Based on record review, interview, and facility policy review, the facility failed to ensure medications were administered according to physician's orders for one (Resident #40) of five residents reviewed. The findings include: A review of Resident #40’s quarterly Minimum Data Set with an Assessment Reference Date of 06/26/2025, indicated the resident had a Brief Interview for Mental Status score of 14, which indicated Resident #40 was cognitively intact. A review of Resident #40's active Physician's Orders, as of 07/01/2025, revealed the resident had diagnoses which included post-traumatic stress disorder, osteoarthritis, and generalized anxiety disorder. The resident’s Physician’s Orders also revealed the resident had medication orders, with an order date of 04/23/2025, for one benzodiazepine tablet for generalized anxiety disorder, to be given at bedtime, and one compound opioid pain medication tablet for pain, to be given every eight hours as needed. Resident #40’s Physician’s Orders also revealed not to administer either medication within two hours of each other. A review of Resident #40’s Administration History Report, from 06/06/2025 through 06/21/2025, revealed a compound opioid pain medication was administered four times, within the restricted period, with a benzodiazepine. Below are the findings: On 06/06/2025, one benzodiazepine tablet was documented as administered by Licensed Practical Nurses (LPN) #2 at 8:00 PM, and one compound opioid pain medication tablet was documented as administered at 8:01 PM. On 06/12/2025, one benzodiazepine tablet and one compound opioid pain medication tablet were documented as administered by LPN #4 at 8:05 PM. On 06/15/2025, one benzodiazepine tablet was documented as administered at 8:13 PM, and one compound opioid pain medication tablet was documented as administered by LPN #3 at 8:14 PM. On 06/21/2025, one benzodiazepine tablet and one compound opioid pain medication tablet were documented as administered by LPN #4 at 7:19 PM. A review of Resident #40’s Psychiatric Clinic Progress Note, dated 04/23/2025, revealed for Medication safety: Instruct nursing home staff to separate administration of pain medication and [benzodiazepine] by a minimum of two hours for patient safety. A review of a Psychiatric Clinic Visit Sheet for Resident #40, dated 04/23/2025, and signed by the provider, read in part, be sure there is a two-hour window between opioid pain pill, and benzodiazepine. During a phone interview on 07/01/2025 at 9:34 AM, with LPN #1 at Resident #40's psychiatric clinic, LPN #1 confirmed the prescriber would routinely write the order as indicated with benzodiazepines and opioids. The medications were not to be administered together, which was why the prescriber ordered not to administer the medications within two hours of each other. During a phone interview on 07/02/25 at 10:02 AM, LPN #2 confirmed her initials were on Resident #40’s electronic medical record for administration of the compound opioid pain medication on 06/06/2025 at 8:00 PM. LPN #2 indicated Resident #40 often voiced complaints of pain, usually in the evening. LPN #2 confirmed the resident would receive pain medication with anxiety medication, and they were usually given at the same time, at the resident’s request. She then confirmed the facility’s expectation of the staff was to administer medications according to the physician's order and to comply with the medication administration policy. LPN #2 was asked to confirm the meaning of an order that specifically stated not to administer a medication within two hours of another medication. LPN #2 confirmed that a physician's order with those parameters would not be administered within the time period specified. She then reported that the purpose of not combining the two medications would be for complications such as oversedation, overdose, and kidney problems. LPN #2 confirmed when administering medications, she compared the medication with the physician's order to ensure the correct rights were observed. LPN #2 confirmed that if Resident #40 had an order not to administer a benzodiazepine and a compound opioid pain medication together, then they should not be administered together. During an interview on 07/02/2025 at 10:15 AM, the Medical Director confirmed he was familiar with Resident #40’s specific medication order not to administer their benzodiazepine and compound opioid pain medication at the same time, and to wait at least two hours between the administrations. The Medical Director indicated he expected staff to administer medications as written by the prescriber, and he had not been notified of a medication error with Resident #40. During an interview on 07/02/2025 at 10:20 AM, the Assistant Director of Nursing (ADON) confirmed Resident #40 often voiced complaints of pain and was medicated with as needed pain medications. The ADON confirmed the expectation of staff was to follow the Physician's Orders as written, and if the order was written as do not administer medications within two hours of each other, then they should not be administered. The ADON confirmed that the order for Resident #40, written by the practitioner, was not to administer the benzodiazepine and compound opioid pain medication within two hours of each other. She then stated the purpose of waiting between benzodiazepines and opioids was the possibility of respiratory depression. The ADON confirmed the facility’s expectation of staff was to follow the facility’s medication administration policy. During an interview on 07/02/2025 at 10:28 AM, the Director of Nursing (DON) confirmed Resident #40 occasionally had complaints of pain and was medicated with as needed medications. The DON confirmed Resident #40 had routine orders for an antianxiety medication, a benzodiazepine, and a compound opioid for pain. He then confirmed the benzodiazepine was given at 8:00 PM. The DON reported the expectation of the facility, was for staff to follow facility policies, and to administer medications as written by the provider. If orders were written not to administer two medications within two hours of each other, then they should not be administered within the restricted time. The DON reported that benzodiazepines and opioids were not given together to avoid respiratory depression. During a phone interview on 07/02/2025 at 5:04 PM, LPN #3 confirmed familiarity with Resident #40. LPN #3 had provided care and administered medications to the resident. LPN #3 confirmed Resident #40 often voiced complaints of pain and was medicated, if it was within the parameters of the physician's order. LPN #3 confirmed the pain medication that Resident #40 often received was an opioid. LPN #3 confirmed Resident #40 had physician's orders for a benzodiazepine antianxiety medication. LPN #3 confirmed the physician's orders should be administered, as written. LPN #3 stated if the order specifically was written not to give medications together, then they should not be given together. LPN #3 confirmed knowledge of the medication administration policy, and to administer medications as written. LPN #3 denied knowledge of the two-hour restriction between Resident #40’s benzodiazepine and compound opioid pain medication. A review of a facility policy, Medication Administration, with a review date of 12/02/2024, revealed medications were to be administered as ordered by the physician. Policy Explanation and Compliance Guidelines ensure that the six rights of medication administration are followed: Right Time, Compare medication with medication administration record to verify the correct time. Administer within one hour before or after the scheduled time unless otherwise ordered by the physician. Administer medication as ordered in accordance with manufacture specification. A review of the National Institute on Drug Abuse, with a review date of 11/07/2022, indicated taking opioids in combination with other central nervous system depressants like benzodiazepines increased the risk of life-threatening overdose.

Based on observation, interview and record review, the facility failed to ensure thickened liquids kept in a cooler remained on ice/with ice packs for 1 (Resident #14) of 1 sampled resident who required thickened liquids. The findings are: The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/08/2024 documented Resident #14 scored 7 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). The Physician orders dated 04/01/2024 documented, Regular diet, Mechanical Soft texture, Nectar consistency add yogurt, applesauce and nectar thick liquids to each meal for choking. On 04/01/2024 at 10:29 AM, Resident #14 had a red and white cooler at the bedside. Thickened water was found in the cooler sitting in water/melted ice. On 04/02/2024 at 10:38 AM, the Surveyor interviewed Certified Nursing Assistant (CNA) #4 at Resident #14's bedside and asked, Should the residents thicken liquids in the cooler be kept on ice? CNA #4 stated, Yes, it should've been passed with ice water because [Resident #14] is nectar thick. On 04/02/2024 at 10:39 AM, the Surveyor interviewed Registered Nurse (RN) #1 at Resident #14's bedside and asked, Should the residents thicken liquids in the cooler be kept on ice? She stated, Yes. When asked, Why should it be kept on ice? She stated, I guess because [Resident #14] likes it cold. On 04/02/2024 at 09:06 AM, the Director of Nursing (DON) was asked, Should [Resident #14's] thickened liquids at the bedside be kept cold with ice or ice packs? She stated, Yes. When asked, Why should thickened liquids be kept cold? She stated, It helps to have them at bedside. A facility policy titled, Thickened Liquids, dated 10/04/20/2022 revealed, .Policy Explanation and Compliance Guidelines: Personal coolers and ice packs will be provided at the resident's bedside to keep thickened liquids within easy reach of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure written information regarding the right to formulate an advanced directive was provided to the residents or their responsible parties, to enable them to make informed decisions regarding which measures would be provided or withheld at the end of life for 2 (Residents #8 and #45) of 3 residents reviewed for Advance Directive. The findings include: 1. Resident #45 was admitted on [DATE] with a diagnosis of Dementia. a. On 04/01/2024 at 02:31 PM, during a review of Resident #45's chart, no advance directive was located. b. On 04/02/2024 at 12:04 PM, the Facility provided a Do Not Resuscitate (DNR) order, and an order appointing guardian of the person and estate and an order for disbursement of funds. c. On 04/04/2024 at 09:01 AM, the Director of Nursing (DON) was asked, Should [Resident #45] have an advance directive located in the resident's medical chart? She stated, Yep. When asked, Why? She stated, So we know what [Resident #45's] wishes are. 2. Resident #8 was admitted on [DATE] with a diagnosis of Dementia. a. On 04/01/2024 at 02:19 PM, during a review of Resident #8's chart, an advance directive was not found. b. On 04/02/2024 at 12:08 PM, the Facility provided a DNR order and a durable Power Of Attorney (POA), but no advance directive for Resident #8. c. On 04/04/2024 at 09:01 AM, the Director of Nursing was asked, Should [Resident #8] have an advance directive located in the residents medical chart? She stated, Ya, should have it on [Resident #8's] chart. When asked, Why? She stated, So we know what [Resident #8's] wishes are.

Based on observation, interview and record review, the facility failed to ensure resident fingernails were kept clean for 3 (Residents #8, #53, and #66) of 3 sampled residents, oral hygiene was being completed for 1 (Resident #66) of 1 sampled resident, and male residents were shaved to promote good personal hygiene for 2 (Resident #53, and #66) of 2 sampled residents. The findings are: A facility policy titled, 'Activities of Daily Living (ADLs)' dated 10/04/2022 documented, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 1. Resident #8's Care Plan dated 03/15/2019 revealed, .CNA'S [Certified Nursing Assistants] assist to keep nails clean and observe for jagged edges report prn [as needed] Nurse provide trimming due to DM [Diabetes Mellitus] . a. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/2023 documented Resident #8 scored 2 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS). Section GG0130. Self- Care revealed in section I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands (excludes baths, showers, and oral hygiene). 05. Setup or clean-up assistance. b. On 04/01/2024 at 11:38 AM, Resident #8's fingernails were long and chipped. When asked, Do staff trim your nails or do you like them long? Resident #8 stated, I wish someone would cut them. c. On 04/02/2024 at 10:47 AM, the Surveyor interviewed CNA #5 at the Resident #8's bedside and asked, Can you describe what is under the resident's fingernails? CNA #05 stated, Looks like food under the nails. When asked, Can you describe what the resident's fingernails look like? She stated, They need to be filed and the nurse will trim them because [Resident #08] is diabetic. When asked, How often should the residents nails be cleaned, filed and trimmed? She stated, When showering and when you have extra time. The nurse trims because we can't, [Resident #8] is diabetic. d. On 04/02/2024 at10:50 AM, the Surveyor asked Registered Nurse (RN) #2, Can you describe what is under the resident's fingernails? She stated, [Resident #8] has a broken nail too, but food. When asked, Can you describe what the resident's fingernails look like? She stated, Some of them are jagged and they shouldn't be. When asked, How often should the residents nails be cleaned, filed and trimmed? She stated, A nurse has to trim the nails, CNA's clean and file them. e. On 04/04/2024 at 09:06 AM, the Surveyor asked the Director of Nursing (DON), Should [Resident #8's] fingernails be kept clean and trimmed? The DON stated, Yes. When asked, Why? She stated, To reduce the risk of infection and injury. 2. During an observation on 04/01/2024 at 10:59 AM, Resident #53 had facial hair 0.5 inches long on the face and neck, and the fingernails were 0.5 to 0.75 inches long with jagged edges and a brown substance under the nails and around the cuticle areas of both hands. a. During a concurrent observation and interview on 04/01/2024 at 03:27 PM, Resident #53 had facial hair 0.5 inches long on the face and neck, and the fingernails were 0.5 to 0.75 inches long with jagged edges and a brown substance under the nails and around the cuticle areas of both hands. b. During a third observation on 04/02/2024 at 08:28 AM, Resident #53 had facial hair 0.5 inches long on the face and neck, and the fingernails were 0.5 to 0.75 inches long with jagged edges and a brown substance under the nails and around the cuticle areas of both hands. During an interview on 04/03/2024 at 03:13 PM, CNA #1 was asked who was responsible for making sure nails were trimmed and cleaned. CNA #1 said the CNAs are, unless they are diabetic then the nurses trim them, but the CNAs still clean them. The Surveyor asked when does a resident get their nails trimmed and cleaned? CNA #1 said daily or as needed. The Surveyor asked should a resident have 0.5 inch jagged nails with a brown substance under the nails and around the cuticle area? CNA #1 replied absolutely not. CNA #1 was asked what negative outcome could occur from long jagged dirty fingernails? CNA #1 said they could scratch themselves and cause a skin tear or get an infection. The Surveyor asked when does a resident get shaved? CNA #1 said on shower days. The Surveyor asked who was responsible for making sure a resident gets shaved? CNA #1 said the CNAs are. The Surveyor asked if a resident has 0.5 inch whiskers on the face and neck and the resident doesn't want them, is this acceptable? CNA #1 said absolutely not. During an interview on 04/03/2024 at 03:18 PM, the DON was asked, who was responsible for making sure residents nails are trimmed and cleaned? The DON said, the CNAs are, unless they are diabetic then the nurses do them, but the nursing staff can clean the nails. The DON was asked, when do the residents get their nails trimmed and cleaned? The DON said they should be cleaned daily and trimmed as needed. The DON asked if a resident should have 0.5 to 0.75 inch jagged nails with brown substance under nails and around the cuticles on both hands? The DON said, absolutely not. The DON was asked what negative outcome can occur from nails being left long and jagged with a brown substance under them? The DON said they can get an infection. 3. Resident #66's Care Plan dated 10/06/2022 revealed Resident #66 had an Activity of Daily Living (ADL) self-care performance deficit related to Disease Process . Review of the Admit Diagnoses revealed . impaired balance, weakness, muscle wasting Limited x one assist . bathing/ showering: Provide assist 2 x weekly and prn give choice of AM or PM provide privacy and maintain dignity, assist with nail care keeping clean and trimmed prn - Report Resident #66 request only one shower per week Saturday - staff continue to offer x 2 week respect wishes/[Resident #66] has requested to have only one bath per week and on Saturday. a. The Quarterly MDS with an ARD of 12/28/2023 revealed, Section GG0130. Self-Care . I. Personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face, and hands (excludes baths, showers, and oral hygiene) .3. Partial/ moderate assistance . b. On 04/01/2024 at 02:56 PM, Resident #66 was lying in bed unshaven. Resident #66 stated, They won't shave it. Resident #66's fingernails had a brown/black substance underneath them. Resident #66 stated, I only get one bath every week. Resident #66 stated staff do not help the resident clean the resident's mouth. Resident #66 had a thick yellow build up in the mouth. c. On 04/02/2024 at 10:36 AM, the Surveyor interviewed CNA #4 and asked, Can you describe how the resident ' s nails appear to you? She stated, Dirty. When asked, How often should his fingernails be cleaned? She stated, At least when [he/she] gets a shower. When asked, Does the resident appear to have been recently shaved? She stated, No, it looks long, like it's been a while. When asked, Can you describe how the inside of the residents mouth looks? She stated, [Resident #66] needs oral care definitely. [The resident] has thick stuff in there. d. On 04/02/2024 at 10:42 AM, the Surveyor interviewed RN #1 and asked, Can you describe how the resident's nails appear to you? She stated, They are dirty, and need cleaned. When asked, How often should the residents nails be cleaned? She stated, Every time they are dirty and at every shower. When asked, Does the resident appear to have been recently shaved? She stated, No, [the resident] needs one. When asked, Can you describe how the inside of the residents mouth looks? She stated, [The resident] should be cleaned up, that mouth isn't clean. e. On 04/04/2024 at 09:06 AM, the Surveyor asked the DON, Should [Resident #66] fingernails be kept clean, face shaved, and oral care provided? She stated, Yes. When asked, Why? She stated, To reduce risk of infection, and should be shaved because it's [Resident #66's] choice.

Based on observation, interview and record review, the facility failed to ensure the clothes dryers remained free of lint build-up to decrease the potential for fire and loss of laundry services in 1 of 1 laundry room. This failed practice had the potential to affect all 78 residents due to the potential for the interruption of laundry services and due to the proximity of the laundry room. The findings are: On 04/03/2024 at 11:03 AM, the Surveyor observed all 3 dryers in the laundry room had a 0.5 inch lint buildup on their lint screens. On 04/03/2024 at 11:12 AM, Laundry Worker #1 was asked, how often do you remove the lint from the dryers? Laundry Worker #1 said, every two hours. The Surveyor asked, can you explain why the dryer lint removal log was not signed off on 04/02/2024 for the evening shift? Laundry Worker #1 said, I guess she forgot to sign it. The Surveyor asked, why is the log not signed for this morning (04/03/24)? Laundry Worker #1 said, I was going to sign them off, but I was going to lunch first. The Surveyor asked, what can happen if lint isn't removed every two hours? Laundry Worker #1 said, chance it could catch on fire. On 04/04/2024 at 8:37 AM, the Administrator was asked, how often should lint be removed from the dryers? The Administrator said, every two hours. The Surveyor asked, how is this documented to prove the lint had been removed? The Administrator said, on the log sheet. The Surveyor asked, why is it important to assure the lint is removed from dryers every two hours? The Administrator said it was to prevent a fire. A facility policy titled, Laundry and Linen Services, documented, .job description for Day Laundry . Clean lint filters on dryers every 2 hours. Document on dryer log . The Dryer Log indicates that on 04/02/2024 from 06:00 PM through midnight that all three dryers had not had lint removal checked off. On 04/03/2024 the lint removal log had not been signed off at 08:00 AM or 10:00 AM.

Based on observation, interview and record review, the facility failed to ensure proper handwashing/hand sanitizing was completed during dining observation. The findings are: On 04/01/2024 at 12:06 PM, the Surveyor observed Certified Nursing Assistant (CNA) #2 take a tray from a meal cart and set it up for a resident, then CNA #2 removed another tray from the cart and set it up for another resident. The CNA did not perform hand sanitation before providing either tray. During a concurrent observation on 04/01/2024 at 12:06 PM, the Surveyor observed CNA #3 removing a tray from a meal cart and setting it up for a resident. The CNA then repeated the process without performing hand sanitation for two other residents. CNA #3 then went and picked up a chair and placed it in between 2 residents and began feeding both residents without performing hand sanitization before beginning, or between feeding each resident. During an interview on 04/01/2024 at 12:52 PM, CNA #3 was asked, what should be done before serving a tray to a resident? CNA #3 said, sanitize my hands. During an interview on 04/12/2024 at 12:55 PM, CNA #4 was asked, what should be done before serving a tray to a resident? CNA #4 said, sanitize my hands. CNA #4 was asked, what should be done between passing out trays? CNA #4 said, sanitize my hands. CNA #4 was asked, what should be done after picking up a chair and setting down to start feeding a resident? CNA #4 said, sanitize my hands. CNA #4 was asked, what should be done in between feeding 2 different residents? CNA #4 said, sanitize my hands. During an interview on 04/03/2024 at 03:13 PM, the Director of Nursing (DON) was asked what should be done before and between passing trays. The DON stated, Sanitize hands. The DON was asked when feeding 2 residents what should be done in between feeding each of them? The DON said, sanitize hands. The DON was asked, why should staff sanitize their hands during meal service? The DON said, to prevent spreading germs. A facility policy titled, Hand Hygiene, dated 10/04/2022, indicated, .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .

Based on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) was completed accurately, related to functional status for 1 (Resident #33) of 4 (Resident #32, R #23, R #33, and R #45) sampled residents who required extensive assistance with eating. The findings are: 1.Resident #33 had a diagnosis of Moderate Protein-Calorie Malnutrition. The Annual Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 11/27/22 documented the resident scored 3 (0 - 7 Indicates Severely Impaired) on a Brief Interview for Mental Status (BIMS); required limited assistance with one person assist for eating; had a feeding tube and was on a mechanical altered diet. a. The Physician Order dated 1/12/21 documented, Regular diet Mechanical Soft texture, Nectar consistency . b. The revised Care Plan dated 5/21/21 documented, [Resident's Name] has an ADL [Activities of Daily Living] self-care performance deficit . EATING: feeding tube and oral diet as directed . current order for regular w. Mech [mechanical] soft and Nectar liquids If resi. [resident] eats more than 50% [percent] of breakfast or lunch hold bolus feeding . c. The Physician Order dated 10/26/22 documented, Enteral Feed Order two times a day give 1 can bolus (named fortified nurtrition) 1.5, May substitute [named protein supplement] 1.5 . Enteral Feed Order in the evening Run [named fortified nutrition] 1.5 Cal [calories] at 60mL/hr [milliliter/hour] for 14 hours 4pm-6am May sub with [named protein supplement] 1.5 . d. The MDS section G0110 Functional Status (H) documented, . Eating - Self- Performing (2) limited assistance; Support (2) One-person physical assist[assistance] . e. On 1/30/23 at 12:40 PM, the resident was in the dining room for meal service. A staff member was sitting beside her, spoon feeding her a regular mechanical diet for lunch. f. On 2/02/23 at 2:55 PM, the Surveyor asked the MDS Coordinator, who completes section G of the MDS? The MDS Coordinator stated, I do. The Surveyor asked, what level of assistance does Resident #33 require for eating? The MDS Coordinator stated, extensive. The Surveyor asked, the annual MDS for Resident #33, under functional status for eating, is it coded correctly? She replied, no, I will do a modification.

Based on observation, record review, and interview, the facility failed to ensure palm grips was consistently utilized to prevent further decline in range of motion for 1 (Residents #45) of 5 (Resident #19, R #45, R #32, R #33 and R #23) sample mix residents who had contractures. The findings are: 1.Resident #45 had diagnoses of Alzheimer's and Contractures. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/22 documented the resident was severely impaired in cognitive skills for daily decision, required total assistance of two person assist for bathing, and extensive assistance of two-person assist for bed mobility, transfer, dressing, toilet use, and personal hygiene; had impairment to the upper extremity on one side. a. The Physician Order dated 3/8/22 documented, Ensure bilateral palm grips are in place every morning and at bedtime for contractures . b. The revised Care Plan documented, [Resident's Name] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] . Alzheimer's . Limited Mobility, . CONTRACTURES: . Review Order Ensure Bilateral Palm Grips are in place q [every] morning and at bedtime r/t contractors report s/s [signs/symptoms] of worsening PRN [as needed] . c. On 1/30/23 at 11:48 AM and on 2/2/23 at 10:33 AM, Resident #45 sat in a [named] chair, her right hand was in fist position with no positioning device in place. d. On 2/02/23 at 10:45 AM, LPN [Licensed Practical Nurse] #1 accompanied the Surveyor to Resident #45's room. The Surveyor asked LPN #1, , does Resident #45 have any contractures? LPN #1 stated, I do not think so. The Surveyor asked, is Resident #45 able to open her right hand? LPN #1 attempted to open Resident #45's right hand and stated, no. The Surveyor asked, should Resident #45 have a positioning device in place? LPN #1 stated, I will have to look in her orders and Care Plan. LPN #1 proceeded to search into the resident's Electronic Health Record and stated, according to the Physicians Orders, yes, she should have a device in place. The Surveyor asked, who is responsible to ensure the positioning device is in place? LPN #1the Restorative Assistant. e. On 2/02/23 at 4:24 PM, the Policy on Restorative Nursing Programs was provided by the DON documented, it is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. Nursing personnel are trained on basic, or maintenance nursing care . This training may include, but not limited to: . Assisting residents in adjustment to their disabilities and use of any assistive devices . Residents . will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include: . Splint or brace assistance.

Based on observation, record review, and interview the facility failed ensure humidified oxygen was administered at the physician prescribed rate for 1 (Resident #58) of 6 (R #4, R #17, R #24, R #58, R #69, R #233) sampled residents who received oxygen according to a list provided by the Director of Nursing (DON) on 2/3/23. The findings are: 1.Resident #58 had diagnoses of Chronic Obstructive Pulmonary Disease and Asthma. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/23 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); oxygen used in the past 14 days while a resident. a. Physician Orders dated 4/8/21 documented, .02 [oxygen] at 2L[liters] via NC [nasal canula] PRN [as needed] for SOB [shortness of breath] 02 [oxygen] >90% [percent] .change 02 tubing q [every]72 hours and PRN every 72 hours .Change water on concentrator weekly on Fridays and PRN one time a day every Fri . b. Resident #58's Comprehensive Plan of Care documented, [R #58] .COPD .Revision on: 07/29/2021 .OXYGEN provide 2 lpm via NC as ordered prn .change all tubing and humidifier bottle as directed .Revision on: 10/18/2022 . c. On 01/30/23 at 11:09 AM, Resident #58 sat in a wheelchair in her room. An oxygen concentrator was, set to infuse at a rate between the 3 ½ [half] and 4 liters per minute (lpm). An empty humidifier bottle was attached by tubing to a nasal canula. The empty humidifier bottle was dated 1/6/23. The nasal canula was placed in a plastic bag and attached to the concentrator. The resident was not receiving the oxygen treatment at the time of the observation. d. On 01/30/23 at 02:55 PM, Resident #58 was lying in bed the nasal canula administered oxygen in the nose. The oxygen concentrator administered oxygen at a rate between 3 1/2 to 4 lpm. The nasal canula was attached to an empty humidifier bottle dated 1/6/23. e. On 02/02/23 at 2:31 PM, the Surveyor entered Resident #58 room with Licensed Practical Nurse (LPN) #2. The resident was lying in bed. Oxygen concentrator was not on at that time. The surveyor asked LPN #2 if Resident #58 used oxygen. She stated, yes, prn [as needed]. The Surveyor asked, what is the rate [of administration] ordered? She stated, 2 [liters per minute] (lpm) The Surveyor asked, when is the humidifier filled; should it be administered empty? She stated, it should be done weekly, they change the tubing every 3 days. No. The Surveyor asked, should it be administered between 3 1/2 and 4 lpm? She stated, no. It should be on 2. LPN #2 stated, let me check. She turned on the oxygen concentrator. The concentrator was set to administer between 3 1/2 and 4 lpm. She turned the administration rate to 2 lpm. f. On 02/03/23 at 4:02 PM, the Surveyor asked the DON, if a resident's oxygen is ordered to be administered at 2 lpm, should it be administered at 3 1/2 to 4 lpm? She stated, no. The Surveyor asked, when are the humidifiers filled? She stated, the humidifier is every 72 hours and as needed. The Surveyor asked, should it [the oxygen] be administered when the humidifier is empty? She stated, no. g. A Policy provided by the DON on 2/2/23 titled, Oxygen Administration, documented, .Oxygen is administered under orders of a physician .Change humidifier bottle when empty, every 72 hours .

Based on observation and interview the facility failed to ensure that dishes and utensils were stored properly, food was covered, and hands were washed between clean and dirty tasks to minimize the risk of cross contamination. The failed practice had the potential to affect 82 residents who received their meals from 1 of 1 kitchen according to a list provided by the administrator on 2/3/23 at 8:28 AM. a. On 1/30/23 at 11:20 AM, three nested mixing bowls were stored right side up. There were two large metal pans that were right side up under the steam table. b. On 1/30/23 at 12:05 PM, the tray line was serving lunch, the insulated base and dome plate covers were stored with the inside exposed to air and contaminants. c. On 2/2/23 at 10:42 AM, there were two trays of rolls sitting on the shelf above the range. The rolls were uncovered and open to contaminants. Four full size steam table pans of strawberry cake were cooling on the worktable located toward the back of the kitchen. The cakes were uncovered and open to air and contaminates. d. On 2/2/23 at 10:45 AM, Dietary Employee (DE) #1 used a hot pad and obtained a stainless-steel bowl from the oven. DE #1 placed 10 servings of green beans in the bowl for the residents who required a pureed diet. Dietary Employee #1 used the hot pad and poured the green beans into the bowl of the [named blender]. With contaminated hands, DE #1 obtained a 1/4 steam table pan, a can of nonstick cooking spray, and applied the spray to the pan. As the green beans were blended DE #1 used the scraper in the top of the [named blender] lid and scraped the side of the bowl during processing. DE #1 placed her hand inside her pocket and obtained a marker. She wrote the date and food name on a piece of aluminum foil and then placed the foil on top of the 1/4 steam table pan to cover it. DE #1 opened the oven and placed the green beans in the oven. DE #1 took the bowl, lid, and blade of the [named blender] to the dish room. At no time during this process did DE # wash her hands. e. On 2/2/23 at 10:55 AM, DE #1 approached the oven, used her hand to open the oven door, utilized a hot pad, and removed a bowl of breaded chicken patties. The bowl of chicken patties was placed on the worktable by the base of the [named blender]. DE #1 used tongs and placed the chicken patties into the bowl. DE #1 completed this process 3 times and also completed the mechanical soft diets. When she completed the chopping process DE #1 obtained a marker and wrote the date and food name on top of a piece of aluminum foil which was used to cover the chicken. DE #1 returned the steam table pan to the oven. f. On 2/2/23 at 11:10 AM, DE #1 used a hot pad and retrieved a bowl of chicken patties from the oven to process for 10 residents who received a pureed diet. DE #1 retrieved a Styro-foam cup, opened the reach-in refrigerator and obtained a container of chicken broth base. After she added a spoon full of the base to the cup, she took the cup to the coffee maker/dispenser and added hot water. DE #1 returned to the workstation. DE #1 repeated the process of making chicken broth 3 times. When DE #1 completed the puree of the chicken, DE #1 retrieved her marker from her pocket. She wrote the date and food name on top of foil and placed it on top of the steam table pan and folded the foil around the edges. g. On 2/2/23 at 11:20 AM, Dietary Employee #1 opened the door to the walk-in refrigerator and retrieved a carton of milk. She opened the carton and poured the milk into a measuring cup. She took the cup to the microwave, opened the door, and placed the cup inside for warming. The warm milk was brought back to the workstation and was added to hot rolls which had been placed in the bowl of the [named blender]. DE #1 returned to the walk-in refrigerator for a second carton of milk. She warmed the milk a second time. She did not wash her hands prior to the return to the workstation. When puree process was completed, DE#1 retrieved her marker and wrote the date and food name on the aluminum foil which was then placed on top of the container. The Steam table pan was then returned to the oven. h. On 2/2/23 at 11:51 AM, DE #2 removed the lids of the steam table pans which contained the lunch meal. Without washing her hands, Dietary Employee #2 continued to take the temperatures of the food and served the lunch meal. i. On 2/3/23 at 8:28 AM, a policy entitled, Handwashing Guideline for Dietary Employees states: 6. Frequency of Handwashing a. After hands have touched anything unsanitary i.e. [that is] garbage, soiled utensils/equipment, dirty dishes, etc. f. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. j. After engaging in any activity that may contaminate the hands. j. On 2/3/23 at 8:40 AM, the Surveyor asked the Dietary Manager, how should dishes and pans be stored? She stated, upside down. The Surveyor then asked, when should hands be washed? Dietary Manager stated, after any task.