**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure care plans were developed and implemented for 1 of 2 sample residents (#34) observed during personal care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #34 had a BIMS score of 7 out 15, which indicated severe cognitive impairment, and diagnoses which included renal insufficiency, neurogenic bladder, hypertensive chronic kidney disease, history of traumatic brain injury, and benign prostatic hyperplasia with lower urinary tract symptoms. Further review showed the resident had an indwelling catheter and was dependent on staff for toileting hygiene, personal hygiene, and chair/bed-to-chair transfer. Review of the enhanced barrier precautions care plan initiated on 4/23/24 showed interventions which included .Staff will perform proper donning and doffing of PPE guidelines . The following concerns were identified: a. Observation on 8/21/24 at 10:27 AM showed the resident was seated in his/her wheelchair, in common area, watching television. CNA #2 obtained mechanical lift and attached the lift sling, which was positioned behind the resident, to the lift. The CNA obtained the resident's catheter drainage bag from under the resident's chair, without applying gloves, and attached it to the mechanical lift. After handling the drainage bag, the CNA touched the controls of the mechanical lift, lifted the resident, and positioned him/her over a recliner. The CNA lowered the resident into the recliner and, without applying gloves, removed the catheter drainage bag from the mechanical lift. In addition, the CNA held the drainage bag above the resident's bladder, where urine visible in the tubing flowed toward the resident's bladder, walked it around to the side of the recliner, and placed the drainage bag on the floor next to the recliner. Further observation showed the CNA obtained a blanket and covered the resident, raised the resident's feet, obtained gloves from a box in hanging near the common area and applied them, and wiped down the mechanical lift with sanitizing wipes. b. Review of the indwelling foley catheter care plan last revised on 6/18/24 showed interventions which included Catheter: Position catheter bag and tubing below the level of the bladder . There was no indication the catheter drainage bag should not be positioned on the floor. b. Interview with the DON on 8/21/24 at 3:12 PM revealed the staff member should have donned gloves prior to handling the catheter drainage bag and should not have positioned the bag above the resident's bladder or on the floor. 3. Interview with the DON on 8/22/24 10:13 AM revealed care information should be included on the care plan so staff can know how to provide resident care and staff should follow the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure infection prevention practices were implemented for 2 of 2 sample residents (#18, #34) observed during personal care. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #18 had a BIMS score of 11 out 15, which indicated moderate cognitive impairment, and diagnoses which included hemiplegia or hemiparesis, non-Alzheimer's dementia, and weakness. Further review showed the resident was dependent on staff for toileting hygiene, dressing, and personal hygiene. Review of the ADL self-care performance deficit care plan last revised on 6/12/24 showed interventions which included . [resident name] requires total assist with a full lift for toileting and incontinence care. [s/he] wears a full brief . and . [resident name] is totally dependence [sic] by 1 staff with personal hygiene . The following concerns were identified: a. Observation on 8/21/24 at 10:14 AM showed CNA #1 assisted the resident to his/her room, obtained a mechanical lift, and left the room. At 10:18 AM CNA #1 and CNA #2 returned to the room, attached the lift sling, which was positioned behind the resident, to the mechanical lift, and assisted the resident out of the chair and into bed. The CNAs removed the residents lift sling from the lift, assisted the resident to position side to side, and removed the sling from under the resident. The CNAs removed the resident's pants and brief and CNA #1 performed perineal care due to urinary incontinence. Without removing her contaminated gloves, CNA #1 placed a clean brief under the resident, pulled up the resident's pants, and held the resident's hands. Interview with CNA #1 on 8/21/24 at 10:39 AM confirmed the resident had been incontinent of urine. b. Interview with the DON and ADON on 8/21/24 at 3:18 PM revealed gloves should be removed and hand hygiene performed when they are contaminated and after resident care. They revealed clean items should not be touched or applied with the dirty gloves. Further interview confirmed the CNA should have removed her gloves after performing perineal care and everything she touched with contaminated gloves would be contaminated. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #34 had a BIMS score of 7 out 15, which indicated sever cognitive impairment, and diagnoses which included renal insufficiency, neurogenic bladder, hypertensive chronic kidney disease, history of traumatic brain injury, and benign prostatic hyperplasia with lower urinary tract symptoms. Further review showed the resident had an indwelling catheter and was dependent on staff for toileting hygiene, personal hygiene, and chair/bed-to-chair transfer. Review of the enhanced barrier precautions care plan initiated on 4/23/24 showed interventions which included .Staff will perform proper donning and doffing of PPE guidelines . Review of the indwelling foley catheter care plan last revised on 6/18/24 showed interventions which included Catheter: Position catheter bag and tubing below the level of the bladder . The following concerns were identified: a. Observation on 8/21/24 at 10:27 AM showed the resident was seated in his/her wheelchair, in common area, watching television. CNA #2 obtained mechanical lift and attached the lift sling, which was positioned behind the resident, to the lift. The CNA obtained the resident's catheter drainage bag from under the resident's chair, without applying gloves, and attached it to the mechanical lift. After handling the drainage bag, the CNA touched the controls of the mechanical lift, lifted the resident, and positioned him/her over a recliner. The CNA lowered the resident into the recliner and, without applying gloves, removed the catheter drainage bag from the mechanical lift. In addition, the CNA held the drainage bag above the resident's bladder, where urine visible in the tubing flowed toward the resident's bladder, walked it around to the side of the recliner, and placed the drainage bag on the floor next to the recliner. Further observation showed the CNA obtained a blanket and covered the resident, raised the resident's feet, obtained gloves from a box in hanging near the common area and applied them, and wiped down the mechanical lift with sanitizing wipes. b. Interview with the DON on 8/21/24 at 3:12 PM revealed the staff member should have donned gloves prior to handling the catheter drainage bag and should not have positioned the bag above the resident's bladder or on the floor. 3. Review of the policy titled IFC: Standard Precaution provided by the facility on 8/22/24 showed .D. PPE: Always follow hand hygiene protocol before donning and doffing. a. Gloves: 1. Gloves are to be worn when contact with blood, body fluids, secretions, excretions, or contaminated items are anticipated .3. Gloves are to be changed between tasks and procedures on the same patient after contact with material that may contain high concentration of microorganisms. 4. Gloves are to be removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient .

Based on observation, resident record review, staff interview, professional standard review, and policy and procedure review, the facility failed to ensure administered resident medications were taken in the presence of nursing staff for 1 of 2 resident units (200 unit). The census was 58. The findings were: 1. Observation on 8/19/24 at 5:22 PM showed resident #30 had a medication cup, with medications in it, on the table in front of the resident. Further, observation showed no nurse was present. The resident revealed LPN #1 had dropped it off. 2. Observation on 8/19/24 at 5:55 PM showed resident #47 had a medication cup, with medications in it, sitting in front of resident in dining room. Further, observation showed RN #1 reminded the resident, at 6 PM, to take medication. The RN stated she thought the resident took the medication. 3. Interview with the DON on 8/21/24 at 9:30 AM revealed neither resident was assessed for self-administration of medication and they were not to self-administrator medications. 4. Review of the policy and procedure titled Medication Processing and Administration provided by the facility on 8/21/24 at 10:45 AM by the DON showed .m. a) Process for Administration of Medication .x. The resident is always observed by the licensed nurse during administration to ensure that the dose was completely ingested . 5. Review of the National Library of Medicine's Summary of Safe Medication Administration Guidelines, found at https://www.ncbi.nlm.nih.gov/books/NBK593214/table/ch18adminprntlmeds.T.summary_of_safe_med/ on 9/5/24 showed .Follow a standardized procedure when administering medication for every patient .

Based on observation, resident record review, staff interview, and policy and procedure review, the facility failed to ensure nursing staff dispensed resident medications according to facility policy and procedure for 1 of 2 resident units (200 unit). The census was 58. The findings were: 1. Observation on 8/19/24 at 5:22 PM showed resident #30 had a medication cup, with medications in it, on the table in front of the resident. Further, observation showed no nurse was present. The resident revealed LPN #1 had dropped it off. 2. Observation on 8/19/24 at 5:55 PM showed resident #47 had a medication cup, with medications in it, sitting in front of resident in dining room. Further, observation showed RN #1 reminded the resident, at 6 PM, to take medication. The RN stated she thought the resident took the medication. 3. Interview with the DON on 8/21/24 at 9:30 AM revealed neither resident was assessed for self-administration of medication and they were not to self-administrator medications. 4. Review of the policy and procedure titled Medication Processing and Administration provided by the facility on 8/21/24 at 10:45 AM by the DON showed .m. a) Process for Administration of Medication .x. The resident is always observed by the licensed nurse during administration to ensure that the dose was completely ingested .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, incident log review, and incident investigation review the facility failed to ensure basic life support and advance directives were followed in 1 of 5 sample residents (#1) reviewed for advance directives. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on [DATE]. The findings were: 1. Review the admission minimum data set (MDS) assessment dated [DATE] showed resident #1 had a brief interview for mental status (BIMS) score of 12 out of 15, which indicated moderate cognitive impairment, and diagnoses which included medically complex conditions, atrial fibrillation or other dysrhythmias, pneumonia, depression, respiratory failure, and anxiety disorder. Review of a provider comprehensive 30 day note dated [DATE] and timed 10:52 AM showed .Code status: Full Code . [S/he] was admitted [DATE] - [DATE] for sepsis due to multifocal community-acquired pneumonia (CAP) with acute hypoxic respiratory failure treated with IV antibiotics . Skilled SNF admission for care and physical therapy. Goal is to return to home with assistance from family . The following concerns were identified: a. Review of a progress note dated [DATE] and timed 9:30 AM showed .Writer stated that if s/he wished to pursue hospice, communication could be sent to Doctor (Dr.) [name] for orders to be evaluated .[Daughter name] stated that she thinks the [facility name] would better suite [residents' name]. This information an [sic] request was discussed with nursing management to begin the process of getting hospice orders and a referral for services . b. Review of a progress noted dated [DATE] and timed 10:37 AM showed . [Daughter name] asked that we review options for hospice and keeping his/her mother/father comfortable. Social worker and writer will review with attending . c. Review of a progress note dated [DATE] and timed 12:02 PM showed .Writer communicated with Dr [name] and updated conversation from daughter [name] and social worker. Dr [name] agreed with request for hospice evaluation . d. Review of a progress note dated [DATE] and timed 9 PM showed .Resident sleeping respiratory rate - 28 . e. Review of a progress note dated [DATE] and timed 9:33 PM showed .Resident stopped breathing at 9:15 PM. House supervisor came, pronounced death at 9:20 PM. Called POA at 9:26 PM. Family wants to come in and view resident . f. Interview with the LPN #1 on [DATE] at 8:25 AM confirmed he was the nurse on shift when resident #1 passed away and revealed he did not know or check the resident's code status at the time of passing. The LPN revealed the resident was in a lot of pain and the LPN was trying to get it under control. The LPN revealed he had heard the resident was on hospice when s/he passed away and his/her respirations were 28 when last checked. The LPN revealed he contacted the unit manager and they both thought the resident was DNR because of hospice. The LPN revealed when he identified the resident's code status was full code, he did not feel it would look good to initiate CPR as the family was already at the facility. 2. Review of the policy and procedure titled Code Blue Procedure provided by the administrator on [DATE] at 4:59 PM showed .In the event of a cardiac arrest or respiratory arrest, verify Code status in electronic medical record (EMR). Once verified, Basic Life Support (CPR) will be initiated per code orders and continued until the EMS arrives . 3. Review of the Advanced Directive Action Plan LTC dated [DATE] showed the following: a. Review of the Incident Report - with Follow-up as of [DATE] showed the facility interviewed the LPN and other staff on duty at the time of the incident. The report showed the staff member did not follow policy/process for code status. The staff member was suspended and terminated. All appropriate agencies were contacted. b. The facility verified all resident code status was correct beginning [DATE]. c. The facility performed in-service and 1:1 education beginning on [DATE]. Staff signatures of attendance were verified during the survey. d. The facility updated the policy on [DATE]. e. The facility initiated resident code status review at each care conference beginning [DATE]. 4. Review of the QAPI monthly agenda showed the facility addressed resident code status in January and February meetings. 5. Reviewed the IDT tracking sheets showed the facility team met 3 times a week and under the orders section of their audit triggered any changes or new orders including code status. 6. Review of the staff education Resident Code Status dated [DATE] showed the facility had educated the staff. Interviews during the survey confirmed staff education was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure baths or showers were provided routinely for 1 of 6 sample residents (#109) who required assistance with ADLs. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #109 admitted to the facility on [DATE], had a brief interview for mental status score of 13 out 15 (which indicated the resident was cognitively intact), and diagnoses which included atrial fibrillation, coronary artery disease, heart failure, hypertension, arthritis and osteoporosis. The following concerns were identified: a. Review of the ADL self-care performance care plan last revised on 4/19/23 showed the resident required limited assistance by 1 staff person with bathing/showering as necessary. Further review showed no indication of the resident's bathing preferences related to the frequency of bathing. b. Review of the progress notes showed the resident discharged from the facility on 4/21/23 c. Review of the bathing record from 3/30/23 through 4/30/23 showed the resident received bathing on 3/31/23 and 4/4/23. The resident refused bathing on 4/21/23. There was no other evidence of bathing or refusals for 17 days between 4/4/23 and 4/21/23. d. Interview with the DON on 7/13/23 at 4:27 PM revealed residents should have bathing 2 to 3 times per week and staff should follow the resident preferences. e. Interview with the DON on 7/13/23 at 4:56 PM revealed she checked the bathing lists and found the resident was not on the list during his/her stay. The DON revealed she asked staff about the resident, and to their knowledge, the resident was self-care. She revealed staff gave him/her the supplies and s/he performed the bathing him/herself. Further interview confirmed the facility had no evidence the resident received or refused bathing during his/her stay except on the days documented in the electronic health record (EHR). f. Review of the policy titled Bathing Residents provided by the facility on 7/13/23 showed .2. The Bath Aide will schedule residents for two baths per week. If a resident requests more or less than two baths, the Bath Aide will notify supervisory staff, and this information will be reflected on the resident's care plan. Resident will be given the choice of a bath or shower .14. The Bath Aide is to document all care provided in the eHR .16. The Bath Aide will keep supervisory staff informed on a regular basis of issues that arise, i.e., resident refusal to bath, schedule changes, concerns or complaints .

Based on review of medical records, staff interview and policy review, the facility failed to ensure a monthly medication regimen review was performed by a licensed pharmacist at least once monthly for 1 of 5 sample residents (#8) reviewed for unnecessary medications. The findings were: 1. Review of the electronic health records for resident #8 showed there was no evidence a monthly medication regimen review was performed for the months of April 2023 and June 2023. 2. Interview with the director of pharmacy on 7/13/23 at 8:29 confirmed the monthly medication regimen review was not completed for resident #8 during April 2023 or June 2023 and the medication regimen review should be completed monthly. 3. Review of the policy and procedure titled Medication Regimen Review (MRR) Pharmacy provided by the facility on 7/13/23 showed .A pharmacist will perform a medication regime review and clinical review on each Long Term Care resident at the time of the resident's admission to the facility, at least monthly, and when requested by facility staff or attending/consulting provider .

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure medications were properly labeled to include expiration dates for 1 of 2 medication storage areas (second floor medication cart). The findings were: 1. Observation on 7/12/23 at 2:26 PM showed a bottle of Carbidopa/levodopa (decarboxylase inhibitor) 25-100 milligrams (mg) capsules and a bottle of hydrochlorothiazide (diuretic) 25 mg tablets for resident #52 did not have expiration dates. Interview with LPN #1 and RN #1 at that time confirmed neither bottle had an expiration date and revealed both medications were being administered to the resident from the bottles. 2. Interview with the administrator on 7/13/23 at 4:06 PM revealed the facility expected the admitting nurse and pharmacist to verify the medication bottles, brought to the facility by residents had proper labels before the medications were administered. 3. Review of the policy titled Medication Processing and Administration, provided by the facility on 7/13/2023, showed .c) Labeling requirements for medication for LTCC residents .b. All medications will be labeled with the following information .i. innovator brand or non-innovator .iv. Expiration date .c. improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy .

Based on observation, staff interview, and policy and procedure review, the facility failed to ensure appropriate infection prevention practices during observations of care for 1 of 8 sample residents (#35). The findings were: 1. Observation on 7/12/23 at 3:12 PM showed LPN #1 and RN #1 entered the room of resident #35. At 3:13 PM, LPN #1 exited the room wearing gloves and holding her hands at shoulder height. The LPN walked down the hallway to the nurse's station, without touching items in the hall, and encountered a CNA. The CNA obtained a measuring tool from the nurse's station and walked with the LPN to the resident's room. Upon reentry to the resident's room, RN #1 assisted the resident to roll to his/her right side and the LPN lowered the resident's brief. The LPN used the measuring tool to measure a small open area near the resident's coccyx. At that time, the LPN touched the resident's skin with her gloved hands and manipulated the measuring device and the resident's skin, to obtain wound measurements. When she finished measuring the area and without changing gloves, the LPN touched the outside of the resident's brief to pull it to the proper position, and touched the exterior of the resident's pants to pull them up. 2. Interview with the infection preventionist on 7/13/23 at 2:30 PM revealed staff should remove gloves before exiting a room and should not touch clean items after contact with potentially contaminated surfaces. Further interview confirmed the nurse should have removed her gloves before going into the hallway and she should not have touched the resident's clothing with the gloves worn to measure the resident's wound. 3. Interview with the DON on 7/13/23 at 2:39 PM confirmed the nurse should have removed her gloves before exiting the resident room and should not have touched the resident's brief or clothing with potentially contaminated gloves. 4. Review of the policy titled Hand Hygiene provided by the facility on 7/13/23 showed . Indications for Hand Hygiene .5. Hand Hygiene will be performed: Before and after patient contact. After contact with a patient's intact skin (e.g. when taking a pulse or blood pressure, and when lifting a patient). After contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. Before donning sterile gloves when doing an invasive procedure. After removing gloves. Gloves must be changed between patients or when moving from a contaminated site to a clean site, or when moving from an area where gloves were applied .

Based on observation, staff interview, review of the US Food Code, and policy and procedure review, the facility failed to ensure the food storage equipment was maintained in a clean and sanitary manner in 1 of 1 kitchens. The census was 52. The findings were: 1. Observation on 7/11/23 at 7:04 AM showed the top of the Blodgett oven, Rational Self-Cooking Center, and the Metro c5 1 series proofing cabinet were soiled with dark discolored dust and grime. Further observation showed extra racks were stored on top of the rational self-cooking center and a cookie sheet was stored on top of the Blodgett oven, and had discolored dust and grime on them. 2. Observation on 7/13/23 at 10:53 AM showed the top of the Blodgett oven, Rational Self-Cooking Center, and the Metro c5 1 series proofing cabinet remained soiled with dark discolored dust and grime. Further observation showed the extra racks remained on top of the rational self-cooking center and a cookie sheet remained on top of the Blodgett oven, and continued to have discolored dust and grime on them. 3. Interview with the executive chef on 7/13/23 at 11:19 AM revealed the equipment was scheduled to be cleaned last Sunday; however, he was unable to get them cleaned and put them on the cleaning list for the following Sunday. He confirmed he was the individual who cleaned the ovens; however, he did not clean the top of them. Further interview confirmed the discolored dust and debris were present and could be transferred to food items. 4. Review of policy titled Food Safety and Sanitation provided by the facility on 7/13/23 showed .7. Work surfaced [sic] and equipment should be thoroughly cleaned after each use . 5. According to Food Code 2017, U.S. Public Health Service: 4-601.11 (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch . (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of policy and procedure, the facility failed to ensure appropriate behavior monitoring and interventions were in place for 2 of 5 sample residents (#7, #55) reviewed for unnecessary medications. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #7 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and had diagnoses which included non-Alzheimer's dementia and insomnia. Further review showed the resident had mild depression with a severity score of 2 out of 30 and no additional coded behaviors. Review of the physician orders showed the resident received doxepin hydrochloride (antidepressant) 50 milligrams (mg) by mouth daily at bedtime for adjustment disorder with depressed mood. Review of the depression care plan last revised on 8/2/22 showed interventions which included .Document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness .Document/report PRN any s/sx [signs or symptoms] of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness . The following concerns were identified: a. Review of the medication administration record (MAR) and treatment administration record (TAR) for July 2022, August 2022, and September 2022 showed the facility had monitoring in place for withdrawal symptoms related to the use of psychotropic medication; however, there was no evidence the facility was monitoring the resident for identified target symptoms. b. Interview with the administrator on 9/29/22 at 9:35 AM confirmed behavior symptoms related to medication withdrawal were listed on the TAR; however, there was no monitoring of identified target symptoms for the medication. c. Review of the CNA Behavior Monitoring and Interventions report from 6/28/22 through 9/28/22 showed panic was observed on 7/24/22, expressions of frustration/anger, other behaviors not directed at others, and refusing care was observed on 9/3/22, anxious/restless and refusing care was observed on 9/12/22, and expressions of frustration/anger, agitation, and withdrawn/isolation was observed on 9/17/22. No other behaviors were observed during the time period and resident-specific identified target symptoms identified on the care plan were not monitored. d. Review of the behavior care plan last revised on 8/2/22 showed no identified non-pharmacological interventions related to identified target symptoms. 2. Review of the significant change MDS assessment dated [DATE] showed resident #55 had a BIMS score of 9 out of 15, which indicated the resident had moderate cognitive impairment, and had diagnoses which included depression, and insomnia. Further review showed the resident had mild depression with a severity score of 5 out of 30 and no additional coded behaviors. Review of the physician orders showed the resident received escitalopram oxalate (antidepressant) 10 mg by mouth daily for major depressive disorder and eszopiclone (sedative-hypnotic) 3 mg by mouth at bedtime for insomnia. Review of the depression care plan last revised on 8/5/22 showed interventions which included .Document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness .Document/report PRN any s/sx of depression, including: hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, tearfulness . The following concerns were identified: a. Review of the medication administration record (MAR) for July 2022, August 2022, and September 2022 showed no evidence the facility was monitoring the resident for identified target symptoms. b. Review of the sedative/hypnotic care plan last revised 8/8/22 showed no resident-specific target symptoms for use of the medication or identified non-pharmacological interventions. c. Review of the depression care plan last revised on 8/5/22 showed no identified non-pharmacological interventions related to identified target symptoms. d. Interview with the DON, SSD, and first floor unit manager on 9/29/22 at 8:44 AM revealed the resident was on as needed behavior monitoring and was not being monitored for target symptoms unless the symptoms occurred. 3. Interview with the DON, SSD, and first floor unit manager on 9/29/22 at 8:42 AM revealed resident care plans should have the target symptoms identified for each medication. Behavior tracking is performed by the CNAs in ADL charting; however, specific identified target symptoms were not part of the CNA tracking. Further interview revealed the facility staff should utilize progress notes for charting of target symptoms. 4. Review of the policy titled Monitoring Chemical/Physical Restraints which was un-dated and provided by the facility on 9/29/22 showed .A .2. Upon recognizing a specific behavior that does/or could adversely affect a patient, the RN/LPN or C.N.A. observing the behavior will start a Behavior Monitor. Place the Behavior Monitor in the Medication Administration Review (MAR) notebook. A Behavior Monitor from [sic] will be initiated before a new order (or change in an order) for a psychoactive medication is started. The Social Worker will review behavior monitors on an ongoing basis and will recommend any further approaches to be used for behavior management .B .1. Before a resident is started on psychoactive medication, nursing service will document specific behaviors on the Behavior Monitor form. 2. If a new psychoactive medication is ordered or a medication change is begun, the Behavior Monitor will also be used. The resident's behavior will be monitored to assess change, including side effects and adverse reactions .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, review of the Centers for Disease Control (CDC) guidance, and policy review, the facility failed to ensure oxygen tubing and nasal cannulas were stored in a way that ensured they were protected from contamination for 2 of 6 sample residents (#8, #27) reviewed for oxygen use. Additionally, the facility failed to ensure appropriate personal protective equipment (PPE) was used during 2 random observations. The census was 59. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #27 had a BIMS score of 9 out 15, which indicated moderate cognitive impairment, diagnoses which included multiple sclerosis and chronic obstructive pulmonary disease (COPD), and required extensive physical assistance of 1 person for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. Further review showed the resident had shortness of breath or trouble breathing with exertion and used oxygen therapy. Review of the oxygen therapy care plan last revised on 8/10/22 showed interventions which included Oxygen Settings: O2 via nasal cannula. The following concerns were identified: a. Observation on 9/28/22 at 4:30 PM showed oxygen tubing dated 9/13/22 was connected to an inline wall-mounted oxygen regulator. The oxygen tubing was placed in a recliner in the resident's room, and was lying on top of a pair of shoes. The nasal cannula was in direct contact with the bottom of the shoe sole. b. Observation on 9/28/22 at 6:57 PM showed the resident was in his/her room and the nasal cannula, dated 9/13/22, was inserted in the resident's nares. c. Observation on 9/29/22 at 9:38 AM showed the resident was in his/her room seated in the recliner, and the nasal cannula which was dated 9/13/22, was inserted in the resident's nares. 2. Review of the quarterly MDS assessment dated [DATE] showed resident #8 had a BIMS score of 9 out of 15, which indicted moderate cognitive impairment, and had diagnoses which included COPD and respiratory failure. Further review showed the resident required limited physical assistance of 1 person for mobility and transfers and required oxygen therapy. Review of the resident's physician orders showed maintain SAO2 [arterial oxygen saturation] greater than or equal to 90%. Further review showed the resident received DuoNeb solution (0.5-2.5 mg) via nebulizer four times per day and a Pulmicort flexhaler 1 inhalation two times per day. Review of the oxygen therapy care plan dated 7/21/21 showed interventions which included oxygen via nasal cannula at 6 liters at night and as needed during the day. The following concerns were identified: a. Observation on 9/28/22 at 9:48 AM showed the resident used oxygen from an E cylinder attached to a wheelchair while out of the room and oxygen from a inline wall-mounted oxygen regulator while in the room. The oxygen tubing connected to the inline wall-mounted oxygen regulator was dated 9/28/22 and the nasal cannula was observed lying on the floor, under the wheelchair wheels. b. Observation on 9/29/22 at 8:19 AM showed the resident was in his/her room and the nasal cannula, dated 9/28/22, was inserted in the resident's nares. 3. Interview with CNA #1 on 9/29/22 at 9:48 AM revealed all oxygen tubing was changed out monthly unless it was dirty or fell on the floor. Further interview revealed when a staff member observed oxygen tubing which was stored incorrectly or dirty, the staff member should change the tubing. 4. Interview with the administrator on 9/29/22 at 9:50 AM confirmed oxygen tubing should be changed if it was dirty or not stored correctly. 5. Review of a LTCC [long term care center] EOC/IFC Rounds Checklist which was un-dated and provided by the facility on 9/29/22 showed .VI A. O2 tubing is changed routinely by CP. O2 signs are posted appropriately. B. O2 tubing is placed in plastic bag when not in use . 6. Observation on 9/26/22 at 5:55 PM showed LPN #1 arrived on the second floor wearing a cloth face mask. The LPN entered a door behind the nurses' station with another staff member. Observation on 9/26/22 at 6:18 PM showed LPN #1 was standing at the nurses' cart and wore a cloth mask. Interview with the LPN at that time confirmed the face mask was cloth and revealed the face mask was not provided by the facility. 7. Observation on 9/26/22 at 6:09 PM showed dietitian #1 wore a cloth mask in the dining room during meal service. 8. Interview with the infection preventionist on 9/28/22 at 12:55 PM revealed anyone doing frontline care was required to wear a medical mask and cloth masks should not be used in resident care areas. Further interview revealed the facility was in COVID outbreak status and the community transmission rate was substantial at that time. 9. Review of the policy titled COVID Response Plan which was un-dated and provided by the facility on 9/29/22 showed .Source Control .HCP [health care personnel] should use surgical masks when masks are required as per CDC Guidance, Community levels and outbreak . 10. Review of the CDC Guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic last revised 9/23/22 showed .Cloth mask: Textile (cloth) covers that are intended primarily for source control in the community. They are not personal protective equipment (PPE) appropriate for use by healthcare personnel .