper on 7/10, 70% supper on 7/11 and 10% breakfast on 7/15. On 07/17/23 at 1:16 PM, Surveyor interviewed LPN L. LPN L reported that R37 did not have breakfast this morning. On 07/18/23 at 7:22 AM, Surveyor interviewed Registered Nurse (RN) M. RN M reported that the nurse on duty is responsible for supervision of paid feeding assistants. On 07/18/23 at 8:33 AM, Surveyor interviewed CNA D. CNA D reported that the CNA assigned to R37's hall is responsible to ensure that R37 is offered and assisted with meals, unless a paid feeding assistant is scheduled, then the paid feeding assistant is responsible. On 07/18/23 at 1:55 PM, Surveyor interviewed Director of Nursing (DON) B. DON B reported that she was not aware R37 had not been served breakfast on 7/17/23, stated that documentation for meal intake for breakfast on 7/17/23 was 70%. DON B stated that all residents should receive a meal tray or grab and go breakfast. Facility protocol is if a resident tray is returned to the kitchen untouched, the kitchen is to call the unit where that resident resides and update the nurse. DON B stated that it is the nurses' responsibility to ensure residents are offered all meals. Example 2 Resident (R) 65 has medical diagnoses that include, but are not limited to Alzheimer's disease, dementia, and delusional disorders. According to the most recent Minimum Data Set Assessment (MDSA), which was a quarterly assessment with an Assessment Reference Date (ARD) of 4/18/23, R65 requires staff to set up the meal tray and supervise resident during the meal. According to the Certified Nursing Assistant (CNA) care card, which was provided to Surveyor 7/17/23 and is not dated, R65 Prefers to eat meals in the dining room. I eat my food very fast and get overwhelmed with multiple choices, please offer me 1 food item and 1 drink item at a time. I also do better sitting by myself or I might grab my table mates food . According to the Comprehensive Care Plan developed for R65, the following problems were noted: 1. Impaired Cognition/Memory Loss: I am unable to make my needs known. I am forgetful, am unable to make my own Health Care Decisions. I need you to continue to offer me daily choices and decisions for care times, meals and activities . Because I have Alzheimer's dementia, have a history of Parkinson's vascular dementia do not hear well. (Last revised 6/14/23) 2. Self Care Deficit: . Needs supervision/cues for Eating (3/1/23) . Goal . Feed self after set up and food handed to resident . 3. Potential for alteration in nutrition (11/29/22 and last revised 4/20/23): Because I eat my food rapidly, hand me 1 food item at a time, served in a bowl . Surveyor reviewed the Interdisciplinary Team Notes and noted the following entry: - 07/11/2023 05:01 PM: . EATING: requires setup help only from staff for eating; to provide encouragement and supervision; to prepare his/her plate & food; eats in dining area . - Surveyor then reviewed assessments completed for R65 and noted that on 7/11/23, the facility completed an assessment regarding Activities of Daily Living and included in this assessment was R65's eating abilities. According to this assessment, R65 . requires setup help only from staff for eating; to provide encouragement and supervision; to prepare his/her plate & food; eats in dining area . On 7/16/23, Surveyor observed R65's meal service for the noon meal. The following was noted: - At 11:38 AM, clothing protectors were passed out and placed on tables; R65 was seated at a table for six individuals and picked it up and covered her upper body with same as if it were a blanket - At 11:43 AM, meal cart arrived and taken down the 600 Hallway. - At 11:49 AM, CNA L went around the room with wet wipes to clean residents' hands. - At 11:51 AM, a meal cart arrived on unit. - At 12:03 PM, all residents served at the table except for R65 at this time (5 peers); R65 looked around the room. Registered Nurse M (RN) instructed staff to move R65 to a different table. R65 was placed at a separate table from others by herself. - At 12:09 PM, the second meal cart arrived on the unit. - At 12:17 PM, R65 was served her meal by CNA N. Each item was placed into separate bowls covered with a matching plate. CNA N gave R65 one bowl containing pureed meat and pushed the tray out of R65's reach. - At 12:19 PM, R65 ate this first bowl of food on her own without any issues. - From 12:19 PM - 1:26 PM, R65 repeatedly reached in front of her for an additional bowl of food to eat, but was unable to reach it. R65 repeatedly moved her wheelchair to the corner of the table in order to enhance her reach for the food. R65 was not able to move around the table, as there was a portable floor-standing air conditioning unit on the left side of the table blocking her passage. At one point, R65 took the nearly finished glass of apple juice and tried to manipulate the tray with the bottom of the glass but the tray was too far away and the glass fell onto the edge of the tray, spilling the juice onto the table. Repeated attempts to reach the tray of food caused R65 to run her right arm and hand through the spilled apple juice. There were two additional staff members assisting other residents at one table. However, neither of them looked towards R65 or acknowledged that she needed more food from her tray to assist her. At 1:27 PM, CNA R approached R65 with a clip board to document meal intake. Surveyor asked CNA R what type of assistance R65 required with meal service. CNA R stated that R65 needs to be supervised and placed at a table by herself because she is handsy and will grab other residents' food. Surveyor then asked what it means to supervise a resident. CNA R stated, We need to sit and watch her and give her food one by one. Surveyor then explained to CNA R that R65 was not supervised or assisted with the meal and that she repeatedly attempted to obtain food items from her tray but was unable, and no staff observed the need or monitored her in order to provide her with additional food items. CNA R then removed the plates from the other two bowls on R65's tray, which contained pureed peas in one and pureed bread in the other. CNA R handed R65 the peas, but did not re-heat them prior to giving them to her. Within one minute, R65 had finished the peas and CNA R handed R65 the bread, which she ate just as fast. This was a continuous observation of 1 hour 17 minutes in which R65 was not offered or assisted with her meal. On 7/18/23 at 11:36 AM, Surveyor interviewed Director of Nursing B (DON) in her office. Also present were Nursing Home Administrator A (NHA) and Social Services Director T (SSD). Surveyor asked DON B what the expectation of staff was for meal service for R65. DON B stated that R65 is to sit by herself at a table as she is easily distracted and should also be given one or two things at a time, as she will shovel the food into her mouth or she will mix it all up into one bowl. DON B further stated that staff are to supervise R65 and encourage her. The observation above was explained to DON B and the additional two staff in the room. DON B stated, Someone should have been watching her more closely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 The facility policy, entitled Skin Care Policy and Procedure dated 08/22/22, states: Promoting skin integrity is a multidisciplinary action. The intent is that the resident does not develop pressure injuries unless clinically unavoidable and that the facility provides care and services to promote the prevention of pressure injury development . R15 was admitted to facility on 10/31/22 and has diagnosis that include dementia with behavior disturbances and Parkinson's disease. R15's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated problems with both short term and long-term memory, and severely impaired cognitive skills for daily decision-making regarding tasks of daily life. R15's quarterly MDS, dated [DATE], indicated extensive assistance with two-persons for transfers, toilet use, and bed mobility, and requires total dependence with one-person for locomotion. R15's quarterly MDS, dated [DATE], indicated risk of developing pressure ulcers. R15's Care Plan, dated 03/07/23, states resident requires extensive assist with Activities of Daily Living (ADL) and intervention to reposition every 1-hour when up. On 07/17/23 at 7:06 am, Surveyor observed R15 in lounge in a Broda chair. Surveyor conducted continuous visual observation. On 07/17/23 at 10:46 am, Surveyor observed R15 taken to his room for toileting and repositioning. On 07/18/23 at 7:50 am, Surveyor observed R15 brought to lounge. On 07/18/23 at 10:09 am, Surveyor observed R15 taken to room for toileting and repositioning. Note: This observation was a time frame of 3 hours 3 minutes in which R15 was not offered or attempts made by staff to reposition or toilet. Example 3 R58 was admitted to facility on 08/05/22, and has a diagnosis that include Alzheimer's disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and other reduced mobility. R58's significant change MDS assessment, dated 06/02/23, indicated problem with both short term and long-term memory, and severely impaired cognitive skills for daily decision-making regarding tasks of daily life. R58's significant change MDS assessment, dated 06/02/23, indicated total dependence with assist of two people for transfers, locomotion, and toilet use, placing R58 at high risk for skin breakdown. R58's significant change MDS assessment, dated 06/02/23, indicated risk of developing pressure ulcers. R58's care pan, dated 08/12/22, states: Potential for impaired skin integrity with interventions to include reposition every two hours while in bed. The care plan does not address repositioning when in wheelchair. On 07/17/23 at 7:08 am, Surveyor observed R58 taken in wheelchair to lounge for breakfast. Surveyor conducted continuous visual monitoring until 11:11 am. No observations were observed of R58 being removed from lounge or repositioned while in wheelchair. On 07/18/23 at 7:50 am, Surveyor observed R58 being wheeled out of room and to lounge for breakfast. On 07/18/23 at 9:51 am, Surveyor observed R58 offered and taken in wheelchair to activity area. No repositioning or toileting was completed. Continued visual monitoring. On 07/18/23 at 11:30 am, Surveyor observed R58 still sitting in activities, no offering of repositioning or toileting was completed. Note: This observation was a time frame of 4 hours 22 minutes in which R58 was not offered or attempts made by staff to reposition or toilet. On 07/18/23 at 9:25 am, Surveyor interviewed DON B regarding facility standards of practice for skin breakdown and prevention. DON B stated that a skin assessment and Braden scale are completed upon admission, and with each Minimum Data Set (MDS) or new skin concern development. Interventions would be put into place on care plan based on the assessment and comorbidities. They would get therapy involved for appropriate chair cushions. A repositioning schedule would be developed based on individual needs. DON B stated she would expect a minimum standard of practice of every 2-3 hours being repositioned Based on observations, interviews and record reviews, the facility did not ensure 3 of 7 residents (R65, R15 and R58) reviewed for risk of pressure injury development, received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. R65 was observed on three occasions in which there was no repositioning offered for extended periods of time. R15 was observed on two occasions in which repositioning and toileting was not completed. R58 was observed on two occasions in which staff did not reposition or toilet. This is evidenced by: According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (2018), for immobile or bed bound individuals, a full change in position should be conducted a minimum of every two hours. Some individuals require more frequent repositioning due to their high risk status. Surveyor reviewed the facility policy for repositioning, last revised 4/20/23. This policy states, in part, . Repositioning is a common, effective intervention for prevention skin breakdown, promoting circulation and providing pressure relief .Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning . A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body . Residents who are in a chair should be on an every 2-3 hour repositioning schedule . Example 1 R65 has medical diagnoses that include, but are not limited to Alzheimer's disease, dementia, delusional disorders, repeated falls, and nontraumatic intracerebral hemorrhage. The most recent Minimum Data Set Assessment (MDSA) completed for R65 was a quarterly assessment with an Assessment Reference Date of 4/18/23. According to this MDSA, R65 has both short-term and long-term memory impairment and severely impaired daily decision-making abilities. R65 requires extensive assistance of staff to meet most basic needs of bathing, dressing, toileting and personal hygiene. R65 is non-ambulatory and requires the use of a mechanical lift for transfers. R65 was also assessed as being incontinent of both bowel and bladder function. Surveyor then reviewed the Comprehensive Care Plan (CCP) developed for R65 and noted the following: Under Self Care Deficit dated 3/1/23 and last revised 7/11/23, under Repositioning the CCP directs staff to follow repositioning needs per care card. Surveyor then reviewed the care card, and noted there was no category to inform the reader of what R65's needs were in regards to repositioning. The only indication given regarding R65's needs was listed under Restoratives and stated, in part, . Will be continent of bladder with staff assisting to toilet Prompted Voiding . Assist with toileting q (every) ___ hours (time frame left blank) . Offer toileting prior to activities such as therapy, treatments, etc. Staff will assist resident with toileting upon waking, prior to meals, before activities and prior to sleep . There was no directive on what R65's repositioning needs were. Surveyor then reviewed the Braden Scale for Predicting Pressure Sore Risk. The most recent Braden assessment was dated 3/1/23 and scored R65 18 (scores 15 -18 indicates mild risk for skin breakdown). According to this assessment, the following was noted: MOBILITY: slightly limited - makes frequent though slight changes in body/extremity position independently FRICTION/SHEAR: potential problem - moves with minimum assistance, some sliding with repositioning, occasionally slides down in bed/chair ACTIVITY: walks occasionally - walks occasionally during day, very short distances with or without assistance, in bed/chair most of time Note: Resident no longer ambulates and is transferred with a mechanical lift. MOISTURE: occasionally moist - skin is occasionally moist, requiring an extra linen change approximately once a day Note: Resident is incontinent of bowel and bladder NUTRITION: excellent - eats most of every meal, never refuses meal, eats 4 proteins per day, occasionally eats between meals, no supplement SENSORY PERCEPTION: slightly limited - responds to verbal commands, can't always communicate pain or need to reposition ADDITIONAL RISK FACTORS: incontinence, cognitive deficit, difficulty expressing needs INTERVENTIONS: Staff anticipates needs, provides prompt peri care with incontinence, ongoing skin monitoring, encourages repositioning and good nutrition/hydration Surveyor then reviewed Interdisciplinary Team Progress Notes for R65's current functional status level. On 07/08/2023, an entry was made regarding mobility and stated, MOBILITY: slightly limited - makes frequent though slight changes in body/extremity position independently FRICTION/SHEAR: potential problem - moves with minimum assistance, some sliding with repositioning, occasionally slides down in bed/chair ACTIVITY: chair-fast - ability to walk is severely limited or none, can't bear weight and/or is assisted to chair or wheelchair . On 07/11/2023, an entry regarding Activities of Daily Living was entered and stated, BED MOBILITY: requires one aide assist for bed mobility, to position extremities and trunk with involved weight-bearing & little self-performance, TRANSFERS: requires two aides assist to transfer to provide weight-bearing support during transfers; WALKING: N/A (not applicable) - resident does not walk . TOILETING: requires two aide assist for toilet use; to provide transfer and personal hygiene frequently; GROOMING/HYGIENE: requires one aide assist for personal hygiene; to provide all hygiene tasks for the resident BATHING: requires one aide assist for bathing; to wash his/her entire body, EQUIPMENT: wheelchair, type: manual. Surveyor conducted three continuous observations of R65 in which repositioning and toileting assistance was not offered or attempted. They were as follows: OBSERVATION 1: 7/16/23 At 9:28 AM upon Surveyor's arrival to the facility, R65 was seated in a wheelchair in dining area. R65 was placed at a table for 6 with a personal alarm attached to the back of the wheelchair and clipped to the back of the shirt. R65 was watching the television and would periodically put her head down chin to chest and close her eyes. At 10:35 AM, R65 remained at the table with no staff approaching to offer or encourage repositioning or toileting. She was given an 8 ounce glass of orange juice and drank 100%. R65 continued to vacillate between watching the television and putting her head down chin to chest and close her eyes. At 10:51 AM, CNA E approached R65 and asked if she wanted some more juice. CNA E returned to R65 about 1 minute later with 8 ounces apple juice. At 10:59 AM, R65 stuck the right pointer finger into the juice and stirred the juice with the finger. R65 then began to drink the juice. There were no offers or attempts made at that time to reposition R65. At 11:09 AM, Staff Q (Housekeeper) approached the dining area. There were three additional residents seated at the table with R65 at that time. Staff Q passed out colored pieces of paper to each of the residents and taped these to the table. She then passed out round plexi-glass discs to each and had each of the residents trace the disc onto the paper. They then glued colored letters in the middle of the circle they drew. Staff Q did the task for R65, holding R65's finger on the letter to hold it in place for the glue to set. Once the activity was completed, R65 sat at the table with no staff approach to offer and encourage repositioning or toileting. At 11:38 AM, clothing protectors were passed out on the tables in preparation for the noon meal. Meals were then passed out to all the residents in the dining room. At 12:03 PM, R65 was moved to a different table. At 12:17 PM, R65 was served her meal. Resident sat unassisted during this meal from 12:17 - 1:26 PM at which time CNA R approached. Surveyor asked CNA R what R65's needs were regarding toileting and repositioning. CNA R stated that R65 is assisted with morning cares by the night shift between 5:00 AM - 6:00 AM, in which they also get her up into the wheelchair. CNA R stated that sometimes R65 will tell the staff that she needs to use the toilet, but not often. CNA R stated R65 is always incontinent of bowel and bladder function but will also go on the toilet and have results. She also stated that R65 is taken to the bathroom after meals, but was not assisted on this day. In fact, CNA R stated that R65 was not attended to since she was assisted up by the night shift. At 1:43 PM, CNA R took R65 to her room then left to retrieve a mechanical lift and returned at 1:46 PM with Registered Nurse S (RN) to assist. At 1:47 PM, R65 was assisted to stand with the mechanical lift and placed onto the toilet. Her incontinent brief was saturated with urine. Note: This observation was a time frame of 4 hours 19 minutes in which R65 was not offered or attempts made by staff to reposition or toilet. OBSERVATION 2: 7/17/23 R65 was observed at 7:26 AM fully dressed seated in her wheelchair in the dining area. From 7:26 AM - 8:25 AM, no staff approached to offer or attempt repositioning. At 8:25 AM, Activities Aide O (AA) placed R65 at a table for her meal and handed her a bowl of pureed French toast. From 8:25 AM - 8:35 AM, R65 ate and completed her meal. At 9:03 AM, Licensed Practical Nurse G (LPN) approached R65 with medications. At 9:22 AM, R65 began to wander around the room in her wheelchair, moving between other residents and the dining room tables. R65 continued to do this until 9:35 AM, at which time she positioned herself at a table. At 10:37 AM, staff moved R65 to her room. Surveyor entered the room and noted CNA I and CNA R were assisting R65 with the mechanical lift and placement on the toilet. Again, Surveyor was informed that R65 was assisted by the night shift between 5:00 AM - 6:00 AM and that they had not done any cares for R65 yet this day. This is an observation of 3 hours 11 minutes in which R65 was not offered or attempts made for repositioning or toileting. OBSERVATION 3: 7/18/23 At 7:17 AM, Surveyor noted R65 was seated pin her wheelchair at the table in the dining area of the second floor unit. R65 was fully dressed, head down chin to chest with hands folded as if in prayer, on the table. R65's eyes were closed. There was an empty coffee cup in front of her. At 7:32 AM, R65 woke up and took the cup in her hand by handle, looked around the room and sipped the empty contents. R65 placed the cup back on the table and puts her head down again. R65 closed her eyes. At 8:09 AM, R65 was moved to an over bed table in the corner of an internal wall in the dining area in preparation for the morning meal. R65 was served one bowl of her meal at 8:14 AM, which consisted of pureed scrambled eggs in one bowl and 4 ounces of orange juice. R65 finished eating all of her tray contents at 8:42 AM, at which time Registered Nurse M (RN) approached her with an additional cup of coffee. R65completed this coffee at 8:47 AM. From 8:47 AM- 9:36 AM, R65 moved repeatedly around the room in her wheelchair, going between table, approached additional residents and approached and left other tables, until finally she rested at one of them and appeared to have fallen asleep. At 9:55 AM, an activity started of painting in which R65 participated. This activity ended at 11:19 AM and residents were positioned at tables for the noon meal. R65 began to maneuver herself around the room, once again propelling herself between tables and additional residents, until 11:35 AM, when Surveyor ceased the observation, approached RN M and asked what the expectations for repositioning and toileting R65 were. RN M stated R65 should be repositioned and toileted at least every two hours. Surveyor explained the observation made. RN M stated, Yeah, she should have been taken to the bathroom. At 11:34 AM, Surveyor approached CNA R, who was responsible for R65 on this day, and again, explained the observation made and asked CNA R what happened to prevent R65 from being assisted. CNA R stated, Yeah, I know. I just didn't get to her yet because of the call lights going off and doing cares. I will take her before she eats lunch. This observation began at 7:17 AM and ended at 11:35 AM (4 hours 18 minutes) when Surveyor went to talk to Director of Nursing B (DON) regarding the observations made over the course of the survey. At 11:36 AM, Surveyor approached DON B in her office. Also present was Nursing Home Administrator A (NHA) and Social Services Director T (SSD). Surveyor asked DON B what the expectations were for repositioning and toileting regarding residents at risk for development of pressure injury or skin impairments DON B stated the expectations depend on the resident and their comorbidities, and indicated residents are individually assessed and evaluated by therapy for cushion use in wheelchairs. DON B further stated that her expectation for residents at risk would be at least every two hours. The observations conducted were explained to all staff present in the room. DON B again stated her expectation for R65 was to be repositioned and toileted every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3 The facility policy, entitled Continence Assessment and Management, dated 04/30/23, states: If a resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. A check and change strategy involved checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort to protect the skin. R15 was admitted to facility on 10/31/22 and has diagnosis that include dementia with behavior disturbances and Parkinson's disease. R15's current physician orders dated 7/13/23, indicated R15 was placed on an antibiotic for treatment of a urinary tract infection with last dose to be given on 07/23/23 at 8:00 am. R15's most recent quarterly MDS, dated [DATE], indicated problem with both short term and long-term memory, and severely impaired cognitive skills for daily decision-making regarding tasks of daily life. R15's most recent quarterly MDS, dated [DATE], indicated frequently incontinent (7 or more episodes of urinary incontinence). R15's quarterly MDS, dated [DATE], indicated extensive assistance with two-person for toilet use, and extensive assist with 1-person for personal hygiene. R15's care plan, dated 05/16/23, states R15 is incontinent of bladder and bowel but does become more restless when he needs to use the bathroom, toilet before and after meals, at bedtime and upon rising, monitor for incontinence episodes. On 07/17/23 at 7:06 am, Surveyor observed R15 in lounge in a Broda chair. Surveyor conducted continuous visual observation. On 07/17/23 at 10:46 am, Surveyor observed R15 taken to his room for toileting. On 07/18/23 at 7:50 am, Surveyor observed R15 brought to lounge. On 07/18/23 at 10:09 am, Surveyor observed R15 taken to room for toileting. Note: This observation was a time frame of 3 hours 3 minutes in which R15 was not offered or attempts made by staff to reposition or toilet. On 07/18/23 at 9:25 am, Surveyor interviewed DON B regarding standard of practice for incontinence and toileting care. DON B stated that a bladder and bowel incontinence assessment is completed upon admission, and with each MDSor any change in continence status. DON B stated that based on the assessment a restorative program would be developed. If a resident is not appropriate for a restorative bowel and bladder program the expectation would be based on resident assessment, resident request, or at least every 2 hours. Example 2 Centers for Disease Control and Prevention (CDC), Guidelines for Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) recommends changing catheters and drainage bags based on clinical indications such as infection, obstruction, or when the system is compromised. Facility policy, Urinary Tract Infections-Guidelines for Preventing, reads in part .1. Insert catheters only for indications deemed appropriate for urinary catheter insertions. 2. Leave catheters in place only as long as needed. Document the following information: a. The continued need for indwelling catheter. R37 was admitted to facility on 1/29/20. Diagnoses include retention of urine unspecified, other obstructive and reflux uropathy, urinary tract infection, right side paralysis after stroke, type 2 diabetes with insulin use, and dehydration. Minimum Data Set (MDS) confirmed that R37 was admitted with indwelling Foley catheter, no trial of toileting program, and 2-person assistance with toileting/catheter care, which is consistent since admission. Physician Orders: change indwelling Foley catheter one time per month pattern: administer on the 16th. Reason for Indwelling Foley: obstructive uropathy monthly. Change Foley bag one timer per month pattern, administer on the 16th. Care Plan, 6/15/23: Self-care deficit. Toileting: refer to resident care card. Resident care card: continent foley catheter. Urinary Retention: assure standards of care are followed, monitor intake and output, catheter care per policy. On 07/16/23, Surveyor observed that R37 had a Foley catheter. Record review confirmed that R37 has had five UTIs in the last three months. Record review indicated R37 was not followed by urology. On 07/18/23 at 11:13 AM, Surveyor interviewed DONB. DON B reported that R37 was seen by urology at one time but R37 no longer wanted to attend any outside appointments. DON B stated that urology did trial removal of catheter that was not successful but was unsure of when this occurred. DON B stated, It was a while ago. DON B stated that facility providers order catheters to be changed routinely. DON B stated she has been unsuccessful in attempts to educate providers that this is not standard practice. Surveyor was unable to find documentation that R37 no longer wanted to attend any outside appointments. Surveyor was unable to locate any documentation that R37 was seen by urologist or that trial removal of catheter was attempted and unsuccessful. Surveyor was unable to locate documentation to support order for routine catheter care. Based on observation, interviews and record reviews, the facility did not ensure 3 of 10 residents reviewed for bowel and bladder incontinence or indwelling Foley catheters (R65, R37 and R15) received appropriate treatment and services to prevent Urinary Tract Infections (UTI) and to restore continence to the extent possible. -R65 was observed for extended periods of time on three separate occasions in which staff did not offer or attempt toileting services. -R37 has an indwelling Foley catheter with orders to change every month. There is no documentation to support routine change of R37's catheter. -R15 was observed on two separate occasions for extended periods of time in which toileting assistance was not provided. This is evidenced by: Acello, [NAME] RN MSN. The Long-Term Care Nursing Desk Reference. Chapter 13, pages 214-215 offers the following discussion on urinary incontinence in Long Term Care: . Incontinence is a medical problem that is, in many instances, beyond the resident's control. Incontinence is not a normal consequence of aging and can frequently be cured or improved . Incontinence in long-term care facilities can often be linked to the facility's staff. Over time, staff become insensitive to incontinence . the sensation of needing to use the toilet is one of the last to be lost in cognitively impaired residents. Their problem is often one of communication. They are unable to communicate the need to use the bathroom . Effective urinary management is assessment-based and individualized to the resident . It involves toileting the resident at times in which he or she is most likely to eliminate . The facility policy titled Standards of Care, which was last revised 4/30/23, stated, in part, Care will be provided to each resident based on assessment of needs, identifying and maintaining each resident's individuality, maximizing their strengths, promoting their independence and respecting their right to privacy while maintain dignity and respect . Under the section of Toileting the policy directs staff to toilet residents every two to three hours if the resident is unable to determine their own need. Example 1 R65 has medical diagnoses that include, but are not limited to Alzheimer's disease, dementia, delusional disorders, repeated falls, and nontraumatic intracerebral hemorrhage. The most recent Minimum Data Set Assessment (MDSA) completed for R65 was a quarterly assessment with an Assessment Reference Date of 4/18/23. According to this MDSA, R65 has both short-term and long-term memory impairment and severely impaired daily decision-making abilities. R65 requires extensive assistance of staff to meet most basic needs of bathing, dressing, toileting and personal hygiene. R65 is non-ambulatory and requires the use of a mechanical lift for transfers. R65 was also assessed as being incontinent of both bowel and bladder function. Surveyor then reviewed the Comprehensive Care Plan (CCP) developed for R65 and noted the following: Under Self Care Deficit dated 3/1/23 and last revised 7/11/23, under Repositioning the CCP directs staff to follow Repositioning needs per care card. Surveyor then reviewed the care card, and noted under toileting, . Assist of two. Relies on others to anticipate needs . This then directs staff to the toileting plan. Under Restoratives in this care card stated, in part, . Will be continent of bladder with staff assisting to toilet Prompted Voiding . Assist with toileting q (every) ___ hours (time frame left blank) . Offer toileting prior to activities such as therapy, treatments, etc. Staff will assist resident with toileting upon waking, prior to meals, before activities and prior to sleep . Surveyor then reviewed the Continence Assessment completed for R65, dated 7/9/23. The assessment stated R65 is a risk for urinary incontinence related to immobility, fall history, generalized weakness and Dementia . R65 was identified as having functional urinary incontinence as she has limited mobility and requires staff assistance with meeting her toileting needs. Surveyor conducted three continuous observations of R65 in which toileting assistance was not offered or attempted. They were as follows: OBSERVATION 1: 7/16/23 At 9:28 AM upon Surveyor's arrival to the facility, R65 was seated in a wheelchair in dining area. R65 was placed at a table for 6 with a personal alarm attached to the back of her wheelchair and clipped to the back of her shirt. R65 was watching the television and would periodically put her head down chin to chest and close her eyes. At 10:35 AM, R65 remained at the table with no staff approaching to offer or encourage repositioning or toileting. R65 was given an 8 ounce glass of orange juice and drank 100%. R65 continued to vacillate between watching the television and putting her head down chin to chest and close her eyes. At 10:51 AM Certified Nursing Assistant E (CNA) approached R65 and asked her if she wanted some more juice. CNA E returned to R65 about 1 minute later with 8 ounces apple juice; At 10:59 AM, R65 stuck the right pointer finger into the juice and stirred the juice with the finger. R65 then began to drink the juice. There were no offers or attempts made at that time to toilet R65. At 11:09 AM, Staff Q (Housekeeper) approached the dining area and began a short activity with R65 and other residents. Once the activity was completed, R65 sat at the table with no staff approach to offer and encourage toileting. At 11:38 AM, clothing protectors were passed out on the tables in preparation for the noon meal. Meals were then passed out to all the residents in the dining room. At 12: 03 PM, R65 was moved to a different table. At 12:17 PM, R65 was served her meal. R65 remained in the dining room at the table until 1:26 PM, when CNA R approached to write down the meal intake. Surveyor asked CNA R what R65's needs were regarding toileting and repositioning. CNA R stated that R65 is assisted with morning cares by the night shift between 5:00 AM - 6:00 AM, in which they also get her up into the wheelchair. CNA R stated that sometimes R65 will tell the staff that she needs to use the toilet, but not often. CNA R stated R65 is always incontinent of bowel and bladder function but will also go on the toilet and have results. CNA R also stated that R65 is taken to the bathroom after meals, but was not assisted on this day. In fact, CNA R stated that R65 was not attended to since she was assisted up by the night shift. At 1:43 PM, CNA R took R65 to her room then left to retrieve a mechanical lift and returned at 1:46 PM with Registered Nurse S (RN) to assist. At 1:47 PM, R65 was assisted to stand with the mechanical lift and placed onto the toilet. R65's incontinent brief was saturated with urine. RN S removed the brief and rolled a paper towel around it and placed it on R65's bed, while CNA R retrieved a clean pair of slacks, as R65's were wet with urine. RN S then left the room and CNA N entered the room to assist. R65 was brought to a stand with the lift and CNA R proceeded to cleanse R65's front perineum and buttocks from behind the resident, cleansing only the vaginal region and buttocks. There was no cleansing of the groin and thighs of the urine. R65 was assisted to the wheelchair and CNA R took the paper towel wrapped brief down the hall to dispose of it. At 2:00 PM, Surveyor approached CNA R and asked her what she has been taught regarding perineal care after incontinence episodes. CNA R stated, we do pericare in the mornings wash with soap and water, rinse and dry and use wet wipes during the day. Surveyor explained the observation made and stated the frontal perineal cleansing was not thorough in removing the urine. CNA R stated, I tried to go from behind. I guess I didn't get the front very good. Note: This observation was a time frame of 4 hours 19 minutes in which R65 was not offered or attempts made by staff to toilet, increasing the risk for the development of a UTI. Also, if R65 was not tended to since being assisted to her wheelchair by the night shift, this would be an additional 3-4 hours in which she did not receive necessary care. OBSERVATION 2: 7/17/23 R65 was observed at 7:26 AM fully dressed seated in her wheelchair in the dining area. From 7:26 AM - 8:25 AM, no staff approached to offer or attempt repositioning. At 8:25 AM, Activities Aide O (AA) placed R65 at a table for her meal and handed her a bowl of pureed French toast. From 8:25 AM - 8:35 AM, R65 ate and completed her meal. At 9:03 AM, Licensed Practical Nurse G (LPN) approached R65 with medications. At 9:22 AM, R65 began to wander around the room in her wheelchair, moving between other residents and the dining room tables. R65 continued to do this until 9:35 AM, at which time she positioned herself at a table. At 10:37 AM, staff moved R65 to her room. Surveyor entered the room and noted CNA I and CNA R were assisting R65 with the mechanical lift and placement on the toilet. Again, Surveyor was informed that R65 was assisted by the night shift between 5:00 AM - 6:00 AM and that they had not done any cares for R65 yet this day. This is an observation of 3 hours 11 minutes in which R65 was not offered or attempts made for toileting. OBSERVATION 3: 7/18/23 At 7:17 AM, Surveyor noted R65 was seated in her wheelchair at the table in the dining area of the second floor unit. R65 was fully dressed, head down chin to chest with hands folded as if in prayer, on the table. R65's eyes were closed. There was an empty coffee cup in front of her. At 7:32 AM, R65 woke up and took the cup in her hand by handle, looks around the room and sips the empty contents. She placed the cup back on the table and puts her head down again. R65 closed her eyes. At 8:09 AM, R65 was moved to an over bed table in the corner of an internal wall in the dining area in preparation for the morning meal. R65 was served one bowl of her meal at 8:14 AM, which consisted of pureed scrambled eggs in one bowl and 4 ounces of orange juice. R65 finished eating all of her tray contents at 8:42 AM, at which time Registered Nurse M (RN) approached her with an additional cup of coffee. R65 completed this coffee at 8:47 AM. From 8:47 AM- 9:36 AM, R65 moved repeatedly around the room in her wheelchair, going between table, approached additional residents and approached and left other tables, until finally she rested at one of them and appeared to have fallen asleep. At 9:55 AM, an activity started of painting in which R65 participated. This activity ended at 11:19 AM and residents were positioned at tables for the noon meal. R65 began to maneuver herself around the room, once again propelling herself between tables and additional residents, until 11:35 AM, when Surveyor ceased the observation, approached RN M and asked what the expectations for toileting R65 were. RN M stated R65 should be repositioned and toileted at least every two hours. Surveyor explained the observation made. RN M stated, Yeah, she should have been taken to the bathroom. At 11:34 AM, Surveyor approached CNA R, who was responsible for R65 on this day, and again, explained the observation made and asked CNA R what happened to prevent R65 from being assisted. CNA R stated, Yeah, I know. I just didn't get to her yet because of the call lights going off and doing cares. I will take her before she eats lunch. This observation began at 7:17 AM and ended at 11:35 AM (4 hours 18 minutes) when Surveyor went to talk to Director of Nursing B (DON) regarding the observations made over the course of the survey. At 11:36 AM, Surveyor approached DON B in her office. Also present was Nursing Home Administrator A (NHA) and Social Services Director T (SSD). Surveyor asked DON B what the expectations were for repositioning and toileting regarding residents at risk for development of pressure injury or skin impairments DON B stated the expectations depend on the resident and their comorbidities, and indicated residents are individually assessed and evaluated by therapy for cushion use in wheelchairs. She further stated that her expectation for residents at risk would be at least every two hours. The observations conducted were explained to all staff present in the room. DON B again stated her expectation for R65 was to be repositioned and toileted every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that prior to the installation or use of bed rails, the facility attempted to use alternatives, ensure the resident is assessed for the use of bed rails, which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative for 1 of 1 resident (R) R15. The facility did not ensure the grab bars are appropriate for R15, assess risk of entrapment versus benefit, and did not obtain consent from representative. This is evidenced by: R15 was admitted to facility on 10/32/22 and has diagnosis that include diagnosis of dementia with behavior disturbances and Parkinson's disease. R15's most recent quarterly Minimum Data Set (MDS), dated [DATE], indicated problem with both short term and long-term memory, and severely impaired cognitive skills for daily decision-making regarding tasks of daily life. This would put R15 at risk for entrapment with the use of bedrails. R15's quarterly MDS, dated [DATE], indicated requires extensive assistance with two-person for transfers and bed mobility. R15 is on psychotropic medications that can affect his ability to safely use the bedrails. R15's care plan, dated 03/01/23, with a target date of 3 months, states potential for trauma-falls. Interventions include right side grab bar, mat on floor beside bed, and pull-apart alarm when in bed. Utilize devices/restraint as ordered. On 07/16/23, Surveyor observed bilateral grab bars on R15's bed on the 3 days of survey. On 07/16/23 and 07/17/23, Surveyor observed a motion sensor alarm between bed and door attached to a pole. Surveyor reviewed documentation entitled, Purpose of note: assessment for use, dated 05/09/23, which states that bed rails are not used, and other supportive devices which includes grab bar on right side. The assessment does not include risk of entrapment and indicated that no other alternatives were trialed. The assessment indicated the benefit/purpose is to enable better sitting, balance, positioning, comfort/security, and enable bed mobility The facility did not assess for the risk of entrapment, attempt alternative interventions before implementing bilateral grab bars, obtain informed consent, nor obtain physician order for bed rails. On 07/27/23, LPN L stated that the motion alarm was there because R15 often puts legs over the side of the bed, and it alerts staff to prevent falls and that is why the mat is next to bed as well. On 07/18/23 at 7:56 am, Surveyor interviewed Certified Nursing Assistant (CNA) Manager F, who stated that on a good day, R15 may use the grab bars, but hasn't seen him use them for a while. On 07/18/23 at 1:56 pm, Surveyor interviewed Director of Nursing (DON) B regarding assessment documented by nursing on 05/09/23 of bilateral grab bars on R15's bed and care plan interventions of use of asked if additional information regarding alternative interventions trials, risk versus benefit assessment, signed consent by R15's representative and manufacturer guidelines for grab bars. DON B stated she was unable to locate any further information regarding the care plan discrepancies, risk versus benefit assessment, signed consent or manufacturer guidelines. On 07/18/23 at 2:19 pm, Surveyor interviewed Nursing Home Administrator (NHA) A, along with two maintenance men. NHA A, stated that maintenance does weekly checks of bed rails and the measurement between R15's mattress and grab bar is 1. NHA A stated, there is no signed consent, risk versus benefits documentation, and was unable to provide manufacture guidelines of bed rails and stated R15 has had no recent falls from bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. This occurred for 1 of 3 residents, R11. RN C left R11's 8:00 am medications on his bed side table. R11 was not cognitively able to ensure administration of medications. Findings Include: On 07/18/23 10:10 a.m., Surveyor observed R11 in bed with his bedside table in front of his bed. On the table was a medication cup with 7 pills in the cup. Surveyor asked R11 about the medications and R11 responded, I don't know what the hell they are. Surveyor reported to nurses station and spoke with Registered Nurse (RN) C about the observation. RN C indicated she had left the pills on R11's bedside table at approximately 8:45 a.m. Surveyor asked if it is normal practice to leave R11's pills on his bedside table. RN C responded R11 beats to his own drum and sometimes takes his pills and sometimes waits to take his pills thus she leaves the pills on his bedside table for him when he does not want to take them. Surveyor asked RN C if R11 is a candidate for self administration of medications. RN C and Surveyor reviewed R11's medical record which notes on 6/02/23 and 7/16/23 R11 is not his own decision maker and is not a candidate for self administration of medications. Surveyor asked RN C if there is a physician order indicating medications could be left at R11's bedside. RN C and Surveyor reviewed R11's orders and there was no order for R11 to self administer his medications. Surveyor reviewed R11's care plan and it does not address R11's ability to self administer medications. Surveyor reviewed R11's admission Minimum Data Set (MDS) dated [DATE] which notes R11 is severely impaired in cognition and has impairment in his range of motion on one side of upper extremities. On 07/18/23 at 10:50 a.m., Surveyor spoke with Director of Nursing (DON) B regarding the observation and her expectation related to resident safe self administration of medications. DON B indicated R11 is not a candidate due to his cognitive impairment thus it would not be on his care plan or an order would not be obtained. Staff should not have left the medications at R11's bedside. Surveyor requested a list of medications that were left at R11's bedside. The medications included: Amlodipine 10 mg Aspirin 81 mg Metformin 1000mg Sertraline 100 mg Glipizide 10 mg Magnesium 400 mg Tramadol 50 mg Surveyor requested R11's physician's orders and compared to the medications left at bedside. The orders confirm the medications found at R11's bedside at 10:10 am were ordered for 8:00 am administration. DON B confirmed R11 did not have medications administered in a safe manner as R11 is not a candidate to do so safely.

Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 residents (R37) reviewed for antibiotic medications. R37 had five urinary tract infections (UTIs) in three months. R37 did not meet criteria to determine infection. R37 was prescribed antibiotic therapy prior to laboratory test results. R37 was treated with an antibiotic that laboratory tests confirmed was resistant. This is evidenced by: The facility's Antibiotic Stewardship Policy and Procedure, documents, in part: Antibiotic Stewardship Program (ASP) is established to ensure that a resident who needs an antibiotic receives the appropriate antibiotic and to reduce the risk of antibiotic resistance. Nursing staff will use established methods to communicate with physician when an infection is suspected. Our nurses will incorporate diagnostic criteria from McGeer's 2012 revised definitions to frame their resident assessment for change in condition when infection is suspected. The ASP will promote nursing procedure to ensure antibiotic time-out to reconcile empirically chosen antibiotic with laboratory test results and susceptibility testing as well as with resident clinical progress. Physician antibiotic orders will be monitored for appropriateness based on documented clinical signs and symptoms, clinical culture results, and resident progress The facility policy, Criteria for Determining the Presence of Infection, states in part, .If an indwelling catheter is present both criteria 1 and 2 must be present: 1. At least one of the following sign or symptom sub-criteria a. Fever, rigors, or new onset hypotension, with no alternate sire of infection. b. Either acute change in mental status or acute functional decline. c. New onset flank or suprapubic pain or tenderness. d. Purulent discharge from around the catheter or acute pain, swelling, tenderness of the testes, epididymis or prostate. 2. Urinary catheter specimen culture with at least 100,000 cfu/ml of any organism. According to revised McGeer Criteria for Urinary Tract Infection Surveillance, a symptomatic UTI must meet the following criteria for a resident with an indwelling catheter, at least two of the following symptoms: fever or chills, new flank/suprapubic pain or tenderness, changes in character of urine, and worsening of mental or functional status. R37 was admitted to facility on 01/29/20. Diagnoses include retention of urine unspecified, other obstructive and reflux uropathy, urinary tract infection, right side paralysis after stroke, type 2 diabetes with insulin use, and dehydration. Minimum Data Set (MDS) confirmed that R37 scored 15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R37 was admitted with indwelling Foley catheter, no trial of toileting program, and 2-person assistance with toileting/catheter care, which is consistent since admission. Physician Orders: change indwelling Foley catheter one time per month pattern: administer on the 16th. Reason for Indwelling Foley: obstructive uropathy monthly. Change Foley bag one timer per month pattern, administer on the 16th. Record review confirmed that R37 has had five UTIs in three months. Surveyor was unable to locate documentation that R37 was seen by urology. Surveyor reviewed record regarding R37's UTIs, and noted that record did not indicate a clear timeline of events, such as R37's symptoms or actual date of onset. On 07/18/23 at 11:13 AM, Surveyor interviewed Director of Nursing (DON) B. DON B reported facility uses McGeers criteria prior to obtaining U/A. DON B stated that many urinalysis (U/A) did not meet criteria. DON B stated that it is difficult with agency staff as she will train and then agency staff leave, or agency staff do not follow facility policy. DON B stated long term staff are trained and educated. DON B reported that antibiotic stewardship training has not been completed in the last 8-10 months. Surveyor requested clarification regarding R37's UTIs. DON B stated that she just created a document for R37's physician outlining the last five UTIs. DON B provided document, dated 6/27/23 confirming R37's history of U/A and urine cultures for the previous three months. Five U/As were collected; all required new catheters to be inserted and treated with antibiotics. -4/7/23, symptoms were rusty colored urine with sediment present, culture came back with mixed flora and treated with nitrofurantoin for 7 days; on 4/12/23 R37 had blood and mucous in urine and ciprofloxacin was prescribed for 7 days. -4/22/23, DON B wrote, I am not sure why this was done as there are no symptoms documented. U/A obtained, culture and sensitivity (C&S) positive for E. Coli >50,000 colony count. C&S was resistive to ampicillin, cipro, and Bactrim. Treated with doxycycline for 7 days. -5/20/23, R37 was seen in the ER and positive for UTI. UTI was discovered as part of a work-up, as there were no urinary symptoms. UTI was treated with nitrofurantoin. C&S positive for proteus mirabilis >50,000, resistive to cipro, Levaquin, tetracycline, and nitrofurantoin. Antibiotic was changed to Bactrim. -6/11/23, catheter irrigation was not successful, scant amount of blood noted, no odor, no blood, urine was golden yellow. Provider ordered lab test with U/A and C&S. DON B wrote, I am truly not sure why there was even a call placed, as when staff changed the catheter it was working. C&S positive for E. Coli resistive to ampicillin, cipro, Levaquin, and Bactrim. 2nd bacteria positive for proteus mirabilis resistive to cipro, Levaquin, tetracycline, and nitrofurantoin. Treated with nitrofurantoin for 7 days. -6/22/23, follow up U/A with C&S ordered by R37's provider on 6/11/23. C&S positive for proteus mirabilis >100,000, resistive to cipro, Levaquin, tetracycline, and nitrofurantoin. Treated with Bactrim for 7 days. On 07/18/23 at 11:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN) L. LPN L stated that staff are to call provider if a resident has two or more signs and symptoms of infection, such as fever, behaviors, or disorientation. LPN L stated that when a resident tests positive for UTI, licensed nurses must observe certified nursing assistants provide catheter care over 4-6 shifts. On 07/18/23 at 11:59 AM, Surveyor interviewed Registered Nurse (RN) M. RN M confirmed facility uses McGeer's criteria, and a resident must have three signs and symptoms of infection before calling provider to obtain a U/A. Signs and symptoms can include fever, discomfort, dysuria, and behaviors. RN M reported sometimes providers will call before C&S is back and prescribe an antibiotic. RN M stated that staff try to educate providers to wait until C&S is back but are not always successful in doing that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility must ensure that a resident is free of any significant medication errors for 1 of 1 resident (R60) reviewed. The facility did not ensure R60 was administered insulin on three separate occasions as ordered from physician. This is evidenced by: The facility policy, entitled Medication Administration, dated 04/03/23, states: Medications are administered in accordance with prescriber orders, including any required time frame. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering should mark the reason in the MAR when signing out medications. R60 was readmitted to the facility on [DATE] and has diagnoses of diabetes mellitus. R60 has physician orders for insulin aspart 18 units three times a day at 7:30 am 11:30 am, and 4:30 pm for type 2 diabetes mellitus. Administration Instructions: Hold if Fasting Blood Sugar is <100. R60's care plan, dated 05/26/23, with a target date of 3 months, states: Potential for ineffective disease management and fluctuating blood glucose. Interventions include blood glucose remain within normal limits. On 07/17/23, Surveyor reviewed Medication Administration Record (MAR) which indicated the following: 06/28/23 at 4:30 pm blood glucose level was 258. Administration of insulin record was blank, 07/01/23 at 11:30 am blood glucose level check and administration of insulin record was blank 07/07/23 at 1130 am blood glucose level check and administration of insulin record was blank On 07/18/23, at 9:37 am, Surveyor interviewed Director of Nursing (DON) B regarding the missing documentation noted on R60's MAR for June 2023 and July 2023. DON B stated that she checks MAR monthly for concerns and will discuss with specific nurse and have them document accordingly and her expectations would be that there are no blanks in MAR without any documentation to support as to why it is blank. On 07/18/23 at 11:28 am, DON B stated that was unable to locate any documentation to support why the missing blanks on his MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure each resident (R) is offered a pneumococcal immunization for 1 (R11) of 5 residents reviewed for immunizations. R11's medical record did not contain documentation of R11 being screened and offered pneumococcal vaccine. Findings include: The facility policy, entitled Pneumococcal Vaccination, dated 04/30/2023, states: 1. Residents are assessed upon admission for eligibility to receive the pneumococcal vaccination, and when indicated, are offered the vaccination within thirty (30) days of admission to the facility. R11 was admitted on [DATE] and has diagnoses that include cerebral infarction (cerebral infarction, or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood) and Chronic Obstructive Pulmonary Disease (COPD refers to a group of diseases that cause airflow blockage and breathing-related problems). Review of R11's medical record did not document an assessment upon admission for eligibility to receive pneumococcal vaccination and was not offered the vaccine. On 07/17/23 at 3:15 PM, Surveyor asked Director of Nursing (DON) B for R11's immunization documentation for pneumococcal vaccine. On 07/17/23 at 9:08 AM, Surveyor reviewed immunizations history for R11. R11's record indicates that R11 received Prevnar 23 in December of 2007 which is not current. On 07/18/23 at 9:57 AM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding missing vaccinations on R11. NHA A replied on 03/22/23 the facility realized that some of our residents' vaccinations were not up to date, so we started a Performance Improvement Plan (PIP) and put this in our Quality Committee meetings. NHA A indicated that the pneumococcal screening process was first attempted on 07/05/23 by calling R11's Power of Attorney (POA) who has not returned any of our calls about this. On 07/18/23 at 10:50 AM, the facility attempted another call to the POA and there was no answer. Surveyor reviewed the facility's PIP dated 03/22/23. The facility did not follow the PIP when R11 was admitted to the facility on [DATE] and was not screened on admission for eligibility to receive pneumococcal vaccination and was not offered the vaccine. The first attempt to contact R11's POA was 07/05/23 with no response and did not follow up until 07/18/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 07/17/23, Surveyor observed R1 receive breakfast tray with no hand sanitization provided prior to eating. R1 can feed self and noted to use fingers to eat pieces of cut up French toast. On 07/17/23, Surveyor observed R58 was handed glass of juice. No hand sanitization provided prior to eating. R58 can feed self with cueing. The facility policy, entitled Hand Hygiene, dated 4/30/2023, states, .Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves .4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene. Resident (R) 44 was admitted to the facility on [DATE] and has diagnoses that include cerebral palsy and autistic disorder. On 07/16/23 at 12:58 PM, Surveyor observed incontinent cares on R44 with CNA D and CNA E. Handwashing after taking off gloves was not done when caring with this resident who was incontinent of both urine and stool by both CNAs. CNA E then touched her own hair with her bare hands, rolled it between her fingers and put her hair in her mouth. CNA E then left the room followed by Surveyor to the nurse's station and was taking her hair out of the rubber band and putting it back into the rubber band before using ABHR at the nurse's station. On 07/18/23 at 8:30 AM, Surveyor interviewed CNA D regarding the proper use of hand hygiene in relation to glove use. CNA D replied when you take off your gloves you need to at least use hand sanitizer to clean your hands. On 07/18/23 at 10:56 AM, Surveyor interviewed DON B, Surveyor asked what is the proper hand hygiene when it comes to glove use. DON B replied whenever you take off the gloves you must use hand sanitizer. Surveyor received policy titled Park Manor, Wound Care dated 4/30/2023. The policy in part states: Procedure: Wash and dry hand thoroughly. Put on exam gloves, loosen tape and remove dressing .pull glove over and discard in appropriate receptacle, wash and dry your hands thoroughly with soap and water or hand sanitizer .put on new pair of gloves and redress as ordered. On 7/17/23 at 9:43 AM, Surveyor observed dressing change to R179's incision to back of her neck. R179 was admitted to the facility on [DATE] with diagnosis of fracture of cervical spine with spinal fusion. Surveyor observed R179 lying in bed with a clean packaged dressing on a towel at bedside. Registered Nurse (RN) C was at bedside with gloved hands and supplies. RN C removed R179's dressing and tape from the back of her neck. The dressing was discarded by RN C. RN C obtained clean tape and clean dressing from package and applied the dressing with tape to the back of R179's neck. RN C did not remove her gloves, perform hand hygiene and don clean gloves after handling the dirty dressing and before proceeding to apply clean dressing. Surveyor spoke with RN C after the observation about infection control expectations. RN C expressed she should have removed her gloves, performed hand hygiene and donned clean gloves when going from removing the dirty dressing and before applying the clean dressing. Surveyor asked RN C why that would be important. RN C expressed it would be important to prevent infection and contamination of R179's incision. Surveyor asked RN C about supplies for hand hygiene. RN C expressed she did not have hand gel in her pocket and should get some and place it in pocket so she can perform hand hygiene between dirty and clean tasks at bedside. On 07/17/23 at 10:40 AM, Surveyor spoke with DON B about the observation. DON B expressed she would expect staff to remove gloves, perform hand hygiene and don clean gloves when going from removing dirty dressing to applying a clean dressing. Hand gel can be used if the dressing is not saturated, and hand washing should be done if the dressing is saturated. Surveyor requested the facility policy regarding infection control practices with wound care. Based on observation, interview and record review, the facility did not establish and implement an ongoing infection prevention and control program to prevent and control the onset and spread of infection to the extent possible as evidenced by the cumulative failures of the following 5 observations. Staff did not practice appropriate donning of Personal Protective Equipment (PPE) and hand hygiene with the care and services of a resident in Transmission-Based Precautions (TBP) for Clostridium difficile (R55), a very contagious bacterium. Staff did not practice appropriate hand hygiene with a dressing change for R179. Staff did not practice appropriate hand hygiene after incontinence cares with R44. Staff did not ensure 2 of 4 residents (R1 and R58) were given the opportunity to wash their hands prior to meal service. This is evidenced by: According to the National Institute of Health (NIH), together with the World Health Organization (WHO), one of the main actions in preventing and controlling the spread of the spore-forming bacterium of Clostridium difficile (C. diff) is to ensure that hands are washed thoroughly with soap and water. C. diff passes through the feces of infected individuals in the form of spores, which can survive for a long time on any surface, such as toilet and sink areas, clothing, sheets, medical equipment, cart handles, and furniture, if these items are not regularly and appropriately cleaned. It is possible for anyone to spread the infection (to themselves or others) because they have not performed hand hygiene properly or kept patient surroundings clean. The NIH and WHO recommends that gloves be worn (together with gown and application of other contact precautions) and hands washed with soap and water if exposure to C. diff is suspected or proven. Even when gloves have been worn, handwashing with soap and water is essential because alcohol-based hand rubs are known to be ineffective against C. diff spores. The facility policy and procedure titled Infection Prevention and Control was reviewed by Surveyors. The facility directs staff on Contact Precautions for Clostridium difficile infections and states, Use contact precautions with residents known or suspected to be infected with epidemiologically important microorganisms that can be transmitted by direct contact with the resident (hand or skin-to skin contact that occurs when performing resident care activities that require touching the resident's skin) or by indirect contact with environmentally surfaces or resident care items in the resident's environment. In addition to Standard Precautions for Contact Precautions, personnel should wear a gown and gloves when they will come into direct contact with the resident or their environment . DQA (Division of Quality Assurance) memo number 11-025 outlines Resident Hand Hygiene. Included in the memo is the following: Resident handwashing is an integral component of all nurse aide training program curriculum. Nurse aides are trained to offer, encourage and/or assist residents to perform handwashing to include but not limited to; before eating . Nursing home feeding assistants are trained to assist residents to wash their hands before eating. Resident (R) 55 has medical diagnoses that include but are not limited to surgical aftercare of digestive system- cholecystectomy, cancer, anemia, coronary artery disease, renal failure, diabetes mellitus, chronic obstructive pulmonary disease, respiratory failure, chronic respiratory failure with hypoxia, pyothorax without fistula, atrial fibrillation and morbid obesity. Surveyor reviewed the most recent Minimum Data Set Assessment completed for R55, which was an annual assessment with an Assessment Reference Date of 5/31/23. According to this assessment, R55 required extensive assistance of staff to meet the most basic tasks of bed mobility, bathing, dressing and toileting. R55 was assessed as being totally dependent on staff for the tasks of personal hygiene, has an indwelling Foley catheter and is frequently incontinent of bowel function. R55 is predominantly on bedrest. R55 has undergone numerous hospital visits (9) since admission to the facility 6/23/22, some of which required antibiotic treatment. The last hospital stay was 6/5/23, in which R55 was found to have developed Clostridium difficile (C. diff) infection, requiring Transmission Based Precautions (TBP) and diligent staff practices to prevent transmission of this bacterium to themselves and other residents. On 7/17/23 at 10:10 AM, Surveyor observed Certified Nursing Assistant R (CNA) conduct morning cares for R55 with the resident's consent. The following was noted: CNA R entered the room donned with a gown and gloves. CNA R removed two pitchers from the over the bed table, one contained water and the other was empty of its contents, in which R55 stated was root beer. CNA R then placed a clean towel over the surface of the table and placed a filled basin of water on the top of this towel with additional bathing supplies. CNA R offered R55 bathing but R55 refused and stated, Just wash down there, referring to the perineal areas as he had an incontinent bowel episode. CNA R proceeded with appropriate cleansing of first the front perineum, also conducting catheter care at this time, rolled R55 onto the left side and began to clean up the large incontinence of feces. Once finished with cleaning up the feces, CNA R retrieved a container of special cream from the nightstand, opened this and applied the cream to the front perineal region. CNA R then replaced the cover and placed it back onto the nightstand. CNA R stated to Surveyor that R55's significant other made the cream at home and brought it in for the resident's use. CNA R did not remove the soiled gloves from cleaning up the feces and wash her hands and don new gloves prior to picking up this container of cream, causing the container to now become contaminated with C. diff bacterium. CNA R then placed a clean heavy soaker pad and brief under R55 and fastened the brief tabs. CNA R then emptied the basin of water in the toilet and began to put away the supplies, still with the same gloves on her hands in which she cleaned up the feces. CNA R then removed the gloves, but did not wash her hands, and covered R55 with the top sheet, removed the blanket on R55's request, pulled up the shades on the window. CNA R then donned a new pair of gloves, but still, did not wash her hands, and removed the garbage from the garbage canister and placed it into the soiled hamper in R55's room. Then CNA R washed her hands with soap and water. CNA R then picked up the water pitcher from the nightstand without gloves on, took it down the hall to fill with ice, returned and opened a bottle of root beer for resident and poured the soda into the pitcher. CNA R then moved the over the bed table closer to R55 and clipped the call light to R55's top sheet. Note: These items are touchable surfaces for R55 and potentially contaminated with C diff bacterium. Gloves should have been worn with touching these items. CNA R then left the room without again washing her hands. Surveyor remained in the room in order to interview R55. During the interview at 10:35 AM, Resident Services Aide/Certified Nursing Assistant P (RSA/CNA) entered the room. Without gloves, RSA/CNA P picked up the empty water pitcher from the over bed table, stated, I am going to change this out for you, removed the straw from the used pitcher, placed it into the soiled hamper, took the pitcher into the hall and placed it onto a cart with additional empty pitchers as well as fresh water pitchers to be passed to additional residents. RSA/CNA P then placed a pitcher of fresh ice water on R55's table. RSA/CNA P did not don gloves prior to touching the water pitcher and straw, and did not wash her hands afterwards. On 07/17/23 at 1:16 PM, Surveyor met with CNA R to discuss the observation and asked her what education and knowledge she had regarding caring for an individual with Clostridium difficile infection. CNA R stated that she is supposed to wear a gown and gloves with cares or emptying the catheter bag and that she needs to wash her hands with soap and water. Surveyor then explained the handling of the cream with the soiled gloves and the potentially contaminated items she handled without gloves (sheet, call light, over the bed table, beverage pitchers, etc) and explained to her that anything the resident may have touched is potentially contaminated with the bacterium. CNA R acknowledged that she should have washed her hands after cleaning up the feces and put on a new pair of gloves before handling all the other objects and then washed her hands again afterwards before leaving the room. On 7/18/23 at 11:36 AM, Surveyor approached Director of Nursing B (DON) in her office. Also present were Nursing Home Administrator A (NHA) and Social Services Director T (SSD). Surveyor asked DON B what the expectations of staff were regarding Clostridium difficile transmission prevention. DON B stated that if staff were entering the room of an infected resident, no need to don PPE if only talking to resident and not touching anything in the room. However, staff were to don gloves and gown prior to conducting any cares of if they will touch the resident or any objects in the room. They are then to wash with soap and water upon leaving room. Surveyor explained the observation made above. DON B acknowledged several breaks in infection control practices by CNA R and stated additional training will be completed. DON B also stated RSA P should have donned a pair of gloves prior to entering the room knowing that she would be handling a used water pitcher.