CEDAR RIDGE REHABILITATION AND HEALTHCARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #36, Resident #68, and Resident #79) of fifteen residents reviewed for Care Plans. <BR/>1. <BR/>The facility failed to ensure Resident #36's care plan for catheter, dated 12/17/2024, had appropriate interventions.<BR/>2. <BR/>The facility failed to ensure Resident #68's care plan for catheter, dated 10/02/2024, had appropriate interventions.<BR/>3. <BR/>The facility failed to ensure Resident #79's care plan for catheter, dated 01/09/2025, had appropriate interventions.<BR/>These failures could place the residents at risk of not receiving the necessary care and services needed.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with infection to surgical site to sacrum.<BR/>Record review of Resident #36's Quarterly MDS Assessment, dated 12/03/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had skin problem to her surgical wound and had an indwelling catheter (device to drain the urine from the urinary bladder to a collection bag).<BR/>Record review of Resident #36's Comprehensive Care Plan, dated 12/17/2024, reflected Resident #36's care plan for indwelling catheter related to skin breakdown on sacrum had only one intervention listed. The only intervention indicated was to check for kinks each shift.<BR/>Record review of Resident #36's Physician Order, dated 09/05/2024, reflected Foley Catheter Care Q Shift and PRN.<BR/>In an interview with Resident #36 on 01/14/2025 at 1:36 PM, Resident #36 stated she had a catheter but was removed the day before because she was having abdominal pain. She said she had the catheter because of her wound in her bottom.<BR/>In an interview with the Wound Care Nurse on 01/15/2025 at 8:51 AM, the Wound Care Nurse stated Resident #36 had a wound to her sacrum that was present during her admission. She said she had a catheter to facilitate healing of the wound.<BR/>2. <BR/>Record review of Resident #68's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #68 was diagnosed with urinary retention (the urinary bladder does not empty completely).<BR/>Record review of Resident #68's Quarterly MDS Assessment, dated 01/03/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated the resident had an indwelling catheter.<BR/>Record review of Resident #68's Comprehensive Care Plan, dated 10/02/2024, reflected Resident #68's care plan for indwelling catheter related to urinary retentions had only one intervention listed. The only intervention indicated was to monitor, record, and report signs and symptoms of urinary tract infection.<BR/>Record review of Resident #68's Physician Order, dated 10/02/2024, reflected Foley Catheter Care Q Shift and PRN.<BR/>Observation and interview with Resident #68 on 01/14/2025 at 11:05 AM revealed the resident was sitting in his recliner, awake. It was observed that he had a catheter hanging on his walker. He said he had the catheter because he had an issue with his bladder. <BR/>Observation and interview with the MDS Coordinator on 01/15/2025 at 9:34 AM, the MDS Coordinator stated care plans were done so the staff would know the care needed by the residents. she said if a resident had a catheter, there should be a care plan for catheter. She said the care plan was comprised of problem areas, the goals, and the interventions. She said the interventions should address the underlying problem of the residents. She opened Resident #36's profile and saw the resident had orders for her catheter and was triggered in the MDS for indwelling catheter. When she opened the resident's care plan, she saw the indwelling catheter was listed as one of the problem list. She also saw that there was only one intervention listed. She said there should be more interventions listed like check for trauma, monitor for signs and symptoms of urinary tract infection related to the catheter, check for signs and symptoms of discomfort, monitor the color of the urine, and cover with privacy bag. After looking at Resident #36's care plan, she opened Resident #68's care plan and saw the same thing. She said she would update the care plans for both residents and would input the interventions for indwelling catheter.<BR/>In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated every resident needed a thorough care plan to ensure the residents received the care needed. The DON said the care plan should be in place so the staff providing care would be on the same page and without the care plan, there could be confusion with the care of the residents. The DON said the care plan should reflect the resident's problem lists, the goals, and the interventions. He said a care plan would not be a care plan without appropriate interventions. He said, with indwelling catheters, staff should monitor for urinary tract infection, discomfort, distension of the bladder, cloudiness of the urine, and if there were blood in the urine. He said with only one intervention could be considered an incomplete care plan. He said the expectation was every care plan would be resident-centered and complete. He said he would coordinate with the MDS Coordinator to audit to the care plans of the residents.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated all the care plans of the residents should have all the interventions needed by the residents. She said without the care plan, the staff would not know and understand what kind of care to provide. The Administrator concluded that the expectation was for the staff to ensure that the residents' care plan were complete and individualized. She said he would coordinate with the DON to make sure all the residents were care planned.<BR/>3. <BR/>Record review of Resident #79's Face Sheet, dated 01/16/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #79 was diagnosed with urinary retention.<BR/>Record review of Resident #79's Comprehensive MDS Assessment, dated 01/02/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter.<BR/>Record review of Resident #79's Comprehensive Care Plan, dated 01/09/2025, reflected Resident #79's care plan for indwelling catheter related to history of malignant neoplasm of the prostate had only one intervention listed. The only intervention indicated was to monitor for signs and symptoms of discomfort on urination and frequency.<BR/>Record review of Resident #79's Physician Order, dated 12/29/2024, reflected Foley Catheter Care Q Shift and PRN.<BR/>Observation and interview with Resident #79 on 01/16/2025 at 9:02 AM revealed the resident was in the dining area finishing his breakfast. It was observed that the resident had a catheter leg bag secured to the right leg. When asked how long he had the catheter, the resident did not reply.<BR/>In an interview with LVN D on 01/16/2025 at 9:12 AM, LVN D stated Resident #79 had a catheter because he had an issue with his prostate. She said before he goes out of his room, they would replace his catheter with leg strap because the resident had the tendency to drag his catheter.<BR/>In an interview with the MDS Nurse on 01/16/2025 at 9:43 AM revealed the MDS Coordinator was advised that Resident #79 also only had one intervention for his indwelling catheter. She said she would check on it and update it accordingly.<BR/>Record review of facility's policy, Care Plans, Comprehensive Person-Centered reviewed Jan. 2023 revealed Policy Statement: A comprehensive, person-centered care plan . is developed and implemented for each resident . 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful . 11. Care plan interventions are chosen only after careful data gathering . a. When possible, interventions address the underlying source(s) of the problem area(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #16, #28, #40, and #38) of 14 residents reviewed for Respiratory Care.<BR/>1. <BR/>The facility failed to ensure Resident #16's breathing mask for her nebulizer (machine that turns liquid medication into a mist breathed directly into the lungs) was properly stored when not in use on 01/14/2025. <BR/>2. <BR/>The facility failed to ensure that Resident #28's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 01/14/2025.<BR/>3. <BR/>The facility failed to ensure that Resident #40's nasal cannula was properly stored when not in use on 01/14/2025.<BR/>4. <BR/>The facility failed to ensure that Resident #38's nebulizer mask (medication is inhaled through) was properly stored when not in use on 01/14/2025. <BR/>These failures could place residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>1. <BR/>Record review of Resident #16's Face Sheet, dated 01/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 was diagnosed with anemia (low blood cells).<BR/>Record review of Resident #16's Comprehensive MDS Assessment, dated 11/24/2024, <BR/>reflected the resident had a score of 99 on her BIMS summary score suggesting that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident had anemia.<BR/>Record review of Resident #16's Comprehensive Care Plan, dated 11/04/2024, reflected the resident tested positive for COVID on 01/25/2022 and one of the interventions was to observe for signs and symptoms of respiratory issues.<BR/>Record review of Resident #16's Physician Orders, dated 11/02/2024, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for SOB ONE VIAL Q 4-7 HOURS.<BR/>An observation on 01/14/2025 at 9:20 AM revealed Resident #16 was in her bed, awake. A nebulizer machine was observed beside the room's sink. Beside the nebulizer machine was a breathing mask that was not bagged. The part of the breathing mask that would touch the face when using was touching a bottle of sanitizer. Resident #16 did not respond when asked how long she had been using the breathing mask.<BR/>In an interview with LVN C on 01/14/2025 at 11:33 AM, LVN C stated he was not sure for whom the breathing mask was. He opened the profiles of both residents occupying the room. He said the breathing mask was for Resident #16. He said the order was to administer as needed. He went inside the room and saw the unbagged breathing mask beside the room's sink. He said he did not notice during his rounds that the breathing mask was not inside a bag. He said it should be bagged to prevent cross contamination. He said the issue was not if the resident was using it or not, the breathing mask should be bagged. LVN C went to the storage room and took a new breathing mask and a plastic bag. <BR/>In an interview with the DON on 01/15/2024 at 11:03 AM, the DON stated the breathing mask was supposed to be in a bag when the resident was not using it to prevent cross contamination and worsening of respiratory issues the resident might already had. He said the expectation was for the staff to be mindful and make sure the breathing was bagged when the resident was not using it. He said it did not matter if the order was daily or as needed, the breathing mask must be in a bag or do not leave a breathing mask inside the room and just get one if needed by the resident. He said he would conduct an in-service about respiratory care.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated everything the residents were using should be kept clean to prevent infection. She said she would coordinate with the DON to educate and re-educate the nursing staff to bag the breathing mask if not in use. She said the DON will also in-service the staff about the respiratory care issue.<BR/>2. <BR/>Review of Resident #28's Face Sheet, dated 01/16/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #28 had a diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Review of Resident #28's Quarterly MDS Assessment, dated 07/05/2024, reflected resident had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility.<BR/>Review of Resident #28's Comprehensive Care Plan, dated 10/22/2024, reflected resident has oxygen therapy r/t ineffective gas exchange. Interventions included For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus. Give medications as ordered by physician. Monitor/document side effects and effectiveness.<BR/>Review of Resident #28's Physician Order, dated 04/24/2024, reflected O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 LPM to keep O2 sat &gt;90% every shift. <BR/>An observation on 01/14/2025 at 09:52 AM revealed Resident #28 lying in bed with her eyes closed. Resident #28's wheelchair was next to the bed with a portable oxygen cannister on the back of the wheelchair. Resident #28 was receiving oxygen at 2 LPM (rate of oxygen flow) via the nasal cannula tubing connected to the oxygen cannister on the wheelchair. The resident's oxygen concentrator was next to the head of the bed. The oxygen tubing connected to the concentrator was on the floor between the concentrator and the nightstand. The tubing was not bagged. <BR/>3. <BR/>Review of Resident #40's Face Sheet, dated 01/16/25, reflected Resident #40 was a [AGE] year-old female admitted on [DATE]. Resident #40 had a diagnosis of chronic obstructive pulmonary disease.<BR/>Review of Resident #40's Physician Orders, dated 09/09/24, reflected O2 at 2 liters per minute via nasal cannula PRN. May titrate to 2-4 LPM to keep 02 sats &gt;92% as needed for Shortness of Breath, Wheezing, 02 sat less than 90%. Obtain vital signs BID two times a day document vs q shift. <BR/>Review of Resident #40's Quarterly MDS Assessment, dated 11/01/2024, reflected resident had a moderate impairment in cognition with a BIMS score of 08. Section I reflected resident was treated for chronic obstructive pulmonary disease.<BR/>Review of Resident #40's Comprehensive Care Plan, dated 11/02/2024, reflected resident has oxygen therapy. O2 at 2 liters per minute via nasal cannula PRN. May titrate to 3-4 LPM to keep O2 sats &gt;90%. One intervention was monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate.<BR/>An observation on 01/14/25 at 10:04 AM revealed an oxygen concentrator in Resident #40's room. The concentrator was next to a cabinet with drawers. Oxygen tubing was connected to the concentrator and placed in the top drawer of the cabinet. The oxygen tubing was not bagged. <BR/>4. <BR/>Review of Resident #38's Face Sheet, dated 01/16/25, reflected Resident #38 was a [AGE] year-old male. Resident #38 admitted on [DATE] with asthma (chronic lung disease causing the airway to narrow and can make breathing difficult) and shortness of breath.<BR/>Review of Resident #38's Quarterly MDS Assessment, dated 11/25/24, reflected Resident #38 had intact cognition with a BIMS score of 15. Section I reflected Resident #38 was treated for asthma and shortness of breath. <BR/>Review of Resident #38's Comprehensive Care Plan, dated 10/23/24, reflected the resident has unspecified asthma. One intervention was to give nebulizer treatments as ordered. <BR/>An observation on 01/14/25 at 8:45 am revealed a nebulizer on Resident #38's nightstand. The nebulizer mask was connected to the nebulizer and the mask was placed on top of the nebulizer. It was not stored in a bag. <BR/>In an interview on 01/14/25 at 09:55 AM, LVN D stated the oxygen tubing should have been bagged to prevent contamination. She removed the tubing and stated she was going to get new oxygen tubing. <BR/>In an interview on 1/14/25 at 09:58 AM, CNA F stated the oxygen tubing should have been stored in a bag to keep it clean. <BR/>In an interview on 01/14/25 at 10:35 AM, the DON stated the oxygen tubing and nebulizer masks should have been stored in bags when not used to prevent contamination. The DON stated he was going to follow up with the nurses to be sure those were corrected. <BR/>During an interview on 01/14/25 at 10:42 AM, LVN E stated all respiratory items should have been bagged when not in use to prevent contamination and infection. <BR/>In an interview on 01/16/24 at 10:45 AM, the ADON stated respiratory items were to be stored in bags when residents were not using them. She stated she tells the nurses if oxygen tubing is found on the floor, throw it away and get new tubing. She said her expectation is for all oxygen tubing and nebulizer masks to be stored in bags at all times when not in use by a resident. She stated this was an important measure to prevent contamination of these items. <BR/>After record review of the facility's policy for Oxygen Administration on 01/16/2025 at 10:44 AM, a policy for bagging the nasal cannula and breathing mask was verbally requested on 01/16/2025 at 10:54 AM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #36, Resident #68, and Resident #79) of fifteen residents reviewed for Care Plans. <BR/>1. <BR/>The facility failed to ensure Resident #36's care plan for catheter, dated 12/17/2024, had appropriate interventions.<BR/>2. <BR/>The facility failed to ensure Resident #68's care plan for catheter, dated 10/02/2024, had appropriate interventions.<BR/>3. <BR/>The facility failed to ensure Resident #79's care plan for catheter, dated 01/09/2025, had appropriate interventions.<BR/>These failures could place the residents at risk of not receiving the necessary care and services needed.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with infection to surgical site to sacrum.<BR/>Record review of Resident #36's Quarterly MDS Assessment, dated 12/03/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had skin problem to her surgical wound and had an indwelling catheter (device to drain the urine from the urinary bladder to a collection bag).<BR/>Record review of Resident #36's Comprehensive Care Plan, dated 12/17/2024, reflected Resident #36's care plan for indwelling catheter related to skin breakdown on sacrum had only one intervention listed. The only intervention indicated was to check for kinks each shift.<BR/>Record review of Resident #36's Physician Order, dated 09/05/2024, reflected Foley Catheter Care Q Shift and PRN.<BR/>In an interview with Resident #36 on 01/14/2025 at 1:36 PM, Resident #36 stated she had a catheter but was removed the day before because she was having abdominal pain. She said she had the catheter because of her wound in her bottom.<BR/>In an interview with the Wound Care Nurse on 01/15/2025 at 8:51 AM, the Wound Care Nurse stated Resident #36 had a wound to her sacrum that was present during her admission. She said she had a catheter to facilitate healing of the wound.<BR/>2. <BR/>Record review of Resident #68's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #68 was diagnosed with urinary retention (the urinary bladder does not empty completely).<BR/>Record review of Resident #68's Quarterly MDS Assessment, dated 01/03/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated the resident had an indwelling catheter.<BR/>Record review of Resident #68's Comprehensive Care Plan, dated 10/02/2024, reflected Resident #68's care plan for indwelling catheter related to urinary retentions had only one intervention listed. The only intervention indicated was to monitor, record, and report signs and symptoms of urinary tract infection.<BR/>Record review of Resident #68's Physician Order, dated 10/02/2024, reflected Foley Catheter Care Q Shift and PRN.<BR/>Observation and interview with Resident #68 on 01/14/2025 at 11:05 AM revealed the resident was sitting in his recliner, awake. It was observed that he had a catheter hanging on his walker. He said he had the catheter because he had an issue with his bladder. <BR/>Observation and interview with the MDS Coordinator on 01/15/2025 at 9:34 AM, the MDS Coordinator stated care plans were done so the staff would know the care needed by the residents. she said if a resident had a catheter, there should be a care plan for catheter. She said the care plan was comprised of problem areas, the goals, and the interventions. She said the interventions should address the underlying problem of the residents. She opened Resident #36's profile and saw the resident had orders for her catheter and was triggered in the MDS for indwelling catheter. When she opened the resident's care plan, she saw the indwelling catheter was listed as one of the problem list. She also saw that there was only one intervention listed. She said there should be more interventions listed like check for trauma, monitor for signs and symptoms of urinary tract infection related to the catheter, check for signs and symptoms of discomfort, monitor the color of the urine, and cover with privacy bag. After looking at Resident #36's care plan, she opened Resident #68's care plan and saw the same thing. She said she would update the care plans for both residents and would input the interventions for indwelling catheter.<BR/>In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated every resident needed a thorough care plan to ensure the residents received the care needed. The DON said the care plan should be in place so the staff providing care would be on the same page and without the care plan, there could be confusion with the care of the residents. The DON said the care plan should reflect the resident's problem lists, the goals, and the interventions. He said a care plan would not be a care plan without appropriate interventions. He said, with indwelling catheters, staff should monitor for urinary tract infection, discomfort, distension of the bladder, cloudiness of the urine, and if there were blood in the urine. He said with only one intervention could be considered an incomplete care plan. He said the expectation was every care plan would be resident-centered and complete. He said he would coordinate with the MDS Coordinator to audit to the care plans of the residents.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated all the care plans of the residents should have all the interventions needed by the residents. She said without the care plan, the staff would not know and understand what kind of care to provide. The Administrator concluded that the expectation was for the staff to ensure that the residents' care plan were complete and individualized. She said he would coordinate with the DON to make sure all the residents were care planned.<BR/>3. <BR/>Record review of Resident #79's Face Sheet, dated 01/16/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #79 was diagnosed with urinary retention.<BR/>Record review of Resident #79's Comprehensive MDS Assessment, dated 01/02/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter.<BR/>Record review of Resident #79's Comprehensive Care Plan, dated 01/09/2025, reflected Resident #79's care plan for indwelling catheter related to history of malignant neoplasm of the prostate had only one intervention listed. The only intervention indicated was to monitor for signs and symptoms of discomfort on urination and frequency.<BR/>Record review of Resident #79's Physician Order, dated 12/29/2024, reflected Foley Catheter Care Q Shift and PRN.<BR/>Observation and interview with Resident #79 on 01/16/2025 at 9:02 AM revealed the resident was in the dining area finishing his breakfast. It was observed that the resident had a catheter leg bag secured to the right leg. When asked how long he had the catheter, the resident did not reply.<BR/>In an interview with LVN D on 01/16/2025 at 9:12 AM, LVN D stated Resident #79 had a catheter because he had an issue with his prostate. She said before he goes out of his room, they would replace his catheter with leg strap because the resident had the tendency to drag his catheter.<BR/>In an interview with the MDS Nurse on 01/16/2025 at 9:43 AM revealed the MDS Coordinator was advised that Resident #79 also only had one intervention for his indwelling catheter. She said she would check on it and update it accordingly.<BR/>Record review of facility's policy, Care Plans, Comprehensive Person-Centered reviewed Jan. 2023 revealed Policy Statement: A comprehensive, person-centered care plan . is developed and implemented for each resident . 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful . 11. Care plan interventions are chosen only after careful data gathering . a. When possible, interventions address the underlying source(s) of the problem area(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each residents environment remained as free from accident hazards as possible for 1 (Resident #30) of 9 residents reviewed for environmental hazards. <BR/>The facility failed to ensure Resident #30 did not have pointed scissors in his room on 01/14/2024.<BR/>This failure could place the resident and other residents who came into the room at risk for injury. <BR/>Review of Resident #30's Face Sheet, dated 01/16/25, reflected that resident was an [AGE] year-old male initially admitted on [DATE]. Resident #30 had a diagnosis of dysphagia (difficulty swallowing) following other cerebrovascular disease (condition that impacts blood vessels in the brain). <BR/>Review of Resident #30's Quarterly MDS (tool to assess health and functional capabilities) Assessment, dated 01/13/2025, reflected that Resident #30 had impaired cognition with a BIMS score of 11. Section I did not reflect dementia or a mood disorder. Section I reflected Resident #30 had cognitive communication deficit and other abnormality of gait and mobility. <BR/>Review of Resident #30's Comprehensive Care Plan, dated 12/06/2024, reflected Resident #30 had impaired thought processes. One intervention was COMMUNICATION: Use his preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions. Turn off TV, radio, close door etc. He understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated.<BR/>In an interview and observation on 01/14/25 at 09:40 AM, Resident #30 was lying in bed. Resident #30's wheelchair was parked close to the bed. Prior to leaving the room, surveyor bumped into the wheelchair and a pair of large scissors fell to the floor. The ends were not rounded. Resident #30's wheelchair had a piece of foam wrapped around the arms of the wheelchair. Resident #30 stated he kept the pair of scissors in the opening between the foam and arm of the wheelchair. Resident #30 stated at times he used the scissors to cut the sides of a soiled brief when he was in the restroom. The DON was in the hall at that time and notified of scissors in Resident #30's room. He stated he would take care of it.<BR/>In an interview on 01/14/25 at 02:20 PM, RN G stated Resident #30 used the scissors to cut extra paper (old activity schedules) up for scratch paper. RN G pointed at a stack of letter size sheets that had been cut up into fourths for scratch paper. She stated the resident kept the scissors inside the foam piece that is wrapped around the arm of his wheelchair. While in the room, the resident agreed for RN G to assess his skin. RN G lowered his pants and assessed the skin around Resident #30's brief to ensure he had not caused any injury. Observation revealed there was no redness, scratches, or any injury on Resident #30's skin. RN G stated she had never heard Resident #30 used scissors to cut off his brief. RN G agreed an accident could result in the resident harming himself when using the scissors. <BR/>In an interview on 01/14/25 at 02:28 PM, LVN E stated she had never heard Resident #30 used his scissors to cut the briefs on the sides to remove them. She stated she had thought it was ok for Resident #30 to use the scissors for activities. LVN E stated the scissors had been removed from the resident's room and given to her and she understood an accident could occur involving the resident or another resident who might have found the scissors. <BR/>In an interview on 01/14/25 at 02:36 PM, the Activities Director stated she provided Resident #30 with a daily chronicle. She stated she had never seen him cutting the papers. The Activities Director stated she allowed residents to use scissors when she was observing them. She stated she made sure residents only used scissors with rounded edges. <BR/>In an interview on 01/16/25 at 09:16 AM, the DON stated the facility did not have a policy about residents or family members bringing in personal items like scissors. The DON stated it posed a danger and was not safe for the resident to have the scissors in his room. He stated if staff sees something like that, it should be removed and documented. He stated it was important to educate family about the dangers and to care plan it. He said it was important for the resident to have rights, but there are other residents in the environment too. He stated it was important for staff to be diligent about safety awareness and any danger to residents and he will in-service them about it. <BR/>The facility did not provide a policy about environmental hazards. In an interview on 01/16/25 at 09:16 AM, the DON stated there was not a facility policy regarding a resident or family member bringing sharp objects like scissors into a resident's room.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. <BR/>1. <BR/>The facility failed to ensure staff were wearing the appropriate hair and beard coverings.<BR/>2. <BR/>The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the date the product was received from the vendor.<BR/>3. <BR/>The facility failed to ensure that the sugar and flour bins were cleaned.<BR/>4. <BR/>The facility failed to ensure the ice scoop in the facility kitchen was cleaned.<BR/>5. <BR/>The facility failed to ensure the food in the dry storage area was labeled with the product was received from the vendor.<BR/>6. <BR/>The facility failed to ensure the food stored in the freezer was properly sealed from air-borne contaminants.<BR/>7. <BR/>The facility failed to ensure foods being transported to resident rooms and the memory care unit were properly concealed from air-borne contaminants. <BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings included: <BR/>Observations on 01/14/25 from 9:16 AM to 9:25 AM in the facility's only kitchen reflected: <BR/>The ice scoop, hanging in a blue plastic holder, had a brownish substance and white stains along the bottom of the holder. <BR/>One large tray containing three 2- pound packages of bologna and one 2-pound package of ham, located in the refrigerator, did not have the date the product was received from the vendor. <BR/>One large plastic container of raw, chopped up celery, located in the refrigerator, did not have a date the product was received from the vendor.<BR/>One large bag or frozen okra, located in the freezer, had a large tear in the bag, exposing the food to airborne contaminants. <BR/>One bag of frozen waffles, located in the freezer, had a large tear in the bag, exposing the food to airborne contaminants.<BR/>One small bag of an unknown frozen food substance, located in the freezer, was not labeled and did not have the date the product was received from the vendor.<BR/>Two large boxes of cookie dough, located in the freezer, had a large tear in the bag, exposing the food to airborne contaminants.<BR/>Two large white storage bins, containing sugar and flour, had dark dirt-like stains on the outside of the containers and dark dirt-like stains within the opening and inside walls of the containers.<BR/>Two packages of hamburger buns, containing 12 buns each, located in the dry storage area was not labeled with the date the product was received from the vendor.<BR/>Two packages of large tortillas, located in the dry storage area were not labeled with the date the product was received from the vendor.<BR/>In an observation and interview on 01/16/25 at 10:05 AM, the Dietary Manager was observed preparing food in the kitchen and he was not wearing a beard guard. The DM was observed to have a beard approximately &frac12; inch in length. The DM stated a beard covering should be worn to prevent hair from falling into the food. <BR/>In an observation on 01/15/25 at 11:45 AM, [NAME] S was observed in the kitchen area placing food trays on the serving steam table, and had no head covering on his head. His hair was approximately 1/2 inch in length. He was asked where his hair covering was, and he proceeded to grab one and placed it on her head, before going back to plating the food.<BR/>A dining observation on 01/15/24 at 12:39 PM revealed Kitchen Aide B transporting the food cart to the Memory Care Unit. There were two trays sitting on top of the cart and one of them included a bowl of uncovered desert. The other tray included a bowl of uncovered desert and a bowl of uncovered green beans. Two residents were observed walking up to, and then standing over the cart and looking at the trays, before staff redirected them.<BR/>An observation and interview on 01/15/25 at 01:25 PM revealed three food test trays, that were being observed and tasted by the Surveyor, being removed from the food transfer cart, and all three-desert bowls were uncovered. The DM stated the bowls should have been covered during the transfer from the kitchen to the residents to avoid any food contamination. The DM stated he completed in-services on properly transporting food, food storage, and kitchen sanitation.<BR/> In an interview on 01/15/25 at 01:35 PM, the DM stated that he had been the DM for nearly 3 months. He stated he had cleaned the sugar and flour bins twice since being at the facility. He stated that the ice scoop holder should have been cleaned after every shift at night. He was shown pictures of the concerns observed in the kitchen area. He stated that he thought it was being cleaned but it was not. He stated he needed to check behind them again. He stated the risk to the resident of not addressing the issues mentioned was residents could get food poison. He was made aware that [NAME] S was observed placing food on the steam table and he was not wearing a head covering. The DM stated [NAME] S should have been wearing a head covering to prevent food contamination. <BR/>In an interview on 01/15/25 at 02:05 PM, the Administrator was shown pictures of the concerns observed in the facility's only kitchen. She stated she would follow up with the DM to address the concerns. She stated the concerns observed could result in residents experiencing food contamination. The Administrator was advised of the concern of food being transported to residents eating in their rooms and in the memory care unit without a cover, and she stated she would follow up with the DM to address the concerns. She stated the concerns observed could result in residents experiencing food contamination.<BR/>An interview on 01/16/25 at 01:05 PM, Kitchen Aide B stated that she always transported the deserts desserts and other items that were in bowls, uncovered. She stated she never knew that it needed to be covered. She stated moving forward she would ensure all foods were covered properly when transporting food to residents. She stated the risk of not covering the food when transporting it, could result in germs being spread.<BR/>Record Review of the facility's policy on Food Storage and Supplies dated October 2022, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). All items must be dated with the date that the food was delivered.<BR/>The food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. <BR/>Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under &sect; 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #29, Resident #73, and Resident #82) of eighteen residents reviewed for reasonable accommodation of needs. <BR/>The facility failed to ensure the call light system in Resident #29, Resident #73, and Resident #82's rooms were in a position that was accessible to the resident on 01/14/2025.<BR/>This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.<BR/>Findings included: <BR/>Resident #29 <BR/>Review of Resident #29's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female admitted on [DATE]. Resident #29 was diagnosed with muscle weakness and gait abnormalities.<BR/>Review of Resident #29's Quarterly MDS Assessment, dated 12/24/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that Resident #29 was dependent to staff for toileting hygiene, shower, dressing, and personal hygiene.<BR/>Review of Resident #29's Comprehensive Care Plan, dated 11/18/2024, reflected the resident had an ADL self-care performance deficit and interventions included provide extensive assist for dressing, bed mobility, personal hygiene, and toilet use.<BR/>Observation on 01/14/2025 at 9:40 AM revealed Resident #29 was in her bed, with her eyes closed. It was observed that the resident's call light was on the floor at the foot of the bed.<BR/>Observation and interview on 01/14/2025 at 2:03 PM revealed resident #29 was in her bed, awake. When asked about what she used when she needed to call the staff, the resident did not answer.<BR/>Resident #73<BR/>Review of Resident #73's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male admitted on [DATE]. Resident #73 was diagnosed with muscle weakness and lack of coordination.<BR/>Review of Resident #73's Quarterly MDS Assessment, dated 10/28/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Quarterly MDS Assessment indicated that Resident #73 required maximal assistance for toileting hygiene, dressing, bed mobility, and transfer.<BR/>Review of Resident #73's Comprehensive Care Plan, dated 01/14/2025, reflected the resident had an ADL self-care performance deficit and interventions included provide maximal assistance for toileting hygiene, dressing, bed mobility, and transfer.<BR/>Observation and interview with Resident #73 on 01/14/2025 at 9:45 AM revealed the resident in his bed, awake. It was observed the resident's call light was on the floor and stuck between the bed and the wall. When asked about his call light, the resident just shrugged his shoulders.<BR/>Observation and interview with CNA A on 01/14/2025 at 10:15 AM, CNA A stated call lights were important for the residents because that was how they called the staff if they needed something or if they needed assistance. She said without the call lights, the residents might be upset or might fall if they tried to do things by themselves. She said the call lights were for independent and dependent residents. She went inside Resident's #29's room and pulled the call light from the floor and put it beside the resident. CNA A then went inside Resident # 73's room and saw the call light was stuck between the wall and the bed. She pulled the call light and put it beside the resident. She said she did not notice the call lights were not with Resident #29 and Resident #73 during her morning round that.<BR/>Resident #82 <BR/>Review of Resident #82's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male admitted on [DATE]. Resident #82 was diagnosed with muscle weakness and lack of coordination.<BR/>Review of Resident #82's Quarterly MDS Assessment, dated 11/27/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated that Resident #82 required maximal assistance for toileting hygiene, shower, dressing, and personal hygiene. <BR/>Review of Resident #82's Comprehensive Care Plan, dated 01/14/2025, reflected the resident had an ADL self-care performance deficit and interventions included provide maximal assistance for toileting hygiene, shower, dressing, and personal hygiene.<BR/>Observation and interview with Resident #82 on 01/14/2025 at 9:34 AM revealed the resident was in his wheelchair, awake. It was observed that the resident's call light was hanging by the wall and coiled around where the call light was connected. He said he was transferred to the room the night before because his roommate tested positive for COVID-19. He said the staff did not place the call light near him. He said he could not reach the call light that was on the wall. He said he needed to go out of his room so he could call a staff because he needed something.<BR/>Observation and interview with CNA B on 01/14/2025 at 10:20 AM, CNA B stated call lights should be with the residents at all times so they could call the staff when they needed something. She said the residents might fall trying to get the call light or trying to do some activities that needed assistance. she went inside Resident #82's room and saw the call light on the wall. She pulled the call light on the wall and placed it where the resident could reach it. She said she did not notice the call light was not with the resident during her morning rounds.<BR/>In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated call lights were inside the residents' rooms for a reason. He said the residents used the call lights to call for assistance, a glass of water, pain medication, or because they needed to be changed. The DON said without the call lights, the residents would not be able to tell the staff what they needed and eventually their needs would not be met. The DON added when the residents could not reach their call lights, unfavorable incidents, like falls, could happen. The DON said all the staff were responsible for the call lights. The DON said the expectation was for the staff to scan the resident's room when they do their rounds and ensure the call lights were within reach of the residents before they leave the room. The DON said he would educate the staff about the importance of call lights for the residents and would include the issue on their IDT meeting. <BR/>In an interview with LVN C on 01/15/2025 at 11:20 AM, LVN C stated call light should be with the residents at all times, whether independent or dependent. He said he was also responsible in checking if the call lights were with Resident #29, #73, and #82 because he was the nurse in-charged for their care. He said without the call lights, their needs would not be met. He said he would do his round and check if the call lights were with the residents.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated call lights should be within the reach of the residents at all times. She said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said the residents also use the call lights if they needed to be changed or they needed a pain medication. the Administrator said the residents might fall trying to get up and get what they needed. She said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would collaborate with the DON about the issue regarding call lights.<BR/>Record review of facility's policy Resident Call System reviewed 03/28/2023 revealed Policy: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation . Policy Interpretation and Implementation . 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #36, Resident #68, and Resident #79) of fifteen residents reviewed for Care Plans. <BR/>1. <BR/>The facility failed to ensure Resident #36's care plan for catheter, dated 12/17/2024, had appropriate interventions.<BR/>2. <BR/>The facility failed to ensure Resident #68's care plan for catheter, dated 10/02/2024, had appropriate interventions.<BR/>3. <BR/>The facility failed to ensure Resident #79's care plan for catheter, dated 01/09/2025, had appropriate interventions.<BR/>These failures could place the residents at risk of not receiving the necessary care and services needed.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with infection to surgical site to sacrum.<BR/>Record review of Resident #36's Quarterly MDS Assessment, dated 12/03/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had skin problem to her surgical wound and had an indwelling catheter (device to drain the urine from the urinary bladder to a collection bag).<BR/>Record review of Resident #36's Comprehensive Care Plan, dated 12/17/2024, reflected Resident #36's care plan for indwelling catheter related to skin breakdown on sacrum had only one intervention listed. The only intervention indicated was to check for kinks each shift.<BR/>Record review of Resident #36's Physician Order, dated 09/05/2024, reflected Foley Catheter Care Q Shift and PRN.<BR/>In an interview with Resident #36 on 01/14/2025 at 1:36 PM, Resident #36 stated she had a catheter but was removed the day before because she was having abdominal pain. She said she had the catheter because of her wound in her bottom.<BR/>In an interview with the Wound Care Nurse on 01/15/2025 at 8:51 AM, the Wound Care Nurse stated Resident #36 had a wound to her sacrum that was present during her admission. She said she had a catheter to facilitate healing of the wound.<BR/>2. <BR/>Record review of Resident #68's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #68 was diagnosed with urinary retention (the urinary bladder does not empty completely).<BR/>Record review of Resident #68's Quarterly MDS Assessment, dated 01/03/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated the resident had an indwelling catheter.<BR/>Record review of Resident #68's Comprehensive Care Plan, dated 10/02/2024, reflected Resident #68's care plan for indwelling catheter related to urinary retentions had only one intervention listed. The only intervention indicated was to monitor, record, and report signs and symptoms of urinary tract infection.<BR/>Record review of Resident #68's Physician Order, dated 10/02/2024, reflected Foley Catheter Care Q Shift and PRN.<BR/>Observation and interview with Resident #68 on 01/14/2025 at 11:05 AM revealed the resident was sitting in his recliner, awake. It was observed that he had a catheter hanging on his walker. He said he had the catheter because he had an issue with his bladder. <BR/>Observation and interview with the MDS Coordinator on 01/15/2025 at 9:34 AM, the MDS Coordinator stated care plans were done so the staff would know the care needed by the residents. she said if a resident had a catheter, there should be a care plan for catheter. She said the care plan was comprised of problem areas, the goals, and the interventions. She said the interventions should address the underlying problem of the residents. She opened Resident #36's profile and saw the resident had orders for her catheter and was triggered in the MDS for indwelling catheter. When she opened the resident's care plan, she saw the indwelling catheter was listed as one of the problem list. She also saw that there was only one intervention listed. She said there should be more interventions listed like check for trauma, monitor for signs and symptoms of urinary tract infection related to the catheter, check for signs and symptoms of discomfort, monitor the color of the urine, and cover with privacy bag. After looking at Resident #36's care plan, she opened Resident #68's care plan and saw the same thing. She said she would update the care plans for both residents and would input the interventions for indwelling catheter.<BR/>In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated every resident needed a thorough care plan to ensure the residents received the care needed. The DON said the care plan should be in place so the staff providing care would be on the same page and without the care plan, there could be confusion with the care of the residents. The DON said the care plan should reflect the resident's problem lists, the goals, and the interventions. He said a care plan would not be a care plan without appropriate interventions. He said, with indwelling catheters, staff should monitor for urinary tract infection, discomfort, distension of the bladder, cloudiness of the urine, and if there were blood in the urine. He said with only one intervention could be considered an incomplete care plan. He said the expectation was every care plan would be resident-centered and complete. He said he would coordinate with the MDS Coordinator to audit to the care plans of the residents.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated all the care plans of the residents should have all the interventions needed by the residents. She said without the care plan, the staff would not know and understand what kind of care to provide. The Administrator concluded that the expectation was for the staff to ensure that the residents' care plan were complete and individualized. She said he would coordinate with the DON to make sure all the residents were care planned.<BR/>3. <BR/>Record review of Resident #79's Face Sheet, dated 01/16/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #79 was diagnosed with urinary retention.<BR/>Record review of Resident #79's Comprehensive MDS Assessment, dated 01/02/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter.<BR/>Record review of Resident #79's Comprehensive Care Plan, dated 01/09/2025, reflected Resident #79's care plan for indwelling catheter related to history of malignant neoplasm of the prostate had only one intervention listed. The only intervention indicated was to monitor for signs and symptoms of discomfort on urination and frequency.<BR/>Record review of Resident #79's Physician Order, dated 12/29/2024, reflected Foley Catheter Care Q Shift and PRN.<BR/>Observation and interview with Resident #79 on 01/16/2025 at 9:02 AM revealed the resident was in the dining area finishing his breakfast. It was observed that the resident had a catheter leg bag secured to the right leg. When asked how long he had the catheter, the resident did not reply.<BR/>In an interview with LVN D on 01/16/2025 at 9:12 AM, LVN D stated Resident #79 had a catheter because he had an issue with his prostate. She said before he goes out of his room, they would replace his catheter with leg strap because the resident had the tendency to drag his catheter.<BR/>In an interview with the MDS Nurse on 01/16/2025 at 9:43 AM revealed the MDS Coordinator was advised that Resident #79 also only had one intervention for his indwelling catheter. She said she would check on it and update it accordingly.<BR/>Record review of facility's policy, Care Plans, Comprehensive Person-Centered reviewed Jan. 2023 revealed Policy Statement: A comprehensive, person-centered care plan . is developed and implemented for each resident . 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful . 11. Care plan interventions are chosen only after careful data gathering . a. When possible, interventions address the underlying source(s) of the problem area(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #16, #28, #40, and #38) of 14 residents reviewed for Respiratory Care.<BR/>1. <BR/>The facility failed to ensure Resident #16's breathing mask for her nebulizer (machine that turns liquid medication into a mist breathed directly into the lungs) was properly stored when not in use on 01/14/2025. <BR/>2. <BR/>The facility failed to ensure that Resident #28's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 01/14/2025.<BR/>3. <BR/>The facility failed to ensure that Resident #40's nasal cannula was properly stored when not in use on 01/14/2025.<BR/>4. <BR/>The facility failed to ensure that Resident #38's nebulizer mask (medication is inhaled through) was properly stored when not in use on 01/14/2025. <BR/>These failures could place residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>1. <BR/>Record review of Resident #16's Face Sheet, dated 01/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 was diagnosed with anemia (low blood cells).<BR/>Record review of Resident #16's Comprehensive MDS Assessment, dated 11/24/2024, <BR/>reflected the resident had a score of 99 on her BIMS summary score suggesting that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident had anemia.<BR/>Record review of Resident #16's Comprehensive Care Plan, dated 11/04/2024, reflected the resident tested positive for COVID on 01/25/2022 and one of the interventions was to observe for signs and symptoms of respiratory issues.<BR/>Record review of Resident #16's Physician Orders, dated 11/02/2024, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for SOB ONE VIAL Q 4-7 HOURS.<BR/>An observation on 01/14/2025 at 9:20 AM revealed Resident #16 was in her bed, awake. A nebulizer machine was observed beside the room's sink. Beside the nebulizer machine was a breathing mask that was not bagged. The part of the breathing mask that would touch the face when using was touching a bottle of sanitizer. Resident #16 did not respond when asked how long she had been using the breathing mask.<BR/>In an interview with LVN C on 01/14/2025 at 11:33 AM, LVN C stated he was not sure for whom the breathing mask was. He opened the profiles of both residents occupying the room. He said the breathing mask was for Resident #16. He said the order was to administer as needed. He went inside the room and saw the unbagged breathing mask beside the room's sink. He said he did not notice during his rounds that the breathing mask was not inside a bag. He said it should be bagged to prevent cross contamination. He said the issue was not if the resident was using it or not, the breathing mask should be bagged. LVN C went to the storage room and took a new breathing mask and a plastic bag. <BR/>In an interview with the DON on 01/15/2024 at 11:03 AM, the DON stated the breathing mask was supposed to be in a bag when the resident was not using it to prevent cross contamination and worsening of respiratory issues the resident might already had. He said the expectation was for the staff to be mindful and make sure the breathing was bagged when the resident was not using it. He said it did not matter if the order was daily or as needed, the breathing mask must be in a bag or do not leave a breathing mask inside the room and just get one if needed by the resident. He said he would conduct an in-service about respiratory care.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated everything the residents were using should be kept clean to prevent infection. She said she would coordinate with the DON to educate and re-educate the nursing staff to bag the breathing mask if not in use. She said the DON will also in-service the staff about the respiratory care issue.<BR/>2. <BR/>Review of Resident #28's Face Sheet, dated 01/16/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #28 had a diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Review of Resident #28's Quarterly MDS Assessment, dated 07/05/2024, reflected resident had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility.<BR/>Review of Resident #28's Comprehensive Care Plan, dated 10/22/2024, reflected resident has oxygen therapy r/t ineffective gas exchange. Interventions included For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus. Give medications as ordered by physician. Monitor/document side effects and effectiveness.<BR/>Review of Resident #28's Physician Order, dated 04/24/2024, reflected O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 LPM to keep O2 sat &gt;90% every shift. <BR/>An observation on 01/14/2025 at 09:52 AM revealed Resident #28 lying in bed with her eyes closed. Resident #28's wheelchair was next to the bed with a portable oxygen cannister on the back of the wheelchair. Resident #28 was receiving oxygen at 2 LPM (rate of oxygen flow) via the nasal cannula tubing connected to the oxygen cannister on the wheelchair. The resident's oxygen concentrator was next to the head of the bed. The oxygen tubing connected to the concentrator was on the floor between the concentrator and the nightstand. The tubing was not bagged. <BR/>3. <BR/>Review of Resident #40's Face Sheet, dated 01/16/25, reflected Resident #40 was a [AGE] year-old female admitted on [DATE]. Resident #40 had a diagnosis of chronic obstructive pulmonary disease.<BR/>Review of Resident #40's Physician Orders, dated 09/09/24, reflected O2 at 2 liters per minute via nasal cannula PRN. May titrate to 2-4 LPM to keep 02 sats &gt;92% as needed for Shortness of Breath, Wheezing, 02 sat less than 90%. Obtain vital signs BID two times a day document vs q shift. <BR/>Review of Resident #40's Quarterly MDS Assessment, dated 11/01/2024, reflected resident had a moderate impairment in cognition with a BIMS score of 08. Section I reflected resident was treated for chronic obstructive pulmonary disease.<BR/>Review of Resident #40's Comprehensive Care Plan, dated 11/02/2024, reflected resident has oxygen therapy. O2 at 2 liters per minute via nasal cannula PRN. May titrate to 3-4 LPM to keep O2 sats &gt;90%. One intervention was monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate.<BR/>An observation on 01/14/25 at 10:04 AM revealed an oxygen concentrator in Resident #40's room. The concentrator was next to a cabinet with drawers. Oxygen tubing was connected to the concentrator and placed in the top drawer of the cabinet. The oxygen tubing was not bagged. <BR/>4. <BR/>Review of Resident #38's Face Sheet, dated 01/16/25, reflected Resident #38 was a [AGE] year-old male. Resident #38 admitted on [DATE] with asthma (chronic lung disease causing the airway to narrow and can make breathing difficult) and shortness of breath.<BR/>Review of Resident #38's Quarterly MDS Assessment, dated 11/25/24, reflected Resident #38 had intact cognition with a BIMS score of 15. Section I reflected Resident #38 was treated for asthma and shortness of breath. <BR/>Review of Resident #38's Comprehensive Care Plan, dated 10/23/24, reflected the resident has unspecified asthma. One intervention was to give nebulizer treatments as ordered. <BR/>An observation on 01/14/25 at 8:45 am revealed a nebulizer on Resident #38's nightstand. The nebulizer mask was connected to the nebulizer and the mask was placed on top of the nebulizer. It was not stored in a bag. <BR/>In an interview on 01/14/25 at 09:55 AM, LVN D stated the oxygen tubing should have been bagged to prevent contamination. She removed the tubing and stated she was going to get new oxygen tubing. <BR/>In an interview on 1/14/25 at 09:58 AM, CNA F stated the oxygen tubing should have been stored in a bag to keep it clean. <BR/>In an interview on 01/14/25 at 10:35 AM, the DON stated the oxygen tubing and nebulizer masks should have been stored in bags when not used to prevent contamination. The DON stated he was going to follow up with the nurses to be sure those were corrected. <BR/>During an interview on 01/14/25 at 10:42 AM, LVN E stated all respiratory items should have been bagged when not in use to prevent contamination and infection. <BR/>In an interview on 01/16/24 at 10:45 AM, the ADON stated respiratory items were to be stored in bags when residents were not using them. She stated she tells the nurses if oxygen tubing is found on the floor, throw it away and get new tubing. She said her expectation is for all oxygen tubing and nebulizer masks to be stored in bags at all times when not in use by a resident. She stated this was an important measure to prevent contamination of these items. <BR/>After record review of the facility's policy for Oxygen Administration on 01/16/2025 at 10:44 AM, a policy for bagging the nasal cannula and breathing mask was verbally requested on 01/16/2025 at 10:54 AM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #36 and Resident #39) of eight residents reviewed for Infection Control. <BR/>1. <BR/>The facility failed to ensure CNA A and CNA B changed their gloves and performed hand hygiene while providing incontinent care to Resident #36 on 01/14/2025.<BR/>2. <BR/>The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #39 on 01/14/2025.<BR/>These failures could place residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with personal history of urinary tract infections and cerebrovascular disease (reduction of blood flow to the brain).<BR/>Record review of Resident #36's Quarterly MDS Assessment, dated 12/03/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was incontinent for bowel and bladder.<BR/>Record review of Resident #36's Comprehensive Care Plan, dated 12/17/2024, reflected the resident had actual impairment to ski integrity related to wound to sacrum and one of the interventions was to provide incontinent care as needed.<BR/>Observation on 01/14/2025 at 9:54 AM revealed CNA A and CNA B were about to do incontinent care to Resident #36. Both CNAs washed their hands before putting on their gloves. CNA A went the resident's right side, while CNA B went to the resident's left side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA A placed the wipes and the brief beside the resident's right leg. After placing the wipes and the brief beside the resident's right leg, CNA A put a plastic bag on the trash can. After putting the plastic bag on the trash can, CNA A proceeded with incontinent care without changing her gloves. CNA A cleaned the perineal (area between the legs) area using the front to back technique. After cleaning the perineal area, both CNAs assisted the resident to roll to her left side. CNA A cleaned the resident's bottom. After cleaning the resident's bottom, CNA A took the brief that was placed beside the resident's right leg and placed it under Resident #36. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. The resident was rolled back, both CNA A fixed the brief. CNA B helped in fixing the brief. She did not change her gloves when she touched the soiled brief at the beginning of incontinent care.<BR/>In an interview with CNA A on 01/14/2025 at 10:15 AM, CNA A stated she was not aware she did not change her gloves after placing a plastic bag on the trash can. Said she should have changed her gloves and sanitized her hands after touching the trash can because the trash was not only presumed dirty but was dirty. Said she also should have changed her gloves and sanitized her hands after cleaning the resident's bottom and before touching the new brief because whatever germs that she touched from the soiled bottom and soiled brief would eventually transfer to the new brief. Said her actions could cause transfer of germs and infection. She said she needed to be mindful with how she did incontinent care.<BR/>In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she assisted CNA A with incontinent care for Resident #36. She said she unfastened the soiled brief and tucked it between the thighs of the resident. She said she also helped in fixing the brief when CNA A was done cleaning the resident. She said because she touched the soiled brief, she should have changed her gloves before touching the new brief because her gloves were already considered soiled. She said the resident could have urinary tract infection because the new brief would be considered dirty.<BR/>2. <BR/>Record review of Resident #39's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 was diagnosed with cerebral infarction (stroke).<BR/>Record review of Resident #39's Comprehensive MDS Assessment, dated 11/25/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel.<BR/>Record review of Resident #39's Comprehensive Care Plan, dated 11/24/2024, reflected the resident had incontinence and one of the interventions was to provide pericare after each incontinent episode.<BR/>Observation on 01/14/2025 at 10:32 AM revealed CNA B was about to do incontinent care for Resident #39. She washed her hands before putting on a pair of gloves. When she was about to prepare the brief and the wipes, she realized there was no wipes inside the room. She said she would go out to get some wipes. When CNA B returned inside the room, she put on a pair of gloves and proceeded with incontinent care. She did not wash her hands again or sanitize her hands before doing incontinent care.<BR/>In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she washed her hands when she first entered Resident #39's room. She said after washing her hands, she realized she did not have any wipes to use that was why she went out of the room. She said when she went back inside the room, she should have washed her hands again because she touched the door knobs and other things when she went out of the room. She said her hands were deemed dirty again when she touched the door knob and other things. She said hand washing was important to prevent infection.<BR/>In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and infection.<BR/>The DON said the staff should have washed her hands again when she went back into the room because the staff touched something else when she went out of the room. He said gloves should be changed after touching the trash can and the soiled brief to prevent transfer of microorganisms to any clean items. He said the rule of the thumb was, when you were in doubt, wash the hands and change the gloves. he said the expectations were staff would wash their hands before incontinent care and staff would wound change their gloves before touching anything clean. He said he would do and in-service about hand hygiene and infection control and would randomly monitor the staff doing direct care. He said the issue would also be included in their IDT meeting so everybody would know the issue and discuss the measures that could be implemented.<BR/>In an interview with LVN C on 01/15/2025 at 11:20 AM, LVN C stated hands hygiene was included in all the procedures of any care. He said the staff should do hand hygiene before and after any care like incontinent care. He said gloves should be changed after touching the trash can and after cleaning the residents' bottom to prevent cross contamination and development of infection. He said he would remind the CNAs on his hall to wash their hands and change their gloves as appropriate.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated not washing the hands before any care, not changing the gloves from soiled to clean could contribute to cross contamination and infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said she would coordinate with the DON on how to handle the issue about infection control and hand hygiene.<BR/>Review of facility policy, Handwashing-Hand Hygiene Policy and Procedures revised 10-2020 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. Applying and removing Gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.<BR/>Review of facility policy, Perineal Care revised 04/16/2024 revealed Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . Steps in the Procedure . 2. Wash and apply gloves . For a female resident . b. wash perineal area . 10. Remove gloves . 11. Wash and dry hands thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to secure confidential and personal medical records for two (Resident #1 and Resident #2) of two residents reviewed for privacy and confidentiality.<BR/>1. <BR/>The facility failed to ensure RN A would close, lock, or minimize her laptop's monitor while administering medications to Resident #1 on 12/17/2024.<BR/>2. <BR/>The facility failed to ensure RN A would close, lock, or minimize her laptop's monitor while providing wound care to Resident #2 on 12/17/2024.<BR/>This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals which could cause a loss of dignity. <BR/>Findings included: <BR/>1. <BR/>Record review of Resident #1's Face Sheet, dated 12/17/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #1 was diagnosed with neurocognitive disorder with Lewy bodies (a form of dementia) and hypertension.<BR/>In an observation on 12/17/2024 at 9:30 PM revealed RN A was passing medications in the Memory Care Unit. She prepared Resident #1's medication and then went inside the resident's room. She left her computer open while administering Resident #1's medication. The computer screen displayed Resident #1's name, status, location, gender, date of birth , age, name of physician, latest vital signs, allergies, code status, emergency instructions, and three medications. the screen of the computer was facing the hallway.<BR/>In an interview with RN A at 10:02 AM, RNA stated the monitor of her computer should be locked, minimized, closed every time a staff went somewhere. She said the purpose was to protect the health or personal information of the residents. She said another reason was to prevent access of unauthorized individuals. She said she usually close the screen of her computer everytime she would leave it unattended but did not know what happened that she forgot to close the monitor of the computer she was using. She said she left the monitor open and Resident #1's medications were visible. She said aside from the medications, some personal information about the resident could be seen. She said the information was confidential.<BR/>2. <BR/>Review of Resident #2's Face Sheet, dated 12/17/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #1 was diagnosed with dementia.<BR/>Observation on 12/17/2024 at 11:17 AM revealed RN A was about to perform wound care to Resident #2. She prepared the things needed and went inside Resident #2's room. She left the monitor of her computer open while providing wound care. The computer screen displayed Resident #2's name, status, location, gender, date of birth , age, name of physician, latest vital signs, allergies, code status, emergency instructions, and the order for wound care. The screen of the computer was facing the hallway.<BR/>In an interview with RN A at 11:31 AM, RN A stated, she did it again. She said it was important that the medical records of the residents were protected as specified in HIPAA. She said only the authorized staff and the responsible party could had access to the information of the rsidents. She said she left the monitor open and the order for Resident #2's wound care. She said aside from the order for wound care, some personal information about the resident could be seen. She said the information was confidential and she was supposed to provide privacy for all residents under her care.<BR/>In an interview with the ADON on 12/17/2024 at 12:15 PM, the ADON stated before leaving the medication cart unattended the staff should close the computer screen. She stated the staff should make sure the screen was not open and showing Resident #1's personal information and medications and Resident #2's personal information and order for wound care. She said the information was confidential and should not be seen by unauthorized individuals. She said some residents might be embarrassed that others would know they had hypertension or a wound to their face. She said she would collaborate with the DON about the issue on privacy and confidentiality.<BR/>In an interview with the DON on 12/17/2024 at 12:29 PM, the DON stated personal and medical information about a resident should not be exposed for everybody to see. She said the health information of a resident should be protected and could not be shared without the permission of the resident or the resident's responsible party. She said all employees were expected to provide full privacy and confidentiality of information for all residents. The DON stated the failure to not protect the resident information could cause poor self-esteem and embarrassment for the resident. The DON stated she would start an in-service about privacy and confidentiality of the residents' information.<BR/>In an interview with the Administrator on 12/17/2024 at 1:04 PM, the Administrator stated the staff must make sure the residents' information was not exposed because it was a violation of the residents privacy and confidentiality of the care they were receiving. She said the expectation was for all the staff to make sure the residents information and treatment were not visible to unauthorized individuals. She said she would collaborate with the DON to do an in-service about privacy and confidentiality. <BR/>Record review of facility's policy, Resident Rights 2001 MED-PASS, Inc. revised February 2021 revealed Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . Policy Interpretation and Implementation . 3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues.

Based on observations, interviews, and record review, the facility failed to ensure that one cart (wound care cart) of five carts observed was kept locked or under direct observation of authorized staff in an area where residents could access it.<BR/>The facility failed to ensure that RN A locked her wound care cart before providing wound care on 12/17/2024.<BR/>This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications.<BR/>Findings included: <BR/>Observation on 12/17/2024 at 11:17 AM revealed RN A was about to perform wound care. She prepared the things needed and went inside the resident's room. She left the wound care cart unlocked. The drawers of the wound care cart were facing the hallway. The drawers contained different types of dressings, different sizes of dressings, wound cleansers, normal saline, ointments, gauze pads, bandages, tongue depressors, and tape measures. <BR/>In an interview with RN A at 11:31 AM, RN A stated the cart should not be left open everytime care was provided. She said she forgot to lock her cart before going inside the resident's room because anybody could open it and could get anything from the cart and accidentally ingest it. She said even though it was a wound care cart, there were ointments inside that could cause adverse reactions. She said she would be mindful next time to always lock the cart everytime she would leave it unattended. <BR/>In an interview with the ADON on 12/17/2024 at 12:15 PM, the ADON stated before leaving the wound care cart unattended, the staff should lock the cart to prevent untoward incidents. She said residents might be able to open it and access or ingest something that they were allergic to. She said, if it was a medication cart that was left unlocked, any resident, staff, or visitor could open it and get some medications. She medicines could be accidently ingested and children could mistake it for candies. She said leaving the cart unlocked was a serious incident and should be addressed immediately. She said she would collaborate with the DON about the issue on locking the cart.<BR/>In an interview with the DON on 12/17/2024 at 12:29 PM, the DON stated any cart should always be locked when left unattended to prevent any residents from opening it and taking something from it. she said the wound care cart had wound cleanser and ointments that could accidentally drank or ingested that could result to allergic reactions. She said if the medication cart was left open, resident could take and ingest some pills, and could cause choking and accidental overdose. She said the expectation was the cart would be always locked and secured. The DON stated she would start an in-service about the importance of locking the cart.<BR/>In an interview with the Administrator on 12/17/2024 at 1:04 PM, the Administrator stated should always be locked in protection of the residents. she said it could result to accidental ingestion and overdose, especially if nobody was monitoring the cart. She said the residents could also choke and nobody would know. She said the expectation was for the staff to make sure the carts were locked everytime they leave them. She said she would collaborate with the DON to do an in-service about locking the cart.<BR/>Record review of facility policy, Storage of Medications 2001 MED-PASS, Inc. revised April 2019 revealed Policy Statement: The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation . 9. Unlocked medication carts are not left unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #36 and Resident #39) of eight residents reviewed for Infection Control. <BR/>1. <BR/>The facility failed to ensure CNA A and CNA B changed their gloves and performed hand hygiene while providing incontinent care to Resident #36 on 01/14/2025.<BR/>2. <BR/>The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #39 on 01/14/2025.<BR/>These failures could place residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with personal history of urinary tract infections and cerebrovascular disease (reduction of blood flow to the brain).<BR/>Record review of Resident #36's Quarterly MDS Assessment, dated 12/03/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was incontinent for bowel and bladder.<BR/>Record review of Resident #36's Comprehensive Care Plan, dated 12/17/2024, reflected the resident had actual impairment to ski integrity related to wound to sacrum and one of the interventions was to provide incontinent care as needed.<BR/>Observation on 01/14/2025 at 9:54 AM revealed CNA A and CNA B were about to do incontinent care to Resident #36. Both CNAs washed their hands before putting on their gloves. CNA A went the resident's right side, while CNA B went to the resident's left side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA A placed the wipes and the brief beside the resident's right leg. After placing the wipes and the brief beside the resident's right leg, CNA A put a plastic bag on the trash can. After putting the plastic bag on the trash can, CNA A proceeded with incontinent care without changing her gloves. CNA A cleaned the perineal (area between the legs) area using the front to back technique. After cleaning the perineal area, both CNAs assisted the resident to roll to her left side. CNA A cleaned the resident's bottom. After cleaning the resident's bottom, CNA A took the brief that was placed beside the resident's right leg and placed it under Resident #36. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. The resident was rolled back, both CNA A fixed the brief. CNA B helped in fixing the brief. She did not change her gloves when she touched the soiled brief at the beginning of incontinent care.<BR/>In an interview with CNA A on 01/14/2025 at 10:15 AM, CNA A stated she was not aware she did not change her gloves after placing a plastic bag on the trash can. Said she should have changed her gloves and sanitized her hands after touching the trash can because the trash was not only presumed dirty but was dirty. Said she also should have changed her gloves and sanitized her hands after cleaning the resident's bottom and before touching the new brief because whatever germs that she touched from the soiled bottom and soiled brief would eventually transfer to the new brief. Said her actions could cause transfer of germs and infection. She said she needed to be mindful with how she did incontinent care.<BR/>In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she assisted CNA A with incontinent care for Resident #36. She said she unfastened the soiled brief and tucked it between the thighs of the resident. She said she also helped in fixing the brief when CNA A was done cleaning the resident. She said because she touched the soiled brief, she should have changed her gloves before touching the new brief because her gloves were already considered soiled. She said the resident could have urinary tract infection because the new brief would be considered dirty.<BR/>2. <BR/>Record review of Resident #39's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 was diagnosed with cerebral infarction (stroke).<BR/>Record review of Resident #39's Comprehensive MDS Assessment, dated 11/25/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel.<BR/>Record review of Resident #39's Comprehensive Care Plan, dated 11/24/2024, reflected the resident had incontinence and one of the interventions was to provide pericare after each incontinent episode.<BR/>Observation on 01/14/2025 at 10:32 AM revealed CNA B was about to do incontinent care for Resident #39. She washed her hands before putting on a pair of gloves. When she was about to prepare the brief and the wipes, she realized there was no wipes inside the room. She said she would go out to get some wipes. When CNA B returned inside the room, she put on a pair of gloves and proceeded with incontinent care. She did not wash her hands again or sanitize her hands before doing incontinent care.<BR/>In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she washed her hands when she first entered Resident #39's room. She said after washing her hands, she realized she did not have any wipes to use that was why she went out of the room. She said when she went back inside the room, she should have washed her hands again because she touched the door knobs and other things when she went out of the room. She said her hands were deemed dirty again when she touched the door knob and other things. She said hand washing was important to prevent infection.<BR/>In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and infection.<BR/>The DON said the staff should have washed her hands again when she went back into the room because the staff touched something else when she went out of the room. He said gloves should be changed after touching the trash can and the soiled brief to prevent transfer of microorganisms to any clean items. He said the rule of the thumb was, when you were in doubt, wash the hands and change the gloves. he said the expectations were staff would wash their hands before incontinent care and staff would wound change their gloves before touching anything clean. He said he would do and in-service about hand hygiene and infection control and would randomly monitor the staff doing direct care. He said the issue would also be included in their IDT meeting so everybody would know the issue and discuss the measures that could be implemented.<BR/>In an interview with LVN C on 01/15/2025 at 11:20 AM, LVN C stated hands hygiene was included in all the procedures of any care. He said the staff should do hand hygiene before and after any care like incontinent care. He said gloves should be changed after touching the trash can and after cleaning the residents' bottom to prevent cross contamination and development of infection. He said he would remind the CNAs on his hall to wash their hands and change their gloves as appropriate.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated not washing the hands before any care, not changing the gloves from soiled to clean could contribute to cross contamination and infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said she would coordinate with the DON on how to handle the issue about infection control and hand hygiene.<BR/>Review of facility policy, Handwashing-Hand Hygiene Policy and Procedures revised 10-2020 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. Applying and removing Gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.<BR/>Review of facility policy, Perineal Care revised 04/16/2024 revealed Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . Steps in the Procedure . 2. Wash and apply gloves . For a female resident . b. wash perineal area . 10. Remove gloves . 11. Wash and dry hands thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each residents environment remained as free from accident hazards as possible for 1 (Resident #30) of 9 residents reviewed for environmental hazards. <BR/>The facility failed to ensure Resident #30 did not have pointed scissors in his room on 01/14/2024.<BR/>This failure could place the resident and other residents who came into the room at risk for injury. <BR/>Review of Resident #30's Face Sheet, dated 01/16/25, reflected that resident was an [AGE] year-old male initially admitted on [DATE]. Resident #30 had a diagnosis of dysphagia (difficulty swallowing) following other cerebrovascular disease (condition that impacts blood vessels in the brain). <BR/>Review of Resident #30's Quarterly MDS (tool to assess health and functional capabilities) Assessment, dated 01/13/2025, reflected that Resident #30 had impaired cognition with a BIMS score of 11. Section I did not reflect dementia or a mood disorder. Section I reflected Resident #30 had cognitive communication deficit and other abnormality of gait and mobility. <BR/>Review of Resident #30's Comprehensive Care Plan, dated 12/06/2024, reflected Resident #30 had impaired thought processes. One intervention was COMMUNICATION: Use his preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions. Turn off TV, radio, close door etc. He understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated.<BR/>In an interview and observation on 01/14/25 at 09:40 AM, Resident #30 was lying in bed. Resident #30's wheelchair was parked close to the bed. Prior to leaving the room, surveyor bumped into the wheelchair and a pair of large scissors fell to the floor. The ends were not rounded. Resident #30's wheelchair had a piece of foam wrapped around the arms of the wheelchair. Resident #30 stated he kept the pair of scissors in the opening between the foam and arm of the wheelchair. Resident #30 stated at times he used the scissors to cut the sides of a soiled brief when he was in the restroom. The DON was in the hall at that time and notified of scissors in Resident #30's room. He stated he would take care of it.<BR/>In an interview on 01/14/25 at 02:20 PM, RN G stated Resident #30 used the scissors to cut extra paper (old activity schedules) up for scratch paper. RN G pointed at a stack of letter size sheets that had been cut up into fourths for scratch paper. She stated the resident kept the scissors inside the foam piece that is wrapped around the arm of his wheelchair. While in the room, the resident agreed for RN G to assess his skin. RN G lowered his pants and assessed the skin around Resident #30's brief to ensure he had not caused any injury. Observation revealed there was no redness, scratches, or any injury on Resident #30's skin. RN G stated she had never heard Resident #30 used scissors to cut off his brief. RN G agreed an accident could result in the resident harming himself when using the scissors. <BR/>In an interview on 01/14/25 at 02:28 PM, LVN E stated she had never heard Resident #30 used his scissors to cut the briefs on the sides to remove them. She stated she had thought it was ok for Resident #30 to use the scissors for activities. LVN E stated the scissors had been removed from the resident's room and given to her and she understood an accident could occur involving the resident or another resident who might have found the scissors. <BR/>In an interview on 01/14/25 at 02:36 PM, the Activities Director stated she provided Resident #30 with a daily chronicle. She stated she had never seen him cutting the papers. The Activities Director stated she allowed residents to use scissors when she was observing them. She stated she made sure residents only used scissors with rounded edges. <BR/>In an interview on 01/16/25 at 09:16 AM, the DON stated the facility did not have a policy about residents or family members bringing in personal items like scissors. The DON stated it posed a danger and was not safe for the resident to have the scissors in his room. He stated if staff sees something like that, it should be removed and documented. He stated it was important to educate family about the dangers and to care plan it. He said it was important for the resident to have rights, but there are other residents in the environment too. He stated it was important for staff to be diligent about safety awareness and any danger to residents and he will in-service them about it. <BR/>The facility did not provide a policy about environmental hazards. In an interview on 01/16/25 at 09:16 AM, the DON stated there was not a facility policy regarding a resident or family member bringing sharp objects like scissors into a resident's room.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. <BR/>1. <BR/>The facility failed to ensure staff were wearing the appropriate hair and beard coverings.<BR/>2. <BR/>The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the date the product was received from the vendor.<BR/>3. <BR/>The facility failed to ensure that the sugar and flour bins were cleaned.<BR/>4. <BR/>The facility failed to ensure the ice scoop in the facility kitchen was cleaned.<BR/>5. <BR/>The facility failed to ensure the food in the dry storage area was labeled with the product was received from the vendor.<BR/>6. <BR/>The facility failed to ensure the food stored in the freezer was properly sealed from air-borne contaminants.<BR/>7. <BR/>The facility failed to ensure foods being transported to resident rooms and the memory care unit were properly concealed from air-borne contaminants. <BR/>These failures could place residents at risk for cross contamination and other air-borne illnesses.<BR/>Findings included: <BR/>Observations on 01/14/25 from 9:16 AM to 9:25 AM in the facility's only kitchen reflected: <BR/>The ice scoop, hanging in a blue plastic holder, had a brownish substance and white stains along the bottom of the holder. <BR/>One large tray containing three 2- pound packages of bologna and one 2-pound package of ham, located in the refrigerator, did not have the date the product was received from the vendor. <BR/>One large plastic container of raw, chopped up celery, located in the refrigerator, did not have a date the product was received from the vendor.<BR/>One large bag or frozen okra, located in the freezer, had a large tear in the bag, exposing the food to airborne contaminants. <BR/>One bag of frozen waffles, located in the freezer, had a large tear in the bag, exposing the food to airborne contaminants.<BR/>One small bag of an unknown frozen food substance, located in the freezer, was not labeled and did not have the date the product was received from the vendor.<BR/>Two large boxes of cookie dough, located in the freezer, had a large tear in the bag, exposing the food to airborne contaminants.<BR/>Two large white storage bins, containing sugar and flour, had dark dirt-like stains on the outside of the containers and dark dirt-like stains within the opening and inside walls of the containers.<BR/>Two packages of hamburger buns, containing 12 buns each, located in the dry storage area was not labeled with the date the product was received from the vendor.<BR/>Two packages of large tortillas, located in the dry storage area were not labeled with the date the product was received from the vendor.<BR/>In an observation and interview on 01/16/25 at 10:05 AM, the Dietary Manager was observed preparing food in the kitchen and he was not wearing a beard guard. The DM was observed to have a beard approximately &frac12; inch in length. The DM stated a beard covering should be worn to prevent hair from falling into the food. <BR/>In an observation on 01/15/25 at 11:45 AM, [NAME] S was observed in the kitchen area placing food trays on the serving steam table, and had no head covering on his head. His hair was approximately 1/2 inch in length. He was asked where his hair covering was, and he proceeded to grab one and placed it on her head, before going back to plating the food.<BR/>A dining observation on 01/15/24 at 12:39 PM revealed Kitchen Aide B transporting the food cart to the Memory Care Unit. There were two trays sitting on top of the cart and one of them included a bowl of uncovered desert. The other tray included a bowl of uncovered desert and a bowl of uncovered green beans. Two residents were observed walking up to, and then standing over the cart and looking at the trays, before staff redirected them.<BR/>An observation and interview on 01/15/25 at 01:25 PM revealed three food test trays, that were being observed and tasted by the Surveyor, being removed from the food transfer cart, and all three-desert bowls were uncovered. The DM stated the bowls should have been covered during the transfer from the kitchen to the residents to avoid any food contamination. The DM stated he completed in-services on properly transporting food, food storage, and kitchen sanitation.<BR/> In an interview on 01/15/25 at 01:35 PM, the DM stated that he had been the DM for nearly 3 months. He stated he had cleaned the sugar and flour bins twice since being at the facility. He stated that the ice scoop holder should have been cleaned after every shift at night. He was shown pictures of the concerns observed in the kitchen area. He stated that he thought it was being cleaned but it was not. He stated he needed to check behind them again. He stated the risk to the resident of not addressing the issues mentioned was residents could get food poison. He was made aware that [NAME] S was observed placing food on the steam table and he was not wearing a head covering. The DM stated [NAME] S should have been wearing a head covering to prevent food contamination. <BR/>In an interview on 01/15/25 at 02:05 PM, the Administrator was shown pictures of the concerns observed in the facility's only kitchen. She stated she would follow up with the DM to address the concerns. She stated the concerns observed could result in residents experiencing food contamination. The Administrator was advised of the concern of food being transported to residents eating in their rooms and in the memory care unit without a cover, and she stated she would follow up with the DM to address the concerns. She stated the concerns observed could result in residents experiencing food contamination.<BR/>An interview on 01/16/25 at 01:05 PM, Kitchen Aide B stated that she always transported the deserts desserts and other items that were in bowls, uncovered. She stated she never knew that it needed to be covered. She stated moving forward she would ensure all foods were covered properly when transporting food to residents. She stated the risk of not covering the food when transporting it, could result in germs being spread.<BR/>Record Review of the facility's policy on Food Storage and Supplies dated October 2022, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). All items must be dated with the date that the food was delivered.<BR/>The food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. <BR/>Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under &sect; 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 (Residents #2) of 4 residents reviewed for ADL's.<BR/>1. The facility failed to ensure Resident #2 was getting assistance with changing her brief and catheter care as needed.<BR/>This failure had the potential to affect residents by placing them at risk for skin breakdown and a decline in their quality of life. <BR/>Findings included:<BR/>Review of Resident #2's MDS assessment, dated 08/22/23, reflected she was a [AGE] year-old-female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included morbid obesity and chronic obstructive pulmonary disease. She was always incontinent of bladder and bowel and had an indwelling catheter. <BR/>Review of Resident #2's Physician's Orders, dated 09/13/23 reflected a new order (following Surveyor intervention) was written for:<BR/>Change briefs every shift even if it's not wet or has bowel movement every shift. <BR/>Additional orders included:<BR/>07-14-23 Foley Catheter Care every shift and as needed. <BR/>Review of Resident #2's September 2023 MARs/TARs reflected the nurses had documented the catheter care was completed. <BR/>Review of Resident #2's Care Plan, dated 08/17/21, reflected:<BR/>The resident has bowel incontinence and prefers to be laying/sitting in bed when she has bowel elimination. Facility interventions included to check resident every two hours and assist with incontinent care as needed.<BR/>There was no care plan for Foley catheter or catheter care. <BR/>An observation and interview on 09/13/23 at 10:55 AM revealed Resident #2 was lying in a bariatric bed. She was awake, alert, and oriented. She had a Foley catheter with yellow-orange urine. She said she was not receiving catheter care or brief changes and went three days, 08/18/23-08/21/23 without a brief change. She said she was able to press her call light and ask for help, but the problem was that staff would not assist her. She said she did not know why staff would not assist her. <BR/>An interview on 09/13/23 at 4:50 PM with LVN B revealed Resident #2 did not receive a brief change from 08/18/23 - 08/21/23. She said the resident was not receiving routine brief changes and to prove it, CNA D dated and timed Resident #2's brief for 08/18/23, 2:00-10:00 PM shift. LVN B said when she and CNA D returned to work on 08/21/23 for the 2:00 PM-10:00 PM shift; the resident still had a Foley catheter and the resident was still wearing the same brief. LVN B said Resident #2 reported that no one provided catheter care or a brief change for her 08/18/23-08/21/23. LVN B said she reported the incident to the DON.<BR/>An interview on 09/13/23 at 5:15 PM with CNA D revealed on 08/18/23 at 9:45 PM she changed the brief for Resident #2. She said she put the date and time on the brief because the resident told her she was not receiving incontinence care. She said she came in to work on 08/21/23 at 2:00 PM and the resident was wearing the same brief. CNA D said she then changed the resident's brief. CNA D said she reported the incident to LVN B. CNA D said the resident continued to not receive brief changes , but she did not report it further because the DON was already aware. CNA D said there were many shifts when she came to work that the resident was incontinent and had been left that way. She said the resident was not receiving catheter care as ordered either. She said the staff would just peek in on her and did not know why they did not want to go into her room. <BR/>An interview on 09/14/23 at 10:00 AM with the Administrator revealed she was aware Resident #2 did not receive a brief change from 08/18/23-08/21/23. She said the DON told her about it and had spoken to staff about it. The Administrator said she thought the resident had received catheter care during that time, just not a brief change. She said the resident was supposed to receive catheter care every shift and as needed. <BR/>An interview on 09/14/23 at 11:35 AM with LVN E revealed she said she performed catheter care as ordered for Resident #2 on 08/18/23 - 08/21/23. She said she did not change the resident's brief because it was not soiled. She said the brief stayed clean and dry. She said she did not notice a date and time on the brief and that catheter care was ordered every shift and residents were supposed to receive a brief change, if it was soiled, every 2 hours. She said she did not know why the resident said she did not receive the catheter care. She said that she was not able to make sure the CNAs changed the resident's brief because she did not have time. She said there could be skin breakdown if a brief was not changed when soiled. <BR/>An interview on 09/14/23 at 12:05 pm with CNA F revealed he worked with Resident #2 from 08/18/23-08/21/23. He said he did not remember if he gave the resident a brief change. He said he was supposed to change a resident's brief every two hours. He said he did not know if the nurses provided the resident with catheter care. <BR/>An interview on 09/14/23 at 12:30 PM with LVN G revealed she was assigned to Resident #2 from 08/18/23-08/20/23 for the 10:00 PM - 6:00 AM shift. She said she documented providing catheter care but did not actually provide it. She said the resident refused the care. <BR/>An interview on 09/14/23 at 12:35 PM with LVN H revealed she said she provided care to Resident #2 on 08/21/23 for the 6:00 AM-2:00 PM shift. She said she did the catheter care. She said a resident's brief was supposed to be changed every shift. She said she did not make sure the resident's brief was clean and dry, she usually would just check to make sure the resident was comfortable. <BR/>An interview on 09/14/23 at 12:55 PM with the DON revealed she was aware Resident #2 did not receive brief changes from 08/18/23-08/21/23. She said she talked to 2 CNAs about it . She said the brief was supposed to be changed every shift even if it was not soiled. The DON said the nurses said they did the catheter care. The DON said she understood the CNA's point of view that the brief did not need to be changed if it was not soiled. The DON said she spoke to the resident and told her that her brief would be changed at least every shift. The DON said she did not know what the policy said about when a brief should be changed, and that skin breakdown could occur if a brief was not changed. <BR/>Review of the Facility Policy, Catheter Care, Urinary, dated January 2023, reflected:<BR/>Equipment and Supplies<BR/>The following equipment and supplies will be necessary when performing this procedure:<BR/>1. Wash basin;<BR/>2. Soap and water;<BR/>3. Washcloth;<BR/>4. Towel;<BR/>5. Bed protector; and<BR/>6. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).<BR/>Steps in the Procedure<BR/>1. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached.<BR/>2. Wash and dry your hands thoroughly.<BR/>3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside <BR/>stand within easy reach.<BR/>4. If the resident's physical or medical condition permits, assist the female resident into the dorsal recumbent position .<BR/>5. Put on gloves.<BR/>6. Place bed protector under resident.<BR/>7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry.<BR/>8. Pour wash water down the commode. Flush the commode.<BR/>9. Place soiled linen into designated container.<BR/>10. Put on clean gloves.<BR/>11. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly.<BR/>12. Provide privacy. Cover the resident with a sheet, exposing only the perineal area.<BR/>13. With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure.<BR/>14. Assess the urethral meatus.<BR/>15. For a female resident: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique .<BR/>17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.<BR/>18. Secure catheter utilizing a leg band.<BR/>19. Check drainage tubing and bag to ensure that the catheter is draining properly.<BR/>20. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly.<BR/>21. Reposition the bed covers. Make the resident comfortable.<BR/>22. Place the call light within easy reach of the resident .<BR/>Review of the facility policy, Perineal Care, dated February 2023, reflected: <BR/>Purpose<BR/>The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .<BR/>For a female resident:<BR/>a. Wet washcloth and apply soap or skin cleansing agent.<BR/>b. Wash perineal area, wiping from front to back.<BR/>(1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area.)<BR/>(2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth.<BR/>(3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.<BR/>(4) Gently dry perineum.<BR/>c. Ask the resident to turn on her side with her top leg slightly bent, if able.<BR/>d. Rinse wash cloth and apply soap or skin cleansing agent.<BR/>e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.<BR/>f. Rinse and dry thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 6 residents (Resident #13) reviewed for nutrition and hydration.<BR/>The facility failed to assess Residents #13's weight on a weekly basis per the resident's care plan and the resident experienced an 11% weight loss in a 3-month period. <BR/>This failure could place resident at risk of experiencing a decline in health due to malnutrition. <BR/>Findings included:<BR/>Review of Resident #13's MDS assessment, dated 10/13/23, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE]. Her cognitive status was severely impaired. The resident's diagnoses included anemia, osteoporosis, non-Alzheimer's dementia, and malnutrition. Her weight was 78 pounds and 63 inches tall. The resident was on a pureed diet. <BR/>Record review of Resident #13's Care plan, revised 07/27/22, reflected the resident had unplanned/unexpected weight loss.<BR/>Facility interventions included:<BR/>Alert dietician if consumption is poor for more than 48 hours.<BR/>Give the resident supplements as ordered. Alert nurse/ dietitian if not consuming on a routine basis.<BR/>If weight decline persists, contactphysician and dietician immediately.<BR/>Labs as ordered. Report results to physician and ensure dietician is aware.<BR/>Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss.<BR/>Monitor and record food intake at each meal.<BR/>Offer substitutes as requested or indicated.<BR/>Weigh at same time of day and record: Weekly on Sundays at 8 am.<BR/>Review of Resident #13's Physician's Orders dated 11/16/23 reflected:<BR/>Ensure Clear or Boost Breeze 1 carton two times a day as available. <BR/>Prostat (protein supplement) at bedtime, may add to nectar thick juice or water.<BR/>Regular diet, Pureed texture, Nectar Thickened consistency.<BR/>Record review of Resident #13's Weight Summary reflected:<BR/>11/21/23 <BR/>72.0 lbs <BR/>Mechanical Lift <BR/>11/14/23 <BR/>72.0 lbs <BR/>Mechanical Lift <BR/>11/8/23 <BR/>75.4 lbs <BR/>Wheelchair <BR/>11/7/23 <BR/>72.0 lbs <BR/>Mechanical Lift <BR/>10/24/23 <BR/>73.0 lbs <BR/>Mechanical Lift <BR/>10/6/23 <BR/>77.8 lbs <BR/>Wheelchair<BR/>09/5/23 <BR/>81.0 lbs <BR/>Wheelchair <BR/>From 09/05/23 to 11/21/23 on the facility's system of records indicated the resident experienced a 11% weight loss in a 3-month period. <BR/>Review of a Nutrition nurse notes for Resident #13 reflected:<BR/>11/10/2023 11:32 AM /Dietary Note <BR/>Note Text: Nutrition Progress Note<BR/>Current diet: Regular, puree textures, nectar thick liquids, large protein portions, additional bread portion. Avg. intake 50-75% of meals. Small spoon. Super cereal at breakfast, encourage 4-8 oz nutrients to limit TID, Arginaid (protein supplement) BID, Prostat 30ml TID, 30 ml HS, snacks BID. Medications: iron-vitamins, probiotic, vitamin C, zinc, multivitamin. Height: 63 inches, weight: 72 lbs 11/7/23, 75.4 lbs 11/8 , BMI 13.4. Significant weight loss of 7.4% for 1 month - October 2023 weight of 77.8 lbs, 9.7% 3 months - August 2023 weight of 79.8 lbs and 15.4% from 6 months - May 2023 weight of 85.2 lbs. Assisted with meals. Recommend: Trial ensure clear or boost breeze twice a day as available - milk free. Monitor weights for stability. Goal: Weight stable: +/- 1-3 lbs/month. Skin: healing/improvement. - Dietician<BR/>An observation and interview on 11/28/23 at 11:22 AM of Resident #13 revealed she was lying in bed. She was severely thin. She was confused but able to say she was doing ok . <BR/>An interview with CNA A on 11/20/23 at 9:53 am for Resident #13 revealed she would assist the resident with her meals. CNA A said she thought the resident was losing weight because some days she would not eat regularly, and she would spit out her food or choked on it. CNA A said the resident required supplements when she did not eat . <BR/>An interview with the WCN on 11/29/23 at 2:46 PM for Resident #13 revealed the resident was difficult to feed. She said the resident had to be fed a certain way or she would throw up her food. She said staff had to be very careful with their spoon sizes. <BR/>An interview with the ADON on 11/30/23 at 12:22 PM regarding Resident #13 revealed she did not know the resident's care plan indicated she was supposed to be weighed weekly . The ADON said the resident would eat 100% of what she was fed. The ADON said the resident was at risk for deterioration if her weight was not monitored carefully. <BR/>An interview with the Dietician on 11/30/23 at 3:20 PM regarding Resident #13 revealed she said the resident was losing weight because she was of advanced age, had dementia, and required assistance with meals . The Dietician said she did not know why the resident was not being weighed weekly and that decision was up to the facility. <BR/>Record review of the facility policy, Weight Management, reviewed on 01/17/23, reflect:<BR/>Standard:<BR/>The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for residents .<BR/>Additionally, the interdisciplinary team will assure that below tasks are accomplished .<BR/>Care Planning revisions .<BR/>Ongoing follow-through on resident's status once the interventions have been implemented .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #36 and Resident #39) of eight residents reviewed for Infection Control. <BR/>1. <BR/>The facility failed to ensure CNA A and CNA B changed their gloves and performed hand hygiene while providing incontinent care to Resident #36 on 01/14/2025.<BR/>2. <BR/>The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #39 on 01/14/2025.<BR/>These failures could place residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with personal history of urinary tract infections and cerebrovascular disease (reduction of blood flow to the brain).<BR/>Record review of Resident #36's Quarterly MDS Assessment, dated 12/03/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was incontinent for bowel and bladder.<BR/>Record review of Resident #36's Comprehensive Care Plan, dated 12/17/2024, reflected the resident had actual impairment to ski integrity related to wound to sacrum and one of the interventions was to provide incontinent care as needed.<BR/>Observation on 01/14/2025 at 9:54 AM revealed CNA A and CNA B were about to do incontinent care to Resident #36. Both CNAs washed their hands before putting on their gloves. CNA A went the resident's right side, while CNA B went to the resident's left side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA A placed the wipes and the brief beside the resident's right leg. After placing the wipes and the brief beside the resident's right leg, CNA A put a plastic bag on the trash can. After putting the plastic bag on the trash can, CNA A proceeded with incontinent care without changing her gloves. CNA A cleaned the perineal (area between the legs) area using the front to back technique. After cleaning the perineal area, both CNAs assisted the resident to roll to her left side. CNA A cleaned the resident's bottom. After cleaning the resident's bottom, CNA A took the brief that was placed beside the resident's right leg and placed it under Resident #36. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. The resident was rolled back, both CNA A fixed the brief. CNA B helped in fixing the brief. She did not change her gloves when she touched the soiled brief at the beginning of incontinent care.<BR/>In an interview with CNA A on 01/14/2025 at 10:15 AM, CNA A stated she was not aware she did not change her gloves after placing a plastic bag on the trash can. Said she should have changed her gloves and sanitized her hands after touching the trash can because the trash was not only presumed dirty but was dirty. Said she also should have changed her gloves and sanitized her hands after cleaning the resident's bottom and before touching the new brief because whatever germs that she touched from the soiled bottom and soiled brief would eventually transfer to the new brief. Said her actions could cause transfer of germs and infection. She said she needed to be mindful with how she did incontinent care.<BR/>In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she assisted CNA A with incontinent care for Resident #36. She said she unfastened the soiled brief and tucked it between the thighs of the resident. She said she also helped in fixing the brief when CNA A was done cleaning the resident. She said because she touched the soiled brief, she should have changed her gloves before touching the new brief because her gloves were already considered soiled. She said the resident could have urinary tract infection because the new brief would be considered dirty.<BR/>2. <BR/>Record review of Resident #39's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 was diagnosed with cerebral infarction (stroke).<BR/>Record review of Resident #39's Comprehensive MDS Assessment, dated 11/25/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel.<BR/>Record review of Resident #39's Comprehensive Care Plan, dated 11/24/2024, reflected the resident had incontinence and one of the interventions was to provide pericare after each incontinent episode.<BR/>Observation on 01/14/2025 at 10:32 AM revealed CNA B was about to do incontinent care for Resident #39. She washed her hands before putting on a pair of gloves. When she was about to prepare the brief and the wipes, she realized there was no wipes inside the room. She said she would go out to get some wipes. When CNA B returned inside the room, she put on a pair of gloves and proceeded with incontinent care. She did not wash her hands again or sanitize her hands before doing incontinent care.<BR/>In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she washed her hands when she first entered Resident #39's room. She said after washing her hands, she realized she did not have any wipes to use that was why she went out of the room. She said when she went back inside the room, she should have washed her hands again because she touched the door knobs and other things when she went out of the room. She said her hands were deemed dirty again when she touched the door knob and other things. She said hand washing was important to prevent infection.<BR/>In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and infection.<BR/>The DON said the staff should have washed her hands again when she went back into the room because the staff touched something else when she went out of the room. He said gloves should be changed after touching the trash can and the soiled brief to prevent transfer of microorganisms to any clean items. He said the rule of the thumb was, when you were in doubt, wash the hands and change the gloves. he said the expectations were staff would wash their hands before incontinent care and staff would wound change their gloves before touching anything clean. He said he would do and in-service about hand hygiene and infection control and would randomly monitor the staff doing direct care. He said the issue would also be included in their IDT meeting so everybody would know the issue and discuss the measures that could be implemented.<BR/>In an interview with LVN C on 01/15/2025 at 11:20 AM, LVN C stated hands hygiene was included in all the procedures of any care. He said the staff should do hand hygiene before and after any care like incontinent care. He said gloves should be changed after touching the trash can and after cleaning the residents' bottom to prevent cross contamination and development of infection. He said he would remind the CNAs on his hall to wash their hands and change their gloves as appropriate.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated not washing the hands before any care, not changing the gloves from soiled to clean could contribute to cross contamination and infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said she would coordinate with the DON on how to handle the issue about infection control and hand hygiene.<BR/>Review of facility policy, Handwashing-Hand Hygiene Policy and Procedures revised 10-2020 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. Applying and removing Gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.<BR/>Review of facility policy, Perineal Care revised 04/16/2024 revealed Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . Steps in the Procedure . 2. Wash and apply gloves . For a female resident . b. wash perineal area . 10. Remove gloves . 11. Wash and dry hands thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 1 (Residents #2) of 4 residents reviewed for ADL's.<BR/>1. The facility failed to ensure Resident #2 was getting assistance with changing her brief and catheter care as needed.<BR/>This failure had the potential to affect residents by placing them at risk for skin breakdown and a decline in their quality of life. <BR/>Findings included:<BR/>Review of Resident #2's MDS assessment, dated 08/22/23, reflected she was a [AGE] year-old-female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included morbid obesity and chronic obstructive pulmonary disease. She was always incontinent of bladder and bowel and had an indwelling catheter. <BR/>Review of Resident #2's Physician's Orders, dated 09/13/23 reflected a new order (following Surveyor intervention) was written for:<BR/>Change briefs every shift even if it's not wet or has bowel movement every shift. <BR/>Additional orders included:<BR/>07-14-23 Foley Catheter Care every shift and as needed. <BR/>Review of Resident #2's September 2023 MARs/TARs reflected the nurses had documented the catheter care was completed. <BR/>Review of Resident #2's Care Plan, dated 08/17/21, reflected:<BR/>The resident has bowel incontinence and prefers to be laying/sitting in bed when she has bowel elimination. Facility interventions included to check resident every two hours and assist with incontinent care as needed.<BR/>There was no care plan for Foley catheter or catheter care. <BR/>An observation and interview on 09/13/23 at 10:55 AM revealed Resident #2 was lying in a bariatric bed. She was awake, alert, and oriented. She had a Foley catheter with yellow-orange urine. She said she was not receiving catheter care or brief changes and went three days, 08/18/23-08/21/23 without a brief change. She said she was able to press her call light and ask for help, but the problem was that staff would not assist her. She said she did not know why staff would not assist her. <BR/>An interview on 09/13/23 at 4:50 PM with LVN B revealed Resident #2 did not receive a brief change from 08/18/23 - 08/21/23. She said the resident was not receiving routine brief changes and to prove it, CNA D dated and timed Resident #2's brief for 08/18/23, 2:00-10:00 PM shift. LVN B said when she and CNA D returned to work on 08/21/23 for the 2:00 PM-10:00 PM shift; the resident still had a Foley catheter and the resident was still wearing the same brief. LVN B said Resident #2 reported that no one provided catheter care or a brief change for her 08/18/23-08/21/23. LVN B said she reported the incident to the DON.<BR/>An interview on 09/13/23 at 5:15 PM with CNA D revealed on 08/18/23 at 9:45 PM she changed the brief for Resident #2. She said she put the date and time on the brief because the resident told her she was not receiving incontinence care. She said she came in to work on 08/21/23 at 2:00 PM and the resident was wearing the same brief. CNA D said she then changed the resident's brief. CNA D said she reported the incident to LVN B. CNA D said the resident continued to not receive brief changes , but she did not report it further because the DON was already aware. CNA D said there were many shifts when she came to work that the resident was incontinent and had been left that way. She said the resident was not receiving catheter care as ordered either. She said the staff would just peek in on her and did not know why they did not want to go into her room. <BR/>An interview on 09/14/23 at 10:00 AM with the Administrator revealed she was aware Resident #2 did not receive a brief change from 08/18/23-08/21/23. She said the DON told her about it and had spoken to staff about it. The Administrator said she thought the resident had received catheter care during that time, just not a brief change. She said the resident was supposed to receive catheter care every shift and as needed. <BR/>An interview on 09/14/23 at 11:35 AM with LVN E revealed she said she performed catheter care as ordered for Resident #2 on 08/18/23 - 08/21/23. She said she did not change the resident's brief because it was not soiled. She said the brief stayed clean and dry. She said she did not notice a date and time on the brief and that catheter care was ordered every shift and residents were supposed to receive a brief change, if it was soiled, every 2 hours. She said she did not know why the resident said she did not receive the catheter care. She said that she was not able to make sure the CNAs changed the resident's brief because she did not have time. She said there could be skin breakdown if a brief was not changed when soiled. <BR/>An interview on 09/14/23 at 12:05 pm with CNA F revealed he worked with Resident #2 from 08/18/23-08/21/23. He said he did not remember if he gave the resident a brief change. He said he was supposed to change a resident's brief every two hours. He said he did not know if the nurses provided the resident with catheter care. <BR/>An interview on 09/14/23 at 12:30 PM with LVN G revealed she was assigned to Resident #2 from 08/18/23-08/20/23 for the 10:00 PM - 6:00 AM shift. She said she documented providing catheter care but did not actually provide it. She said the resident refused the care. <BR/>An interview on 09/14/23 at 12:35 PM with LVN H revealed she said she provided care to Resident #2 on 08/21/23 for the 6:00 AM-2:00 PM shift. She said she did the catheter care. She said a resident's brief was supposed to be changed every shift. She said she did not make sure the resident's brief was clean and dry, she usually would just check to make sure the resident was comfortable. <BR/>An interview on 09/14/23 at 12:55 PM with the DON revealed she was aware Resident #2 did not receive brief changes from 08/18/23-08/21/23. She said she talked to 2 CNAs about it . She said the brief was supposed to be changed every shift even if it was not soiled. The DON said the nurses said they did the catheter care. The DON said she understood the CNA's point of view that the brief did not need to be changed if it was not soiled. The DON said she spoke to the resident and told her that her brief would be changed at least every shift. The DON said she did not know what the policy said about when a brief should be changed, and that skin breakdown could occur if a brief was not changed. <BR/>Review of the Facility Policy, Catheter Care, Urinary, dated January 2023, reflected:<BR/>Equipment and Supplies<BR/>The following equipment and supplies will be necessary when performing this procedure:<BR/>1. Wash basin;<BR/>2. Soap and water;<BR/>3. Washcloth;<BR/>4. Towel;<BR/>5. Bed protector; and<BR/>6. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).<BR/>Steps in the Procedure<BR/>1. Place the clean equipment on the bedside stand or overbed table. Arrange the supplies so they can be easily reached.<BR/>2. Wash and dry your hands thoroughly.<BR/>3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside <BR/>stand within easy reach.<BR/>4. If the resident's physical or medical condition permits, assist the female resident into the dorsal recumbent position .<BR/>5. Put on gloves.<BR/>6. Place bed protector under resident.<BR/>7. Wash the resident's genitalia and perineum thoroughly with soap and water. Rinse the area well and towel dry.<BR/>8. Pour wash water down the commode. Flush the commode.<BR/>9. Place soiled linen into designated container.<BR/>10. Put on clean gloves.<BR/>11. Remove gloves and discard into the designated container. Wash and dry your hands thoroughly.<BR/>12. Provide privacy. Cover the resident with a sheet, exposing only the perineal area.<BR/>13. With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. Maintain the position of this hand throughout the procedure.<BR/>14. Assess the urethral meatus.<BR/>15. For a female resident: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. Do not allow the washcloth to drag on the resident's skin or bed linen. With a clean washcloth, rinse with warm water using the above technique .<BR/>17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward.<BR/>18. Secure catheter utilizing a leg band.<BR/>19. Check drainage tubing and bag to ensure that the catheter is draining properly.<BR/>20. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly.<BR/>21. Reposition the bed covers. Make the resident comfortable.<BR/>22. Place the call light within easy reach of the resident .<BR/>Review of the facility policy, Perineal Care, dated February 2023, reflected: <BR/>Purpose<BR/>The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .<BR/>For a female resident:<BR/>a. Wet washcloth and apply soap or skin cleansing agent.<BR/>b. Wash perineal area, wiping from front to back.<BR/>(1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area.)<BR/>(2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth.<BR/>(3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter.<BR/>(4) Gently dry perineum.<BR/>c. Ask the resident to turn on her side with her top leg slightly bent, if able.<BR/>d. Rinse wash cloth and apply soap or skin cleansing agent.<BR/>e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.<BR/>f. Rinse and dry thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of three residents observed for infection control.<BR/>CNA A failed to ensure Resident #1's Foley catheter did not pull or hang from the resident during incontinence care. <BR/>This failure could place residents at risk for infection and or trauma at the catheter site. <BR/>Findings included:<BR/>Review of Resident #1's MDS, dated [DATE], reflected he was admitted on [DATE]. He was 72 years' old. He had a diagnosis of stroke. The resident was incontinent of urine and stool and had an indwelling catheter . <BR/>An interview and observation on 09/13/23 at 11:55 AM with Resident #1 revealed he was lying in bed with his blanket pulled back. He was alert and able to answer questions. He was wearing a brief and was incontinent of a large amount of stool that was spilling from his brief. He said he was waiting for staff to come change him. He had a Foley catheter hanging off the bed frame of his bed. The Surveyor notified the staff that the resident was incontinent of stool. At 12:00 PM, CNA A entered Resident #1's room. CNA A drained cloudy, yellow urine from the Foley catheter into a urinal and dumped it into the toilet. CNA A unfastened the resident's brief and there was green stool all over it. CNA A used wipes to cleanse the resident's peri-area and catheter tubing. CNA A removed the Foley catheter bag from the bed frame and placed the Foley catheter bag on the floor. At 12:15 PM, CNA C entered the resident's room. CNA C performed hand hygiene and put on gloves. CNA A was still wearing her same gloves. The resident was turned onto his right side. The Foley catheter was not secured to his leg and was hanging from him over the side of the bed. CNA A and CNA C cleaned the resident's stool off his body. CNA C removed her gloves and put on new gloves. CNA A was still wearing the same gloves. The resident was rolled to his left side and the Foley catheter continued to hang from the resident and off the side of the bed. CNA A continued to clean the resident. The Foley catheter was cleaned and was in the penis. The penis meatus (area of the penis next to the urethra) was torn all the way down the penis shaft (old injury per ADON.) CNA A continued to clean the resident. The Surveyor asked the WCN, who had entered the room, if it was okay for the Foley bag to be hanging from the resident . The WCN said no and instructed CNA A to place the bag on the bed frame. CNA A moved to get a clean brief. CNA A put on the resident's clean brief.<BR/>An interview on 09/13/23 at 1:20 PM with the ADON revealed during incontinence care, the Foley bag should stay at the end of the bed at bladder level so that it did not get pulled or kinked. <BR/>An interview on 09/14/23 at 1:50 PM with CNA A and the ADON revealed CNA A was supposed to empty the Foley catheter bag and put it on the bed, so it did not stretch and hurt the resident. CNA A said that during care for Resident #1 she forgot to. CNA A and the ADON said they did not know why Resident #1 did not have a catheter leg strap on. <BR/>Review of the facility's policy Catheter Care, Urinary revised January 2023, reflected, <BR/> . Maintaining Unobstructed Urine Flow<BR/>1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.<BR/>2. Unless specifically ordered, do not apply a clamp to the catheter.<BR/>3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .<BR/>Be sure the catheter tubing and drainage bag are kept off the floor .<BR/>Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #36 and Resident #39) of eight residents reviewed for Infection Control. <BR/>1. <BR/>The facility failed to ensure CNA A and CNA B changed their gloves and performed hand hygiene while providing incontinent care to Resident #36 on 01/14/2025.<BR/>2. <BR/>The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #39 on 01/14/2025.<BR/>These failures could place residents at risk of cross-contamination and development of infections.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with personal history of urinary tract infections and cerebrovascular disease (reduction of blood flow to the brain).<BR/>Record review of Resident #36's Quarterly MDS Assessment, dated 12/03/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was incontinent for bowel and bladder.<BR/>Record review of Resident #36's Comprehensive Care Plan, dated 12/17/2024, reflected the resident had actual impairment to ski integrity related to wound to sacrum and one of the interventions was to provide incontinent care as needed.<BR/>Observation on 01/14/2025 at 9:54 AM revealed CNA A and CNA B were about to do incontinent care to Resident #36. Both CNAs washed their hands before putting on their gloves. CNA A went the resident's right side, while CNA B went to the resident's left side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA A placed the wipes and the brief beside the resident's right leg. After placing the wipes and the brief beside the resident's right leg, CNA A put a plastic bag on the trash can. After putting the plastic bag on the trash can, CNA A proceeded with incontinent care without changing her gloves. CNA A cleaned the perineal (area between the legs) area using the front to back technique. After cleaning the perineal area, both CNAs assisted the resident to roll to her left side. CNA A cleaned the resident's bottom. After cleaning the resident's bottom, CNA A took the brief that was placed beside the resident's right leg and placed it under Resident #36. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. The resident was rolled back, both CNA A fixed the brief. CNA B helped in fixing the brief. She did not change her gloves when she touched the soiled brief at the beginning of incontinent care.<BR/>In an interview with CNA A on 01/14/2025 at 10:15 AM, CNA A stated she was not aware she did not change her gloves after placing a plastic bag on the trash can. Said she should have changed her gloves and sanitized her hands after touching the trash can because the trash was not only presumed dirty but was dirty. Said she also should have changed her gloves and sanitized her hands after cleaning the resident's bottom and before touching the new brief because whatever germs that she touched from the soiled bottom and soiled brief would eventually transfer to the new brief. Said her actions could cause transfer of germs and infection. She said she needed to be mindful with how she did incontinent care.<BR/>In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she assisted CNA A with incontinent care for Resident #36. She said she unfastened the soiled brief and tucked it between the thighs of the resident. She said she also helped in fixing the brief when CNA A was done cleaning the resident. She said because she touched the soiled brief, she should have changed her gloves before touching the new brief because her gloves were already considered soiled. She said the resident could have urinary tract infection because the new brief would be considered dirty.<BR/>2. <BR/>Record review of Resident #39's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 was diagnosed with cerebral infarction (stroke).<BR/>Record review of Resident #39's Comprehensive MDS Assessment, dated 11/25/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel.<BR/>Record review of Resident #39's Comprehensive Care Plan, dated 11/24/2024, reflected the resident had incontinence and one of the interventions was to provide pericare after each incontinent episode.<BR/>Observation on 01/14/2025 at 10:32 AM revealed CNA B was about to do incontinent care for Resident #39. She washed her hands before putting on a pair of gloves. When she was about to prepare the brief and the wipes, she realized there was no wipes inside the room. She said she would go out to get some wipes. When CNA B returned inside the room, she put on a pair of gloves and proceeded with incontinent care. She did not wash her hands again or sanitize her hands before doing incontinent care.<BR/>In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she washed her hands when she first entered Resident #39's room. She said after washing her hands, she realized she did not have any wipes to use that was why she went out of the room. She said when she went back inside the room, she should have washed her hands again because she touched the door knobs and other things when she went out of the room. She said her hands were deemed dirty again when she touched the door knob and other things. She said hand washing was important to prevent infection.<BR/>In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and infection.<BR/>The DON said the staff should have washed her hands again when she went back into the room because the staff touched something else when she went out of the room. He said gloves should be changed after touching the trash can and the soiled brief to prevent transfer of microorganisms to any clean items. He said the rule of the thumb was, when you were in doubt, wash the hands and change the gloves. he said the expectations were staff would wash their hands before incontinent care and staff would wound change their gloves before touching anything clean. He said he would do and in-service about hand hygiene and infection control and would randomly monitor the staff doing direct care. He said the issue would also be included in their IDT meeting so everybody would know the issue and discuss the measures that could be implemented.<BR/>In an interview with LVN C on 01/15/2025 at 11:20 AM, LVN C stated hands hygiene was included in all the procedures of any care. He said the staff should do hand hygiene before and after any care like incontinent care. He said gloves should be changed after touching the trash can and after cleaning the residents' bottom to prevent cross contamination and development of infection. He said he would remind the CNAs on his hall to wash their hands and change their gloves as appropriate.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated not washing the hands before any care, not changing the gloves from soiled to clean could contribute to cross contamination and infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said she would coordinate with the DON on how to handle the issue about infection control and hand hygiene.<BR/>Review of facility policy, Handwashing-Hand Hygiene Policy and Procedures revised 10-2020 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. Applying and removing Gloves . 1. Perform hand hygiene before and after applying non-sterile gloves.<BR/>Review of facility policy, Perineal Care revised 04/16/2024 revealed Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . Steps in the Procedure . 2. Wash and apply gloves . For a female resident . b. wash perineal area . 10. Remove gloves . 11. Wash and dry hands thoroughly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each residents environment remained as free from accident hazards as possible for 1 (Resident #30) of 9 residents reviewed for environmental hazards. <BR/>The facility failed to ensure Resident #30 did not have pointed scissors in his room on 01/14/2024.<BR/>This failure could place the resident and other residents who came into the room at risk for injury. <BR/>Review of Resident #30's Face Sheet, dated 01/16/25, reflected that resident was an [AGE] year-old male initially admitted on [DATE]. Resident #30 had a diagnosis of dysphagia (difficulty swallowing) following other cerebrovascular disease (condition that impacts blood vessels in the brain). <BR/>Review of Resident #30's Quarterly MDS (tool to assess health and functional capabilities) Assessment, dated 01/13/2025, reflected that Resident #30 had impaired cognition with a BIMS score of 11. Section I did not reflect dementia or a mood disorder. Section I reflected Resident #30 had cognitive communication deficit and other abnormality of gait and mobility. <BR/>Review of Resident #30's Comprehensive Care Plan, dated 12/06/2024, reflected Resident #30 had impaired thought processes. One intervention was COMMUNICATION: Use his preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions. Turn off TV, radio, close door etc. He understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated.<BR/>In an interview and observation on 01/14/25 at 09:40 AM, Resident #30 was lying in bed. Resident #30's wheelchair was parked close to the bed. Prior to leaving the room, surveyor bumped into the wheelchair and a pair of large scissors fell to the floor. The ends were not rounded. Resident #30's wheelchair had a piece of foam wrapped around the arms of the wheelchair. Resident #30 stated he kept the pair of scissors in the opening between the foam and arm of the wheelchair. Resident #30 stated at times he used the scissors to cut the sides of a soiled brief when he was in the restroom. The DON was in the hall at that time and notified of scissors in Resident #30's room. He stated he would take care of it.<BR/>In an interview on 01/14/25 at 02:20 PM, RN G stated Resident #30 used the scissors to cut extra paper (old activity schedules) up for scratch paper. RN G pointed at a stack of letter size sheets that had been cut up into fourths for scratch paper. She stated the resident kept the scissors inside the foam piece that is wrapped around the arm of his wheelchair. While in the room, the resident agreed for RN G to assess his skin. RN G lowered his pants and assessed the skin around Resident #30's brief to ensure he had not caused any injury. Observation revealed there was no redness, scratches, or any injury on Resident #30's skin. RN G stated she had never heard Resident #30 used scissors to cut off his brief. RN G agreed an accident could result in the resident harming himself when using the scissors. <BR/>In an interview on 01/14/25 at 02:28 PM, LVN E stated she had never heard Resident #30 used his scissors to cut the briefs on the sides to remove them. She stated she had thought it was ok for Resident #30 to use the scissors for activities. LVN E stated the scissors had been removed from the resident's room and given to her and she understood an accident could occur involving the resident or another resident who might have found the scissors. <BR/>In an interview on 01/14/25 at 02:36 PM, the Activities Director stated she provided Resident #30 with a daily chronicle. She stated she had never seen him cutting the papers. The Activities Director stated she allowed residents to use scissors when she was observing them. She stated she made sure residents only used scissors with rounded edges. <BR/>In an interview on 01/16/25 at 09:16 AM, the DON stated the facility did not have a policy about residents or family members bringing in personal items like scissors. The DON stated it posed a danger and was not safe for the resident to have the scissors in his room. He stated if staff sees something like that, it should be removed and documented. He stated it was important to educate family about the dangers and to care plan it. He said it was important for the resident to have rights, but there are other residents in the environment too. He stated it was important for staff to be diligent about safety awareness and any danger to residents and he will in-service them about it. <BR/>The facility did not provide a policy about environmental hazards. In an interview on 01/16/25 at 09:16 AM, the DON stated there was not a facility policy regarding a resident or family member bringing sharp objects like scissors into a resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received care, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 (Resident #3 and Resident #69) of 4 residents reviewed for pressure ulcers.<BR/>The facility failed to ensure nursing staff provided pressure ulcer treatment as ordered by the physician to Resident #3 and when his wound dressing became dislodged. <BR/>The facility failed to provide wound care per physician's orders for Resident #69's wound on coccyx which was identified on 7/24/22. <BR/>These failures could place residents with pressure ulcers at risk developing new pressure ulcers, pain, and deterioration in existing pressure ulcers.<BR/>Findings included:<BR/>Review of Resident #3's MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dementia and his BIMS score was a 6, indicating he had a severe cognitive impairment. Section M of the assessment reflected Resident #3 was at risk for the development of pressure wounds and had 2 unhealed Stage 3 pressure wounds. Skin and wound treatments included a pressure reducing device for his bed and chair, pressure wound care, and nutrition or hydration intervention to manage skin problems. Treatments did not include a turning/repositioning program. <BR/>Review of Resident #3's care plans was initiated on 06/06/22 for stage 3 wounds to his right and left buttocks. Interventions included weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, treatments as ordered, monitoring for signs or symptoms of infection, or worsening and report to MD, and treating for pain as needed prior to wound care. The care plan did not address the wound to Resident #3's coccyx.<BR/>Review of Resident #3's September 2022 TAR reflected an order initiated on 06/06/22 for a stage 3 pressure wound to the right side of his coccyx which discontinued on 09/27/22 at 9:30 PM. Further review of the TAR indicated an order was entered 09/27/22 at 9:30 PM for a treatment to a stage 2 pressure wound to the right side of Resident #3's coccyx. There was not an order for a treatment to his coccyx.<BR/>Review of Resident #3's wound assessments from 06/06/22 through 09/27/22 reflected the following pressure wounds: <BR/>Coccyx:<BR/>1. <BR/>06/06/22- stage 3 pressure ulcer to Left side of coccyx-, stage 3 pressure ulcer to right side of coccyx. Date acquired 06/06/22/. <BR/>2. <BR/>06/13/22- stage 3 wound to right side of coccyx, healed wound to left side of coccyx. <BR/>3. <BR/>06/20/22- stage 3 pressure ulcer to right side of coccyx, length 0.7cm and width 0.3cm. <BR/>4. <BR/>06/27/22- stage 3 pressure ulcer to right side of coccyx, length 0.5cm and width 0.3cm. <BR/>5. <BR/>07/04/22- stage 3 pressure ulcer to right side of coccyx, length 0.5cm and width 0.2cm.<BR/>6. <BR/>07/11/22- stage 3 wound to right side of coccyx, length 0.3cm and width 0.2cm. <BR/>7. <BR/>07/18/22- stage 3 wound to right side of coccyx, length 0.5 and width 1.5 cm. <BR/>8. <BR/>07/25/22- stage 3 pressure ulcer to right side of coccyx, length 0.5cm and width 0.3cm. <BR/>9. <BR/>08/01/22- stage 3 pressure ulcer to right side of coccyx, length 1.5 and width 0.5cm. <BR/>10. <BR/>08/08/22- pressure wound to coccyx, length 2cm and width 1.5cm.<BR/>11. <BR/>08/16/22- stage 2 pressure wound coccyx, length 2.2cm and width 1.5cm. Date acquired 07/07/22.<BR/>12. <BR/>09/24/22- documented by LVN E. The wound was described as a stage 2 pressure wound to his coccyx, first acquired on 09/24/22, and the measurements were 2cm x 0.5cm x 0.1cm.<BR/>An observation and interview on 09/28/22 at 8:00AM revealed CNA A and CAN B entered Resident #3's room to get the resident up for breakfast. During incontinent care, CNA A, CNA B, and the CNA Scheduler observed an open wound to Resident #3's coccyx without a dressing. The wound bed was pink and had a small amount of clear drainage. There was also a shearing skin injury to the residents' medial right buttocks adjacent to the coccyx. The CNA Scheduler stated she did not think the nurses had been covering the wound to Resident #3's coccyx and LVN C and LVN D had instructed the aides to place a barrier cream to Resident #3's wounds. The CNA Scheduler left the resident room and returned with a tube of zinc ointment. CNA A placed the zinc ointment on the resident's buttocks, including to his pressure wound on his coccyx and to a skin tear on his right buttocks lateral to his coccyx using a dirty glove which was previously used to clean the resident's buttocks during incontinent care. <BR/>An observation on 09/28/22 from 8:00AM until 11:00AM revealed Resident #3 was placed in his wheelchair without a dressing covering his coccyx wound.<BR/>In an interview on 09/28/22 at 10:00AM, LVN C said the treatment nurse was responsible for completing wound treatments. She said when the treatment nurse was not working, the floor nurses were responsible for completing wound treatments. LVN C said no one had told her Resident #3 had a wound to his coccyx or that it was uncovered. <BR/>In an interview with CNA A on 09/28/22 at 10:35 AM, she said she did not tell any nurse about Resident #3's wound to his coccyx or that it was uncovered. <BR/>In an interview with CNA B on 09/28/22 at 11:35 AM, CNA B said she did not tell a nurse about Resident #3's wound to his coccyx or that it was uncovered because it was a small wound not a real wound. <BR/>In an interview on 09/29/22 at 10:30 AM, the CNA Scheduler said she notified the DON after breakfast on 09/28/22 that there was not a dressing on Resident #3's wound. <BR/>In an interview on 09/28/22 at 10:40 AM, the DON said she was about to complete wound care for Resident #3. She said CNA A, CNA B, and the CNA Scheduler had notified her Resident #3 had a wound to his coccyx which was not covered. She said she asked them to notify her when they laid the resident in bed so that she could complete his wound care. <BR/>In an observation on 09/28/22 at 11:00AM, Resident #3 was laid in bed and the DON completed wound care to his coccyx wound with MediHoney (a type of gel wound dressing) and covered the wound with an adhesive border dressing. The DON measured the wound and obtained as measurements: length 3cm, width 0.8cm, and depth 0.1cm<BR/>Review of Resident #69's MDS dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included muscle wasting and atrophy, cognitive communication deficit, morbid obesity, protein calorie malnutrition, and edema. Her BIMS score was 99 and indicated the resident was unable to complete the assessment. Resident was totally dependent for toilet use and required extensive assistance with personal hygiene, bed mobility, and transfers. Resident #69 was assessed as at risk for pressure ulcers but did not have any unhealed pressure ulcers. <BR/>Review of Resident #69's undated care plans reflected she required extensive assistance by 2 staff for bed mobility, toileting, and transfers. She did not have a care plan for pressure wounds. <BR/>Review of Resident #69's order summary report dated 09/28/22 reflected the following orders:<BR/>1. <BR/>07/24/22- clean coccyx with normal saline and pat dry then apply alginate and cover one time a day for wound change dressing daily and prn until healed<BR/>2. <BR/>07/24/22- clean right buttock with NS and pat dry. Apply hydrogel and cover change daily and PRN until healed one time a day for wound<BR/>3. <BR/>09/28/22- clean buttocks with NS apply barrier cream pat dry apply comfort foam border change every 3 days and PRN every 72 hours for wound care<BR/>4. <BR/>09/28/2022- clean coccyx stage II with NS apply barrier cream pat dry apply comfort foam border change every 3 days and PRN every 72 hours for wound care<BR/>Review of Resident #69's September 2022 TARs reflected the ordered wound treatment to her coccyx and right buttocks was documented as completed on 09/03/22, 09/09/22, 09/11/22, 09/12/22, and 09/13/22. All other dates from 09/01/22 until 09/28/22 were blank. <BR/>An observation on 09/29/22 at 2:10PM, revealed Resident #69 had one large dressing to both her buttocks and coccyx dated 09/29/22. The DON removed the dressing. Resident #69's bilateral buttocks were bright pink and excoriated. Her coccyx had an opening which measured length 0.8cm, width 0.2cm, and depth 0.1cm. <BR/>In an interview on 09/29/22 at 3:11 PM, LVN E said she was the facility's treatment nurse and had worked at the facility for 3 weeks. LVN E said she was not wound care certified. LVN E said she had been working as a direct care nurse the majority of the time and had worked 16 hour shifts from 2PM to 6AM on 09/26/22, 09/27/22, and 09/28/22. LVN E said when she first started at the facility, she assessed Resident #3 and he did not have any wounds to his buttocks, coccyx, or sacrum. LVN E said on 09/24/22, a CNA told her Resident #3 had something on his bottom, and when she assessed, she noted some kind of maceration (moist skin) and when she completed a second skin assessment, the wound to Resident #3's coccyx had opened. LVN E said there was not a wound physician at the facility but there was a wound care specialist with whom she could complete telehealth visits with if she had a question about a wound or treatment. LVN E said if she was not at the facility, the floor nurses were supposed to do the wound care and they [were] aware of that. LVN E said she wound be notified by the CNAs if there were any new wounds that she needed to be treating but she was not sure if the CNAs told the floor nurses as well. LVN E said she should have discontinued the order for wound care to Resident #3's area to the right of his coccyx which was initiated on 06/06/22 when she assessed and noted the wound had healed. LVN E said Resident #69's buttocks were excoriated, but she did not have any open skin, or she was not told that her skin was open. LVN E said when she first started, she was briefed on several things that were behind and was going from unit to unit checking on all residents and she was trying her best to check as many people as [she] could. LVN E said she could not do her job because she was working as a direct care floor nurse, but even if the treatment nurse was not there, the orders needed to be followed because wounds could worsen if treatments were not provided as ordered. <BR/>In an interview on 09/29/22 at 3:28 PM, the DON said she expected CNAs to notify a nurse if they saw a wound without a dressing because it could be a new wound or if there was an ordered dressing that needed to be applied. The DON said CNA A, CNA B, and the CNA Scheduler should have notified the nurse before placing Resident #3 in his wheelchair on 09/28/22 so the nurse could assess and complete the treatment, or the wound could get worse. The DON said ordered wound care for Resident #3 which was initiated on 06/06/22 should have been discontinued by either the treatment nurse or the floor nurse because the wound had healed and there was nothing to put it on. The DON said she was concerned nurses were documenting that treatment for Resident #3's wound to the right of his coccyx was being done when it was healed. The DON said LVN E started as the treatment nurse on 08/30/22 but she had been working the floor. The DON said when the treatment nurse was not present, each floor nurse was responsible for completing ordered wound care. The DON stated she completed wound care for Resident #3 on 09/28/22 and she noted a wound to his coccyx and shearing to his right buttocks. The DON said the reason for the discrepancy in documenting wounds to the right of Resident #3's coccyx and a wound to Resident #3's coccyx could be because different people could see different things and one person may see the wound as more to the right of the coccyx and another may see it more midline on the coccyx. The DON said the facility did not work with a wound physician, but they worked with a wound care consultant who was a PT and certified wound specialist, PT F. The DON said they would do telehealth visits with PT F and could show her the wounds with the iPad. The DON said they also asked PT F for advice on treatment but would get their treatment orders from the NP. <BR/>Review of the facility's policy, .Skin Integrity Prevention and Treatment Program, dated revised 02/2022, reflected: Weekly assessments looking for new wounds- completed by a licensed nurse . If a new area is found . complete new wound evaluation/ assessment . Notify MD- obtain treatment orders . Referrals to therapy, dietician or other consultants as deemed necessary . Monitor weekly . Each identified skin issue/area is assessed weekly in electronic medical record. If treatment or interventions change or wound presentation is reclassified . update care plan .<BR/>Review of the facility's policy, . Pressure Injury Prevention Program, dated revised 10/2022, reflected: . The following is a list of commonly used interventions to possibly prevent the development of pressure injuries . Frequent turning and repositioning .Keep resident clean and dry. Provide incontinent care as appropriate . If new area found . Assessment must include . Size. Location. Drainage amount . Wound bed description. Wound edge and surrounding tissue description .<BR/>Review of the facility's policy, Perineal Care Policy and Procedure, dated revised 10/2020, reflected, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition . Report any red or open areas to nurse .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #1) of three residents observed for infection control.<BR/>CNA A failed to ensure Resident #1's Foley catheter did not pull or hang from the resident during incontinence care. <BR/>This failure could place residents at risk for infection and or trauma at the catheter site. <BR/>Findings included:<BR/>Review of Resident #1's MDS, dated [DATE], reflected he was admitted on [DATE]. He was 72 years' old. He had a diagnosis of stroke. The resident was incontinent of urine and stool and had an indwelling catheter . <BR/>An interview and observation on 09/13/23 at 11:55 AM with Resident #1 revealed he was lying in bed with his blanket pulled back. He was alert and able to answer questions. He was wearing a brief and was incontinent of a large amount of stool that was spilling from his brief. He said he was waiting for staff to come change him. He had a Foley catheter hanging off the bed frame of his bed. The Surveyor notified the staff that the resident was incontinent of stool. At 12:00 PM, CNA A entered Resident #1's room. CNA A drained cloudy, yellow urine from the Foley catheter into a urinal and dumped it into the toilet. CNA A unfastened the resident's brief and there was green stool all over it. CNA A used wipes to cleanse the resident's peri-area and catheter tubing. CNA A removed the Foley catheter bag from the bed frame and placed the Foley catheter bag on the floor. At 12:15 PM, CNA C entered the resident's room. CNA C performed hand hygiene and put on gloves. CNA A was still wearing her same gloves. The resident was turned onto his right side. The Foley catheter was not secured to his leg and was hanging from him over the side of the bed. CNA A and CNA C cleaned the resident's stool off his body. CNA C removed her gloves and put on new gloves. CNA A was still wearing the same gloves. The resident was rolled to his left side and the Foley catheter continued to hang from the resident and off the side of the bed. CNA A continued to clean the resident. The Foley catheter was cleaned and was in the penis. The penis meatus (area of the penis next to the urethra) was torn all the way down the penis shaft (old injury per ADON.) CNA A continued to clean the resident. The Surveyor asked the WCN, who had entered the room, if it was okay for the Foley bag to be hanging from the resident . The WCN said no and instructed CNA A to place the bag on the bed frame. CNA A moved to get a clean brief. CNA A put on the resident's clean brief.<BR/>An interview on 09/13/23 at 1:20 PM with the ADON revealed during incontinence care, the Foley bag should stay at the end of the bed at bladder level so that it did not get pulled or kinked. <BR/>An interview on 09/14/23 at 1:50 PM with CNA A and the ADON revealed CNA A was supposed to empty the Foley catheter bag and put it on the bed, so it did not stretch and hurt the resident. CNA A said that during care for Resident #1 she forgot to. CNA A and the ADON said they did not know why Resident #1 did not have a catheter leg strap on. <BR/>Review of the facility's policy Catheter Care, Urinary revised January 2023, reflected, <BR/> . Maintaining Unobstructed Urine Flow<BR/>1. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks.<BR/>2. Unless specifically ordered, do not apply a clamp to the catheter.<BR/>3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .<BR/>Be sure the catheter tubing and drainage bag are kept off the floor .<BR/>Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #16, #28, #40, and #38) of 14 residents reviewed for Respiratory Care.<BR/>1. <BR/>The facility failed to ensure Resident #16's breathing mask for her nebulizer (machine that turns liquid medication into a mist breathed directly into the lungs) was properly stored when not in use on 01/14/2025. <BR/>2. <BR/>The facility failed to ensure that Resident #28's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 01/14/2025.<BR/>3. <BR/>The facility failed to ensure that Resident #40's nasal cannula was properly stored when not in use on 01/14/2025.<BR/>4. <BR/>The facility failed to ensure that Resident #38's nebulizer mask (medication is inhaled through) was properly stored when not in use on 01/14/2025. <BR/>These failures could place residents at risk for respiratory infection and not having their respiratory needs met.<BR/>Findings included: <BR/>1. <BR/>Record review of Resident #16's Face Sheet, dated 01/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 was diagnosed with anemia (low blood cells).<BR/>Record review of Resident #16's Comprehensive MDS Assessment, dated 11/24/2024, <BR/>reflected the resident had a score of 99 on her BIMS summary score suggesting that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident had anemia.<BR/>Record review of Resident #16's Comprehensive Care Plan, dated 11/04/2024, reflected the resident tested positive for COVID on 01/25/2022 and one of the interventions was to observe for signs and symptoms of respiratory issues.<BR/>Record review of Resident #16's Physician Orders, dated 11/02/2024, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for SOB ONE VIAL Q 4-7 HOURS.<BR/>An observation on 01/14/2025 at 9:20 AM revealed Resident #16 was in her bed, awake. A nebulizer machine was observed beside the room's sink. Beside the nebulizer machine was a breathing mask that was not bagged. The part of the breathing mask that would touch the face when using was touching a bottle of sanitizer. Resident #16 did not respond when asked how long she had been using the breathing mask.<BR/>In an interview with LVN C on 01/14/2025 at 11:33 AM, LVN C stated he was not sure for whom the breathing mask was. He opened the profiles of both residents occupying the room. He said the breathing mask was for Resident #16. He said the order was to administer as needed. He went inside the room and saw the unbagged breathing mask beside the room's sink. He said he did not notice during his rounds that the breathing mask was not inside a bag. He said it should be bagged to prevent cross contamination. He said the issue was not if the resident was using it or not, the breathing mask should be bagged. LVN C went to the storage room and took a new breathing mask and a plastic bag. <BR/>In an interview with the DON on 01/15/2024 at 11:03 AM, the DON stated the breathing mask was supposed to be in a bag when the resident was not using it to prevent cross contamination and worsening of respiratory issues the resident might already had. He said the expectation was for the staff to be mindful and make sure the breathing was bagged when the resident was not using it. He said it did not matter if the order was daily or as needed, the breathing mask must be in a bag or do not leave a breathing mask inside the room and just get one if needed by the resident. He said he would conduct an in-service about respiratory care.<BR/>In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated everything the residents were using should be kept clean to prevent infection. She said she would coordinate with the DON to educate and re-educate the nursing staff to bag the breathing mask if not in use. She said the DON will also in-service the staff about the respiratory care issue.<BR/>2. <BR/>Review of Resident #28's Face Sheet, dated 01/16/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #28 had a diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). <BR/>Review of Resident #28's Quarterly MDS Assessment, dated 07/05/2024, reflected resident had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility.<BR/>Review of Resident #28's Comprehensive Care Plan, dated 10/22/2024, reflected resident has oxygen therapy r/t ineffective gas exchange. Interventions included For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus. Give medications as ordered by physician. Monitor/document side effects and effectiveness.<BR/>Review of Resident #28's Physician Order, dated 04/24/2024, reflected O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 LPM to keep O2 sat &gt;90% every shift. <BR/>An observation on 01/14/2025 at 09:52 AM revealed Resident #28 lying in bed with her eyes closed. Resident #28's wheelchair was next to the bed with a portable oxygen cannister on the back of the wheelchair. Resident #28 was receiving oxygen at 2 LPM (rate of oxygen flow) via the nasal cannula tubing connected to the oxygen cannister on the wheelchair. The resident's oxygen concentrator was next to the head of the bed. The oxygen tubing connected to the concentrator was on the floor between the concentrator and the nightstand. The tubing was not bagged. <BR/>3. <BR/>Review of Resident #40's Face Sheet, dated 01/16/25, reflected Resident #40 was a [AGE] year-old female admitted on [DATE]. Resident #40 had a diagnosis of chronic obstructive pulmonary disease.<BR/>Review of Resident #40's Physician Orders, dated 09/09/24, reflected O2 at 2 liters per minute via nasal cannula PRN. May titrate to 2-4 LPM to keep 02 sats &gt;92% as needed for Shortness of Breath, Wheezing, 02 sat less than 90%. Obtain vital signs BID two times a day document vs q shift. <BR/>Review of Resident #40's Quarterly MDS Assessment, dated 11/01/2024, reflected resident had a moderate impairment in cognition with a BIMS score of 08. Section I reflected resident was treated for chronic obstructive pulmonary disease.<BR/>Review of Resident #40's Comprehensive Care Plan, dated 11/02/2024, reflected resident has oxygen therapy. O2 at 2 liters per minute via nasal cannula PRN. May titrate to 3-4 LPM to keep O2 sats &gt;90%. One intervention was monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate.<BR/>An observation on 01/14/25 at 10:04 AM revealed an oxygen concentrator in Resident #40's room. The concentrator was next to a cabinet with drawers. Oxygen tubing was connected to the concentrator and placed in the top drawer of the cabinet. The oxygen tubing was not bagged. <BR/>4. <BR/>Review of Resident #38's Face Sheet, dated 01/16/25, reflected Resident #38 was a [AGE] year-old male. Resident #38 admitted on [DATE] with asthma (chronic lung disease causing the airway to narrow and can make breathing difficult) and shortness of breath.<BR/>Review of Resident #38's Quarterly MDS Assessment, dated 11/25/24, reflected Resident #38 had intact cognition with a BIMS score of 15. Section I reflected Resident #38 was treated for asthma and shortness of breath. <BR/>Review of Resident #38's Comprehensive Care Plan, dated 10/23/24, reflected the resident has unspecified asthma. One intervention was to give nebulizer treatments as ordered. <BR/>An observation on 01/14/25 at 8:45 am revealed a nebulizer on Resident #38's nightstand. The nebulizer mask was connected to the nebulizer and the mask was placed on top of the nebulizer. It was not stored in a bag. <BR/>In an interview on 01/14/25 at 09:55 AM, LVN D stated the oxygen tubing should have been bagged to prevent contamination. She removed the tubing and stated she was going to get new oxygen tubing. <BR/>In an interview on 1/14/25 at 09:58 AM, CNA F stated the oxygen tubing should have been stored in a bag to keep it clean. <BR/>In an interview on 01/14/25 at 10:35 AM, the DON stated the oxygen tubing and nebulizer masks should have been stored in bags when not used to prevent contamination. The DON stated he was going to follow up with the nurses to be sure those were corrected. <BR/>During an interview on 01/14/25 at 10:42 AM, LVN E stated all respiratory items should have been bagged when not in use to prevent contamination and infection. <BR/>In an interview on 01/16/24 at 10:45 AM, the ADON stated respiratory items were to be stored in bags when residents were not using them. She stated she tells the nurses if oxygen tubing is found on the floor, throw it away and get new tubing. She said her expectation is for all oxygen tubing and nebulizer masks to be stored in bags at all times when not in use by a resident. She stated this was an important measure to prevent contamination of these items. <BR/>After record review of the facility's policy for Oxygen Administration on 01/16/2025 at 10:44 AM, a policy for bagging the nasal cannula and breathing mask was verbally requested on 01/16/2025 at 10:54 AM but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (Rooms #1, #2, #3, #4, #5, and #6) of 10 resident rooms and the hallway floors reviewed for cleanliness and sanitization.<BR/>The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized.<BR/>This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. <BR/>Findings included:<BR/>An observation on 01/14/25 at 10:35 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. <BR/>An observation on 01/14/25 at 10:39 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. The bottom of the bedside table had red stains on it.<BR/>An observation on 01/14/25 at 10:42 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. <BR/>An observation on 01/14/25 at 10:47 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. Inside the mini fridge revealed hairbrushes, a towel, and two sandwiches wrapped in white napkins. <BR/>An observation on 01/14/25 at 10:50 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris.<BR/>An observation on 01/14/25 at 10:53 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. <BR/>In an interview on 01/15/25 at 02:05 PM, the Administrator was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, and #6. She stated housekeeping was responsible for cleaning the outside of the air condition units in the resident rooms. She stated she would consider purchasing hand vacuums to assist with removing the dirt particles between the outer vents. She stated the risk of the area not being addressed could impact residents' respiratory system. <BR/>In an interview on 01/16/25 at 10:10 AM, Housekeeper L stated she had been at the facility 1 year. She was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, and #6. She stated housekeeping was responsible for cleaning the outside of the air condition units in the resident rooms. She stated she had a challenging time removing the dirt particles from between the vents, but she would meet with the house keeping supervisor to see how the units could be clean more thoroughly. She stated the risk of the air condition units not being thoroughly cleaned could impact residents' health.<BR/>In an interview on 01/16/25 at 10:19 AM, Housekeeping Supervisor stated she had been at the facility nearly 3 years. She was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, and #6. She stated she had met with the Administrator on 01/15/25 to solve how to clean the air condition units better. She stated the risk to the residents having the dirty air condition unit could impact their health.<BR/>Review of the facility's policy on Homelike Environment (February 2021) revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. <BR/>2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:<BR/>a. <BR/>clean, sanitary and orderly environment;

Based on record reviews and interviews, the facility failed to employ a certified Dietary Manager or a qualified fulltime dietitian or other clinically qualified nutrition professional for the facility's only kitchen. <BR/>The facility failed to ensure the Dietary Manager met all required state guidelines or employed a full-time dietician, who also assisted in managing the facility kitchen's daily food and nutrition services. <BR/>This failure could impact a resident's ability to receive acceptable and appropriated food and nutrition services. <BR/>Findings include:<BR/>Record review of the facility's documents for a Qualified Dietary Manager revealed the Dietary Manager had not completed qualified certification course that met the requirement of a qualified nutrition professional . The Dietary Manager and facility produced a college enrollment form for the Dietary Manager courses starting from 03/15/23 and completing on 06/20/24.<BR/>Interview with the Dietary Manager on 11/30/23 at 02:05 PM, she stated she was a cook at the facility before being promoted to the Dietary Manager in March 2023. She stated she was very familiar with food storage and kitchen sanitation guidelines, and she always trained the kitchen staff on the guidelines as well. She stated she had started a Dietary Manager course in March 2023 and was scheduled to be completed in June 2024. She stated she was aware of the risks of the facility not having a qualified dietary manager could result in residents missing out on proper nutrition services.<BR/>Interview with the Dietitian on 11/30/23 at 03:20 PM, she stated she had been contracted by the facility since 2020. She stated she was not involved in the management of the facility's only kitchen, and she visited the facility as least quarterly.<BR/>Interview with the Administrator on 11/30/23 at 03:33 PM, she stated she had been at the facility since June 2023. She stated she was aware that the Dietary Manager was currently not a qualified dietary manager. She stated the facility had enrolled the Dietary Manager into a course to complete her certification and she was scheduled to be completed in June 2024. She stated she works closely with the Dietary Manager to ensure the kitchen was meeting all guidelines; however, she understood that the risk of the facility not having a qualified dietary manager could result in residents missing nutrition services and proper kitchen sanitation. The Administrator stated she had not documents related to qualified dietary manager requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient needs for 1 of 3 residents (Resident #59) reviewed for hospice services. <BR/>The facility failed to ensure Resident #59's hospice care was care planned. <BR/>This failure could place residents at risk of needs not being met. <BR/>Findings include :<BR/>Record review of Resident #59's Face Sheet, dated 11/30/23, revealed he was a 93 -year-old male admitted on [DATE]. Relevant diagnoses included Permanent Atrial Fibrillation (irregular heartbeat), and Rheumatic Tricuspid Insufficiency (heart valve complications ). <BR/>Record review of Resident #59's records in the facility's system of records indicated the resident was moved to hospice services on 10/12/23 .<BR/>Review of Resident #59's Comprehensive Care Plan revised on 08/24/2023 reflected no care plan for hospice care.<BR/>Interview on 11/30/23 at 11:45 AM with Social Services, she stated she that it was primarily the MDS Nurse's responsibility to enter data such as a resident receiving hospice care, and she was the backup. She stated that Resident #59 was on hospice, and he should have been care planned for it. She stated that they were still working on a process to ensure care plans are updated timely and appropriately. She stated the risk of the resident not being care planned for hospice could result in missed care.<BR/>Interview on 11/30/23 at 12:11 PM with the ADON, she stated she had been the ADON for a year. She stated Resident #59 was receiving hospice care and it should be care planned. She stated that she was unsure how it was overlooked during their care plan meetings, and she stated that it was the responsibility of the MDS Nurse to update any changes to the care plan. She stated the risk of the resident not having the hospice services could result in the resident not receiving all of the care hospice provided.<BR/>Interview on 11/30/23 at 01:00 PM with the MDS Nurse, she stated she was not aware that Resident #59 was on hospice and was just made aware of this on 11/29/23. She stated she did not know how the resident was overlooked. She stated they usually received communication from the business office that the resident had been placed into hospice and then they are notified, and the hospice is care planned. She stated she had updated the resident's care plan to reflect the hospice care. She stated the risk of the resident not having hospice services care planned it that the resident may miss out of services he should be receiving.<BR/>Record review of facility's policy on Care Planning, dated January 2023, stated The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (Rooms #1, #2, #3, #4, #5, and #6) of 10 resident rooms and the hallway floors reviewed for cleanliness and sanitization.<BR/>The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized.<BR/>This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. <BR/>Findings included:<BR/>An observation on 01/14/25 at 10:35 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. <BR/>An observation on 01/14/25 at 10:39 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. The bottom of the bedside table had red stains on it.<BR/>An observation on 01/14/25 at 10:42 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. <BR/>An observation on 01/14/25 at 10:47 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. Inside the mini fridge revealed hairbrushes, a towel, and two sandwiches wrapped in white napkins. <BR/>An observation on 01/14/25 at 10:50 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris.<BR/>An observation on 01/14/25 at 10:53 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. <BR/>In an interview on 01/15/25 at 02:05 PM, the Administrator was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, and #6. She stated housekeeping was responsible for cleaning the outside of the air condition units in the resident rooms. She stated she would consider purchasing hand vacuums to assist with removing the dirt particles between the outer vents. She stated the risk of the area not being addressed could impact residents' respiratory system. <BR/>In an interview on 01/16/25 at 10:10 AM, Housekeeper L stated she had been at the facility 1 year. She was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, and #6. She stated housekeeping was responsible for cleaning the outside of the air condition units in the resident rooms. She stated she had a challenging time removing the dirt particles from between the vents, but she would meet with the house keeping supervisor to see how the units could be clean more thoroughly. She stated the risk of the air condition units not being thoroughly cleaned could impact residents' health.<BR/>In an interview on 01/16/25 at 10:19 AM, Housekeeping Supervisor stated she had been at the facility nearly 3 years. She was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, and #6. She stated she had met with the Administrator on 01/15/25 to solve how to clean the air condition units better. She stated the risk to the residents having the dirty air condition unit could impact their health.<BR/>Review of the facility's policy on Homelike Environment (February 2021) revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. <BR/>2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:<BR/>a. <BR/>clean, sanitary and orderly environment;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents' bed was free from any physical or chemical restraints imposed for purposes of discipline or convenience for 4 (Resident #1, #5, #25, and #29) of 5 residents reviewed for physical restraints,<BR/>The facility failed to obtain physician orders or a physician assessment as of 01/16/25 for Residents #1, #5, #25, and #29, for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. <BR/>This failure could prevent residents from having an environment that was free from any physical or chemical restraints.<BR/>Findings included:<BR/>Resident #1<BR/>Record review of Resident #1's Face Sheet, dated 01/16/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included restlessness and irritation, and cerebral palsy (movement disorder). <BR/>Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a Brief Interview for Mental Status (BIMS) score of 00, (severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance.<BR/>Record review of Resident #1's physician's orders, dated 01/14/25, reflected no physician's orders for a scoop or bolster mattress. <BR/>Record review of Resident #1's Comprehensive Care plan, dated 01/15/25, reflected air mattress with boosters as an intervention for fall prevention.<BR/>Resident #5<BR/>Record review of Resident #5's Face Sheet, dated 01/16/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included repeated falls, muscle weakness, and lack of coordination. <BR/>Record review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 04, (severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance.<BR/>Record review of Resident #5's physician's orders, dated 01/15/25, reflected no physician's orders for a scoop or bolster mattress. <BR/>Record review of Resident #5's Comprehensive Care plan, dated 0/18/24, reflected no scoop or bolster mattress as an intervention for fall prevention.<BR/>Resident #25<BR/>Record review of Resident #25's Face Sheet, dated 01/16/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included repeated adult failure to thrive, muscle weakness, and lack of coordination. <BR/>Record review of Resident #25's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 06, (severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance.<BR/>Record review of Resident #25's physician's orders, dated 01/15/25, reflected no physician's orders for a scoop or bolster mattress. <BR/>Record review of Resident #25's Comprehensive Care plan, dated 0/18/24, reflected no scoop or bolster mattress as an intervention for fall prevention.<BR/>Resident #29<BR/>Record review of Resident #29's Face Sheet, dated 01/16/25, reflected he was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included seizures, muscle weakness, and lack of coordination. <BR/>Record review of Resident #29's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 00, (severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance.<BR/>Record review of Resident #29's physician's orders, dated 01/14/25, reflected no physician's orders for a scoop or bolster mattress. <BR/>Record review of Resident #29's Comprehensive Care plan, dated 0/18/24, reflected a scoop mattress as an intervention for fall prevention.<BR/>Observations on 01/14/25 from 10:00 AM to 11:00 AM, revealed Residents #1, #5, #25, and #29 had a scoop or bolster mattress on their bed, which restricted their movement in bed.<BR/>In an interview on 01/15/25 at 10:00 AM, LVN D and the DON were asked if Residents #1, #5, #25, and #29 had physicians' orders for a bolster and scoop mattress, and the DON stated he was not sure, but he would check. After checking, he stated the residents did not have physicians' orders, which would be required for the residents to have a scoop or bolster mattress. The DON stated the physician would need to complete an assessment to ensure that the scoop or bolster mattress would not injure or restrain the resident. <BR/>The facility's policy Physical Restraints and Involuntary Seclusion (03/2023) reflected Patients/Residents have the right to be free from any physical restraint imposed for purposes of discipline or convenience and when not required to treat the patient's/resident's medical condition. Patients/Residents have the right to function at their highest practicable level in the least restrictive environment possible.