Every finding on record at Wisteria Gardens

Based on observation, interview, record review, and facility statment review the facility failed to ensure a safe smoking program and failed to assess a resident for safe smoking practices for one (1) of three (3) residents reviewed for accident hazards. Resident #17.FindingsRecord review of a typed statement on facility letterhead dated 3/11/26 and signed by the Director of Nursing (DON) revealed, (Name of Facility) does not have a policy requiring the completion of a smoking assessment for Residents who use tobacco products.On 03/09/26 at 11:41 AM, Resident #17 was observed eating lunch in his room with cigarettes visible in the front pocket of his shirt.On 03/11/26 at 8:18 AM, Resident #17 was observed traveling in a wheelchair down the hallway near the nurse's station with cigarettes in the front pocket of his shirt.During an interview on 03/11/26 at 12:53 PM, Certified Nursing Assistant (CNA) #1 stated the resident's family visits and the resident smokes outside with family members or a staff member present. CNA #1 stated the resident is able to hold a cigarette independently but does not have access to a lighter. CNA #1 reported the resident keeps cigarettes in his shirt pocket while in his room. CNA #1 stated she had not noticed burn marks on the resident's skin or clothing. CNA #1 further stated staff had not received in service training regarding residents who smoke.Record review of the medical record revealed no smoking assessment had been completed for Resident #17.During aninterview on 03/11/26 at 1:09 PM, the Director of Nursing stated smoking assessments are important so staff can determine if a resident can safely smoke. The Director of Nursing stated the consequence of not completing a smoking assessment could include potential burns.Observation of the designated smoking area on 03/11/26 at 1:15 PM, revealed no smoking aprons were immediately available. No fire extinguisher was located directly in the outdoor smoking area, although one was located inside near the hallway exit to the outdoor area. No gate or barrier was present to secure the area for residents while smoking.During an interview on 03/11/26 at 3:15 PM, Resident #17 stated he smokes on the side of the building, sometimes late morning but mostly in the evenings. The resident stated family members or a CNA are present when he smokes. The resident confirmed he keeps his cigarettes in the pocket of his shirt while in his room.Record review of the admission Record revealed Resident #17 was admitted on [DATE] with diagnoses that included traumatic ischemia of muscle.Record review of the Minimum Data Set with an Assessment Reference Date of 03/11/26 revealed the assessment was still in process due to the resident's recent admission.

Based on observation, interview, record review, and policy review, the facility failed to ensure staff followed infection prevention and hand hygiene practices during catheter care for one (1) of three (3) residents observed for infection control. Resident #32.Findings included:Record review of the facility policy Handwashing reviewed 1/25 revealed Policy: Employees must wash their hands using antimicrobial or non-antimicrobial soap and water; alcohol-based hand rub may be used if hands are not visibly soiled.After handling items potentially contaminated with blood, body fluids, or secretions .On 03/10/26 at 1:18 PM, Certified Nurse Aide (CNA) #1 was observed performing catheter care for Resident #32. During care, the resident's perineal area was observed to have an open area that was actively bleeding. CNA #1 wiped the resident's perineum four separate times using incontinent wipes while wearing the same gloves that had become visibly contaminated with blood. CNA #1 did not remove the contaminated gloves, perform hand hygiene, or apply clean gloves between wipes.During an interview on 03/10/26 at 1:31 PM, CNA #1 stated she should have removed the contaminated gloves, performed hand hygiene, and applied clean gloves after each wipe of the perineal area to prevent infection and cross contamination.During an interview on 03/10/26 at 1:35 PM, the Director of Nursing (DON) confirmed CNA #1 should have changed gloves during catheter care to prevent the possible spread of infection to the catheter site. The DON stated staff are expected to follow infection prevention guidelines and perform appropriate hand hygiene during resident care.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/14/26 revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.Record review of the admission Record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy.Record review of the Order Summary Report with active orders as of 3/10/26 revealed a physician order dated 9/5/25 to monitor catheter output every day shift and night shift related to urinary tract infection.

Based on observation, staff interview, and facility policy review, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to expired foods, freezer burned foods, improperly stored foods, and unlabeled and undated foods for two (2) of (2) kitchen observations. Findings include: A review of the facility's policy, Handling of Perishable Foods, Revision Date: [DATE] revealed, Policy: To ensure foods are protected from contamination or spoilage. Any growth of organisms is prevented by proper storage and temperatures .Policy .10. All items .will be properly labeled with the Item, Initials, Date and use by date .12. Any food items not properly stored will be disposed of immediately . On [DATE] at 10:15 AM, during an observation of the kitchen and an interview with the Certified Dietary Manager (CDM), the walk-in refrigerator was observed to contain a one (1) gallon bottle of lime juice with a manufacturer's date of [DATE] on the lid and a white cloudy film at the bottom of the bottle. There were (2) unopened containers of beef tips with no date or identifying label and (1) opened package of diced ham with no label. An unopened package of roast beef slices was observed with manufacturer's instructions to use or freeze by [DATE], but it did not have a facility thawed on or use by date. Additionally, there was an unopened bag of chopped cabbage labeled Best if used by [DATE]. In the freezer, (2) opened and three (3) unopened bags of chicken gizzards were observed without identifying labels and had white discoloration consistent with freezer burn. The CDM acknowledged the outdated, unlabeled, and inappropriately stored food items and explained that it is the responsibility of all kitchen staff to check for and discard expired foods, as well as to label and date food items. The CDM stated that food items should have been labeled and dated according to facility practices. She explained that she conducts food safety training in-services for the kitchen staff twice a year and stated that labels are available to identify the date of opening, thawed on, and use by dates. The CDM stated that she would review the labeling procedures with the kitchen staff. On [DATE] at 9:17 AM, during an interview, the [NAME] stated that all kitchen staff are responsible for labeling and dating food items and ensuring expired foods are discarded. The [NAME] explained that once a food item is opened, staff have three (3) days to use it or discard it. The [NAME] emphasized that everyone in the kitchen is responsible for labeling, dating, and monitoring for expired foods. The [NAME] also stated that staff receive in-service training on food safety every six (6) weeks. On [DATE] at 9:20 AM, during an interview, the Dietary Aide (DA) stated that the staff member assigned to put away items from the delivery truck is responsible for labeling them. The DA explained that all kitchen staff are responsible for monitoring food items and discarding expired foods. The DA also stated that staff receive in-service training on food safety once a month. On [DATE] at 10:05 AM, an interview with the Administrator, she acknowledged the outdated, unlabeled, and inappropriately stored items in the kitchen. The Administrator stated and the owner of the facility currently has a practice of conducting spot checks in the kitchen every two (2) weeks. The Administrator stated she will increase her presence in the kitchen to assist with making sure the food is monitored appropriately. The Administrator stated that her expectation for the kitchen staff is that they will do it right by monitoring for outdated, undated and unlabeled foods.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than five percent (5%) as evidenced by three (3) errors were observed out of 29 medication administration opportunities. This affected two (2) of four (4) residents observed during medication pass, resulting in a medication error rate of 10.34%. (Resident #43 and Resident #154) Findings Include: A record review of facility's policy Medication and Treatment Orders, undated, revealed, .Orders for medications and treatments will be consistent with principles of safe and effective order writing . Resident #43 A record review of the Admission Record revealed the facility admitted Resident #43 on 01/20/2025 with current diagnoses including Chronic Obstructive Pulmonary Disease (COPD). A record review of the Order Summary Report, with Active Orders As Of: 2/19/25, revealed Resident #43 ' s had a Physician ' s Order, dated 2/13/25 for Breo Ellipta Inhalation Powder Breath Activated, one (1) puff one puff inhaled orally once daily for COPD . On 2/19/25 at 9:40 AM, during observation, Licensed Practical Nurse (LPN) #3 was unable to locate Breo Ellipta inhaler in the medication cart for Resident #43. LPN #3 went into the resident's room and asked if the medication was in her room and Resident #43 stated that she did not know where it was. The medication was not administered. On 02/19/2025 at 11:08 AM, during an interview, LPN #3 stated she had not been able to locate the Breo Ellipta to administer to Resident #43. On 02/19/2025 at 2:14 PM, during an interview, LPN #3 confirmed that she had not given Resident #43 the Breo Ellipta because she could not locate it. On 02/19/2025 at 2:33 PM, during an interview, the Director of Nursing (DON) stated that failing to administer the Breo Ellipta as prescribed could cause Resident #43 to experience shortness of breath (SOB) and lightheadedness. The DON stated she expected nurses to administer medication as prescribed and to order a replacement if a medication could not be located. A review of Resident #43's February 2025 Electronic Medication Administration Record (EMAR) revealed the Breo Ellipta was not administered on 02/19/2025. Resident #154 A record review of the Admission Record revealed the facility admitted Resident #154 on 02/13/2025 with current diagnoses including Unspecified Glaucoma. A record review of the Order Summary Report with active orders as of 2/19/25, revealed Resident #154 had a physician's order, dated 2/13/25, for Timolol Maleate Ophthalmic Solution 0.5%, instill one (1) drop in both eyes two times daily. On 2/19/25 at 9:20 AM, during an observation, LPN #3 administered Timolol Maleate Ophthalmic Solution two (2) drops in each eye for Resident #154. On 02/19/2025 at 9:29 AM, during an interview, LPN #3 confirmed that she administered (2) drops in each eye for Resident #154 and stated she should have administered (1) drop in each eye as per physician orders. On 02/19/2025 at 2:28 PM, during an interview, the DON stated that LPN #3 should have administered only (1) drop per eye according to the physician's order. The DON stated she expected staff to follow physician orders accurately during medication administration.

Based on facility policy review, record reviews, and staff interviews, the facility failed to correctly code a Minimum Data Set (MDS) discharge assessment for one (1) of fourteen (14) sampled residents reviewed for assessment accuracy. Resident #48 Findings Include: Record review of the facility's, Accurate Completion of Social Determinates of Health -Minimum Data Set (MDS) Policy dated October 2023 revealed It is the policy of this facility to ensure that . data are accurately captured within the MDS per the current Resident Assessment Instrument (RAI) Guidelines .The MDS Coordinator will ensure that these data elements are carried out timely and coded accurately . Record review of the Discharge Minimum Data Set (MDS) for Resident #48 revealed an admitted [DATE]. Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/10/24 in Section A revealed Resident #48 was discharged to an acute hospital. Record review of the facility's, Progress Notes revealed Resident #48 was discharged home with Hospice on 12/10/2024. During an interview with the Registered Nurse (RN) #2, MDS Coordinator on 2/19/25 at 2:00 PM, confirmed he failed to accurately code Resident #48's Discharge MDS assessment dated [DATE]. During an interview with the Director of Nursing (DON) on 02/20/2025 at 8:55 AM confirmed the facility failed to code the discharge MDS correctly. MDS discrepancy is a result in error of interpretation of notes. Progress notes states that resident was released to Baptist Hospice- Note was interpreted as resident was released to Hospital. DON stated that correction has been submitted and DON expectations of the MDS Coordinator is to code correctly per regulation guidelines. During an interview on 2/20/25 at 10:05 AM with the Administrator, stated she was informed of the MDS inaccurate coding for discharge for resident #48.

Based on observations, interviews, and record and facility policy review, the facility failed to follow infection prevention guidelines in two (2) of (10) observed care procedures as evidenced by staff did not don (put on) appropriate personal protective equipment (PPE), including gowns, per Enhanced Barrier Precautions (EBP) during Percutaneous Endoscopic Gastrostomy (PEG) tube and Foley catheter care for Resident #43 and Resident #251. Findings Include: A record review of the facility's policy Enhanced Barrier Precautions dated April 2024 revealed .Policy Interpretation and Implementation: 1. EBP will be used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multidrug resistant organism (MDROs) to staff . Resident #43 On February 19, 2025, at 1:42 PM, Licensed Practical Nurse (LPN) 1 was observed providing care to Resident #43's PEG tube site. LPN #1 did not don a gown before initiating the procedure and completed the entire care process without wearing a gown. During an interview at 1:42 PM, LPN #1 confirmed that EBP signage was posted on Resident #43's door. She acknowledged that the signage indicated that a gown and gloves should be worn when providing care. She further stated that she should have donned a gown before entering the resident's room to perform care, as the resident had a PEG tube that required site care, and failure to wear PPE could contribute to infection transmission. A review of the Admission Record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses that included Cerebral infarction due to unspecified occlusion or stenosis of the right middle cerebral artery. A record review of Resident #43's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/27/25 revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severely impaired cognition. A record review of Resident #43's Order Summary Report with active orders as of 2/29/25 revealed an order dated 1/21/2025 Clean PEG tube site with normal saline. Pat dry. Cover with gauze, and secure with tape daily on every day shift. Resident #251 On February 19, 2025, at 1:55 PM, Certified Nurse Aide (CNA) 1 was observed providing Foley catheter care for Resident #251. CNA #1 did not apply a gown before starting the procedure and completed the catheter care without wearing a gown. During an interview on February 19, 2025, at 2:10 PM, CNA #1 confirmed that she did not wear a gown during the procedure but stated that she should have worn one, as the resident was on EBP. She acknowledged that a sign on the resident's door indicated that the resident had a Foley catheter, requiring staff to wear gowns to prevent infection transmission. A review of Resident #251's Admission Record revealed the resident was admitted on [DATE], with diagnoses that included Chronic kidney disease, Stage 3B. A review of Resident #251's MDS revealed the resident had a BIMS score of 3, indicating severely impaired cognition. A record review of Resident #251's Order Summary Report with active orders as 2/19/25 revealed a physician order dated 2/18/2025 8 (eight) ounces of water every 8 hours for hydration. An additional order dated 2/7/2025 revealed Monitor output of cath (catheter) every shift. During an interview on February 19, 2025, at 2:44 PM, the Infection Preventionist (IP) nurse stated that EBP requires staff to wear gowns and gloves when providing hands-on care to residents with invasive lines and tubes, such as PEG tubes or Foley catheters. She emphasized that gowns prevent the spread of MDROs and staff are expected to comply with PPE requirements per facility policy. During an interview on February 19, 2025, at 3:49 PM, the Director of Nursing (DON) stated that EBP requires gowns to be worn when caring for residents with MDROs, chronic wounds, Foley catheters, or PEG tubes, as these conditions place residents at increased risk for infection. The DON further stated that staff have been in-serviced on infection control protocols and are expected to follow Centers for Disease Control and Prevention (CDC) guidelines and facility policy to prevent the spread of infection.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency. Specifically, the facility was cited for failing to label, date, and discard expired items stored in the refrigerator, freezer, and dry storage room during an annual recertification survey on [DATE] and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of six (6) deficiencies cited. F812 Findings Include: Review of the facility's policy Quality Assessment and Performance Improvement (QAPI) Program, undated, revealed .The facility shall .maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program .Committee Audit Process .2. The QAPI Committee shall help various departments .develop and implement plans of correction and monitoring approaches .3. The committee shall track the progress of any active plans of corrections. 4. The committee shall advise the administration of the need for policy or procedural changes and, as appropriate, monitor to ensure that such changes are implemented . Record review of the Centers for Medicare and Medicaid Services (CMS-2567) (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of [DATE], revealed the facility received a citation for F812, .Based on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerator, freezers, and the dry storage room were dated, labeled, and discarded by the expiration date . During the current annual recertification survey, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to expired foods, freezer burned foods, improperly stored foods, and unlabeled and undated foods for two (2) of (2) kitchen observations. On [DATE] at 11:45 AM, during an interview the Administrator, stated that she was aware that on the last annual survey on [DATE], the facility was cited for food procurement and unlabeled food items. She stated that she performed random checks of the kitchen for dates and labels several times a month along with the facility owner.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure medications were safely and securely stored for one (1) of four (4) residents observed for medication administration. Resident #43 Findings Include: A record review of the facility's Medication Labeling and Storage revised 2/2023, revealed, .The facility stores all medication and biologicals in locked compartments .Medication Storage .2. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner . On 02/19/2025 at 9:45 AM, during an observation with Licensed Practical Nurse (LPN) #3, Albuterol Sulfate HFA Inhalation Aerosol Solution was observed on Resident #43's nightstand table in a clear plastic bag. On 02/19/2025 at 2:14 PM, during an interview, LPN #3 stated that no medications should be left at the bedside unless there is a physician's order permitting it. She explained that leaving medications at the bedside could result in the resident overdosing on the medication, which could cause damage to the lungs if overdosed. She confirmed that the Albuterol inhaler should not have been left on the nightstand. On 02/19/2025 at 2:33 PM, during an interview, the Director of Nursing (DON) stated that no medications should be left at the bedside unless ordered by a physician. She explained that if medications are left at the bedside, residents could use more than prescribed, leading to overuse. The DON stated that overuse of Albuterol could cause Resident #43 to experience shortness of breath (SOB) and lightheadedness. She confirmed that it was her expectation that nursing staff would ensure medications are securely stored according to facility policy. A record review of the Admission Record revealed the facility admitted Resident #43 on 01/20/2025 with current diagnoses including Chronic obstructive pulmonary disease (COPD). A record review of the Order Summary Report with active orders as of 2/19/25, revealed Resident #43 had a physician order dated 1/20/25, for Albuterol Sulfate HFA Inhalation Aerosol Solution one (1) puff inhale orally every six hours as needed for Shortness of breath/wheezing related to COPD.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerators, freezers, and the dry storage room were dated, labeled, and discarded by the expiration date for one (1) of three (3) dietary observations. This has the potential to affect all residents receiving meals prepared by the facility's dietary department. Findings include: Review of the facility's policy titled, Food Storage (Dry, Refrigerated, and Frozen) dated 2016, revealed, . Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration . An observation of the kitchen on [DATE] at 9:15 AM, with the Dietary Manager (DM), revealed several expired food items. There were three (3) 46 ounce (oz). cartons of [NAME] Ready Care cranberry cocktail, with a received date of [DATE], and an expiration date of ,d+[DATE]. There were six (6) 24 oz bottles of Hershey's chocolate syrup, with an expiration date of ,d+[DATE]. One of the Hershey chocolate syrup bottles had been opened, with approximately ,d+[DATE] of the syrup remaining in the bottle. The opened bottle was labeled with an open date of [DATE]. There were three (3) 46 oz. cartons of [NAME] orange juice, with an open date of [DATE], and an expiration date of [DATE]. There was a one (1) gallon jug of Worcestershire Sauce, with an open date of [DATE], and an expiration date of [DATE]. Additionally, there were eight (8) frozen pancakes wrapped in plastic wrap, without a name or date on it. During an interview with the DM on [DATE] at 9:50 AM, she revealed that in their facility, the DM is responsible for discarding expired foods. The DM confirmed that if residents were served expired foods, they could get sick. On [DATE] at 12:18 PM, in an interview with the Assistant Administrator, she confirmed that the expired foods should have been discarded, as serving expired foods to residents could cause foodborne illnesses.

Based on observation, interviews, record reviews, and facility policy review the facility failed to manage a resident's pain by not administering medication per physician orders for one (1) of three (3) residents reviewed for pain. Resident # 6 Findings include: A review of the facility policy, Pain Assessment Management, with a revision date of 9/2023, revealed, Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain . The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate . On 10/16/23 at 10:32 AM, in an interview with Resident #6, she revealed she has back and leg pain. She stated her pain is controlled by a pain patch on her back, but the nurse had told her that the facility is out of the patch. On 10/17/23 at 11:09 AM, during an interview with Resident #6, she commented that the facility was still out of her pain patch. On a scale of one to ten (1-10), the resident rated her pain level as 8. The resident explained the pain patch helps with her back pain and that she really needed it. She stated when they put the patch on, she has very little back pain. Resident #6 revealed her pain level is never completely gone, but the patch decreases it to a 1 or 2. The resident was unable to remember the last time that a pain patch had been applied but stated that she thinks it was either Thursday or Friday of last week. The resident further explained that the nurse had told her that it had been ordered from the pharmacy, and she will be glad when it comes in, as she needs the patch. On 10/17/23 at 11:25 AM, in an interview with Licensed Practical Nurse #1 (LPN), she stated the Lidocaine patches came in today and were in the medication room. The nurse revealed she had not yet applied a pain patch; however, the resident told her she was not in pain. On 10/17/23 at 11:30 AM, an observation of the medication room with LPN #1, revealed the Lidocaine patches were not in stock in the medication room. On 10/17/23 at 11:32 AM, in an interview with the Director of Nursing (DON, she) stated there is a button in the Electronic Medication Administration Record (EMAR), that allows the nurses to reorder medications. The DON revealed the reorder of medications usually takes about a week, but sometimes the order does not come in and they have to contact the pharmacy. On 10/17/23 at 2:30 PM, in an interview with LPN #1, she stated she had not talked with the DON about Resident #6's lidocaine patches but will do so prior to leaving today. LPN #1 once again stated Resident #6 continued to rate her pain level at a zero (0). On 10/18/23 11:03 AM, in an interview with LPN #2, he revealed Resident #6 had an order for a 5% (five percent) Lidocaine patch. LPN #2 stated they had been out of the patch for several days, as the patch was on back order. However, he revealed they now have a new order for Resident #6 to receive a 4% (four percent) Lidocaine patch. On 10/18/23 11:10 AM, in an interview with the Director of Nursing (DON), she stated she did not know the resident was out of Lidocaine patches until yesterday. She revealed she had contacted the pharmacy and was told it is on back order, so she had contacted the physician and received an order to change the Lidocaine patch from 5% to 4%. The DON confirmed that the nurse should have called the pharmacy to follow-up on the Lidocaine patches and when she found out that they were not available, she should have contacted the physician, as the physician would have changed the order earlier to meet the needs of the resident. On 10/18/23 at 3:04 PM, in an interview with Resident #6, she stated they put her patch back on today and her pain level had decreased to a level 2. A record review of Face Sheet for Resident # 6 revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Periprosthetic fracture Around Internal Prosthetic Right Knee Joint, Spinal Stenosis, Spondylosis Without Myelopathy or Radiculopathy of Cervical Region, and Radiculopathy of Lumbar Region. Record review of the October 2023 Physician Orders for October 2023 revealed an order dated 9/28/23 Lidocaine 5% Patch Apply 1 patch topically daily to lower back (on for 12 hours and off for 12 hours). Review of the Admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 9/28/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A record review of the pharmacy invoices for September and October 2023 revealed the facility received a 14-day supply of Lidocaine 5% patches on 9/28/23 for Resident #6. The facility had not received additional Lidocaine 5% patches for Resident #6 since 9/28/23. The start date was 9/29/23, which indicates Resident #6 was out of the Lidocaine patches for five days. On 10/19/23 1:17 PM, in an interview with Resident #6 stated that they put her pain patch on this morning. She denied being in any pain.

Based on observation, staff interview, and facility policy review, the facility failed to post the daily staffing hours for public viewing (4) of four (4) days reviewed for staff posting. Findings include: Record review of the facility's policy, Posting Direct Care Daily Staffing Numbers, undated, revealed .Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) (Registered Nurses, Licensed, Practical Nurses, and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (CNAs) (Certified Nurse Aides) directly responsible for resident care will be posted in a prominent location (accessible to, residents and visitors) .5. Within two (2) hours of the beginning of the shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form . and post the staffing information in the location(s) designated by the Administrator .9. Staffing information during the recorded time period shall be made available to residents, family members, and the public . On 10/16/2023 at 10:23 AM, an observation of the staffing board opposite the nurses' station revealed only the date, nurses' hall assignments, and CNA hall assignments. Daily staffing hours were not posted anywhere in the facility. On 10/17/2023 at 12:20 PM, an observation of the staffing board opposite the nurses' station revealed only the date, nurses' hall assignments, and CNA hall assignments. Daily staffing hours were not posted anywhere in the facility. On 10/17/23 at 12:23 PM, during an interview with the Director of Nursing (DON), she verified that shift-specific work hours are not included on the staffing board. She did mention that she records the hours worked on a daily staffing sheet that has been maintained in her office for several months. On 10/18/2023 at 9:17 AM, an observation of the staffing board opposite the nurses' station revealed only the date, nurses' hall assignments, and CNA hall assignments. Daily staffing hours were not posted anywhere in the facility. On 10/19/2023 at 11:57 AM, an observation of the staffing board opposite the nurses' station revealed only the date, nurses' hall assignments, and CNA hall assignments. Daily staffing hours were not posted anywhere in the facility. On 10/19/23 at 12:02 PM, in an interview with the Director of Nursing (DON) stated that visibly posting actual hours worked ensures that residents, staff, and visitors know that the facility is adequately staffed. On 10/19/23 at 12:16 PM, CNA Team Leader #1 stated in an interview that she was unaware of the facility posting the hours worked by licensed and unlicensed personnel in the building On 10/19/2023 at 1:22 PM, in an interview with the Assistant Administrator, she confirmed that actual hours worked by licensed and unlicensed personnel should be posted daily for staff, visitors, and residents to see.

Based on observation, staff and resident representative interview, record review, Resident Council Committee review and facility policy review the facility failed to honor the resident's rights for visitation with family for six (6) of 6 resident/resident representative interviews. Resident #138's Resident Representative and Resident #6, #8, #21, #87 and #140. Findings Include: Record review of the facility visitation policy titled, Visitation during COVID-19 Public Health Emergency ([NAME]), updated March 2021, revealed, wisteria gardens follows current guidelines and recommendations for the prevention and control of COVID-19. It is the goal of this facility to provide reasonable ways to facilitate in-person visitation to address the psychosocial needs of residents .Indoor Visitation During an Outbreak .1. When a new onset of COVID-19 among residents or staff is identified, the facility will immediately begin testing and suspend all visitation (except for compassionate care) until at least one round of facility-wide testing is completed. Visitation can resume based on the following criteria: a. If the first round of outbreak testing reveals no additional Covid-19 cases in other areas of the facility, then resume visitation in the areas/units with no COVID-19 cases. The facility will suspend visitation on the affected unit until the facility meets criteria to discontinue outbreak testing . Resident #138 During an interview on 9/7/21 at 1:00 PM, with Resident #138's Resident Representative revealed the facility failed to let her visit her husband during the time he was in the facility. The wife said the facility said she could come to the window and talk to him on Face Time. The wife said her husband did not have COVID-19 and his room was on the other side of the building. Record review of the Admission Record revealed Resident #138 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/21 revealed Resident#138 had a Brief Interview for Mental Status (BIMS) score of eight (8) which indicated Resident #138's cognitive status is moderaterly impaired. During a Resident Council members meeting on 09/08/21 at 10:30 AM, the members confirmed the facility does not allow them to have visits because of the COVID-19 outbreak. The residents said they all have private rooms and they do not have COVID-19. The residents also said the facility only allowed the family to come to the windows of the room. They are not allowed to let the window up. They must Face Time on the phone or a computer device. The residents stated they do not understand why they can't have visitors. During an interview on 09/8/21 at 02:12 PM, with Registered Nurse (RN) #1 confirmed the facility did not allow family visits because the facility had a COVID-19 out break starting August 3,2021. RN #1 said the facility county positivity rate is 15.2% and 85 % of the residents are vaccinated. RN #1 said the Administrator decided to not allow the families to visit. RN #1 also said the families could come to the window and Face Time the residents but the family could not enter the building. During an interview on 09/09/21 at 02:24 PM, with the Administrator confirmed the facility did not allow visitors as of August 3, 2021. The Administrator said he knew what the latest guidance from the Centers for Medicare and Medicaid (CMS) said but he was erroring on the side of safety. The Administrator said he would rather take the tag than to see an outbreak in the building. Resident Council Committee Members: Resident #8: Record review of the Admission Record revealed Resident #8 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS which contained a BIMS score was the 5 day Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 07/19/21. It revealed Resident#8 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #8 is cognitively intact. Resident #87: Record review of the Admission Record revealed Resident #87 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 9/8/21 at 10:30 AM during the Resident Council meeting revealed the Resident #87 was cognitively intact and took part in the meeting. Resident #6: Record review of the Admission Record revealed Resident #6 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/21 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) of 15 that indicated Resident #6 is cognitively intact. Resident #140: Record review of the Admission Record revealed Resident # 140 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the most recent MDS that contained a BIMS score was the Discharge Minimum Data Set (MDS) with an Assessment Reference Date of 5/5/21. It revealed Resident #140 had a Brief Interview for Mental Status (BIMS) of 15 which indicated Resident #140 is cognitively intact. Resident #21: Record review of the Admission Record revealed Resident #21 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date of 8/13/21 revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #21 is cognitively intact.

Based on observation, staff interviews, physician interview, record review and facility policy review the facility failed to code the Minimum Data Set (MDS) correctly regarding Bi-level Positive Airway Pressure ([CONDITION(S)]) for one (1) of three (3) resident's with [CONDITION(S)]'s observed. Resident #9 Findings include: Record review of a statement on facility letterhead, undated revelaed In correcting a MDS, (Formal Name of Facility) follows the RAI manual's guidelines. During an interview and observation on 09/07/21 at 03:00 PM, with Resident #9 revealed she wears oxygen (O2) at all times. O2 was in use at 2L/min (liters/minute) via nasal cannula. She reported the [CONDITION(S)] machine is new, and she has never worn it. She explained no one knows how to work it. She explained a guy just brought the supplies and set the numbers. She tried it on but she told him something is not right with the setting or the mask, but it does not feel right. She reported he told her the setting are correct and did nothing else and left. She reported she didn't wear her [CONDITION(S)] that night because when she asked the nurse she said she didn't know anything about the settings but knows how to put it on. During an observation and interview on 09/08/21 at 8:30 AM, Resident #9 was sitting up in her wheelchair. Oxygen was in use at 2L/min via nasal cannula. Resident reported she did not use the [CONDITION(S)] last night. She explained she has not had any problems from not using the [CONDITION(S)] but needs her oxygen at all times. In an interview on 09/08/21 at 4:30 PM, with Resident #9, she explained she has never refused wearing the [CONDITION(S)] but has not worn [CONDITION(S)] since she has been here. She explained the settings for the machine was either too high when the little guy set up the machine or something because it just didn't feel or work right. She explained she used the [CONDITION(S)] while at the other place but reported it just didn't work right at this place. She explained when staff would ask her if she wanted to wear [CONDITION(S)], she explained she only asked if they knew how to do the settings. She explained the nurses would just look confused. She explained the Director of Nurse (DON) did come and ask her about the mask but she explained it was not the mask, but it was the air flow and the settings. She explained no one else ever talked to her about the [CONDITION(S)] machine. During an interview on 09/08/21 at 05:00 PM, with the Assistant Director of Nurses (ADON), when asked if a resident refused medication or oxygen what does the facility do, she explained, if a resident refused medication, the nursing staff will wait 3 days before reporting it to the doctor due to the resident could just be confused and it could be a new medication but should make a nurses note regarding refusal. When ask if a resident refused oxygen what the facility would do, she explained the doctor would be notified on the 1st day of refusal so the doctor can evaluate and determine if the resident needs the oxygen. She further explained either a Physician or a Nurse Practitioner is here at the facility almost every day and at least weekly. She explained the nursing staff also communicates with the physicians through an app to get in touch or send a message regarding a resident. She explained she did not know anything about Resident#9 not wearing her [CONDITION(S)] or any problems with the machine. She reviewed the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained if the resident did not want to wear the [CONDITION(S)] the Nurse Practitioner or Physician should have been notified but explained there is no documentation of the physician being notified. During an interview on 09/09/21 at 8:40 AM, with the LPN#1/Admission Nurse, she explained she did work a night shift around 08/04/21 and when she went to try and put on the [CONDITION(S)], Resident #9 complained of [CONDITION(S)] not fitting correctly but never did mention anything about the settings. She explained she did not mention to the Physician or Nurse Practitioner about the resident not wearing but did report the incident to the DON. During an interview on 09/09/21 at 08:50 AM, with the DON, she explained she did go and talk to Resident #9 after LPN#1/ Admission Nurse reported to her the resident's complaints regarding the [CONDITION(S)] not fitting right. She explained when she spoke to Resident #9 she denied any problems with the settings for the [CONDITION(S)]. The DON explained she offered to reorder another mask for the machine, but the resident denied wanting a new mask. The DON further explained after she spoke to the resident she just forgot about the situation and did not think any more about it and no one else mentioned anything about the [CONDITION(S)]. She reported that during the time she talking to Resident #9, the resident denied any problems with shortness of breath. On 09/09/21 at 2:30 PM, during an interview with Physician #1, he explained he has seen Resident #9 several times and spoken to the resident and her daughter about the disease process for [NAME]-Johnsons Syndrome. He explained Resident #9 was seen on 08/14/2021 and 08/19/2021 regarding shortness of breath and had a chest x-ray. He explained the resident had several lung infiltrates since admission but explained this is due to resident's [NAME]-Johnsons Syndrome and the [CONDITION(S)] would have not helped with the infiltrates but Resident #9 would have benefited from receiving the [CONDITION(S)]. He further reported he was not aware Resident #9 was not receiving the [CONDITION(S)] as ordered and if she was not wanting to use it the [CONDITION(S)] could have been discontinued. He explained his Nurse Practitioner or him could have discontinued it because it would not made a difference in the infiltrates and it won't fix her problem due to [NAME]-Johnsons Syndrome. When explained to him the resident had complained the settings were not correct or the [CONDITION(S)] didn't feel like it did at the other places, he explained the oxygen flow is different in a hospital setting. On 09/10/21 at 12:50 PM, during an interview with the Minimum Data Set (MDS) nurse/RN#2 he explained all staff should follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When ask if a resident continues to refuse a medication or treatment what should be done, he explained the physician should be notified and a care plan should be revised. On 09/10/21 at 01:15 PM, during an interview with MDS nurse/LPN#2 when asked does the facility do a check system to verify MDS before being submitted, he explained RN# 2 and therapy will review the MDS for accuracy before submitting the MDS. When asked him to review Resident #9's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/10/21 at 01:30 PM, during an interview with the DON, when asked does she review the MDS for accuracy, she explained she knows nothing about MDS and that is the MDS nurse responsibility. Record review of Resident #9's Admission Record revealed the facility admitted Resident #9 on 07/15/21 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date of 7/22/21 revealed Section O, item O0100, Special Treatments, Procedures, and Programs, line G, Non-Invasive Mechanical Ventilator ([CONDITION(S)]/[CONDITION(S)]), column 2 was not checked. Record review of Resident #9's Order Summary Report dated 9/9/2021, revealed an order dated 07/15/2021 for [CONDITION(S)] ON at bedtime. Record review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A check mark was recorded for the dates of 7/15/2021, 7/19/2021 and 7/20/2021.

Based on observation, interviews, record review and facility policy review the facility failed to anchor a Foley catheter tube securely while performing catheter care and failed to secure the tubing with a catheter leg strap for one (1) of three (3) catheter observations. Resident #11 Findings include: Record review of the facility's Catheter Care undated, revealed Policy: it is the policy of the facility to ensure that residents with indwelling catheters recieve appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Policy Explanation:1. Catheter care will be performed every shift and as needed by nursing personnel .Female: 12. with a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold catheter in place so as to not pull on the catheter . Resident #11 Observation on 09/09/21 at 09:32 AM, of catheter care with Certified Nursing Assistant (CNA) #1 revealed CNA #1 failed to secure the catheter tubing near the meatus while cleaning the tubing. CNA #1 pulled on the catheter tube with a wet wipe cloth. During the care the catheter bag was attached to the left side of the bed frame. CNA #1 turned the resident to the right side to cleanse Resident #11 buttocks. CNA #1 did not transfer the catheter bag to the right side of the bed. The catheter tubing tugged tightly on the meatus. Resident #11 did not have a leg strap on to secure the catheter to prevent friction. During an interview on 09/9/21 at 02:50 PM, CNA #1 confirmed Resident #11 did not have a leg strap or securing device to her leg to prevent friction. CNA #1 said the resident has not had a securing device on since she was admitted . The CNA confirmed she did not secure the resident tubing while cleaning it and the tubing was tugging tightly to the meatus. CNA #1 also confirmed the tubing was tugging tightly on the resident when she turned her and cleansed the tubing. During an interview with RN #1 on 09/09/21 at 3:08 PM, revealed the facility does catheter training with the staff once a year. RN #1 confirmed CNA #1 should have secure the tubing at the tip near the meatus to prevent it from coming out or causing infection. RN #1 said CNA #1 should have removed the catheter bag from the bed frame on the left side when she turned the resident and placed it on the right side of the bed frame to keep the catheter from tugging tightly. During an interview 09/09/21 at 03:10 PM, with the Director of Nursing (DON) The DON said CNA #1 should have held the tip of the catheter near the meatus while wiping the tubing to prevent friction. The DON also said CNA #1 should have put the catheter bag on the right side of the bed frame to prevent the catheter from tugging on the meatus. Record review of the Admission Record revealed Resident #11 was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #11's Care Plan initiated 07/27/21 revealed, Focus, Indwelling Urinary Catherization Status; urinary retention, Goal, Resident will have no complications associated with urinary catherization through next review date. Target Date: 10/26/2021, Interventions .Catheter care per routine each shift .Keep catheter tubing secured to leg to prevent friction and discomfort . Record review of the Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 07/22/21 revealed Resident#11 had Brief Interview for Mental Status (BIMS) score of 7 that indicated Resident #11 has moderate cognitive impairment.

Based on staff interview, Resident Representative interview, Sitter interview, record review and facility policy review the facility failed to report a major injury of unknown origin to the State Agency (SA) in a timely manner for one (1) of three (3) residents reviewed for injury. Resident #145 Findings Include: Record review of the facility's policy, Incident and Accident Policy and Procedure Reporting, undated, Policy: It is the policy of (Formal name of Facility) shall strive to maintain an environment that promotes resident safety to ensure that each resident remains as free of acccident hazards as is possible .Procedure: 11. Incidents and accidents of suspected abuse, neglect or unexplained injury shall be reported to Mississippi State Department of Health(MSDH) with in twenty-four (24) hours of discovery (excluding Saturdays and Sundays and legal holidays) and within seventy- two (72) hours of discovery. A written report shall be completed. On 09/08/21 12:14 PM, in an interview with License Master Social Worker (LMSW) at a local hospital stated she cannot remember the resident. She stated when the Medical Doctor (MD) sees something suspicious, he tells the LMSW to report it to the SA. She stated she remembered doing the report. She stated she goes by the Physician documentation when she calls it in to the SA. LMSW gave SA Resident #145's name. Record review of the Admission Record revealed Resident #145 was originally admitted on [DATE] and was readmitted on [DATE]. Record review of the Physician Orders, dated 2/11/20, revealed send Resident #145 to local, hospital for evaluation Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/8/21 at 2:31 PM, in an interview with Resident #145's Resident Representative (RR) stated, the sitter called and told him Resident #145 tried to get out of the bed and fell on the floor. He stated she fell in the middle of the night and broke her femur. RR #1 stated she was transferred to a local hospital. He stated the sitter told him that Certified Nursing Assistant (CNA) #4 came in to take the vital signs and left the bed rail down. RR #1 stated the sitter told him she was in the bathroom. On 9/8/21 at 3:33 PM, in an interview with the Director of Nursing (DON), stated the steps the nurses use for an incident are assess the resident, call the Physician, and family. She stated sitter was in the room. She stated she was told resident was found standing against the wall. She stated the nurse assessed the resident and did not find anything. She stated RP #1 came and resident was complaining of right leg pain. She stated the local hospital X-ray revealed Resident #145 had a right spiral fracture. She stated she reported to the SA state as a fall. She stated she did not send the final investigation report to the stateSA. She stated she was supposed to send it in after she completed the investigation. She stated the report should have been sent in to the SA. She stated the reason for sending it in is to show the SA the outcome of the incident and the report would show if there was abuse or neglect. On 9/8/21 at 4:07 PM, in an interview with the DON she stated the steps she uses to investigate an incident is the following: read the incident, talk to the nurse, talk to all the people involved, find out exactly what happened, review the X ray, and get a statement from the people in the room. She stated she uses what the nurse wrote on the incident report. It happened at night. She stated she talk to the sitter. She stated she called in the incident in on 2/11/20 and faxed it on 2/14/21. She stated she did not send the results of her investigation into the SA. She stated she was supposed to send it in five (5) days. On 9/10/21 at 8:52 AM, in a phone interview with Licensed Practical Nurse (LPN) #3 stated I do not remember the resident or incident. We had a lot of residents come and go. My mind is not as good as it used to be. I cannot remember anything right now. On 9/10/21 at 11:37 AM, in an interview with CNA #4 stated when she went to answer the call light, Resident #145 was on the floor. She stated the sitter told her she heard a thump and came out of the bathroom and found the resident on the floor. She stated the nurse, sitter, and CNA #4, got the resident off the floor. She stated LPN #3 assessed the resident. She left the room during the assessment. She stated she returned to the room to check on the resident about 45 minutes after the fall and the resident was moaning. She stated she thinks she wrote a statement about the incident and gave it to the DON. She stated the resident would come out of the bottom of the bed rails. She stated that is why the resident's spouse got a sitter. On 9/10/21 at 12:27 PM, in an interview with the sitter for Resident #145 stated, she was in the bathroom and heard a thump sound. She stated she came out of the bathroom and found the resident leaning against the wall. She stated when she saw the resident leaning on the wall, she caught the resident and they both went down on the floor. She stated the resident did not land on the floor but landed on top of her. She managed to get the resident back in the bed alone. She stated she should have got some help. I was there to prevent her from falling. Record review of the nurses' notes dated 2/11/20 revealed about 4:20 AM, Resident #145's sitter called the nurse to come to the resident room. Resident was standing by the bedside and the sitter assisted the resident to the bed. Resident was lying on her back. Resident told the nurse her leg was hurting. Resident #145's knees were bent. The nurse asked the resident if she could straighten her knees out and the resident stated they are hurting. The nurse noted no open skin or tears.The nurse gave the resident [MEDICATION(S)] as ordered for pain. Later that night the sitter called out and stated resident has a reddened area at her upper back and shoulders area. The nurse called the resident's husband and asked him about the reddened area. The sitter told the facility the resident's family wanted her sent out to a local hospital for X-ray. On 9/10/21 at 2:58 PM, in an interview with the DON stated she called the nurse to find out what happened that night. She stated LPN #3, did not do an incident report. She stated normally the nurse does the incident report. She stated she filled the incident report out. She stated she investigated the incident as a fall. She stated she usually get a witness statement from all those involved if they witness the incident. She stated she filled out the report because the nurse did not fill it out. Normally the staff fills it out. If an injury occurs, that staff calls me and lets me know. She stated she did not get any statements from the witnesses. She stated what she did was not a thorough investigation. On 9/10/21 at 3:03 PM, in an interview with the Administrator stated I cannot remember. I cannot recall if I was informed of the incident. On 9/13/21 at 8:05 AM, in a post survey interview with the Sitter for Resident #145, she stated Resident #145 was on the floor when she came out of the bathroom. She stated she believes the resident climbed over the rail. She stated she told LPN #3 that the Resident #145 had fallen on the floor, and she picked her up by herself. She stated she knew she shouldn't have picked the resident up off the floor. She stated she should have gone and gotten help. She stated she told LPN #3 that she did not think the resident was okay. She stated CNA #4 and LPN #3 checked the resident. She stated she called the spouse and told him what had happened. Spouse wanted the resident sent out to the local hospital.

Based staff interviews, sitter interview, record review and facility policy review the facility failed to do a thorough investigation regarding a resident with a possible fall for one (1) of three (3) residents reviewed for falls. Resident # 145 Findings Include: Record review of the facility's policy, Accidents and Incidents - Investigating and Reporting, revised April 2013, revealed, Policy Statement, All accidents or incidents involving residents . occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation, 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. The following data, as applicable, shall be included on the Report of Incident/Accident form: . k. Any corrective action l. Follow up information . Record review of the Culic Incident Report dated 2/11/2020 revealed, Date: 2/11/2020, Time: blank .IF A RESIDENT, GIVE CONDITION PRIOR TO INCIDENT: Alert, Confused and Semi-Ambulatory, DESCRIPTION OF INCIDENT & TREATMENT ADMINISTERED: DON was informed from 7P nurse that resident was leaning up against the wall when sitter came out of bathroom. Sitter was unsure if resident had fallen or not. Resident was put back to bed and assessed-no injuries noted at that time. Later resident started c/o (complaint of) pain to RT (right) leg. Husband asked for resident to be transferred to (local hospital) .Shift: 11-7, Area Incident Occurred: Resident Room, Locate Injury (body drawings were not marked), Incident result of fall: ? in yes box, Physician Notified: check mark in Yes, Treatment: (checks by) Referred to ER, Clinic, Hospital, Family Notified, State Notified .Final Disposition .Res. admitted to (local hospital) . This was signed by the DON and Administrator on 2/11/2020. Record review of the Facility Self-Reported Incidents Information Needed checklist completed by the DON revealed, .Date of Incident - 2-11-2020, Incident Type - Fracture, .Diagnosis - Acute RT spiral femur fx(fracture), admitted with Left Pubis fx, Depressive d/o (disorder), anxiety, Alzheimers, Muscle wasting, [CONDITION(S)], hx of mult (multiple) fractures, If the resident was taken to hospital or examined by a physician-Resident transported to ER and subsequently admitted Was a body audit performed? Yes .Lab results or x-ray results-none for this incident .Corrective actions-NA. Record review of a statement written on facility letterhead by the Director of Nursing (DON), no date, revealed, To Whom It May Concern: DON was notified the am of 2/11/20 concerning Resident (formal name). PM nurse stated that she was called to residents room per sitter. Sitter reported that resident was standing up against wall when sh came out of the restroom. Sitter assisted resident back to bed. The nurse assessed the resident and did not find any evidence of a fall. Later residents husband arrived and resident started complaining of pain to RT leg. The husband asked that resident be sent to (local hospital). Later that am DON spoke with residents husband and he stated she had a spiral RT femur fracture. Husband stated resient must have turned when she got out of bed and fell up against wall. Res is expected to readmit to our facility after surgery and is stable. Sincerely, (DON) On 09/08/21 12:14 PM, in an interview with License Master Social Worker (LMSW) at a local hospital stated she cannot remember the resident. She stated when the Medical Doctor (MD) sees something suspicious, he tells the LMSW to report it to the State Agency (SA). She stated she remembered doing the report. She stated she goes by the Physician documentation when she calls it in to the SA. LMSW gave SA Resident #145's name. Record review of the Admission Record revealed Resident #145 was originally admitted to the facility on [DATE] with primary diagnoses, onset date 12/18/19, to include but not limited to Unspecified fracture of left pubis, subsequent encounter for fracture with routine healing and Age-related [CONDITION(S)] with current pathological fracture, unspecified site. Record review of the Physician Orders, dated 2/11/20, revealed transfer Resident #145 to the local hospital for evaluation. On 9/8/21 at 2:31 PM, in an interview with Resident #145's Resident Representative (RR) stated, the sitter called and told him Resident #145 tried to get out of the bed and fell on the floor. He stated she fell in the middle of the night and broke her femur. RR #1 stated she was transferred to a local hospital. He stated the sitter told him that Certified Nursing Assistant (CNA) #4 came in to take the vital signs and left the bed rail down. RR #1 stated the sitter told him she was in the bathroom. On 9/8/21 at 3:33 PM, in an interview with the Director of Nursing (DON), stated the steps the nurses use for an incident are assess the resident, call the Physician, and family. She stated sitter was in the room. She stated she was told resident was found standing against the wall. She stated the nurse assessed the resident and did not find anything. She stated RP #1 came and resident was complaining of right leg pain. She stated the local hospital X-ray revealed Resident #145 had a right spiral fracture. She stated she reported to the State Agency (SA) as a fall. She stated she did not send the final investigation report to the state SA. She stated she was supposed to send it in after she completed the investigation. She stated the report should have been sent in to the SA. She stated the reason for sending it in is to show the SA the outcome of the incident and the report would show if there was abuse or neglect. On 9/8/21 at 4:07 PM, in an interview with the DON she stated the steps she uses to investigate an incident is the following: read the incident, talk to the nurse, talk to all the people involved, find out exactly what happened, review the X ray, and get a statement from the people in the room. She stated she uses what the nurse wrote on the incident report. It happened at night. She stated she talked to the sitter. She stated she called in the incident in on 2/11/20 and faxed it on 2/14/21. She stated she did not send the results of her investigation into the SA. She stated she was supposed to send it in five (5) days. On 9/10/21 at 8:52 AM, LPN #3 in a telephone interview, stated I do not remember the resident or incident. We had a lot of residents come and go. My mind is not as good as it used to be. I cannot remember anything right now. On 9/10/21 at 11:37 AM, in an interview with CNA #4 stated when she went to answer the call light, Resident #145 was on the floor. She stated the sitter told her she heard a thump and came out of the bathroom and found the resident on the floor. She stated the nurse, sitter, and CNA #4, got the resident off the floor. She stated LPN #3 assessed the resident. She left the room during the assessment. She stated she returned to the room to check on the resident about 45 minutes after the fall and the resident was moaning. She stated she thinks she wrote a statement about the incident and gave it to the DON. She stated the resident would come out of the bottom of the bed rails. She stated that is why the resident's spouse got a sitter. Record review of the Minimum Data Set (MDS) with and Assessment Reference Date of 12/24/19 revealed a Brief Interview of Mental Status score of double zero (00) indicating Resident #145 was non-interviewable. Record review of the nurses' notes dated 2/11/20 revealed about 4:20 AM, Resident #145's sitter called the nurse to come to the resident room. Resident was standing by the bedside and the sitter assisted the resident to the bed. At this time resident was lying on her back. Resident said her leg was hurting. She had them bent at the knees. The nurse asked the resident if she could straighten her knees out and the resident stated they are hurting. The nurse noted no open skin or tears. The nurse gave the resident [MEDICATION(S)] as ordered for pain. Later that night the sitter called out and stated resident has a reddened area at her upper back in her shoulder area. She called the resident's husband and asked him if he knew about the red area. The sitter told the nurse that the resident's family wanted her sent out to a local hospital for X-ray. Resident #145 was transported to the local ER for evaluation. On 9/10/21 at 2:58 PM, in an interview with the DON stated she called the nurse to find out what happened that night. She stated LPN #3 did not do an incident report. She stated normally the nurse does the incident report. She stated she filled the incident report out. She stated she investigated the incident as a fall. She stated she usually gets a witness statement from all those involved if they witness the incident. She stated she filled out the report because the nurse did not fill it out. Normally the staff fills it out. If an injury occurs, that staff calls me and lets me know. She stated she did not get any statements from the witnesses. She stated what she did was not a thorough investigation. On 9/10/21 at 3:03 PM, in an interview with the Administrator stated I cannot remember. I cannot recall if I was informed of the incident. On 9/13/21 at 8:05 AM, in a post survey interview with the Sitter for Resident #145, she stated Resident #145 was on the floor when she came out of the bathroom. She stated she believes the resident climbed over the rail. She stated she told LPN #3 that the Resident #145 had fallen on the floor, and she picked her up by herself. She stated she knew she shouldn't have picked the resident up off the floor. She stated she should have gone and gotten help. She stated she told LPN #3 that she did not think the resident was okay. She stated CNA #4 and LPN #3 checked the resident. She stated she called the spouse and told him what had happened. Spouse wanted the resident sent out to the local hospital. Review of Resident #145's discharge instructions from the hospital, (not the name of the form in attachments) dated 2/17/20, revealed Resident#145 had a closed displaced spiral fracture of shaft of right femur.

Based on observation, staff interviews, record review and facility policy review the facility failed to prevent the possible spread of infection during catheter/incontinent care observations for three (3) of six (6) observations. Resident #5, Resident #11, Resident #144. Findings include: Review of the facility's Infection Control, undated, revealed Policy: It is the policy of (Formal Name of Facility) to ensure that residents admitted without an infection does not develop an infection unless clinically unavoidable and that a resident who is admitted with an infection receives care and services to promote healing and to prevent additional infections from developing. Review of the facility Policy, Hand Washing, undated, revealed, Policy: It is the policy of the facility to provide a clean, healthy, environment for staff and residents by cleaning the hands to prevent the spread of possible infection. Resident #5 On 9/9/21 at 4:10 PM, during an observation and interview of incontinence care being provided by Certified Nursing Assistant #2 (CNA), revealed no barrier was placed on the bedside table prior to beginning incontinent care. CNA #2 entered Resident #5's room, put gloves on, then raised Resident #5's bed with the remote control using her gloved hands. She then positioned Resident#5 and began care. CNA #2 removed her gloves and left the room to get [MEDICATION(S)] ointment. When CNA #2 returned to the room she did not wash her hands and applied clean gloves. CNA #2 used her gloved right hand to put extra packs of ointment in the bedside table drawer. CNA #2 did not change her gloves, then applied cream to Resident #5's buttocks. CNA#2 put the dirty brief on the floor along with dirty gloves. CNA #2 donned clean gloves and adjusted the resident's bed with the remote control. CNA #2 put the brief and gloves in the garbage bag and exited the room. CNA #2 did not wash hands. She took the garbage bag and placed it in the biohazard room and then washed her hands. During an interview, CNA #2 stated to the State Agency (SA), I would have washed my hands before coming out of the resident room. SA asked CNA #2 why did you not wash your hands. CNA#2 stated I don't like washing my hands in the resident room. Review of the Resident #5's Admission Record revealed an original admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/5/21 revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicates Resident #5 has severe cognitive impairment. On 09/09/21at 4:54 PM, in an interview with CNA #2, stated she should have washed her hands and changed gloves while doing care. She stated she was nervous with the SA watching and she forgot to change gloves and wash her hands. She stated not washing hands and changing gloves can cause the resident to get an infection. It can make the resident sick. On 9/9/21 at 5:07 PM ,in an interview with the Director of Nursing (DON), stated CNA #2's actions put the resident at risk for infection, when she did not wash her hands before exiting the room. That placed the resident at risk for infection. She stated CNA #2 actions is an infection control issue. She stated CNA #2 should have changed gloves and washed her hands. She stated CNA #2 should have not placed a soiled brief and gloves on the floor. She stated by placing the soiled brief on the floor and picking it up and not washing her hands transferred whatever was on the floor to the doorknob and to other residents. On 9/9/21 at 5:10 PM, in an interview with Assistant Director of Nursing (ADON), stated CNA #2 could have caused the resident to get an infection. She stated CNA #2 should have washed her hands and changed gloves. Review of the CNA #2's Infection Control Orientation checklist, dated 8/18/21. revealed her initials on understanding the importance of hand washing in preventing infection, Resident #11 Record review of the Admission Record revealed Resident #11 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) with the an Assessment Reference Date (ARD) of 07/22/21 revealed Resident#11 had a Brief Interview for Mental Status (BIMS) score of 7 that indicated Resident #11 is cognitively impaired. Observation on 09/09/21 at 09:32 AM, of catheter care with Certified Nursing Assistant (CNA) #1 revealed CNA #1 did not have a barrier on the table. CNA #1 had wet wipes, a brief and gloves on the table. CNA #1 took the wipes off the uncleaned table and cleansed Resident #11's perineal area. CNA #1 also cleansed Resident #11's catheter tubing with the wipes that had been placed on the table with no barrier. During an interview on 09/9/21 at 02:50 PM, with CNA #1 confirmed she did not have a barrier on the table. CNA #1 said she was nervous and forgot to put one on the table. CNA #1 said she forgot to wipe the table off and realized she could cause the resident to receive an infection by using the wipes and gloves from a table that had not been properly cleaned. During an interview on 09/09/21 at 03:10 PM, with the Director of Nursing (DON) confirmed CNA #1 should have cleaned the table and placed a barrier on the table to prevent infection. During an interview on 09/10/21 at 1:00 PM, with RN #1 confirmed CNA #1 should have cleansed the table and place a barrier on the table prior to providing care. RN #1 said by using dirty supplies the CNA could cause possible infection to Resident #11. Resident #144 During an observation of catheter care on 09/09/21 at 4:00 PM, revealed CNA#3 put gloves on bedside table. The bedside table did not have a barrier on it. CNA #3 began cleaning the catheter tubing then and stopped cleaning and went got the garbage can with gloves on. CNA #3 did not change gloves or clean her hands after picking up garbage can. She placed the garbage can beside her and continued to do catheter care with the same gloves on. CNA #3 finished and removed the garbage bag from the can and exited the room. CNA #3 did not her wash hands before exiting room. On 9/9/21 at 4:43 PM, in an interview with CNA #3 stated she should have used a barrier on the bedside table, and she should have changed gloves after moving the garbage can. She stated her actions can cause the resident to get an infection. She stated it was contamination. She stated it can do a lot of harm to the resident's body. On 9/9/21 at 5:04 PM, in an interview with the DON, she stated CNA #3's actions could cause infection control issues. She stated residents can get urinary tract infections. She stated CNA #3 should have changed gloves after picking up the garbage can. On 9/9/21 at 5:06 PM, in an interview with the ADON stated CNA #3's actions were infection control. She stated whatever was on the garbage can was transferred to the resident. She stated CNA #3 should have changed gloves. Record review of the Admission record revealed Resident #144 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission MDS with an ARD of 8/27/21 revealed in Section C, Resident #144's BIMS score was 10 which indicated Resident #144 had moderate cognitive impairment.

Based on observation, staff interviews, record review and facility policy review the facility failed to ensure a resident who was ordered a bi-level positive airway pressure ([CONDITION(S)]) machine received necessary services for one (1) of three (3) residents reviewed. Resident #9. Findings include: Record review of the facility's policy for Refusal of Medication and Treatments with a revision date of 09/11 revealed six key elements including, Refusals of treatment should be countered by discussion with the resident of the health and safety consequences of the refusal and the availability of any therapeutic alternatives that might exist. Physician and Responsible Party must be notified . During an observation and interview on 09/07/21 at 03:00 PM, revealed the State Survey Agency (SSA) observed Resident #9 lying in bed. Resident #9 reported the [CONDITION(S)] machine is new, and she has never worn it at this facility. She explained no one knows how to work it. She explained a guy just brought the supplies and set the numbers and she tried it on, but she told him something is not right with the setting or the mask, but it does not feel right. She reported he told her the setting are correct and did nothing else and left. She reported she didn't wear her [CONDITION(S)] that night because when she asked the nurse, she said she didn't know anything about the setting but knows how to put it on. On 09/08/21 at 4:30 PM, interview with Resident #9, she explained she has never refused wearing [CONDITION(S)] but has not worn [CONDITION(S)] since she has been here. She explained the settings for the machine was either too high when the guy set up the machine or something because it just didn't feel or work right. She explained she used the [CONDITION(S)] while at the other place but reported it just didn't work right at this place. She explained when staff would ask her if she wanted to wear the [CONDITION(S)], she explained she only asked if they knew how to do the settings, she explained the nurses would just look confused and would say nothing. She explained the Director of Nurses(DON) did come and ask her about the mask, but she explained it was not the mask, but it was the air flow and the settings. She explained no one else ever talked to her about the [CONDITION(S)] machine. On 09/08/21 at 05:00 PM, during an interview with the Assistant Director of Nurses (ADON), when asked if a resident refused oxygen what the facility would do, she explained the doctor would be notified on the first day of refusal so the doctor can evaluate and determine if the resident needs the oxygen. She further explained either a Physician or a Nurse Practitioner is here at the facility almost every day and at least weekly. She explained the nursing staff also communicates with the physicians through an app to get in touch or send a message regarding a resident. She explained she did not know anything about Resident #9 not wearing her [CONDITION(S)] or any problems with the machine. She reviewed the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained if the resident did not want to wear the [CONDITION(S)] the Nurse Practitioner or Physician should had been notified but explained there is no documentation of the physician being notified. On 09/09/21 at 8:40 AM, during an interview with Licensed Practical Nurse (LPN) #1, Admission Nurse, she explained she did work a night shift around 08/04/21 and when she went to try and put on the [CONDITION(S)], Resident #9 complained of the [CONDITION(S)] not fitting correctly but never did mentioned anything about the settings. She explained she did not notify the Physician or Nurse Practitioner about the resident not wearing [CONDITION(S)] but did report the incident to the DON. On 09/09/21 at 08:50 AM, during an interview with the DON, she explained she did go and talk to Resident #9 after LPN #1/Admission Nurse reported to her Resident #9's complaints regarding [CONDITION(S)] not fitting right. She explained when she spoke to Resident #9, resident denied any problems with the settings for the [CONDITION(S)]. The DON explained she offered to reorder another mask for the machine, but resident denied wanting a new mask. The DON further explained after she spoke to the resident she just forgot about the situation and did not think any more about it and no one else mentioned anything about the [CONDITION(S)]. On 09/09/21 at 2:30 PM, during an interview with Physician #1, he explained he has seen Resident #9 several times and spoke to the resident and her daughter about the disease process of [NAME]-Johnsons Syndrome. He explained the resident was seen on 08/14/2021 and 08/19/2021 regarding shortness of breath and had a chest x-ray. He explained Resident #9 would have benefited from receiving the [CONDITION(S)]. He further reported he was not aware Resident #9 was not receiving the [CONDITION(S)] as ordered and if she was not wanting to use it the [CONDITION(S)] could have been discontinued. On 09/10/21 at 2:50 PM, during an interview with Resident #9's Resident Representative (RR), her daughter revealed she explained she has spoken to the doctor regarding her mother's lung disease but no one ever mentioned to her about her mother not wearing her [CONDITION(S)]. Record review of Resident #9's Admission Record revealed the facility admitted Resident #9 on 07/15/21 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's hospital discharge instructions dated 7/15/21, revealed .[CONDITION(S)] during hours of sleep or when experiencing shortness of breath or sleepiness Your settings are 15/8/40% .when not using the [CONDITION(S)] please use oxygen at two (2) liters per minute via nasal cannula. Record review of Resident #9's Order Summary Report dated 7/15/21, revealed orders for [CONDITION(S)] on at bedtime .oxygen at two (2) liters per minute via nasal cannula every shift. Record review of Resident #9's Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/22/21 Section C revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated resident is cognitively intact. Section O of the MDS revealed only oxygen marked for special treatments and the section for [CONDITION(S)] was not marked. Record review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's MAR for July and August 2021 revealed the resident wore [CONDITION(S)] for total of six (6) times. Record review of nurse progress note for 08/04/21 revealed resident did not wear [CONDITION(S)] all night and was having increased anxiety . Record review of Resident #9's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 had 13 days recorded as a 9 indicating other and 1 day on 7/29/21 recorded as 2 indicating Refused. Record review of Resident #9's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #9 had 17 days coded as a 9 indicating other, 10 days coded 2 indicating Refused, and one (1) day on 8/7/21 coded as a 5 indicating Hold/See Nurses Note. The #9, other is not included in the legend on the MAR.

Based on observation, staff interviews, record review and facility policy review the facility failed to follow the comprehensive care plan by not securing a foley catheter tube to the residents leg and by not ensuring a resident received bi-level positive airway pressure ([CONDITION(S)]) respiratory therapy for two (2) or 25 care plans reviewed, Resident #9 and Resident # 11. Resident #11 Findings Include: Record review of the facility's policy for Minimum Data Set (MDS) and Care Plan Responsibilities revealed no date for the policy. The policy stated, it is the policy of the facility to develop a comprehensive care plan for each resident to provide the highest level of functioning for the resident to attain. Record review of Resident #11's Care Plan initiated 07/27/21 revealed, Focus, Indwelling Urinary Catherization Status; urinary retention, Goal, Resident will have no complications associated with urinary catherization through next review date. Target Date: 10/26/2021, Interventions .Catheter care per routine each shift .Keep catheter tubing secured to leg to prevent friction and discomfort . Observation on 09/09/21 at 09:32 AM, during of catheter care with Certified Nursing Assistant (CNA) #1 revealed CNA #1 failed to secure the tubing near the meatus while cleaning the tubing on the catheter. CNA #1 pulled on the tube with a wet wipe cloth. During the care the catheter bag was attached to the left side of the bed frame. CNA #1 turned the resident to the right side to cleanse Resident #11's buttocks. CNA #1 did not transfer the catheter bag to the right of the bed. The catheter tubing tugged tightly on the meatus. Resident #11 did not have a leg strap on to secure the catheter to prevent friction. Record review of the Admission Record revealed Resident #11 was admitted to the facility on [DATE], with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with the an Assessment Reference Date (ARD) of 07/22/21 revealed Resident#11 had a Brief interview of for Mental Status (BIMS) of 7 that indicated Resident #11 is cognitively impaired. During an interview on 09/9/21 at 02:50 PM, CNA #1 confirmed Resident #11 did not have a leg strap or securing device to her leg to prevent friction. CNA #1 said the resident has not had one every since she was admitted . CNA #1 said she did not know the resident needed a securing device because it was not on her care plan. CNA #1 confirmed she did not secure the resident tubing while cleaning it and the tubing was tugging tightly to on the meatus. CNA #1 also confirmed the tubing was tugging tightly on the resident when she turned her to the right side and cleansed the resident's buttocks. During an interview on 09/09/21 at 3:08 PM, Interview with Registered Nurse (RN) #1 confirmed CNA #1 did not have the securing device on the CNA's care plan. RN #1 said she thought the orders automatically transferred to the CNA's task/care plan. RN #1 said this would be corrected as of today. During an interview on 09/09/21 at 03:10 PM, with the Director of Nursing (DON) confirmed CNA #1 failed to follow the Comprehensive Care Plan by not securing the catheter to Resident #11 leg and not holding the tip of the tubing near the meatus while providing catheter care. The DON said that could have caused the catheter friction and possible trauma to the meatus. The DON also said CNA #1 should have put the catheter bag on the right side of the bed frame to prevent the catheter from tugging on the meatus. The DON revealed she was not aware the catheter care did not transfer from the comprehensive care plan to the CNA's task/care plan. During an interview on 09/10/21 at 12:51 PM, RN #2 said he expected the staff to follow the comprehensive care plan. RN #2 confirmed CNA #2 did not follow the care plan because the care plan states the staff should keep catheter tubing secured to the leg to prevent friction and discomfort. RN #2 also stated that the CNA's and floor nurses are responsible for making sure the residents have a securing device connected to their leg to prevent tugging and friction. RN #2 also said this could cause trauma and or infection. Resident #9 Record review of Resident #9's Comprehensive Care Plan initiated 7/27/21 revealed problem, Oxygen therapy due to Acute Hypoxic Respiratory Failure and included the intervention/task [CONDITION(S)]/[CONDITION(S)] (Bi-level positive airway pressure/Continuous positive airway pressure) at night. Resident may manage device. Offer assistance as needed. During an observation and interview on 09/07/21 at 03:00 PM, the State Survey Agency (SSA) observed Resident #9 lying in bed. Resident #9 reported the [CONDITION(S)] machine is new, and she has never worn it at this facility. She explained no one knows how to work it. She explained a guy just brought the supplies and set the numbers and she tried it on, but she told him something is not right with the setting or the mask, but it does not feel right. She reported he told her the setting are correct and done nothing else and left. She reported she didn't wear her [CONDITION(S)] that night because when she asked the nurse, she said she didn't know anything about the settings but knows how to put it on. On 09/08/21 at 8:30 AM, the SSA observed Resident #9 sitting up wheelchair with oxygen in use at 2L/min (liters per minute) via nasal cannula. Resident #9 reported she did not use the [CONDITION(S)] last night. In an interview on 09/08/21 at 4:30 PM, with Resident #9, she explained she has never refused wearing the [CONDITION(S)] but has not worn [CONDITION(S)] since she has been here. She explained the settings for the machine was either too high when the little guy set up the machine or something because it just didn't feel or work right. She explained she used the [CONDITION(S)] while at the other place but reported it just didn't work right at this place. She explained when staff would ask her if she wanted to wear [CONDITION(S)], she explained she only asked if they knew how to do the settings. She explained the nurses would just look confused. She explained the Director of Nurse (DON) did come and ask her about the mask but she explained it was not the mask, but it was the air flow and the settings. She explained no one else ever talked to her about the [CONDITION(S)] machine. On 09/09/21 at 08:50 AM, during an interview with DON, when asked her the purpose of the care plans and physician orders, she explained to ensure the resident receives care to benefit the resident. When asked if a resident refused a treatment what should happen, she explained the physician should be notified and the care plan revised as needed. On 09/10/21 at 12:50 PM, during an interview with Registered Nurse #2, he explained all staff should follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if a resident has a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked if a resident continue to refuse a medication or treatment what should be done, he explained the physician should be notified and a care plan should be revised. Record review of Resident #9's Admission Record revealed the facility admitted Resident #9 on 07/15/21 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's hospital discharge instructions dated 7/15/21, revealed .[CONDITION(S)] during hours of sleep or when experiencing shortness of breath or sleepiness Your settings are 15/8/40% .when not using the [CONDITION(S)] please use oxygen at two (2) liters per minute via nasal cannula. Record review of Resident #9's Order Summary Report dated 7/15/21, revealed orders for [CONDITION(S)] on at bedtime .oxygen at two (2) liters per minute via nasal cannula every shift. Record review of Resident #9's Admission MDS with ARD of 07/22/21, Section C revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #9 is cognitively intact.

Based on observations, staff interviews, record review and review of the facility's policy entitled, CDC guidelines entitled, Responding to Coronavirus (COVID-19) in Nursing Homes, the facility failed to ensure staff cleaned and/or disinfected a blood pressure machine and thermometer between resident use to prevent the possible spread of infection for six (6) of six (6) sampled residents (Resident #'s 1, 2, 3, 4, 5 and 6). The findings included: During an observation on the 300 hall (Quarantined Unit) on 6/9/2020 at 10:10 a.m., Certified Nurse Assistant (CNA) #1 entered six (6) rooms (308, 310, 311, 312, 313, and 314) with a blood pressure machine and thermometer. Without cleaning equipment between each resident, the CNA checked each resident's vital signs. Review of medical records for Residents' #1, #2, #3, #4, #5, and #6 revealed they were new admissions and/or readmissions quarantined for 14 days. Observations on 6/9/2020 at 10:10 a.m. revealed there were no isolation signs posted outside of the rooms. Review of the undated facility policy entitled, Cleaning and Disinfecting Medical Equipment, revealed 9. Vital sign equipment is sanitized with Sani-Wipes after each resident use on isolation hall. (300 hall). During an interview with CNA #1 on 6/9/2020 at 10:40 a.m., she stated equipment should be cleaned between each resident using a purple top wipe (disinfectant wipe). During an interview with the ADON (Assistant Director of Nursing) who was also the Infection Control Nurse on 6/9/2020 at 11:43 a.m., she stated all medical equipment should be cleaned between each point of contact with all residents. During an interview with the Assistant Administrator on 6/9/2020 at 11:45 a.m., she stated each resident was quarantined for at least 14 days and equipment should be cleaned according to the facility policy.