Every finding on record at Sage Park San Antonio

Based on observations, interviews and record reviews, 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 disease and infections for 4 of 29 residents (Residents #38, #39, #8 and #3) reviewed for incontinent care. 1. facility failed to ensure LVN C sanitized the blood pressure cuff when she used it between two residents (Residents #38 and #39) during medication pass. 2. The facility failed to ensure CNA D discarded her soiled gloves, sanitized her hands and put clean gloves on when she placed Resident #8's soiled brief in the trash can and continued to place clean items onto the resident. 3. The facility failed to ensure CNA D retracted Resident #3's foreskin on his penis and to clean his buttock and anal area completely. These deficient practices could place residents at risk of cross contamination and infections.The findings included: Observation on 01/08/2026 at 08:40 am revealed LVN C took the blood pressure for Resident #38 who received blood pressure medication and then proceeded to Resident #39 who received blood pressure medication and did not sanitize the blood pressure cuff between residents. During an interview on 01/08/2026 at 08:45 am, LVN C stated she forgot to sanitize the blood pressure cuff between residents. She stated not sanitizing the blood pressure cuff could cause cross contamination and spread infection. She stated she had training on infection control and knew she had to sanitize equipment. 2. Record review of Resident #8's electronic face sheet, dated 01/06/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: hypertensive heart disease with heart failure (long term condition that develops due to unmanaged high blood pressure and can lead to heart failure, thickening of the heart muscle and other serious health issues), anxiety disorders (a group of mental disorders characterized by significant and uncontrollable feelings of nervousness and fear that interferes with daily life), and pain (physical discomfort). Record review of Resident #8's quarterly MDS assessment dated [DATE] reflected she rarely understood and sometimes was able to understand. She was not a candidate for a BIMS which signified her cognitive status was severely impaired. Resident #8 was dependent on staff for her ADLs. She had an indwelling urinary catheter and was always incontinent of bowel. Record review of Resident #8's comprehensive person-centered care plan dated 09/04/2025 reflected Focus, has bowel incontinence, interventions, check resident every two hours and assist with toileting as needed. Further review of Resident #8's comprehensive care plan dated 10/06/2025 reflected she had a urinary tract infection and was placed on antibiotics. Observation on 01/08/2026 at 10:20 am revealed CNA D and CNA E performed incontinent care for Resident #8. CNA E wiped Resident #8's groin area, split labia, wiped the front to back and cleaned the buttocks and anal area. She then changed gloves and sanitized hands to position the resident toward CNA D, who took the dirty brief off the bed, put it in the trashcan near the bed, and continued to place the clean brief onto the resident without changing her soiled gloves or sanitizing her hands. During an interview on 01/08/2026 at 10:30 am, CNA D stated she was trained on infection control and knew she should have discarded the soiled gloves and sanitized her hands prior to working with clean items. She stated cross contamination could result in an infection for the residents. She stated she did not know why she did not sanitize her hands or change gloves. 2. Record review of Resident #3's electronic face sheet, dated 01/07/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: acute respiratory failure with hypoxia (severe impairment of gas exchange in the lungs, leading to low oxygen levels in the blood), muscle weakness (loss of muscle strength), anemia (not having enough health red blood cells to carry oxygen to the body's tissues), atrial fibrillation (irregular and rapid heart rhythm) and heart failure (chronic and progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of Resident #3's admission MDS assessment dated [DATE], reflected he could understand and be understood. He scored a 15 of 15 on his BIMS which indicated his cognitive status was intact. He was dependent on staff for the ability to maintain perineal hygiene. He was always incontinent with bowel and bladder. Record review of Resident #3's comprehensive person-centered care plan dated 11/26/2025 reflected Focus, risk for impaired skin integrity, interventions, evaluate for bladder and bowel incontinence, Focus, risk for infection, interventions, educate resident/representative on techniques to prevent infection. Record review of Resident #3's Active Orders as of : 01/07/2026 reflected, apply Zinc (vital mineral essential for wound healing) barrier cream to bilateral buttocks with brief change. Observation on 01/08/2026 at 11:20 am revealed CNA D and CNA E performed incontinent care for Resident #3. CNA D wiped around Resident #3's penis and genital area without pulling back his foreskin to clean his penis. She left dried feces on his buttock area near his thighs after cleaning his anal area. During an interview on 01/08/2026 at 11:30 am, CNA D stated she was trained to pull back the foreskin on uncircumcised males who required incontinent care and to clean the penis. She stated she did not know why she did not do that, and not cleaning under the foreskin could cause infection. She stated Resident #3's stools were sometimes thick, sticky, and difficult to clean off his skin. She stated it was important for the resident to be clean because he could get an infection or have skin irritation. During an interview on 01/08/2026 at 12:00 pm, Resident #3 stated he trusted the staff to provide him with good care, and he thought he was cleaned. He stated he would receive a shower the following day. During an interview on 01/09/2026 at 2:23 pm, the DON stated CNA D should have pulled back Resident #3's foreskin on his penis when he received incontinent care to ensure he was clean and to prevent infection and she needed to completely clean the feces off his skin. She stated Resident #3 could have skin breakdown. She stated she was accountable for the nursing care in the facility and the CNA was trained in infection control and incontinent care. She added LVN C should have sanitized the blood pressure cuff between residents to prevent cross contamination and CNA D needed to change gloves and sanitize hands after throwing the soiled brief away when she performed incontinent care for Resident #8. Record review of Wellness Associate CNA Competency Appraisal for CNA D dated 04/16/2025 reflected Assist residents as needed to include continence management. Follows established safety regulations, including infection control. She was noted to have passed the competencies. Record review of the facility's policy and procedure titled Incontinent Care dated 07/01/2025 reflected, purpose, to remove feces/urine, to maintain skin integrity/comfort and to promote dignity. Procedure, Perineal Care, Male, pull foreskin back of the uncircumcised male to clean the area (be careful to push foreskin back in place after drying well. Record review of the facility's policy and procedure titled Cleaning-Contamination dated 07/10/2020 reflected Clean contaminated surfaces in accordance with CDC recommendations between resident use. Record review of the facility's policy and procedure titled Handwashing dated 07/10/2020 reflected When to wash hands, before and after direct contact with residents, after handling any soiled equipment or linens and after removing gloves. Review of Environmental Cleaning Procedures | HAIs | CDC dated 03/19/2024 reflected shared equipment, clean and disinfect before and after each use.

Based on observation, interview, and record review, the 1 of 1 kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. 1-The facility failed to have four kitchen staff complete their food handler certificates (Cook-I, DA-J, DA-K, DA-L) These failures could place residents at risk for food borne illness. The findings included: During an interview on 1/8/26 at 1:10pm with the Executive Chef she stated not having the four identified staff (Cook-I, DA-J,DAK,DA-L) completed their Food Handlers Certificates was an oversight. Record review of the Dietary Staff's Food Handler Certificates revealed four kitchen staff had not completed their Food Handler Certificates (Cook-I, DA-J, DA-K, and DA-L) Review of the Texas Food Code revealed the following: The Texas Department of State Health Services (TXDSHS) requires that all food employees must successfully complete an accredited food handler training course within 60 days of employment The training courses teach employees about food safety, including good hygiene practices and how to avoid cross-contamination

Based on observation, interview, and record review, the 1 of 1 kitchen failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen. 1. The facility failed to clean two wall vents which measured approximately 4x2 ft which were located across from the kitchen's freezer. 2. The facility failed to clean a 3x3 ft ceiling vent in the dry storage room. 3. The facility failed to clean a 3x3 ft ceiling vent located at the entrance to the dish room. 4. The facility failed to maintain proper hair restraints on two kitchen employees (Cook-G and DA-H) 5. The facility failed to maintain the required dish machine rinse temperature, and only reached 110 degrees Fahrenheit. 6.-The facility failed to clean the top surface of the dish machine in the kitchen's pantry room. 7.-The facility failed to repair the brown stained ceiling markings around the sprinkler head in the kitchen's pantry room. These failures could place residents at risk for food borne illness. The findings included: 1-Observation on 1/6/26 from 9:15am-9:55am with the Cook-G revealed the following:a- two wall vents which measured approximately 4x2 ft across from the kitchen's freezer that had dust and dirt on the ventsb- a 3x3 ceiling vent in the dry storage room that had dust and dirt on the vent's outer surface.c- a 3x3 ceiling vent located at the entrance to the dish machine room that had dust and dirt on the vent's outer surface.d- two kitchen staff (Cook-G and Dietary Aide-H) were not wearing hair restraints over the beards.e- the dish machine after running three cycles did not reach the required rinse temperature for a cold rinse machine of 120 degrees Fahrenheit. During each cycle the dish machine only reached 110 degrees Fahrenheit. f- the top surface of the dish machine in the kitchen's pantry had dirt particles on the surface.f- there were numerous brown stain markings on the ceiling around the sprinkler head in the kitchen's pantry. During an interview on 1/6/26 at 10:25am with [NAME] G and Clinical Specialist they stated having clean ceiling vents and wearing beard restraints would prevent dust and hair particles from falling on the kitchen's floor surface or onto prepared food and having the proper dish machine rinse temperature would ensure kitchen plates and silverware were properly cleaned. During an interview on 1/8/26 at 1:10pm the Executive Chef stated that she had not placed a work order for kitchen vents to be cleaned. The Executive Chef stated that the dish machine was a low rinse machine and the required rinse temperature was 120 degrees. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of the facility's policy, Sanitation, revised January 2024, revealed, The food service area shall be maintained in a clean and sanitary manner. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the facility's policy titled-Cleaning-Keeping the Floors, Walls, and Ceilings Clean dated 7/10/20 revealed Floors, walls, and ceiling must be free of dirt, letter, and moisture.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 2 of 27 resident rooms on (rooms [ROOM NUMBERS]) and the beauty salon and laundry room reviewed for environmental concerns.1-The facility failed to replace an overhead bathroom sink light cover in room [ROOM NUMBER].2-The facility failed to replace an overhead bathroom sink light cover in room [ROOM NUMBER].3-The facility failed to clean an 18 x 18 ceiling air vent in the beauty salon.4-The facility failed to clean an 18 x 18 ceiling air vent in the laundry room. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.The findings included: Observations during rounds on 1/8/26 from 12:15pm to 12:25pm with the Administrator and Environmental Services Director revealed the following:a-In resident room [ROOM NUMBER] there was a missing light cover on 1 of 4 bathroom sink overhead lights.b-In resident room [ROOM NUMBER] there was a missing light cover on 1 of 4 bathroom sink overhead lightsc-In the Beauty Salon there was an 18 x 18 overhead ceiling vent that was stained and had dirt particles.d-In the Laundry room there was an 18 x 18 overhead ceiling vent that was stained and had dirt particles. During an interview on 1/8/26 at 12:30pm with the Administrator and Environmental Services Director, the Environmental Services Director stated he had not received a work order request for repair of the observed areas. The Environmental Services Director stated building repairs had to be completed for facility upkeep and resident safety. The Administrator stated that building repairs were necessary to be done on a timely basis for facility operations. Record review of facility maintenance work orders from 12/1/25 thru 12/31/25 revealed the observed areas for repair were not noted for completion.Record review of the facility's policy titled Preventative Maintenance Program dated 7/10/20 revealed A preventative maintenance program promotes cost-effectiveness throughout the community, enhances the quality of life for residents, and improves the working conditions for associates.

Based on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 16 residents (Resident #8) reviewed for accurate MDS assessments.The Facility failed to ensure Resident #8's fall status was accurately reflected on her quarterly MDS assessment, dated 11/14/2025.This deficient practice could place residents at risk of missed or inaccurate care. The findings include: Record review of Resident #8's electronic face sheet, dated 01/06/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: hypertensive heart disease with heart failure (long term condition that develops due to unmanaged high blood pressure and can lead to heart failure, thickening of the heart muscle and other serious health issues), anxiety disorders (a group of mental disorders characterized by significant and uncontrollable feelings of nervousness and fear that interferes with daily life), and pain (physical discomfort). Record review of Resident #8's quarterly MDS assessment, dated 11/14/2025 reflected she was rarely understood and sometimes was able to understand. She was not a candidate for a BIMS which signified her cognitive status was severely impaired. Resident #8 was dependent on staff for her ADLs. She had an indwelling urinary catheter and was always incontinent of bowel. She was not noted to have any falls since admission/entry or reentry or the prior assessment whichever was more recent. Record review of Resident #8's FRA dated 08/04/2025 reflected she was at risk for falls. Record review of Resident #8's incident report dated 10/06/2025 reflected she was found responsive on the floor with a laceration to her forehead. Record review of the facility incidents and accidents reflected Resident #8 had falls on 10/08/2025 ad on 11/08/2025 prior to her quarterly MDS assessment dated [DATE]. Record review of Resident #8's comprehensive person-centered care plan dated 09/04/2025 reflected Focus, has bowel incontinence, interventions, check resident every two hours and assist with toileting as needed. Further review of Resident #8's comprehensive care plan dated 10/06/2025 reflected she had a urinary tract infection and was placed on antibiotics. Focus, has laceration to forehead r/t a fall, resolved 10/27/2025. No history of falls or fall risk was noted on the care plan to include interventions. Observations on 01/06/2026 at 10:30 am, 01/07/2026 at 08:30 am, 01/08/2026 at 1:00 pm and 01/09/2026 at 2:00 pm revealed Resident #8 was laying in bed in her room with the bed in a low position with floor mats positioned on each side of the bed. During an interview on 01/09/2026 at 2:23 pm, the DON stated she had only been at the facility since October 2025 and was accountable for the MDSs, and at present there was an issue with the MDS nurse, and the MDS nurse was not available for interview. She confirmed stated Resident #8 was at risk for falls and had 2 falls recently with interventions in place. She stated Resident #8's quarterly MDS dated [DATE] was inaccurate and needed to reflect the resident history of falls. She stated an inaccurate MDS assessment could lead to an inaccurate plan of care and provision of care. She stated she did not know why the MDS was inaccurate. During an interview on 01/09/2026 at 2:30 pm with the RNC, he stated an inaccurate MDS assessment could result in missed or inaccurate care provided. He stated the facility did not have an RAI policy and procedure and they followed CMS's User Manual. Record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, dated October 2025 reflected The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status.

Based on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 16 residents (Resident #8) reviewed for comprehensive person-centered care plans.The facility failed to ensure a care plan was developed to address Resident #8 as a fall risk and include interventions to prevent falls. This deficient practice could place residents at risk for falls and could result in injury. The findings include: Record review of Resident #8's electronic face sheet dated 01/06/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: hypertensive heart disease with heart failure (long term condition that develops due to unmanaged high blood pressure and could lead to heart failure, thickening of the heart muscle and other serious health issues), anxiety disorders (a group of mental disorders characterized by significant and uncontrollable feelings of nervousness and fear that interferes with daily life), and pain (physical discomfort). Record review of Resident #8's quarterly MDS assessment dated [DATE] reflected she rarely understood and sometimes was able to understand. She was not a candidate for a BIMS which signified her cognitive status was severely impaired. Resident #8 was dependent on staff for her ADLs. She had an indwelling urinary catheter and was always incontinent of bowel. She was not noted to have had any falls since admission/entry or reentry or the prior assessment whichever was more recent. Record review of Resident #8's FRA dated 08/04/2025 reflected she was at risk for falls. Record review of Resident #8's incident report dated 10/06/2025 reflected she was found responsive on the floor with a laceration to her forehead. Record review of the facility incidents and accidents reflected Resident #8 had falls on 10/08/2025 ad on 11/08/2025 prior to her quarterly MDS assessment dated [DATE]. Record review of Resident #8's comprehensive person-centered care plan dated 09/04/2025 reflected Focus, has laceration to forehead r/t a fall, resolved 10/27/2025. No history of falls or fall risk was noted on the care plan to include interventions. Observations on 01/06/2026 at 10:30 am, 01/07/2026 at 08:30 am, 01/08/2026 at 1:00 pm and 01/09/2026 at 2:00 pm revealed Resident #8 was laying in bed in her room with the bed in a low position with floor mats positioned on each side of the bed. During an interview on 01/09/2026 at 2:23 pm, the DON stated she had only been at the facility since October 2025 and was accountable for the care plans, and at present there was an issue with the MDS nurse who was involved in care planning, and the MDS nurse was not available for interview. She stated Resident #8 was at risk for falls and had 2 falls recently with interventions in place. She stated Resident #8's comprehensive person-centered care plan needed to reflect she was at risk for falls and the interventions such as low bed with a floor mat on both sides of the bed needed to be noted. She stated it could cause injury or harm to the residents if the interventions were not communicated through the care plan. She did not know why this information was not placed in the care plan. During an interview on 01/09/2026 at 2:30 pm with the RNC, he stated the comprehensive care plan for Resident #8 needed to reflect her risk of falls and the interventions required to take care of her. Record review of the facility's policy and procedure titled Care Planning Assessment dated 07/01/2025 reflected Residents will receive initial, quarterly, annual, and significant change assessments according to the State and Federal regulations. In addition, residents will have care plans created that address the individualized needs the resident presents. This process will be accomplished through observations, assessments, and interviews. In addition, quarterly reviews and updated are completed by the Care Plan Team to clarify goals and evaluate effectiveness of interventions.

Based on observation, interviews and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 resident of 2 residents (Resident #3) reviewed for incontinent care. CNA D failed to pull back Resident #3's foreskin to clean his penis during incontinent care. This deficient practice could place residents risk of urinary tract infections (bacteria in the urine) or skin breakdown. The findings include: Record review of Resident #3's electronic face sheet, dated 01/07/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: acute respiratory failure with hypoxia (severe impairment of gas exchange in the lungs, leading to low oxygen levels in the blood), muscle weakness (loss of muscle strength), anemia (not having enough health red blood cells to carry oxygen to the body's tissues), atrial fibrillation (irregular and rapid heart rhythm) and heart failure (chronic and progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of Resident #3's admission MDS assessment dated [DATE] reflected he could understand and be understood. He scored a 15 of 15 on his BIMS which indicated his cognitive status was intact. He was dependent on staff for the ability to maintain perineal hygiene. He was always incontinent with bowel and bladder. Record review of Resident #3's comprehensive person-centered care plan dated 11/26/2025 reflected Focus, risk for impaired skin integrity, interventions, evaluate for bladder and bowel incontinence, Focus, risk for infection, interventions, educate resident/representative on techniques to prevent infection. Record review of Resident #3's Active Orders as of : 01/07/2026 reflected, apply Zinc (vital mineral essential for wound healing) barrier cream to bilateral buttocks with brief change. Observation on 01/08/2026 at 11:20 am CNA D and CNA E performed incontinent care for Resident #3, CNA D wiped around Resident #3's penis and genital area without pulling back his foreskin to clean his penis. During an interview on 01/08/2026 at 11:30 am, CNA D stated she was trained to pull back the foreskin on uncircumcised males who required incontinent care and to clean the penis. She stated she did not know why she did not do that, and not cleaning under the foreskin could cause infection. During an interview on 01/08/2026 at 12:00 pm, Resident #3 stated he trusted the staff to provide him with good care, and he thought he was cleaned. He stated he would receive a shower the following day. During an interview on 01/09/2026 at 2:23 pm, the DON stated CNA D should have pulled back Resident #3's foreskin on his penis when he received incontinent care to ensure he was clean and to prevent infection. She stated she was accountable for the nursing care in the facility. Record review of Wellness Associate CNA Competency Appraisal for CNA D dated 04/16/2025 reflected Assist residents as needed to include continence management. Follows established safety regulations, including infection control. She was noted to have passed the competencies. Record review of the facility policy and procedure titled Incontinent Care dated 07/01/2025 reflected, purpose, to remove feces/urine, to maintain skin integrity/comfort and to promote dignity. Procedure, Perineal Care, Male, pull foreskin back of the uncircumcised male to clean the area (be careful to push foreskin back in place after drying well.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 5 residents (Residents #14 and #15) reviewed for oxygen therapy. The facility failed to replace a dirty and worn oxygen filter in Resident #14's oxygen concentrator, humidifier bottle was not changed and NC tubing was not bagged when not in use. 2. The facility failed to replace a dirty and dusty oxygen filter in Resident #15's oxygen concentrator, nebulizer mask was not bagged when not in use. These deficient practices could places residents at risk of respiratory infection and difficulty breathing.The findings included: Record review of Resident #14's electronic face sheet, dated 01/07/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included: fracture of neck of right femur (a break in the strong bone, just below the ball of the hip joint), muscle weakness (a general lack of strength, where muscles don't contract as powerfully as they should), dysphagia (difficulty swallowing) and Parkinsonism (broad term for a group of neurological conditions causing similar movement problems, slowness, muscle stiffness, tremors and balance issues). Record review of Resident #14's admission MDS assessment dated [DATE], reflected she could understand and be understood. She scored 09 of 15 on her BIMS which indicated her cognitive status was moderately impaired. She required moderate amount of assistance with her ADLs. Record review of Resident #14's Active Orders as of: 01/09/2026 reflected she was ordered O2 at 2LPM via NC at nighttime, start date 01/05/2026. Oxygen tubing changes every Wednesday night and PRN, Clean oxygen filters every Wednesday and PRN. Humidifier cannister change every Wednesday and PRN. Start date was 01/05/2026. Record review of Resident #14's baseline care plan dated 12/18/2025 reflected she was not on oxygen therapy at the time of admission. Observation on 01/06/2026 at 10:00 am revealed Resident #14's oxygen concentrator had a dirty worn and crumbling filter; humidifier bottle was labeled 12/31/2026 and nasal canula oxygen tubing was draped over the concentrator and not in a plastic bag when not in use. Observation on 01/07/2026 at 11:00 am, and 01/08/2026 at 1:00 pm of Resident #14's oxygen concentrator revealed the filter was dirty and worn, the oxygen tubing with the nasal canula was unbagged and lying on the floor near the concentrator, The humidifier bottle was dated 12/31/2025. During an interview on 01/08/2026 at 1:00 pm, Resident #14 stated she used oxygen at night, and the nurses took care of the concentrator. Observation on 01/09/2026, at 11:10 am with the RNC revealed Resident #14's oxygen filter was old, worn, torn, and had dirt and dust on it. The humidifier bottle was dated 12/31/2025, and the oxygen tubing with NC was on the floor next to the concentrator. During an interview on 01/09/2026 at 11:13 am, the RNC stated the oxygen filter on Resident #14's concentrator needed to be changed completely, the unit appeared to be old, and he stated the tubing with the NC needed to be bagged when not in use and the humidifier bottle should have been changed on 01/07/2026. He stated dust and dirt could be an obstacle for the oxygen to be clean and to flow freely and it could result in URI or hypoxia (low oxygen blood level). During an interview on 01/09/2026 at 2:23 pm, the DON stated Resident #14's oxygen concentrator filter should have been checked initially prior to hook up and use, and the oxygen filter should have been replaced. She stated she would put the oxygen care issues into the MAR, so the nurses would be reminded to change the tubing, filter and humidifiers as needed. She stated a dirty and worn filter could cause disruption of air flow and result in respiratory distress or a URI. Information provided by the DON revealed, RN B, who was the charge nurse for Resident #14 on the day shift, was not available for interview. During an interview on 09/09/2026 at 2:55 pm, LVN F, who was the charge nurse for Resident #14 on the evening shift stated nurses were supposed to check the oxygen concentrators and change the humidifier bottles and filters if needed. She stated she did not check Resident #14's filter or humidifier bottle and did not know why she did not. She stated not changing the tubing, filter and humidifier bottle as ordered could result in a URI or shortness of breath. During an interview on 09/09/2026 at 3:10 pm, LVN C stated she took care of Resident #14, and the Resident was out of her room most of the day and used her oxygen in the evening. She stated the tubing should be bagged when it was not in use and the filter and humidifier bottle needed to be checked and changed as ordered to prevent infection. Record review of Resident #15's electronic face sheet, dated 01/07/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: acute respiratory failure with hypoxia (condition where there is insufficient oxygen in the blood, causing respiratory distress), metabolic encephalopathy (diffuse brain dysfunction), chronic obstructive pulmonary disease (COPD) (lung and airway disease that restricts breathing) and acute pulmonary edema (accumulation of blood in the pulmonary tissue). Record review of Resident #15's admission MDS assessment dated [DATE], reflected she could understand and be understood. She required moderate assistance with her ADLs. She scored 14 of 15 on her BIMS which indicated her cognitive status was intact. She was noted to receive continuous oxygen therapy while a resident and received respiratory therapy at least 15 minutes per day. Record review of Resident # 15's comprehensive person-centered care plan dated 09/23/2025 reflected Focus, has oxygen therapy r/t acute respiratory failure/COPD, interventions, clean oxygen filter every Wednesday and PRN, O2 via NC at 5-7L/min continuously with humidified cannister. Observation on 01/06/2026 at 10:53 am revealed Resident #15, in her room and oxygen was set at 6L/min via NC, the concentrator filter dirty with dust. The nebulizer mask was not bagged. Observation on 1/07/2026 at 11:00 am revealed Resident #15 received her nebulizer treatment and returned to her room at 1:00 pm the nebulizer mask was not bagged after her treatment. During an interview on 01/07/2026 at 11:05 am, Resident #15 stated she was on oxygen for her breathing and had nebulizer treatments. She stated the nurses were the ones who checked her equipment. During an interview on 01/09/2026 at 2:23 pm, the DON stated Resident #15's oxygen concentrator filter should have been checked initially prior to hook up and use, and the oxygen filter should have been replaced on admission. She stated she would put the oxygen care issues in the MAR, so the nurses would be reminded to change the tubing, filter and humidifiers as needed. She stated a dirty filter could cause disruption of air flow and result in respiratory distress or URI. During an interview on 01/09/2026 at 3:10 pm, LVN C stated she had taken care of Resident #15, and she was the one who administered her nebulizer treatments. She stated the nebulizer mask should be bagged when it was not in use and the filter and humidifier bottle needed to be checked and changed as ordered to prevent infection. She stated she had not noticed the equipment was not bagged or the filter was dirty. Record review of the facility's policy and procedure titled Oxygen Administration dated 07/01/2025 reflected Purpose, to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues, Procedure, at regular intervals, check and clean oxygen equipment, masks, tubing and canula. Change masks and tubing and cannula's every 7 days and as needed.

Based on observation, interviews and record reviews, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Medication Cart B and C Halls) of 2 medication carts reviewed for expired medications.The facility failed to ensure the Medication Cart for B and C Halls did not contain an expired bottle of Atropine 1% drops.This deficient practice could place residents at risk to receive expired medication with less effective results.Observation on 01/08/2026 at 08:20 am accompanied by LVN F when checking the Medication Cart for B and C Halls, revealed a plastic bottle of Atropine 1%, with an expiration date of 08/29/2025 was found on the cart.During an interview on 01/08/2026 at 3:05 pm, LVN F stated she would usually check the medication cart for expired medications when she worked. She did not know how the expired bottle of Atropine was not removed from the cart sooner. She stated the effectiveness of the medication could decrease after the expiration date and that would harm a resident. During an interview on 01/09/2026 at 2:23 pm, the DON stated the medication carts were checked routinely and the Atropine should have been removed earlier since it had been expired for 6 months. She stated expired medication could have less effect on a resident and might cause harm. During an interview on 01/09/2026 at 3:20 pm, the RNC stated expired medications needed to be removed from carts, and nurses must ensure medication carts and the treatment cart were either within view or locked. He stated medications expired and could have less effectiveness for the residents. Per the DON, no facility policy and procedure addressed expired medications on the medication cart.

Based on observations, interviews and record reviews, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for and 1 of 1 treatment cart (Treatment Cart) reviewed for medication storage. The facility failed to ensure RN A and the ADON did not leave the treatment cart unlocked when they went to perform a treatment on a resident. These deficient practices could place residents at risk of misappropriation of treatment medications and supplies. The findings were: Observation on 01/07/2026 at 3:20 pm, revealed RN A and the ADON performed wound care for Resident #3 revealed RN A took the wound care treatment and supplies into the residents room without securing the treatment cart and then the ADON closed the door to the room, leaving the treatment cart in the hall unlocked and out of view. During an interview on 01/07/2026 at 3:40 pm, RN A stated she should have secured the treatment cart because there were medicated ointments and solutions used for wound care, and a drug diversion could occur or someone without need to access the cart and it could result in harm. RN A stated she had the keys and it was her responsibility to secure the cart. During an interview on 01/09/2026 at 2:23 pm, the DON stated medications and treatment solutions or ointments must be secured in the medication and treatment cart when out of sight of the nurse. During an interview on 01/09/2026 at 3:20 pm, the RNC stated expired medications needed to be removed from carts, and nurses must ensure medication carts and the treatment cart were either within view or locked. He stated medication carts or the treatment cart left unlocked and attended could result in harm of others or misappropriation of supplies or drugs. Record review of the facility's policy and procedure titled Storage of Medication dated 02/22/2016 reflected purpose of this procedure is to ensure medications are stored in a safe, secure, and orderly manner. Compartments containing medications are locked when not in use.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 Dumpsters (Dumpsters #1 and #2) reviewed for garbage and refuse disposal. The facility failed to ensure Dumpster #1 and Dumpster #2 had lids that were completely closed This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents. The findings included: Observation on 01/6/26 at 10:00 am revealed Dumpster #1 and Dumpster #2 both had lids which measured approximately 3x5 ft that were not secured to the dumpster basin due to overflowing garbage inside the bin. There were also two bags of garbage and a pile of cooked noodles laying on the ground beside Dumpster #2. Interview on 1/6/26 at 10:05am with the Clinical Specialist who stated he was aware of the garbage lids needing to be secure to the garbage bins to prevent rodent infestation. The Clinical Specialist stated that the facility's garbage was to be picked up later in the day but was unsure of the exact time of pick up. Record review of the facility's policy titled Cleaning-Trash Collection Areas dated 7/20/10 revealed Trash containers must have a lid and be closed at all times when not in use.

47622 Based on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 5 of 12 residents (Residents #15, #18, #5, #1, and #20) whose assessments were reviewed, in that: 1. Resident #15 had falls on 8/30/2024 and 9/5/2024 but Resident #15's Quarterly MDS dated [DATE] revealed falls after admission was not coded for falls after admissioon or readmission. 2. Resident #18 had been using oxygen per nasal canula at 2 liters continuously since admission, but the Admission MDS dated [DATE] was not coded for oxygen use. 3. Resident #5 had a fall on 9/8/2021 but Resident #5's QMDS dated [DATE] revealed falls after admission was not coded for falls after admission or readmission. 4. Resident #1 had been receiving hospice care since 11/30/2022, but Resident #1's quarterly MDS, dated [DATE], indicated regarding the question of if or not resident was receiving hospice care, the answer was marked as no. 5. Resident #20 had deep tissue injury to his left heel, but Resident #20's admission MDS, dated [DATE], indicated the resident did not have any deep tissue injury. This failure could place residents at-risk for inadequate care and services due to inaccurate MDS assessment. The findings included: 1.Record review of Resident #15's face sheet revealed the resident was a [AGE] year-old male with an admitted [DATE] and readmitted on [DATE] with diagnoses that included: abdominal aortic aneurysm (enlargement of the aorta), muscle weakness, traumatic subdural hemorrhage (blood clot that forms in the brain after an injury) with out loss of consciousness. Record review of Resident #15's Quarterly MDS 9/20/2024 revealed the resident had a BIMS score of 4. Resident #15 had falls on 08/30/2024 and 09/05/2024 per Care Plan dated 10/8/2024 that were not reflected on the Quarterly MDS. Record review of Resident #15's Care Plan dated 10/8/2024 revealed falls dated 08/30/2024 and 09/05/2024 that were care planned with interventions. 2. Record review of Resident #18's face sheet revealed the resident was a [AGE] year-old female with an admitted [DATE] and readmitted [DATE] with diagnoses that included: acute pulmonary edema (build up of fluid in the lungs), prosthetic left knee joint ( knee joint replacement), and hypertension (high blood pressure). Record review of Resident #18's Admission MDS dated [DATE] revealed the resident had a BIMS score of 13. Resident #18 had an order for oxygen on admission, per physician orders, but was not reflected on the Admission MDS. Record review of Resident 18's Care Plan dated 9/30/2024 revealed oxygen therapy was care planned with interventions. 3.Record review of Resident #5's face sheet revealed the resident was a [AGE] year-old female with an admitted [DATE] and was readmitted [DATE] with diagnoses that included: hypothyroidism (thyroid gland does not produce enough thyroid hormone), aphasia (disorder that affects a person's ability to understand or understand written or spoken language), muscle weakness. Record review of Resident #5's Quarterly MDS dated [DATE] revealed the resident had a BIMS score that was not obtainable. Resident #5 had a fall on 09/08/2021 per Care Plan dated 8/10/2024 that was not reflected on the Quarterly MDS. Record review of Resident #5's Care Plan dated 8/10/2024 revealed a fall on 09/08/2021 that was care planned with interventions in place. Interview on 10/10/2024 at 3:45PM MDS nurse LVN-B stated she acknowledged Resident #18's Admission MDS dated [DATE] was inaccurate for the oxygen therapy not coded and that it did not affect the resident because Resident #18 received the oxygen per physician orders. LVN B stated the purpose of the MDS is for financial reimbursement. LVN B agreed the MDS and the Care Plan should reflect each other. Interview on 10/10/2024 at 3:54PM the Administrator stated the MDS should be correct and accurate because it explained the correct care that should be provided as well as financial reimbursements for the facility. The Administrator agreed the Care Plan and the MDS should have the same information. Interview on 10/10/2024 at 3:57PM the DON stated the MDS should be accurately coded to reflect the residents' needs and the care needed to provide, that it should match the residents' needs-the MDS drives the CP. The DON reviewed the MDS for Resident #15 for falls that was not coded on the MDS and acknowledged the error for falls not coded. The DON reviewed Resident #5's MDS for falls was not coded and agreed with the error and stated the fall should have been coded. The DON also reviewed the MDS for Resident #18 for oxygen not coded and acknowledged the error. The DON agreed the MDS, and the CP should match one another. 4. Record review of Resident #1's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnosis of atherosclerotic hear disease of native coronary artery without angina pectoris (heart disease caused by the buildup of plaque in the arteries), cerebral infarction (disrupted blood flow to the brain), epilepsy (chronic brain disorder that causes recuring seizures), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hypertension (high blood pressure). Record review of Resident #1's hospice informed consent, dated 11/29/2022, revealed the resident started receiving hospice care on 11/30/2022. Record review of Resident #1's care plan, dated revised 06/13/2023, revealed the resident had the care plan of 11-30-2022, the resident was admitted to hospice care services; intervention - consult with physician and social services to have hospice care for resident in the facility and contact [hospice care company] before any x-ray for any change in conditions, transfer, or death. Record review of Resident #1's quarterly MDS, dated [DATE], revealed her BIMS score was 9 of 15 reflecting she had moderate cognitive impairment. Further record review of Resident #1's quarterly MDS, dated [DATE], indicated the question of Hospice care in the Section 0 (Special Treatments and Program) was answered No. Interview on 10/09/2024 at 9:36 a.m. with LVN-A stated Resident #1 had been receiving hospice care since 11/30/2022. Interview on 10/11/2024 at 9:06 a.m. with MDS nurse LVN-B acknowledged Resident #1's quarterly MDS, dated [DATE], was inaccurate regarding the resident's hospice in the Section 0 (Special Treatments and Program) because the resident had been receiving hospice care since 11/30/2022. The question of Hospice care should had been answered Yes. Further interview with the MDS nurse LVN-B stated she did not know what reason she answered inaccurately to the resident quarterly MDS. Interview on 10/11/2024 at 9:14 a.m. with DON acknowledged Resident #1's quarterly MDS, dated [DATE], was inaccurate. It should had been answered Yes because the resident had been receiving hospice care since 11/30/2022. The potential harm was inaccurate MDS might affect inaccurate plan of care, and staff could provide inaccurate care to Resident #1. 5. Record review of Resident #20's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old male and admitted to the facility 08/21/2024 and readmitted to the facility on [DATE] with diagnosis of acute respiratory failure (lung cannot release enough oxygen into blood), anemia (not have enough red blood cells), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), pressure ulcer of sacral region-stage 3 (bed sore to buttock area), hypertension (high blood pressure), and spinal stenosis (narrowing of the spinal canal). Record review of Resident #20's care plan, dated initiated 08/21/2024, revealed Resident #20 had pressure injury to sacrum and left heel. For intervention, administering treatments as ordered and monitor for effectiveness. Record review of Resident #20's physician order, dated 09/30/2024, revealed the resident had the order of Wound care to left heel - cleanse with normal saline, pat dry, apply skin prep to peri-wound, then apply nickel thick Santyl ointment to wound bed, then calcium alginate, and cover with dry dressing every day and as needed. Record review of Resident #20's admission MDS, dated [DATE], revealed his BIMS score was 12 of 15 reflecting he had moderate cognitive impairment. Further record review of Resident #20's admission MDS, dated [DATE], indicated the question of number of unstageable pressure injuries presenting as deep tissue injury in the Section M (Skin Conditions) was answered 0. Observation on 10/10/2024 at 12:12 p.m. revealed wound care nurse RN-C provided wound care as ordered to Resident #20. There were two pressure injuries. One was sacrum area (buttock area), and the other was left heel. Interview on 10/10/2024 at 12:12 p.m. with wound care nurse RN-C acknowledged Resident #20 had pressure injury presenting as deep tissue injury to the resident's left heel. Interview on 10/10/2024 at 3:42 p.m. with MDS nurse LVN-B acknowledged Resident #20's admission MDS, dated [DATE], was inaccurate regarding the resident's skin condition because the resident had one pressure injury presenting as deep tissue injury to the resident's left heel. The question of number of unstageable pressure injuries presenting as deep tissue injury should had been answered one. Further interview with the MDS nurse LVN-B stated she did not know what reason she answered inaccurately to the resident's annual MDS. The potential harm was Resident #20 might not receive correct wound care because of inaccurate MDS assessments. Interview on 10/10/2024 at 3:45PM MDS nurse LVN-B stated she acknowledged Resident #18's Admission MDS dated [DATE] was inaccurate for the oxygen therapy not coded and that it did not affect the resident because Resident #18 received the oxygen per physician orders. LVN B stated the purpose of the MDS is for financial reimbursement. LVN B agreed the MDS and the Care Plan should reflect each other. Interview on 10/10/2024 at 3:54PM the Administrator stated the MDS should be correct and accurate because it explained the correct care that should be provided as well as financial reimbursements for the facility. The Administrator agreed the Care Plan and the MDS should have the same information. Interview on 10/10/2024 at 3:57PM the DON stated the MDS should be accurately coded to reflect the residents' needs and the care needed to provide, that it should match the residents' needs. The DON reviewed the MDS for Resident #15 for falls that was not coded and the MDS for Resident #5 for falls not coded. The DON also reviewed the MDS for Resident #18 for oxygen not coded. The DON agreed the MDS, and the CP should match one another. Interview on 10/11/2024 at 3:00 p.m. with DON stated the facility did not have specific policies regarding MDS assessments. The facility was following the CMS guidelines for MDS assessments. Record review of the CMS MDS 3.0 Manual dated October 2023 revealed in part, .The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0 is part of that assessment process and is required by CMS .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: During observation of the kitchen on 10/08/2024 at 10:01AM with the DM revealed: 1. There was a bag of kernel corn left open in the walk-in freezer. 2. There was container with slices of turkey not labeled or dated in the walk-in cooler. 3. There was a bag with two rolls left open in the dry storage room. 4. There was a box of oatmeal with the top off in the dry storage room. 5. There were six containers of seasoning not closed in the dry storage room. 6. There were two backpacks stored on a shelf next to food in the dry storage room. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation and interview on 10/08/2024 at 10:01AM revealed there was a bag of kernel corn in a box left open on a shelf in the walk-in freezer. The DM stated they should not be left open in the freezer and should have been placed in a zip lock bag. Observation and interview on 10/08/2024 at 10:02AM revealed a container with turkey not labeled or dated in the walk-in cooler. The DM stated he did not know the sliced turkey was in the cooler in the container and he did not know how long it had been there. Observation on 10/08/2024 at 10:03AM revealed a bag with two rolls open in the dry storage room. Observation on 10/08/2024 at 10:03AM revealed a box of oatmeal with the lid off in the dry storage room. Observation and interview on 10/08/2024 at 10:04AM revealed two backpacks that belonged to employees on the shelf next to foods. The DM stated the staff did not have anywhere to place their belongings but in the dry storage room was not the place to put them. Observation on 10/08/2024 at 10:04AM revealed six bottles of seasoning left open. During an interview on 10/09/2024 at 10:10AM the DM stated the foods that were found open in the freezer and the seasoning containers that were open would cause bacteria to enter the food and could cause food borne infection. He stated the food in the freezer that was opened could decrease the quality of the food with freezer burn as well as food borne illness. He stated the 2 backpacks that belonged to the staff that was in the dry storage area on the shelf next to food was not the appropriate place to be stored. He stated, once again, that would not be good infection control. During an interview on 10/09/2024 at 12:13PM DA stated it was important to serve the residents in a clean environment because the residents could easily get an illness if the food was not served in a clean manner. She stated personal items should not be stored near the food whether cooked or not because it could pass bacteria to the food. Record review of facility policy titled Storage- Dry Goods undated revealed 2. Food storage areas are to be used for food and paper products only; 6. Opened packages are resealed to prevent contamination. Review of facility policy 3-17 Food Storage, 2013, revealed, 14. Refrigerated Food Storage: f. All foods should be covered, labeled and dated.

Based on observation, interview, and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 5 residents reviewed for new admissions. (Resident #78) The facility failed to develop Resident #78's baseline care plan dated 10/01/2024 regarding the resident's physician order dated 10/01/2024 for colostomy care within 48 hours of admission on 09/30/2024. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #78's face sheet, dated 10/10/2024, reflected the resident was [AGE] years old female and admitted to the facility on [DATE] with diagnosis of laceration of sigmoid colon (injury that can occur after penetrating trauma to the abdomen), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), colostomy status (artificial opening in the abdominal wall to allows stool to be excreted through the skin), anemia (not have enough red blood cells), hypertension (high blood pressures), and dysphagia (swallowing difficulty). Record review Resident #78's baseline care plan, dated initiated 10/01/2024, reflected there was no baseline care plan regarding Resident #78's colostomy care. Record review of Resident #78's physician order, dated 10/01/2024, reflected the resident had the order of Change colostomy bag every day 72 hours and as needed, colostomy care, and colostomy appliance change weekly and as needed. Observed on 10/10/2024 at 11:37 a.m. revealed Resident #78 had colostomy as evidence by LVN-A emptied Resident #78's colostomy bag in the resident's room. Interview on 10/10/2024 at 11:37 a.m. LVN-A stated Resident #78 was admitted to the facility on [DATE] and had a colostomy when admitted . Interview on 10/10/2024 at 4:45 p.m. MDS nurse (LVN-B) acknowledged Resident #78 had colostomy when the resident was admitted to the facility on [DATE]. Further interview with the MDS nurse LVN-B stated she should have developed Resident #78's baseline care plan within 48 hours regarding the resident's colostomy care because the resident was admitted with colostomy. The MDS nurse LVN-B said she might think not developing baseline care plan related to colostomy was fine because Resident #78 had physician orders related to colostomy. Interview on 10/11/2024 at 1:58 p.m. DON stated the MDS nurse should have developed Resident #78's baseline care plan within 48 hours regarding the resident's colostomy care because the resident was admitted with colostomy, and baseline care plans affected Kardex through which CNAs knew how to provide care appropriately to Resident #78; therefore, no baseline care plan might affect inappropriate care to the resident. Record review of the facility policy, titled Care Planning, undated, reflected To write activity goals and approaches based on MDS triggers and current needs of the resident.

Based on observation, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 12 Residents (Resident #1) whose records were reviewed for care plan revision/timing, in that: Resident #1's care plan dated 08/25/2022 was not updated after her quarterly MDS assessment, dated 09/05/2024, reflected she was always incontinence to bowel. These deficient practices could affect any resident and contribute to Residents not receiving the care and services they needed. The findings included: Record review of Resident #1's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnosis of atherosclerotic hear disease of native coronary artery without angina pectoris (heart disease caused by the buildup of plaque in the arteries), cerebral infarction (disrupted blood flow to the brain), epilepsy (chronic brain disorder that causes recuring seizures), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], revealed her BIMS score was 9 of 15 reflecting she had moderate cognitive impairment. Further record review of Resident #1's quarterly MDS, dated [DATE], indicated the resident was always incontinence to bowel and for toilet transfer, the resident was not attempted due to medical condition or safety concerns. Record review of Resident #1's care plan, date revised 08/25/2022, revealed Resident #1 required one staff participation to use toilet. Observation on 10/10/2024 at 2:04 p.m. revealed CNAs provided incontinence care, including changing a brief, for bladder and bowel to Resident #1. Interview on 10/11/2024 at 8:35 a.m. with LVN-A stated Resident #1 could not use toilet anymore. The resident was always incontinence to bladder and bowel. Interview on 10/11/2024 at 8:38 a.m. with the MDS nurse LVN-B acknowledged the MDS nurse did not update Resident #1's care plan regarding the resident's incontinence care to bowel because the resident could not use toilet anymore for her bowel movement. Further interview with the MDS nurse said when she revised Resident #1's care plan on 08/25/2022, the resident could use toilet with one staff's assist when she had bowl movement, but when she assessed Resident #1 on 09/05/2024 for quarterly MDS, the resident could not use toilet anymore. The resident was incontinence to bowel all the time. The MDS nurse should have updated Resident #1's care plan after quarterly MDS dated [DATE]. Interview on 10/11/2024 at 9:00 a.m. with the DON said the MDS nurse should have updated Resident #1's care plan after quarterly MDS dated [DATE] because the resident was incontinence to bowel all the time and could not use toilet anymore. The potential harm was staff might provide incorrect care to Resident #1. Record review of the facility policy, titled Care Planning Assessment, undated, revealed . 2. When a comprehensive MDS assessment is done, the CAA's will be completed for each triggered area. From the CAA, it is determined which area need to be care planned to provide the necessary care for the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and safe environment to prevent accidents for 1 of 12 residents (Residents #20) reviewed for environment. The facility failed on 10/08/2024 when there was one used disposable razor found on the sink faucet of Resident # 20's bathroom. This deficient practice cause infection or other physical injuries to residents and even staff. Findings included: Record review of Resident #20's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old male and admitted to the facility 08/21/2024 and readmitted to the facility on [DATE] with diagnosis of acute respiratory failure (lung cannot release enough oxygen into blood), anemia (not have enough red blood cells), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), pressure ulcer of sacral region-stage 3 (bed sore to buttock area), hypertension (high blood pressure), and spinal stenosis (narrowing of the spinal canal). Record review of Resident #20's admission MDS, dated [DATE], revealed his BIMS score was 12 of 15 reflecting he had moderate cognitive impairment. Further record review of Resident #20's admission MDS, dated [DATE], indicated the resident required dependent to staff for shower/bathe self and chair-to-bed transfer and required substantial/maximal assistance (helper does more than half the efforts) to personal hygiene. Record review of Resident #20's care plan, dated revised 09/17/2024, revealed [Resident #20] has an activities of daily livings self-care performance deficit related to left sided hand contractor and weakness. For interventions, assist personal hygiene. Observation on 10/08/2024 at 9:50 a.m. revealed one old disposable razor was on the sink faucets in Resident #20's bathroom. Interview on 10/08/2024 at 10:21 a.m. with LVN-A acknowledged she saw one old disposable razor was on the sink faucet in Resident #20's bathroom. Further interview with the LVN-A stated Resident #20 could not use the razor by himself. The resident's family might bring and use it for him. However, staff had responsibility to discard any used disposable razor to a sharp container after using it to prevent infection and for safety. The potential harm was other confused residents might use it and could cause physical injury or infection. Interview on 10/11/2024 at 1:58 p.m. with the DON stated staff should have discarded the old disposable razor to a sharp container after every use to prevent infection and physical injury. Record review of the facility policy, titled Infectious waste, handling of, undated, revealed 4. Disposable items, contaminated with resident excretions or secretions must be placed in red plastic bags, sealed, and placed in biohazard storage until removal from the premises.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 medication carts (A and B hall nursing cart) reviewed for pharmacy services. There was one medication (Benadryl itching stopping gel topical for skin use only) expired on 05/2021 found inside A and B hall nursing cart on 10/9/2024. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Observation on 10/09/2024 at 1:54 p.m. revealed one gel of Benadryl itching stopping gel topical for skin use only was found inside A and B hall nursing cart, and it was expired 05/2021. Interview on 10/09/2024 at 2:00 p.m. with ADON acknowledged one gel of Benadryl itching stopping gel topical for skin use only was found inside A and B hall nursing cart, and it was expired 05/2021. Further interview with the ADON said she did not know what reason the expired medication was inside the nursing cart, and nurses should discard all expired medications from the medication carts as the facility policy. Potential harm was nurses might use the expired medication, and the expired medication might not have therapeutic effects. Record review of the facility policy, titled Medication Storage, undated, reflected 7. Expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of in accordance with community policy.

Based on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys to 1 of 12 residents (Resident #9) reviewed for medications at the bedside. Resident #9's ear wax remove kit was left unattended and unsecured on the nightstand at the resident's bedside on 10/08/2024. These failures could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects. The findings included: Record review of Resident #9's face sheet, dated 10/10/2024, reflected the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: pneumonia (lung infection), hypomagnesemia (low magnesium in the blood), cerebral vascular disease (problems with blood flow to the brain), heart failure (heart unable to pump enough blood), dementia (decline in mental abilities), and hypertension (high blood pressures). Record review of Resident #9's admission MDS, dated [DATE], reflected her BIMS score was 3 of 15 reflecting she had severe cognitive impairment. Further record review of Resident #9's admission MDS, dated [DATE], indicated the resident required supervision or touching assistance (helper provides verbal clues or touching assistance as resident completes activity) to eating and substantial/maximal assistance (helper does more than half the effort) to chair/bed-to-chair transfer. Observation on 10/08/2024 at 10:44 a.m. revealed in Resident #9's room, one box of the ear wax remove kit was on the nightstand at the resident's bedside unattended. Resident #9 was not in her room. Interview on 10/08/2024 at 10:49 a.m. with LVN-D stated Resident #9's ear wax remove kit was on the nightstand at the resident's bedside unattended. Further interview with the LVN-D stated it might be medication, and all medications should not be in resident's room. They did not know the reason the medication was on the nightstand unattended in Resident #9's room. The resident's family might bring it. The potential harm was that Resident #9 or other residents might use the medication incorrectly. Interview on 10/11/2024 at 1:58 p.m. the DON stated all medications should not be in resident's room unattended per the facility policy. Record review of the facility policy, titled Medication Storage, undated, revealed 1. Medications, prescriptions, over the counter and CAM (complementary and alternative medicine) will be stored in a locked cabinet, cart or medication room accessible to authorized personnel.

Based on observation, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #20) of 12 residents reviewed for accuracy and completeness of clinical records. Wound care nurse RN-C documented on the skin evaluation, dated 08/21/2024 Resident #20's deep tissue injury was to the resident's right heel, when the resident had deep tissue injury to his left heel on 10/10/2024. This failure placed facility residents at risk for lack of wound care or incorrect wound care due to misinformation by incomplete and inaccurate medical record. Findings included: Record review of Resident #20's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old male and admitted to the facility 08/21/2024 and readmitted to the facility on [DATE] with diagnosis of acute respiratory failure (lung cannot release enough oxygen into blood), anemia (not have enough red blood cells), type 2 diabetes mellitus (not properly use insulin to process sugar for energy), pressure ulcer of sacral region-stage 3 (bed sore to buttock area), hypertension (high blood pressure), and spinal stenosis (narrowing of the spinal canal). Record review of Resident #20's care plan, dated initiated 08/21/2024, revealed Resident #20 had pressure injury to sacrum and left heel. For intervention, administering treatments as ordered and monitor for effectiveness. Record review of Resident #20's physician order, dated 09/30/2024, revealed the resident had the order of Wound care to left heel - cleanse with normal saline, pat dry, apply skin prep to peri-wound, then apply nickel thick Santyl ointment to wound bed, then calcium alginate, and cover with dry dressing every day and as needed. Record review of Resident #20's admission MDS, dated [DATE], revealed his BIMS score was 12 of 15 reflecting he had moderate cognitive impairment. Further record review of Resident #20's admission MDS, dated [DATE], indicated the resident required dependent to staff for put on/take off footwear and chair/bed-to-chair transfer. Record review of Resident #20's skin evaluation, dated 08/21/2024, revealed the resident had pressure injury to sacrum and deep tissue injury to right heel. Observation on 10/10/2024 at 12:12 p.m. revealed wound care nurse RN-C provided wound care as ordered to Resident #20. There were two pressure injuries. One was sacrum area (buttock area), and the other was left heel. Interview on 10/10/2024 at 12:12 p.m. with wound care nurse RN-C acknowledged Resident #20 had pressure injury presenting as deep tissue injury to the resident's left heel. There was no skin problem to the resident's right heel. The wound care nurse assessed Resident #20's skin on 08/21/2024 and documented the resident had deep tissue injury to his right heel on the skin evaluation form. It was incorrect because Resident #20 had deep tissue injury to his left heel. Further interview with the wound care nurse said she was mistaken when she documented, and the potential harm was Resident #20 might have resulted in lack of wound care or incorrect wound care due to misinformation by inaccurate medical record. Interview on 10/11/2024 at 3:00 p.m. with the DON said the facility did not have policy regarding medical record, but medical records should be accurate to reflect correct medical status for residents.

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #1) of 12 residents reviewed for infection control. The facility failed on 10/08/2024 to discard in a red plastic bag, sealed, and placed in biohazard storage a Suction tube Yankauer (oral suction tool used in medical procedure) that was found opened, covered in the plastic bag, connected to the suction machine and was on Resident #1's nightstand. The Yankauer appeared to be dirty with brown colored residual. These deficient practices affect residents who require suction and could place residents at risk for cross contamination and infections. The findings included: Record review of Resident #1's face sheet, dated 10/10/2024, revealed the resident was [AGE] years old female and admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnosis of atherosclerotic hear disease of native coronary artery without angina pectoris (heart disease caused by the buildup of plaque in the arteries), cerebral infarction (disrupted blood flow to the brain), epilepsy (chronic brain disorder that causes recuring seizures), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and hypertension (high blood pressure). Record review of Resident #1's quarterly MDS, dated [DATE], revealed her BIMS score was 9 of 15 reflecting she had moderate cognitive impairment. Further record review of Resident #1's quarterly MDS, dated [DATE], indicated the resident required partial/moderate assistance 9helper does less than half for the effort) to oral hygiene. Record review of Resident #1's care plan, date initiated 02/19/2020, revealed [Resident #1] has a potential for aspiration. For intervention - suction as needed and ordered. Observation on 10/08/2024 at 10:01 a.m. revealed a suction tube Yankauer opened covered in the plastic bag connected to the suction machine was on Resident #1's nightstand, and the Yankauer was dirty with brown colored residual. Interview on 10/08/2024 at 10:25 a.m. with LVN-A stated Yankauer opened covered in the plastic bag connected to the suction machine was on Resident #1's nightstand, and the Yankauer was dirty with brown colored residual. Further interview with the LVN-A said nurses should discard the Yankauer after every using it to prevent infection. The nurse did not know what reason the Yankauer was on Resident #1's nightstand. The potential harm was the resident could have infection. Interview on 10/11/2024 at 1:58 p.m. with the DON stated nurses should discard the Yankauer after every using it to prevent infection. Record review of the facility policy, titled Infectious waste, handling of, undated, revealed 4. Disposable items, contaminated with resident excretions or secretions must be placed in red plastic bags, sealed, and placed in biohazard storage until removal from the premises.

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for respiratory care, in that: 1. The facility failed to monitor Resident #1 to ensure she was connected to continuous oxygen in accordance with her physician's order. 2. The facility failed to accurately document Resident #1's oxygen saturation levels when they were discovered to be in the 60s as a result of not being connected to continuous oxygen in accordance with her physician's order. 3. The facility failed to accurately document Resident #1's change of condition in her progress notes upon discovering Resident #1 was not connected to continuous oxygen in accordance with her physician's order. 4. The facility failed to ensure Resident #1 was connected to an oxygen concentrator with a functioning humidifier upon being transferred to a different location within the facility. These failures resulted in the identification of an Immediate Jeopardy (IJ) on [DATE] at 4:45 p.m. While the IJ was removed on [DATE] at 4:02 p.m., the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. These failures could place residents at risk of respiratory complications, injury to vital organs, or death. Findings included: Record review of a document titled, Monthly Grievance Log, for ,d+[DATE], stated, Date of Grievance [DATE], (Resident #1) - PT connected to empty e-cylinder . Record review of Resident #1's electronic face sheet revealed Resident #1 was admitted [DATE] and was [AGE] years old at the time of admission and died on [DATE]. Resident #1's diagnoses included: altered mental status, muscle weakness, depression, post covid-19 condition (unspecified), acute respiratory failure with hypoxia. Record review of Resident #1's electronic chart revealed no care plan or MDS. Record review of Resident #1's physician orders stated, O2: Oxygen at 5 liters per nasal cannula every shift for Dyspnea/Shortness of Breath - Start [DATE]. Record review of Resident #1's February 2024 TAR stated, Oxygen at 5 liters per nasal cannula every shift for Dyspnea/SOB (Order date [DATE] at 1:01 PM) Record review of Resident #1's physician orders stated, Check Oxygen Saturation Q2 hours. (Start Date [DATE] at 6:00 PM - End Date [DATE]) Record review of Resident #1's electronic chart, section, Weights and Vitals, revealed the following oxygen saturation readings and times (note: Oxygen saturation level of 67% that occurred on [DATE] at 1:45 PM was not recorded. Additionally, label, Room Air was inaccurately labeled). [DATE] @ 12:14 PM - 96% (Oxygen Via Nasal Cannula) [DATE] @ 12:20 AM - 95% (Room Air) [DATE] @ 2:27 PM - 83% (Oxygen via Mask) [DATE] @ 5:58 PM - 93% (Oxygen via Mask) [DATE] @ 12:12 AM - 91% (Room Air) [DATE] @ 2:13 AM - 92% (High Flow Oxygen) [DATE] @ 5:26 AM - 91% (High Flow Oxygen) [DATE] @ 6:41 AM - 90 % (Room Air) [DATE] @ 2:49 PM - 93% (Oxygen Nasal Cannula) [DATE] @ 5:51 PM - 96% (Oxygen Via Mask) [DATE] @ 5:52 PM - 96 % (Oxygen Via Mask) Record review of Resident #1's MAR/TAR (page 12 and 13 of 28) for February 2024, stated, Check oxygen saturation Q 2 hours. Every 2 hours - Order Date- [DATE] at 4:15 PM -D/C Date - [DATE] at 1:34 PM. Further review revealed missed Oxygen Saturation level recording the following dates and shifts: 12:00 AM on [DATE] and [DATE], 2:00 AM [DATE], [DATE], [DATE] 4:00 AM [DATE], [DATE], [DATE] 6:00 AM [DATE], [DATE], [DATE] 8:00 AM [DATE], [DATE], [DATE] 10:00 AM [DATE], [DATE], [DATE] 12:00 PM [DATE], [DATE] 2:00 PM [DATE] 4:00 PM 6:00 PM [DATE] 8:00 PM [DATE] 10:00 PM [DATE] Record review of Resident #1's MAR/TAR (page 18 of 28) for February 2024 revealed the following: O2: Oxygen at 5 liters per nasal cannula every shift for Dyspnea/SOB. Order date [DATE] at 1:01 PM. -D/C Date - [DATE] at 5:34 PM. Record review of Resident #1's Progress note dated [DATE] at 3:02 PM: .Nursing observations, evaluation, and recommendations are: (Resident #1) continues with respiratory distress with hypoxia. Caregiver stated that (Resident #1) has been less responsive and was not waking up. E-cylinder noted to be empty, (Resident #1) placed on concentrator at 6L/min, and was beginning to stir and open eyes. (Resident #1) die (sic) respond verbally once. Request scheduled Duonebs until O2 stabilizes, continue O2 6L/min via mask until O2 90% or greater. Record review of Resident #1's Progress note dated [DATE] at 7:55 AM: .Note Text: Resident resting in bed, eyes open but no verbal response. Skin warm/ dry. Resp shallow and rapid with accessory muscle use. SpO2 is ,d+[DATE]%. Resident repositioned in bed and HOB elevated. Caregiver education on keeping HOB elevated to help with breathing. DuoNeb administered with no significant improvement in oxygen saturation. SpO2 ,d+[DATE]%. Call placed to hospice nurse, voice message re: decreased SpO2 in spite of repositioning and Bx treatment. Return call pending). Record review of Resident #1's electronic chart, titled, SBAR Communication Form, dated [DATE], stated, Situation: The change of condition, symptoms, signs observed and evaluated is/are: Shortness of breath: This started on [DATE] . Further review revealed, 1. Mental Status Evaluation (compared to baseline; check all changes that you observe) - Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse). Record review of an in-service in response to Resident #1's change of condition, a document titled, Oxygen Administration, dated, [DATE] revealed the signatures of 10 facility staff which did not include all facility nursing staff. Record review of a list of Facility Staff, full time and part time, revealed a total of 47 staff. Record review of a written statement, dated [DATE] written by LVN D (2:00 PM to 10:00 PM on [DATE]) stated, .This nurse did apply portable o2 tank to (Resident #1) @ 4 liters. This was around 3:30 PM. LVN D's statement indicated Resident #1's hospice nurse had assisted Resident #1 from her wheel chair to her bed which resulted in a skin tare at around 4pm and was assessed and treated at 4:15 PM by RN F. LVN D further stated she reconnected Resident #1 to her oxygen concentrator .@ 4 liters ., and that she, .did leave O2 tank in room for future use . (Note, Resident #1's order was for 5 liters - see Resident #1's order in above record review). Record review of a written statement, dated [DATE], authored by LVN B, stated, .On [DATE] the sitter for (Resident #1) in room [resident's room] approached my workstation at 1345 stating that she had not been able to get (Resident #1) to wake up or talk the whole day. I went to [resident's room], (Resident #1) was lying in bed head of bed was slightly elevated. She had an oxygen cannula in place, but her breathing appeared more labored than it had earlier in the shift. During my morning shift the oxygen saturation was 93% and (Resident #1) appeared comfortable. Upon checking her oxygen, it was in the upper 60s- lower 70's. I realized that she was not on her concentrator and looked at the E cylinder her cannula was connected to and saw that it was empty. I changed her cannula to the concentrator, the sitter assisted me with repositioning her in the bed and I raised the head of the bed. I increased the liters per minute of oxygen from 5 to 6. Her saturation improved only to ,d+[DATE]% . I was instructing the sitter to please communicate soon ER when she observed a change in the resident when she told me that she told the girl who brought her tray at lunch. I requested in the future she come get me or the other nurse or a director rather than relaying the information through the CNA's . Record review of written statement, dated [DATE], Author, LVN E (10:00 PM - 6:00 AM for shift [DATE]-[DATE]), stated, . I do not recall if (Resident #1) was using a concentrator or O2 tank. Record review of a Resident #1's Hospice Documentation (regarding [DATE] incident), Author, HRN A, received via email on [DATE], page 18 of 22, stated, .Facility Nurse (LVN B) notified this RN that (Resident #1) had been lethargic the whole morning and when staff took pts vitals, they notified the pt oxygen saturation was in the 60%. Facility nurse (LVN B) noticed the pts NC was connected to a oxygen tank that was empty. They placed the NC tubbing to oxygen concentrator and pts oxygen saturation increased to 85% at 6 LPM. Upon RN assessment, pt lung sounds are diminished to all lobes. Pt has RR 35. Lorazepam .5 mg .[sic] Telephone interview on [DATE] at 1:16 PM, Hospice RN (HRN A) stated she was familiar with Resident #1 as she was her Hospice Case Manager. HRN A said she was informed by the Resident #1's caretaker, Caretaker A, that Resident #1's nurse forgot to reconnect Resident #1 to her oxygen concentrator after Resident #1 returned to her bedroom following a tour of the facility while utilizing an e-cylinder as her oxygen source. HRN A said Caretaker A told her Resident #1 was still discovered to be connected to her oxygen e-cylinder, which was empty, the following afternoon ([DATE]) after approximately 21 hours had passed and that her oxygen . HRN A said the Resident #1 was receiving ,d+[DATE] liters of continuous oxygen which would have caused her oxygen tank to run out of oxygen within ,d+[DATE] hours. HRN A said Caretaker A informed her Resident #1 was lethargic the next day and her oxygen saturation was in the 60s. HRN A said she saw Resident #1 the day before and then again the day after she was without her oxygen and observed her to have a major decline in that she was very talkative and eating popcorn on [DATE] and then bedbound and lethargic when she saw her on [DATE]. HRN A was asked if Resident #1 was hospitalized as a result but responded that she was not as she was already on hospice services and being treated with comfort measures. Interview on [DATE] at 2:50 PM, RN C stated the only interaction she had with Resident #1 was when she discovered Resident #1 deceased in her bed. RN C was asked if she had knowledge of Resident #1 being without oxygen and said she heard LVN C mention Resident #1 had gone without her oxygen for an extended period of time which resulted in a change of condition and responded that she had heard various staff say Resident #1 had been connected to an empty oxygen e-cylinder overnight which resulted in a major change of condition. Telephone interview on [DATE] at 3:04 PM, Care Manager B said he was very familiar with Resident #1 and would see her weekly. Care Manager B stated he was made aware Resident #1 was disconnected from her oxygen for an extended period of time and, .experienced a major decline as a result up until her death. Care Manager B said he went to the DON regarding this incident and was told the DON and the Administrator were investigating the incident but would not divulge any additional information. Telephone interview on [DATE] at 10:43 AM, Caretaker A stated she and CGRN B were with Resident #1 when she admitted to the facility on [DATE] and said Resident #1 had a caretaker with her 24 hours per day. Caretaker A said she and CGRN B elected to show the Resident #1 around the facility via wheelchair and said facility staff removed her from her oxygen concentrator and placed her on a portable oxygen tank affixed to her wheelchair so that she could tour the facility while remaining on continuous oxygen. The Caretaker A said that she, the CGRN B, and Resident #1 returned to her room approximately an hour later and said CGRN B notified staff Resident #1 needed to be placed back on her oxygen concentrator. Caretaker A said she left the facility around 5:00 PM or 5:30 PM that evening when relieved by the overnight Caretaker and then returned to the facility around 8:00 AM on [DATE]. Caretaker A said that at around 1:00 PM, she asked LVN B why Resident #1 was not connected to her oxygen concentrator as she had the same oxygen tank next to her from the day before. Caretaker A said at that point LVN B indicated that an oversight had occurred in that they were unaware, and then proceeded to connect Resident #1 back onto her oxygen concentrator. Caretaker A said Resident #1 had a significant change in condition from one day to another in that Resident #1, was eating popcorn and able to change her own clothing one day to almost being in a damn coma the next. Caretaker A explained that there was another similar incident several days later when staff moved Resident #1 to a private room and connected her to an oxygen concentrator that was broken. Caretaker A said that she noticed the oxygen concentrator was not functioning the way her previous oxygen concentrator had functioned, specifically, the humidifier reservoir had no condensation, and alerted LVN B who then agreed Resident #1's oxygen condenser was not adequately functioning and said, 'How strange, that never happens.' Caretaker A said that on that occasion, Resident #1 had gone at least 20 minutes without oxygen. Caretaker A confirmed during this interview that she never connected or disconnected Resident #1 to her oxygen concentrator or oxygen cylinder. Caretaker A stated she had no clinical background or licensure and that she and Resident #1's other caretakers were primarily tasked with keeping Resident #1 company as she had not immediate family in the area. Caretaker A stated she had known and worked with Resident #1 for multiple years and were very close. Telephone interview on [DATE] at 11:27 AM, Hospice Director of Clinical Services (HD), said HRN A observed Resident #1 at the facility on [DATE] at 11:00 AM and again on [DATE] at approximately 5:05 PM, because Resident #1 had a change in condition. During this interview, HD reviewed her agency's documentation and which she said stated Resident #1 was discovered to be attached to an empty oxygen tank and her oxygen saturation was in the 60s. HD further stated Resident #1 was subsequently placed on her oxygen concentrator which brought her oxygen saturation levels up to the 80s. Interview on [DATE] at 1:35 PM, the DON revealed she was aware Resident #1 was discovered connected to an empty oxygen e-cylinder on the afternoon of [DATE]. The DON also confirmed that Caretaker A informed nursing staff Resident #1 was in distress at around 1:35 PM on [DATE] and was assessed to have an oxygen saturation in the upper 60s. The DON said she was unsure how long Resident #1 could have gone without being connected to continuous oxygen but said LVN D wrote a statement saying she had connected the resident to her oxygen concentrator on the evening of [DATE] during her shift. The DON confirmed Resident #1's care takers were unlicensed said indicated they should have been responsible for ensuring Resident #1 was having her needs being medically met. The DON opined that perhaps Resident #1's caretaker could have removed her from her oxygen concentrator and connected her to an empty tank to take her out on her wheelchair again but agreed there were no witnesses of such activities. The DON agreed that it was ultimately the facility's responsibility to ensure Resident #1 was receiving adequate medical care even if she had paid caretakers, 24 hours a day. The DON was asked why staff did not document Resident #1's oxygen saturation on [DATE] when it was in the 60s percentage range but did not have an answer and agreed that it should have been documented. The DON indicated Resident #1 must have been ok until the time she was discovered to be hypoxic in that Resident #1's caretaker had not bring any concerns to her staff until then. The DON was asked why Resident #1's oxygen saturation levels were only documented at 12:20 AM (95%) and again after Resident #1's oxygen saturation was brought back up on [DATE] at 2:27 PM (83%),but did not include the readings in the 60s and responded that she was unsure. The DON was asked if she had reported this incident to HHS and responded that she had not. When asked why, the DON said that she conducted an investigation with inconclusive findings and that there had been no harm. At this time, this investigator confirmed with the DON that Resident #1 was documented to have had a change of condition and was hypoxic, with oxygen saturation levels in the 60s, as a result of not being attached to continuous oxygen per her physician's orders. Interview on [DATE] at 3:10 PM, LVN D stated she was on the 2pm-10pm shift on [DATE] and said she was providing care for Resident #1. LVN D said Resident #1 was attached to a portable oxygen cylinder that evening and that she had placed Resident #1 back on her oxygen concentrator but was unsure why the oncoming staff could not recall Resident #1 being attached to the oxygen concentrator per their written statements. LVN D was asked which staff relieved her on the evening of [DATE] but responded that she could not recall. LVN D was asked once more if that staff was LVN E and responded that yes, it was LVN E. When asked if LVN E still worked at the facility LVN D responded that he did not as she hadn't seen him for a while. LVN D was asked how she knew for certain that she had attached Resident #1 to her oxygen concentrator and responded that she had wheeled it into her room, and connected Resident #1 to the oxygen concentrator and then took her vitals according to her physician's orders, which included her oxygen saturation levels as she did near the end of every shift (Note: Resident #1 had already been connected to her oxygen concentrator in her room prior to being connected to the e-cylinder). LVN D was asked when and where the documentation would have occurred and responded that it would have been documented in Resident #1's electronic chart under weights and vitals at around 9:45 PM on [DATE]. LVN D was shown the Resident #1's electronic chart and confirmed the Resident #1's oxygen saturation levels were not documented at or around that time but were only documented once on [DATE] at 12:14 PM (96 % @ 5 L/Min). LVN D then insisted on checking Resident #1's electronic chart via her own computer access and again could not locate where she had documented Resident #'1s oxygen saturation levels. LVN D said Resident #1 had a caretaker in her room at the time of her shift, Caretaker A and then another Caretaker, Caretaker B when she left her shift that evening. LVN D was asked once more if there may have been an oversight on her part, specific to reattaching Resident #1 back to her oxygen concentrator and responded that it might have been possible in that she was very busy that day and a lot was going on. Telephone interview on [DATE] at 10:31 AM, Caretaker A stated when she arrived to the facility around 8:00 AM on [DATE], the overnight caretaker informed her Resident #1 was still sleeping and difficult to arouse, implying Resident #1 was just really tired. Caretaker A said she could not recall who the overnight Caretaker was given that several months had passed. Caretaker A said she allowed Resident #1 to continue sleeping for several hours until she finally attempted to wake her at around lunch time and discovered at that time, she was non-responsive. Caretaker A said neither she nor the CGRN B made any adjustments to Resident #1's oxygen and said that was the responsibility of the facility staff. Caretaker A said she was unlicensed, and her primary responsibility was to keep Resident #1 company and would never provide any type of medical interventions. Caretaker A said before leaving Resident #1 on [DATE], CGRN B informed facility staff Resident #1 needed to be placed back onto her oxygen concentrator. Caretaker A said she arrived at the facility on the morning of [DATE], the oxygen concentrator was not on because it was not making any noise and said it was located behind the portable oxygen tank. Caretaker A said Resident #1 was still attached to the portable oxygen tank as opposed to the oxygen concentrator at that time. Telephone interview on [DATE] at 11:05 AM, Caretaker C said her first time seeing Resident #1 was on the evening of [DATE] when she relieved Caretaker A. Caretaker C said that when she arrived, Resident #1 was connected to her oxygen concentrator but said Resident #1 would not open her eyes and she could not get the resident to eat. Telephone interview on [DATE] at 1:56 PM, Caretaker D said she initially met Resident #1 at the hospital before Resident #1 was discharged to the facility. Caretaker D said Resident #1 was much more alert and talkative while at the hospital. Caretaker D said she stayed with Resident #1 at around the time of her 103rd birthday ([DATE]) and said Resident #1 would only sleep, would not talk, and would not eat. Caretaker D said she could never have guessed Resident #1 would have been given a tour of the facility in her wheelchair as she appeared bedbound and would only sleep at the time she saw Resident #1. Interview and record review on [DATE] at 3:03 PM, LVN B stated she checked on Resident #1 during her morning rounds on [DATE] between 7:00 AM and 8:00 AM. She stated the resident was a bit sleepier than normal but said she measured the Resident #1's oxygen saturation and that it was 93%. LVN B was asked why she did not document Resident #1's oxygen saturation at that time responded that she did not as she would typically document by exception. LVN B was asked if she Resident #1 was connected to her oxygen concentrator at that time but said she could not recall. LVN B said she then checked on Resident #1 once more around lunch time and said the resident was still sleeping. LVN B said she was alerted by Caretaker A at around 1:30 PM that Resident #1 could not be awoken and was not eating. LVN B said at that time she noticed Resident #1 was still connected to an empty oxygen e-cylinder as opposed to her oxygen concentrator so she said she then attached Resident #1 to her oxygen concentrator and was able to bring her oxygen saturation up to the 80s. LVN B was asked why she did not notice Resident #1 was not connected to her oxygen concentrator during her morning round, she responded that she was likely preoccupied and distracted as another resident in the hall was requesting her attention. LVN B was asked why she hadn't documented Resident #1's oxygen saturation when it was in the 60s at the time of that observation but did not have an answer. LVN B was asked if there was ever a time Resident #1's oxygen concentrator was not functioning adequately, LVN B denied knowledge of this incident. When asked once more, LVN B confirmed that several days later, Resident #1 had moved to a private room and said Caretaker A brought to her attention that the humidifier on the oxygen concentrator was not working so LVN B said she replaced Resident #1s oxygen concentrator at that time because she wanted to ensure the tension Caretaker A was experiencing was diffused given the recent trauma Resident #1 had experienced and wanted to make her happy. LVN B said Resident #1's oxygen saturation levels went back up to the 90s once she connected Resident #1 to the new oxygen concentrator. LVN B was asked once more why Resident #1's oxygen saturation levels were not documented to be in the 60s on [DATE] upon discovery and then reviewed Resident #1's progress notes with this investigator. During this record review, LVN B confirmed Resident #1's progress note for [DATE] at 7:55 AM, .SpO2 is ,d+[DATE]%, was documented on the wrong date and said, that's strange, it doesn't even say it is a late entry. Telephone interview on [DATE] at 4:40 PM, CGRN B stated she and Caretaker A asked facility staff on [DATE] if they could place Resident #1 on a portable oxygen cylinder so she could tour the facility with them. CGRN B said after this occurred, she and Caretaker A took Resident #1 on a tour of the facility and enjoyed some popcorn with her. She said Resident #1 was talkative and in good spirits. CGRN B said that up returning Resident #1 to her bed an hour later, Resident #1 attempted to self-transfer at which time CGRN B indicated Resident #1 looked as though she could fall so CGRN B said she attempted to assist Resident #1 by catching her and pivoting her to her bed but said Resident #1 caught her foot on a footrest located on her wheelchair and sustained a cut which required treatment by the facility's wound care nurse. After the treatment, CGRN B said she informed LVN D that Resident #1 needed to be placed back onto her oxygen condenser and said the wound care nurse, RN F, was present when she said this. CGRN B said upon leaving, she told another nurse at the nurse's station that Resident #1 still had not been transferred to her oxygen condenser and was told that staff would soon reattach Resident #1 to her oxygen condenser. CGRN B said she was informed the following day that Resident #1 had a change of condition after LVN B discovered Resident #1 was still connected to the portable oxygen cylinder and had never been reconnected to her oxygen condenser. CGRN B said several days later Resident #1 had a room change and was connected to a non-functioning oxygen concentrator and again experienced a drop in her oxygen saturation levels until Caretaker A brought it to LVN B's attention and was issued a functioning oxygen concentrator. CGRN B confirmed during this interview that she never connected or disconnected Resident #1 to her oxygen concentrator or oxygen cylinder and that it was not policy for her nor other staff within her agency to do so. Interview and record review on [DATE] at 3:10 PM, LVN B confirmed Resident #1's electronic TAR for February [DATE] did not reflect Resident #1's oxygen saturation levels every two hours per her physician's order. Attempted telephone interview on [DATE] at 2:48 PM, with LVN E. The call went directly to voicemail and voice message was left requesting a returned telephone call. Interview on [DATE] at 3:05 PM, the DON was asked why only 10 staff were listed as having received in-servicing regarding this incident. The DON responded that, some staff are PRN, and that only staff directly involved with the incident had been in-serviced but she would work on getting all other staff in-serviced. Interview on [DATE] at 12:17 PM, RN F stated Resident #1 sustained a large skin tear to her left lower extremity on the afternoon of [DATE] when her Hospice RN attempted to assist her to her bed which resulted in Resident #1 catching her foot on the footrest leading to the wound. RN F stated she treated Resident #1's wound at that time and then again treated Resident #1's wound shortly after lunchtime on [DATE]. RN F said she was concerned because Resident #1 was unable to be aroused and slept through her wound treatment at that time. RN F said she was told by Resident #1's caretaker, Caretaker A, that Resident #1 had slept through both breakfast and lunch. RN F said she asked if Resident #1 had been placed on any new medications that would have caused her to be so unresponsive but was told that she had not. RN F said she then approached LVN B and said soon after it was determined Resident #1 was connected to an empty oxygen cylinder which caused her oxygen saturation to be so low. RN F was asked if she had checked to see if Resident #1 was connected to her oxygen concentrator at the time, she was treating the resident's wound and responded that she had not as she was preoccupied with the wound treatment. Telephone interview on [DATE] at 1:30 PM, the facility's Medical Director and Resident #1's physician stated an individual requires supplemental oxygen if and when that person's oxygen saturation levels drop below 90%. Resident #1's physician stated that if an individual experiences hypoxia it can lead to damage of vital organs in that they require oxygen to adequately function. Review of an article title Hypoxia by The Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/23063-hypoxia, and was accessed on [DATE] indicated, Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin. Many chronic heart and lung conditions can put you at risk for hypoxia. Hypoxia can be life-threatening. If you are experiencing symptoms of hypoxia, call 911 or go to the nearest ER . The treatment for hypoxia depends on the underlying cause. The cause might be a one-time event, or it could be an ongoing condition. The Administrator was notified of an IJ on [DATE] at 4:45 PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on [DATE] at 4:02 PM and included the following: [DATE], Plan of Removal F695 All residents have been assessed to ensure respiratory needs are in place. A facility-wide audit was completed by Regional Nurse on [DATE] and identified all residents in need of oxygen. Resident's responsible party, Residents care management provider Hospice Agency A and primary physician were notified February 21, 2024. A facility wide audit of residents in need of oxygen concentrators, e-tanks, etc. have been assessed to ensure respiratory needs are in place. There were no residents identified to have an issue with oxygen devices on [DATE]. In-service training that includes checking the levels of the e-tanks, the source of O2, O2 saturation rates and method of O2 delivery began [DATE] with all licensed staff. CNA's will be in-service on the basic principles of O2, able identify e-cylinder levels, and notify charge nurse immediately if there are any in discrepancies. The Administrator, all will ensure all in-serviced prior to working shift going forward. Monitoring will be completed by all residents on O2 that have O2 saturation, method of oxygen delivery, source of O2 delivery, and liters per minute will be added to their physicians' orders and documented on the MAR/TAR q shift by the licensed nurse. DON and/or designee will conduct routine checks on MARs/TARs daily to ensure compliance. Each shift, the charge nurse will visually check the source (i.e. E-Cylinder) of O2 delivery and document on the MAR/TAR daily. Facility will ensure that ensure that staff receive any in-service training to address the issues prior to the start of their next shift if a staff member is unavailable due to leave, FMLA, new hire, or agency by attending required in-servicing on ensuring that respiratory care is provided consistent with professional standards of practice. This will be via required new hire orientation before working their first shift, required in-servicing via Relias Training have been assigned to those that may be out FMLA, leave, agency, etc. Going forward, the facility will intervene as needed through daily rounds conducted by The Director of Nursing or designee; daily standups meeting conducted by the Administrator or designee; and reviewed by Quality Assurance Committee conducted on [DATE], monthly or as needed for the next 3 months and/or as needed. The verfication of the Plan of Removal was completed as follow: Record review of a typed statement dated [DATE] and signed by the Corporate RN revealed he had reviewed/assessed all residents at the facility for respiratory needs. His statement indicated he reviewed oxygen orders in the electronic medical records for oxygen route, amount, source and method. His statement also indicated all residents on oxygen had the appropriate orders written and respiratory equipment available. Record review of the electronic medical records revealed 14 residents with orders for oxygen. During observations

Based on observation, interview, and record review, the facility failed to ensure that the facility was administered in a manner that enabled it to use resources effectively to attain the highest practicable physical well-being for 7 of 17 residents (Resident #1, #3, #4, #5, #7, #9 and #15) reviewed for infection control, blood glucose testing, catheter care, medication, and treatment administration. (The following deficient practices were included in the IJ) AA. 1. The ADON failed to implement the facility's Infection Control policies and procedures for 3 of 3 residents (Resident #3, #4 and #7) reviewed on isolation related to identification of isolation rooms and the type Personal Protective Equipment (PPE) required for isolation, 2. The ADON failed to train 5 of 5 Staff (Staff LVN K, LVN M, MA H, CNA E and CNA F), 2 of 2 residents (Resident #9 and an unidentified resident), a private sitter and visitors on the type of PPE used when entering isolation rooms. 3. The ADON failed to train 3 of 3 licensed nurses (RN Q, LVN M and LVN EE), on cleaning both glucometers (a device used to monitor the blood sugar level) before and after use which could affect 3 of 3 residents (Resident #1, #4 and #7) requiring blood sugar testing; and the disposal of lancets. 4. The ADON failed to train 1 of 1 RN (RN Q), on preventing cross-contamination and waste disposal during provision of treatments Resident #15 and Resident #5. 5. The ADON failed to train 1 of 1 CNA (CNA P) on catheter care for 1 of 1 resident (Resident #1) with an indwelling catheter related to cleansing the catheter tubing down to the meatus. 6. The ADON failed to maintain the facility's Infection Control Program to prevent the spread of infections within the facility, to include tracking and trending. (The following deficient practices were not included in the IJ) BB. The ADON failed to assure competency and train a RN on insulin administration for Resident #1 and on administration of medication and water flush to Resident #5, who had a gastrostomy tube, while lying flat in bed when the head of the bed should have been elevated. CC. The ADON failed to train 2 of 2 nurses (RN Q and LVN M), in the operation of the glucometer in a manner to obtain an accurate blood sugar reading for 3 of 3 residents (Resident #1, Resident #4 and #7) reviewed for blood glucose testing, DD. The ADON failed to assure the facility's CNAs demonstrate competency in skills and techniques necessary to care for residents' needs for the 7 of 7 CNAs (CNA E, F, P, X, Z, BB and FF) employed at the facility for at least 1 year. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of "widespread" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. These failures could affect the facility's 29 residents and placed them at risk for the potential of being exposed to [MEDICAL CONDITIONS], cross-contamination and infection, inaccurate blood sugar results, administration of the wrong amount of Insulin resulting in the potential need for isolation procedures and techniques, antibiotics, skin irritation and excoriation, dehydration, unplanned weight loss, [MEDICAL CONDITION] and [DIAGNOSES REDACTED], aspiration pneumonia, and potentially, admission to the hospital. The findings were: AA. Interview with the Acting DON/MDS Coordinator on [DATE] at 10:30 am revealed the DON had been terminated at the beginning of [DATE] and the Administrator had left approximately ,[DATE] weeks later. She stated prior to the Administrator leaving he appointed her Acting DON until someone could be hired but she was not required to complete any new duties with the title. She stated she did not hire staff, schedule staff, provide training, go to quality assurance meetings or actually perform any of the duties a DON would and to check with the ADON/Infection Control Coordinator;. Interview with the ADON/Infection Control Coordinator [DATE] at 11:00 AM, who was responsible for staff training, on [DATE] at 11:00 am revealed she had not provided training provided the staff, residents or visitors on any Infection Control policies and procedures, proper PPE to be used, cross-contamination, cleaning the glucometer, disposal of infectious waste and catheter care nor did she have documentation of the training. a. Record Review of Resident #3's face sheet dated [DATE] revealed that Resident #3 was admitted to facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the admission nursing report dated [DATE] documented Resident #3 was positive for VRE of the stool. There was no information [MEDICAL CONDITION] of the nares on the report. Record view of the labs faxed from the hospital on [DATE] at 5:20 PM revealed that Resident #3 was found on [DATE] to be positive [MEDICAL CONDITION] of the nares. Record review of the initial care plan for Resident #3 dated [DATE], documented under the sub heading Special Needs: "resident on isolation". There was no further information regarding isolation such as the type of isolation precautions and PPE to be used. The infection control log labeled "C.A.R.E. log" dated [DATE] revealed Resident #3 was admitted with VRE of the stool but did not mention [MEDICAL CONDITION] of the nares. Record review of the labs faxed from the hospital on [DATE] at 5:20 PM revealed that Resident #3 was found on [DATE] to be positive [MEDICAL CONDITION] of the nares. Record review of the admission nursing report dated [DATE] documented Resident #3 positive for VRE. Interview with LVN K on [DATE] at 2:55 PM confirmed she conducted the admission nursing assessment report for Resident #3 and received the information by telephone from the discharging hospital. LVN K stated the hospital said Resident #3 was positive for VRE but did not mention Resident #3 being positive [MEDICAL CONDITION]. LVN K stated that nursing is responsible for notifying the CNAs and MA's of the types of isolation residents are on and the LVN's received what type of isolation from the doctor or from the infection control nurse. She further stated that she had not been in-serviced on isolation precautions. Review of the facility policy and procedures titled "Categories of Isolation Precautions", revised [DATE], revealed the types of isolation precautions used by the facility and how to identify them: Airborne Precautions: must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small particle residue{5 microns or smaller in size} of evaporated droplets containing microorganisms that remain suspended in the air and can be widely dispersed by air currents within a room or over long distance.). The policy also stated a blue sign should be placed at the doorway instructing visitors to report to the nurses' station before entering and a blue sticker without writing should be placed on the wall above the resident's bed and on the front of the resident's chart. PPE: Mask Contact Precautions: must be implemented for a resident known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. The policy also stated an orange sign should be placed at the doorway instructing visitors to report to the nurses' station before entering and a orange sticker without writing should be placed on the wall above the resident's bed and on the front of the resident's chart. PPE: Gloves and gowns if anticipated clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room. Droplet Precautions: must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by droplet (large-particle droplets {larger than 5 microns} that can be generated by the resident coughing, sneezing, talking, or by the performance of procedures.). The policy also stated a yellow sign should be placed at the doorway instructing visitors to report to the nurses' station before entering and a yellow sticker without writing should be placed on the wall above the resident's bed and on the front of the resident's chart. PPE: Mask when working within three feet of a resident in isolation, wearing gloves when touching blood, body fluids, secretions, excretions, and contaminated items; wearing a mask and eye protection to protect mucous membranes of the eyes, nose, and mouth during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Further precautions included the use of gowns to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluid, secretions, or excretions. During initial tour on [DATE] at 10:15 AM, a sign was observed propped on the handrail outside Resident #3's room. The sign read "please see nurse before entering." A plastic container with drawers containing gloves, mask, and gowns was also observed outside the resident's room. In an interview with LVN M on [DATE] at 10:15 AM, the LVN said that Resident #3 was on isolation for VRE [MEDICAL CONDITION] of the nares (nostrils) but the VRE had been discontinued yesterday ([DATE]). On [DATE] at 11:30 AM, Resident #9 was observed in Resident #3's room. Resident #9 was observed sitting in her wheelchair at the foot of Resident #3's bed and talking with Resident #3. Resident #9 was not wearing a gown, gloves, or mask. On [DATE] at 11:35 AM, a confused unidentified resident was observed wandering in a wheelchair into the room of Resident #3 and was escorted out by Resident #9's personal sitter. On [DATE] at 12:40 PM, CNA E was observed entering Resident #3's room with out donning gloves, mask, or gown. CNA E was observed assisting the resident to transfer from bed to the restroom. Interview with CNA E on [DATE] at 12:43 PM confirmed he did not wear gloves, gown, or mask when entering the resident's room because he was not going to have physical contact with the resident. He further stated that when he entered the room he saw the resident falling out of the bed and had to provide assistance. CNA E stated he was aware the resident was on isolation and stated staff are supposed to wear gloves and gown when coming into contact with the resident. When CNA E was asked if a mask was also required, CNA E stated he didn't think a mask was required because the resident was on contact isolation only. Interview with LVN K on [DATE] at 5:15 PM revealed that Resident #3 was either on contact or airborne isolation and staff and visitors should wear a mask, gown, and gloves when entering the resident's room at all times. Observation on [DATE] at 9:13 AM, revealed MA H administering medications to Resident #3 who was on isolation. MA H put on gloves and obtained a blood pressure machine from a container located outside of the resident's room. After obtaining the resident's blood pressure, while touching the resident's bed with his clothes, the MA removed his gloves in the resident's bathroom and picked up the contaminated blood pressure machine with his bare hands and returned it to the container outside the room. The MA proceeded to the medication cart and poured the resident's medications without washing his hands. Observation with LVN M on [DATE] at 9:20 AM revealed that before entering Resident #3's room, the LVN donned gloves but no mask or gown. LVN M went into the resident's room to assist the resident to the bathroom. When the resident put on his light, the LVN returned to the resident's room, donned gloves but no mask or gown and assisted the resident again. The LVN continued to provide care to the rest of the residents in the facility. On [DATE] at 9:30 AM LVN M questioned the surveyor on what type of PPE was required for Resident #3 who was on airborne isolation [MEDICAL CONDITION] of the nares and contact isolation for VRE of the stool. On [DATE] at 10:20 AM, CNA F was observed entering Resident #3's room wearing gloves but no gown or mask. Interview with CNA F at this time confirmed that she used gloves and no other PPE when caring for Resident #3. When the CNA was asked what type of isolation Resident #3 was on, the CNA stated contact isolation and was told by nursing only to wear gloves. Observation on [DATE] at 11:50 AM, revealed Resident #9 going into Resident #3's room without wearing PPE. Interview with CNA F on [DATE] at 12:18 PM, revealed she had been caring for Resident #3 since admission. The CNA stated she had been told by Charge Nurse LVN M that gloves were the only PPE she needed to use when providing care to Resident#3. On [DATE] at 8:35 AM, MA H was observed in the room of Resident #3 taking the resident's blood pressure. MA H was observed exiting the room and placed the blood pressure cuff into the isolation cart outside the resident's door. MA H put on gloves and re-entered Resident #3's room to administer medications. MA H did not don a mask or gown prior to entering the resident's room. MA H then continued to provide medications down the hall to other residents. Interview with MA H on [DATE] at 8:37 AM revealed Resident #3 was on contact isolation and the MA entered the resident's room without wearing a gown or mask. MA H stated he was taking the resident's blood pressure prior to giving medications, did not need to wear a mask or gown and was only required to wear a gown if there was actual contact with the resident. On [DATE] at 1:46 PM, Resident #9 was observed in the room of Resident #3. Resident #9 was observed sitting in a wheel chair at the foot of the bed using Resident #3's telephone with the cord observed lying across the bed. Resident #9 was not wearing gloves, mask, or gown. Interview with LVN M on [DATE] at 1:46 PM confirmed Resident #9 did not have gloves, mask, or gown on while in Resident #3's room. Interview with LVN M on [DATE] stated that he received an order on [DATE] from the physician to continue droplet isolation until a negative culture [MEDICAL CONDITION] of the nares was obtained on Resident #3. LVN M further stated that there was no documentation prior to [DATE] of an order for [REDACTED]. Review of a facility policy and procedure titled "[MEDICATION NAME] Resistant [MEDICATION NAME]", revised 2002, revealed the precautions to use with a resident that has VRE: Wear a gown when entering the room of a VRE-infected or colonized resident. Wear gloves when entering the room of a VRE-infected or colonized resident because VRE can extensively contaminate such an environment. Remove gloves and gown before leaving the resident's room and immediately wash hands. Ensure that after glove and gown removal and handwashing, clothing and hands do not contact environment surfaces (e.g., a door knob or curtain) in the resident's room that are potentially contaminated with VRE. Names of residents who have had VRE infections/colonization should be recorded onto a VRE log. Only employees trained in prevention of transmission of VRE should provide care to residents infected/colonized with VRE. Volunteers should not provide care for these residents. Review of a facility policy and procedure titled "Administering Medications", revised 2001, revealed the process of giving medications: Established facility infection control procedures must be followed during the administration of medications (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) b. Record review of Resident #4's face sheet dated [DATE], revealed the resident was admitted on [DATE] and acquired [MEDICAL CONDITION] toxin in the facility as per laboratory results on [DATE]. A color-coded sticker to identify the resident as being on isolation was not available. Observation on [DATE] at 9:20 AM revealed Resident #4 had a sign propped on the handrail outside her door. The sign, written on plain, white paper said to see the nurse prior to entering the room. Observation upon entering Resident #4's room revealed 2 uncovered bio-hazardous boxes in the corner. One box was lined with a red bag and the other was lined with a yellow bag. Resident #4 was observed sitting up in her wheelchair next to her bed and no isolation signs or stickers were observed in the room. An interview with the ADON/Infection Control Coordinator immediately following the observation revealed Resident #4 was on contact isolation for facility acquired [MEDICAL CONDITIONS] toxin (a contagious infection that causes severe diarrhea and other intestinal disease) in the stool. Observation on [DATE] at 11:22 AM revealed RN Q performing blood glucose testing with the use of a glucometer on Resident #4 after using the device on Resident #1 without cleaning it. RN Q placed the blood glucose testing supplies, including the glucometer, on the resident's bedside table without cleaning the area. RN Q used the glucometer on Resident #4, disposed of the bloody lancet used on Resident #4 in the yellow bagged lined bio-hazardous box used for laundry isolation and returned the glucometer to a container and placed it in the treatment cart. RN Q did not clean the device prior to or after use. Interview with RN Q on [DATE] at 11:50 AM, she confirmed she had disposed of the lancet for Resident #4 in the bio-hazardous yellow bagged box. RN Q stated she was unsure the difference between the red or yellowed bagged boxes for the residents on isolation. Observation [DATE] at 4:40 PM revealed LVN M conducted blood glucose testing for Resident #4. LVN M placed the blood glucose testing supplies, including the glucometer, on the resident's bedside table without cleaning the area. After using the glucometer, he took the device and placed it in the container in the treatment cart. LVN M did not clean the device prior to or after use. Interview with RN Q on [DATE] at 10:30 AM revealed she did not clean the glucometer and had not received instruction on cleaning the glucometer. Interview with LVN M on [DATE] at 11:43 AM, revealed he had not cleaned the glucometer on [DATE]. LVN M stated he thought the night shift cleaned the devices. LVN M stated he had not received training on cleaning glucometers. Interview with LVN EE on [DATE] at 7:15 AM, revealed she was one of the night nurses responsible for checking the glucometer on Hall B. The LVN said she does not clean the glucometer and had not received training on cleaning the glucometer. Observation on [DATE] at 9:40 AM revealed a group of children go into Resident #4's isolation room to sing to her. Review of a facility policy and procedure, titled "Obtaining a fingerstick glucose level", revised [DATE], revealed steps in performing a blood glucose test: Preparation: Infection Control Protocol and Safety: Maintain clean technique and isolation precautions as indicated. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. Clean and disinfect reusable equipment before storing with other clean equipment. Steps in the Procedure: Clean reusable equipment according to the manufacturer's instructions. Review of the manufacture's policy and procedure, titled "Performing a Blood Glucose test with the...meter ", undated, revealed steps in performing a blood glucose test: Procedure: Verify that the bottle of test strips has not expired and/or the bottle has not been opened for longer than 90 days. Aftercare: Clean.... Blood glucose meter between patient tests. Review of a facility policy and procedure titled "Infection Control, Standard Precautions", revised ,[DATE], revealed the following procedures to prevent the spread of infections: Handwashing: Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between resident contact, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Gloves: Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of microorganisms to other residents or environments. Resident-Care Equipment: Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned. Environmental Control: Ensure that environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned. Review of a facility policy and procedure, titled "Infectious Waste, Handling of", revised [DATE], revealed steps in the procedure for disposal of waste: All sharps must be handled as infectious waste and placed in approved sharps containers. Disposable items, which are contaminated with excretions or secretions from resident's believed to be infectious, must be placed in red plastic bad. Disposable items soiled with visible blood must be placed in red plastic bags or containers. The facility's list of residents that received blood glucose testing in the facility, provided on [DATE] by the Acting DON/MDS Coordinator, revealed there were 3 residents receiving blood glucose testing by the staff. c. Record review of Resident #7's face sheet dated [DATE], revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. The resident acquired [MEDICAL CONDITION] toxin in the facility as per laboratory results on [DATE]. Review of the "C.A.R.E. log" dated [DATE] revealed Resident #7 was admitted with [MEDICAL CONDITION] instead of acquiring the infection in house. Observation on [DATE] at 11:43 AM revealed LVN M performing blood glucose testing on Resident #7, who was on isolation, with a different glucometer. LVN M placed the blood glucose testing supplies, including the glucometer, on the resident's bedside table without cleaning the area. After use, LVN M returned the glucometer to a container and placed it in the treatment cart. The device was not cleaned. d. Record Review of Resident #1's face sheet dated [DATE] revealed that Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on [DATE] at 11:22 AM revealed RN Q performing blood glucose testing with the use of a glucometer on Resident #1. RN Q placed the blood glucose testing supplies, including the glucometer, on the resident's bedside table without cleaning the area. The RN cleaned the index finger of Resident #1 with an alcohol pad then attempted to puncture the resident's finger with a lancet. The RN was unsuccessful in getting enough blood to test the resident's blood sugar. Without removing her gloves or washing her hands, RN Q left the room and returned to the treatment cart to get another lancet and extra supplies, including alcohol pads. On her third attempt, RN Q squeezed the finger until she was able to get serosanguineous fluid (body fluid consisting of both blood and serous fluids) to drop on the blood glucose strip. RN Q removed her gloves, gathered the extra alcohol pads and put them back into the treatment cart with other treatment cart supplies. RN Q disposed of the lancets in the trash bag on the treatment cart. Interview with RN Q on [DATE] at 11:50 AM, she confirmed she had disposed of the lancets for Resident #1 in the trash. Observation on [DATE] at 4:30 PM revealed LVN M performing blood glucose testing on Resident #1. LVN M placed the glucometer on the blanket covering the resident. LVN M did not clean the device prior to or after use or in between uses for Resident #4 (on contact isolation) and #1. Further review of Resident #1's physician's orders, dated [DATE], revealed an order for [REDACTED]. Observations on [DATE] at 11:22 AM, 4:05 PM and 4:30 PM revealed Resident #1's urine catheter bag hanging on the foot board of the resident's bed. The collection bag was hanging above the level of the resident's bladder and urine was not flowing into the bag. Observation on [DATE] at 10:05 AM revealed CNA P provided catheter care for Resident #1 in the resident's room. CNA P was observed to use pre-moistened wipes. CNA P wiped up the catheter tubing from the connection site of the catheter to the urinary bag towards the urethra 3 times. There was a small amount of blood observed on the penis head. CNA P wiped down the left side of Resident #1's groin but did not clean the penis or the right side of the groin. Interview with CNA P on [DATE] at 10:05 AM confirmed CNA P did not cleanse the catheter from the urethra outwards nor did she clean the penis when providing catheter care. Review of a facility policy and procedure titled "Catheter Care, Urinary", revised 2002, revealed the following steps were included in the catheter care for a male: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. For a male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular [MEDICAL CONDITION] from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site to approximately four inches outward. Review of the Form CMS 672, provided by the facility's Acting DON/MDS Coordinator and dated [DATE], revealed there was 1 resident with an indwelling catheter. e. Observation on [DATE] at 7:30 AM, revealed RN Q providing a coccyx wound treatment and dressing change to Resident #15's left buttocks. RN Q gathered supplies including wound cleanser, scissors, a container of 4 X 4 gauze and a [MEDICATION NAME] dressing from the treatment cart. After pushing Resident #15's belongings out of the way, RN Q proceeded to place the supplies on the resident's bedside table. RN Q did not clean the table before use despite visible debris including food particles and spilled liquids on the tabletop. After positioning the resident onto the right side, RN Q removed the resident's brief exposing soiled dressing on the coccyx. RN Q removed the dressing and discarded it in the resident's trash can. Without changing gloves, RN Q opened a container of 4 x 4 gauzes and removed some. RN Q retrieved wound cleanser and alternated between spraying the wound and rubbing the same 4 x 4 gauze repeatedly over multiple surfaces of the left buttocks. RN Q disposed of the used bloody gauze in the resident's trash can. Without changing gloves, the RN obtained more gauze from the container. Her gloves were visibly soiled with blood. The RN again sprayed the wound cleaner on the resident and rubbed the buttocks with gauze causing increased bleeding and further contamination of her gloves. RN Q disposed of the bloody gauze in the resident's trash can and obtained more gauze from the container. Continuing to wear the original pair of gloves, the RN patted the wound with the gauze. The RN picked up clean dressing for the resident's wound and a pair of scissors off the bedside table. She placed the entire dressing over the wound for measuring proposes, touching the wound with the dressing. Using the scissors, she cut the dressing to the desired size and placed it on the resident. RN Q replaced the resident's brief and covered the resident with a sheet. RN Q proceeded to remove the bloody gloves and dispose of them in the resident's trash. She washed her hands, gathered the supplies including the scissors, wound cleaner, the unused portion of the [MEDICATION NAME] dressing and the container of 4 X 4 gauze and placed them back in the treatment cart. RN Q proceeded on to perform a treatment on Resident #5. The RN retrieved the contaminated gauze container and spray bottle of wound cleanser from the treatment cart and placed it on the resident's bedside table. The RN did not clean or cover the bedside table before use. RN Q cleaned the resident's gastrostomy stoma (an incised opening for a feeding tube into the stomach) using gauze sprayed with wound cleanser. Resident #5's stoma appeared to be red, swollen, and had green drainage. f. Record review of Resident #5's face sheet dated [DATE], revealed the resident was readmitted on [DATE] with the [DIAGNOSES REDACTED]. Observation of Resident #5's stoma on [DATE] at 3:00 PM, [DATE] at 10:10 PM and [DATE] at 7:50 AM, revealed Resident #5's stoma site to be red, swollen and had green drainage. Interview with RN Q on [DATE] at 7:50 AM, revealed that she did not realize she had contaminated the 4 x 4 gauzes, scissors, or wound cleanser with Resident #15's blood. The RN stated she had seen the sign and symptoms of an infection of Resident #5's stoma but had not contacted the resident's physician. Review of a facility policy and procedure titled "Wound Care", revised 2002, revealed the following steps were included in wound care: Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Wash hands. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves. Pour liquid solutions directly on gauze sponges on their papers. Clean. Dress wound. Be certain all clean items are on clean field. Remove the disposable cloth next to the resident and discard into the designated container. Discard disposable items into the designated container. Remove disposable gloves and discard into designated container. Wash and dry hands thoroughly. Reposition the bed covers. Use clean field saturated with alcohol to wipe overbed table. Wipe reusable supplies with alcohol as indicated. Return reusable supplies to resident's drawer in the treatment cart. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. Wash and dry hands thoroughly. Record review of the facility's infection control program revealed no documentation for the causative organism on UTIs, isolation precautions, potential cross-contamination concerns, trending of infections, corrective actions and training provided to the staff. There were [MEDICAL CONDITION] or VRE logs as outlined in the infection control policy and procedure. The infection control log labeled "C.A.R.E. log" dated [DATE] revealed Resident #1 had a UTI but did not identify the causative organism or corrective actions to be taken. Record review of Resident #1's chart revealed the resident had a urine culture, dated [DATE] which identified [DIAGNOSES REDACTED] (an uncommon bacterium and human infection is difficult to treat) count of greater than 100,000. Review of a facility policy and procedure titled "[MEDICATION NAME] Resistant [MEDICATION NAME]", revised 2002, revealed names of residents who have had VRE infections/colonization should be recorded onto a VRE log. CONTINUED IN F9999 Interview with ADON/Infection Control Coordinator on [DATE] at 9:40 AM revealed she had never provided the staff training on infection control to include cleaning of the glucometers, types of isolation, and what PPE is required. She stated it was the responsibility of the nurses to inform

Based on observation, interview, and record review, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 7 of 15 residents (Residents #1, 3, 4, 5, 7, 9 and 15) reviewed for infection control issues. The Facility: 1. Failed to implement the facility's Infection Control policies and procedures for 3 of 3 residents (Resident #3, #4 and #7) reviewed on isolation related to identification of isolation rooms and the type Personal Protective Equipment (PPE) required for isolation. 2. Failed the assure the correct PPE was used when entering isolation rooms for 5 of 5 Staff (Staff LVN K, LVN M, MA H, CNA E and CNA F), 2 of 2 residents (Resident #9 and an unidentified resident), a private sitter and visitors. 3. Failed to assure the cleaning of both glucometers (a device used to monitor the blood sugar level) before and after use by 3 of 3 licensed nurses (RN Q, LVN M and LVN EE), which could affect 3 of 3 residents (Resident #1, #4 and #7) requiring blood sugar testing; and the disposal of lancets. 4. Failed to prevent cross-contamination and waste disposal during provision of treatments for Resident #15 and Resident #5 by 1 of 1 RN (RN Q). 5. Failed to assure correct catheter care by 1 of 1 CNA (CNA P) for 1 of 1 resident (Resident #1) with an indwelling catheter related to cleansing the catheter tubing down to the meatus. 6. Failed to maintain the facility's Infection Control Program to prevent the spread of infections within the facility, to include tracking and trending. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of "No actual harm with a potential for more than minimal harm that is not immediate jeopardy" and a scope of "widespread" because staff were still being trained and the plan of removal was still being monitored for implementation and compliance. Failure to maintain an infection control program to prevent the transmission of disease and infection could result in the spread of infection and could affect the 29 residents in the facility. The findings were: A. Record Review of Resident #3's face sheet dated [DATE] revealed that Resident #3 was admitted to facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the admission nursing report dated [DATE] documented Resident #3 was positive for VRE of the stool. There was no information of MRSA of the nares on the report. Record view of the labs faxed from the hospital on [DATE] at 5:20 PM revealed that Resident #3 was found on [DATE] to be positive for MRSA of the nares. Record review of the initial care plan for Resident #3 dated [DATE], documented under the sub heading Special Needs: "resident on isolation". There was no further information regarding isolation such as the type of isolation precautions and PPE to be used. The infection control log labeled "C.A.R.E. log" dated [DATE] revealed Resident #3 was admitted with VRE of the stool but did not mention the MRSA of the nares. Record review of the labs faxed from the hospital on [DATE] at 5:20 PM revealed that Resident #3 was found on [DATE] to be positive for MRSA of the nares. Record review of the admission nursing report dated [DATE] documented Resident #3 positive for VRE. Interview with LVN K on [DATE] at 2:55 PM confirmed she conducted the admission nursing assessment report for Resident #3 and received the information by telephone from the discharging hospital. LVN K stated the hospital said Resident #3 was positive for VRE but did not mention Resident #3 being positive for MRSA. LVN K stated that nursing is responsible for notifying the CNAs and MA's of the types of isolation residents are on and the LVN's received what type of isolation from the doctor or from the infection control nurse. She further stated that she had not been in-serviced on isolation precautions. Review of the facility policy and procedures titled "Categories of Isolation Precautions", revised [DATE], revealed the types of isolation precautions used by the facility and how to identify them: Airborne Precautions: must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small particle residue{5 microns or smaller in size} of evaporated droplets containing microorganisms that remain suspended in the air and can be widely dispersed by air currents within a room or over long distance.). The policy also stated a blue sign should be placed at the doorway instructing visitors to report to the nurses' station before entering and a blue sticker without writing should be placed on the wall above the resident's bed and on the front on the resident's chart. PPE: Mask Contact Precautions: must be implemented for a resident known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. The policy also stated an orange sign should be placed at the doorway instructing visitors to report to the nurses' station before entering and a orange sticker without writing should be placed on the wall above the resident's bed and on the front on the resident's chart. PPE: Gloves and gowns if anticipated clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room. Droplet Precautions: must be implemented for a resident documented or suspected to be infected with microorganisms transmitted by droplet (large-particle droplets {larger than 5 microns} that can be generated by the resident coughing, sneezing, talking, or by the performance of procedures.). The policy also stated a yellow sign should be placed at the doorway instructing visitors to report to the nurses' station before entering and a yellow sticker without writing should be placed on the wall above the resident's bed and on the front on the resident's chart. PPE: Mask when working within three feet of a resident in isolation, wearing gloves when touching blood, body fluids, secretions, excretions, and contaminated items; wearing a mask and eye protection to protect mucous membranes of the eyes, nose, and mouth during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Further precautions included the use of gowns to protect skin and prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluid, secretions, or excretions. During initial tour on [DATE] at 10:15 AM, a sign was observed propped on the handrail outside Resident #3's room. The sign read "please see nurse before entering." A plastic container with drawers containing gloves, mask, and gowns was also observed outside the resident's room. In an interview with LVN M on [DATE] at 10:15 AM, the LVN said that Resident #3 was on isolation for VRE and MRSA of the nares (nostrils) but the VRE had been discontinued yesterday ([DATE]). On [DATE] at 11:30 AM, Resident #9 was observed in Resident #3's room. Resident #9 was observed sitting in her wheelchair at the foot of Resident #3's bed and talking with Resident #3. Resident #9 was not wearing a gown, gloves, or mask. On [DATE] at 11:35 AM, a confused unidentified resident was observed wandering in a wheelchair into the room of Resident #3 and was escorted out by Resident #9's personal sitter. On [DATE] at 12:40 PM, CNA E was observed entering Resident #3's room with out donning gloves, mask, or gown. CNA E was observed assisting the resident to transfer from bed to the restroom. Interview with CNA E on [DATE] at 12:43 PM confirmed he did not wear gloves, gown, or mask when entering the resident's room because he was not going to have physical contact with the resident. He further stated that when he entered the room he saw the resident falling out of the bed and had to provide assistance. CNA E stated he was aware the resident was on isolation and stated staff are supposed to wear gloves and gown when coming into contact with the resident. When CNA E was asked if a mask was also required, CNA E stated he didn't think a mask was required because the resident was on contact isolation only. Interview with LVN K on [DATE] at 5:15 PM revealed that Resident #3 was either on contact or airborne isolation and staff and visitors should wear a mask, gown, and gloves when entering the resident's room at all times. Observation on [DATE] at 9:13 AM, revealed MA H administering medications to Resident #3 who was on isolation. MA H put on gloves and obtained a blood pressure machine from a container located outside of the resident's room. After obtaining the resident's blood pressure, while touching the resident's bed with his clothes, the MA removed his gloves in the resident's bathroom and picked up the contaminated blood pressure machine with his bare hands and returned it to the container outside the room. The MA proceeded to the medication cart and poured the resident's medications without washing his hands. Observation with LVN M on [DATE] at 9:20 AM revealed that before entering Resident #3's room, the LVN donned gloves but no mask or gown. LVN M went into the resident's room to assist the resident to the bathroom. When the resident put on his light, the LVN returned to the resident's room, donned gloves but no mask or gown and assisted the resident again. The LVN continued to provide care to the rest of the residents in the facility. On [DATE] at 9:30 AM LVN M questioned the surveyor on what type of PPE was required for Resident #3 who was on airborne isolation for MRSA of the nares and contact isolation for VRE of the stool. On [DATE] at 10:20 AM, CNA F was observed entering Resident #3's room wearing gloves but no gown or mask. Interview with CNA F at this time confirmed that she used gloves and no other PPE when caring for Resident #3. When the CNA was asked what type of isolation Resident #3 was on, the CNA stated contact isolation and was told by nursing only to wear gloves. Observation on [DATE] at 11:50 AM, revealed Resident #9 going into Resident #3's room without wearing PPE. Interview with CNA F on [DATE] at 12:18 PM, revealed she had been caring for Resident #3 since admission. The CNA stated she had been told by Charge Nurse LVN M that gloves were the only PPE she needed to use when providing care to Resident#3. On [DATE] at 8:35 AM, MA H was observed in the room of Resident #3 taking the resident's blood pressure. MA H was observed exiting the room and placed the blood pressure cuff into the isolation cart outside the resident's door. MA H put on gloves and re-entered Resident #3's room to administer medications. MA H did not don a mask or gown prior to entering the resident's room. MA H then continued to provide medications down the hall to other residents. Interview with MA H on [DATE] at 8:37 AM revealed Resident #3 was on contact isolation and the MA entered the resident's room without wearing a gown or mask. MA H stated he was taking the resident's blood pressure prior to giving medications, did not need to wear a mask or gown and was only required to wear a gown if there was actual contact with the resident. On [DATE] at 1:46 PM, Resident #9 was observed in the room of Resident #3. Resident #9 was observed sitting in a wheel chair at the foot of the bed using Resident #3's telephone with the cord observed lying across the bed. Resident #9 was not wearing gloves, mask, or gown. Interview with LVN M on [DATE] at 1:46 PM confirmed Resident #9 did not have gloves, mask, or gown on while in Resident #3's room. Interview with LVN M on [DATE] stated that he received an order on [DATE] from the physician to continue droplet isolation until a negative culture for MRSA of the nares was obtained on Resident #3. LVN M further stated that there was no documentation prior to [DATE] of an order for [REDACTED]. Review of a facility policy and procedure titled "[MEDICATION NAME] Resistant [MEDICATION NAME]", revised 2002, revealed the precautions to use with a resident that has VRE: Wear a gown when entering the room of a VRE-infected or colonized resident. Wear gloves when entering the room of a VRE-infected or colonized resident because VRE can extensively contaminate such an environment. Remove gloves and gown before leaving the resident's room and immediately wash hands. Ensure that after glove and gown removal and handwashing, clothing and hands do not contact environment surfaces (e.g., a door knob or curtain) in the resident's room that are potentially contaminated with VRE. Names of residents who have had VRE infections/colonization should be recorded onto a VRE log. Only employees trained in prevention of transmission of VRE should provide care to residents infected/colonized with VRE. Volunteers should not provide care for these residents. Review of a facility policy and procedure titled "Administering Medications", revised 2001, revealed the process of giving medications: Established facility infection control procedures must be followed during the administration of medications (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) B. Record review of Resident #4's face sheet dated [DATE], revealed the resident was admitted on [DATE] and acquired[DIAGNOSES REDACTED] toxin in the facility as per laboratory results on [DATE]. A color-coded sticker to identify the resident as being on isolation was not available. Observation on [DATE] at 9:20 AM revealed Resident #4 had a sign propped on the handrail outside her door. The sign, written on plain, white paper said to see the nurse prior to entering the room. Observation upon entering Resident #4's room revealed 2 uncovered bio-hazardous boxes in the corner. One box was lined with a red bag and the other was lined with a yellow bag. Resident #4 was observed sitting up in her wheelchair next to her bed and no isolation signs or stickers were observed in the room. An interview with the ADON/Infection Control Coordinator immediately following the observation revealed Resident #4 was on contact isolation for facility acquired Clostridium Difficile (C-Diff) toxin (a contagious infection that causes severe diarrhea and other intestinal disease) in the stool. Observation on [DATE] at 11:22 AM revealed RN Q performing blood glucose testing with the use of a glucometer on Resident #4 after using the device on Resident #1 without cleaning it. RN Q placed the blood glucose testing supplies, including the glucometer, on the resident's bedside table without cleaning the area. RN Q used the glucometer on Resident #4, disposed of the bloody lancet used on Resident #4 in the yellow bagged lined bio-hazardous box used for laundry isolation and returned the glucometer to a container and placed it in the treatment cart. RN Q did not clean the device prior to or after use. Interview with RN Q on [DATE] at 11:50 AM, she confirmed she had disposed of the lancet for Resident #4 in the bio-hazardous yellow bagged box. RN Q stated she was unsure the difference between the red or yellowed bagged boxes for the residents on isolation. Observation [DATE] at 4:40 PM revealed LVN M conducted blood glucose testing for Resident #4. LVN M placed the blood glucose testing supplies, including the glucometer, on the resident's bedside table without cleaning the area. After using the glucometer, he took the device and placed it in the container in the treatment cart. LVN M did not clean the device prior to or after use. Interview with RN Q on [DATE] at 10:30 AM revealed she did not clean the glucometer and had not received instruction on cleaning the glucometer. Interview with LVN M on [DATE] at 11:43 AM, revealed he had not cleaned the glucometer on [DATE]. LVN M stated he thought the night shift cleaned the devices. LVN M stated he had not received training on cleaning glucometers. Interview with LVN EE on [DATE] at 7:15 AM, revealed she was one of the night nurses responsible for checking the glucometer on Hall B. The LVN said she does not clean the glucometer and had not received training on cleaning the glucometer. Observation on [DATE] at 9:40 AM revealed a group of children go into Resident #4's isolation room to sing to her. Review of a facility policy and procedure, titled "Obtaining a fingerstick glucose level", revised [DATE], revealed steps in performing a blood glucose test: Preparation: Infection Control Protocol and Safety: Maintain clean technique and isolation precautions as indicated. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. Clean and disinfect reusable equipment before storing with other clean equipment. Steps in the Procedure: Clean reusable equipment according to the manufacturer's instructions. Review of the manufacture's policy and procedure, titled "Performing a Blood Glucose test with the...meter ", undated, revealed steps in performing a blood glucose test: Procedure: Verify that the bottle of test strips has not expired and/or the bottle has not been opened for longer than 90 days. Aftercare: Clean.... Blood glucose meter between patient tests. Review of a facility policy and procedure titled "Infection Control, Standard Precautions", revised ,[DATE], revealed the following procedures to prevent the spread of infections: Handwashing: Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between resident contact, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Wash hands between tasks and procedures on the same resident to prevent cross-contamination of different body sites. Gloves: Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non contaminated items and environmental surfaces, and before going to another resident. Wash hands immediately to avoid transfer of microorganisms to other residents or environments. Resident-Care Equipment: Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned. Environmental Control: Ensure that environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces are appropriately cleaned. Review of a facility policy and procedure, titled "Infectious Waste, Handling of", revised [DATE], revealed steps in the procedure for disposal of waste: All sharps must be handled as infectious waste and placed in approved sharps containers. Disposable items, which are contaminated with excretions or secretions from resident's believed to be infectious, must be placed in red plastic bad. Disposable items soiled with visible blood must be placed in red plastic bags or containers. The facility's list of residents that received blood glucose testing in the facility, provided on [DATE] by the Acting DON/MDS Coordinator, revealed there were 3 residents receiving blood glucose testing by the staff. C. Record review of Resident #7's face sheet dated [DATE], revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. The resident acquired[DIAGNOSES REDACTED] toxin in the facility as per laboratory results on [DATE]. Review of the "C.A.R.E. log" dated [DATE] revealed Resident #7 was admitted with[DIAGNOSES REDACTED] instead of acquiring the infection in house. Observation on [DATE] at 11:43 AM revealed LVN M performing blood glucose testing on Resident #7, who was on isolation, with a different glucometer. LVN M placed the blood glucose testing supplies, including the glucometer, on the resident's bedside table without cleaning the area. After use, LVN M returned the glucometer to a container and placed it in the treatment cart. The device was not cleaned. D. Record Review of Resident #1's face sheet dated [DATE] revealed that Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on [DATE] at 11:22 AM revealed RN Q performing blood glucose testing with the use of a glucometer on Resident #1. RN Q placed the blood glucose testing supplies, including the glucometer, on the resident's bedside table without cleaning the area. The RN cleaned the index finger of Resident #1 with an alcohol pad then attempted to puncture the resident's finger with a lancet. The RN was unsuccessful in getting enough blood to test the resident's blood sugar. Without removing her gloves or washing her hands, RN Q left the room and returned to the treatment cart to get another lancet and extra supplies, including alcohol pads. On her third attempt, RN Q squeezed the finger until she was able to get serosanguineous fluid (body fluid consisting of both blood and serous fluids) to drop on the blood glucose strip. RN Q removed her gloves, gathered the extra alcohol pads and put them back into the treatment cart with other treatment cart supplies. RN Q disposed of the lancets in the trash bag on the treatment cart. Interview with RN Q on [DATE] at 11:50 AM, she confirmed she had disposed of the lancets for Resident #1 in the trash. Observation on [DATE] at 4:30 PM revealed LVN M performing blood glucose testing on Resident #1. LVN M placed the glucometer on the blanket covering the resident. LVN M did not clean the device prior to or after use or in between uses for Resident #4 (on contact isolation) and #1. Further review of Resident #1's physician's orders, dated [DATE], revealed an order for [REDACTED]. Review of the Medication Administration Record for [DATE], revealed the last dose of Bactrim DS was administered on [DATE]. Observations on [DATE] at 11:22 AM, 4:05 PM and 4:30 PM revealed Resident #1's urine catheter bag hanging on the foot board of the resident's bed. The collection bag was hanging above the level of the resident's bladder and urine was not flowing into the bag. Observation on [DATE] at 10:05 AM revealed CNA P provided catheter care for Resident #1 in the resident's room. CNA P was observed to use pre-moistened wipes. CNA P wiped up the catheter tubing from the connection site of the catheter to the urinary bag towards the urethra 3 times. There was a small amount of blood observed on the penis head. CNA P wiped down the left side of Resident #1's groin but did not clean the penis or the right side of the groin. Interview with CNA P on [DATE] at 10:05 AM confirmed CNA P did not cleanse the catheter from the urethra outwards nor did she clean the penis when providing catheter care. Review of a facility policy and procedure titled "Catheter Care, Urinary", revised 2002, revealed the following steps were included in the catheter care for a male: Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. For a male: Use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from the insertion site to approximately four inches outward. Review of the Form CMS 672, provided by the facility's Acting DON/MDS Coordinator and dated [DATE], revealed there was 1 resident with an indwelling catheter. E. Observation on [DATE] at 7:30 AM, revealed RN Q providing a coccyx wound treatment and dressing change to Resident #15's left buttocks. RN Q gathered supplies including wound cleanser, scissors, a container of 4 X 4 gauze and a [MEDICATION NAME] dressing from the treatment cart. After pushing Resident #15's belongings out of the way, RN Q proceeded to place the supplies on the resident's bedside table. RN Q did not clean the table before use despite visible debris including food particles and spilled liquids on the tabletop. After positioning the resident onto the right side, RN Q removed the resident's brief exposing soiled dressing on the coccyx. RN Q removed the dressing and discarded it in the resident's trash can. Without changing gloves, RN Q opened a container of 4 x 4 gauzes and removed some. RN Q retrieved wound cleanser and alternated between spraying the wound and rubbing the same 4 x 4 gauze repeatedly over multiple surfaces of the left buttocks. RN Q disposed of the used bloody gauze in the resident's trash can. Without changing gloves, the RN obtained more gauze from the container. Her gloves were visibly soiled with blood. The RN again sprayed the wound cleaner on the resident and rubbed the buttocks with gauze causing increased bleeding and further contamination of her gloves. RN Q disposed of the bloody gauze in the resident's trash can and obtained more gauze from the container. Continuing to wear the original pair of gloves, the RN patted the wound with the gauze. The RN picked up clean dressing for the resident's wound and a pair of scissors off the bedside table. She placed the entire dressing over the wound for measuring proposes, touching the wound with the dressing. Using the scissors, she cut the dressing to the desired size and placed it on the resident. RN Q replaced the resident's brief and covered the resident with a sheet. RN Q proceeded to remove the bloody gloves and dispose of them in the resident's trash. She washed her hands, gathered the supplies including the scissors, wound cleaner, the unused portion of the [MEDICATION NAME] dressing and the container of 4 X 4 gauze and placed them back in the treatment cart. RN Q proceeded on to perform a treatment on Resident #5. The RN retrieved the contaminated gauze container and spray bottle of wound cleanser from the treatment cart and placed it on the resident's bedside table. The RN did not clean or cover the bedside table before use. RN Q cleaned the resident's gastrostomy stoma (an incised opening for a feeding tube into the stomach) using gauze sprayed with wound cleanser. Resident #5's stoma appeared to be red, swollen, and had green drainage. F. Record review of Resident #5's face sheet dated [DATE], revealed the resident was readmitted on [DATE] with the [DIAGNOSES REDACTED]. Observation of Resident #5's stoma on [DATE] at 3:00 PM, [DATE] at 10:10 PM and [DATE] at 7:50 AM, revealed Resident #5's stoma site to be red, swollen and had green drainage. Interview with RN Q on [DATE] at 7:50 AM, revealed that she did not realize she had contaminated the 4 x 4 gauzes, scissors, or wound cleanser with Resident #15's blood. The RN stated she had seen the sign and symptoms of an infection of Resident #5's stoma but had not contacted the resident's physician. Review of a facility policy and procedure titled "Wound Care", revised 2002, revealed the following steps were included in wound care: Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Wash hands. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. Put on exam glove. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves. Pour liquid solutions directly on gauze sponges on their papers. Clean. Dress wound. Be certain all clean items are on clean field. Remove the disposable cloth next to the resident and discard into the designated container. Discard disposable items into the designated container. Remove disposable gloves and discard into designated container. Wash and dry hands thoroughly. Reposition the bed covers. Use clean field saturated with alcohol to wipe overbed table. Wipe reusable supplies with alcohol as indicated. Return reusable supplies to resident's drawer in the treatment cart. Take only the disposable supplies that are necessary for the treatment into the room. Disposable supplies cannot be returned to the cart. Wash and dry hands thoroughly. Record review of the facility's infection control program revealed no documentation for the causative organism on UTIs, isolation precautions, potential cross-contamination concerns, trending of infections, corrective actions and training provided to the staff. There were no MRSA or VRE logs as outlined in the infection control policy and procedure. The infection control log labeled "C.A.R.E. log" dated [DATE] revealed Resident #1 had a UTI but did not identify the causative organism or corrective actions to be taken. Record review of Resident #1's chart revealed the resident had a urine culture, dated [DATE] which identified [DIAGNOSES REDACTED] (an uncommon bacterium and human infection is difficult to treat) count of greater than 100,000. Review of a facility policy and procedure titled "[MEDICATION NAME] Resistant [MEDICATION NAME]", revised 2002, revealed names of residents who have had VRE infections/colonization should be recorded onto a VRE log. Interview with ADON/Infection Control Coordinator on [DATE] at 9:40 AM revealed she had never provided the staff training on infection control to include cleaning of the glucometers, types of isolation, and what PPE is required. She stated it was the responsibility of the nurses to inform the rest of the staff and visitors on the type of PPE required when a resident was on isolation. The ADON stated she knew she did not have an infection control program which investigated, controlled, and prevented the spread of infections. The ADON was unaware of the facility policies and procedures related to infection control. She stated she does not document isolation precautions, organism or corrective actions. The ADON also stated she does not keep a MRSA or VRE log. Review of a facility policy and procedure titled "Methicillin Resistant Staphylococcus Aureus", revised 2002, revealed the precautions to use with a resident that has MRSA: Residents known or suspected to have MRSA infection or colonization will be placed on contact isolation precautions. Names of residents who have MRSA infection/colonization must be recorded onto an MRSA log. The facility's list of residents with active infections in the facility, provided on [DATE] by the Acting DON/MDS Coordinator, revealed there were 7 (Resident # 3 {MRSA of Nares}, #4 {C-Diff}, #7 {C-Diff}, #14 {UTI}, #16 {UTI}, #17 {UTI and Pneumonia} and #18 {UTI}) residents with infections and out of the 7 residents 4 residents acquired the infection inside the facility. The Administrator was informed of the IJ on [DATE] at 12:00 PM. Review of the Form CMS 672, provided by the facility's Acting DON/MDS Coordinator and dated [DATE], revealed there were 4 residents on antibiotic therapy. The administrator was informed of the removal of the IJ on [DATE] at 9:30 AM. The [DATE] plan of removal provided by the facility included: ? All staff will be educated on contact and droplet isolation. This education will be based on the Heaton policies. Any employee not present for education today will receive 1:1 education prior to returning to the floor. This training will be provided by regional RN, consultant RN, Staff Development nurse, and/or MDS nurse. This was initiated [DATE] at approximately 4:00 PM. Continued in F999 ? Isolation type notifications will be placed in isolation bins per NHA. Nurse educated per Regional RN, Consultant RN, Staff Development Nurse as to use of form. This form will replace the color code procedure in the isolatio