STERLING COUNTY NURSING HOME

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the 3 of 6 nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs as identified through residents' assessments, and described in the care plan for two of four residents (Resident #20 and Resident #23) reviewed for transfers, in that:<BR/>CNA H and NA G hooked their arms under Resident #20 while transferring the resident. <BR/>CNA C hooked her arms under Resident #23's arms while transferring the resident. <BR/>This failure could affect residents who required assistance with transfers by placing them at risk for discomfort, pain and or injury.<BR/>The findings were:<BR/>Review of Resident #20's admission Record, dated 6/22/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, muscle wasting and atrophy, muscle weakness, and repeated falls. <BR/>Review of Resident #20's quarterly MDS Assessment, dated 4/19/23 revealed:<BR/>She had long and short-term memory impairment with severely impaired decision-making abilities and signs of delirium including inattention continuously. <BR/>She needed extensive assistance of two people for transfers<BR/>She needed substantial/maximal assistance for chair/ bed-to-chair transfers. <BR/>She had one fall with no injury and another fall with minor injury in the three months prior to the assessment. <BR/>Review of Resident #20's Care Plan updated 4/21/23 revealed: Resident #20 was a on to two person assist for ADL's related to cognition/ muscle weakness/ impaired vision. The Goal was Resident #20 would have daily needs met as evidenced by being odor free and a well-groomed appearance. Identified interventions included: increase level of assistance based on Resident #20's physical need. <BR/>Observation on 06/20/23 at 11:49 AM revealed Resident #20 in a recliner in the living room. CNA C applied the gait belt. Resident #20 fought the gait belt as it was put around her. CNA C hooked her arm under Resident #20's while CNA E grabbed the back of the gait belt, lifted the resident, and placed her in a wheelchair. <BR/>Review of Resident #23's admission Record, dated 6/21/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, stroke, age-related osteoporosis, repeated falls, and weakness.<BR/>Review of Resident #23's quarterly MDS Assessment, dated 6/6/23 revealed:<BR/>Resident #23 had a mental status score of 11 of 15 with no signs of delirium. (Indicating moderate cognitive impairment)<BR/>Resident #23 needed extensive assistance of two or more people for transfers. <BR/>She had range of motion impairments of both upper and lower extremities and used a wheelchair. <BR/>She needed substantial or maximum assistance with chair or bed-to-chair transfer. <BR/>She had one fall with minor injury (skin tear, abrasion superficial bruising) in the previous assessment.<BR/>Review of Resident #23's Care Plan, updated on 12/19/22, revealed: Resident #23 required assistance with all ADLs (1-2 staff) related to impaired cognitive status and muscle weakness. The goal was Resident #23 would have her goals met as evidenced by her odor free, neat, and well-groomed appearance. Identified interventions included: assist Resident #23 with all ADLs related to impaired cognition and muscle weakness (initiated 5/22/23); increase level of staff assistance when needed dependent upon Resident #23's physical need (initiated 12/20/21); and provide wheelchair for mobility (foot pedals to wheelchair) (revised on 6/20/23). <BR/>Observation on 6/20/23 at 11:55 AM revealed CNA C pulled Resident #23 up from a reclining position in the day room by her arm. CNA E put the gait belt on Resident #23. CNA C hooked her arm under Resident #23's arm and CNA E grabbed the back of Resident #23 gait belt and shirt. Resident #23 was not able to bear weight. The two CNA's drug Resident #23 to the wheelchair and placed her in it. <BR/>Interview on 06/21/23 at 10:55 AM the DON stated Resident #23 had good days and bad days. The DON explained when Resident #23's family was at the facility Resident #23 was active and involved. The DON said prior to 6/20/23 Resident #23 was able to bear weight but Resident #23's balance was not good.<BR/>Interview on 06/21/23 at 11:24 AM CNA D confirmed she was familiar with Resident #23's needs. CNA D described Resident #23 as liking to sleep a lot but would get up for meals. CNA D stated Resident #23 would fall asleep in the middle of a conversation or while eating. CNA D said Resident #23 needed assistance with being fed. CNA D said Resident #23 needed a lot of help with ADLs. CNA D stated Resident #23 could be bribed with hot chocolate to get up as a one person assist. CNA D stated Resident #23 could bear weight, but the aides had to know how to wake Resident #23 up. CNA D said to transfer with Resident #23 the aide would put the gait belt on, hold the gait belt, Resident #23 would put her arms around the aide and stand and pivot. CNA D said when Resident #23 was sleep it would take two people to transfer her with a gait belt. CNA D described a two-person gait belt transfer as holding the gait belt and keeping arms under the resident's arm. <BR/>Interview on 06/21/23 at 1:32 PM LVN B stated she began working the floor on 4/1/23. LVN B stated she was aware of Resident #23's needs. LVN B described Resident #23 as having dementia and combative. LVN B said Resident #23 would rather stay in bed most days but the family insisted Resident #23 get up. LVN B explained even when Resident #23 was awake she would not engage with her surroundings. LVN B said Resident #23's care needs were she was completely dependent on the CNAs for all ADL care. LVN B said Resident #23 was a two-person transfer. LVN B said two days prior she helped with transferring Resident #23, and she (Resident #23) did not bear weight. LVN B added that Resident #23 would bear weight for some of the aides but was not weight bearing the day LVN B transferred Resident #23. LVN B said if Resident #23 would not consistently bear weight she probably needed to be a mechanical lift transfer - at least a sit to stand lift transfer. LVN B stated she did not communicate this to anyone because of her (LVN B's) lack of experience working with Resident #23 and she (LVN B) could see Resident #23 had good and bad days. <BR/>Interview on 6/21/23 at 3:12 PM OTA F stated Resident #23 had never been on therapy, so the therapy department did not know if Resident #23 was weight bearing or not. OTA F stated if Resident #23 could not reliably bear weight a mechanical lift transfer would be appropriate. He stated possible outcomes to not transferring the resident correctly was skin tears, abrasions, and further fractures. <BR/>Interview on 06/21/23 at 3:26 PM the DON stated prior to 6/20/23,/ Resident #23 could bear some weight and was sometimes a one or two person assist with transfers. The DON stated she guessed Resident #23 was one who determined what kind of transfer Resident #23 was. The DON stated it also depended on how comfortable the aide felt on transferring the resident. The DON said Resident #23 was able to bear weight when the DON was the one completing the transfer. The DON stated the last time she transferred Resident #23 was approximately six months prior. <BR/>Observation on 06/21/23 at 4:00 PM revealed Resident #23 in bed. NA G raised Resident #23 into a sitting position and placed the gait belt onto Resident #23. CNA H hooked her (CNA H) right arm under Resident #23's arm while NA G hooked her (NA G) left arm under Resident #23's arms. The aides grabbed the gait belt from behind and lifted Resident #23. Resident #23 was unable to bear weight or assist. Resident #23's legs bent, and the aides quickly swung Resident #23 to her wheelchair. Resident #23's pants slid to her knees. The aides readjusted the gait belt, hooked their (CNA H and NA G) arms under Resident #23, and lifted Resident #23 to adjust Resident #23's pants. <BR/>Interview on 6/21/23 at 3:00 PM the DOR stated to complete a two-person gait belt transfer the aides were to put on the gait belt, lock the resident's wheelchair, one person on each side while holding the front and back of the gait belt and assist the resident to stand and pivot. The DOR said the risk of the staff hooking arms under the resident's arm was shoulder dislocation, pain, falls, or back injury. The DOR said she had been at the facility for a week and did not have a chance to observe or train staff in transfers. The DOR said assessments on transfer ability was typically done quarterly and when the nurses reported a decline in function as needed such as noted contractures or falls. The DOR was informed of the two-person gait belt transfers observations. The DOR stated, we'll have to do some in-services <BR/>Interview on 6/21/23 at 3:26 PM the ADON stated the expectation for a two-person transfer was to put on the gait belt, each person stands on each side of the resident, holding the gait belt and assist the resident to stand, pivot and sit. The ADON said the consequences of not doing it that way was fall. The ADON stated the ADON, DON, and charge nurse were up and down the hallways all day. The ADON and DON were informed of the 6/20/23 11:55 a.m. transfers observations with Resident #20 and #23 and stated it was not an appropriate transfer and there was a risk of injury to the resident. The ADON stated they would have to in-service. The ADON stated she did not know when the last time the facility in-serviced on transfers. The ADON said assessments for types of transfers should be in the resident's clinical record. Surveyor requested a copy of any in-services on transfers done in the previous six months. <BR/>Interview on 6/21/23 at 4:22 PM the Administrator was informed of the transfer observation. The Administrator stated Resident #23 had always been highly dependent on staff. <BR/>Review of the facility's Competency Assessment on Transfers, undated, documented:<BR/>Two-Person Transfer Weight Bearing:<BR/>Assemble equipment - gait belt<BR/>Apply gait belt over clothing just above the hip bone, never against bare skin.<BR/>The belt should be snug; not too loose, not too tight. You should be able to fit 2 -3 fingers between the belt and the resident.<BR/>Make sure you double-lock the belt, meaning you thread it through the teeth portion of the belt which locks in place.<BR/>On person will be on each side of the resident.<BR/>Each attendants outside hand will be on the gait belt while the inside arm will be just under the resident's armpit. The arm under the armpit is just to balance the resident. <BR/>The lifting force should come from the outside hand which is on the gait belt.<BR/>On the count of three the resident should be lifted into a standing position and then pivoted to the chair or bed.<BR/>Two-Person Transfer - Non-weight bearing<BR/>A draw sheet is positioned to extend from the back of the head to the k eeks.<BR/>The edges of the draw sheet are rolled under, towards the resident, until the rolled edges are against the resident.<BR/>The wheelchair/ Geri-chair is placed as close to the resident as is possible with the brakes locked <BR/>One attendant is positioned on each side of the resident and the resident is brought safely to the edge of the bed.<BR/>One person moves to the head of the bed, the other to the area of the knees. If more attendants are needed they will be positioned at the resident's side. <BR/>The person at the head should place their knee closest to the head of the bed, onto the bed so that the resident can be brought into a semi-reclined position and the draw sheet can be brushed on the sides of the upper arms. <BR/>The person at the knees should grasp the draw sheet on the sides in the area of mid-thighs.<BR/>On the count of three, the resident is lifted up and over onto the wheelchair/Geri-chair. <BR/>Review of the facility's policy and procedure on Safe Lifting and Movement of Residents, revised June 2017, revealed:<BR/>In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.<BR/>Interpretation and Implementation<BR/>Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. <BR/>Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include: Resident's mobility (degree of dependency); weight-bearing ability; cognitive status; <BR/>Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. <BR/>In-services prior to the survey were not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for each resident, in that three rooms did not provide full visual privacy .<BR/> Resident #8 had a track for privacy curtains, but no privacy curtains in place.<BR/>Residents #6 and #29 had a privacy curtain between beds, but the curtains at the foot of the beds did not go all the way across. <BR/>Residents # 12 and #24 had a privacy curtain between beds, but no privacy curtain at the foot of the beds. <BR/>This failure could affect residents by placing them at risk for loss of privacy and dignity. <BR/>The findings include:<BR/>Record review of Resident #6's admission record dated 06/21/23 indicated the resident was admitted to the facility on [DATE] with diagnoses of athetoid cerebral palsy (movement disorder caused by damage to the developing brain), epilepsy (neurological disorder marked by recurrent episodes of sensory disturbance, loss of consciousness, or convulsions), severe intellectual disability, anxiety disorder and feeding tube. He was [AGE] years of age.<BR/>Record review of Resident #6's Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) totaled 0 indicating the resident had severe impairment. The resident was always incontinent of bowel and urine. <BR/>Record review of Resident #6's care plan dated 04/06/23 indicated in part: <BR/>Focus: Skin/Pressure Ulcer: Resident is at risk for impaired skin integrity/pressure ulcer related to bowel/bladder incontinence and impaired mobility. Goal: will maintain intact skin during review period. Intervention: Provide incontinence care after each incontinent episode.<BR/>Record review of Resident #29's admission record dated 06/21/23 indicated the resident was admitted to the facility on [DATE] with diagnoses of cerebral infarction, sepsis, diabetes mellitus, and depression. He was [AGE] years of age.<BR/>Record review of Resident #29's Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) totaled 09 indicating the resident had moderate impairment. The resident was always incontinent of bowel and urinary continence. <BR/>Record review of Resident #29's care plan revised 08/11/23 indicated in part: <BR/>Focus: ADLs: Resident will be assisted with ADLs related to muscle weakness/recent hip fracture and requires partial to substantial assistance of 1-2 staff members to complete ADLs. Goal: Resident will participate in his ADL care to his safest and fullest extent. Intervention: Provide prompt incontinent care (total bowel/bladder incontinence) and apply moisture barrier cream after each incontinent episode and as needed.<BR/>Record review of Resident #8's admission record dated 06/21/23 indicated the resident was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, bipolar disorder, CHF and diabetes mellitus. She was [AGE] years of age.<BR/>Record review of Resident #8's Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) totaled 14 indicating the resident had no impairment. The resident required 1 person assist. <BR/>Record review of Resident #8's care plan dated 06/08/23 indicated in part: <BR/>Focus: Resident is independent with most ADLs but is at risk for decline related to Bi-polar disorder and history of medical non-compliance. Goal: Resident will remain as independent as safely possible with ADLs. Interventions: Assist with incontinent care promptly and as needed.<BR/>Record review of Resident #24's admission record dated 06/21/23 indicated the resident was admitted to the facility on [DATE] with diagnoses of cerebral infarction, diabetes mellitus, and stage 3 kidney disease. He was [AGE] years of age.<BR/>Record review of Resident #24's Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) totaled 0 indicating the resident had severe impairment. The resident was sometimes incontinent of bowel and urine. <BR/>Record review of Resident #24's care plan dated 04/27/23 indicated in part: <BR/>Focus: Resident is a one person assist for most ADLs related to right sided muscle weakness, due to stroke. Goal: Resident will participate in his ADL care to the safest level possible. Intervention: Provide prompt incontinent care and apply moisture barrier cream after each incontinent episode and as needed.<BR/>Record review of Resident #12's admission record dated 06/21/23 indicated the resident was admitted to the facility on [DATE] with diagnoses of cerebral infarction, schizoaffective disorder, and dementia. He was [AGE] years of age.<BR/>Record review of Resident #12's Minimum Data Set (MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) totaled 9 indicating the resident had moderate impairment. The resident was always incontinent of bowel and urine. <BR/>Record review of Resident #12's care plan dated 04/06/23 indicated in part: <BR/>Focus: Resident requires 1-2 staff assist for most ADLS related to left side hemiparesis, muscle weakness, resistance to care. Goal: Resident will be clean, dry, and odor free throughout the review period. Interventions: Provide prompt incontinent care.<BR/>During an interview and observation on 06/20/23 at 4:45 PM CNA I performed incontinent care for Resident #29. The staff pulled the privacy curtain, but it did not go all the way around the resident's side of the room. The curtain was approximately 3 feet short from providing full visual privacy to A bed in room [ROOM NUMBER]. The resident had a roommate. CNA I stated that the curtain is not long enough to provide privacy and she has told the DON, but no new curtains have been hung.<BR/>During an observation on 06/22/23 at 11:00 AM of Resident #8's room revealed that a track for privacy curtains, but no privacy curtains in place and did not provide full visual privacy.<BR/>During an observation on 06/22/23 at 12:32 PM of Resident #24's and Resident #12's room, revealed that room had a privacy curtain between beds, but not at the foot of the beds and did not provide full visual privacy. <BR/>During an interview on 06/21/23 10:30PM DON stated that she was aware that many rooms have privacy curtains that do not go all the way around the residents' bed, and that there are rooms with no privacy curtains at all. DON stated that she has informed Administrator of this problem. DON stated that all they have to do is add an extra curtain. When asked why the extra curtains had not been hung, DON stated that they had not gotten to it yet.<BR/>Record review of the facility's policy dated 12/2016 and titled Resident Rights indicated in part: <BR/>Employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy Interpretation and Implementation:<BR/>1.Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to:<BR/>a. <BR/>a dignified existence.<BR/>b. <BR/>Be treated with respect, kindness, and dignity.<BR/>c. <BR/>Privacy and confidentiality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 5 of 7 (Residents #2, #7, #9, #18, and #21) reviewed for infection control. <BR/>The facility failed to ensure:<BR/>Resident #7, #9, #18, and #21's small volume nebulizer (SVN) masks were bagged when not in use. <BR/>LVN B washed her hands prior to putting gloves on and changing them once they were used to provide care for Resident #2. <BR/>Resident #7, #9, #18, and #21 oxygen tubing was bagged when not in use. <BR/>These failures could place resident's risk for cross contamination and the spread of infection. <BR/>Findings included:<BR/>RESIDENT #2<BR/>Record review of Resident #2's admission record dated 06/21/23 indicated she was admitted to the facility on [DATE] with diagnoses of paraplegia and muscle weakness. She was [AGE] years of age.<BR/>Record review of Resident #2's order summary reports dated 06/21/2023 indicated in part:<BR/>Wound care: Paint Left pinkie toe using Iodine until healed, monitor for s/s of infection each shift. Order status active. Start 05/09/2023.<BR/>Record review of Resident #2's care plan dated 06/07/23 indicated in part: Problem: Skin/Pressure Ulcer: Resident is at risk for impaired skin integrity r/t bowel/bladder incontinence/ impaired physical mobility/thin fragile skin/history of pressure ulcers/history of slow wound healing. Goal: Resident will maintain intact skin integrity. Interventions: Assist with turning and repositioning every 2 hours and as needed to prevent pressure from forming, especially to boney prominences.<BR/>During an observation on 06/21/23 at 4:03 PM revealed LVN B grabbed a pair of gloves without first washing her hands or using alcohol gel. She pulled a bottle of iodine out of the wound care cart with her bare, unwashed hands. LVN B got a stack of gauze pads with her bare hands. LVN B knocked on Resident #2's door and entered the room. LVN B placed the iodine bottle and the stack of gauze pads on the un-sanitized bedside table with no barrier between the iodine bottle and gauze. LVN B washed her hands and donned her gloves. LVN B pulled off Resident #2's sock which revealed a pin-prick sized closed scab on the left toe. LVN B grabbed a stack of gauze, poured the iodine on the gauze and dabbed the gauze on the scab and re-wiped the scab with the same pad of gauze. With the same gloves, LVN B threw out the used gauze, took the left-over gauze and gloves and threw them in the trash can. With the same gloves, LVN B placed Resident #2's sock and heel protector on and repositioned her feet. Then with the same gloves LVN B checked Resident #2's right foot, straightened the sheets, and replaced pillows. LVN B took off her gloves, washed her hands and placed it back in the wound care cart.<BR/>During an interview on 06/22/23 at 03:00 PM with DON and ADON, ADON stated that she was responsible for trainings pertaining to hand washing, glove use and wound care. ADON stated that her expectations are that staff should always wash hands, sanitize tabletop, place barrier on tabletop, and set up supplies on barrier prior to wound care. Then staff should bring treatment cart to residents' room, wash hands, don gloves, remove soiled dressing, doff gloves. Then staff should wash hands or sanitize hands, don gloves, perform wound care wiping from clean to dirty, not circular motion. Next, staff should apply new dressing, doff gloves, and wash hands, then position resident for comfort.<BR/>Review of the facility's competency Assessment for Wound Care, undated, revealed:<BR/>Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. <BR/>Wash and dry your hands thoroughly<BR/>Discard disposable items into the designated container. Removed disposable gloves and discard into designated container. Wash and dry your hands thoroughly.<BR/>Reposition the bed covers. Make the resident comfortable. <BR/>Use clean field saturated with alcohol to wipe overbed table. <BR/>RESIDENT #7<BR/>Review of Resident #7's admission Record, dated 6/22/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure.<BR/>Review of Resident #7's admission MDS Assessment, dated 4/4/23 revealed:<BR/>Mental Status Score of 15 of 15 with no signs of delirium indicating she was cognitively intact. <BR/>Oxygen was not checked as a measure. <BR/>Review of Resident #7's Order Summary dated 6/22/23 revealed orders dated:<BR/>Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath Active 03/29/2023<BR/>There was no order for oxygen <BR/>Care Plan initiated 4/11/23 revealed:<BR/>Decreased Cardiac Output: Resident #7 was at risk for decreased cardiac output related to diagnosis of hypertension and Congestive Heart Failure. Date Initiated: 04/11/2023. The identified goal was Resident #7 will demonstrate adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm with her normal parameters. Interventions included: Albuterol nebulizer treatment as ordered as needed per Doctor's order for Shortness of Breath.<BR/>Observation on 6/20/23 at 10:38 a.m. revealed the Resident #7 was out of the room with an SVN mask on the bed unbagged and open to air. There was also oxygen tubing wrapped up and hanging off the oxygen concentrator dated 6/12/23. <BR/>RESIDENT #9<BR/>Review of Resident #9's admission record dated 6/22/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Respiratory Failure, and heart failure. <BR/>Review of Resident #9's admission MDS assessment dated [DATE] revealed she had mental status of 15 of 15 indicating she was cognitively intact and used oxygen while a resident. <BR/>Review of Resident #9's Care Plan, initiated 5/22/23 revealed:<BR/>Activity Intolerance: Resident #9 was at risk for activity intolerance related to diagnoses of COPD and can become easily fatigued with ADLs. Revision on: 06/07/2023<BR/>Goal: Resident #9 will be able to perform ADLs without becoming overly exerted. Identified interventions included: Administer prescribed inhalers as ordered per MD; assess Resident #9's respiratory response to activity which includes monitoring of respiratory rate and depth, oxygen saturation, and use of accessory muscles for respiration; and oxygen as ordered per MD. Date Initiated: 05/22/2023<BR/>Review of Resident #9's Order Summary dated 6/22/23 revealed order dated:<BR/>5/12/23- Oxygen 3 Liters per nasal cannula as needed and at night every day and night<BR/>5/10/23 Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 3 ml inhale orally via nebulizer every 4 hours as needed for Wheezing<BR/>Observation on 6/20/23 at 10:02 AM revealed oxygen tubing wrapped in a coil, draped on the oxygen machine unbagged and open to air. <BR/>RESIDENT #18<BR/>Record review of Resident #18's admission record dated 06/20/23 indicated she was admitted to the facility on [DATE] with diagnosis of congestive heart failure (chronic condition in which the heart does not pump blood as well as it should) and dyspnea (shortness of breath). She was [AGE] years of age.<BR/>Record review of Resident #18's MDS dated [DATE] indicated in part: Oxygen was being used.<BR/>Record review of Resident #18's order summary reports dated 03/21/2023 indicated in part:<BR/>Change oxygen tubing, water and clean filter every 7 days (Sunday night shift). [NAME] with time, date and initials. Keep the tubing in a bag marked with date, time and initials. <BR/>Record review of Resident #18's care plan dated 05/15/23 indicated in part: Problem: Cardiac: Resident is at is at risk for fluid overload and decreased cardiac output related to diagnosis of Congestive Heart Failure and Atrial Fibrillation. Goal: will maintain adequate cardiac output as<BR/>evidenced by ability to perform ADLs without becoming overly exerted and stable vital signs.<BR/>Interventions: wear oxygen at 2 liters per minute via nasal cannula throughout the day, or as needed, for shortness of breath or to maintain oxygen saturations above 90%.<BR/>During an observation and interview on 06/20/23 at 09:40 AM of Resident #18's room, the oxygen tubing and cannula were observed, rolled up and hanging on the oxygen concentrator knob. The oxygen tubing was dated 6/18/23 but remained unbagged. Resident #18 stated that she wears her nasal cannula every night, and it hangs there during the day. <BR/>RESIDENT #21<BR/>Record review of Resident #21's admission record dated 06/20/23 indicated she was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure. She was [AGE] years of age.<BR/>Record review of Resident #21's MDS dated [DATE] indicated in part: BIMS = 4 meaning severe impairment. <BR/>Record review of Resident #21's order summary reports dated 06/20/2023 indicated in part:<BR/>Change oxygen tubing (cannula or mask) and SVN tubing every 7 days (Sunday<BR/>night shift), or as needed. mark with time, date an initials. keep the tubing in a bag<BR/>marked with date, time and initials. Every night shift every Monday. <BR/>Record review of Resident #21's care plan dated 06/02/23 indicated in part: Problem: Cardiac: Resident is at risk for decreased cardiac output related to heart disease. Goal: cardiac output as evidenced by good activity tolerance and stable blood pressure readings. Interventions: Oxygen at 2 liters per minute Via NC continuously.<BR/>During an observation and interview on 06/20/23 at 10:40 AM the SVN machine and mask were on bedside dresser. The SVN mask was laying on top of the dresser. Resident #21 said the nurse would come by and give her breathing treatments with the SVN mask and then they would place the mask back on the dresser. <BR/>During an observation and interview on 06/20/23 at 10:40 AM the SVN machine and mask were on bedside dresser. The SVN mask was laying on top of the dresser. Resident #21 said the nurse would come by and give her breathing treatments with the SVN mask and then they would place the mask back on the dresser. <BR/>During an interview on 06/21/23 at 04:20 PM LVN B said she had administered SVN treatments for Resident #21. LVN B said she would place the SVN mask on the resident then after the treatment was done she would place the mask back on the table and in the bag if there was one available. LVN B said the masks were usually placed in a bag to prevent contamination. LVN B said if they used the mask that was not stored in a bag it could possibly lead to respiratory infections. <BR/>During an interview on 06/22/23 at 01:40 PM the DON said her expectations for respiratory equipment was to be changed every Sunday. The DON said the equipment was supposed to be checked every day for water in the humidifier, wash filters, date tubing and bag them if they were not in use. The DON said it was the same thing with the nebulizer, when they are not to in use they were supposed to be bagged. The DON said the charge nurses were responsible for doing it and they were responsible for ensuring it was done. The DON said the CNAs would also check to make sure the items were bagged. The DON said they also conducted angel rounds which meant all department heads did rounds once a week and go into rooms to look see if the items were bagged. The DON said the CNAs knew to place the nasal cannula in the bag when they were not in use. The DON said nurses gave nebulizer treatments so when it was completed, they should be put in bag. The DON said if items were not bagged it could lead to contamination, infection and a trip hazard. <BR/>During an interview on 06/22/23 at 03:27 PM the Administrator said the SVN masks and nasal cannulas were supposed to be bagged when not in use unless the resident removed it and left it outside of the bag. The Administrator said if the items were left unbagged that could lead to bacteria or dirt getting into the masks or cannula and then the residents could inhale it.<BR/>Record review of the facility's policy dated 11/2011 and titled respiratory therapy - prevention of infection indicated in part: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators among residents and staff. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Infection control considerations related to medication nebulizers/continuous aerosol: After completion of therapy - remove the nebulizer container; rinse the container with fresh tap water; dry on a clean paper towel or gauze sponge; store the circuit in plastic bag, marked with date and resident's name between uses.<BR/>Record review of the facility's policy dated 08/2019 and titled handwashing/ hand hygiene, indicated in part: The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as best practice. Single use disposable gloves should be used before aseptic procedures. Procedure: perform hand hygiene before applying non-sterile gloves.<BR/>Review of the facility's policy and procedure on Wound Care, revised October 2010, revealed:<BR/>The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.<BR/>Steps in the procedure:<BR/>Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. <BR/>Wash and dry your hands thoroughly.<BR/>Remove the disposable cloth next to the resident and discard into the designated container.<BR/>Discard disposable items into the designated container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.<BR/>Reposition the bed covers. Make the resident comfortable. <BR/>Use clean field saturated with alcohol to wipe overbed table. <BR/>Record review of the facility's policy revised July 2009 and titled personal protective equipment- gloves indicated in part: Gloves must be worn when handling blood, bodily fluids, secretions, mucous membranes and/or non-intact skin. The use of disposable gloves is indicated: when employees hands will come in contact with blood, bodily fluids, secretions, mucous membranes and/or non-intact skin while performing the procedure. When employee has cuts, wounds, or scrapes. When employee is handling soiled linen or items that may be contaminated. Wash hands after removing gloves.<BR/>Review of the facility's policy and procedure on Handwashing/ Hand Hygiene, revised August 2019, documented:<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations:<BR/>Before performing any non-surgical invasive procedures<BR/>Before donning gloves<BR/>Before handling clean or soiled dressings, gauze pads etc.<BR/>Before moving from a contaminated body site to a clean body site during resident care; <BR/>Hand hygiene is the final step after removing and disposing of personal protective equipment.<BR/>The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing health-care associated infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 5 of 7 (Residents #2, #7, #9, #18, and #21) reviewed for infection control. <BR/>The facility failed to ensure:<BR/>Resident #7, #9, #18, and #21's small volume nebulizer (SVN) masks were bagged when not in use. <BR/>LVN B washed her hands prior to putting gloves on and changing them once they were used to provide care for Resident #2. <BR/>Resident #7, #9, #18, and #21 oxygen tubing was bagged when not in use. <BR/>These failures could place resident's risk for cross contamination and the spread of infection. <BR/>Findings included:<BR/>RESIDENT #2<BR/>Record review of Resident #2's admission record dated 06/21/23 indicated she was admitted to the facility on [DATE] with diagnoses of paraplegia and muscle weakness. She was [AGE] years of age.<BR/>Record review of Resident #2's order summary reports dated 06/21/2023 indicated in part:<BR/>Wound care: Paint Left pinkie toe using Iodine until healed, monitor for s/s of infection each shift. Order status active. Start 05/09/2023.<BR/>Record review of Resident #2's care plan dated 06/07/23 indicated in part: Problem: Skin/Pressure Ulcer: Resident is at risk for impaired skin integrity r/t bowel/bladder incontinence/ impaired physical mobility/thin fragile skin/history of pressure ulcers/history of slow wound healing. Goal: Resident will maintain intact skin integrity. Interventions: Assist with turning and repositioning every 2 hours and as needed to prevent pressure from forming, especially to boney prominences.<BR/>During an observation on 06/21/23 at 4:03 PM revealed LVN B grabbed a pair of gloves without first washing her hands or using alcohol gel. She pulled a bottle of iodine out of the wound care cart with her bare, unwashed hands. LVN B got a stack of gauze pads with her bare hands. LVN B knocked on Resident #2's door and entered the room. LVN B placed the iodine bottle and the stack of gauze pads on the un-sanitized bedside table with no barrier between the iodine bottle and gauze. LVN B washed her hands and donned her gloves. LVN B pulled off Resident #2's sock which revealed a pin-prick sized closed scab on the left toe. LVN B grabbed a stack of gauze, poured the iodine on the gauze and dabbed the gauze on the scab and re-wiped the scab with the same pad of gauze. With the same gloves, LVN B threw out the used gauze, took the left-over gauze and gloves and threw them in the trash can. With the same gloves, LVN B placed Resident #2's sock and heel protector on and repositioned her feet. Then with the same gloves LVN B checked Resident #2's right foot, straightened the sheets, and replaced pillows. LVN B took off her gloves, washed her hands and placed it back in the wound care cart.<BR/>During an interview on 06/22/23 at 03:00 PM with DON and ADON, ADON stated that she was responsible for trainings pertaining to hand washing, glove use and wound care. ADON stated that her expectations are that staff should always wash hands, sanitize tabletop, place barrier on tabletop, and set up supplies on barrier prior to wound care. Then staff should bring treatment cart to residents' room, wash hands, don gloves, remove soiled dressing, doff gloves. Then staff should wash hands or sanitize hands, don gloves, perform wound care wiping from clean to dirty, not circular motion. Next, staff should apply new dressing, doff gloves, and wash hands, then position resident for comfort.<BR/>Review of the facility's competency Assessment for Wound Care, undated, revealed:<BR/>Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. <BR/>Wash and dry your hands thoroughly<BR/>Discard disposable items into the designated container. Removed disposable gloves and discard into designated container. Wash and dry your hands thoroughly.<BR/>Reposition the bed covers. Make the resident comfortable. <BR/>Use clean field saturated with alcohol to wipe overbed table. <BR/>RESIDENT #7<BR/>Review of Resident #7's admission Record, dated 6/22/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure.<BR/>Review of Resident #7's admission MDS Assessment, dated 4/4/23 revealed:<BR/>Mental Status Score of 15 of 15 with no signs of delirium indicating she was cognitively intact. <BR/>Oxygen was not checked as a measure. <BR/>Review of Resident #7's Order Summary dated 6/22/23 revealed orders dated:<BR/>Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath Active 03/29/2023<BR/>There was no order for oxygen <BR/>Care Plan initiated 4/11/23 revealed:<BR/>Decreased Cardiac Output: Resident #7 was at risk for decreased cardiac output related to diagnosis of hypertension and Congestive Heart Failure. Date Initiated: 04/11/2023. The identified goal was Resident #7 will demonstrate adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm with her normal parameters. Interventions included: Albuterol nebulizer treatment as ordered as needed per Doctor's order for Shortness of Breath.<BR/>Observation on 6/20/23 at 10:38 a.m. revealed the Resident #7 was out of the room with an SVN mask on the bed unbagged and open to air. There was also oxygen tubing wrapped up and hanging off the oxygen concentrator dated 6/12/23. <BR/>RESIDENT #9<BR/>Review of Resident #9's admission record dated 6/22/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Respiratory Failure, and heart failure. <BR/>Review of Resident #9's admission MDS assessment dated [DATE] revealed she had mental status of 15 of 15 indicating she was cognitively intact and used oxygen while a resident. <BR/>Review of Resident #9's Care Plan, initiated 5/22/23 revealed:<BR/>Activity Intolerance: Resident #9 was at risk for activity intolerance related to diagnoses of COPD and can become easily fatigued with ADLs. Revision on: 06/07/2023<BR/>Goal: Resident #9 will be able to perform ADLs without becoming overly exerted. Identified interventions included: Administer prescribed inhalers as ordered per MD; assess Resident #9's respiratory response to activity which includes monitoring of respiratory rate and depth, oxygen saturation, and use of accessory muscles for respiration; and oxygen as ordered per MD. Date Initiated: 05/22/2023<BR/>Review of Resident #9's Order Summary dated 6/22/23 revealed order dated:<BR/>5/12/23- Oxygen 3 Liters per nasal cannula as needed and at night every day and night<BR/>5/10/23 Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 3 ml inhale orally via nebulizer every 4 hours as needed for Wheezing<BR/>Observation on 6/20/23 at 10:02 AM revealed oxygen tubing wrapped in a coil, draped on the oxygen machine unbagged and open to air. <BR/>RESIDENT #18<BR/>Record review of Resident #18's admission record dated 06/20/23 indicated she was admitted to the facility on [DATE] with diagnosis of congestive heart failure (chronic condition in which the heart does not pump blood as well as it should) and dyspnea (shortness of breath). She was [AGE] years of age.<BR/>Record review of Resident #18's MDS dated [DATE] indicated in part: Oxygen was being used.<BR/>Record review of Resident #18's order summary reports dated 03/21/2023 indicated in part:<BR/>Change oxygen tubing, water and clean filter every 7 days (Sunday night shift). [NAME] with time, date and initials. Keep the tubing in a bag marked with date, time and initials. <BR/>Record review of Resident #18's care plan dated 05/15/23 indicated in part: Problem: Cardiac: Resident is at is at risk for fluid overload and decreased cardiac output related to diagnosis of Congestive Heart Failure and Atrial Fibrillation. Goal: will maintain adequate cardiac output as<BR/>evidenced by ability to perform ADLs without becoming overly exerted and stable vital signs.<BR/>Interventions: wear oxygen at 2 liters per minute via nasal cannula throughout the day, or as needed, for shortness of breath or to maintain oxygen saturations above 90%.<BR/>During an observation and interview on 06/20/23 at 09:40 AM of Resident #18's room, the oxygen tubing and cannula were observed, rolled up and hanging on the oxygen concentrator knob. The oxygen tubing was dated 6/18/23 but remained unbagged. Resident #18 stated that she wears her nasal cannula every night, and it hangs there during the day. <BR/>RESIDENT #21<BR/>Record review of Resident #21's admission record dated 06/20/23 indicated she was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure. She was [AGE] years of age.<BR/>Record review of Resident #21's MDS dated [DATE] indicated in part: BIMS = 4 meaning severe impairment. <BR/>Record review of Resident #21's order summary reports dated 06/20/2023 indicated in part:<BR/>Change oxygen tubing (cannula or mask) and SVN tubing every 7 days (Sunday<BR/>night shift), or as needed. mark with time, date an initials. keep the tubing in a bag<BR/>marked with date, time and initials. Every night shift every Monday. <BR/>Record review of Resident #21's care plan dated 06/02/23 indicated in part: Problem: Cardiac: Resident is at risk for decreased cardiac output related to heart disease. Goal: cardiac output as evidenced by good activity tolerance and stable blood pressure readings. Interventions: Oxygen at 2 liters per minute Via NC continuously.<BR/>During an observation and interview on 06/20/23 at 10:40 AM the SVN machine and mask were on bedside dresser. The SVN mask was laying on top of the dresser. Resident #21 said the nurse would come by and give her breathing treatments with the SVN mask and then they would place the mask back on the dresser. <BR/>During an observation and interview on 06/20/23 at 10:40 AM the SVN machine and mask were on bedside dresser. The SVN mask was laying on top of the dresser. Resident #21 said the nurse would come by and give her breathing treatments with the SVN mask and then they would place the mask back on the dresser. <BR/>During an interview on 06/21/23 at 04:20 PM LVN B said she had administered SVN treatments for Resident #21. LVN B said she would place the SVN mask on the resident then after the treatment was done she would place the mask back on the table and in the bag if there was one available. LVN B said the masks were usually placed in a bag to prevent contamination. LVN B said if they used the mask that was not stored in a bag it could possibly lead to respiratory infections. <BR/>During an interview on 06/22/23 at 01:40 PM the DON said her expectations for respiratory equipment was to be changed every Sunday. The DON said the equipment was supposed to be checked every day for water in the humidifier, wash filters, date tubing and bag them if they were not in use. The DON said it was the same thing with the nebulizer, when they are not to in use they were supposed to be bagged. The DON said the charge nurses were responsible for doing it and they were responsible for ensuring it was done. The DON said the CNAs would also check to make sure the items were bagged. The DON said they also conducted angel rounds which meant all department heads did rounds once a week and go into rooms to look see if the items were bagged. The DON said the CNAs knew to place the nasal cannula in the bag when they were not in use. The DON said nurses gave nebulizer treatments so when it was completed, they should be put in bag. The DON said if items were not bagged it could lead to contamination, infection and a trip hazard. <BR/>During an interview on 06/22/23 at 03:27 PM the Administrator said the SVN masks and nasal cannulas were supposed to be bagged when not in use unless the resident removed it and left it outside of the bag. The Administrator said if the items were left unbagged that could lead to bacteria or dirt getting into the masks or cannula and then the residents could inhale it.<BR/>Record review of the facility's policy dated 11/2011 and titled respiratory therapy - prevention of infection indicated in part: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators among residents and staff. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Infection control considerations related to medication nebulizers/continuous aerosol: After completion of therapy - remove the nebulizer container; rinse the container with fresh tap water; dry on a clean paper towel or gauze sponge; store the circuit in plastic bag, marked with date and resident's name between uses.<BR/>Record review of the facility's policy dated 08/2019 and titled handwashing/ hand hygiene, indicated in part: The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as best practice. Single use disposable gloves should be used before aseptic procedures. Procedure: perform hand hygiene before applying non-sterile gloves.<BR/>Review of the facility's policy and procedure on Wound Care, revised October 2010, revealed:<BR/>The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.<BR/>Steps in the procedure:<BR/>Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. <BR/>Wash and dry your hands thoroughly.<BR/>Remove the disposable cloth next to the resident and discard into the designated container.<BR/>Discard disposable items into the designated container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.<BR/>Reposition the bed covers. Make the resident comfortable. <BR/>Use clean field saturated with alcohol to wipe overbed table. <BR/>Record review of the facility's policy revised July 2009 and titled personal protective equipment- gloves indicated in part: Gloves must be worn when handling blood, bodily fluids, secretions, mucous membranes and/or non-intact skin. The use of disposable gloves is indicated: when employees hands will come in contact with blood, bodily fluids, secretions, mucous membranes and/or non-intact skin while performing the procedure. When employee has cuts, wounds, or scrapes. When employee is handling soiled linen or items that may be contaminated. Wash hands after removing gloves.<BR/>Review of the facility's policy and procedure on Handwashing/ Hand Hygiene, revised August 2019, documented:<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations:<BR/>Before performing any non-surgical invasive procedures<BR/>Before donning gloves<BR/>Before handling clean or soiled dressings, gauze pads etc.<BR/>Before moving from a contaminated body site to a clean body site during resident care; <BR/>Hand hygiene is the final step after removing and disposing of personal protective equipment.<BR/>The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing health-care associated infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 (Resident #9 and Resident #12) of 6 residents observed for oxygen management. The facility failed to ensure oxygen in use signage was on Resident #9's and Resident #12's doorway. This failure could place residents at risk of hazards such as explosions which could lead to physical harm.The findings included: Record review of Resident #9's admission record, dated 09/10/2025, indicated she was admitted to the facility on [DATE]. Diagnosis included COPD ((chronic obstructive pulmonary disease) (A group of lung diseases that cause airflow obstruction and breathing problems)). She was [AGE] years of age. Record review of Resident #9's quarterly MDS assessment, dated 06/26/2025, indicated in part: BIMS = 10 indicating the resident was moderately impaired. Section O - Special Treatments, Procedures, and Programs = Oxygen therapy while a resident. Record review of Resident #9's order summary report, dated 09/10/25, indicated Resident #9 had an order for oxygen at 2 lpm (Liters per minute) via nasal cannula effective 04/17/25. Record review of Resident #9's undated care plan indicated in part: Resident is unable to lay flat r/t (related/to) will become SOB. May have oxygen at 2-4L/min (L/min = liters per minute) via nasal cannula PRN oxygen below 90%. Date revised: 07/29/2025. During an observation and interview on 09/10/2025 at 09:48 AM, indicated no oxygen sign posted outside of Resident #9's door. Resident #9 was sitting up in her room on her recliner. The resident was observed wearing a nasal cannula that was connected to the oxygen concentrator. On the back of her wheelchair was an oxygen tank as well. Resident #9 said she had been using oxygen for a long time. Record review of Resident #12's admission record, dated 09/10/2025, indicated he was admitted to the facility on [DATE]. Diagnosis included chronic obstructive pulmonary disease (A group of lung diseases that cause airflow obstruction and breathing problems). He was [AGE] years of age. Review of Resident #12's quarterly MDS assessment, dated 08/25/2025, indicated, in part a BIMS score of 15 indicating the resident was cognitively intact. Record review of Resident #12's order summary report, dated 09/10/25, indicated Resident #12 had an order for oxygen at 2 lpm via nasal cannula effective 04/17/25. Record review of Resident #12's undated care plan indicated in part: Resident is at risk for ineffective breathing pattern and activity intolerance r/t Dx: COPD, CHF, Atrial Fibrillation, and is an active smoker. May have oxygen at 2-4L/min via nasal cannula PRN oxygen level below 90%. Date revised: 08/01/2025. During an observation and interview on 09/10/2025 at 09:58 AM, Resident #12 was observed outside in the smoking area sitting up in his wheelchair. The resident was wheeling himself back into the facility. Resident #12 said he used oxygen when he was in his room and when he went to bed. Observation of Resident #12's door reflected there was no oxygen signage displayed. During an interview on 09/10/2025 at 11:05 AM, LVN C said Resident #12 wore his oxygen whenever he was in his room due to shortness of breath. The LVN said the resident did spend a lot of time sitting outside in the smoking area but when he was in his room, he would use the oxygen. LVN C said Resident #12 wore his oxygen most of the time and also when he went to bed. During an interview on 09/11/2025 at 2:02 PM, the DON said it was expected for oxygen signs be posted outside of resident rooms that were using oxygen. The DON said she was not sure why there were no signs on the 2 rooms as they usually had them posted. She said the signs might have fallen off. The DON said the signs were supposed to be posted for safety of the residents or fires. During an interview on 09/11/2025 at 2:22 PM, the Administrator was made aware of the observation of the resident rooms without oxygen signs posted outside of the doors. The Administrator said it was expected for those resident rooms to have the signs and that they must have forgotten to post them. Record review of the facility undated policy, titled Oxygen administration, indicated in part: Supplies/equipment - appropriate oxygen signs for door and room. Place appropriate oxygen signs per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for two of five residents (Residents #5 and #11) reviewed for food meeting residents' needs, in that: Resident #5 did not receive a puree diet (a diet consistency of highly blended food) as recommended by the physician.Resident #11 did not receive a puree diet as recommended by the physician. This deficient practice could place residents at risk of choking, poor intake, and/or weight loss. The findings included:Resident #5Record review of Resident #5's admission Record, dated 9/11/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (a neurological disorder affecting memory) dysphagia (difficulty swallowing) and protein-calorie malnutrition (a condition where the body does not absorb protein and may use resident tissue including muscle to replace the depleted nutrient) Review of Resident #5's Quarterly MDS Assessment, dated 9/1/25, revealed a BIMS of 9 of 15 indicating she was moderately cognitively impaired and was on a mechanically altered diet. Review of Resident #5's Care Plan Report, updated 8/12/25, revealed: Problem: Resident #5 was at risk for imbalanced nutritional status related to a diagnosis of dysphagia, Vitamin B-12 deficiency, and hypomagnesemia (low magnesium level). She had diagnoses of protein calorie malnutrition and weight loss may be unavoidable related to terminal diagnosis. The identified goal was Resident #5 would be offered an appropriate substitute if less than half of her meal was consumed or if Resident #5 had a problem with the food that was being served, initiated 8/20/2020. Identified interventions included: Serve diet as ordered: Pureed texture, Resident #5 may have mechanical soft solids at her request, initiated 9/9/25. Review of Resident #5's Care Plan Report, updated 4/23/25, revealed: Problem: Aspiration (choking): Resident #5 was at risk for aspiration related to diagnosis of Dysphagia revised on 4/23/25. Goal: Resident #5 would not aspirate during review period, revised 7/22/25. Identified interventions included: Serve diet as ordered per doctor: Puree. Review of Resident #5's Order Summary Report, dated 9/11/25, revealed orders:Puree texture, regular consistency, Patient may have mechanical soft solids at her request. Start date 9/9/25. Review of the Meal Service Report, dated 9/9/25, revealed Resident #5 had an order for a Pureed diet and resident could have mechanical soft on request. Resident #11Review of Resident #11's admission Record, dated 9/11/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including moderate protein-calorie malnutrition, Barrett's Esophagus with Dysplasia (the lining of the lower esophagus resembles the lining of a small intestine developing pre-cancerous changes),and dysphagia. Review of Resident #11's Annual MDS Assessment, dated 8/6/25, revealed:She scored a 3 of 15 on her BIMS (indicating severe cognitive impairment) and was on a mechanically altered diet. Review of Resident #11's Care Plan, revised 7/29/25, revealed:Problem: Resident #11 was at risk for imbalanced nutritional status related to mechanically altered diet and diagnosis of Dysphagia. Resident #11 had a diagnosis of Moderate Protein Calorie Malnutrition. Goal: Resident #11 would maintain adequate nutritional status as evidenced by stable weights. Interventions included: Puree diet, plate guard with meals to help reduce food spillage. Review of Resident #11's Order Summary Report, dated 9/11/25 revealed:Regular diet puree texture. Start dated 7/11/25. Review of the Meal Service Report, dated 9/9/25, revealed Resident #11 had an order for a puree texture. Observation and interview of the noon meal on 09/09/2025 at 11:46 AM, revealed Resident #5 had puree diet that showed the meat portion blended to rice sized pieces and the pasta serving looked like it was chopped up (approximately 1/4 inch pieces) and a piece of regular bread. Interview with LVN E stated the facility was offering Resident #5 both mechanical soft and a puree diet. Interview and observation on 09/09/2025 at 11:57 AM, the Speech Therapist looked at Resident #5's plate. The Speech Therapist stated the puree serving should be a little smother. The Speech therapist stated the chunks of food had a chance of choking Resident #5. The Speech Therapist stated Resident #5 had an order for a mechanical soft diet on request. The Speech Therapist said it was not the safest, but it was Resident #5's choice. The Speech Therapist said she was more worried about Resident #11 choking. The Speech Therapist said she did not know who was responsible for training the dietary staff on how to do the right consistency diet. The Speech Therapist said she fed residents prior to the observation and had not identified an issue with puree diets. Observation on 9/11/25 at 12:00 PM revealed the residents on a puree diet (Resident #5 and#11) did not get the recommended bread serving (the cook failed to follow the menu and provide the recommended calories to the resident) and were served regular (soft) potatoes, including Resident #5 and Resident #11. Interview on 9/11/25 at 12:00 PM, the Dietary Manager stated a chopped diet was supposed to be cut in to 1/4 inch cuts cups, a mechanical soft diet was supposed to be blended into very small pieces, and a puree diet should be blended to look like baby food. Interview on 09/11/2025 at 1:16 PM, [NAME] F stated she worked as the cook for about a year. [NAME] F stated she really did not get any training on how to do a puree diet. [NAME] F said she was throw in and was trying to learn as she went. [NAME] F stated a puree diet had to be like baby food, but Resident #5 would not eat even though it was on her orders. [NAME] F said she was not the cook on 9/9/25. [NAME] F said no one came behind her to check if the puree was correct. [NAME] F stated a mechanical soft diet was supposed to be the size of ground beef. [NAME] F said the roast pork that was served for the lunch meal on 9/11/24 was not that sized, it was just shredded. [NAME] F said she would add the bread to the meat portion of the puree diet because the residents did not the puree bread by itself. [NAME] F admitted she forgot to add the bread to the meat puree because the meal ticket read diced potato for the puree diets and everyone was staring at her to get the lunch meal out on time. Interview on 09/11/2025 1:36 PM, LVN C stated she passed out trays as they came out the window. LVN C said when the food came out the window, she was supposed to check the meal ticket against what was on the tray. LVN C said chopped pieces on a diet meant it was usually bite sized, she described it as 2 centimeters. LVN C stated a mechanical soft diet usually meant the diet had to be able to be smooshed with a fork. LVN C said a puree diet was almost like a smoothie and all blended. LVN C stated she had not noticed a wrong texture issue. LVN C stated she did notice there was no mechanical soft diets on 9/11/25 noon meal and thought the shredded was mechanical soft. Interview on 09/11/2025 at 1:49 PM, CNA G stated she did feed residents of all textured of diet depending on what the resident could eat. CNA G described a chopped meat diet as probably pea sized, a mechanical soft diet as shredded, and a puree texture like pudding. CNA G said she did pay attention to what the residents were fed. CNA G stated she sometimes noticed issues with the diet textures. CNA G stated when there was a problem, if she knew the resident was on a different texture than what ordered she would bring it back. CNA G said if a resident had an issue with the nursing department had to run it by the speech therapist. CNA G said there was a problem with the diet textures probably once a month. CNA G said one of the residents got a chopped diet on 9/11/25 noon meal instead of mechanical soft and she had to cut the meat up more finely. Interview on 09/11/2025 at 2:01 PM, the ADON stated the facility offered specialized diets including mechanical soft, chopped diet, and puree. The ADON stated the chopped diets needed be tiny approximately pea sized. The ADON said mechanical soft just needed to be soft and the puree needed to be liquid. The ADON described the process to ensure the resident had the right diet as the nurses checked trays as they came out the window and were supposed to be checking consistency. The ADON said there was not an issue to her knowledge. The ADON said Resident #5 had an order for mechanical soft for pleasure feeding. The ADON stated she did not normally supervise meals, usually the charge nurse did. Interview on 09/11/2025 at 2:17 PM, the DON stated mechanically altered diets needed to be soft so the resident could chew it, and she want the residents to have some sort of gravy to moisten dry meat. The DON said a chopped meat diet had meat that was chopped to probably dime sized and a mechanical soft had to be about 1 centimeter. The DON said a puree diet needed to be a pudding consistency. The DON said the charge nurse should be at the window checking tickets to make sure the ticket and the plate matched. The DON stated if the texture was wrong, she expected the nurse to ask for the correct texture and not give it to the resident. The DON stated rice sized pieces of food was not puree. The DON stated the nurses did not catch it and were trusting what came out kitchen was ok. The DON added the CNAs should have probably caught too, because the aides knew the residents. The DON said she thought there was confusion when a resident got mechanical soft verses a puree diet. The DON said Resident #5 was supposed to get both and the order did say on request. Surveyor requested a policy and any in-services on what the nurses were responsible for doing regarding a specialized diet. Interview 09/11/2025 at 2:51 PM, the Administrator said his understanding of a chopped meat diet was up to dime sized pieces. The Administrator stated when he usually saw a mechanical soft diet it looked like ground up hamburger meat. The Administrator said a puree diet had to have some consistency like mashed potatoes, not runny. Review of the Diet Guide for the cooks, undated revealed:Soft Chopped Diet is food cut by hand into even bite sized pieces or as prescribed by a doctor. Food must be moist throughout and cannot include any food that is hard, sticky, or crunchy. Ground Diet - is food that is moist, soft-textured and easily formed in a rounded ball in the mouth. Meats are ground or minced into pieces no larger than a quarter inch; all pieces are moist and stick together slightly (cohesively).Pureed Diet is food with very smooth consistency or foods that have been well processed in a food processor or blender to a very smooth consistency or texture. No solid pieces or parts can be noticed in the food. Pureed food has no lumps and feels very soft and smooth in the mouth. Review of the Meal Service Report, dated 9/9/25, revealed there were 5 residents on a chopped meats diet, 2 residents on a mechanical soft diet, and 2 residents on a puree diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 12 residents (Resident #22 and #6) reviewed for care plans.<BR/>1. <BR/>The facility failed to have a care plan in place to accurately address Resident #6's oxygen use. <BR/>2. <BR/>The facility failed to have a care plan in place to accurately address Resident #22's &frac14; side rail use. <BR/>This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.<BR/>The findings included:<BR/>Resident #6<BR/>Resident #6 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #6 had medical diagnoses that included chronic diastolic congestive heart failure, heart disease, acute kidney failure, morbid obesity due to excess calories, and shortness of breath.<BR/>Review of Resident #6's Quarterly MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident was cognitively intact. She required maximum assistance and dependent on staff for all ADL's except for eating. She used a wheelchair for mobility. Under section O for Respiratory treatments C1. Oxygen therapy was selected as continuous while a resident at the facility. <BR/>Record review of Resident #6's had order summary dated August 2024 that include, GIVE OXYGEN AT 1-10 LITERS VIA FACE MASK OR NASAL CANNULA CONTINUOUS. - every day and night shift Hospice has delivered a black concentrator that can deliver up to 10L, OXGEN: Oxygen AT 2-4 LPM CONTINUOUS via NC. Titrate for comfort. every shift.<BR/>Record review of Resident #6's care plan dated 07/24/2024 revealed there was no care plan for oxygen use. <BR/>Interview on 08/08/24 at 03:18 PM with MDS E stated that she would check orders and medical diagnosis for items that should be care planned. MDS E stated that there should be a care plan for oxygen especially for continuous oxygen use. MDS E stated that the care staff could look at the care plan and if her continuous oxygen use was not on there, they could miss that she needs to have O2 on continuously.<BR/>Review of Resident #22's admission Record, dated 8/7/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, high blood pressure, arthritis, and neuropathy (nerve disorder causing numbness or tingling).<BR/>Review of Resident #22's Quarterly MDS Assessment, dated 6/24/24, revealed:<BR/>She scored a 10 of 15 on her mental status exam (indicating moderate cognitive impairment)<BR/>She had range of motion impairment on one side of the lower extremity and used a walker.<BR/>She was independent in all of her ADLs including transfers and sitting to standing. <BR/>Review of Resident #22's care plan, last revised on 6/27/24, revealed no care plan for side rails. <BR/>Observation and interview on 8/6/24 at 10:49 a.m. revealed Resident #22 had &frac14; rails on both sides of her bed. Resident #22 said she did not know why she had the rails; they were built onto the bed. Resident #22 said she did not mind the rails, but she did not use them. <BR/>Interview and record review on 08/08/24 at 03:34 PM the MDS Coordinator stated indicators for care plans started with cognition, pain, diagnoses, then MDS triggers. The MDS Coordinator stated &frac14; side rails would be just for mobility since they did not keep Resident #22 in the bed but would require a care plan. The MDS Coordinator stated the system for side rails was therapy did an assessment, if rails were indicated ADON got a consent from the resident or the responsible party. The MDS Coordinator said once the consent was obtained, she would get the order and do the care plan. The MDS Coordinator checked Resident #22's electronic file and said she did not see a consent for side rails.<BR/>Review of undated facility policy titled Comprehensive Person-Centered Resident Care Planning revealed, in part:<BR/>A comprehensive person-centered care plan is developed and implemented for each resident, consistent with the resident's rights, and will incorporate resident-centered goals and wishes about their care, activities, and lifestyle to include measurable short-term and long-term objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 5 of 7 (Residents #2, #7, #9, #18, and #21) reviewed for infection control. <BR/>The facility failed to ensure:<BR/>Resident #7, #9, #18, and #21's small volume nebulizer (SVN) masks were bagged when not in use. <BR/>LVN B washed her hands prior to putting gloves on and changing them once they were used to provide care for Resident #2. <BR/>Resident #7, #9, #18, and #21 oxygen tubing was bagged when not in use. <BR/>These failures could place resident's risk for cross contamination and the spread of infection. <BR/>Findings included:<BR/>RESIDENT #2<BR/>Record review of Resident #2's admission record dated 06/21/23 indicated she was admitted to the facility on [DATE] with diagnoses of paraplegia and muscle weakness. She was [AGE] years of age.<BR/>Record review of Resident #2's order summary reports dated 06/21/2023 indicated in part:<BR/>Wound care: Paint Left pinkie toe using Iodine until healed, monitor for s/s of infection each shift. Order status active. Start 05/09/2023.<BR/>Record review of Resident #2's care plan dated 06/07/23 indicated in part: Problem: Skin/Pressure Ulcer: Resident is at risk for impaired skin integrity r/t bowel/bladder incontinence/ impaired physical mobility/thin fragile skin/history of pressure ulcers/history of slow wound healing. Goal: Resident will maintain intact skin integrity. Interventions: Assist with turning and repositioning every 2 hours and as needed to prevent pressure from forming, especially to boney prominences.<BR/>During an observation on 06/21/23 at 4:03 PM revealed LVN B grabbed a pair of gloves without first washing her hands or using alcohol gel. She pulled a bottle of iodine out of the wound care cart with her bare, unwashed hands. LVN B got a stack of gauze pads with her bare hands. LVN B knocked on Resident #2's door and entered the room. LVN B placed the iodine bottle and the stack of gauze pads on the un-sanitized bedside table with no barrier between the iodine bottle and gauze. LVN B washed her hands and donned her gloves. LVN B pulled off Resident #2's sock which revealed a pin-prick sized closed scab on the left toe. LVN B grabbed a stack of gauze, poured the iodine on the gauze and dabbed the gauze on the scab and re-wiped the scab with the same pad of gauze. With the same gloves, LVN B threw out the used gauze, took the left-over gauze and gloves and threw them in the trash can. With the same gloves, LVN B placed Resident #2's sock and heel protector on and repositioned her feet. Then with the same gloves LVN B checked Resident #2's right foot, straightened the sheets, and replaced pillows. LVN B took off her gloves, washed her hands and placed it back in the wound care cart.<BR/>During an interview on 06/22/23 at 03:00 PM with DON and ADON, ADON stated that she was responsible for trainings pertaining to hand washing, glove use and wound care. ADON stated that her expectations are that staff should always wash hands, sanitize tabletop, place barrier on tabletop, and set up supplies on barrier prior to wound care. Then staff should bring treatment cart to residents' room, wash hands, don gloves, remove soiled dressing, doff gloves. Then staff should wash hands or sanitize hands, don gloves, perform wound care wiping from clean to dirty, not circular motion. Next, staff should apply new dressing, doff gloves, and wash hands, then position resident for comfort.<BR/>Review of the facility's competency Assessment for Wound Care, undated, revealed:<BR/>Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. <BR/>Wash and dry your hands thoroughly<BR/>Discard disposable items into the designated container. Removed disposable gloves and discard into designated container. Wash and dry your hands thoroughly.<BR/>Reposition the bed covers. Make the resident comfortable. <BR/>Use clean field saturated with alcohol to wipe overbed table. <BR/>RESIDENT #7<BR/>Review of Resident #7's admission Record, dated 6/22/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure.<BR/>Review of Resident #7's admission MDS Assessment, dated 4/4/23 revealed:<BR/>Mental Status Score of 15 of 15 with no signs of delirium indicating she was cognitively intact. <BR/>Oxygen was not checked as a measure. <BR/>Review of Resident #7's Order Summary dated 6/22/23 revealed orders dated:<BR/>Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer every 6 hours as needed for Shortness of Breath Active 03/29/2023<BR/>There was no order for oxygen <BR/>Care Plan initiated 4/11/23 revealed:<BR/>Decreased Cardiac Output: Resident #7 was at risk for decreased cardiac output related to diagnosis of hypertension and Congestive Heart Failure. Date Initiated: 04/11/2023. The identified goal was Resident #7 will demonstrate adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm with her normal parameters. Interventions included: Albuterol nebulizer treatment as ordered as needed per Doctor's order for Shortness of Breath.<BR/>Observation on 6/20/23 at 10:38 a.m. revealed the Resident #7 was out of the room with an SVN mask on the bed unbagged and open to air. There was also oxygen tubing wrapped up and hanging off the oxygen concentrator dated 6/12/23. <BR/>RESIDENT #9<BR/>Review of Resident #9's admission record dated 6/22/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Respiratory Failure, and heart failure. <BR/>Review of Resident #9's admission MDS assessment dated [DATE] revealed she had mental status of 15 of 15 indicating she was cognitively intact and used oxygen while a resident. <BR/>Review of Resident #9's Care Plan, initiated 5/22/23 revealed:<BR/>Activity Intolerance: Resident #9 was at risk for activity intolerance related to diagnoses of COPD and can become easily fatigued with ADLs. Revision on: 06/07/2023<BR/>Goal: Resident #9 will be able to perform ADLs without becoming overly exerted. Identified interventions included: Administer prescribed inhalers as ordered per MD; assess Resident #9's respiratory response to activity which includes monitoring of respiratory rate and depth, oxygen saturation, and use of accessory muscles for respiration; and oxygen as ordered per MD. Date Initiated: 05/22/2023<BR/>Review of Resident #9's Order Summary dated 6/22/23 revealed order dated:<BR/>5/12/23- Oxygen 3 Liters per nasal cannula as needed and at night every day and night<BR/>5/10/23 Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3ML) 0.083% (Albuterol Sulfate) 3 ml inhale orally via nebulizer every 4 hours as needed for Wheezing<BR/>Observation on 6/20/23 at 10:02 AM revealed oxygen tubing wrapped in a coil, draped on the oxygen machine unbagged and open to air. <BR/>RESIDENT #18<BR/>Record review of Resident #18's admission record dated 06/20/23 indicated she was admitted to the facility on [DATE] with diagnosis of congestive heart failure (chronic condition in which the heart does not pump blood as well as it should) and dyspnea (shortness of breath). She was [AGE] years of age.<BR/>Record review of Resident #18's MDS dated [DATE] indicated in part: Oxygen was being used.<BR/>Record review of Resident #18's order summary reports dated 03/21/2023 indicated in part:<BR/>Change oxygen tubing, water and clean filter every 7 days (Sunday night shift). [NAME] with time, date and initials. Keep the tubing in a bag marked with date, time and initials. <BR/>Record review of Resident #18's care plan dated 05/15/23 indicated in part: Problem: Cardiac: Resident is at is at risk for fluid overload and decreased cardiac output related to diagnosis of Congestive Heart Failure and Atrial Fibrillation. Goal: will maintain adequate cardiac output as<BR/>evidenced by ability to perform ADLs without becoming overly exerted and stable vital signs.<BR/>Interventions: wear oxygen at 2 liters per minute via nasal cannula throughout the day, or as needed, for shortness of breath or to maintain oxygen saturations above 90%.<BR/>During an observation and interview on 06/20/23 at 09:40 AM of Resident #18's room, the oxygen tubing and cannula were observed, rolled up and hanging on the oxygen concentrator knob. The oxygen tubing was dated 6/18/23 but remained unbagged. Resident #18 stated that she wears her nasal cannula every night, and it hangs there during the day. <BR/>RESIDENT #21<BR/>Record review of Resident #21's admission record dated 06/20/23 indicated she was admitted to the facility on [DATE] with diagnosis of chronic respiratory failure. She was [AGE] years of age.<BR/>Record review of Resident #21's MDS dated [DATE] indicated in part: BIMS = 4 meaning severe impairment. <BR/>Record review of Resident #21's order summary reports dated 06/20/2023 indicated in part:<BR/>Change oxygen tubing (cannula or mask) and SVN tubing every 7 days (Sunday<BR/>night shift), or as needed. mark with time, date an initials. keep the tubing in a bag<BR/>marked with date, time and initials. Every night shift every Monday. <BR/>Record review of Resident #21's care plan dated 06/02/23 indicated in part: Problem: Cardiac: Resident is at risk for decreased cardiac output related to heart disease. Goal: cardiac output as evidenced by good activity tolerance and stable blood pressure readings. Interventions: Oxygen at 2 liters per minute Via NC continuously.<BR/>During an observation and interview on 06/20/23 at 10:40 AM the SVN machine and mask were on bedside dresser. The SVN mask was laying on top of the dresser. Resident #21 said the nurse would come by and give her breathing treatments with the SVN mask and then they would place the mask back on the dresser. <BR/>During an observation and interview on 06/20/23 at 10:40 AM the SVN machine and mask were on bedside dresser. The SVN mask was laying on top of the dresser. Resident #21 said the nurse would come by and give her breathing treatments with the SVN mask and then they would place the mask back on the dresser. <BR/>During an interview on 06/21/23 at 04:20 PM LVN B said she had administered SVN treatments for Resident #21. LVN B said she would place the SVN mask on the resident then after the treatment was done she would place the mask back on the table and in the bag if there was one available. LVN B said the masks were usually placed in a bag to prevent contamination. LVN B said if they used the mask that was not stored in a bag it could possibly lead to respiratory infections. <BR/>During an interview on 06/22/23 at 01:40 PM the DON said her expectations for respiratory equipment was to be changed every Sunday. The DON said the equipment was supposed to be checked every day for water in the humidifier, wash filters, date tubing and bag them if they were not in use. The DON said it was the same thing with the nebulizer, when they are not to in use they were supposed to be bagged. The DON said the charge nurses were responsible for doing it and they were responsible for ensuring it was done. The DON said the CNAs would also check to make sure the items were bagged. The DON said they also conducted angel rounds which meant all department heads did rounds once a week and go into rooms to look see if the items were bagged. The DON said the CNAs knew to place the nasal cannula in the bag when they were not in use. The DON said nurses gave nebulizer treatments so when it was completed, they should be put in bag. The DON said if items were not bagged it could lead to contamination, infection and a trip hazard. <BR/>During an interview on 06/22/23 at 03:27 PM the Administrator said the SVN masks and nasal cannulas were supposed to be bagged when not in use unless the resident removed it and left it outside of the bag. The Administrator said if the items were left unbagged that could lead to bacteria or dirt getting into the masks or cannula and then the residents could inhale it.<BR/>Record review of the facility's policy dated 11/2011 and titled respiratory therapy - prevention of infection indicated in part: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators among residents and staff. Keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Infection control considerations related to medication nebulizers/continuous aerosol: After completion of therapy - remove the nebulizer container; rinse the container with fresh tap water; dry on a clean paper towel or gauze sponge; store the circuit in plastic bag, marked with date and resident's name between uses.<BR/>Record review of the facility's policy dated 08/2019 and titled handwashing/ hand hygiene, indicated in part: The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as best practice. Single use disposable gloves should be used before aseptic procedures. Procedure: perform hand hygiene before applying non-sterile gloves.<BR/>Review of the facility's policy and procedure on Wound Care, revised October 2010, revealed:<BR/>The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.<BR/>Steps in the procedure:<BR/>Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. <BR/>Wash and dry your hands thoroughly.<BR/>Remove the disposable cloth next to the resident and discard into the designated container.<BR/>Discard disposable items into the designated container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.<BR/>Reposition the bed covers. Make the resident comfortable. <BR/>Use clean field saturated with alcohol to wipe overbed table. <BR/>Record review of the facility's policy revised July 2009 and titled personal protective equipment- gloves indicated in part: Gloves must be worn when handling blood, bodily fluids, secretions, mucous membranes and/or non-intact skin. The use of disposable gloves is indicated: when employees hands will come in contact with blood, bodily fluids, secretions, mucous membranes and/or non-intact skin while performing the procedure. When employee has cuts, wounds, or scrapes. When employee is handling soiled linen or items that may be contaminated. Wash hands after removing gloves.<BR/>Review of the facility's policy and procedure on Handwashing/ Hand Hygiene, revised August 2019, documented:<BR/>This facility considers hand hygiene the primary means to prevent the spread of infections.<BR/>Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations:<BR/>Before performing any non-surgical invasive procedures<BR/>Before donning gloves<BR/>Before handling clean or soiled dressings, gauze pads etc.<BR/>Before moving from a contaminated body site to a clean body site during resident care; <BR/>Hand hygiene is the final step after removing and disposing of personal protective equipment.<BR/>The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine hand hygiene is recognized as the best practice for preventing health-care associated infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistance devices was provided for 2 of 4 residents reviewed for transfers and accidents (Resident #20 and #23).<BR/>The facility failed to ensure that Resident #23 had foot pedals on her wheelchair after demonstration she was unable to hold her feet up resulting in a possible fracture/ sprain. <BR/>CNA C, NA G, and CNA H transferred Resident # 20 and Resident #23 by hooking their arms under the resident's armpits .<BR/>This deficient practice has the potential to affect residents in the building who required extensive assistance which could result in residents having pain, falls or injuries including lacerations and fractures. <BR/>The findings included:<BR/>Review of Resident #23's admission Record, dated 6/21/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, stroke, age-related osteoporosis, repeated falls, and weakness.<BR/>Review of Resident #23's quarterly MDS Assessment, dated 6/6/23 revealed:<BR/>Resident #23 had a mental status score of 11 of 15 (Indicating moderate cognitive impairment), with no signs of delirium. <BR/>Resident #23 needed extensive assistance of two or more people for transfers. <BR/>She had range of motion impairments of both upper and lower extremities and used a wheelchair. <BR/>She needed substantial or maximum assistance with chair or bed-to-chair transfer. <BR/>She had one fall with minor injury (skin tear, abrasion superficial bruising) in the previous assessment.<BR/>Review of Resident #23's Care Plan, updated on 12/19/22, revealed: Resident #23 required assistance with all ADLs (1-2 staff) related to impaired cognitive status and muscle weakness. The goal was Resident #23 would have her goals met as evidenced by her odor free, neat, and well-groomed appearance. Identified interventions included: assist Resident #23 with all ADLs related to impaired cognition and muscle weakness (initiated 5/22/23); increase level of staff assistance when needed dependent upon Resident #23's physical need (initiated 12/20/21); and provide wheelchair for mobility (foot pedals to wheelchair) (revised on 6/20/23). <BR/>Review of Resident #23's Incident Note dated 5/27/2023 at 5:16 pm revealed: Back of left foot was bumped by wheelchair while being pushed by staff to dining room. No injury noted. Resident unable to describe incident only states ouch that hurt. Toe wiggle present, able to perform range of motion to lower extremity and left ankle. No redness, swelling noted. <BR/>Review of Resident #23's Incident Note dated 5/27/23 at 5:23 p.m. revealed: Notified Responsible party of incident. This writer recommends new, higher wheelchair and use of foot supports. Responsible Party states they were testing out this wheelchair because it reclined, and resident tends to fall asleep quite often while in sitting position. Placed on 24-hour report and risk management filed with facility. <BR/>Review of Resident #23's incident/accident report, dated 5/27/23 revealed: CNA reported resident was being pushed in hallway via wheelchair and resident was holding feet up and suddenly dropped both feet when wheelchair bumped back of left foot. Resident was unable to explain incident, stated, ouch, that hurt. The nurse documented other information no foot brackets on wheelchair while in use <BR/>Review of Resident #23's incident/accident report, dated 6/20/23 revealed: This nurse heard resident yell out that hurts. Right foot hit by wheelchair front right wheel while being pushed by staff down hallway. Resident description: stated that hurts Resident crying and unable to describe facts of incident. Other information documented: Resident assigned reclining wheelchair, no foot pedals in use. <BR/>Review of Resident #23's Xray result dated 6/20/23 revealed: images of the right foot were performed and reveal minimal cortical disruption (outside bone fracture) of the fibula (calf bone). <BR/>Review of Resident #23's emergency room Summary, dated 6/20/23, revealed: [AGE] year-old from the nursing home with chief complaint of possible right ankle fracture. The patient was being pushed in her wheelchair and her right foot was hyper plantar flexed on the ground. An x-ray and the nursing home shows distal fibular fracture. <BR/>Emergency Department Course: Discussed ankle x-ray with Radiology. Soft tissue swelling. Cannot rule out a fracture since other x-ray from outside facility noted distal fibular fracture. Patient has no definitive fracture on x-ray it is still questionable per radiology. Due to ankle effusion (swelling) she was placed in a walking-boot. Clinical Impressions: sprain of ankle, fracture of fibula. <BR/>Review of Resident #23's After Visit Summary from the Emergency Department at a local hospital, dated 6/20/23, revealed: Reason for Visit: Ankle Pain. Diagnoses: Stretching or Tearing of a ligament (connects bones or joints) of the ankle and Closed (no skin break) fracture of the shaft (middle section) of the fibula (smaller lower leg bone). <BR/>Observation on 6/20/23 at 11:55 AM revealed CNA C pulled Resident #23 up from a reclining position in the day room. CNA E put the gait belt on Resident #23. CNA C hooked her arm under Resident #23's arm and CNA E grabbed the back of Resident #23 gait belt and shirt. Resident #23 was not able to bear weight . The two CNA's drug Resident #23 to the wheelchair and placed her in it. <BR/>Interview on 06/20/23 at 12:02 PM Resident #23's family member said Resident #23 had a problem with her feet dragging. The family said a few weeks ago Resident #23 got a wound on her foot from dragging it . The family explained Resident #23 had a problem with pointing her feet and that caused the injuries.<BR/>Follow up interview on 06/20/23 at 2:13 PM Resident #23's family member said Resident #23 had problems holding her feet up when she was tired. The family said Resident #23's foot dropped and drug that morning (6/20/23) and she got a skin tear on the foot. The family said Resident #23 had been doing that a lot lately. <BR/>Observation on 06/20/23 at 3:57 PM revealed the EMTs present and leaving the facility with Resident #23. <BR/>Interview on 06/20/23 at 4:10 PM LVN B said the aides were taking Resident #23 down the hall that morning (6/20/23), Resident #23's foot started to drag and got caught under the wheelchair. LVN B said the doctor ordered x-rays because there was bruising and swelling . LVN B said the x-ray showed a possible tibial fracture. <BR/>Interview on 06/21/23 at 10:55 AM the DON stated Resident #23 had good days and bad days. The DON explained when Resident #23's family was at the facility Resident #23 was active and involved. The DON said Resident #23 sprained her ankle when it got caught falling from the foot pedal. The DON said Resident #23 was sent to emergency room yesterday for x-ray for possible fracture, but the hospital thought it was sprain. The DON said Resident #23 was not good about keeping feet on pedal. The DON said Resident #23 had an incident about two weeks prior when Resident #23's foot went under the wheelchair and the facility put in foot pedals. The DON said the facility was now looking into putting in a foot board so her feet could not fall off. The DON said prior to the incident Resident #23 was able to bear weight but Resident #23's balance was not good.<BR/>Interview on 06/21/23 at 11:24 AM CNA D confirmed she was familiar with Resident #23's needs. CNA D described Resident #23 as liking to sleep a lot but would get up for meals. CNA D stated Resident #23 would fall asleep in the middle of a conversation or while eating. CNA D said Resident #23 needed assistance with being fed. CNA D said Resident #23 needed a lot of help with ADLs. CNA D stated prior to the incident, Resident #23 could be bribed with hot chocolate to get up as a one person assist. CNA D stated Resident #23 could bear weight, but the aides had to know how to wake Resident #23 up. CNA D said to transfer with Resident #23 the aide would put the gait belt on, hold the gait belt, Resident #23 would put her arms around the aide and stand and pivot. CNA D said when Resident #23 was sleep it would take two people to transfer her with a gait belt. CNA D described a two-person gait belt transfer as holding the gait belt and keeping arms under the resident's arm. CNA D said on the morning of 6/20/ 23 they got Resident #23 up , reclined her wheelchair a little bit and started rolling down the hallway. CNA D said as they were rolling down the hallway Resident #23 started screaming because her ankle hit the wheelchair and twisted. CNA D said Resident #23's ankle was red and then started getting real swollen. CNA D stated they offered to put ice on Resident #23's ankle, but she refused so the nurse (LVN B) got orders for an x-ray. CNA D said there was a similar incident. CNA D explained Resident #23's other foot was purple because Resident #23 hit her foot before . CNA D said the staff knew Resident #23 needed footrests on the wheelchair. CNA D said the nurse told the aides Resident #23 needed the footrests. CNA D explained there were not any that fit Resident #23's wheelchair so Resident #23 did not have them. CNA D said Resident #23 got the footrests the morning of 6/21/23. CNA D stated usually the aides would tilt Resident #23's wheelchair back but CNA D felt tilting the wheelchair back was scary. <BR/>Interview on 06/21/23 at 1:32 PM LVN B stated she began working the floor on 4/1/23. LVN B stated she was aware of Resident #23's care needs . LVN B described Resident #23 as having dementia and combative. LVN B said Resident #23 would rather stay in bed most days but the family insisted Resident #23 get up. LVN B explained even when Resident #23 was awake she would not engage with her surroundings. LVN B said Resident #23's care needs was she was completely dependent on the CNAs for all ADL care. LVN B said Resident #23 was a two-person transfer. LVN B said two days prior she helped with transferring Resident #23 and she (Resident #23) did not bear weight. LVN B added that Resident #23 would bear weight for some of the aides but was not weight bearing the day LVN B transferred Resident #23. LVN B said if Resident #23 would not consistently bear weight she probably needed to be a mechanical lift transfer - at least a sit to stand lift transfer. LVN B stated she did not communicate this to anyone because of her (LVN B's) lack of experience working with Resident #23 and she (LVN B) could see Resident #23 had good and bad days. LVN B stated she was the nurse on duty they morning of 6/20/23. LVN B said the first thing she (LVN B) heard was Resident #23 yelling ow; LVN B said she saw no foot pedals in use and Resident #23 looking at her (Resident #23's) foot. LVN B stated Resident #23 was awake and alert at that time. LVN B said Resident #23 was injured one other time and she wrote in the risk management note to change Resident #23's wheelchair or to put in foot pedals. LVN B stated she had to call the family on the first incident and then the CNA said there was no foot pedals available for the wheelchair. LVN B stated Resident #23's family insisted on Resident #23's wheelchair because it reclined and helped Resident #23 be more comfortable. LVN B stated she felt Resident #23's fracture/sprain was easily preventable with the use of foot pedals. LVN B said she did not know why there were not foot pedals after the first incident in May 2023. LVN B explained that at the moment the facility was doing a re-model and the equipment was stored in the basement. LVN B said she thought there might have been a miscommunication about getting the foot pedals. LVN B stated no one in upper management talked to her about the first incident. LVN B said the need for foot pedals was communicated by the nurses to nurses on the nurse-to-nurse report and verbally to the aides. LVN B said a two-person gait-belt transfer would look like someone put the gait belt on the resident and both aides hold the gait belt on either side of the resident at the front and back and lift. LVN B said the aides were supposed to help the resident stand, stabilize, and pivot. <BR/>Interview on 6/21/23 at 3:00 PM the DOR stated she had worked at the facility for a week so she was not aware of Resident #23's abilities. The DOR said there was no need to get an order for wheelchair pedals. The DOR explained since different wheelchair manufacturers wanted the consumer to buy from that manufacturer, foot pedals were not interchangeable. <BR/>Interview on 6/21/23 at 3:12 PM OTA F stated Resident #23 had never been on therapy, so the therapy department did not know if Resident #23 was weight bearing or not. OTA F stated if Resident #23 could not reliably bear weight a mechanical lift transfer would be appropriate. He stated possible outcomes to not transferring the resident correctly was skin tears, abrasions, and further fractures. <BR/>Interview on 06/21/23 at 3:26 PM the DON stated prior to the incident Resident #23 could bear some weight and was sometimes a one or two person assist with transfers. The DON stated she guessed Resident #23 was one who determined what kind of transfer Resident #23 was. The DON stated it also depended on how comfortable the aide felt on transferring the resident. The DON said Resident #23 was able to bear weight when the DON was the one completing the transfer. The DON stated the last time she transferred Resident #23 was approximately six months prior. The DON said she thought the fracture/sprain could have been prevented by making sure foot pedals were in place. The DON said Resident #23 was supposed to have foot pedals since the first incident that occurred 5/27/23. The DON stated the aides were responsible for making sure the foot pedals were in place. The DON stated the charge nurses were responsible for ensuring the aides used the foot pedals. The DON said no one informed her the foot pedals were unavailable and she did not know why no one told her. The DON stated every wheelchair came with foot pedals and she did not know where the foot pedals went missing or why they were not in place. At that time, the ADON joined the conversation and stated maintenance was supposed to take the foot pedals downstairs. The ADON stated the facility needed to figure who was responsible for getting the foot pedals. The DON stated it had just been a disaster with the remodel due to residents swapping rooms and stuff being moved. The DON said Resident #23 could self-propel in the wheelchair when she was awake but said for the most part staff did the work of transporting Resident #23. <BR/>Observation on 06/21/23 at 4:00 PM revealed Resident #23 in bed. NA G raised Resident #23 into a sitting position and placed the gait belt onto Resident #23. CNA H hooked her (CNA H) right arm under Resident #23's arm while NA G hooked her (NA G) left arm under Resident #23's arms. The aides grabbed the gait belt from behind and lifted Resident #23. Resident #23 was unable to bear weight or assist. Resident #23's legs bent and the aides quickly swung Resident #23 to her wheelchair. Resident #23's pants slid to her knees. The aides readjusted the gait belt, hooked their (CNA H and NA G) arms under Resident #23, and lifted Resident #23 to adjust Resident #23's pants. <BR/>Resident #20<BR/>Review of Resident #20's admission Record, dated 6/22/23, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, muscle wasting and atrophy, muscle weakness, and repeated falls. <BR/>Review of Resident #20's quarterly MDS Assessment, dated 4/19/23 revealed:<BR/>She had long and short-term memory impairment with severely impaired decision-making abilities and signs of delirium including inattention continuously. <BR/>She needed extensive assistance of two people for transfers<BR/>She needed substantial/maximal assistance for chair/ bed-to-chair transfers. <BR/>She had one fall with no injury and another fall with minor injury in the three months prior to the assessment. <BR/>Review of Resident #20's Care Plan updated 4/21/23 revealed: Resident #20 was a on to two person assist for ADL's related to cognition/ muscle weakness/ impaired vision. The Goal was Resident #20 would have daily needs met as evidenced by being odor free and a well-groomed appearance. Identified interventions included: increase level of assistance based on Resident #20's physical need. <BR/>Observation on 06/20/23 at 11:49 AM revealed Resident #20 in a recliner in the living room. CNA C talked to Resident #20 in Spanish and applied the gait belt. Resident #20 fought the gait belt as it was put around her (just the gait belt, not the aide). CNA C hooked her arm under Resident #20's while CNA E grabbed the back of the gait belt, lifted the resident, and placed her in a wheelchair. <BR/>Interview on 6/21/23 at 3:00 PM the DOR stated to complete a two-person gait belt transfer the aides were to put on the gait belt, lock the resident's wheelchair, one person on each side while holding the front and back of the gait belt and assist the resident to stand and pivot. The DOR said the risk of the staff hooking arms under the resident's arm was shoulder dislocation, pain, falls, or back injury. The DOR said she had been at the facility for a week and did not have a chance to observe or train staff in transfers. The DOR said assessments on transfer ability was typically done quarterly and when the nurses reported a decline in function, or as needed such as noted contractures or falls. The DOR was informed of the two-person gait belt transfers observations. The DOR stated, we'll have to do some in-services <BR/>Interview on 6/21/23 at 3:26 PM the ADON stated the expectation for a two-person transfer was to put on the gait belt, each person stand on each side of the resident, holding the gait belt and assist the resident to stand, pivot and sit. The ADON said the consequences of not doing it that way was fall. The ADON stated the ADON, DON, and charge nurse were up and down the hallways all day. The ADON and DON were informed of the 6/20/23 11:55 a.m. transfers observations with Resident #20 and #23 and stated it was not an appropriate transfer and there was a risk of injury to the resident. The ADON stated they would have to in-service. The ADON stated she did not know when the last time the facility in-serviced on transfers. The ADON said assessments for types of transfers should be in the resident's clinical record. <BR/>Interview on 6/21/23 at 4:22 PM the Administrator was informed of the transfer observation. He stated surveyor would have to ask the nursing department if that was an acceptable transfer. The Administrator stated when Resident #23's first incident in May 2023 first happened it was discussed in the morning meeting and the next day the person who brought up the need for foot pedals went on vacation so the foot pedals slipped through the cracks. The Administrator added Resident #23 had always been highly dependent on staff.<BR/>Review of the facility's Competency Assessment on Transfers, undated, documented:<BR/>Two-Person Transfer Weight Bearing:<BR/>Assemble equipment - gait belt<BR/>Apply gait belt over clothing just above the hip bone, never against bare skin.<BR/>The belt should be snug; not too loose, not too tight. You should be able to fit 2 -3 fingers between the belt and the resident.<BR/>Make sure you double-lock the belt, meaning you thread it through the teeth portion of the belt which locks in place.<BR/>On person will be on each side of the resident.<BR/>Each attendant's outside hand will be on the gait belt while the inside arm will be just under the resident's armpit. The arm under the armpit is just to balance the resident. <BR/>The lifting force should come from the outside hand which is on the gait belt.<BR/>On the count of three the resident should be lifted into a standing position and then pivoted to the chair or bed.<BR/>Two-Person Transfer - Non-weight bearing<BR/>A draw sheet is positioned to extend from the back of the head to the k eeks.<BR/>The edges of the draw sheet are rolled under, toward the resident, until the rolled edges are against the resident.<BR/>The wheelchair/ Geri-chair is placed as close to the resident as is possible with the brakes locked <BR/>One attendant is positioned on each side of the resident and the resident is brought safely to the edge of the bed.<BR/>One person moves to the head of the bed, the other to the area of the knees. If more attendants are needed they will be positioned at the resident's side. <BR/>The person at the head should place their knee closest to the head of the bed, onto the bed so that the resident can be brought into a semi-reclined position and the draw sheet can be brushed on the sides of the upper arms. <BR/>The person at the knees should grasp the draw sheet on the sides in the area of mid-thighs.<BR/>On the count of three, the resident is lifted up and over onto the wheelchair/Geri-chair. <BR/>Review of the facility's policy and procedure on Safe Lifting and Movement of Residents, revised June 2017, revealed:<BR/>In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.<BR/>Interpretation and Implementation<BR/>Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. <BR/>Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include: Resident's mobility (degree of dependency); weight-bearing ability; cognitive status; <BR/>Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment from bed rails prior to installation, and review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1 of 4 (Resident #22) residents reviewed for bed rails. <BR/>Resident #22 had two quarter-rail bed rails on her bed with no documentation of resident consent, physician orders, and no care plan prior to installation.<BR/>This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.<BR/>Findings included:<BR/>Review of Resident #22's admission Record, dated 8/7/24, revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, high blood pressure, arthritis, and neuropathy (nerve disorder causing numbness or tingling).<BR/>Review of Resident #22's Quarterly MDS Assessment, dated 6/24/24, revealed: She scored a 10 of 15 on her mental status exam (indicating moderate cognitive impairment). She had range of motion impairment on one side of the lower extremity and used a walker. She was independent in all of her ADLs including transfers and sitting to standing. <BR/>Review of Resident #22's care plan, last revised on 6/27/24, revealed no care plan for side rails. <BR/>Review of Resident #22's Order Summary, dated 8/7/24, revealed no orders for any kind of side rails. <BR/>Review of Resident #22's Side Rail Assessment, dated 6/24/24, revealed: Resident expressed a desire to have side rails raise in bed for their own safety and/or comfort? Yes. Is the resident able to get in and out of bed? Yes. Is the resident able to get in and out of bed safely? Yes. Does the resident have a history of falls? Yes. Summary of Findings: The resident requested side rails while in bed, &frac14; rails, right rail, left rail. Comments: Patient requires bed rail on B side for bed mobility and transfers. Signed by the Director of Rehabilitation.<BR/>Review of Resident #22's electronic record revealed no consent for the side rails informing the resident and/or their responsible party of the risks and benefits of the side rail(s).<BR/>Observation and interview on 8/6/24 at 10:49 a.m. revealed Resident #22 had &frac14; rails on both sides of her bed. Resident #22 said she did not know why she had the rails; they were built onto the bed. Resident #22 said she did not mind the rails, but she did not use them. <BR/>Interview and record review on 08/08/24 at 03:34 PM the MDS Coordinator stated the system for side rails were, therapy did an assessment, if rails were indicated the ADON got a consent from the resident or the responsible party. The MDS Coordinator said once the consent was obtained, she would get the order and do the care plan. The MDS Coordinator checked Resident #22's electronic file and said she did not see a consent for side rails. The MDS Coordinator said as far as she knew Resident #22 did not need side rails. The MDS Coordinator stated therapy did assessments on everyone in Mid-June and she (the MDS Coordinator) was given a list of residents who were indicated for side rails. The MDS Coordinator showed the State Surveyor the list of residents assessed for side rails and Resident #22's column had a dash through it. The MDS Coordinator explained that meant Resident #22 did not need side rails and the MDS Coordinator did not know why Resident #22 had any. The MDS Coordinator said she care planned side rails according to the list. The MDS Coordinator said she would have to get consent from Resident #22's responsible party because Resident #22 had dementia and was very forgetful. <BR/>Interview on 08/08/24 at 03:44 PM the DON confirmed the MDS Coordinator's list showed Resident #22 should not have side rails. The DON said she did not know why Resident #22 had the rails and would have to go look. At 3:46 p.m. the DON came back and said Resident #22 decided she wanted the rails later. When asked about the consent the DON left and returned with a consent signed by the resident. <BR/>Interview on 08/08/24 at 04:29 PM the Administrator was informed Resident #22 did not have siderail consent, order, or care plan. The Administrator said Resident #22 had the consent now. The Administrator said he did not understand why there were side rails on the bed at all because the facility just bought new furniture and all the new beds had grab bars for them.<BR/>Review of the facility's policy and procedure on Bed Safety and Bed Rails, revised August 2022, revealed:<BR/>Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for the use of bed rails has been met. <BR/>The use of bed rails or side rails (including temporarily raising the side rails for episodic use during car) is prohibited unless the criteria for the use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. <BR/>Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The follow information will be included in the consent:<BR/>a. the assessed medical needs that will be addressed with the use of bed rails;<BR/>b. The resident's risks from the use of bed rails and how these will be mitigated;<BR/>c. The alternatives that were attempted but failed to meet the resident's needs; and<BR/>d. the alternatives that were considered but not attempted and the reason.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards in the facility's only kitchen. <BR/>The facility failed to ensure the dishwasher machine dispensed the correct amount of chlorine sanitizer.<BR/>This failure could place residents who receive food prepared in the facility kitchen at increased risk of exposure to food-borne illnesses.<BR/>Findings included:<BR/>During an observation and interview on 06/21/23 at 09:40 AM DA A was seen washing the dishes with the use of the automatic dishwasher. DA A was in the process of checking the sanitizing chemicals on the dishwasher. The DA took a test strip and placed it in the dishwasher water compartment. DA A then compared the results of the test strip to the color codes on the test strip container and he said it looked like the PPMs were at level 10. DA A said the PPMs were supposed to between 50 and 100 PPM. DA A said he had used the dishwasher to wash some of the dishes already this morning. DA A said he was not sure why the PPM were not at 50 PPM and would go and report it to the dietary manager. <BR/>During an observation and interview on 06/21/23 at 09:45 AM dietary manager checked the automatic dishwasher sanitizer with the chemical test strips and the results were 10 PPM or less. The manager said the sanitizing results should be at 50 PPM and was not sure why it was not working properly. The manager said they were going to bring back the dishes that DA A had already washed and re-wash them with the 3-compartment sink sanitizer. <BR/>During an interview on 06/22/23 at 02:02 PM the dietary manger said he monitored the dishwasher was working properly by reviewing the dishwasher log where the dietary aides documented the PPMs and water temperature. The manager said he would also rely on feedback from the dietary aides if they noticed the dishwasher was not working properly. The manager was made aware of the observation of DA A using the dishwasher on 06/21/23 and was in the process of washing the dishes even though the PPM on the test strips was reading below 50 PPMs. The manager said he had trained the dietary aides on how to check the PPMs on the dishwasher and to document the results on the logs. The manager said he was not sure why DA A had documented that the PPMs were at 100 that day of 06/21/23 and the reading was at 10 PPMs as indicated by DA A. The manager said he would conduct more training with the staff. The manager said if the dishes were not sanitized correctly that could lead to residents getting ill from improper dishwashing. <BR/>During an interview on 06/22/23 at 03:27 PM the Administrator said the dietary manager would monitor the kitchen department to make sure things were being done properly. The Administrator was made aware of the observations with the dishwasher and DA A on 06/21/23. The Administrator said if the dishwasher was not sanitizing the dishes correctly then that could lead to bacteria build up on the dishes. <BR/>Review of facility's commercial dishwasher manufacturer plaque which was located on the wall of the machine indicated in part: Minimum chlorine required 50 PPM.<BR/>

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards in the facility's only kitchen. <BR/>The facility failed to ensure the dishwasher machine dispensed the correct amount of chlorine sanitizer.<BR/>This failure could place residents who receive food prepared in the facility kitchen at increased risk of exposure to food-borne illnesses.<BR/>Findings included:<BR/>During an observation and interview on 06/21/23 at 09:40 AM DA A was seen washing the dishes with the use of the automatic dishwasher. DA A was in the process of checking the sanitizing chemicals on the dishwasher. The DA took a test strip and placed it in the dishwasher water compartment. DA A then compared the results of the test strip to the color codes on the test strip container and he said it looked like the PPMs were at level 10. DA A said the PPMs were supposed to between 50 and 100 PPM. DA A said he had used the dishwasher to wash some of the dishes already this morning. DA A said he was not sure why the PPM were not at 50 PPM and would go and report it to the dietary manager. <BR/>During an observation and interview on 06/21/23 at 09:45 AM dietary manager checked the automatic dishwasher sanitizer with the chemical test strips and the results were 10 PPM or less. The manager said the sanitizing results should be at 50 PPM and was not sure why it was not working properly. The manager said they were going to bring back the dishes that DA A had already washed and re-wash them with the 3-compartment sink sanitizer. <BR/>During an interview on 06/22/23 at 02:02 PM the dietary manger said he monitored the dishwasher was working properly by reviewing the dishwasher log where the dietary aides documented the PPMs and water temperature. The manager said he would also rely on feedback from the dietary aides if they noticed the dishwasher was not working properly. The manager was made aware of the observation of DA A using the dishwasher on 06/21/23 and was in the process of washing the dishes even though the PPM on the test strips was reading below 50 PPMs. The manager said he had trained the dietary aides on how to check the PPMs on the dishwasher and to document the results on the logs. The manager said he was not sure why DA A had documented that the PPMs were at 100 that day of 06/21/23 and the reading was at 10 PPMs as indicated by DA A. The manager said he would conduct more training with the staff. The manager said if the dishes were not sanitized correctly that could lead to residents getting ill from improper dishwashing. <BR/>During an interview on 06/22/23 at 03:27 PM the Administrator said the dietary manager would monitor the kitchen department to make sure things were being done properly. The Administrator was made aware of the observations with the dishwasher and DA A on 06/21/23. The Administrator said if the dishwasher was not sanitizing the dishes correctly then that could lead to bacteria build up on the dishes. <BR/>Review of facility's commercial dishwasher manufacturer plaque which was located on the wall of the machine indicated in part: Minimum chlorine required 50 PPM.<BR/>

Based on observation and interview, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for physical environment. The facility failed to ensure the dishwasher met manufacturer's recommendation of 120 degrees Fahrenheit for the wash and sanitize cycle. This failure could place residents at risk of foodborne illnesses and residents and staff. Findings included: Observation and interview on 9/10/25 at 1:38 p.m. revealed DA H said the dish machine was supposed to get up to 120 degrees. DA H ran the machine three times, and the wash temperature got to 100 degrees, the sanitizer level reached 114 degrees. After reading the posted machine instructions DA H stated he needed to report the dish machine not reaching temperature to the Dietary Manager. Observation on 9/10/25 at 1:51 p.m. revealed Dietary Manager verified the machine was not reaching the correct temperature, took a picture of the dial and sent it to the Maintenance Director. Interview on 09/11/2025 at 2:41 PM, DA H stated the dish machine was brand new and he thought they turned down the water temperature because it had not worked correctly since the weekend. DA H said he did not tell anyone because he did not realize it needed to be reported. Interview on 09/11/2025 at 2:51 PM, the Administrator said the dish machine was just changed out. The Administrator said the thought maintenance lowered the temperature to raise the sanitization level. He said he did not know, he was not there. Surveyor requested the policy on dish sanitization if there was one. There was no policy provided. Review of the Dish Machine Logbook for September 2025 (9/1/25 - 9/10/25) revealed: AM Wash Temp AM Final Rinse9/1/25 95 degrees 114 degrees9/2/25 110 degrees 122 degrees 9/3/25 110 degrees 120 degrees 9/4/25 112 degrees 123 degrees 9/5/25 114 degrees 123 degrees9/6/24 115 degrees 120 degrees9/7/25 116 degrees 120 degrees9/8/25 115 degrees 120 degrees9/9/25 116 degrees 120 degrees9/10/25 112 degrees 121 degrees Noon Wash Temp Noon Final Rinse Temp 9/1/25 100 degrees 123 degrees9/2/25 105 degrees 121 degrees9/3/25 110 degrees 120 degrees9/4/25 106 degrees 120 degrees9/5/25 110 degrees 120 degrees9/6/25 110 degrees 121 degrees9/7/25 111 degrees 120 degrees9/8/25 116 degrees 120 degrees9/9/25 115 degrees 120 degrees 9/10/25 114 degrees 119 degrees PM Wash Temp PM Final Rinse Temp9/1/25 105 degrees 125 degrees9/2/25 110 degrees 122 degrees9/3/25 110 degrees 120 degrees9/4/25 111 degrees 120 degrees9/5/25 115 degrees 122 degrees9/6/25 114 degrees 120 degrees9/7/25 115 degrees 122 degrees9/8/25 114 degrees 120 degrees9/9/25 116 degrees 120 degrees Review of the posted General Operating Instructions, undated, by the manufacturer revealed:It is recommended that 140 degrees water be used. Report to your supervisor if it is lower than 120 degrees or higher than 160 degrees.