BRIARCLIFF HEALTH CENTER OF GREENVILLE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 3 resident reviewed for resident records.The facility failed to reflect that Resident # 1 presented with alterations in skin integrity on daily Skilled Evaluation forms. This failure placed residents at risk of having inaccurate assessments to include those with alterations in skin integrity, that could lead to residents not receiving care as needed due to inaccurate medical records.The findings included: Record review of Resident # 1's EMR and face sheet dated 10/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/05/2025. Her diagnoses included: Right femur (thigh bone) fracture, sacral region (area of the back and buttock) pressure ulcer, right buttock pressure ulcer, left buttock deep tissue injury, MRSA (Methicillin Resistant Staphylococcus Aureus, a type of bacteria that is resistant to many antibiotics), right lung cancer with lobectomy (removal of lobe of lung), post-operative anemia (blood loss after surgery), and Osteoporosis (a bone disorder where bones become thinner). Record review of Resident #1's admission MDS assessment dated [DATE] reflected that she was admitted from a short-term general hospital. The MDS report indicated she admitted with surgical wounds after hip replacement, an unstageable pressure ulcer to her right buttocks, a Stage 2 pressure ulcer to her sacrum and a deep tissue injury to her left buttock. She scored 15/15 on her BIMS which signified she was cognitively intact. Record review revealed resident required supervision in eating, maximum assistance in toileting, moderate assistance in upper body dressing and was dependent in lower body dressing, bathing, bed mobility and transfers. Record review of Resident #1's nurse's Skilled Evaluation assessments dated 08/12/2025 (completed by LVN A), 08/21/25 (completed by LVN A) and 08/25/25 (completed by LVN B) revealed that no skin issues or surgical wounds were identified, and no isolation-Active Infectious Disease or Contact Isolation precautions were identified. An interview on 10/08/2025 at 10:51 a.m. with LVN A revealed skilled charting is done on all new admissions and on residents receiving skilled services. LVN A stated that there is a section on the skilled evaluation form to check off any skin concerns. LVN A stated she tries to be accurate when completing the evaluation form. An interview on 10/08/2025 at 2:00 p.m. with LVN B revealed that the skilled evaluation form should reflect the current conditions of each resident. LVN B stated that she does not measure the wounds herself, but that active skin concerns and infections should be checked off on the skilled evaluation note. An interview on 10/08/2025 at 2:40 p.m. with Tx Ns confirmed that Resident #1 did admit with right hip surgical sites with sutures and staples, and a sacral, right buttock pressure ulcer and a left buttock deep tissue injury. An interview on 10/08/2025 at 3:30 p.m. with the DON revealed that she expects nursing staff to accurately identify and code current skin issues and infection control concerns on the daily skilled charting for all residents. The DON stated that the facility had recently changed assessment forms as the Skilled Evaluation form was complicated and too long. The DON stated the failure to ensure accuracy of documentation could place the residents at risk for missed assessment that could result in harm to residents. An interview on 10/08/2025 at 3:30 p.m. with the Administrator revealed that she expected nursing staff to follow all protocols and procedures for accurate documentation for all residents. The Administrator stated that poor documentation reflects on the credibility of nursing care and facility overall. Record review of policy and procedures titled Charting and Documentation, Revised October 2021 revealed medical records should be complete and accurately document residents' medical condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 3 residents (Resident #1) reviewed for pest control.The facility failed to ensure Resident #1's room remained free from ants. Resident #1 had ants in her bed on 07/27/25.This failure could place residents at risk of injury or infection related to ant bites, unsanitary environment, and decreased quality of life. <BR/>Findings include:<BR/>Record review of Resident #1&rsquo;s face sheet, dated 7/28/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included lack of coordination, abnormal posture, abnormalities of gait and mobility. <BR/>Record review of Resident #1&rsquo;s admission MDS, dated [DATE], indicated she was cognitively intact with a BIMS score of 14. Resident #1 was dependent on staff for transfers. She required substantial to maximal assist with bed mobility with the helper doing more than half of the effort. <BR/>Record review of Resident #1&rsquo;s care plan, dated 6/9/25, indicated she was total dependent on staff for bed mobility, dressing, toilet use, transfers and walking.<BR/>Record review of the facility&rsquo;s Pest Control Chemical and Log Sheets indicated service was provided to the facility on 5/2/25, 6/2/25 and 7/2/25 treatment to all permissible areas for roaches, crickets, spiders, silver fish and ants. <BR/>Record review of the facility insect report sheet indicated on 7/25/25 there were ants reported in Resident #1&rsquo;s room.<BR/>Record review of Resident #1&rsquo;s nursing notes, dated 7/27/25 at 8:15 a.m., indicated Resident #1 was noted with medium bleeding from the perineal area and a small amount of blood on the upper tubing of her foley catheter. She was also noted with several small ants in her bed and over her thigh. The resident was sent to the hospital. <BR/>Record review of Resident #1&rsquo;s hospital records, dated 7/27/25, indicated the resident had blood in her urine and stool. She had a foley and a colostomy with blood in both. The EMS said the resident was laying in a bed that was covered with ants. The skin assessment indicated no rashes or lesions.<BR/>During an observation on 7/28/25 at 9:20 a.m. Resident #1&rsquo;s room showed it was clean there were no clothes in the closet, the smell of bug spray was noted. Observation of the room did not show any signs of ants, the bed had been stripped of everything including the mattress. During an observation on 7/28/25 at 9:23 a.m. the three rooms that share the same outside wall and courtyard as Resident #1&rsquo;s room, did not show any signs of ants. There were no signs of ants inside or outside. Observations showed snacks in two of the rooms without any ants being visible.<BR/>During an interview on 7/28/25 at 9:15 a.m. the Administrator said Resident #1 was sent to the hospital yesterday, 7/27/25 due to GI bleed. She said the staff reported they saw ants in Resident #1&rsquo;s bed. The room was sprayed after she left. The Administrator said Resident #1 had a lot of snacks in her room, and the room was cleaned. <BR/>During an observation and interview on 7/28/25 at 9:30 a.m., CNA A said she worked on 7/27/25 and was present when Resident #1 was sent out to the hospital. She said RN B called her to the room and Resident #1 was in bed. She said Resident #1 said she felt &ldquo;tingly.&rdquo; CNA A said Resident #1 could not get up unassisted and required a Hoyer for transfer. She said when RN B pulled the covers back, Resident #1 had ants on her. CNA A said it was not a lot of ants, just a few. She said she did not know if the resident had been bitten or not, she could not tell. She said the ants appeared to be coming from her back and coming from around her right thigh. She said she did not see any bites the resident said she felt &ldquo;itchy,&rdquo; but did not say she was bitten. CNA A said said Resident #1 used the A bed. She said the ants were mostly on Resident #1&rsquo;s nightstand and on the handrail on the right side of the bed. Observation of Resident #1's room did not reveal any ants. CNA A said she pulled the sheets off the bed and the housekeeper cleaned and sprayed the room on 7/27/25. <BR/>During an interview on 7/28/25 at 10:00 a.m. the Housekeeper stated she worked on 7/27/25. She said when she arrived in Resident #1&rsquo;s room she saw one or two ants on the side rail. She said she disinfected the bed. She said a nurse brought in liquid to kill the ants. She said the family took the resident&rsquo;s clothes. The Housekeeper said it was just a few ants. The Housekeeper said she did not see the resident; she only came in after she was gone and cleaned the room. <BR/>During an observation and interview on 7/28/25 starting at 10:05 a.m., the Maintenance Director said someone told him on Friday, 7/25/25 Resident #1 had ants at the head of the bed. (He could not recall who, and interviews with staff did not reveal who.) He said he had gone into the room, looked, and did not see any ants. He had taken his flashlight and did a thorough search of Resident #1&rsquo;s room. He said just to be on the safe side he went on the outside and around the perimeter of that hall and spayed. The Maintenance Director said he was not allowed to spray a room if a resident resided in it. He said he did not see any mounds or any live active ants on Friday, 7/25/25. He said he was told today there were ants in Resident #1&rsquo;s room on 07/27/25. The Maintenance Director shined a flashlight on Resident #1's bed, wall, floor, nightstand and window seal and no ants were seen. Observation with the Maintenance Director of the outside perimeter of the E hall did not reveal any mounds, or live visible ant activity. He said when he sprayed, he usually spayed on the ground, and around the window unit. He used Ortho B-gone insect killer that was labeled for ants, roached, and spiders. He said he was told sometimes the ants made nests in the walls. He said they had a pest control company, and they came and treated the inside and the outside of the facility monthly. <BR/>During a telephone interview on 7/28/25 at 10:46 a.m., RN B said she had gone into Resident #1&rsquo;s room to administer medications. She said she had saw several ants and had pulled the covers back. She said there were several ants around Resident #1&rsquo;s right thigh. She said there were more ants on the bed. RN B said it appeared the ants were coming from the night stand up the call light to the side rail of the bed. She said they took the snacks out of the way and cleaned the side rail. She said they were busy trying to get the ants off the resident, she was not sure if Resident #1 had any bites or not. RN B said she performed a skin assessment and there were some pinpoint red marks on the right thigh, but she was not sure if they were ant bites or not. She said Resident #1 said she felt &ldquo;tingly&rdquo; Resident #1 did not know if she was bitten or not. She said Resident #1 was sent to the hospital due to a possible GI bleed. RN B said Resident #1 had a pressure sore and the dressing was intact, and skin tears on her right arm with the dressing intact. She said there were no ants noted in those areas. RN B said CNA A and the weekend supervisor, RN C, were in the room to assist with getting Resident #1 ready to send to the hospital. <BR/>During a telephone interview on 7/28/25 at 10:59 a.m., RN C said she was in the room with RN B to help Resident #1 and get her sent out to the hospital due to a possible GI bleed. She said she noticed ants on the bed on 7/27/25 and could see them moving around. She said she did notice ants were coming from the nightstand on the call light onto the bed. She said it appeared there were snacks on the nightstand. RN C said she saw ants on Resident #1&rsquo;s feet and couple on her thigh. She said Resident #1 did not know the ants were there. She said Resident #1 said, &ldquo;I feel prickly&rdquo;. RN C said Resident #1 could not tell if she was being bitten or not. She said the ants were small and light brown. RN C said she would not have seen the ants if they were not moving. RN C said she could not see any bites and did not see any ants attached to Resident #1. She said housekeeping did most of the cleaning. RN C said she spayed, and CNA A packed up all the snacks and bagged the sheets. <BR/>During an interview on 7/28/25 at 1:25 p.m., the hospital RN charge nurse said she was not aware Resident #1 had of any ant bites. She said Resident #1 had a lot of edema and it was hard to tell if she had any skin issues. She said the family was in the process of placing Resident #1 on hospice. She said she did not want to disturb the resident or family due to the resident&rsquo;s current condition. <BR/>During an observation and interview on 7/28/25 at 1:30 p.m. revealed Resident #1 was asleep in a hospital bed and did not awaken during the visit. There were several family members present. The family members said on 7/27/25 Resident #1 said she was bitten by ants. They said she mentioned the day before she thought there were ants in her bed. Observations were conducted during the interview of Resident #1&rsquo;s left hand which had one small red area on her wrist and two small red areas on the top of her hand by her thumb that could have been ant bites. The family said they noted what they thought was a bite on her right inner arm. Observation of Resident #1&rsquo;s right arm had an IV tapped and was not visible. Observation of Resident #1&rsquo;s right thigh did not show any visible red marks. Resident #1 did not wake up during the visit. <BR/>During an interview on 7/28/25 at 2:30 p.m., the Pest Control Technician said he was called out due to ants being found in Resident #1&rsquo;s room on 7/27/25. He said he did a thorough inspection of the room and found one dead ant on the window seal of the room. He said he believed it was a sugar ant. He said they did not live in mounds but lived in a tree or were they had easy access to food. He said he put bait out and went to every room to include Resident #1&rsquo;s room and put preventive measures in place. He said he came to the facility once a month and as needed for pest control issues. <BR/>Record review of the facility&rsquo;s Pest Control Policy, dated 9/22/23, indicated the facility shall maintain an effective pest control program. This facility maintains and on-going pest control program for insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 24 residents (Resident #20 and Resident #74) reviewed for resident rights.<BR/>The facility did not ensure Laundry Aide N knocked, introduced herself, and explained what she was doing prior to entering Resident #20's and Resident #74's room. <BR/>This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.<BR/>Findings included:<BR/>1.Record review of the face sheet, dated 11/18/2024, revealed Resident #20 was a [AGE] year old female with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy (diabetic neuropathy was a common and serious complication of type 2 diabetes that occurs when high blood sugar damages nerves over time), acute respiratory failure with hypoxia (a medical emergency where the lungs are unable to adequately provide oxygen to the blood, resulting in dangerously low oxygen levels in the body (hypoxia), and occurring rapidly or suddenly), unspecified diastolic (congestive) heart failure (occurs when the heart's left ventricle stiffens and can't fill properly with blood).<BR/>Record view of the quarterly MDS assessment, dated 07/15/2024, revealed Resident #20 was usually able to make herself understood and understood others. The MDS assessment indicated Resident #20 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #20 required assistance with toileting, partial moderate assistance with personal hygiene, and supervision for eating. The MDS assessment did indicate the use of oxygen. <BR/>Record review of care plan, with a revision date of 08/02/2024, indicated Resident #20 was dependent on staff for activities, cognitive stimulation, social interaction, and interventions included for all staff to converse with resident while providing care. <BR/>During an observation and interview on 11/18/2024 at 11:00 a.m., Surveyor was in Resident #20's room and Laundry Aide N entered the room, went inside Resident #20's closet to place a clothing item, and exited the room. Laundry Aide N did not knock prior to entering the room, and she did not introduce herself. Laundry Aide N did not explain to Resident #20 what she was doing in her room or why she was going in her closet. Resident# 20 stated the staff did not ever knock before entering and she did not like it. <BR/>2. Record review of the face sheet, dated 11/18/2024, revealed Resident #74 was a [AGE] year-old male with diagnoses which included quadriplegia, unspecified (a diagnosis code for paralysis of all four limbs, including the arms and legs, and the chest and abdominal muscles), sick sinus syndrome (a heart condition that occurs when the heart's natural pacemaker, the sinoatrial (SA) node, was damaged and can't generate normal heartbeats), cervical radiculopathy (occurs when a nerve root in the neck was compressed or irritated).<BR/>Record view of the quarterly MDS assessment, dated 09/15/2024, revealed Resident #74 was able to make himself understood and understood others. The MDS assessment indicated Resident #74 had a BIMS score of 15, which indicated his cognition was intact.<BR/>Record review of care plan, with a revision date of 08/20/2024, indicated Resident #74 would maintain involvement in cognitive stimulation, social activities. Intervention: all staff will converse with resident while providing care.<BR/>During an observation and interview on 11/18/2024 at 11:20 a.m., surveyor observed Laundry Aide N go into Resident # 74's room without knocking. Resident #74 stated he felt like it was disrespectful for the staff to enter into his room without knocking first. <BR/>During an interview on 11/18/2023 at 11:33 a.m., Laundry Aide N stated when entering a resident's room, she was supposed to knock, introduce herself and let the resident know why she was in their room. Laundry Aide N stated she did not knock, identify herself, or let Resident #20 know what she was doing because she just forgot. Laundry Aide N stated it was important to knock, introduce herself, and let the residents know what she was doing in their room so they would not feel uncomfortable, for them to know who she was and that she was not a stranger, and to be respectful of the residents.<BR/>During an interview on 11/20/2024 at 2:20 p.m., the DON stated the staff should knock before walking into a room and announce themselves. The DON stated she expected the staff to knock, introduce themselves, and explain what they were doing in the room. The DON stated it was important for the staff to let residents know what they are doing in their rooms to make them feel comfortable and safe. The DON stated she would in-service the staff. <BR/>During an interview on 11/20/2024 at 2:37 p.m., the Administrator stated everybody was responsible for treating the residents with dignity and respect. The Administrator stated she expected the staff to knock, introduce themselves, and tell the residents what they were doing in their room. The Administrator stated it was important because the facility was their home. The Administrator stated she expected the staff to treat the residents with dignity and respect. <BR/>Record review of the facility's policy titled, Quality of Life- Dignity, revised October 4, 2022, indicated residents' private space and property shall be respected at all times. Staff are to knock and request permission before entering residents' room

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 24 residents (Resident #65) reviewed for accommodation of needs.<BR/>The facility treatment nurse failed to ensure Resident #65's call light was in reach for her to use when assistance was needed on 11/17/24-11/19/24. <BR/>This failure could have placed resident at risk of having needs gone unmet.<BR/>Findings Included: <BR/>Record review or Resident #65's face sheet dated 11/25/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with the diagnoses Alzheimer's (a progressive disease that destroys memory and other mental functions), high blood pressure, history of falling, and anxiety (a mental health characterized by worry, anxiety, or fear). <BR/>Record review of Resident #65's MDS dated [DATE] indicated she could usually understand others and usually made herself understood. The MDS also indicated she had a BIMS score of 5 which meant she had severe cognitive impairment. The MDS also indicated Resident #65 required substantial/maximal assistance with transfers and toileting, supervision with dressing, and independent with eating and hygiene. <BR/>Record review of Resident #65's care plan initiated on 06/21/24 indicated she had self-care deficit with bathing, dressing, and feeding related to her Alzheimer's and Dementia diagnosis with interventions in place for the staff to provide assistance with ADLs as needed. The care plan also indicated, after a revision completed on 11/20/24 related to surveyor intervention, that resident would come to the doorway and yell for help without using the call light. <BR/>During an observation and interview on 11/17/24 at 11:14 AM, Resident #65 was laying in her bed sometimes she pressed her call light and the staff would poke their head in and leave. Resident #65's call light was on the floor at the foot of the bed. <BR/>During an observation on 11/18/24 at 08:34 AM, Resident #65 was in her bed asleep. Call light on the floor under the bed. <BR/>During an observation and interview on 11/19/24 at 08:30 AM, Resident #65 was laying in her bed and said come on here i need help as this surveyor was at the door. The call light continued to be on the floor under the bed. Resident said, i can't find my rooter(referring to the call light) to call you for help but it was here before. LVN K came into the room and noted the call light was on the floor under Resident #65's bed. She said she should have had the call light within her reach to call for help when she needed to. She said all staff who entered the room were responsible for ensuring all resident call lights were in reach for use. LVN K said the failure placed a risk for Resident #65 not to get help when she needed. <BR/>During an interview on 11/20/24 at 02:33 PM, the DON said her expectation was for Resident #65 to always have the call light in reach so that she could use it if she needed help. The DON said the failure placed a risk for the resident not having the access to care that she needed. She said all staff that go in the rooms were responsible for ensuring the call lights were in reach. <BR/>During an interview on 11/20/24 at 03:03 PM, the Administrator said she expected the call lights to be in the reach of the residents, that way the resident could use it if needed. She said the CNAs were immediately responsible for ensuring the call lights were in reach, but the department heads were responsible as well during rounding of the halls. The Administrator said the failure placed a risk of the resident's needs not being met or possible injury. <BR/>Record review of the facility policy Resident Call Light System revised 6/2023 indicated:<BR/>Purpose<BR/>The purpose of this procedure is to respond to the resident's requests and needs.<BR/>Policy Implementation<BR/>A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need .General Guidelines .4. Ensure that the call light is easily reachable by the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 21 residents (Resident #49 and Resident #36) reviewed for comprehensive person-centered care plans.<BR/>1. The facility failed to develop a care plan for Resident # 49's urostomy (surgical procedure that creates a stoma (artificial opening) for the urinary system). <BR/>2. The facility failed to care plan Resident #36's side rails.<BR/>These failures could place residents at risk for unmet care needs and decreased quality of care.<BR/>Findings included:<BR/>1. Record review of Resident #49's face sheet dated 09/21/23, indicated he was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #49's diagnoses included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), emphysema (lung disease that makes it hard to breathe and get enough oxygen), hydronephrosis (condition that occurs when a kidney swells and can't get rid of urine like it should), and other artificial openings of the urinary tract. <BR/>Record review of Resident #49's clinical admission evaluation dated 08/14/23, indicated under general note .staff to assist with ostomy (surgical procedure that allows bodily waste to pass through a surgically created stoma on the abdomen into a 'pouch' or 'ostomy bag' on the outside of the body) care . The clinical evaluation under the MDS responses had ostomy checked. <BR/>Record review of Resident #49's admission MDS assessment dated [DATE], indicated he had clear speech, was able to make himself understood, and understood others. The MDS assessment indicated Resident #49 had a BIMS score of 4, which indicated he had severe cognitive impairment. The MDS assessment indicated Resident #49 required limited assistance with dressing, toileting and personal hygiene and required supervision with bed mobility, transfers, walking, locomotion, and eating. The MDS assessment under section H, bladder and bowel, had indwelling catheter and ostomy checked. <BR/>Record review of Resident #49's comprehensive care plan dated 08/15/2023 did not indicate he had a urostomy. <BR/>Record review of Resident #49's order summary report dated 09/21/23, indicated he had an order to change the urostomy every 3 days as needed with an order start date of 08/15/23, and an order for urostomy care every shift and as needed with an order start date of 08/15/23. <BR/>During an interview and observation on 09/18/23 at 2:48 PM, Resident #49 said he had a urostomy and showed surveyor his urostomy which was located on his right side of abdomen.<BR/>During an interview on 09/21/23 at 2:42 PM, the ADON said Resident #49's urostomy should have been care planned with interventions so that everyone would be aware he had one. The ADON said Resident #46 not having his urostomy care planned would cause a new employee to miss he had one and not provide the care needed. The ADON said the DON, MDS Coordinator and herself were responsible for ensuring the care plans were updated. <BR/>During an interview on 09/21/23 at 3:01 PM, the DON said she expected the comprehensive care plans to be accurate and specific to the resident care and said she expected Resident #49's urostomy to have been care planned. The DON said she did not feel there was a potential for harm as the staff was taking care of Resident #49's urostomy and documenting it. The DON said any nurse was responsible for updating the residents care plan.<BR/>During an interview on 09/21/23 at 3:13 PM, the Administrator said she expected Resident #49's urostomy to have been care planned and with appropriate care interventions. The Administrator said the MDS nurse was responsible for updating the care plans. The Administrator said she did not feel Resident #49 would have any risks for not having his urostomy care planned as he has orders for his urostomy and will trigger staff to care for it.<BR/>2. Record review of Resident #36's face sheet dated 09/20/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted o 06/15/23. Resident #36's diagnoses included spasmodic torticollis (a painful condition in which the neck muscles contract involuntary, causing the head to twist or turn to one side), dehydration (loss of body fluid caused by illness, sweating or inadequate intake), restless leg syndrome (irresistible urge to move the legs, typically in the evenings), repeated falls, and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).<BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #36 was able to make herself understood and understood others. The MDS assessment indicated Resident #36 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #36 required limited assistance with bed mobility, transfers, dressing, and extensive assistance with toilet use. The MDS assessment did not indicate Resident #36's bed rails were used as a restraint. <BR/>Record review of the care plan with date initiated 03/27/2023, did not indicate Resident #36 had side rails to assist her in turning and repositioning. <BR/>Record review of the Order Summary Report dated 09/20/2023 indicated Resident #36 had an order for side rails up x 2 to enable resident to assist in turning and repositioning with a start date of 03/27/2023. <BR/>During an observation and interview on 09/19/2023 at 10:55 AM, Resident #36 had side rails on each side of the bed. Resident #36 said she used the side rails to assist her in repositioning herself while in the bed. <BR/>During an interview on 09/21/2023 at 3:37 PM, the ADON said the care plan was completed by the IDT (Interdisciplinary Team). The ADON said Resident #36 should have had her side rails in her care plan. The ADON said the side rails were in place to assist Resident #36 with repositioning and turning that they were used as an enabler. The ADON said it was important for the side rails to be included in the care plan, so all the nurses knew Resident #36 required the side rails for repositioning. <BR/>During an interview on 09/21/2023 at 4:08 PM, the DON said the care plans were done by the charge nurses, MDS nurses, and herself. The DON said Resident #36's side rails should be included in her care plan. The DON said she did not know why Resident #36's side rails were not in her care plan. The DON said it was important for Resident #36's side rails to be in her care plan for an accurate reflection of her care and needs, and so all the staff could see a clear picture of her needs. The DON said she performed random reviews of the care plans twice daily to ensure they included all the residents' needs. <BR/>During an interview on 09/21/2023 at 4:20 PM, the Administrator said the care plans were completed by the IDT. The Administrator said the side rails should be in the residents' care plans. The Administrator said it was important to include the side rails in the residents' care plans, so the staff knew the residents required side rails and to ensure they were in place. <BR/>Record review of the facility's policy Care Plan Meetings dated 03/09, indicated . (The Facility) is to work as a team to ensure effective and efficient care of each resident .2. Care plans and Quarterly Assessments will be reviewed and updated prior to the scheduled meeting. Each Interdisciplinary Team will review the resident's chart to identify any significant changes since the last Care Plan Meeting. Such review included but is not limited to .nursing and medical concerns .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 3 residents (Resident #90, Resident #203, and Resident #8) out of 24 sampled residents whose care plans were reviewed for timing and revision.<BR/>The facility failed to ensure Resident #90's care plan was updated and accurate by not resolving the care plan for a PICC line and antibiotic administration that resident no longer had an order for. <BR/>The facility failed to ensure Resident #203's care plan was updated by resolving her melatonin and rash in which she no longer had those orders.<BR/>The facility failed to ensure Resident #8's care plan was updated by resolving her antibiotics and IV fluids in which she no longer had those orders.<BR/>These failures could place residents at risk for not receiving the care and services to meet their needs.<BR/>Findings include:<BR/>1.Record review of Resident #90's face sheet indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses fracture of femur (broken hip), stage 4 pressure ulcer, and dementia (thinking and social symptoms that interfere with daily functioning). <BR/>Record review of Resident #90's quarterly MDS dated [DATE] indicated he was sometimes understood and sometimes understood others, and he had a BIMS score 7 of which meant he had severe cognitive impairment. The MDS also indicated he required maximal assistance with transfers and hygiene, total assistance with toileting, dressing, and bathing, and independent with eating. <BR/>Record review of Resident #90's care plan initiated 06/14/24 and revised 09/23/24 indicated he was on IV Medications r/t an infection to his sacral wound with interventions that included:<BR/>1. If IV is infiltrated: stop infusion and thoroughly examine the site. <BR/>2. If the catheter appears to be lodged in the tissues, an attempt to aspirate any fluid remaining in the catheter can be made in order to lessen the amount of drug at the site. After removing the cannula, elevate the affected arm, notify the physician (for large infiltrations and extravasations), and apply cool compresses (warm, if [NAME] alkaloids are involved).<BR/>3. IV DRESSING: PICC line dressing change q week & prn. Observe dressing q shift. Change dressing and record observations of site. Monitor/document/report PRN. <BR/>During an interview on 11/20/24 at 02:47 PM, the DON said her expectation was for the care plan to be accurate. She said the MDS nurse was responsible for ensuring care plans were accurate, but the DON updated and oversaw care plans as well. The DON said she expected the care plans to be revised within at least the week of the order change. She said the failure could prevent the resident care plan from being accurate. <BR/>During an interview on 11/20/24 at 03:06 PM, the Administrator said her expectation was for the care plans to be resolved as they were finished with the care. She said the MDS nurse was responsible for ensuring the care plans were updated and accurate. The Administrator said the failure placed a risk for Resident #90 getting care that was not needed (getting IV medications that were not ordered). <BR/>2.Record review of Resident #203's face sheet, dated 11/20/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of the superior rim of the right pubis (a break in the pelvic area that usually caused by a direct blow, such as from a fall or a motor vehicle accident), pressure wounds (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body), and dementia (decline in mental abilities that affects a person's daily life).<BR/>Record review of Resident #203's admission MDS assessment, dated 08/13/24, indicated Resident #203 was understood and usually understood by others. Resident #203's BIMS score was a 04 indicating she was severely cognitively impaired. The MDS indicated she required assistance with her activities of daily living. <BR/>Record review of Resident #203's comprehensive care plan dated 08/08/24 indicated she was taking melatonin related to insomnia. The intervention was for staff to give medication as ordered.<BR/>Record review of Resident #203's comprehensive care plan dated 08/08/24 indicated, she had a rash on the right side with a diagnosis of Shingles. The interventions were for staff to provide medication as ordered and for her to be in contact isolation.<BR/>Record review of Resident #203's Physician order dated 11/01/24 through 11/20/24 did not indicate an order for a rash or diagnosis of shingles. <BR/>Record review of Resident #203's Physician order dated 08/14/24 indicated all contact was discontinued for shingles.<BR/>Record review of Resident #203's Physician order dated 11/01/24 through 11/20/24 did not indicate an order for melatonin.<BR/>Record review of Resident #203's Physician order dated 09/10/24 indicated Melatonin was discontinued.<BR/>3.Record review of Resident #8's face sheet, dated 11/20/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Cerebral palsy also known as CP (a group of neurological disorders that affect a person's ability to move, balance, and maintain postured), depression (sadness), high blood pressure, seizures (a sudden burst of electrical activity in the brain), and Quadriplegia (a medical condition that causes partial or total loss of movement and sensation in all four limbs and the torso). <BR/>Record review of Resident #8's admission MDS assessment, dated 09/24/24, indicated Resident #8 was sometimes understood and understood by others. Resident #8's BIMS score was a 03 indicating she was severely cognitively impaired. The MDS did indicate she was on antibiotics. <BR/>Record review of Resident #8's comprehensive care plan revised on 10/07/24 indicated she was on antibiotic therapy related to chronic urinary tract infections. The intervention was for staff to give medication as ordered.<BR/>Record review of Resident #8's comprehensive care plan revised on 10/25/24 indicated she was at risk for altered fluid balance related to hydration and sodium chloride solution. The intervention was for staff to give medication as ordered.<BR/>Record review of Resident #8's physician's orders dated 11/01/24 through 11/20/24 did not indicate any orders for an antibiotic for a urinary tract infection.<BR/>Record review of Resident #8's physician's orders dated 11/01/24 through 11/20/24 did not indicate any orders for IV sodium chloride 0.9%. <BR/>During an interview on 11/20/24 at 10:22 a.m., MDS nurse #1 said she was responsible for the care plans for the long-term and private residents. She said the care plan was done so the staff would know how to care for the resident. She said she was made aware of the residents' changes in the morning meeting. She said she brought her computer to the morning meetings and updated any changes during the meeting. She said she was unaware she missed deleting Resident #90's PICC and antibiotics off his care plan. She said failure to update a care plan could cause staff not to know how to care for the residents.<BR/>During an interview on 11/20/24 at 2:36 p.m., MDS nurse #2 said she was responsible for the Medicare resident's care plans She said care plans were done for staff to know the needs of the residents. She said she was made aware of changes or new orders in the morning meeting. She said she was new to this position and was learning. She said she was unaware she had not updated Resident #8 or Resident #203's, care plan. She said it was important to ensure the resident's care plan was updated with any new orders or changes. She said care plans should be done and or updated so that staff knew how to care for the resident.<BR/>During an interview on 11/20/24 at 3:07 p.m., the Administrator said the MDS nurse was responsible for the care plans. She said the DON was the overseer of the care plans. She said if care plans were not done residents might receive something they do not need or not receive something they do need.<BR/>Record review of the facility's policy titled, Care Plans and Comprehensive Person-Centered, dated December 2016 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 21 residents (Resident #32) reviewed for ADLs.<BR/>1. The facility failed to provide assistance with facial hair removal for Resident #32.<BR/>2. The facility failed to ensure Resident #32 received her shower as scheduled. <BR/>These failures could place residents at risk of not receiving services and care, and a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #32's face sheet dated 09/20/23, indicated a [AGE] year-old female who initially admitted to the facility 03/27/23 and readmitted on [DATE]. Resident #32's diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), depression (persistently depressed mood) and orthostatic hypotension (a form of low blood pressure that happens when standing up from a sitting or lying down).<BR/>Record review of Resident #32's admission MDS assessment dated [DATE], indicated she was understood and understood others. The MDS indicated Resident #32 had a BIMS score of 14, which indicated her cognition was intact. The MDS indicated Resident #32 did not refuse care. The MDS indicated Resident #32 required extensive assistance with bed mobility, toileting, and bathing. Resident #32 required limited assistance with transfers, locomotion, dressing and personal hygiene. <BR/>Record review of Resident #32's comprehensive care plan revised on 09/17/23, indicated Resident #32 had a self-care deficit for bathing, dressing, and feeding. The care plan interventions included to encourage resident to participate in planning day to day care, maintain consistent schedule with daily routine, and provide assistance with ADLs as needed.<BR/>Record review of the bath and shower sheets for the month of September 2023 indicated there was no shower sheet for 09/16/2023<BR/>Record review of the bathing task documentation for Resident #32 for the month of September 2023 indicated Resident #32 did not receive a shower on 09/16/2023. <BR/>During an observation and interview on 09/19/2023 at 9:02 AM, Resident #32 said sometimes the staff shaved the facial hair off and sometimes they did not. Resident #32 said she liked the facial hair to be removed. Resident #32 said she thought she was getting her showers as scheduled. Resident #32 appeared well-groomed.<BR/>During an observation on 09/20/2023 at 8:12 AM, Resident #32 had chin hairs approximately 2 cm long and upper lip hairs approximately 0.5 cm-1cm long.<BR/>During an observation on 09/21/2023 at 9:12 AM, Resident #32 had chin hairs approximately 2 cm long and upper lip hairs approximately 0.5 cm-1cm long.<BR/>During an interview on 09/21/2023 at 3:18 PM, LVN Q said the charge nurse was responsible for ensuring the residents received their baths. LVN Q said the CNAs brought the charge nurses the shower sheets for them to review or documented the showers in the residents' electronic health record. LVN Q said it was important for the residents to receive their showers/baths to keep them clean and prevent infections, and for their dignity and for them to look presentable. LVN Q said facial hair was supposed to be removed on the residents' shower days. LVN Q said the CNAs should be removing the resident's facial hair, and the charge nurses should supervise by visually inspecting the residents daily. LVN Q said the CNAs were supposed to document on the shower sheets when they shaved the residents. LVN Q said it was important for facial hair to be removed for the residents' dignity. LVN Q said she had not noticed Resident #32's facial hair. <BR/>During an interview on 09/21/2023 at 3:31 PM, the ADON said the charge nurses were responsible for ensuring the residents received their showers. The ADON said the showers were monitored by the shower sheets the CNAs filled out and gave to the charge nurses. The ADON said it was important for the residents to receive their showers to keep them clean and keep infections down. The ADON said she had not noticed that any showers were not given. The ADON said the CNAs were supposed to be shaving the residents when they showered them. The ADON said it was important for facial hair to be removed for the resident's appearance. <BR/>During an interview on 09/21/2023 at 3:47 PM, CNA R said on Saturday (09/16/2023), she had not given Resident #32 her shower and she had not shaved her. CNA R said she had not done it because they were short on Saturday, and she had not gotten to it. CNA R said the CNAs and the nurses were responsible for ensuring the residents received their showers and facial hair was removed. CNA R said she had not noticed Resident #32's facial hair, and she assumed she should have removed it. CNA R said it was important for the residents to get their showers and facial hair be removed because it was a part of grooming, and she did not want the residents to look like they had not been attended to. <BR/>During an attempted interview on 09/21/2023 at 3:54 PM, CNA S did not answer the phone.<BR/>During an interview on 09/21/2023 at 3:59 PM, the DON said the CNAs should have offered to remove the residents' facial hair by their preferred method of removal daily. The DON said the charge nurses were responsible for overseeing that the CNAs were giving showers and removing facial hair. The DON said the CNAs should be documenting the showers in the electronic health record, but some of the CNAs were still documenting on the shower sheets. The DON said she was not aware Resident #32 had facial hair. The DON said CNA R should have notified her she was not able to shower Resident #32 on Saturday, so she could have scheduled for her to get one the next day. The DON said it was important for the residents to receive their showers for hygiene purposes, for their skin to be clean, for them to have good skin integrity, for their dignity, and to prevent odors. The DON said it was important for facial hair to be removed for the residents' dignity. <BR/>During an interview on 09/21/2023 at 4:17 PM, the Administrator said she expected all the residents to receive their showers on their scheduled days. The Administrator said the CNAs were responsible for bathing the residents. The Administrator said it was important for the residents to receive their showers for them to remain clean and for their dignity. The Administrator said she expected that facial hair be removed by the residents' preferred method. The Administrator said the CNAs were responsible for facial hair removal and the charge nurses should follow up. The Administrator said it was important for facial hair to be removed for the residents' dignity and cleanliness. <BR/>Record review of the facility's undated policy titled, Bath, Shower, indicated, Objective 1. To cleanse and refresh the resident . help resident with bath as needed . chart on nursing record. Include pertinent observations . The policy did not address facial hair removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 1 of 24 Residents (Resident #98) reviewed for accidents and hazards.<BR/>The facility failed to ensure Resident #98's fall mat was beside his bed on 11/17/24, 11/18/24 and 11/19/24.<BR/>This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.<BR/>Findings included:<BR/>1.Record review of Resident #98's face sheet, dated 11/20/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included muscle weakness, dementia (loss of memory), atrial fibrillation (a common type of irregular heartbeat), and high blood pressure.<BR/>Record review of Resident 98's 5-day MDS assessment, dated 10/22/24, indicated Resident #98 understood and was understood by others. Resident #98's BIMS score was a 03 indicating his cognition was severely impaired. The MDS indicated Resident #98 required extensive assistance with his ADLs including transfers and bed mobility. The MDS indicated he had a fall in the prior month. <BR/>Record review of Resident #98's comprehensive care plan dated 11/13/24 indicated, he had an actual fall related to poor balance, and impaired mobility, and was at risk for further falls with injury. The intervention was for staff to apply a fall mat at the bedside.<BR/>Record review of Resident 98's Physician order dated 11/13/24 indicated, he had an order for a fall mat at the bedside every shift. <BR/>Record review of Resident 98's incident report dated 11/13/24 indicated he had a fall. The intervention was to place a fall mat beside his bed.<BR/>During an observation on 11/17/24 at 11:35 a.m., Resident #98 was in bed with his eyes closed. No fall mat was noted beside his bed. <BR/>During an observation on 11/18/24 at 4:35 p.m., Resident #98 was in his bed with no mat beside his bed.<BR/>During an observation and interview on 11/19/24 at 9:00 a.m., LVN A went into Resident #98's room and verified he did not have a fall mat beside his bed. She then looked into his electronic chart and said Resident #98 had an order for a fall mat. She said Resident #98 had a fall the other day and they must have placed the fall mat as an intervention. She said fall mats were important to prevent falls or injuries from falling.<BR/>During an interview on 11/20/24 at 2:37 p.m., the DON said Resident #98 was supposed to have a fall mat beside his bed because he had a fall and was at risk for further falls. She said all staff was responsible for ensuring the fall mat was beside his bed. She said if he did not have his fall mat down then he could fall and obtain an injury. <BR/>During an interview on 11/20/24 at 3:07 p.m., the Administrator said if Resident #98 had an order for a fall mat to be beside his bed, then all staff were responsible for ensuring it was beside his bed. She said failure to have the fall mat could cause an injury from the fall.<BR/>Record review of facility policy titled, Falls dated November 14, 2023, indicated, The Assessment: The Nursing Staff with physician's support will identify residents with a history of falls and risk factors for falling. a. The Staff Nurse will complete a Fall Risk Screening or equivalent form, on the resident upon admission, readmission, routine quarterly, annual, significant change MDS, and PRN. Treatment/Management: Based on the preceding assessment, the Nursing Staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Monitoring and Follow-Up: The Nursing Staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling during the Standard of Care/High-Risk Management Meetings. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practices for 3 of 16 residents (Resident #36, Resident #224, and Resident #225) reviewed for respiratory care. <BR/>The facility failed to ensure the nasal cannula tubing was dated for Resident #36 and Resident #224. <BR/>The facility failed to ensure Resident #225's oxygen concentrator had a filter in place. <BR/>These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. <BR/>Findings included:<BR/>1. Record review of the order summary report dated 7/13/22 indicated Resident #36 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain chemical imbalance in the blood), acute respiratory failure with hypoxia (not enough oxygen in blood), essential hypertension (force of the blood against the artery walls is too high) and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen).<BR/>Record review of the order summary report dated 7/13/22 indicated Resident #36 received oxygen at 2-4 LPM (liters per minute) via nasal cannula every 8 hours as needed for O2 (oxygen) usage with a start date 7/28/21. There was an order to change O2 tubing and nebulizer machine tubing every week (night shift on Saturday) and PRN (as needed) with a start date 6/4/22. <BR/>Record review of the MDS dated [DATE] indicated Resident #36 understood others and made herself understood. She had a BIMS score of 3, which indicated severe cognitive impairment. The MDS indicated she required supervision with bed mobility, transfers; limited assistance with dressing, toileting, personal hygiene; and total dependence with bathing. The MDS indicated Resident #36 did not become SOB (shortness of breath) at rest or with exertion. The MDS indicated Resident #36 was not receiving oxygen therapy.<BR/>Record review of the care plan dated 5/25/21 indicated Resident #36 had a diagnosis of congestive heart failure. The care plan interventions were to apply O2 via N/C (nasal cannula) as needed. The care plan dated 6/23/21 indicated Resident #36 received oxygen therapy related to respiratory illness aspiration PNE (an infection of the lungs caused by inhaling saliva, food, liquid, vomit, and even small foreign objects). The care plan interventions were to apply O2 via N/C as needed and keep saturations &gt;92%. The care plan interventions did not address nasal cannula tubing. <BR/>During an interview and observation on 7/11/22 at 11:07 a.m., Resident #36 was lying in bed. Resident #36's nasal cannula was sitting on her bed side dresser. There was no date on the nasal canula tubing. Resident #36 was non-interview able. <BR/>During an observation on 7/12/22 at 9:10 a.m., Resident #36 was lying in bed and oxygen was in use via nasal cannula. There was no date on the nasal canula tubing.<BR/>During an observation on 7/13/22 at 8:42 a.m., Resident #36 was lying in bed and oxygen was in use via nasal cannula. There was no date on the nasal canula tubing.<BR/>2. Record review of the order summary report dated 7/13/22 indicated Resident #224 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including end stage renal disease (kidneys cease functioning on a permanent basis), acute diastolic (congestive) heart failure (heart unable to relax normally between beats), type 2 diabetes mellitus with hyperglycemia (occurs when blood sugar elevates to potentially dangerous levels that require medical treatment) and essential hypertension (force of the blood against the artery walls is too high). <BR/>Record review of the order summary report dated 7/13/22 indicated Resident #224 received oxygen at 2-3 LPM (liters per minute) via nasal cannula every shift for CHF (congestive heart failure) with a start date 7/11/22. There was an order to change O2 tubing and nebulizer machine tubing every week (night shift on Saturday) with a start date 7/9/22. <BR/>During an interview on 7/13/22 at 2:35 p.m., the DON said Resident #224 did not have an MDS at this time due to residing in the facility less than the allotted 14 days required to have the MDS completed. <BR/>Record review of the care plan dated 7/7/22 indicated Resident #224 had an altered respiratory status related to difficulty breathing. The care plan interventions were to apply O2 via N/C (nasal cannula) at 2-3 LPM. The care plan interventions did not address nasal cannula tubing.<BR/>During an observation and interview on 7/12/22 at 1:06 p.m., Resident #224 was eating her lunch while sitting on the edge of her bed, oxygen was in use via nasal cannula. There was no date on the nasal canula tubing. Resident #224 said she wears oxygen continuously for SOB. <BR/>During an interview on 7/13/22 at 8:48 a.m., Resident #224 was eating her breakfast while sitting on the edge of her bed and oxygen was being used by the resident via nasal cannula. There was no date on the nasal canula tubing.<BR/>3. Record review of the order summary report dated 7/13/22 indicated Resident #225 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood), essential hypertension (force of the blood against the artery walls is too high), acute diastolic (congestive) heart failure (heart unable to relax normally between beats), and paroxysmal atrial fibrillation (irregular, often rapid heart rate). <BR/>Record review of the order summary report indicated Resident #225 received oxygen at 3 LPM (liters per minute) via nasal cannula every shift with a start date 7/7/22. There was an order to change O2 tubing and nebulizer machine tubing every week (night shift on Saturday) with a start date 7/9/22. <BR/>During an interview on 7/13/22 at 2:35 p.m., the DON said Resident #225 did not have a MDS at this time due to residing in the facility less than the allotted 14 days required to have the MDS completed. <BR/>Record review of the care plan dated 7/10/22 indicated Resident #225 received oxygen therapy at 3L/min via n/c related to CHF. The care plan interventions did not address oxygen concentrator filters. <BR/>During an interview and observation on 7/11/22 at 3:34 p.m., Resident #225 was lying in bed and oxygen was in use via nasal cannula. The oxygen concentrator did not have a filter in place. Resident #225 said she wears oxygen continuously for SOB. <BR/>During an observation on 7/12/22 at 1:42 p.m., Resident #225 was lying in bed and oxygen was in use via nasal cannula. The oxygen concentrator did not have a filter in place.<BR/>During an observation on 7/13/22 at 8:51 p.m., Resident #225 was lying in bed and oxygen was in use via nasal cannula. The oxygen concentrator did not have a filter in place.<BR/>During an interview and observation on 7/13/22 at 12:41 p.m., LVN A said she was Resident #225's charge nurse on the 6a-2p shift. LVN A said all nursing staff were responsible for ensuring oxygen concentrators had filters in place. LVN A said it was the responsibility of the charge nurse on Saturday nights to clean and change the filters. LVN A observed with the surveyor Resident #225's oxygen concentrator with no filter in place. LVN A said she unaware that Resident #225 filter was missing from her concentrator. LVN A said this failure could place Resident #225 at risk for respiratory infection. <BR/>During an interview on 7/13/22 at 12:51 p.m., LVN B said she was Resident #36 and Resident #224's charge nurse on the 6a-2p shift. LVN B said nursing staff on Saturday nights were responsible for changing and labeling tubing. LVN B said all staff were responsible for making sure it was done. LVN B said she did not notice Resident #36 and Resident #224 nasal cannula tubing was not dated. She said this failure could place residents at risk for respiratory infection. <BR/>During an interview on 7/13/22 at 2:10 p.m., the DON said nursing staff on Saturday nights and the nurse who first applied the O2 were responsible for ensuring oxygen concentrator filters were in place, changing and labeling tubing. The DON said rounds were done every Monday by the DON, ADON, unit manager and MDS coordinator. The DON said she expected the nasal cannula to be dated for clarity and filter in place. She said rounds were not done this Monday due to call ins and state in the building. The DON said not providing this care could cause the resident to have an upper respiratory infection.<BR/>Record review of the facility's oxygen policy tilted Cleaning Oxygen Concentrators and equipment dated 06/2014 indicated . facility staff will perform care of oxygen concentrators and equipment to prevent the spread of infection and diseases within the facility Weekly on Saturday unplug concentrator and remove oxygen tubing with nasal cannula/mask . remove filter from concentrator and either vacuum filter or wash with warm soapy water and allow to dry completely prior to replacing . replace oxygen tubing with new tubing and nasal cannula/mask .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure:<BR/> *food items were dated and sealed appropriately.<BR/> *expired food items were discarded.<BR/> *a dented can was stored separately.<BR/> *the can opener was clean.<BR/> *the pantry was clean. <BR/> *Hydrion test strips (test strips used to measure the concentration of chemicals in sanitizing solution) <BR/> were not expired.<BR/> *the dishwasher reached 120 F.<BR/>These failures could place residents at risk for foodborne illness.<BR/>Findings included:<BR/>During an observation of the kitchen on 09/18/2023, starting at 10:12 AM, accompanied by the Dietary Manager the following observations were made:<BR/>Reach in refrigerator:<BR/> *Multiple half sandwiches in plasic bags with no date<BR/> *Multiple cups of apple juice, cranberry, and orange juice with no date<BR/> *A container filled with puddings, protein shakes, gelatin had crumbs and a sticky like dark <BR/> yellowish substance in it <BR/> *Plastic bag with an opened bag of lettuce no date lettuce was brown <BR/> *Plastic bag with sliced tomatoes no date<BR/> *A can of buttermilk biscuits with a best by date of 09/09/23<BR/>Walk in cooler:<BR/> *A bag of lettuce (lettuce was brown) and dated best by 09/04/2023<BR/>Freezer:<BR/> *Plastic bag with a bag of opened pork chops with no open date<BR/> *Plastic bag with a bag of opened broccoli no open date <BR/> *Plastic bag with a bag of opened chicken breasts with no open date<BR/> *Opened bag of small pepperoni pizzas with no open date<BR/>Pantry:<BR/> *Plastic bag with vanilla wafers not sealed and not dated<BR/> *Corn Mill container not dated and white particles covered the top of the container <BR/> *1 gallon of Worcestershire sauce had dried sauce from the top of the gallon down the sides to the <BR/> bottom of the gallon <BR/> *1 gallon of light corn syrup expired 05/15/2021<BR/> *1 gallon of light corn syrup expired 10/23/2020 with open date 11/1 (no year)<BR/> *1 gallon of light corn syrup expired 10/23/2020 with open date 11/13 (no year)<BR/> *An opened container of soy sauce best by date was faded only 2021 was legible <BR/> *An opened container of crushed pepper with no open date<BR/> *Cheerios on the floor under the rack in the dry storage room buildup of dirt and dust on the edges of <BR/> the wall<BR/> *Opened bag of cocoa unsealed not dated <BR/> *Plastic bag with opened packages of cream of wheat, gravy, classy, mashed potatoes with no <BR/> open dates <BR/> *Crumbs on the floor in the dry storage room <BR/> *Dented can of green beans on the rack<BR/>In the kitchen area:<BR/> *The can opener had a dried red thick substance on it <BR/> *Hydrion test strips had expiration date of 08/01/2019, the Dietary Manager said she had not <BR/> noticed they had an expiration date on them. <BR/> *both spice racks in the kitchen had dust build up on them.<BR/> *The dishwasher temperature during the wash cycle was between 110 F-112 F. The Dietary <BR/> Manager said she had notified the Maintenance Director and the Administrator several times since <BR/> July 2023 that the dishwasher was not reaching 120 F. <BR/>During an interview on 09/18/2023 at 4:20 PM, the Administrator said she was told by the technician that services the dishwasher that it was a cold-water dishwasher, and it did not have to reach 120 F. <BR/>During an interview on 09/18/2023 at 4:26 PM, the territory manager with the facility's restaurant supply said during his visit last week on Wednesday, he had noticed the temperature was low between 100 F and 105 F, and he had notified the Dietary Manager and the Administrator that the dishwasher was not reaching the proper temperature of 120 F. The Territory Manager said it was important for the dishwasher to reach the appropriate temperature to make sure the grease was liquified and the dishes were cleaned better. The Territory Manager said the dishwasher not reaching 120 F should not harm the residents because the chemical sanitation was at the correct level. <BR/>During an observation on 09/21/2023 at 10:00 AM, the can opener still had the thick red substance on it, and the floor in the dry storage area still had crumbs on the floor. <BR/>During an interview on 09/21/2023 at 10:09 AM, the Dietary Manager said the can opener still had the thick red substance and the pantry had crumbs on the floor because the dietary staff were not doing what she asked them to do. The Dietary Manager said the can opener should be cleaned after every use by the person who used it. The Dietary Manager said the cooks were responsible for sweeping and mopping the kitchen area and the pantry after every shift. The Dietary Manager said all items in the cooler, freezer, refrigerator should have had an open date on them, and all items were supposed to be stored in a sealed bag or container. The Dietary Manager said the snacks in the fridge should have had a date on them. The Dietary Manager said the dietary staff were responsible for ensuring all items were labeled and stored appropriately. The Dietary Manager said items in the pantry should be open dated and stored in a sealed container. The Dietary Manager said she tried to discard expired items in the cooler, freezer, and refrigerator twice a week. The Dietary Manager said [NAME] T was responsible for discarding expired items in the dry storage because she was the one that put up the dry goods. The Dietary Manager said [NAME] T should be pulling the old stuff forward and the new food items back to ensure they were used prior to being expired. The Dietary Manager said she was responsible for ensuring the kitchen was clean. The Dietary Manager said, in the past, she had a cleaning schedule but had done away with it because the staff were signing off the items as completed but were not cleaning. The Dietary Manager said it was important for all food items to be stored, labeled, and dated appropriately so the staff knew how long the food had been there and to avoid food poisoning. The Dietary Manager said it was important for expired food items to be discarded so the residents would not get salmonella or food poisoning. The Dietary Manager said it was important for the kitchen to be cleaned to keep infection down. The Dietary Manager said it was important for the dishwasher machine to reach 120 F for the chemicals to work appropriately. The Dietary Manager said if the dishwasher was not reaching 120 F the dishes were not getting dried or cleaned well enough and the residents could have gotten sick. The Dietary Manager said she had not realized the test strips for the sanitizer had an expiration date, and it was important for them not to be expired to ensure the chemical sanitizer was at the correct level. <BR/>During an interview on 09/21/2023 at 10:21 AM, [NAME] T said all items in the refrigerator, cooler, freezer should have an open date once opened. [NAME] T said the snacks in the refrigerator should have a date on them. [NAME] T said all the dietary staff were responsible for ensuring food items were dated. [NAME] T said she was not the only one that put up the food items in the pantry. [NAME] T said she tried to discard expired items when she saw them. [NAME] T said she was responsible for sweeping and mopping the pantry, and she thought she had swept it and mopped it the day before. [NAME] T said the can opener should have been cleaned after every use by the person that used it. [NAME] T said she had not cleaned it that week because she had not used it. [NAME] T said it was important for all the food items to be stored and dated and for expired food items to be discarded so the residents would not get poisoned or an upset stomach. [NAME] T said it was important for the kitchen to be clean because of contamination. <BR/>During an interview on 09/21/2023 at 10:33 AM, [NAME] U said all food items in the refrigerator, freezer, and pantry should have been dated when opened and stored in a sealed container or bag. [NAME] U said the snacks in the refrigerator should have been dated by the person who made them. [NAME] U said sometimes she got in a hurry, and she might not have dated a food item when opened. [NAME] U said it was important for all food items to be stored and dated appropriately to keep them clean and so the residents would not get food poisoning. [NAME] U said she was supposed to sweep and mop the kitchen area after every shift. [NAME] U said when putting up food items in the pantry, the old stuff should have been pulled to the front and the new items placed in the back. [NAME] U said it was important to do this to use the older items first so they would not expire. [NAME] U said all the dietary staff should have been discarding expired food items when they noticed something was expired. [NAME] U said it was important for expired food items to be discarded to prevent food borne illness. [NAME] U said the can opener should have been cleaned after every use by the person that used it. [NAME] U said she had not cleaned the can opener because she had not used it. [NAME] U said it was important for the kitchen to be clean so the residents would not get sick. <BR/>During an interview on 09/21/2023 at 4:23 PM, the Administrator said she expected all food items to be stored, labeled and dated appropriately. The Administrator said she expected for food items to be discarded when expired. The Administrator said she expected for the kitchen to be kept clean. The Administrator said the Dietary Manager and herself were responsible for monitoring the kitchen. The Administrator said, in the past, they had issues with labeling and dating and occasionally cleanliness of the kitchen. The Administrator said it was important for all food items to be labeled, stored, and dated appropriately for the safety of the residents. The Administrator said it was important for the dishwasher to reach the adequate temperature to ensure the dishes were clean and sanitized.<BR/>Record review of the [NAME] Customer Service Report dated 09/13/2023 indicated the water temperature did not meet the health department minimum today. The booster heater needed to be used to reach 140-degree water temperature for best results. That was discussed with the Dietary Manager. <BR/>Record review of the facility's undated policy titled, Sanitation and Food Handling, indicated, . Equipment and supplies will be available for proper cleaning and sanitizing of dishes. a. wash temperature: 1. 120 degrees manual . <BR/>Record review of the facility's undated policy titled, Purchasing, Receiving and Storage, did not address the labeling and storage of food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #61) reviewed for hospice services.<BR/>The facility did not ensure Resident #61's hospice records were a part of their records in the facility. <BR/>This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. <BR/>Findings included: <BR/>Record review of Resident #61's face sheet, dated 09/21/2023, indicated Resident #61 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions), and essential hypertension (high blood pressure). <BR/>Record review of the physician order report dated 09/21/2023 indicated Resident #61 had an order to admit to hospice with an order date of 04/19/2023. <BR/>Record review of the admission MDS assessment, dated 04/30/2023, indicated Resident #61 usually understood other others, and usually made herself understood. The assessment did not address the BIMS score. The assessment did not indicate <BR/>Resident #61 had a life expectancy of less than 6 months and received hospice services. <BR/>Record review of the comprehensive care plan, revised on 05/16/2023, indicated Resident #61 had a DNR and received hospice services. The care plan interventions included instruct family/resident on palliative care/hospice for any progressive decline in condition and instruct family/resident that all acute illnesses will be treated at onset. <BR/>Record review of Resident #61's hospice binder, assessed on 09/20/2023 at 8:30 a.m., revealed no updated plan of care, nurses' notes, or aides visit notes from the certification period 08/24/23-09/7/23. <BR/>During an interview on 09/20/2023 at 4:03 p.m., the Executive Director for the hospice company stated the last visit for Resident #61 was on 09/18/2023. The Executive Director stated the nurses were required to see Resident #61 two times per week and the aides were required to see her five times a week. The Executive Director stated the case manager should have printed the nurses' notes, aides visit, and updated plan of care and any new orders after the meeting on 09/07/23 and return them to the facility on [DATE]. The Executive Director stated the process for collaborating with the facility was completed verbally with the nurses and DON.<BR/>During an interview on 09/21/2023 at 3:18 p.m., the DON stated she was unaware the hospice company brought Resident #61's updated paperwork on 09/20/23. The DON stated the charge nurses communicated verbally one on one with the hospice. The DON stated she was unaware of the documentation requirements according to the hospice policy. The DON stated it was important to ensure recent hospice documentation was in the facility for coordination of care. <BR/>During an interview on 09/21/2023 at 4:00 p.m., the Administrator stated there was no process in place for monitoring the hospice binders and documentation to ensure the most up to date information was in the facility. The Administrator stated she expected the hospice to update the binder because the nurses had been in communication with the hospice verbally. The Administrator stated it was important to ensure recent hospice documentation was in the facility for continuity of care. <BR/>Record review of the Nursing Facility Contract Agreement, dated 12/28/2016, indicated, 2. Documentation: Provide facility with the following hospice documentation for the clinical record: copy of the client's plan of care, updates of the plan of care, and visit documentation on regular hospice forms as well as nursing home chart .<BR/>Record review of the facility's undated policy titled Hospice & Palliative Care indicated , to ensure that the care and services provided meet the needs of residents identified through assessment by the physician and nursing services. A comprehensive plan of care will be developed by the facility and the Physician to meet the needs of resident's identified with end stage disease with a six-month medical prognosis

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 3 of 21 residents (Resident #49, Resident #84, and Resident #61) reviewed for MDS assessment accuracy. <BR/>1. The facility inaccurately coded Resident #49 having a foley catheter on his admission MDS assessment.<BR/>2. The facility did not ensure Resident #84's admission MDS identified a medication as an anti-platelet instead of an anticoagulant.<BR/>3.The facility did not acccurately code Resident #61 receiving hospice services on her admission MDS assessment. <BR/>These failures could place residents at risk for not receiving care and services to meet their needs.<BR/>Findings included:<BR/>1. Record review of Resident #49's face sheet dated 09/21/23, indicated he was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #49's diagnoses included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), emphysema (lung disease that makes it hard to breathe and get enough oxygen), hydronephrosis (condition that occurs when a kidney swells and can't get rid of urine like it should), and other artificial openings of the urinary tract. <BR/>Record review of Resident #49's clinical admission evaluation dated 08/14/23, indicated under general note .staff to assist with ostomy (surgical procedure that allows bodily waste to pass through a surgically created stoma on the abdomen into a 'pouch' or 'ostomy bag' on the outside of the body) care . The clinical evaluation under the MDS responses had ostomy checked. Resident #49's clinical evaluation did not indicate he had a foley catheter. <BR/>Record review of Resident #49's admission MDS assessment dated [DATE], indicated he had clear speech, was able to make himself understood, and understood others. The MDS assessment indicated Resident #49 had a BIMS score of 4, which indicated he had severe cognitive impairment. The MDS assessment indicated Resident #49 required limited assistance with dressing, toileting and personal hygiene and required supervision with bed mobility, transfers, walking, locomotion, and eating. The MDS assessment under section H, bladder and bowel, had indwelling catheter and ostomy checked. <BR/>Record review of Resident #49's comprehensive care plan dated 08/15/2023 did not indicate he had a urostomy (surgical procedure that creates a stoma (artificial opening) for the urinary system) or a foley catheter. <BR/>Record review of Resident #49's order summary report dated 09/21/23, indicated he had an order to change the urostomy every 3 days as needed with an order start date of 08/15/23, and an order for urostomy care every shift and as needed with an order start date of 08/15/23. The order summary did not indicate Resident #49 had order for a foley catheter. <BR/>During an interview and observation on 09/18/23 at 2:48 PM, Resident #49 said he did not have a foley catheter and said he had a urostomy. Resident #49 showed surveyor his urostomy which was located on his right side of abdomen.<BR/>During an interview on 09/20/23 at 3:48 PM, the DON said Resident #49 did not have a foley catheter she could recall and that he only had a urostomy. The DON said the foley catheter on the MDS assessment was probably marked in error. <BR/>During an interview on 09/20/23 at 4:33 PM, the ADON said MDS Coordinator D had completed Resident #49's admission MDS. The ADON said she recalled Resident #49 only having a urostomy. The ADON said not coding the MDS correctly was a MDS discrepancy. The ADON said the MDS Coordinator was responsible for ensuring the MDS was accurate and believed MDS Coordinator D probably marked the foley catheter by accident. The ADON said she was unsure of the risks for Resident #49 having an inaccurate MDS assessment. <BR/>An attempted telephone interview on 09/21/23 at 10:56 AM, with MDS Coordinator D, who completed Resident #49's admission MDS assessment, was unsuccessful.<BR/>During an interview on 09/21/23 at 09:27 AM, RN C said Resident #49 never had a foley catheter and only had a urostomy since he admitted to the facility on [DATE].<BR/>During an interview on 09/21/23 at 2:59 PM, RN C said she had signed Resident #49's admission MDS assessment after completion. RN C said Resident #49 having foley catheter coded on his MDS assessment was an oversight on her part. RN C said she usually scanned over the MDS prior to signing it. RN C said the MDS Coordinator was responsible for ensuring the MDS was accurate. <BR/>During an interview on 09/21/23 at 3:01 PM, the DON said MDS Coordinator D marked the foley catheter in error. The DON said she expected the MDS assessments to be accurate for submission. The DON said Resident #49 should not have had foley catheter checked and inaccurate information was submitted on the MDS. The DON said the MDS Coordinator and she were responsible for ensuring the MDS assessments were accurate when submitted. <BR/>During an interview on 09/21/23 at 3:13 PM, the Administrator said she expected the MDS to reflect the individual. The Administrator said the MDS Coordinator was responsible for ensuring the MDS was accurate. The Administrator said there was no negative outcome as Resident #49's urostomy was coded on the MDS. <BR/>2. Record review of Resident #84's face sheet, dated 09/21/2023, indicated Resident #84 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included specified fracture of unspecified pubis (pair of bones forming the two sides of the pelvis)<BR/>Record review of Resident #84's order summary report, dated 09/21/2023, indicated Resident #84 was prescribed Clopidogrel Bisulfate (anti-platelet medication that prevent blood cells from collecting and forming a blood clot). <BR/>Record review of Resident #84's admission MDS assessment, dated 08/23/2023, in Section N0410 Medications Received revealed item E. Anticoagulant was marked as having been given for the last 7 days. The instructions for this section read, Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. <BR/>Record review of Resident #84's care plan did not address Clopidogrel Bisulfate. <BR/>An attempted telephone interview on 09/21/2023 at 10:56 a.m. with MDS Coordinator D, the nurse who coded Clopidogrel Bisulfate as an anti-platelet, was unsuccessful. <BR/>During an interview on 09/21/2023 at 2:27 p.m., MDS Coordinator B stated MDS Coordinator D was responsible for coding Clopidogrel Bisulfate under the anticoagulant section on the MDS. MDS Coordinator B stated she should have not coded Clopidogrel Bisulfate under anticoagulant because it was classified as an anti-platelet. MDS Coordinator B stated it was important to complete the MDS assessment accurately to reflect the best assessment for the resident at that time the assessment was completed. MDS Coordinator B stated there was no negative outcome because the patient needs were still met. <BR/>During an interview on 09/21/2023 at 2:37 p.m., RN C stated she was responsible for signing the MDS after completion. RN C stated the MDS nurses were responsible for coding accurately. RN C stated Plavix was classified as an anti-platelet and should have not been coded as an anticoagulant. RN C stated she monitored MDS assessments for accuracy by performing random audits. RN C stated her last audit was done a few months ago; unable to give exact date. RN C stated Resident #84's assessment was not part of the audit. RN C stated it was important to complete the MDS accurately to reflect the full assessment of the resident. RN C stated there was no negative outcome because everything she needed was still met. <BR/>3.Record review of Resident #61's face sheet, dated 09/21/2023, indicated Resident #61 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions), and essential hypertension (high blood pressure). <BR/>Record review of the physician order report dated 09/21/2023 indicated Resident #61 had an order to admit to hospice with an order date of 04/19/2023. <BR/>Record review of the admission MDS assessment, dated 04/30/2023, indicated Resident #61 usually understood other others, and usually made herself understood. The assessment did not address the BIMS score. The assessment did not indicate Resident #61 had a life expectancy of less than 6 months and received hospice services. <BR/>Record review of the comprehensive care plan, revised on 05/16/2023, indicated Resident #61 had a DNR and received hospice services. The care plan interventions included instruct family/resident on palliative care/hospice for any progressive decline in condition and instruct family/resident that all acute illnesses will be treated at onset. <BR/>During an interview on 09/21/2023 at 4:00 p.m., the Administrator stated she expected the MDS assessments to be completed accurately. The Administrator stated it was important to have an accurate assessment of the resident so you would be able to care plan appropriately.<BR/>Record review of the facility's policy MDS dated 08/2020, indicated .It is in the policy that the facility must conduct, initially, and periodically, a comprehensive, accurate, standardized, reproducible, assessment of a resident's functional capacity .The assessment must accurately reflect the resident's status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 21 residents (Resident #49 and Resident #36) reviewed for comprehensive person-centered care plans.<BR/>1. The facility failed to develop a care plan for Resident # 49's urostomy (surgical procedure that creates a stoma (artificial opening) for the urinary system). <BR/>2. The facility failed to care plan Resident #36's side rails.<BR/>These failures could place residents at risk for unmet care needs and decreased quality of care.<BR/>Findings included:<BR/>1. Record review of Resident #49's face sheet dated 09/21/23, indicated he was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #49's diagnoses included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), emphysema (lung disease that makes it hard to breathe and get enough oxygen), hydronephrosis (condition that occurs when a kidney swells and can't get rid of urine like it should), and other artificial openings of the urinary tract. <BR/>Record review of Resident #49's clinical admission evaluation dated 08/14/23, indicated under general note .staff to assist with ostomy (surgical procedure that allows bodily waste to pass through a surgically created stoma on the abdomen into a 'pouch' or 'ostomy bag' on the outside of the body) care . The clinical evaluation under the MDS responses had ostomy checked. <BR/>Record review of Resident #49's admission MDS assessment dated [DATE], indicated he had clear speech, was able to make himself understood, and understood others. The MDS assessment indicated Resident #49 had a BIMS score of 4, which indicated he had severe cognitive impairment. The MDS assessment indicated Resident #49 required limited assistance with dressing, toileting and personal hygiene and required supervision with bed mobility, transfers, walking, locomotion, and eating. The MDS assessment under section H, bladder and bowel, had indwelling catheter and ostomy checked. <BR/>Record review of Resident #49's comprehensive care plan dated 08/15/2023 did not indicate he had a urostomy. <BR/>Record review of Resident #49's order summary report dated 09/21/23, indicated he had an order to change the urostomy every 3 days as needed with an order start date of 08/15/23, and an order for urostomy care every shift and as needed with an order start date of 08/15/23. <BR/>During an interview and observation on 09/18/23 at 2:48 PM, Resident #49 said he had a urostomy and showed surveyor his urostomy which was located on his right side of abdomen.<BR/>During an interview on 09/21/23 at 2:42 PM, the ADON said Resident #49's urostomy should have been care planned with interventions so that everyone would be aware he had one. The ADON said Resident #46 not having his urostomy care planned would cause a new employee to miss he had one and not provide the care needed. The ADON said the DON, MDS Coordinator and herself were responsible for ensuring the care plans were updated. <BR/>During an interview on 09/21/23 at 3:01 PM, the DON said she expected the comprehensive care plans to be accurate and specific to the resident care and said she expected Resident #49's urostomy to have been care planned. The DON said she did not feel there was a potential for harm as the staff was taking care of Resident #49's urostomy and documenting it. The DON said any nurse was responsible for updating the residents care plan.<BR/>During an interview on 09/21/23 at 3:13 PM, the Administrator said she expected Resident #49's urostomy to have been care planned and with appropriate care interventions. The Administrator said the MDS nurse was responsible for updating the care plans. The Administrator said she did not feel Resident #49 would have any risks for not having his urostomy care planned as he has orders for his urostomy and will trigger staff to care for it.<BR/>2. Record review of Resident #36's face sheet dated 09/20/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted o 06/15/23. Resident #36's diagnoses included spasmodic torticollis (a painful condition in which the neck muscles contract involuntary, causing the head to twist or turn to one side), dehydration (loss of body fluid caused by illness, sweating or inadequate intake), restless leg syndrome (irresistible urge to move the legs, typically in the evenings), repeated falls, and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).<BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #36 was able to make herself understood and understood others. The MDS assessment indicated Resident #36 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #36 required limited assistance with bed mobility, transfers, dressing, and extensive assistance with toilet use. The MDS assessment did not indicate Resident #36's bed rails were used as a restraint. <BR/>Record review of the care plan with date initiated 03/27/2023, did not indicate Resident #36 had side rails to assist her in turning and repositioning. <BR/>Record review of the Order Summary Report dated 09/20/2023 indicated Resident #36 had an order for side rails up x 2 to enable resident to assist in turning and repositioning with a start date of 03/27/2023. <BR/>During an observation and interview on 09/19/2023 at 10:55 AM, Resident #36 had side rails on each side of the bed. Resident #36 said she used the side rails to assist her in repositioning herself while in the bed. <BR/>During an interview on 09/21/2023 at 3:37 PM, the ADON said the care plan was completed by the IDT (Interdisciplinary Team). The ADON said Resident #36 should have had her side rails in her care plan. The ADON said the side rails were in place to assist Resident #36 with repositioning and turning that they were used as an enabler. The ADON said it was important for the side rails to be included in the care plan, so all the nurses knew Resident #36 required the side rails for repositioning. <BR/>During an interview on 09/21/2023 at 4:08 PM, the DON said the care plans were done by the charge nurses, MDS nurses, and herself. The DON said Resident #36's side rails should be included in her care plan. The DON said she did not know why Resident #36's side rails were not in her care plan. The DON said it was important for Resident #36's side rails to be in her care plan for an accurate reflection of her care and needs, and so all the staff could see a clear picture of her needs. The DON said she performed random reviews of the care plans twice daily to ensure they included all the residents' needs. <BR/>During an interview on 09/21/2023 at 4:20 PM, the Administrator said the care plans were completed by the IDT. The Administrator said the side rails should be in the residents' care plans. The Administrator said it was important to include the side rails in the residents' care plans, so the staff knew the residents required side rails and to ensure they were in place. <BR/>Record review of the facility's policy Care Plan Meetings dated 03/09, indicated . (The Facility) is to work as a team to ensure effective and efficient care of each resident .2. Care plans and Quarterly Assessments will be reviewed and updated prior to the scheduled meeting. Each Interdisciplinary Team will review the resident's chart to identify any significant changes since the last Care Plan Meeting. Such review included but is not limited to .nursing and medical concerns .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 21 residents (Resident #32) reviewed for ADLs.<BR/>1. The facility failed to provide assistance with facial hair removal for Resident #32.<BR/>2. The facility failed to ensure Resident #32 received her shower as scheduled. <BR/>These failures could place residents at risk of not receiving services and care, and a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #32's face sheet dated 09/20/23, indicated a [AGE] year-old female who initially admitted to the facility 03/27/23 and readmitted on [DATE]. Resident #32's diagnoses included metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), depression (persistently depressed mood) and orthostatic hypotension (a form of low blood pressure that happens when standing up from a sitting or lying down).<BR/>Record review of Resident #32's admission MDS assessment dated [DATE], indicated she was understood and understood others. The MDS indicated Resident #32 had a BIMS score of 14, which indicated her cognition was intact. The MDS indicated Resident #32 did not refuse care. The MDS indicated Resident #32 required extensive assistance with bed mobility, toileting, and bathing. Resident #32 required limited assistance with transfers, locomotion, dressing and personal hygiene. <BR/>Record review of Resident #32's comprehensive care plan revised on 09/17/23, indicated Resident #32 had a self-care deficit for bathing, dressing, and feeding. The care plan interventions included to encourage resident to participate in planning day to day care, maintain consistent schedule with daily routine, and provide assistance with ADLs as needed.<BR/>Record review of the bath and shower sheets for the month of September 2023 indicated there was no shower sheet for 09/16/2023<BR/>Record review of the bathing task documentation for Resident #32 for the month of September 2023 indicated Resident #32 did not receive a shower on 09/16/2023. <BR/>During an observation and interview on 09/19/2023 at 9:02 AM, Resident #32 said sometimes the staff shaved the facial hair off and sometimes they did not. Resident #32 said she liked the facial hair to be removed. Resident #32 said she thought she was getting her showers as scheduled. Resident #32 appeared well-groomed.<BR/>During an observation on 09/20/2023 at 8:12 AM, Resident #32 had chin hairs approximately 2 cm long and upper lip hairs approximately 0.5 cm-1cm long.<BR/>During an observation on 09/21/2023 at 9:12 AM, Resident #32 had chin hairs approximately 2 cm long and upper lip hairs approximately 0.5 cm-1cm long.<BR/>During an interview on 09/21/2023 at 3:18 PM, LVN Q said the charge nurse was responsible for ensuring the residents received their baths. LVN Q said the CNAs brought the charge nurses the shower sheets for them to review or documented the showers in the residents' electronic health record. LVN Q said it was important for the residents to receive their showers/baths to keep them clean and prevent infections, and for their dignity and for them to look presentable. LVN Q said facial hair was supposed to be removed on the residents' shower days. LVN Q said the CNAs should be removing the resident's facial hair, and the charge nurses should supervise by visually inspecting the residents daily. LVN Q said the CNAs were supposed to document on the shower sheets when they shaved the residents. LVN Q said it was important for facial hair to be removed for the residents' dignity. LVN Q said she had not noticed Resident #32's facial hair. <BR/>During an interview on 09/21/2023 at 3:31 PM, the ADON said the charge nurses were responsible for ensuring the residents received their showers. The ADON said the showers were monitored by the shower sheets the CNAs filled out and gave to the charge nurses. The ADON said it was important for the residents to receive their showers to keep them clean and keep infections down. The ADON said she had not noticed that any showers were not given. The ADON said the CNAs were supposed to be shaving the residents when they showered them. The ADON said it was important for facial hair to be removed for the resident's appearance. <BR/>During an interview on 09/21/2023 at 3:47 PM, CNA R said on Saturday (09/16/2023), she had not given Resident #32 her shower and she had not shaved her. CNA R said she had not done it because they were short on Saturday, and she had not gotten to it. CNA R said the CNAs and the nurses were responsible for ensuring the residents received their showers and facial hair was removed. CNA R said she had not noticed Resident #32's facial hair, and she assumed she should have removed it. CNA R said it was important for the residents to get their showers and facial hair be removed because it was a part of grooming, and she did not want the residents to look like they had not been attended to. <BR/>During an attempted interview on 09/21/2023 at 3:54 PM, CNA S did not answer the phone.<BR/>During an interview on 09/21/2023 at 3:59 PM, the DON said the CNAs should have offered to remove the residents' facial hair by their preferred method of removal daily. The DON said the charge nurses were responsible for overseeing that the CNAs were giving showers and removing facial hair. The DON said the CNAs should be documenting the showers in the electronic health record, but some of the CNAs were still documenting on the shower sheets. The DON said she was not aware Resident #32 had facial hair. The DON said CNA R should have notified her she was not able to shower Resident #32 on Saturday, so she could have scheduled for her to get one the next day. The DON said it was important for the residents to receive their showers for hygiene purposes, for their skin to be clean, for them to have good skin integrity, for their dignity, and to prevent odors. The DON said it was important for facial hair to be removed for the residents' dignity. <BR/>During an interview on 09/21/2023 at 4:17 PM, the Administrator said she expected all the residents to receive their showers on their scheduled days. The Administrator said the CNAs were responsible for bathing the residents. The Administrator said it was important for the residents to receive their showers for them to remain clean and for their dignity. The Administrator said she expected that facial hair be removed by the residents' preferred method. The Administrator said the CNAs were responsible for facial hair removal and the charge nurses should follow up. The Administrator said it was important for facial hair to be removed for the residents' dignity and cleanliness. <BR/>Record review of the facility's undated policy titled, Bath, Shower, indicated, Objective 1. To cleanse and refresh the resident . help resident with bath as needed . chart on nursing record. Include pertinent observations . The policy did not address facial hair removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 3 of 3 residents (Resident #43, #391, #20) reviewed for treatment of urinary tract infections and 3 of 4 residents (Resident #12, #66, and #2) reviewed for incontinent care. <BR/>1. Resident #43 was admitted to the hospital on [DATE] with septic shock related to a urinary tract infection.<BR/>2. Resident #391 was admitted to the hospital on [DATE] with a diagnosis of sepsis related to a urinary tract infection.<BR/>3. Resident #20 was admitted to the hospital on [DATE] with a diagnosis of urinary tract infection.<BR/>4. CNA M failed to clean the foley catheter tubing during foley catheter care for Resident #12 who currently had a urinary tract infection.<BR/>5. CNA P failed to provide appropriate incontinent care for Resident #66 who had a recent history of urinary tract infection.<BR/>6. The facility failed to ensure CNA V provided proper incontinent care to Resident #2. <BR/>7. The facility failed to ensure in-services were provided since May 2023 regarding hand hygiene, foley catheter care, and incontinent care.<BR/>An Immediate Jeopardy (IJ) situation was identified on 9/20/2023 at 10:50 a.m. While the IJ was removed on 9/21/2023 at 2:22 p.m., the facility remained out of compliance at a severity level of actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems.<BR/>These deficient practices could place residents at risk for infections, serious infections, and even death due to improper care practices.<BR/>Findings included:<BR/>1. Record review of Resident #43's face sheet, dated 09/21/2023, indicated Resident #43 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included COVID-19 (an infectious disease caused by a virus), urinary tract infection (an infection in any part of the urinary system), and sepsis (occurs when your body has a life-threatening response to an infection). <BR/>Record review of annual MDS assessment, dated 12/7/2022, indicated Resident #43 made herself understood and usually understood others. The assessment indicated Resident #43's BIMS score was 3, which indicated her cognition was severely impaired. The assessment indicated Resident #43 required total dependence for toilet use. The assessment indicated Resident #43 was always incontinent of bladder and bowel. The assessment indicated Resident #43 did not have an UTI in the last 30 days of this assessment. <BR/>Record review of Resident #43's care plan, revised on 08/16/2023, indicated Resident #43 returned from the hospital with a diagnosis of urinary tract infection and sepsis The care plan interventions included administer antibiotic therapy as prescribed, encourage fluids, encourage resident to void frequently and fully empty bladder and monitor laboratory results. <BR/>Record review of Resident #43's hospital Discharge summary dated [DATE]<BR/>revealed resolved septic shock and UTI. <BR/>2. Record review of Resident #391's face sheet, dated 09/21/2023, indicated Resident #391 was an [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included unilateral (one side) primary osteoarthritis ( degeneration of joint cartilage and the underlying bone) to the right knee, urinary tract infection, and sepsis. <BR/>Record review of annual MDS assessment, dated 07/28/2023, indicated Resident #391 made himself understood and understood others. The assessment indicated Resident #391's BIMS score was 9, which indicated his cognition was moderately impaired. The assessment indicated Resident #391 required limited assistance for toilet use. The assessment indicated Resident #391 was occasionally incontinent of bladder and always continent with bowel. The assessment indicated Resident #391 did not have an UTI in last 30 days of this assessment. <BR/>Record review of Resident #391's care plan, revised on 08/14/2023, indicated Resident #391 had a urinary tract infection and was at risk for dehydration. The care plan interventions included administer antibiotic therapy as prescribed, monitor cognitive changes, and evaluate for urinary complaints. <BR/>Record review of Resident #391's hospital Discharge summary dated [DATE]<BR/>revealed urosepsis (caused by a bacterial infection that starts in the urinary tract and spreads to the blood). The hospital microbiology report dated 08/05/2023 revealed Escherichia coli (a bacteria that lives in the intestines). <BR/>3. Record review of Resident #20's face sheet, dated 09/21/2023, indicated Resident #20 was an [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included urinary tract infection. <BR/>Record review of annual MDS assessment, dated 04/03/2023, indicated Resident #20 made herself understood and understood others. The assessment indicated Resident #20's BIMS score was 13, which indicated her cognition was intact. The assessment indicated Resident #20 required total dependence for toilet use. The assessment indicated Resident #20 was always incontinent of bladder and bowel. The assessment indicated Resident #20 did not have a UTI in last 30 days of this assessment. <BR/>Record review of Resident #20's care plan, revised on 07/26/2023, indicated Resident #20 had a urinary tract infection. The care plan interventions included encourage adequate fluid intake, give antibiotic therapy as ordered and monitor/document/report to MD for s/sx of UTI. <BR/>Record review of Resident #20's hospital Discharge summary dated [DATE]<BR/>revealed UTI due to extended ESBL (enzymes that break down and destroy some commonly used antibiotics) producing Escherichia coli (a bacteria that lives in the intestines). <BR/>4. Record review of a face sheet dated 9/20/2023 indicated Resident #12 was initially admitted [DATE] and readmitted on [DATE] with the diagnoses of urinary tract infection, shock (a life-threatening medical condition as a result of insufficient blood flow throughout the body. Shock often accompanies severe injury or illness), and acute kidney failure with tubular necrosis (kidney disorder involving damage to the tubule cells of the kidneys, which can lead to acute kidney failure caused by a lack of blood and oxygen to the kidneys).<BR/>Record review of the consolidated physician orders dated 9/20/2023 indicated as of 9/15/2023 Resident #12 was receiving Merrem (meropenem) 1 gram intravenously two times daily for 14 administrations ending on 9/23/2023.<BR/>Record review of an annual MDS dated [DATE] indicated Resident #12 understands and was understood. The MDS indicated Resident #12's BIMS score was 8 indicating moderate cognitive impairment. Record review of Resident #12's MDS indicated she required extensive assistance of two staff with personal hygiene and toileting. Record review of the MDS indicated Resident #12 had an indwelling catheter.<BR/>Record review of the comprehensive care plan dated 11/07/2019 and updated on 9/12/2023 indicated Resident #12 had a foley catheter related to urine retention and overactive bladder with a history of urinary tract infections. The care plan indicated Resident #12 was treated:<BR/>7/18/2023 with Levofloxacin 500 milligrams one tablet by mouth daily for 7 days related to UTI provider urologist<BR/>7/31/2023 with Bactrim DS one tablet by mouth twice daily for 7 days for UTI.<BR/>8/18/2023 Merrem 1 gram twice daily for 7 days for an UTI<BR/>The interventions included was to change the foley catheter per the physician orders, check the catheter tubing for kinks with turning and repositioning and monitor/report symptoms of an UTI.<BR/>Record review of the medication administration record dated July 2023 indicated Resident #12 received Levofloxacin 500 milligrams daily for 6 days for a urinary tract infection starting on 7/18/2023 and ending on 7/24/2023. <BR/>Record review of a urinalysis culture and sensitivity report dated 7/25/2023 indicated Resident #12's urine had 50,000 - 100,000 Escherichia coli (E coli) organism colony count. <BR/>Record review of the medication administration record dated July 2023 indicated on 7/31/2023 Resident #12 was administered Bactrim DS 800-160 milligrams one tablet twice daily for 10 days for a UTI. <BR/>Record review of a UTI Screener Evaluation dated 7/31/2023 indicated Resident #12 had an indwelling foley catheter and had suprapubic pain.<BR/>Record review of a urinalysis culture and sensitivity report dated 8/13/2023 indicated Resident #12's urine had 50,000 - 100,000 colony count of Escherichia coli (E coli) organism count.<BR/>Record review of a medication administration record dated August 2023 indicated Resident #12 was administered Meropenem intravenously 1 gram twice daily for 13 administrations. The intravenous meropenem was started on 8/19/2023 and ended on 8/24/2023 for a urinary tract infection.<BR/>Record review of a medication administration record dated September 2023 indicated Resident #12 was administered Meropenem intravenously 1 gram twice daily starting on 9/17/2023 and completing on 9/23/2023 for a urinary tract infection.<BR/>During an interview on 9/18/2023 at 10:31 a.m., Resident #12 said she had her intravenous antibiotic therapy for repeat urinary tract infections. Resident #12 said the urologist said the urinary tract infections were caused from not cleaning her perineal area well. Resident #12 said she did not feel as though the staff provided her good catheter care. Resident #12 said she had to complete the antibiotics before he would do the surgery to give her a suprapubic catheter (a catheter placed directly in the bladder by entering the skin on the abdomen).<BR/>During an observation on 9/20/2023 at 9:26 a.m., CNA M raised Resident #12's bed to an appropriate height, Resident #12's brief was opened, then she obtained the clean under pad. CNA M rolled the clean pad up and instructed Resident #12 to roll to her right while CNA M placed the rolled pad underneath the current pad. CNA N then had Resident #12 roll toward her left while removing the current pad. CNA M took Resident #12's foley catheter bag from the side of the bed and laid it up in the bed at Resident #12's feet. CNA M had not changed her gloves when she took a clean washcloth, placed the washcloth in the basin of clean water and sprayed the washcloth with perineal cleanser. CNA M then wiped Resident #12's perineal area from top to bottom 4 times using a different fold of the cloth with each wiping. Then CNA M obtained a clean bath towel and dried Resident #12's perineal area without changing her gloves. Then CNA M discarded the used washcloth in the dirty linen bag. Resident #12 was instructed to roll to her right then CNA M obtained a clean washcloth, moistened the towel in the basin of water and then sprayed perineal wash on the toweling. CNA M then cleansed Resident #12's buttocks, 4 times wiping away and folding the cloth each time. CNA M discarded the cloth in the dirty linen. CNA M then used the bath towel and dried Resident #12's buttocks. CNA M then obtained the barrier cream, squeezed the cream in her hand and applied the barrier cream using the same pair of gloves throughout the incontinent care process. CNA M applied Resident #12's clean brief. CNA M then changed her gloves and repositioned Resident #12. <BR/>During an interview on 9/20/2023 at 9:26 a.m., CNA N said CNA M failed to clean the foley catheter tubing. CNA N said Resident #12 could get a urinary tract infection from not doing catheter care correctly. CNA M said she failed to clean the foley catheter tubing and she failed to change her gloves between clean and dirty when she provided incontinent care to Resident #12. CNA M said catheter care and incontinent care should be done correctly to prevent urinary tract infections.<BR/>Record review of a Certified Nursing Assistant Competency Checklist indicated CNA M was evaluated on 6/03/2023 for perineal care-female (with/without a catheter). The evaluation indicated CNA M received a satisfactory (S) score.<BR/>5. Record review of a face sheet dated 9/21/2023 indicated Resident #66 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia, left hip fracture, urinary tract infection, and dehydration.<BR/>Record review of an Annual MDS dated [DATE] indicated Resident #66 was usually understood and usually understood others. The MDS indicated Resident #66's BIMS score was 3 indicating severely impaired cognition. The MDS indicated Resident #66 required extensive assistance of one staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #66 was frequently incontinent of bowel and bladder. <BR/>Record review of the comprehensive care plan dated 8/23/2023 and revised on 9/04/2023 indicated Resident #66 had a urinalysis with a culture and sensitivity completed on 8/14/2023 due to confusion and altered mental status. The care plan indicated on 8/21/2023 Resident #66 had another urinalysis with a culture and sensitivity due to altered mental status and increased confusion. The care plan indicated on 8/24/2023 the physician ordered Macrobid 2 capsules by mouth twice daily for 7 days for a urinary tract infection. The goal of the care plan included Resident #66 would not have signs or symptoms of infection. The interventions included administering the antibiotics as ordered, encouraged fluids, evaluate pain, evaluate urinary complaints, monitor for cognitive changes, and monitor laboratory results. <BR/>Record review of a urinalysis dated 8/15/2023 indicated Resident #66 had 0-5 red blood cells (none seen), bacteria was many (none seen), mucous light (none seen), appearance cloudy (clear), and leukocyte esterase moderate (negative). There were no orders written on the laboratory sheet but was signed by the physician. <BR/>Record review of a urinalysis with a culture dated 8/22/2023 indicated Resident #66 had a urinary tract infection with greater than 100,000 Raoultella Planticola (bacteria) organism. The order provided on the laboratory result was Macrobid 100 milligrams one capsule twice daily for 7 days. <BR/>During an observation on 9/18/2023 at 2:36 p.m., Resident #66 was assisted to her bed by two staff using a gait belt. Resident #66 was assisted by CNA P to remove her pants. CNA P, with her gloves on, touched the clean wipes and the brief. Resident #66's brief was opened by CNA P. CNA P then used a wipe and wiped down on each side of Resident #66's perineal area. Then CNA P wiped one wipe down the middle. Resident #66 was assisted by CNA O to roll to the right and CNA P cleansed her buttocks using three wipes. CNA P then removed her gloves, washed her hands, reapplied gloves, and then attempted to apply the brief. During the application of the brief. The brief tabbed area tore. CNA P removed her gloves and washed her hands again. Resident #66 urinated again on the clean brief. CNA O was aware Resident #66 urinated on the clean brief. Upon CNA P's return to the bedside CNA O indicated to CNA P Resident #66 urinated again. CNA P applied the clean brief and Resident #66 was repositioned. <BR/>During an interview on 9/18/2023 at 2:36 p.m., CNA O said she believed incontinent care went well with no mistakes. During an interview with CNA P she said she was nervous but she thought the incontinent care went well. When asked why she failed to provide Resident #66 incontinent care again after she urinated on her torn brief, she said she did not have any more wipes. CNAs O and P said Resident #66 could get a UTI or a rash from improper incontinent care.<BR/>Record review of CNA P's Certified Nursing Assistant Competency Checklist dated 8/24/2023 indicated CNA P was evaluated for perineal care-female with and without a catheter. The evaluation indicated CNA P met the evaluation criteria with a satisfactory (s) skill level.<BR/>6. During an observation and interview on 09/20/2023 starting at 8:45 AM, CNA V provided incontinent care to Resident #2. CNA V unfastened Resident #2's dirty brief and removed it. CNA V wiped Resident #2's front perineal area with the same wipe twice in different areas. CNA V failed to use a new wipe when going to a different area. CNA V turned Resident #2 and wiped her buttocks and removed the dirty brief. CNA V removed her dirty gloves and applied new gloved. CNA V did not perform hand hygiene after removing her gloves. CNA V placed the new brief under Resident #2 and applied barrier cream to her buttocks. CNA V removed her gloves and applied clean gloves. CNA V did not perform hand hygiene after removing her gloves. CNA V finished applying the new brief. CNA V removed her gloves and gathered the bag with trash. CNA V repositioned Resident #2 in her bed. CNA V exited the room and disposed of the trash and washed her hands. CNA V said when providing perineal care, she was supposed to use a different wipe every time she wiped. CNA V said she did not realize she had wiped twice in different areas with the same wipe. CNA V said she should have performed hand hygiene after removing her gloves. CNA V said she got nervous and forgot to perform hand hygiene. CNA V said she had been checked off on incontinent care about a month ago. CNA V said the CNAs were responsible for providing proper incontinent care. CNA V said it was important to provide proper incontinent care and perform hand hygiene during incontinent care to prevent cross contamination and UTIs. <BR/>During an interview on 09/21/2023 at 3:15 PM, LVN Q said the charge nurses were responsible for making sure the CNAs provided proper incontinent care. LVN Q said she monitored the CNAs by going in with them when they provided incontinent care at least once a shift. LVN Q said sometimes she had to prompt them to change their gloves, and she had to prompt them to completely clean the residents. LVN Q said it was important for the CNAs to provided proper incontinent care and perform hand hygiene to decrease UTIs and any kind of infections, and to make sure the residents were clean and did not have any skin breakdown. <BR/>During an interview on 09/21/2023 at 3:34 PM, the ADON said as a team the nurses and department heads were responsible for making sure the CNAs were providing proper incontinent care and performing hand hygiene adequately while providing incontinent care. The ADON said skills check offs were performed by the DON yearly and in-services were done as needed. The ADON said the CNAs providing proper incontinent care was monitored by the skills check offs and random checks. The ADON said she had not noticed any issues with incontinent care. The ADON said it was important for the CNAs to provide proper incontinent care and perform hand hygiene to keep infections down and so the residents would not get a UTI. <BR/>During an interview on 09/21/2023 at 4:01 PM, the DON said the nurse managers and herself were responsible for ensuring the CNAs were providing proper incontinent care and performing hand hygiene. The DON said this was monitored by the competency checks and random pop-ins on the CNAs while they were performing incontinent care. The DON said it was important for the CNAs to provide proper incontinent care and perform hand hygiene to prevent infection and UTIs. <BR/>During an interview on 09/21/2023 at 4:19 PM, the Administrator said she expected the CNAs to provide proper incontinent care and perform hand hygiene. The Administrator said the charge nurses and nurse managers were responsible for ensuring the CNAs provided proper incontinent care and performed hand hygiene. The Administrator said it was important for the CNAs to provide proper incontinent care and perform hand hygiene for cleanliness and to reduce infections. <BR/>During an interview on 9/21/2023 at 11:52 a.m., the ADON said she expected incontinent care and catheter to be performed correctly. The ADON said when incontinent care and catheter care was not performed correctly the resident was at risk for a urinary tract infection. The ADON said she expected catheter care to include cleaning of the tubing. The ADON said changing of the gloves should occur as often as needed but no less than 3 times during the process. The ADON said when a resident urinated again after just receiving incontinent care, she expected the resident to receive incontinent care again. The ADON said she expected the CNAs to clean the labia to prevent bowel movement from being pressed inside the urethral area causing an infection. The ADON said she had been in-serviced on incontinent care male and female, foley catheter, she had been checked off on skills in this area. The ADON said she had been given the task of infection control now. The ADON said she was unsure of her role as of yet, but her role would include identifying the infectious organism. The ADON said identification of the organism was important to monitor for trends. <BR/>During an interview on 9/21/2023 at 12:04 p.m., RN C (unit manager) said she had in-serviced CNAs on incontinent care, catheter care, and infection control. RN C said she had in serviced the DON and ADON on tracking and trending of infections, monitoring of organisms, and the importance of identification of the organism to in-service staff on hydration and cleanliness, and to perform skills checks on incontinent care. RN C said she expected the CNAs to not wipe the residents from back to front, to change gloves between dirty and clean, and to ensure the female labia were cleansed.<BR/>During an interview on 9/21/2023 at 12:15 p.m., the DON said she had conducted in-services regarding catheter care, hand hygiene, incontinent care, and prevention of infections. The DON said she had been in-serviced by RN C on tracking and trending of the organism and the importance. The DON said the tracking and trending log for infections had a column now added for organism. The DON said the tracking of the organism would help to see a trend and to identify if a certain hall or staff member may factor in on the results. The DON said the team will meet weekly and discuss the bacteria in the infections and then implement interventions. The DON said prior to this, there had been no formal meetings to involve everyone. The DON said the infection preventionist would just look over the infections. The DON said she had in serviced the hospice provider and the medical director on the antibiotic stewardship. The DON said she in-serviced in May and had the staff checked off on their skills but was still unsure of the deficient practice at an IJ level. <BR/>During an interview on 9/21/2023 at 12:27 p.m., the Administrator said she would be more involved in monitoring, competencies, and in-servicing for infection control. The Administrator said she would attend the weekly infection control meetings and ensure during the QA meetings the infections were also discussed. The Administrator said she believed the tracking and trending of the organisms could help not to spread infections.<BR/>During an interview on 9/21/2023 at 12:29 p.m., the Assistant Administrator/Owner said she would be involved in looking over the infections, and in-services. The Assistant Administrator/Owner said she was present in the facility 7 days a week and she would be involved in the monitoring more so. The Administrator/Owner said the infections would also be discussed in the morning meeting. The Assistant Administrator said she had been more involved in the past, but her spouse had become ill over the summer, and she had spent half days away from the facility and the DON herself had suffered a loss which took her away from the facility, but she remained unsure why the in-service in May and the staff check offs failed to prevent the deficient practice. <BR/>7. Record review of the Infection Control-Donning/Doffing, PPE and Handwashing in-service was completed on 01/02/2023. <BR/>Record review of the Incontinent Care/UTI in-service was completed on 05/08/2023.<BR/>Record review of the undated Antimicrobial Stewardship policy, indicated, the facility will establish a multidisciplinary antimicrobial stewardship program that defines and provides guidance for optimal antimicrobial use 3. The members of the antimicrobial stewardship program will develop, endorse, and adopt established guidelines for use by facility staff for appropriate identification and assessment of infections and treatment guidelines 4. The members of the antimicrobial stewardship program will meet at least quarterly to review collected date and facility trends, analyze performance, and develop action plans to improve antimicrobial date and facility trends, analyze performance and develop action plans to improve antimicrobial use. Essential date to review includes a. antimicrobial orders b. clinical documentation c. supplemental information from d. effective communication among nursing staff and between nurses and physicians/prescribers <BR/>Record review of the undated Infection Control Program policy, indicated It is the policy of this facility to have an infection control program, which assures a clean, safe, and sanitary environment for the residents 1. The facility will have an infection control system which will monitor and identify concerns in the following areas: Provides definition of acquired and communicable diseases, A means of identification of risk for infection factors, A means of identification and tracking of infections in the facility, to prevent spread of infections, Protocols for identification and isolation of residents with infectious process, Education information process to assure the staff understands how to care for residents and contain the infectious process to prevent further spread, Education and refresher in-services on infection control and standard precautions, Screening of staff to assure a decrease in the odds of transmission of infectious processes in the community, Sanitization methods for use in showers, whirlpools and multiple use equipment 2. The Director of Nursing or Designee will review staff procedures observations of standard precaution, infection control and isolation procedures 4. Labs will be reviewed by DON and/or Designee 5. Infection control log will be maintained with documentation of Resident/type of infection/antibiotic/treatment, start date .<BR/>Record review of the facility's policy effective date 06/09/2023, titled, Hand Hygiene, indicated, Policy It is the policy of this facility to sanitize/clean hands properly to prevent the spread of infection . <BR/>https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447<BR/>A urinary tract infection (UTI) is an infection in any part of the urinary system. The urinary system includes the kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract - the bladder and the urethra.<BR/>Women are at greater risk of developing a UTI than are men. If an infection is limited to the bladder, it can be painful and annoying. But serious health problems can result if a UTI spreads to the kidneys.<BR/>Health care providers often treat urinary tract infections with antibiotics. You can also take steps to lower the chance of getting a UTI in the first place.<BR/>UTIs typically occur when bacteria enter the urinary tract through the urethra and begin to spread in the bladder. The urinary system is designed to keep out bacteria. But the defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract.<BR/>The most common UTIs occur mainly in women and affect the bladder and urethra.<BR/>o <BR/>Infection of the bladder. This type of UTI is usually caused by Escherichia coli (E. coli). E. coli is a type of bacteria commonly found in the gastrointestinal (GI) tract. But sometimes other bacteria are the cause.<BR/>When treated promptly and properly, lower urinary tract infections rarely lead to complications. But left untreated, UTIs can cause serious health problems.<BR/>Complications of a UTI may include:<BR/>o <BR/>Repeated infections, which means you have two or more UTIs within six months or three or more within a year. Women are especially prone to having repeated infections.<BR/>o <BR/>Permanent kidney damage from a kidney infection due to an untreated UTI.<BR/>o <BR/>Delivering a low birth weight or premature infant when a UTI occurs during pregnancy.<BR/>o <BR/>A narrowed urethra in men from having repeated infections of the urethra.<BR/>o <BR/>Sepsis, a potentially life-threatening complication of an infection. This is a risk especially if the infection travels up the urinary tract to the kidneys.<BR/>Prevention<BR/>These steps may help lower the risk of UTIs:<BR/>o <BR/>Drink plenty of liquids, especially water. Drinking water helps dilute the urine. That leads to urinating more often - allowing bacteria to be flushed from the urinary tract before an infection can begin.<BR/>o <BR/>Try cranberry juice. Studies that look into whether cranberry juice prevents UTIs aren't final. However, drinking cranberry juice is likely not harmful.<BR/>o <BR/>Wipe from front to back. Do this after urinating and after a bowel movement. It helps prevent the spread of bacteria from the anus to the vagina and urethra.<BR/>https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf<BR/>Record review of Urinary Tract Infection (Catheter-Associated Urinary Tract Infection (CAUTI) and Non-Catheter-Associated Urinary Tract Infection (UTI) events<BR/>Urinary tract infections (UTIs) are the fifth most common type of healthcare-associated infection, with an estimated 62,700 UTIs in acute care hospitals in 2015. UTIs additionally account for more than 9.5% of infections reported by acute care hospitals1 . Virtually all healthcare associated UTIs are caused by instrumentation of the urinary tract. Approximately 12%-16% of adult hospital inpatients will have an indwelling urinary catheter (IUC) at some time during their hospitalization, and each day the indwelling urinary catheter remains, a patient has a 3%-7% increased risk of acquiring a catheter-associated urinary tract infection (CAUTI).2-3 CAUTI can lead to such complications as prostatitis, epididymitis, and orchitis in males, and cystitis, pyelonephritis, gram-negative bacteremia, endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and meningitis in patients. Complications associated with CAUTI cause discomfort to the patient, prolonged hospital stay, and increased cost and mortality4 . It has been estimated that each year, more than 13,000 deaths are associated with UTIs.5 . <BR/>https://www.ncbi.nlm.nih.gov/books/NBK436013/<BR/>Record review of Complicated Urinary Tract Infections:<BR/>Urinary tract infections (UTIs) are among the most common presenting causes of sepsis in hospitals. Some are simple UTIs that can be managed with outpatient antibiotics and lead to almost universally good outcomes. However, complicated urinary tract infections may lead to florid urosepsis, which can be fatal. Several risk factors can complicate urinary tract infections and lead to treatment failure, repeat infections, or significant morbidity and mortality. It is vitally important to determine if the patient's infection may have resulted from one of these risk factors and whether the episode is likely to resolve with first-line antibiotics. Complicated urinary tract infections are those that present with greater morbidity, carry a higher risk of treatment failure, and typically require longer antibiotic courses, fr[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practices for 3 of 16 residents (Resident #36, Resident #224, and Resident #225) reviewed for respiratory care. <BR/>The facility failed to ensure the nasal cannula tubing was dated for Resident #36 and Resident #224. <BR/>The facility failed to ensure Resident #225's oxygen concentrator had a filter in place. <BR/>These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. <BR/>Findings included:<BR/>1. Record review of the order summary report dated 7/13/22 indicated Resident #36 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain chemical imbalance in the blood), acute respiratory failure with hypoxia (not enough oxygen in blood), essential hypertension (force of the blood against the artery walls is too high) and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen).<BR/>Record review of the order summary report dated 7/13/22 indicated Resident #36 received oxygen at 2-4 LPM (liters per minute) via nasal cannula every 8 hours as needed for O2 (oxygen) usage with a start date 7/28/21. There was an order to change O2 tubing and nebulizer machine tubing every week (night shift on Saturday) and PRN (as needed) with a start date 6/4/22. <BR/>Record review of the MDS dated [DATE] indicated Resident #36 understood others and made herself understood. She had a BIMS score of 3, which indicated severe cognitive impairment. The MDS indicated she required supervision with bed mobility, transfers; limited assistance with dressing, toileting, personal hygiene; and total dependence with bathing. The MDS indicated Resident #36 did not become SOB (shortness of breath) at rest or with exertion. The MDS indicated Resident #36 was not receiving oxygen therapy.<BR/>Record review of the care plan dated 5/25/21 indicated Resident #36 had a diagnosis of congestive heart failure. The care plan interventions were to apply O2 via N/C (nasal cannula) as needed. The care plan dated 6/23/21 indicated Resident #36 received oxygen therapy related to respiratory illness aspiration PNE (an infection of the lungs caused by inhaling saliva, food, liquid, vomit, and even small foreign objects). The care plan interventions were to apply O2 via N/C as needed and keep saturations &gt;92%. The care plan interventions did not address nasal cannula tubing. <BR/>During an interview and observation on 7/11/22 at 11:07 a.m., Resident #36 was lying in bed. Resident #36's nasal cannula was sitting on her bed side dresser. There was no date on the nasal canula tubing. Resident #36 was non-interview able. <BR/>During an observation on 7/12/22 at 9:10 a.m., Resident #36 was lying in bed and oxygen was in use via nasal cannula. There was no date on the nasal canula tubing.<BR/>During an observation on 7/13/22 at 8:42 a.m., Resident #36 was lying in bed and oxygen was in use via nasal cannula. There was no date on the nasal canula tubing.<BR/>2. Record review of the order summary report dated 7/13/22 indicated Resident #224 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including end stage renal disease (kidneys cease functioning on a permanent basis), acute diastolic (congestive) heart failure (heart unable to relax normally between beats), type 2 diabetes mellitus with hyperglycemia (occurs when blood sugar elevates to potentially dangerous levels that require medical treatment) and essential hypertension (force of the blood against the artery walls is too high). <BR/>Record review of the order summary report dated 7/13/22 indicated Resident #224 received oxygen at 2-3 LPM (liters per minute) via nasal cannula every shift for CHF (congestive heart failure) with a start date 7/11/22. There was an order to change O2 tubing and nebulizer machine tubing every week (night shift on Saturday) with a start date 7/9/22. <BR/>During an interview on 7/13/22 at 2:35 p.m., the DON said Resident #224 did not have an MDS at this time due to residing in the facility less than the allotted 14 days required to have the MDS completed. <BR/>Record review of the care plan dated 7/7/22 indicated Resident #224 had an altered respiratory status related to difficulty breathing. The care plan interventions were to apply O2 via N/C (nasal cannula) at 2-3 LPM. The care plan interventions did not address nasal cannula tubing.<BR/>During an observation and interview on 7/12/22 at 1:06 p.m., Resident #224 was eating her lunch while sitting on the edge of her bed, oxygen was in use via nasal cannula. There was no date on the nasal canula tubing. Resident #224 said she wears oxygen continuously for SOB. <BR/>During an interview on 7/13/22 at 8:48 a.m., Resident #224 was eating her breakfast while sitting on the edge of her bed and oxygen was being used by the resident via nasal cannula. There was no date on the nasal canula tubing.<BR/>3. Record review of the order summary report dated 7/13/22 indicated Resident #225 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood), essential hypertension (force of the blood against the artery walls is too high), acute diastolic (congestive) heart failure (heart unable to relax normally between beats), and paroxysmal atrial fibrillation (irregular, often rapid heart rate). <BR/>Record review of the order summary report indicated Resident #225 received oxygen at 3 LPM (liters per minute) via nasal cannula every shift with a start date 7/7/22. There was an order to change O2 tubing and nebulizer machine tubing every week (night shift on Saturday) with a start date 7/9/22. <BR/>During an interview on 7/13/22 at 2:35 p.m., the DON said Resident #225 did not have a MDS at this time due to residing in the facility less than the allotted 14 days required to have the MDS completed. <BR/>Record review of the care plan dated 7/10/22 indicated Resident #225 received oxygen therapy at 3L/min via n/c related to CHF. The care plan interventions did not address oxygen concentrator filters. <BR/>During an interview and observation on 7/11/22 at 3:34 p.m., Resident #225 was lying in bed and oxygen was in use via nasal cannula. The oxygen concentrator did not have a filter in place. Resident #225 said she wears oxygen continuously for SOB. <BR/>During an observation on 7/12/22 at 1:42 p.m., Resident #225 was lying in bed and oxygen was in use via nasal cannula. The oxygen concentrator did not have a filter in place.<BR/>During an observation on 7/13/22 at 8:51 p.m., Resident #225 was lying in bed and oxygen was in use via nasal cannula. The oxygen concentrator did not have a filter in place.<BR/>During an interview and observation on 7/13/22 at 12:41 p.m., LVN A said she was Resident #225's charge nurse on the 6a-2p shift. LVN A said all nursing staff were responsible for ensuring oxygen concentrators had filters in place. LVN A said it was the responsibility of the charge nurse on Saturday nights to clean and change the filters. LVN A observed with the surveyor Resident #225's oxygen concentrator with no filter in place. LVN A said she unaware that Resident #225 filter was missing from her concentrator. LVN A said this failure could place Resident #225 at risk for respiratory infection. <BR/>During an interview on 7/13/22 at 12:51 p.m., LVN B said she was Resident #36 and Resident #224's charge nurse on the 6a-2p shift. LVN B said nursing staff on Saturday nights were responsible for changing and labeling tubing. LVN B said all staff were responsible for making sure it was done. LVN B said she did not notice Resident #36 and Resident #224 nasal cannula tubing was not dated. She said this failure could place residents at risk for respiratory infection. <BR/>During an interview on 7/13/22 at 2:10 p.m., the DON said nursing staff on Saturday nights and the nurse who first applied the O2 were responsible for ensuring oxygen concentrator filters were in place, changing and labeling tubing. The DON said rounds were done every Monday by the DON, ADON, unit manager and MDS coordinator. The DON said she expected the nasal cannula to be dated for clarity and filter in place. She said rounds were not done this Monday due to call ins and state in the building. The DON said not providing this care could cause the resident to have an upper respiratory infection.<BR/>Record review of the facility's oxygen policy tilted Cleaning Oxygen Concentrators and equipment dated 06/2014 indicated . facility staff will perform care of oxygen concentrators and equipment to prevent the spread of infection and diseases within the facility Weekly on Saturday unplug concentrator and remove oxygen tubing with nasal cannula/mask . remove filter from concentrator and either vacuum filter or wash with warm soapy water and allow to dry completely prior to replacing . replace oxygen tubing with new tubing and nasal cannula/mask .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 3 of 3 residents (Resident #78, Resident #36, Resident #2) reviewed for bed rails. <BR/>The facility failed to ensure Resident #78, Resident #36, and Resident #2 had assessments or informed consents for the use of bed rails.<BR/>This failure could place the residents at risk for entrapment, injury, or harm.<BR/>Findings included:<BR/>1. Record review of Resident #78's face sheet dated 09/20/23, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #78's diagnoses included periprosthetic fracture (fracture and breaks of the bone around a total knee replacement) around internal prosthetic right knee joint, transient cerebral ischemic attack (mini stroke), osteoarthritis (type of arthritis that occurs when flexible tissue at the end of bones wears down), and bilateral hearing loss.<BR/>Record review of Resident #78's clinical admission evaluation dated 07/25/23, under section safety, indicated Resident #78 had assistive device and had grab bar, low bed, and &frac12; rails checked. The clinical admission evaluation under section MDS responses indicated bed rails were used daily. <BR/>Record review of Resident #78's admission MDS assessment dated [DATE], indicated she had clear speech, was able to make herself understood, and understood others. The MDS indicated Resident #78 had a BIMS score of 15, which indicated her cognition was intact. The MDS indicated Resident #78 required extensive assistance with bed mobility and supervision with eating. The MDS indicated Resident #78 was totally dependent on staff for bathing. The MDS assessment did not indicate Resident #78's bed rails were used as a restraint<BR/>Record review of Resident #78's comprehensive care plan dated 07/26/23, indicated resident had impaired physical mobility with interventions to encourage use of prescribed assistive devices . The care plan did specify bed rails. <BR/>Record review of Resident #78's order summary report dated 09/20/23, indicated she had an order for side rails up, times 2 (one bed rail on each side of the bed) to enable resident to assist in turning and repositioning and were used as enablers with a start date of 08/03/23. <BR/>Record review of Resident #78's EMR on 09/20/23, did not reveal a side rail assessment or a consent for the use side rails.<BR/>During an observation on 09/18/23 at 10:32 AM, Resident # 78 was in her room sitting up in her wheelchair. Resident #78 had &frac12; bed rails up to each side of her bed.<BR/>During an observation on 09/20/23 at 08:46 AM, Resident #78 was in bed and continued to have &frac12; bed rails up to each side of the bed. <BR/>2. Record review of Resident #2's face sheet dated 09/20/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2's diagnoses included history of urinary tract infections, dementia (memory loss), diverticulitis (inflammation or infection in one or more small pouches in the digestive tract), and essential hypertension (high blood pressure). <BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #2 was able to make herself understood and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #2 required limited assistance with bed mobility, toilet use and extensive assistance with dressing and transfers. The MDS assessment did not indicate Resident #2's bed rails were used as a restraint.<BR/>Record review of Resident #2's comprehensive care plan revised on 04/15/23 indicated she side rails up times 2 to enable resident to turn and reposition . The care plan intervention was to encourage use of prescribed assistive devices. <BR/>Record review of Resident #2's order summary report dated 09/20/23, indicated she had an order for side rails up, times 2 to enable resident to assist in turning and repositioning and were used as enablers with a start date of 05/24/21. <BR/>Record review of Resident #2's electronic health record on 09/21/2023 did not indicate assessments for side rails or a consent for the use of side rails. <BR/>During an observation and interview on 09/18/2023 at 12:52 AM, Resident #2 had side rails on each side of the bed. Resident #2 said she needed the side rails to assist her with turning while she was in the bed. <BR/>3. Record review of Resident #36 's face sheet dated 09/20/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #36's diagnoses included spasmodic torticollis (a painful condition in which the neck muscles contract involuntary, causing the head to twist or turn to one side), dehydration (loss of body fluid caused by illness, sweating or inadequate intake), restless leg syndrome (irresistible urge to move the legs, typically in the evenings), repeated falls, and Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors).<BR/>Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #36 was able to make herself understood and understood others. The MDS assessment indicated Resident #36 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #36 required limited assistance with bed mobility, transfers, dressing, and extensive assistance with toilet use. The MDS assessment did not indicate Resident #36's bed rails were used as a restraint. <BR/>Record review of Resident #36's comprehensive care plan dated 03/27/23, did not indicate Resident #36 had bed rails to assist her in turning and repositioning. <BR/>Record review of Resident #36's order summary report dated 09/20/23, indicated she had an order for side rails up, times 2 to enable resident to assist in turning and repositioning and were used as enablers with a start date of 03/27/23. <BR/>Record review of Resident #36's electronic health record on 09/21/2023 did not indicate assessments for side rails or a consent for the use of side rails. <BR/>During an observation and interview on 09/19/2023 at 10:55 AM, Resident #36 had side rails on each side of the bed. Resident #36 said she used the side rails to assist her in repositioning herself while in the bed. <BR/>During an interview on 09/21/23 at 2:42 PM, the ADON said the residents had bed rails to assist them in turning and repositioning. The ADON said every resident had the bed rails on admission unless they had requested not to have them. The ADON said since the bed rails were used as an enabler and not a restraint, an assessment or a consent was not required to be completed. The ADON said the nurses looked at the bed rails daily as part of a task on the nurse's administration record.<BR/>During an interview on 09/21/23 at 3:01 PM, the DON said the facility beds have had side rails on them since 2007 and it had never been an issue. The DON said the side rails were assessed by the nurse on admission and on the MDS assessment. The DON said when a resident was admitted to the facility, the side rails were on the bed but were down and not in use. Upon assessment, the nurse determined if the resident wanted the side rails up. The DON said the side rails were frequently requested to be up as the side rails held the bed control. The DON said there were no consents obtained for use of the bed rails as they were not considered restraints. The DON said she did not feel the residents were at any risks since the side rails were being used as enablers. <BR/>During an interview on 09/21/23 at 3:13 PM, the Administrator said the bed rails were assessed on admission and daily on the skilled Medicare charting. The Administrator said those assessments were adequate. The Administrator said the bed rails were used as enablers so residents could turn and reposition themselves. The Administrator said there were no obtained consents for the use of the bed rails. The Administrator said she did not feel the residents were placed at risk for having the bed rails since they were not being used as a restraint.<BR/>During an interview on 09/21/2023 at 4:11 PM, the DON said the side rails on Resident #36 and Resident #2 had been in place since the residents admitted to the facility. The DON said there were no interventions attempted prior to placing the side rails since they had been there since admission. The DON said the side rails were in place to assist the residents with sitting up and down, and repositioning in the bed. The DON said she had not obtained consents for the side rails because they were not considered a restraint. The DON said she was responsible for assessing the side rails and placement of the side rails. The DON said it was important to assess for the use of side rails because there was a potential for injury. <BR/>During an interview on 09/20/2023 at 10:10 AM, the DON said the only policy addressing side rails was the Resident Assessment policy. <BR/>Record review of the facility's policy with an effective date of March 2014, titled, Resident Assessment, did not address the assessment for the use of or informed consent for side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #84) of 21 residents reviewed for pharmacy services.<BR/>The facility did not ensure Resident #84 amlodipine (blood pressure medication) and lisinopril (blood pressure medication) was held when her blood pressure was outside of parameters. <BR/>This failure could place the resident at risk of low blood pressure, dizziness, or fall. <BR/>Findings include: <BR/>Record review of Resident #84's face sheet, dated 09/21/2023, indicated Resident #84 was an [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses which included essential hypertension (high blood pressure). <BR/>Record review of Resident #84's order summary report, dated 09/21/2023, indicated Resident #84 was prescribed amlodipine besylate 10mg, 1 tablet by mouth one time a day related to essential hypertension, hold for SBP (top number) less than 110, DBP (bottom number) less than 60 or pulse less than 60. <BR/>Record review of Resident #84's order summary report, dated 09/21/2023, indicated Resident #84 was prescribed lisinopril 20mg , 1 tablet by mouth one time a day related to essential hypertension, hold for SBP (top number) less than 110, DBP (bottom number) less than 60 or pulse less than 60. <BR/>Record review of Resident #84's admission MDS assessment, dated 08/23/2023, indicated Resident #84 understood others and made herself understood. The assessment indicated Resident #84 BIMS was 6, which indicated severe cognitive impairment. The assessment indicated Resident #84 had a diagnosis of hypertension (high blood pressure). <BR/>Record review of Resident #84's care plan, revised on 08/23/2023, indicated Resident #84 had hypertension. The care plan interventions included give anti-hypertensive medications as ordered, monitor for side effects such as orthostatic hypotension (low blood pressure that happens when standing up from sitting or lying down), increased heart rate, and effectiveness. <BR/>Record review of the MAR dated 08/01/2023-08/31/2023, indicated RN A administered Resident #84's amlodipine besylate and lisinopril on 08/27/2023. Resident #84's blood pressure was 109/60 on 08/27/2023. <BR/>Record review of the MAR dated 09/01/2023-09/30/2023, indicated RN A administered Resident #84's amlodipine besylate and lisinopril on 09/03/2023. Resident #84 's blood pressure was 108/63 on 09/03/2023. <BR/>During an interview on 09/18/2023 at 2:30 p.m., Resident #84 was lying in bed. Resident #84 stated she received all of her medications. Resident #84 was unable to recall if she did not receive her blood pressure medications on 08/27/2023 and 09/03/2023. Resident #84 did not have any negative outcomes from the amlodipine besylate and lisinopril given. <BR/>During an interview on 09/21/2023 at 3:03 p.m., RN A stated the blood pressure medications should have been held if Resident #84 blood pressure was outside of the parameters. RN A stated he was unsure why he administered the medications. RN A stated it was important to ensure physician orders were followed to prevent hypotension, dizziness, and falls. RN A stated the negative outcome of giving blood pressure medications outside of the parameters was hypotension.<BR/>During an interview on 09/21/2023 at 3:18 p.m., the DON stated the blood pressure medications should have been held because Resident #84 blood pressure was below the parameters. The DON stated she monitored by auditing medications record and staff reports. The DON stated she also did spots checks sporadically. The DON stated the last audit was completed about three weeks ago. The DON stated Resident #84 was not part of the sample batch that was being audited. The DON stated it was important to follow physician parameters because failure to do so could cause hypotension (low blood pressure) or bradycardia (low heart rate). The DON stated she was unaware of any negative outcome with these medications given. The DON stated she would complete a medication error report, notify the physician, and educate the nurse. <BR/>During an interview on 09/21/2023 at 4:00 p.m., the Administrator stated she expected physician orders to be followed. The Administrator stated she expected the medications to be held if the blood pressure was outside the parameters. The Administrator stated this potential failure could result in falls, dizziness, and hypotension. <BR/>A request for the facility's policy regarding following physician orders was submitted to the DON on 09/21/2023 at 1:30 p.m. A policy regarding following physician orders was not received prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure:<BR/> *food items were dated and sealed appropriately.<BR/> *expired food items were discarded.<BR/> *a dented can was stored separately.<BR/> *the can opener was clean.<BR/> *the pantry was clean. <BR/> *Hydrion test strips (test strips used to measure the concentration of chemicals in sanitizing solution) <BR/> were not expired.<BR/> *the dishwasher reached 120 F.<BR/>These failures could place residents at risk for foodborne illness.<BR/>Findings included:<BR/>During an observation of the kitchen on 09/18/2023, starting at 10:12 AM, accompanied by the Dietary Manager the following observations were made:<BR/>Reach in refrigerator:<BR/> *Multiple half sandwiches in plasic bags with no date<BR/> *Multiple cups of apple juice, cranberry, and orange juice with no date<BR/> *A container filled with puddings, protein shakes, gelatin had crumbs and a sticky like dark <BR/> yellowish substance in it <BR/> *Plastic bag with an opened bag of lettuce no date lettuce was brown <BR/> *Plastic bag with sliced tomatoes no date<BR/> *A can of buttermilk biscuits with a best by date of 09/09/23<BR/>Walk in cooler:<BR/> *A bag of lettuce (lettuce was brown) and dated best by 09/04/2023<BR/>Freezer:<BR/> *Plastic bag with a bag of opened pork chops with no open date<BR/> *Plastic bag with a bag of opened broccoli no open date <BR/> *Plastic bag with a bag of opened chicken breasts with no open date<BR/> *Opened bag of small pepperoni pizzas with no open date<BR/>Pantry:<BR/> *Plastic bag with vanilla wafers not sealed and not dated<BR/> *Corn Mill container not dated and white particles covered the top of the container <BR/> *1 gallon of Worcestershire sauce had dried sauce from the top of the gallon down the sides to the <BR/> bottom of the gallon <BR/> *1 gallon of light corn syrup expired 05/15/2021<BR/> *1 gallon of light corn syrup expired 10/23/2020 with open date 11/1 (no year)<BR/> *1 gallon of light corn syrup expired 10/23/2020 with open date 11/13 (no year)<BR/> *An opened container of soy sauce best by date was faded only 2021 was legible <BR/> *An opened container of crushed pepper with no open date<BR/> *Cheerios on the floor under the rack in the dry storage room buildup of dirt and dust on the edges of <BR/> the wall<BR/> *Opened bag of cocoa unsealed not dated <BR/> *Plastic bag with opened packages of cream of wheat, gravy, classy, mashed potatoes with no <BR/> open dates <BR/> *Crumbs on the floor in the dry storage room <BR/> *Dented can of green beans on the rack<BR/>In the kitchen area:<BR/> *The can opener had a dried red thick substance on it <BR/> *Hydrion test strips had expiration date of 08/01/2019, the Dietary Manager said she had not <BR/> noticed they had an expiration date on them. <BR/> *both spice racks in the kitchen had dust build up on them.<BR/> *The dishwasher temperature during the wash cycle was between 110 F-112 F. The Dietary <BR/> Manager said she had notified the Maintenance Director and the Administrator several times since <BR/> July 2023 that the dishwasher was not reaching 120 F. <BR/>During an interview on 09/18/2023 at 4:20 PM, the Administrator said she was told by the technician that services the dishwasher that it was a cold-water dishwasher, and it did not have to reach 120 F. <BR/>During an interview on 09/18/2023 at 4:26 PM, the territory manager with the facility's restaurant supply said during his visit last week on Wednesday, he had noticed the temperature was low between 100 F and 105 F, and he had notified the Dietary Manager and the Administrator that the dishwasher was not reaching the proper temperature of 120 F. The Territory Manager said it was important for the dishwasher to reach the appropriate temperature to make sure the grease was liquified and the dishes were cleaned better. The Territory Manager said the dishwasher not reaching 120 F should not harm the residents because the chemical sanitation was at the correct level. <BR/>During an observation on 09/21/2023 at 10:00 AM, the can opener still had the thick red substance on it, and the floor in the dry storage area still had crumbs on the floor. <BR/>During an interview on 09/21/2023 at 10:09 AM, the Dietary Manager said the can opener still had the thick red substance and the pantry had crumbs on the floor because the dietary staff were not doing what she asked them to do. The Dietary Manager said the can opener should be cleaned after every use by the person who used it. The Dietary Manager said the cooks were responsible for sweeping and mopping the kitchen area and the pantry after every shift. The Dietary Manager said all items in the cooler, freezer, refrigerator should have had an open date on them, and all items were supposed to be stored in a sealed bag or container. The Dietary Manager said the snacks in the fridge should have had a date on them. The Dietary Manager said the dietary staff were responsible for ensuring all items were labeled and stored appropriately. The Dietary Manager said items in the pantry should be open dated and stored in a sealed container. The Dietary Manager said she tried to discard expired items in the cooler, freezer, and refrigerator twice a week. The Dietary Manager said [NAME] T was responsible for discarding expired items in the dry storage because she was the one that put up the dry goods. The Dietary Manager said [NAME] T should be pulling the old stuff forward and the new food items back to ensure they were used prior to being expired. The Dietary Manager said she was responsible for ensuring the kitchen was clean. The Dietary Manager said, in the past, she had a cleaning schedule but had done away with it because the staff were signing off the items as completed but were not cleaning. The Dietary Manager said it was important for all food items to be stored, labeled, and dated appropriately so the staff knew how long the food had been there and to avoid food poisoning. The Dietary Manager said it was important for expired food items to be discarded so the residents would not get salmonella or food poisoning. The Dietary Manager said it was important for the kitchen to be cleaned to keep infection down. The Dietary Manager said it was important for the dishwasher machine to reach 120 F for the chemicals to work appropriately. The Dietary Manager said if the dishwasher was not reaching 120 F the dishes were not getting dried or cleaned well enough and the residents could have gotten sick. The Dietary Manager said she had not realized the test strips for the sanitizer had an expiration date, and it was important for them not to be expired to ensure the chemical sanitizer was at the correct level. <BR/>During an interview on 09/21/2023 at 10:21 AM, [NAME] T said all items in the refrigerator, cooler, freezer should have an open date once opened. [NAME] T said the snacks in the refrigerator should have a date on them. [NAME] T said all the dietary staff were responsible for ensuring food items were dated. [NAME] T said she was not the only one that put up the food items in the pantry. [NAME] T said she tried to discard expired items when she saw them. [NAME] T said she was responsible for sweeping and mopping the pantry, and she thought she had swept it and mopped it the day before. [NAME] T said the can opener should have been cleaned after every use by the person that used it. [NAME] T said she had not cleaned it that week because she had not used it. [NAME] T said it was important for all the food items to be stored and dated and for expired food items to be discarded so the residents would not get poisoned or an upset stomach. [NAME] T said it was important for the kitchen to be clean because of contamination. <BR/>During an interview on 09/21/2023 at 10:33 AM, [NAME] U said all food items in the refrigerator, freezer, and pantry should have been dated when opened and stored in a sealed container or bag. [NAME] U said the snacks in the refrigerator should have been dated by the person who made them. [NAME] U said sometimes she got in a hurry, and she might not have dated a food item when opened. [NAME] U said it was important for all food items to be stored and dated appropriately to keep them clean and so the residents would not get food poisoning. [NAME] U said she was supposed to sweep and mop the kitchen area after every shift. [NAME] U said when putting up food items in the pantry, the old stuff should have been pulled to the front and the new items placed in the back. [NAME] U said it was important to do this to use the older items first so they would not expire. [NAME] U said all the dietary staff should have been discarding expired food items when they noticed something was expired. [NAME] U said it was important for expired food items to be discarded to prevent food borne illness. [NAME] U said the can opener should have been cleaned after every use by the person that used it. [NAME] U said she had not cleaned the can opener because she had not used it. [NAME] U said it was important for the kitchen to be clean so the residents would not get sick. <BR/>During an interview on 09/21/2023 at 4:23 PM, the Administrator said she expected all food items to be stored, labeled and dated appropriately. The Administrator said she expected for food items to be discarded when expired. The Administrator said she expected for the kitchen to be kept clean. The Administrator said the Dietary Manager and herself were responsible for monitoring the kitchen. The Administrator said, in the past, they had issues with labeling and dating and occasionally cleanliness of the kitchen. The Administrator said it was important for all food items to be labeled, stored, and dated appropriately for the safety of the residents. The Administrator said it was important for the dishwasher to reach the adequate temperature to ensure the dishes were clean and sanitized.<BR/>Record review of the [NAME] Customer Service Report dated 09/13/2023 indicated the water temperature did not meet the health department minimum today. The booster heater needed to be used to reach 140-degree water temperature for best results. That was discussed with the Dietary Manager. <BR/>Record review of the facility's undated policy titled, Sanitation and Food Handling, indicated, . Equipment and supplies will be available for proper cleaning and sanitizing of dishes. a. wash temperature: 1. 120 degrees manual . <BR/>Record review of the facility's undated policy titled, Purchasing, Receiving and Storage, did not address the labeling and storage of food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practices for 3 of 16 residents (Resident #36, Resident #224, and Resident #225) reviewed for respiratory care. <BR/>The facility failed to ensure the nasal cannula tubing was dated for Resident #36 and Resident #224. <BR/>The facility failed to ensure Resident #225's oxygen concentrator had a filter in place. <BR/>These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress. <BR/>Findings included:<BR/>1. Record review of the order summary report dated 7/13/22 indicated Resident #36 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain chemical imbalance in the blood), acute respiratory failure with hypoxia (not enough oxygen in blood), essential hypertension (force of the blood against the artery walls is too high) and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen).<BR/>Record review of the order summary report dated 7/13/22 indicated Resident #36 received oxygen at 2-4 LPM (liters per minute) via nasal cannula every 8 hours as needed for O2 (oxygen) usage with a start date 7/28/21. There was an order to change O2 tubing and nebulizer machine tubing every week (night shift on Saturday) and PRN (as needed) with a start date 6/4/22. <BR/>Record review of the MDS dated [DATE] indicated Resident #36 understood others and made herself understood. She had a BIMS score of 3, which indicated severe cognitive impairment. The MDS indicated she required supervision with bed mobility, transfers; limited assistance with dressing, toileting, personal hygiene; and total dependence with bathing. The MDS indicated Resident #36 did not become SOB (shortness of breath) at rest or with exertion. The MDS indicated Resident #36 was not receiving oxygen therapy.<BR/>Record review of the care plan dated 5/25/21 indicated Resident #36 had a diagnosis of congestive heart failure. The care plan interventions were to apply O2 via N/C (nasal cannula) as needed. The care plan dated 6/23/21 indicated Resident #36 received oxygen therapy related to respiratory illness aspiration PNE (an infection of the lungs caused by inhaling saliva, food, liquid, vomit, and even small foreign objects). The care plan interventions were to apply O2 via N/C as needed and keep saturations &gt;92%. The care plan interventions did not address nasal cannula tubing. <BR/>During an interview and observation on 7/11/22 at 11:07 a.m., Resident #36 was lying in bed. Resident #36's nasal cannula was sitting on her bed side dresser. There was no date on the nasal canula tubing. Resident #36 was non-interview able. <BR/>During an observation on 7/12/22 at 9:10 a.m., Resident #36 was lying in bed and oxygen was in use via nasal cannula. There was no date on the nasal canula tubing.<BR/>During an observation on 7/13/22 at 8:42 a.m., Resident #36 was lying in bed and oxygen was in use via nasal cannula. There was no date on the nasal canula tubing.<BR/>2. Record review of the order summary report dated 7/13/22 indicated Resident #224 was a [AGE] year-old female, readmitted to the facility on [DATE] with diagnoses including end stage renal disease (kidneys cease functioning on a permanent basis), acute diastolic (congestive) heart failure (heart unable to relax normally between beats), type 2 diabetes mellitus with hyperglycemia (occurs when blood sugar elevates to potentially dangerous levels that require medical treatment) and essential hypertension (force of the blood against the artery walls is too high). <BR/>Record review of the order summary report dated 7/13/22 indicated Resident #224 received oxygen at 2-3 LPM (liters per minute) via nasal cannula every shift for CHF (congestive heart failure) with a start date 7/11/22. There was an order to change O2 tubing and nebulizer machine tubing every week (night shift on Saturday) with a start date 7/9/22. <BR/>During an interview on 7/13/22 at 2:35 p.m., the DON said Resident #224 did not have an MDS at this time due to residing in the facility less than the allotted 14 days required to have the MDS completed. <BR/>Record review of the care plan dated 7/7/22 indicated Resident #224 had an altered respiratory status related to difficulty breathing. The care plan interventions were to apply O2 via N/C (nasal cannula) at 2-3 LPM. The care plan interventions did not address nasal cannula tubing.<BR/>During an observation and interview on 7/12/22 at 1:06 p.m., Resident #224 was eating her lunch while sitting on the edge of her bed, oxygen was in use via nasal cannula. There was no date on the nasal canula tubing. Resident #224 said she wears oxygen continuously for SOB. <BR/>During an interview on 7/13/22 at 8:48 a.m., Resident #224 was eating her breakfast while sitting on the edge of her bed and oxygen was being used by the resident via nasal cannula. There was no date on the nasal canula tubing.<BR/>3. Record review of the order summary report dated 7/13/22 indicated Resident #225 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood), essential hypertension (force of the blood against the artery walls is too high), acute diastolic (congestive) heart failure (heart unable to relax normally between beats), and paroxysmal atrial fibrillation (irregular, often rapid heart rate). <BR/>Record review of the order summary report indicated Resident #225 received oxygen at 3 LPM (liters per minute) via nasal cannula every shift with a start date 7/7/22. There was an order to change O2 tubing and nebulizer machine tubing every week (night shift on Saturday) with a start date 7/9/22. <BR/>During an interview on 7/13/22 at 2:35 p.m., the DON said Resident #225 did not have a MDS at this time due to residing in the facility less than the allotted 14 days required to have the MDS completed. <BR/>Record review of the care plan dated 7/10/22 indicated Resident #225 received oxygen therapy at 3L/min via n/c related to CHF. The care plan interventions did not address oxygen concentrator filters. <BR/>During an interview and observation on 7/11/22 at 3:34 p.m., Resident #225 was lying in bed and oxygen was in use via nasal cannula. The oxygen concentrator did not have a filter in place. Resident #225 said she wears oxygen continuously for SOB. <BR/>During an observation on 7/12/22 at 1:42 p.m., Resident #225 was lying in bed and oxygen was in use via nasal cannula. The oxygen concentrator did not have a filter in place.<BR/>During an observation on 7/13/22 at 8:51 p.m., Resident #225 was lying in bed and oxygen was in use via nasal cannula. The oxygen concentrator did not have a filter in place.<BR/>During an interview and observation on 7/13/22 at 12:41 p.m., LVN A said she was Resident #225's charge nurse on the 6a-2p shift. LVN A said all nursing staff were responsible for ensuring oxygen concentrators had filters in place. LVN A said it was the responsibility of the charge nurse on Saturday nights to clean and change the filters. LVN A observed with the surveyor Resident #225's oxygen concentrator with no filter in place. LVN A said she unaware that Resident #225 filter was missing from her concentrator. LVN A said this failure could place Resident #225 at risk for respiratory infection. <BR/>During an interview on 7/13/22 at 12:51 p.m., LVN B said she was Resident #36 and Resident #224's charge nurse on the 6a-2p shift. LVN B said nursing staff on Saturday nights were responsible for changing and labeling tubing. LVN B said all staff were responsible for making sure it was done. LVN B said she did not notice Resident #36 and Resident #224 nasal cannula tubing was not dated. She said this failure could place residents at risk for respiratory infection. <BR/>During an interview on 7/13/22 at 2:10 p.m., the DON said nursing staff on Saturday nights and the nurse who first applied the O2 were responsible for ensuring oxygen concentrator filters were in place, changing and labeling tubing. The DON said rounds were done every Monday by the DON, ADON, unit manager and MDS coordinator. The DON said she expected the nasal cannula to be dated for clarity and filter in place. She said rounds were not done this Monday due to call ins and state in the building. The DON said not providing this care could cause the resident to have an upper respiratory infection.<BR/>Record review of the facility's oxygen policy tilted Cleaning Oxygen Concentrators and equipment dated 06/2014 indicated . facility staff will perform care of oxygen concentrators and equipment to prevent the spread of infection and diseases within the facility Weekly on Saturday unplug concentrator and remove oxygen tubing with nasal cannula/mask . remove filter from concentrator and either vacuum filter or wash with warm soapy water and allow to dry completely prior to replacing . replace oxygen tubing with new tubing and nasal cannula/mask .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 (Resident #123 and #223) of 18 residents reviewed for baseline care plans.<BR/>The facility failed to ensure Resident #123 and #223 had a baseline care plan completed within 48 hours of admission.<BR/>This failure could place newly admitted residents at risk of receiving inadequate care and services.<BR/>Findings included: <BR/>Record review of the admission face sheet dated 06/17/22 indicated Resident #123 was an [AGE] year-old male, admitted [DATE]. The face sheet revealed the following diagnoses: history of embolisms (clots), cervical (bones of the spine) disc disorder, sick sinus syndrome (type of heart rhythm disorder), CKD (decreased kidney function), Cerebral Infarction (stroke), Dementia (the loss of cognitive functioning: thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), Atrial Fibrillation (an irregular heartbeat), Heart Failure, anxiety (mental illness that causes constant and overwhelming worry and fear about everyday situations), HTN (high blood pressure), hypothyroidism (low thyroid function) and pain.<BR/>Record review of the admission MDS dated [DATE], revealed a BIMS of 03 indicating severely impaired cognition. He required limited to extensive assistance from one staff member for most ADLs. He received antianxiety medications, antidepressant medication, anticoagulant (blood thinning) medication, antibiotics, diuretics (causing increased urine production) and opioids (narcotic pain medication) during the review period.<BR/>Record review of the consolidated Physician Orders dated 06/17/22-07/13/22 for Resident #123 documented orders for meal supplementation, Senna/Dulcolax/Milk of Magnesia/Fleet enemas (for constipation), Tylenol/Norco (for pain), Alprazolam (for anxiety) with antianxiety monitoring, Apixaban (blood thinner) with anticoagulant monitoring, Metoprolol (for HTN), Levothyroxine (for low thyroid), Paxil (for depression) with antidepressant monitoring, Zofran (for nausea/vomiting and Furosemide (for edema).<BR/>Record review of Resident #123s electronic and physical chart revealed no baseline care plan was completed. <BR/>During an interview on 07/13/22 at 10:05 AM, RN C said newly admitted residents baseline care plans would be in the electronic chart, completed by a nurse or the MDS Coordinator. She and the DON monitored that the Baseline Care Plans were completed.<BR/>During an interview on 07/13/22 at 10:29 AM, the DON said it seemed Resident #123 Baseline Care Plan was not completed by a nurse or the MDS Coordinator and that it slipped through the cracks. She and RN C monitored that they were being completed. She also stated there would be no negative affect to the resident because the CNAs look at the tasks and the [NAME] for resident care needs. She stated the facility would implement the Baseline Care Plan under the assessments tab in the resident's electronic health record to ensure it is completed on admission within 48 hours, which is her expectation. The DON said the facility did not have a Baseline Care Plan Policy.<BR/>Record review of the admission face sheet dated 06/10/22 for Resident #223, an [AGE] year-old female admitted [DATE], revealed the following diagnosis: abnormal finding of the lung field, gout (defective metabolism of uric acid), HTN (high blood pressure), GERD (overproduction of acid in the stomach), jaundice (yellowing of the skin), fibromyalgia (widespread muscle pain), obesity, Heart Failure, Diabetes Mellitus (impaired insulin response), Metabolic encephalopathy (chemical imbalance in blood that affects the brain function) and UTI with ESBL infection (enzymes that are resistant to most antibiotics).<BR/>Record review of the admission MDS dated [DATE] for Resident #223 revealed a staff assessment for mental status noting short/long term memory problems, modified independence for daily decision making. She required extensive to total dependence for assistance of one staff member for most ADLs. She received antibiotics, diuretics (causing increased urine production) and opioids (narcotic pain medication) during the review period. <BR/>Record review of the consolidated Physician Orders dated 06/10/22-07/13/22 for Resident #223 documented orders for a PICC Line (for intravenous medications), Oxygen via nasal cannula at 2-3 liters per minute and the antibiotics Meropenem and Doxycycline for UTI/ESBL.<BR/>Record review of Resident #223's electronic and physical chart revealed that no baseline care plan was completed. <BR/>During an interview on 07/13/22 at 10:05 AM, RN C said newly admitted residents baseline care plans would be in the electronic chart, completed by a nurse or the MDS Coordinator. She and the DON monitored that the Baseline Care Plans were completed.<BR/>During an interview on 07/13/22 at 10:29 AM, the DON said it seemed Resident #223's Baseline Care Plan was not completed by a nurse or the MDS Coordinator and that it slipped through the cracks. She and RN C monitored that they were being completed. She also stated there would be no negative affect to the resident because the CNAs look at the tasks and the [NAME] for resident care needs. She stated the facility would implement the Baseline Care Plan under the assessments tab in the resident's electronic health record to ensure it is completed on admission within 48 hours, which is her expectation. The DON said the facility did not have a Baseline Care Plan Policy.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) viewed for infection control.<BR/>The facility failed to ensure the Treatment Nurse performed changed gloves and performed hand hygiene after moving a dirty napkin from the bedside table, picking oxygen tubing up out of the floor, and before starting wound care.<BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include:<BR/>During an observation on 4/23/24 at 8:51 a.m. the Treatment Nurse grabbed a dirty napkin off the bedside table and threw it away in the Resident #1's trash, then picked up the Resident #1's oxygen tubing out of the floor. The Treatment Nurse did not change his gloves or perform hand hygiene prior to starting wound care after picking up these items. <BR/>During an interview on 4/23/24 at 9:02 am the Treatment Nurse said after he picked up the napkin off the bedside table and oxygen tubing out of the floor his gloves would have been contaminated. The Treatment Nurse said he only touched the dirty dressing with the contaminated gloves in place. The Treatment Nurse said it would be important to change gloves and perform hand hygiene after picking items up from a bedside table or the floor was because the gloves that were worn when picking these items up were contaminated. <BR/>During an interview on 4/24/24 at 1:17 p.m. the DON said while providing care to a resident if a staff member picked up something off the bedside table or the floor, she expected them to perform hand hygiene prior to continuing care. The DON said if the care required gloves, she would expect the staff to change gloves and perform hand hygiene. The DON said the importance of proper hand hygiene and changing glove was to prevent cross contamination.<BR/>Record review of the facility's Handwashing/Hand Hygiene policy revised 12/22/23 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections Use can alcohol-based hand rub containing at least 60-90% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents .g. Before handling clean or soiled dressings, gauze pads, etc.l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) viewed for infection control.<BR/>The facility failed to ensure the Treatment Nurse performed changed gloves and performed hand hygiene after moving a dirty napkin from the bedside table, picking oxygen tubing up out of the floor, and before starting wound care.<BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include:<BR/>During an observation on 4/23/24 at 8:51 a.m. the Treatment Nurse grabbed a dirty napkin off the bedside table and threw it away in the Resident #1's trash, then picked up the Resident #1's oxygen tubing out of the floor. The Treatment Nurse did not change his gloves or perform hand hygiene prior to starting wound care after picking up these items. <BR/>During an interview on 4/23/24 at 9:02 am the Treatment Nurse said after he picked up the napkin off the bedside table and oxygen tubing out of the floor his gloves would have been contaminated. The Treatment Nurse said he only touched the dirty dressing with the contaminated gloves in place. The Treatment Nurse said it would be important to change gloves and perform hand hygiene after picking items up from a bedside table or the floor was because the gloves that were worn when picking these items up were contaminated. <BR/>During an interview on 4/24/24 at 1:17 p.m. the DON said while providing care to a resident if a staff member picked up something off the bedside table or the floor, she expected them to perform hand hygiene prior to continuing care. The DON said if the care required gloves, she would expect the staff to change gloves and perform hand hygiene. The DON said the importance of proper hand hygiene and changing glove was to prevent cross contamination.<BR/>Record review of the facility's Handwashing/Hand Hygiene policy revised 12/22/23 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections Use can alcohol-based hand rub containing at least 60-90% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents .g. Before handling clean or soiled dressings, gauze pads, etc.l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) viewed for infection control.<BR/>The facility failed to ensure the Treatment Nurse performed changed gloves and performed hand hygiene after moving a dirty napkin from the bedside table, picking oxygen tubing up out of the floor, and before starting wound care.<BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include:<BR/>During an observation on 4/23/24 at 8:51 a.m. the Treatment Nurse grabbed a dirty napkin off the bedside table and threw it away in the Resident #1's trash, then picked up the Resident #1's oxygen tubing out of the floor. The Treatment Nurse did not change his gloves or perform hand hygiene prior to starting wound care after picking up these items. <BR/>During an interview on 4/23/24 at 9:02 am the Treatment Nurse said after he picked up the napkin off the bedside table and oxygen tubing out of the floor his gloves would have been contaminated. The Treatment Nurse said he only touched the dirty dressing with the contaminated gloves in place. The Treatment Nurse said it would be important to change gloves and perform hand hygiene after picking items up from a bedside table or the floor was because the gloves that were worn when picking these items up were contaminated. <BR/>During an interview on 4/24/24 at 1:17 p.m. the DON said while providing care to a resident if a staff member picked up something off the bedside table or the floor, she expected them to perform hand hygiene prior to continuing care. The DON said if the care required gloves, she would expect the staff to change gloves and perform hand hygiene. The DON said the importance of proper hand hygiene and changing glove was to prevent cross contamination.<BR/>Record review of the facility's Handwashing/Hand Hygiene policy revised 12/22/23 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections Use can alcohol-based hand rub containing at least 60-90% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents .g. Before handling clean or soiled dressings, gauze pads, etc.l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (Treatment Nurse) viewed for infection control.<BR/>The facility failed to ensure the Treatment Nurse performed changed gloves and performed hand hygiene after moving a dirty napkin from the bedside table, picking oxygen tubing up out of the floor, and before starting wound care.<BR/>These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. <BR/>Findings Include:<BR/>During an observation on 4/23/24 at 8:51 a.m. the Treatment Nurse grabbed a dirty napkin off the bedside table and threw it away in the Resident #1's trash, then picked up the Resident #1's oxygen tubing out of the floor. The Treatment Nurse did not change his gloves or perform hand hygiene prior to starting wound care after picking up these items. <BR/>During an interview on 4/23/24 at 9:02 am the Treatment Nurse said after he picked up the napkin off the bedside table and oxygen tubing out of the floor his gloves would have been contaminated. The Treatment Nurse said he only touched the dirty dressing with the contaminated gloves in place. The Treatment Nurse said it would be important to change gloves and perform hand hygiene after picking items up from a bedside table or the floor was because the gloves that were worn when picking these items up were contaminated. <BR/>During an interview on 4/24/24 at 1:17 p.m. the DON said while providing care to a resident if a staff member picked up something off the bedside table or the floor, she expected them to perform hand hygiene prior to continuing care. The DON said if the care required gloves, she would expect the staff to change gloves and perform hand hygiene. The DON said the importance of proper hand hygiene and changing glove was to prevent cross contamination.<BR/>Record review of the facility's Handwashing/Hand Hygiene policy revised 12/22/23 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections Use can alcohol-based hand rub containing at least 60-90% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact with residents .g. Before handling clean or soiled dressings, gauze pads, etc.l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #190) reviewed for Medicare/Medicaid coverage. <BR/>The facility failed to ensure Resident #190 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted.<BR/>This failure could place residents at risk for not being aware of changes to provided services.<BR/>Findings include: <BR/>1. Record review of Resident #190's face sheet, dated 09/21/2023, indicated Resident #190 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included encephalopathy (brain disease that alters brain function or structure), and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar). <BR/>Record review of admission MDS assessment, dated 03/16/2023, indicated Resident #190 made herself understood and understood others. The assessment indicated Resident #190's BIMS score was 11, which indicated his cognition was moderately impaired. The assessment indicated Resident #190 was receiving speech, occupational and physical therapy. <BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #190 was receiving Medicare Part A services starting on 03/09/2023 and the last covered day of Part A services was 04/20/2023, However, it was revealed that a SNF ABN was not completed which would have informed Resident #190 of the option to continue services at the risk of out-of-pocket. <BR/>During an interview on 09/21/2023 at 10:50 a.m., the Social Worker stated she was responsible for ensuring Resident #190 was issued a SNF ABN. The Social Worker stated Resident #190 had 51 days remaining. The Social Worker stated the form should have been issued if the resident had skilled benefit days remaining and was being discharged from Part A services and continued living in the facility. The Social Worker stated the information was provided verbally to the resident and family but not documented. The Social Worker stated it was important for the resident to receive the form just in case they wanted to appeal, and they would know they had days remaining on their benefit. The Social Worker stated there was no negative outcome because his wishes were met. <BR/>During an interview on 09/21/2023 at 4:00 p.m., the Administrator stated the Social Worker was responsible for ensuring the SNF ABN was completed. The Administrator stated a SNF ABN did not have to be given because he came off Part A services and went to end of life hospice and paid out of pocket. The Administrator stated there was no negative outcome for not receiving a SNF ABN form prior to covered days being exhausted. The Administrator stated no one was monitoring to ensure the forms are given beside the social worker. The Administrator stated there was no policy and procedures regarding SNF/ABN's.

Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 5 of 22 employees (DON, ADON, Dietician, Social Worker and Housekeeping Supervisor) reviewed for freedom from abuse, neglect, and exploitation .<BR/>The facility failed to ensure the Human Resource (HR) Coordinator completed an Employee Misconduct Registry (EMR) check annually for the for the DON, ADON, Dietician, Social Worker.<BR/>This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.<BR/>Findings included:<BR/>Record review of the facility's Abuse/Neglect policy revised on 9/2014, indicated, the facility, will do all that can reasonably be done to prohibit, report and prevent abuse, neglect, exploitation and involuntary seclusion of residents through the implementation of this policy. This policy consists of several components. The Facility Abuse and neglect policy did not mention annual checks of the State nursing registry.<BR/>Procedure<BR/>I. Screening of potential employees.<BR/>A. The facility will not employ individuals who have been convicted by a court of law or have plead guilty to abuse, neglect or exploitation of others; have a finding entered into the state nursing registry concerning abuse, neglect or exploitation.<BR/>Record review of the DON's personnel file on 09/21/23 at 2:03 p.m., indicated the DON was hired on 12/15/21. The DON's employee misconduct registry check was not completed annually upon hire month. The DON's EMR was completed on 09/18/23 which was approximately 9 months late. The last EMR check was completed on 4/18/22.<BR/>Record review of the ADON's personnel file on 9/21/23 at 2:03 p.m., indicated the ADON was hired on 7/28/10. The ADON's employee misconduct registry was not completed annually upon hire month. The ADON's EMR was completed on 09/19/23 which was approximately 2 months late. The last EMR check was completed on 4/18/22.<BR/>Record review of the Dietician's personnel file on 9/21/23, indicated the Dietician was hired on 4/24/12. The Dietician's employee misconduct registry was not completed annually upon hire month. The Dietician's EMR was completed on 09/19/23 which was approximately 5 months late. The last EMR check was completed on 7/12/22.<BR/>Record review of the Social Worker's personnel file on 9/21/23, indicated the Social Worker's was hired on 5/13/16. The Social Worker's employee misconduct registry was not completed annually upon hire month. The Social Worker's EMR was completed on 09/18/23 which was approximately 4 months late. The last EMR check was completed on 4/18/22<BR/>Record review of the Housekeeping Supervisor's personnel file on 9/21/23, indicated the Housekeeping Supervisor was hired on 5/10/22. The Housekeeping Supervisor's employee misconduct registry was not completed annually upon hire month. The Housekeeping Supervisor EMR was completed on 09/19/23 which was approximately 4 months late. The last EMR check was completed on 5/11/22.<BR/>During an interview on 9/20/23 at 2:31 p.m., HR stated EMR checks were to be ran annually within the same month they were previously ran. HR stated she does expect EMR checks to be completed annually. HR stated she did not realize the EMR checks were to be ran annually on the same month that the employee was hired. HR stated that she did not have a process in place for monitoring EMR checks annually. HR stated it was important to conduct EMR checks on staff annually to ensure their safety and to ensure no incidents have been reported that would make them unemployable.<BR/>During an interview on 9/20/23 at 2:40 p.m., the DON stated annual checks were to be ran yearly on each staff member's hire month. The DON stated HR was responsible for completing annual EMR checks. The DON stated she was not aware that EMR was not run on hire month annually for those 6 employees. The DON stated she does not have a process for monitoring annual EMR checks. The DON stated that she expected EMR checks to be completed annually upon on hire month. The DON stated EMR checks were to be completed annually on hire month in order to ensure the safety and well-being of staff and residents.<BR/>During an interview on 9/20/23 at 2:50 p.m., the Administrator stated EMR checks were to be completed upon hire and annually for each employee. The Administrator stated HR was responsible for ensuring EMR checks were completed for each employee annually and upon hire. The Administrator stated that she was not aware that the EMR checks were not completed upon hire month for those 6 employees. The Administrator stated that she did not have a process in place for monitoring that EMR checks were completed annually. The Administrator stated EMR checks were to be completed annually on hire month to ensure there are no concerns concerning the employee's record that would cause harm to the residents.

Based on interview, and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 8 of 8 confidential residents reviewed for weekend mail delivery.<BR/>The facility failed to ensure residents received their mail on the weekend.<BR/>This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life.<BR/>Findings included:<BR/>During a confidential group interview 8 of 8 residents stated mail was not distributed on Saturdays. They stated mail did not get delivered until Monday or even picked up until Monday. The residents stated the little mailbox inside the facility even had a note on it to that effect. <BR/>During a telephone interview on 9/19/2023 at 1:56 p.m., the Postmaster stated mail was not delivered to this facility on Saturdays. The supervisor for the mail carriers indicated the business was considered closed when they could not enter on the weekends and mail was not delivered or picked up.<BR/>During an interview on 9/21/2023 at 3:26 p.m., the DON said honestly, she was unsure if the residents received their mail on Saturday. The DON said she expected the residents to receive their mail. The DON said a resident not receiving their mail could cause them to be upset, have increased anxiety waiting on their expected delivery.<BR/>During an interview on 9/21/2023 at 4:13 p.m., the Administrator said she believed the mail was delivered on Saturday. The Administrator said the BOM separates the mail and provides it to the residents. The Administrator said the BOM did not work weekends. The Administrator said she did not know a negative impact to the resident by not receiving their mail on the weekend. The Administrator said residents still received packages from like Amazon etc. The Administrator said she was unaware of the regulation related to receiving communications specifically on weekends.<BR/>Record review of a nursing procedure manual policy and procedure Statement of Residents' Rights indicated, Right to Privacy Each resident shall have the right to privacy unwritten communications, including: 1. The right to send and receive mail promptly that is unopened

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment for 1 of 1 of 21 (Resident #29) resident reviewed for environment.<BR/>The facility failed to replace Resident #29's over the bed light bulb when burned out.<BR/>The facility failed to ensure Resident #29's light cover was covering the fluorescent light bulbs in the over the bed lighting.<BR/>These failures could potenially cause a skin injury. <BR/>Findings included:<BR/>Record review of Resident #29's face sheet dated 9/21/2023 indicated Resident #29 was an [AGE] year-old female who originally admitted on [DATE], and then readmitted on [DATE] with the diagnosis of heart failure, heart attack, and low blood pressure.<BR/>Record review of an annual MDS assessment dated [DATE] Resident #29 was usually understood by others and usually understood others. The MDS indicated Resident #29's vision was severely impaired. The MDS indicated Resident #29's BIMS score was a 3 indicating a severe cognitive deficit. The MDS indicated Resident #29 required extensive assistance of one staff with bed mobility, transfers, and toilet use. The MDS indicated Resident #29 required total assistance of one staff with locomotion on and off the unit, dressing, eating, personal hygiene and bathing. <BR/>During an observation on 9/19/2023 at 12:10 p.m., Resident #29's over the bed light had a broken light bulb and the light had no light cover. <BR/>During an observation on 9/19/2023 at 12:10 p.m., Resident #29's over the bed light had a broken light bulb and the light had no light cover. The old light bulb was still in the fixture and one end was broken, black and had sharp edges. <BR/>During an observation and interview on 9/20/2023 at 4:00 p.m., the Maintenance Supervisor said he was unaware Resident #29's light bulb in the over the bed light was broken and not functioning. He was looking about Resident #29's room but said the light cover was not in the room. The Maintenance Supervisor said this broken equipment was not in his maintenance book and he was unaware, but he was responsible. <BR/>During an interview on 9/21/2023 at 3:24 p.m., the DON said she expected each resident to have a working overbed light to ensure adequate lighting. The DON said there was a potential for injury due to the bulb bursting. The DON said all staff were responsible for monitoring broken equipment. The DON said there was a maintenance book to write broken items in, but she would call the supervisor due to the need of the light.<BR/>During an interview on 9/21/2023 at 4:08 p.m., the Administrator said she expected the Maintenance Supervisor to fix the broken items as soon as he became aware. The Administrator said the Maintenance Supervisor was responsible to maintain lighting and keep them functioning. The Administrator said the facility used a maintenance notebook for broken items needing repair. The Administrator said the broken bulb could cause broken pieces to injure the resident. A relevant policy was requested but the Administrator indicated there was no policy.

Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 medication cart (Hall 100 medication cart) of 5 medication carts.<BR/>The facility failed to ensure LVN R the 100 Hall medication cart was locked when it was left unattended in the hallway with the door closed while he provided a treatment for a resident.<BR/>This failure could place residents at risk for overdose or injury from sharp needles.<BR/>Findings included:<BR/>During an observation on 11/18/24 at 09:56 AM, LVN R left the treatment cart unlocked and unattended on the A hall with door closed while he provided a wound treatment to a resident who resided on A hall. <BR/>During an observation and interview on 11/18/24 at 10:03 AM, LVN R walked out of the resident's room and locked the treatment cart that was left open and unattended. He said he was responsible for locking the cart, but he forgot to lock the cart because he got distracted. LVN R said he normally would have the cart against the door with it unlocked. He said the failure placed a risk for any resident, visitor, or staff to get into the cart and take medications or anything out of the cart. He said a resident could have ingested medications from the cart. <BR/>During an interview on 11/20/24 at 02:43 PM, the DON said her expectation was for the medications to be secure and locked in the cart when the cart was not in direct vision. The DON said the nurse or medication aide using the cart was responsible to keep cart secure. The DON said the failure placed a risk for wandering resident getting medications or supplies that are harmful to them as well as risk for a drug diversion or theft. <BR/>During an interview on 11/20/24 at 03:09 PM, the Administrator said her expectation was for the medication and treatment carts to be locked if they were unattended. She said all nurses and medication aides were responsible for ensuring the carts were locked when they were not in use. The Administrator said the failure placed a risk for anyone (residents, visitors, or staff) getting into the cart and having access to the medications. <BR/>Record review of the facility policy Storage of Medications revised April 2019 indicated:<BR/>Policy Statement<BR/>The facility stores all drugs and biologicals in a safe, secure, and orderly manner.<BR/>Policy Interpretation and Implementation<BR/>1.Drugs and Biologicals used in the facility are stored in locked compartments .9. Unlocked medication carts are not left unattended .12. Only persons authorized to prepare and administer medications have access to locked medications.