Based on observation, interviews, and record review, it was determined that the facility failed to ensure dignity was maintained for 1 (Resident #10) of 1 sampled resident reviewed for dignity while passing meal trays. Finding included: 1.Review of a facility policy titled Resident Rights and Responsibilities with no date indicated, The facility protects and promotes the rights of each resident admitted in order to provide a dignified existence. Review of an admission Record indicated the facility admitted Resident # 10 on 12/14/2012, with diagnoses of bipolar disorder and generalized anxiety disorder. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #10 was moderately cognitively impaired. On 01/15/2025 at 7:39 AM this surveyor observed Certified Nursing Assistant (CNA) #1 serving meal trays to the residents in the dining room. CNA #1 served all the residents in the dining room except Resident #10. CNA #1 left the dining room without serving Resident #10 a breakfast tray. Resident #10 yelled out to CNA #1 that the resident wanted a meal tray. CNA #1 stopped and provided him with his meal tray. Resident #10 was interviewed on 01/15/2025 at 7:45AM. Resident #10 stated that it was not right for the CNA to leave the dining room without passing all trays. On 01/15/2025 at 8:00 AM, CNA #1 was asked if all trays should have been served before leaving the dining room. She stated Resident #10's tray should have been served before leaving the dining room to pass other trays. On 01/15/2025 at 8:30 AM, Licensed Practical Nurse (LPN) #5 was asked if all trays should have been served before leaving the dining room. She stated she should have served Resident #10's tray before leaving the dining room to pass other trays. On 01/15/2025 at 3:00 PM, the Director of Nursing (DON) was interviewed and asked if CNA #1 should have served all the trays before leaving the dining room. The DON stated that CNA #1 should have served Resident #10's tray before leaving the dining room to pass other trays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure Advance Directives were up to date in the electronic medical record (EMR) for 1 (Resident #24) of 1 resident reviewed for Advance Directives. The findings include: A review of the facility's undated policy titled Advance Directives, indicated that revocation will be documented in the resident's plan of care and/or the medical record. A review of the admission Record, indicated the facility admitted Resident #24 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction and post-traumatic stress disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. A review of Resident #24's Care Plan, initiated on [DATE], revealed the resident had requested that no cardiopulmonary resuscitation (CPR) measures be performed and a code status of Do Not Resuscitate (DNR). Interventions included: communicate choice to all appropriate staff members and to follow the DNR instructions as detailed inside the Advance Directive &/or living will. A review of an Order Summary Report revealed Resident #24 had orders to: Admit to Palliative Care and DNR. A review of the Miscellaneous tab in the electronic medical record revealed Resident #24 had an advance directive dated [DATE], which was marked yes for CPR, life support/other artificial support, treatment of new conditions and tube feeding/intravenous fluids (IV). A review of the new Advance Directive Acknowledgement, signed and dated [DATE], supplied by the Director of Nursing (DON) on [DATE], indicated Resident #24 was a DNR and wished not to execute an Advance Directive. A review of a note from the Advanced Practiced Registered Nurse (APRN), dated [DATE], stated that Resident #24's wife wished to go with Palliative Care and that Resident #24 would not want CPR. The APRN's summary of the treatment plan based on the discussion with Resident #24's wife was that the resident would be changed to DNR status when the wife was available to sign papers and Resident #24 would admit to Palliative Care to be done by the facility. During an interview on [DATE] at 11:33 AM, Medical Records stated the Advance Directive dated [DATE], had not been scanned into the Electronic Medical Record, but that it would be. Medical Records reported an audit had been completed and it was found at that time. Medical Records responded that the nursing staff would have been trained on what paperwork would be needed if a resident was sent out to the hospital. During an interview on [DATE] at 11:40 AM, Registered Nurse (RN) 3, explained the process for sending someone to the hospital and what paperwork had to be sent. RN #3 reported that the admission Record, order summary report and the Advance Directive/Code Status would be sent. During an interview on [DATE] at 11:50 AM, the DON confirmed that the paperwork that would be sent with a resident transferring to the hospital from the facility would include the face sheet, order, Emergency Medical Services (EMS)/DNR order and the Advance Directive, if the resident had one. The DON agreed that the most current Advance Directive dated [DATE], was scanned into the EMR on [DATE].

Based on observation, record review and interview, the facility failed to ensure call lights were placed in reach for resident's use and failed to ensure residents with functional limited range of motion call lights were placed in reach and accessible for use for 3 (Resident #27, Resident #35, and Resident #270) of 59 sampled residents. The findings are: 1. Review of the of Resident #27 ' s admission Record reveal diagnoses of Alzheimer's disease and severe dementia with agitation. a. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024, indicated the resident had a Brief Interview for Mental Status (BIMS) of 00 which indicated severely impaired cognitive skills. b. On 01/13/2025 at 2:21PM this surveyor observed Resident #27 in bed. The call light was at the foot of the bed along the side of the wall. Resident #27 could not reach it. c. On 01/13/25 at 2:30 PM, Resident #27 was observed lying in bed with eyes closed. The call light was at the bottom of the bed along the side of the wall. The call light was not within reach of the resident. d. On 01/13/25 3:31 PM, Resident #27 was observed with the call light to be in the same location at the bottom of the bed along the side of the wall. The call light was not within reach of the resident. e. On 01/13/25 3:38 PM, during an interview, Certified Nursing Assistant (CNA) #1 was asked if the call light was in reach of Resident #27. CNA #1 confirmed the call light was not in Resident #27's reach, but it should have been. 2. Review of Resident #35 ' s admission Record revealed diagnoses of severe dementia with agitation and anxiety disorder. f. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/24 indicated Resident #35 had a Brief Interview for Mental Status (BIMS) 00 which indicated the resident had impaired cognitive skills. g. On 01/13/25 at 2:32 PM, Resident #35 was observed lying in bed with eyes closed. The call light was located along the wall at the end of the resident's bed. The call light was not within the reach of the resident. h. On 01/13/25 at 3:39 PM, this surveyor observed CNA #2 reach back behind Resident 35's bed, pull the call light cord up, and clipped the cord on the blanket next to the resident. i. On 01/13/2025 at 4:00 PM, during an interview, Licensed Practical Nurse (LPN) #5 stated the call light should be placed within the resident's reach at all times. j. On 01/14/2025 at 9:00 AM, during an interview, the Director of Nursing (DON) stated the call light should always be placed within the resident's reach. k. On 01/16/2025, The DON stated there was no policy on placement of call lights. 3) A review of the admission Record, indicated the facility admitted Resident #270 with diagnoses that included chronic obstructive pulmonary disease, acute and chronic respiratory failure, dysphagia, cognitive communication deficit, the need for assistance with personal care and quadriplegia. a. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2024, revealed Resident #270 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact and had an impairment to one of the upper extremities and impairment to bilateral lower extremities. Resident #270 was using oxygen therapy and had non-invasive mechanical ventilator use. b. Review of Resident #270's Care Plan, initiated on 02/13/2024, revealed Resident #270's usual performance was weight bearing assist with Activities of Daily Living (ADL's). Interventions included: one (1) staff member to assist with bed mobility and Resident #270 used grab assist rails on bed for bed mobility. There was no indication in the current care plan of Resident #270's ability to use the call light. c. During an observation on 01/13/2024 at 11:35 AM, upon entering Resident #270's room, a therapist was noted to be leaving the room. Resident #270 was lying in bed with oxygen being delivered at four (4) liters per minute via nasal cannula. The call light for Resident #270's use was observed to be behind the lamp sitting on the nightstand and not within reach of Resident #270. d. During a concurrent observation and interview on 01/13/2024 at 11:37 AM, Registered Nurse (RN) #3 was asked to come into Resident #270's room and give the call light to the resident. RN #3 looked around and was unable to locate the call light button. This surveyor told RN #3 where the call light could be found. RN #3 then placed the call light in Resident #270's hand. RN #3 confirmed that the call light was not within reach of the resident while it was behind the lamp on the nightstand. e. During an interview on 01/14/25 at 10:00 AM, the Rehab Director was asked if the call light had been placed within reach of Resident #270 before leaving the room on 01/13/2025 at 11:35 AM. The Rehab Director stated, Yes, she had the little beige box in her hand. When it was explained that box was not the call light, but the bed control and that the call light was behind Resident #270's lamp and nightstand, the Rehab Director stated, I'm sorry, I thought it was the call light.

Based on record review, interviews, facility document review, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) for 1 (Resident #7) of 8 sample mix residents reviewed for MDS accuracy. The findings are: Review of Resident #7's Administration Record dated 05/2/2022, noted a diagnosis of Stroke (Cerebral Infarction). Review of Resident #7s Care Plan with a date of 07/11/2022, noted Resident #7 on prevention for blood clots from forming (antiplatelet) therapy related to stroke. Administer blood thinner (anticoagulant) medications as ordered by physician. Review of Resident #7's quarterly MDS with an Assessment Reference Date (ARD) of 12/12/2024, noted on Section N0415- High- Risk Drug Classes: Use and Indication, E. Anticoagulant: Yes. Review of Resident #7's Order Summary Report dated 01/14/2025, noted [Medication used to help prevent blood clots] tablet chewable 81 milligrams (MG) give 1 tablet by mouth one time a day for stroke (CVA), with a start date of 03/24/2023. Review of Resident #7's Order Summary Report Active, Completed, Discontinued, On Hold, dated 01/14/2025, noted the resident had not received an anticoagulant. During an interview with the MDS Coordinator on 01/16/2025 at 1:52 PM, she confirmed Resident #7 does not receive an anticoagulant, had not received one in the past and the MDS should have been coded for an antiplatelet.

Based on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 3 (Resident #20, # 37, 30) of 14 sample mix residents reviewed for care plans. The findings are: Review of Resident #37's admission Record dated 10/07/2024, noted diagnoses for hypothyroidism, type 2 diabetes mellitus, chronic heart failure, schizophrenia, pain, depressive episodes, pain in joints, heart attack (myocardial infarction), and atrial fibrillation (A-Fib). Review of Resident #37's Care plan dated 10/7/2024, did not note medication names or black box warnings. Review of Resident #37's Order Summary Report with a date of 1/15/2025, noted [Name brand thyroid medication] oral tablet 75 micrograms (MCG) give 75 mcg by mouth in the morning related to low thyroid (hypothyroidism); [Name brand glucagon-like peptide-1 receptor agonist medication] (1 milligram (MG) per dose) subcutaneous solution pen-injector 4 MG per 3 (milliliter (ML) inject 2 mg subcutaneously one time a day every Thu related to Type 2 Diabetes; [Name brand diuretic] oral tablet 80 MG give 1 tablet by mouth two times a day related to Chronic Heart Failure; [Name brand angiotensin receptor neprilysin inhibitor medication]oral tablet 24-26 MG give 1 tablet by mouth two times a day related to Chronic Heart Failure;[Name brand atypical antipsychotic medication] oral tablet 10 MG give 10 mg by mouth one time a day related to Schizophrenia; [Name brand combination opioid pain medication]oral tablet 10-325 MG give 0.5 tablet by mouth at bedtime related to pain; [Name brand selective serotonin reuptake inhibitor medication]oral tablet 10 MG give 1 tablet by mouth one time a day related to Depressive episodes; [Brand name medication used to treat depression] oral tablet 100 MG give 1 tablet by mouth at bedtime related to Depressive episodes; [Brand name opioid agonist used to treat chronic pain] Oral Tablet 50 MG Give 1 tablet by mouth every 6 hours as needed for pain related to pain in joint; [Brand name anticoagulant] oral tablet 75 MG give 1 tablet by mouth one time a day related to Myocardial Infarction; [Brand name medication used to treat heart dysrhythmias] oral tablet 200 MG give 1 tablet by mouth one time a day related to Atrial Fibrillation; -[Brand name fast acting insulin] injection solution 100 unit per ML inject as per sliding scale starting at 200 subcutaneously two times a day related to Type 2 Diabetes. Review of Resident #30's admission Record dated 1/31/2024, noted diagnoses of chronic pain, history of blood clot in the deep vein and artery blockage (venous thrombosis and embolism), and mild neurocognitive disorder due to known physiological condition with behavioral disturbance. Review of Resident #30's Care Plan dated 8/16/2024 did not note medication names or black box warnings. Review of Resident #30's Order Summary Report dated 1/16/2025, noted [Name brand anti-depressant medication] oral tablet 100 MG Give 100 mg by mouth one time a day related to Depression; [Brand name narcotic pain medication] tablet 300-30 MG Give 0.5 tablet by mouth three times a day related to Chronic Pain; [Brand name medication used to treat deep vein thrombosis]oral tablet 5 MG give 5 mg by mouth two times a day related to History of venous thrombosis and embolism; [Brand name anti-psychotic medication] oral tablet 0.5 MG give 0.5 mg by mouth two times a day related to Psychosis not due to a substance or known physiological condition. Review of an admission Record indicated that the facility admitted Resident #20 with a diagnosis of paraplegia. The admission/ 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/22/2024, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Review of Resident #20 ' s Care Plan revealed, that it did not have any therapy, nor black box warnings listed within the care plan. During an interview on 01/15/2025 at 10:39 AM, the MDS Coordinator reported that black box warnings alert an individual of certain medications and what to look out for. The MDS Coordinator stated, From what I understand, no, we don't care plan black box warnings. During an interview on 01/15/2025 at 10:57 AM, the DON (Director of Nursing) revealed that black box warnings were not in care plan and should be added to the care plan. During an interview on 01/16/2025 10:14 AM, the MDS Coordinator revealed Resident #20 came off therapy on the 14th of this month. The MDS Coordinator stated, therapy was not in care plan and that there are orders for therapy that need to be discontinued.

Based on observations, interviews, and facility document review, it was determined that the facility failed to ensure mechanical soft food was ground to the right consistency to meet the needs of residents who required a mechanical soft diet during one (1) of one (1) meal service observed. The failed practice had the potential to affect eight (8) residents who required mechanical soft diets. The findings include: On 11/15/2025 at 7:36 AM, the Dietary Manager stated the facility did not have a policy for mechanically altered foods. On 11/14/2025 at 11:07 AM, [NAME] #4 stated the facility had 3 pureed and 8 mechanical soft diets and 2 regular diets who requested mechanical soft meat. After gathering supplies needed to begin preparing for mechanical soft, [NAME] #4 began by using the processor machine and added 10 pork chops to process into mechanical soft. After completing the blending process, [NAME] #4 poured the mechanically altered pork chops into a pan, covered the pan with aluminum foil, and placed on the steam table. During a concurrent observation and interview, on 11/14/2025 at 12:10 PM with [NAME] #4, the mechanically altered pork chop was at 157.8 degrees Fahrenheit temperature. [NAME] #4 was asked what the consistency was for the mechanical pork chop. [NAME] #4 responded, pork chops always have looked that way and [NAME] #4 stated it does appear to look like a thick paste. The Dietary Manager, at that time, came over to the steam table and was asked to describe the pork chops. The Dietary Manager stated, looks a little thick, and the Dietary Manager confirmed that the mechanically altered pork chops had a paste consistency. The Dietary Manager asked cook #4 if the processor machine had been pulsated and cook #4 replied, I just hit the green button. The Dietary Manager explained to [NAME] #4 that the green button was to be pushed, stopped, pushed and stopped again to pulsate. The Dietary Manager agreed that the thick paste-like mechanically altered pork chop could cause an issue with swallowing.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure infection control processes are maintained for 2 (Resident #8 and #270) residents of 3 residents reviewed for improper handling of eating utensils and not being under contact isolation for communicable disease. Finding included: Review of a facility undated policy titled, PP Infection Control, indicated, The facility will establish and maintain an infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. A review of a facility policy titled, Transmission-Based (Isolation) Precautions, dated 2022, indicated, for a resident who is immuno-compromised; should be on contact isolation for herpes zoster (shingles). Review of the admission Record, indicated the facility admitted Resident #270 with diagnoses that included: chronic obstructive pulmonary disease, acute and chronic respiratory failure; malnutrition, myocardial infarction, iron deficiency anemia, thrombocytosis and the presence of a cerebrospinal fluid drainage device. Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/2024, revealed Resident #270 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of Resident #270's Care Plan, initiated on 01/10/2025, revealed the resident required enhanced barrier precautions related to indwelling medical device (feeding tube). Interventions included: was to wear disposable gloves and gowns when providing high contact care. Resident #270 had a Care Plan initiated 01/09/2025, for a yeast rash in between and to the right finger. Interventions included: to avoid scratching and keep hands and body parts from excessive moisture, evaluate rash weekly with skin audit, give antiviral medication as ordered. Observe for any adverse reactions. Notify medical doctor as needed and observe skin rashes for increased spread or signs of infection. A review of the Order Summary Report, revealed Resident #270 had enhanced barrier precautions related to feeding tube and an order for valacyclovir hydrochloride 1000 milligrams (mg) by mouth every eight (8) hours for rash to the right arm. A review of Medication Administration Record (MAR), revealed Resident #270 had been receiving enhanced barrier precautions since 01/10/2025. A review of the Infection Screening Evaluation completed 01/15/2025 at 11:09 AM, revealed Resident #270 had the symptom: vesicular rash. A review of the Skilled Note A Every 8 hours, dated 01/13/2025, revealed no documented rash or skin issue. A review of the Advanced Practice Registered Nurse (APRN) progress note dated 01/13/2025, revealed that Resident #270 had a new rash to right arm with small vesicles present. APRN observed erythematous, warm rash to inner aspect of right arm extending to fingers on right hand with small, closed blisters noted throughout the rash. Per the APRN note, Resident #270 denied itching but stated that the area was burning. The Assessment/Plan per the APRN included: 1. Herpes Zoster-acute, start valacyclovir 1000mg every 8 hours for 7 days. To keep the area clean and dry. To Keep area covered if blisters rupture/open. Isolation precautions as necessary. Notify the provider of any acute concerns. During an interview on 01/15/2025 at 1:28 PM, Director of Nursing (DON), stated the order for the Valacyclovir (antiviral) was written on 01/13/2025 at 11:00 PM. DON stated that the rash was noted by the certified nursing assistants who then went to the nurse and then the nurses went to assess the rash. DON was asked to review the nurse's notes and confirmed there was only a note stating that the medication had started. DON stated that the APRN had seen the resident that day (01/13/2024) and it was just uploaded into the electronic medical record on 01/15/2025. DON stated the resident had not been placed on isolation because the blisters were not ruptured and because Resident #270 had intact skin. DON stated that on 01/13/2025, per nursing documentation, there were no nurses notes that mentioned any skin issues. When asked if there was any antibiotic stewardship follow up on the infection, DON replied, it did not require antibiotic stewardship due to it being an antiviral medication. On 01/15/2025 at 7:39 AM, CNA #1 was assisting Resident #8 on the male unit with meal set up. Without washing her hands, after touching trays and opening containers, she picked up a fork by the tines (the end of the fork that goes into the mouth) and handed it to Resident #8. On 01/15/2025 at 8:45 AM, CNA #1 was asked if she should have picked the fork up by the tines and she stated, No, I should have handed it to him by the handle and washed my hands. On 01/16/2025 at 9:00 AM, the DON was asked if the CNA should have handled the fork by the tine, and stated she should have handed it to the resident by the handle.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure the internal components of the ice machine were cleaned and the container for storing the ice scoop were cleaned when reviewed for safety and infection control to prevent waterborne illnesses. Findings include: On 01/16/2025 at 8:20 AM, the Administrator stated the facility did not have a policy for the ice machine. During an observation on 01/16/2025 at 8:00 AM, the Dietary Manager used a napkin to go around the edges inside the ice machine. Inside the ice machine was a metal border on the top portion of the machine. After wiping the metal plate, a black residue was noted to be on the napkin. After completing the ice machine, the ice scoop drawer was removed and inside the drawer was a pink/beige residue in the corners around the drawer. On 01/16/2025 at 8:05 AM, the Dietary Manager reported that the Maintenance Supervisor was responsible for cleaning the ice machine, and that the Dietary Department was responsible for washing the scoop holder. A review of the Ice Machine Cleaning Log on 01/16/2025, indicated that the ice machine had been wiped down to ensure there was no build up on the ice machine, and the hopper had been emptied out, and disinfected on 01/14/2025. During an interview on 01/16/2025 at 8:30 AM, the Dietary Manager confirmed that it was important for the ice machine to be cleaned because it could cause harm and make someone sick. The Dietary Manager then stated, we are going to shut it down and clean it. The Dietary Manager reported that the scoop drawer was on a cleaning schedule, but that there was no log for the cleaning to be recorded. During an interview on 01/16/2025 at 1:04 PM, the Maintenance Supervisor stated the ice machine was digital, and lets the facility know when it is time for it to be cleaned. The Maintenance Supervisor reported that even if the light was not on to indicate the ice machine needed cleaning, the ice machine was cleaned every two (2) weeks or monthly. The Maintenance Supervisor confirmed that the ice machine was descaled, and the ice machine hopper was emptied out every 2 weeks or as needed.

Based on record review and interview, the facility failed to ensure a resident with mental disorder was referred for a level II PASRR [Preadmission Screening and Resident Review] evaluation for one (Resident #28) of 1 sampled resident. The findings are: Resident #28 had diagnoses of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/2023 documented both PTSD and Depression. On 01/09/24 at 11:00 AM, the Surveyor was unable to locate the level II PASRR screening report in Resident #28's medical record. Resident #28's Care Plan documented, .has a diagnosis of depression and PTSD .Psych consult as necessary . 01/11/24 at 09:57 AM, the Surveyor asked the Business Office Manager (BOM) if she could provide a copy of Resident #28's Level II PASSR, from the screening agency. After the BOM searched in the Electronic Health Record and two separate paper charts, she was unable to locate a completed PASSR. The BOM was able to locate a paper application that had been sent to the screening agency dated 8/16/2016. On 01/12/2024 at 11:15 AM, the Director of Nursing (DON) was asked why it was important for a PASSR to be performed on a resident prior to admission. The DON stated, So we know the mental status, we know what the appropriate was to care for the resident. The Surveyor asked what can happen if a PASSR is not completed on a new admission? She stated, I can't tell you that, I am still learning this. On 01/12/2024 at 11:20 AM, Registered Nurse (RN) #1 was asked why it was important for a PASSR to be performed prior to admitting a new resident. She stated, To determine if the resident is safe to be in a nursing home, for them and for other residents. On 01/12/2024 at 11:45 AM, the Administrator said the facility did not have a policy on PASSR.

Based on interview, observation and record review, the facility failed to review and revise the resident care plan in a timely manner to address a decline in function for 1 (Resident #3) sampled resident. The findings are: Resident #3 had a diagnosis of dementia. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/2023 documented Brief Interview for Mental Status (BIMS) of 6, which indicates severe cognitive impairment and was independent for transfers, bed mobility and toileting. Always continent of bowel and bladder. The Significant Change in Status MDS with an ARD of 12/21/23 documented a BIMS of 4, which indicates severe cognitive impairment and was always incontinent of bowel and bladder. On 01/10/2024 at 10:45 AM, observed two Certified Nursing Assistants (CNAs) position Resident #3 in bed as well as preform incontinent care. Resident #3's Care Plan with a revision date of 9/15/2023 documented, .has an ADL [activities of daily living] self-care performance deficit .is independent with toileting, transfers and bed mobility . On 01/12/2024 at 11:15 AM, the Director of Nursing (DON) was asked why it was important for a care plan to be updated in a timely manner. She stated, So the staff know how to care for the residents. The Surveyor asked if the care plan is not updated what could happen? The DON stated, The resident may not get the proper care. On 01/12/2024 at 11:25 AM, Registered Nurse (RN) #1 was asked why it was important for the care plan to be updated in a timely manner, she responded to take care of the resident, it gives information to everyone, so they know what the resident needs. So, all the staff can work together to care for the resident, if it's not updated the resident could receive improper care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure staff sat at eye level while assisting residents with meals for 2 (Residents #22 and #33) of 2 sampled residents who required assistance with meals; and failed to provide privacy during care for 1 (Resident #33) of 1 sampled resident who required assistance with activities of daily living. The findings are: 1. A review of an admission Record, indicated the facility admitted Resident #22 with a diagnosis of stage 5 chronic kidney disease. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #22 had a Staff Assessment for Mental Status (SAMS) score of 2, which indicated the resident had moderate cognitive impairment. The resident required maximum assistance for eating. Review of Resident #22's Care Plan, revised on 10/25/2021, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to seizures, fibromyalgia, type 2 diabetes mellitus, lack of coordination, cerebral vascular accident (CVA) with right sided deficits. Interventions included, requires substantial/maximum assistance with meals/eating, revised on 1/3/2024. A review of the facility's undated policy titled, Summary of Residents' [NAME] of Rights, indicated, The facility must ensure and protect the human right of every individual in residence and to that end will provide a clean healthy attractive environment wherein the resident will receive treatment without discrimination as to race, color, religion, sex, national origin, disability or source of payment. Every resident has the right to considerate and respectful care. Every resident will be treated with consideration, respect and full recognition of his/her dignity and individuality. Privacy during treatment and care of personal needs. On 01/08/2024 at 12:55 PM, the Director of Nursing (DON) was observed standing next to Resident #22 while assisting the resident with eating. On 01/08/2024 at 12:58 PM, the DON was observed to give Resident #22 a drink while standing over the resident. 2. A review of an admission Record indicated the facility admitted Resident #33 with a diagnosis of dementia. The Annual MDS, dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The resident was dependent for all activities of daily living (ADLs). Review of Resident #33's Care Plan, revised on 10/26/2023, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to dementia with behaviors. Interventions included the resident was dependent upon staff for feeding, initiated on 6/16/2021. The resident was dependent on staff for all activities of daily living (ADLs). On 01/08/2024 at 12:56 PM, Certified Nursing Assistant (CNA) #6 was observed standing next to Resident #33 while assisting Resident #33 with eating. CNA #6 gave Resident #33 a drink while standing over the resident. CNA #6 gave Resident #33 a bite of food while standing over the resident. CNA #6 gave Resident #33 another bite of green beans while standing over the resident. On 01/08/2024 at 12:58 PM, CNA #6 gave Resident #33 another bite of food while standing over the resident. On 01/08/2024 at 1:21 PM, CNA #6 was asked why did you stand while assisting Resident #33 with meal service? CNA #6 stated, Because I was going to sit there, but I was trying to help Resident #33 eat. CNA #6 was asked why should staff sit at eye level while assisting residents with meals? CNA #6 stated, Not to hover over them. On 01/08/2024 at 2:08 PM, the DON was why did you stand while assisting Resident #22 during meal service? The DON stated, Because I thought the CNA had the chair. We were short a chair. The DON was asked why should staff sit at eye level while assisting residents with meals? The DON stated, It's less intimidating. The DON was asked why were the residents meals left on the meal trays during meal service? The DON stated, I'm not sure. The DON was asked how do you ensure residents are served meals in a non-institutionalized manner and their dignity is maintained during meals? The DON stated, Make sure their meals are individualized, let them make choices, don't stand over them, sit at eye level. 3. Review of Resident #33's Care Plan, revised on 6/16/2021, revealed the resident had incontinence related to (r/t) dementia with behaviors and psychosis. Interventions included uses disposable briefs initiated on 6/16/2021; and an intervention initiated on 6/16/2021 to clean peri-area with each incontinence episode. On 01/08/2024 at 02:34 PM, CNA #6 assisted Resident #33 to the residents' room in a specialized chair. Resident #33's roommate was in bed. Resident #33 was laying back in the specialized chair. CNA #6 moved to the left side of Resident #33 specialized chair. CNA #7 moved to the right side of Resident #33's specialized chair. Observed CNA #6 and CNA #7 lift Resident #33 up in the specialized chair to a sitting position. Staff did not pull the privacy curtain. The CNAs did not use a gait belt or a lift. On 01/08/2024 at 2:36 PM, the Surveyor asked CNA #6 and CNA #7 why they didn't pull the privacy curtain when assisting Resident #33. CNA #7 stated, We didn't think, we just did it. The Surveyor asked how do you normally pull Resident #33 up in the chair? CNA #7 stated, If we are just pulling up in the chair, one on each side and pull up, but if chair to bed, or bed to chair, we use a lift. [Resident #33] is a total lift.

Based on observation and interview, the facility failed to ensure 1 (Resident #222) of 1 sampled resident received lunch choices ordered the morning of 1/8/2024. The findings are: a. On 01/08/24 at 12:53 PM, observed Resident #222 sitting up in a motorized wheelchair in the dining room. Lunch was served to Resident #222 by Licensed Practical Nurse (LPN) #2. Resident #222 stated, I ordered sausage, and they brought me chicken and dumplings. The Surveyor observed chicken and dumplings, green beans, cornbread, strawberry ice cream, iced tea, and water on Resident #222's tray. b. On 01/08/24 at 12:55 PM, sausage and corn were delivered to Resident #222 by LPN #2. Resident #222 asked for a slice of bread and mustard at 12:56 PM. Resident #222 stated, I didn't get any cobbler either. c. On 01/08/24 at 12:58 PM, a Certified Nursing Assistant (CNA) brought Resident #222 mustard and bread as requested and told Resident #222 they had run out of cobbler. d. On 01/09/24 at 02:30 PM, Resident #222 was sitting up in a specialized wheelchair in the resident's room watching TV. Dietary Employee (DE) #3 came in to get Resident #222's order for dinner, a choice between pork chops, or breakfast food. Resident #222 ordered breakfast food with no tomato juice. DE #3 wrote Resident #222's preferences on a clipboard she was carrying. e. On 01/11/24 at 09:38 AM, the Surveyor asked DE #1 who was responsible for making sure residents got their food choices daily. DE #1 stated, I have someone that goes around and asks the residents what they want for their meal, if they want an alternative, or if they want soup and a sandwich. The Surveyor asked what time does staff usually make rounds? DE #1 stated, Usually at nine am and again at three pm. The Surveyor asked how is it ensured that the process is followed for the residents to get their food choices. DE #1 stated, I've been here for fifteen years and have good communication with my helpers. The Certified Nurse Assistants usually come and tell me if there is a problem and I get it for them. Sometimes residents themselves will come and tell me. The Surveyor asked what the breakdown in the process was with what had happened with Resident #222's lunch on Monday? DE stated, To be honest with you, I didn't hear nothing about it. Sometimes people will order something, and they will look at someone else's plate and decide that they want that instead. It happens all the time. f. On 1/10/24 at 09:00 AM, the Administrator provided a document titled, Summary of Residents' [NAME] of Rights, which documented, . ACTIVITIES AS A RESIDENT, YOU HAVE THE RIGHT TO: .· Individual preferences regarding such things as food, clothing, religious activities, friendships, activity programs and entertainment. Such preferences shall be elicited and respected by nursing home staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/09/24 at 08:44 AM, observed the bathroom shared by room [ROOM NUMBER] and 403. There was a black and brown substance built up around the base of both faucets and the chrome hardware spigot. There was a white residue built up on the chrome soap dispenser above the sink, and multiple smears and spots of an opaque substance up and down the chrome hardware on the sink. There was light brown, yellow and orange colored particles visible on the surface of both sides of the white sink. There was an empty white toilet paper holder resting on the left side of the sink that had a brown colored spot on it, and a blue sticky substance was smeared on the front left corner of the sink. There were dried opaque spots on the mirror above the sink. The floor around the base of the toilet was brown colored and there were packages of briefs lying on the floor next to the toilet, and there were brown colored streaks visible in the toilet bowl. The bathroom smelled of old urine. On 01/10/24 at 08:48 AM, room [ROOM NUMBER] and room [ROOM NUMBER]'s bathroom sink remained the same with a black substance around the bases of both faucets. The blue sticky substance remained on the lower left corner of the sink. On 01/10/24 at 02:15 PM, room [ROOM NUMBER]and 403's bathroom sink remained the same. There was also a chrome piece observed lying on the floor next to the toilet. The floor around the base of the toilet was stained dark brown and there were small black specks of debris accumulated and scattered on the base of the white toilet. There was another chrome piece attached to the wall. There was a metal square with sharp edges on the wall where the chrome piece that was lying on the floor had been attached. There were specks of an unidentified substance on the mirror, and brown streaks in the toilet bowl. On 01/09/24 at 09:18 AM, the resident in room [ROOM NUMBER]-A was lying in bed asleep. There were 2 empty urine bottles hanging over the side of trashcan in the room to the left of the resident's bed. There was an empty urine bottle with a dried drop of light brown substance on the outside surface sitting on top of the bookshelf to the right as the Surveyor walked into the room. The empty opened urine bottle on the bookshelf was sitting directly under the hand sanitizer dispenser on the wall. There were snacks and vitamin C tablets sitting next to the open urine bottle on the bookshelf. On 01/08/24 at 11:27 AM, the exit door at the end of the 300 Hall had a draft, and the hinge mechanism at the top of the door was missing 2 out of 3 bolts. On 01/09/24 at 12:28 PM, the exit door at the end of the 300 Hall remained the same with 2 out of 3 bolts missing from the hinge mechanism at the top of the door. On 01/10/24 at 08:52 AM, in room [ROOM NUMBER]-A, the open empty urine bottle remained on the bookshelf under the hand sanitizer on the wall. The 2 empty open urine bottles were still hanging on the edge of the trashcan in the room between the wall and the bed. On 01/10/24 at 12:10 PM, observed CNA #5 sitting in room [ROOM NUMBER]. The resident was in the bathroom. The open, empty urine bottle remained on the bookshelf, and the 2 open empty urine bottles remained hanging over the edge of the trash can as before. On 01/10/24 at 02:21 PM, in room [ROOM NUMBER]-A, the urine container had been removed from the bookshelf. The 2 empty urine bottles remained hanging on the trashcan between the wall and the resident's bed. On 01/10/24 at 02:41 PM, the Surveyor asked Housekeeping (HK) #1 what rooms she was assigned to clean. HK #1 answered, Today I have 300 and 400 halls. I've already done 400 Hall. The Surveyor asked HK #1 to talk through the process of cleaning the resident rooms. HK #1 answered, I get one rag and clean everything off like the side table, the countertop and I pull stuff out and clean behind it. In the bathroom, I use one rag for the commode and another rag for the sink and another rag for the paper towel and another rag for the soap thing. The Surveyor asked what the rags were made of. HK #1 answered, Cloth from the laundry. I also use peroxide in the commode for three seconds to kill the odor. Well, I pull the bed out, clean the bed off. Then I mop the bathroom. Come out. Rinse the mop out and then mop the room. I put out a yellow caution sign. before I start. On 01/10/24 at 02:43 PM, the Surveyor accompanied HK #1 to the bathroom shared by room [ROOM NUMBER] and 403. HK #1 took her bare hand and scraped the black substance from around the right faucet on the sink. The Surveyor observed a black colored liquid substance on the index finger of HK #1's right hand, and under the index fingernail as she proceeded to push the paper towel dispenser to get a towel to wipe her hand. The Surveyor asked if there were any issues with touching the paper towel dispenser with dirty hands. HK #1 replied, Oh, I guess I shouldn't have done that. The Surveyor asked if she knew about the toilet paper dispenser chrome pieces being broken and the sharp metal piece left on the wall, and if she saw any issue with it being that way. HK #1 answered, No I didn't know about that, but I'll pick it up and clean the floor. HK #1 then left the room without sanitizing, or washing hands stating she would come back right away and wipe the sink and clean the toilet which had brown streaks visible on the inside of the toilet bowl. On 01/10/24 at 03:10 PM, the Surveyor accompanied the Maintenance Supervisor to room [ROOM NUMBER] and 403's bathroom where HK #2 was cleaning the sink, and HK #1 was mopping the floor. The Surveyor asked the Maintenance Supervisor if he knew about the toilet paper holder needing repair. He answered, I didn't know about the toilet paper holder, but I've been planning on replacing that toilet since there have been problems with it leaking and staining the floor. The Surveyor asked if he thought there were any issues with the chrome pieces left on the wall. The Maintenance Supervisor answered, Well it looks like it might need to be moved back so they don't have to reach as far to get to it. The chrome piece was no longer lying on the floor next to the toilet. The Surveyor asked HK #1 what had happened to the chrome piece. HK #1 answered, I put it on my cart out in the hallway. On 01/10/24 at 03:21 PM, HK #2 (Housekeeping Supervisor) stopped the Surveyor in hall 400 and asked the Surveyor to accompany him to look at the bathroom in room [ROOM NUMBER] and 403. The Surveyor accompanied HK #2 to the bathroom where HK #1 was finishing cleaning the bathroom. The sink was clean, the toilet was cleaner, the chrome fixtures were clean, and the mirror had been cleaned. The Surveyor asked HK #2 what had been done differently that hadn't been done earlier when it was cleaned. HK #2 answered, She [HK #1] used a stone cleaner that she didn't use on it before. The Surveyor asked if gloves were worn when cleaning the resident rooms. HK #2 answered, Yes, we normally do. The Surveyor noticed HK #2 was not wearing gloves. HK #1 was wearing gloves. The Surveyor asked why HK #1 was wearing gloves, and HK #2 was not. HK #2 answered, Well we usually wear them. The Surveyor asked if there were any issues with scraping the black substance from the faucet with a bare hand, wiping it off with a paper towel, and leaving the room without washing or sanitizing, and why washing hands and sanitizing was important? HK #2 answered, Yes, that is a problem, passing germs or mold to residents when you touch paper towel dispensers, anything in the room, doorknobs, other residents, or anything a resident touches. On 01/08/24 at 11:48 AM, observed room [ROOM NUMBER]'s bathroom vanity lights were burned out. The baseboards behind the toilet were peeling from the wall. The metal door frames needed painting and there were deep scrapes in the wooden door. The Surveyor asked the resident in 402-A if it bothered him to have the lighting not working in the bathroom. The resident answered, Yes. The Surveyor asked if he had told anyone. The resident answered, Just the Aide. The Surveyor asked how the Aide responded. The resident answered, They said they would tell someone. The Surveyor asked how long ago he had told the Aide. The resident answered, I don't know. About a year, I think. On 01/10/24 at 02:06 PM, room [ROOM NUMBER]-A's bathroom smelled of old urine. 3 out of 4 round vanity lights above sink were still burned out, and the baseboard behind the toilet was still peeling from the wall. room [ROOM NUMBER] and 404 share the bathroom. On 01/10/24 at 03:14 PM, the Surveyor accompanied the Maintenance Supervisor to room [ROOM NUMBER] and 404 bathroom and asked if he knew about the light bulbs being burned out, and the peeling baseboard behind the toilet. The Maintenance Supervisor answered, No I didn't know about the lights being out or the baseboard peeling, but it is an easy fix, and I will take care of it right away. The Surveyor asked the Maintenance Supervisor how he knew when facility repairs needed to be done. The Maintenance Supervisor answered, The CNAs are supposed to write it down in a book for me so I can keep up with it, but they don't always do that. On 01/10/24 at 03:40 PM, the Surveyor accompanied the Maintenance Supervisor to the end of the 300 hallway where he stated he had replaced the 2 screws on the top door hinge that were missing. The Surveyor asked how long it had been that way. The Maintenance Supervisor answered, I don't really know, I've been battling with that door for a long time. We replaced the hinge, put on a new alarm, and I've replaced these screws before. I think it might have just happened. Housekeeping told me about it, and I just got it fixed today. On 01/10/24 at 08:58 AM, the Assistant Director of Nursing (ADON) provided a document titled, Record of In-Service dated 8/17/23 that documented on Page 1 under Section 1: Introduction, .Hazards in the Workplace .Recognize potential hazards in residential, home, and community settings . and on page 8, Section 3: Conclusion, second paragraph, under Work Place Safety: The Basics, .Employees at all levels of the organization have responsibility for the safety and well being of the individuals they serve and themselves . On 01/11/24 at 07:59 AM, the Administrator provided a cleaning schedule document that documented, .No Food, Drinks, Dangerous Object on HK Cart . and under required Supplies/Tools: .Gloves . and under 7-step (washroom Cleaning), .Clean Commode/Base, Clean Sink/Pipes, Sweep, Damp Mop . On 01/11/24 at 07:50 AM, Admin informed the Surveyor that there was no facility policy on Maintenance, and stated, We follow the Life Safety Book. Based on observations, interview and record review, the facility failed to ensure a safe, clean, comfortable homelike environment was maintained by failing to ensure resident bathrooms were cleaned, foul odors were addressed on the Secure Unit, vinyl furniture was repaired, tiles and bedside tables were maintained and repaired, dead insects were cleaned from window seals, empty urine bottles were stored appropriately, burnt out lightbulbs were changed, and baseboards, walls, and floors were repaired throughout the facility. This failed practice had the potential to affect 66 residents residing in the facility, based on a Midnight Census Report dated 1/7/2024 provided by the Business Office Manager on 01/8/24 at 10:30 AM. The findings are: On 01/08/24 at 12:10 PM, a strong odor of ammonia and urine was noted upon entrance into the 600 Hall Secure Unit. The Dayroom on the 600 Hall Secure Unit contained two vinyl brown couches with torn vinyl on the arms and seams; a nightstand with the top peeling; a brown chair with peeling vinyl exposing the foam; and a plastic over the bed table that was ripped six inches and exposing a hard plastic pointed area. Thirty six inches of baseboard was pulled away from the wall exposing the drywall, rocks, and possible bricks between the bathroom door and the area under the TV. Another baseboard, 36 inches in length, was pulled away from the wall behind a brown chair in the dayroom exposing drywall and bricks. The window seal in the dayroom had dead bugs and/or moths. A broken tile was noted outside of room [ROOM NUMBER], the corners of 4 tiles were 12 centimeters in diameter, and 0.5 centimeters deep. A review of the facility's undated policy titled, Summary of Residents' [NAME] of Rights, indicated, The facility must ensure and protect the human right of every individual in residence and to that end will provide a clean healthy attractive environment wherein the resident will receive treatment without discrimination as to race, color, religion, sex, national origin, disability or source of payment . A review of an admission Record indicated the facility admitted Resident #33 with a diagnosis of dementia. The Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The resident was dependent for all activities of daily living (ADLs). Review of Resident #33's Care Plan, revised on 10/26/2023, revealed the resident had an activity of daily living self-care performance deficit related to dementia with behaviors, anxiety. Interventions with a revision date of 9/16/2022, included, requires total assistance x 2 staff with transfer medium/purple sling. Resident had limited physical mobility due to dementia with behaviors and psychosis, revised on 10/26/2023. Interventions revised on 10/26/2023, included, resident is non-ambulatory and uses a geri-chair for mobility. On 01/08/24 at 10:47 AM, Resident #33 in a specialized chair, with the chair leaned back and Resident #33 kicking outward and restless. The specialized chair cushion was stained with a black wet substance. The strap at the foot of the specialized chair was loose. On 01/08/24 at 12:26 PM, in room [ROOM NUMBER], observed a cloth recliner with a brown rust stain on the seat and a yellow stain on the floor near the recliner. The room had a strong odor of ammonia and urine. On 01/08/24 at 12:29 PM, in room [ROOM NUMBER], there was a cloth recliner. The room had a strong odor of ammonia and urine. On 01/08/24 at 12:35 PM, observed Resident #33 leaned back in a specialized chair in the Dining Room on the 500 Women's Secure Unit. The strap at the foot of the specialized chair was loose. On 01/08/24 at 02:27 PM, observed Resident #33 leaned back in a specialized chair in the Dining Room of the Women's Secure Unit. The strap at the foot of the specialized chair was loose. The pillow was torn at the left side of resident's head with foam exposed. On 01/09/24 at 10:50 AM, upon entry onto the Men's Unit, a strong odor of ammonia and urine was noted. Certified Nursing Assistant (CNA) #11 was asked what the smell was on the unit. CNA #11 said a resident just had a BM [bowel movement]. CNA #11 was asked what is the ammonia/urine smell? CNA #11 said well they just cleaned down here, so it maybe the cleaner they are using. The smell was stronger in the dayroom than at the end of the hall. CNA #11 stated, They think it's the furniture, they ordered new furniture, and it was supposed to be here last week, but now it's supposed to be here this week. On 01/10/24 at 09:03 AM, the Maintenance Logs dated 12/26/23 to 01/10/24 were reviewed with no documentation noted for the odors on the 500 or 600 secure units or the concerns observed on the 500 Hall secure unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure nail care was regularly provided for 1 (Resident #221) of 1 sampled resident who was dependent for nail care and oral care was regularly provided for 1 (Resident #223) of 1 sampled resident who was dependent for oral care to maintain good hygiene, promote a sense of wellbeing, and prevent potential injuries or infections. The findings are: 1. Resident #221 had a diagnosis of aftercare following joint replacement surgery and unspecified systolic congestive heart failure. a. A 5-Day admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/23 documented a Brief Interview for Mental Status (BIMS) of 10 (8-12 indicates moderately cognitively impaired) and was dependent on staff for personal hygiene. b. A Care Plan with an initiation date of 12/22/23 documented, .requires assistance with ADLs [activities of daily living] due to left hip fx [fracture] and arthroplasty . Personal Hygiene: requires partial/mod [moderate] assistance with Personal Hygiene . c. A Physicians Order dated 12/25/23 documented, .OT [Occupational Therapy] to treat 5 times/week for 4 weeks to address deficits related to lack of coordination and need for assistance with personal care . d. On 01/08/24 at 12:14 PM, Resident #221 was sitting in a wheelchair in her room at the bedside table. Her fingernails were 1/4 inch past the fingertips with a brown substance under the right and left index fingernails and the right middle fingernail. The fingernails were uneven in length. The Surveyor asked Resident #221 if it was ok to see her hands and fingernails. Resident #221 stated, My nails are dirty., and pointed to the left index finger with the right hand. The Surveyor asked if she had told anyone. She stated, I haven't had time to tell nobody nothing. e. On 01/09/24 at 08:47 AM, Resident #221 was lying in bed awake. Her fingernails remain 1/4 inch past the fingertips in length and uneven, with a brown substance observed under the nails. Her hair was uncombed and disheveled looking. f. On 01/09/24 at 02:50 PM, Resident #221 was lying in bed awake. The Surveyor asked if she had gotten a bath or shower recently. She stated, Yes, I had one yesterday I believe. The Surveyor asked to see her fingernails. Resident #221 stated, They are still dirty and need to be cleaned out. The Surveyor asked if she thought her fingernails needed to be trimmed. Resident #221 stated, They sure do. The Surveyor asked if she liked the way they looked. Resident #221 stated, No they need to be cleaned. Can you clean them for me? Do you have one of those sticks? The Surveyor asked if she had asked staff to help with her nails. Resident #221 stated, No, they are too busy and don't want to do that, I'm sure. g. On 01/09/24 at 02:57 PM, the Surveyor accompanied Certified Nursing Assistant (CNA) #3 to Resident #221's room and asked her to describe Resident #221's fingernails. CNA #3 stated, Well, they are long and dirty. The Surveyor asked if she thought they needed to be cleaned and trimmed. CNA #3 stated, Yes ma'am The Surveyor asked who was responsible for nail care for the residents. CNA #3 stated, It depends on if she's diabetic. If she is, the treatment nurse does them. If not, it would be the CNA on the hall giving the shower. She's a three to eleven shift shower. The Surveyor asked CNA #3 what are Resident #221's shower days. CNA #3 stated, Monday, Wednesday, Friday afternoon. The Surveyor asked how often fingernails should be checked. CNA #3 stated, Frequently. The Surveyor asked why regular nail care was important. CNA #3 stated, Hygiene and infection control. h. On 01/09/24 at 03:03 PM, CNA #1 and CNA #4 entered Resident #221's room. The Surveyor asked CNA #4 to describe Resident #221's fingernails. CNA #4 stated, They are dirty and long. The Surveyor asked CNA #4 if she thought Resident #221's fingernails needed to be trimmed. CNA #4 stated Yeah, they need to be filed, cleaned, and clipped. The Surveyor asked CNA #4 how often nail care should be done for residents. CNA #4 stated, A few times a week. The Surveyor asked CNA #4 who was responsible for providing resident nail care. CNA #4 stated, If diabetic, the nurses. The Surveyor asked why regular nail care was important. CNA #4 stated, It's just part of taking care of them like taking showers. CNA #1 stated, It's part of infection control too. i. On 01/10/24 at 01:31 PM, the Assistant Director of Nursing (ADON) informed the Surveyor that there was no policy or procedure guide for nail care and/or oral care. j. On 01/11/24 at 12:42 PM, the Surveyor asked the Director of Nursing (DON) who was responsible for nail care and oral care for the residents. The DON stated, CNAs. The Surveyor asked what could happen if nail care and oral care was not done on a regular basis. The DON stated, Infection, poor dental hygiene, cavities. The Surveyor asked when or how often nail and oral care should be done. The DON stated, Nailcare should be done when residents do their showers. Oral care is supposed to be done daily. The Surveyor asked for a list of residents who were dependent on staff's assistance with activities of daily living specifically for nail care and oral care. The DON stated, Everyone here is dependent upon staff for nail care. We have a few walkie talkies that do their own. I will get you a list of the one's dependent for oral care. k. On 01/11/24 at 4:05 PM, the DON provided a list of 21 Residents in Facility Dependent upon Oral Care. 2. Resident #223 had diagnoses of type 2 diabetes mellitus, functional quadriplegia, acquired absence of leg above right knee and left knee. a. A Quarterly MDS with an ARD of 12/26/23 documented a BIMS score of 12 (8-12 indicates moderate cognitive impairment) and was dependent on one staff for oral and personal hygiene. b. A Quarterly MDS with an ARD of 9/25/23 documented Resident #223 was dependent on one staff for oral and personal hygiene. c. A Care Plan with an initiation date of 06/20/23 documented, .has an ADL self-care performance deficit . Personal Hygiene/oral care: .is totally dependent on staff for personal hygiene and oral care . d. On 01/08/24 at 02:26 PM, Resident #223 was sitting up in a specialized chair in his room. The Surveyor observed that Resident #223 had several teeth missing and a foul breath odor. The Surveyor asked if he was able to brush his teeth by himself or if he needed assistance. Resident #223 stated, I don't brush my teeth, but I have a toothbrush. The Surveyor asked if the staff had brushed his teeth. Resident #223 stated, No. The Surveyor asked if he had asked staff to help brush his teeth. Resident #223 stated, Yes, but they don't do it. The Surveyor asked what happens when staff are asked to help you with tooth brushing. Resident #223 stated, They say they will get to it, and then don't come back. e. On 01/09/24 at 03:16 PM, Resident #223 was sitting up in a blue specialized chair in his room watching TV. The Surveyor asked if his teeth had been brushed. Resident #223 stated, No. The Surveyor asked if anyone had offered to help brush his teeth today. Resident #223 stated, No. Resident #223's breath had a foul odor. The Surveyor asked if he would like to have his teeth brushed. Resident #223 stated, Yes. The Surveyor asked if he had asked for help brushing teeth. Resident #223 stated, This morning we didn't have time, and I've given up on asking. f. On 01/10/24 at 10:43 AM, Resident #223 was lying in bed awake with his face covered. The Surveyor asked if his teeth had been brushed today. Resident #223 stated, They didn't brush my teeth. I haven't gotten up yet today. The Surveyor asked permission to pull the covers down to see Resident #223's face. Permission was given, and the Surveyor pulled the covers down. Resident #223's breath still had a foul odor. The Surveyor asked if he would like to have his teeth brushed. Resident #223 stated, Yes. The Surveyor asked if he knew where his toothbrush was. Resident #223 stated, Yes it's in the cabinet. The Surveyor asked permission to open the cabinet, which was given. There was a pink basin with toiletries including a toothbrush in a closed case and toothpaste observed. g. On 1/10/24 at 10:58 AM, the Surveyor accompanied CNA #5 into the dining area and asked her to pull up Resident #223's personal hygiene documentation. CNA #5 pulled up Resident #223 in (Facility Computer Software) and stated, She didn't chart it. There is nothing charted for personal hygiene today. The Surveyor asked if she could pull up yesterday's personal hygiene documentation. CNA #5 stated, No I don't know how to do that, you will have to ask [name]. She's the one that shows me how. h. On 01/10/24 at 11:10 AM, the Surveyor asked LPN #1 to pull up specific documentation for Resident #223's oral care. LPN #1 pulled up the screen the CNAs use to document ADL care from 1/9/24 at 14:12 which documented, 1. 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) Helper does ALL the effort or task requires 2 or more helpers. The Surveyor asked how to tell if oral care or brushing teeth had been done or not done. As she pulled up the options on the screen LPN #1 stated, If it wasn't done, they should have selected the boxes marked either Not attempted, Not Available, or Resident Refused. Those should have been selected if it was not done. The Surveyor informed LPN #1 that Resident #223 had foul breath and stated that he hadn't had his teeth brushed in three days. LPN #1 stated, I will have someone down there to take care of that right away. The Surveyor asked why regular oral care was important. LPN #1 stated, A lot of reasons. Pain, Infection, and overall health. The Surveyor asked who was responsible for providing oral care. LPN #1 stated, Generally the Certified Nursing Assistants do it when they get them out of bed or put them back to bed. It depends on the resident's preference. i. On 01/10/24 at 08:58 AM, the Assistant Director of Nursing (ADON) provided an Inservice Education Report dated 4/2/2023 on Oral Care which documented under Best Practices - Oral Care .Should be done at least twice a day . Conclusion, People in residential or continuing care have an equal right to good oral health as people residing in the community . j. On 01/10/24 at 01:01 PM, the Surveyor asked the ADON how to tell if oral care had been done for residents if it is not specifically documented in the Electronic Health Record (EHR). The ADON stated, The best way to tell is to go down and look to make sure there is no food on their face or particles in between their teeth. If they have dentures, look to see if they are soaking. The Surveyor asked who was responsible for resident oral care. The ADON stated, The CNAs. The Surveyor asked why routine oral or dental care was important. The ADON stated, A lot of things. Infection from bacteria building up in the mouth, and dignity as far as looks and smells. k. On 01/10/24 at 01:31 PM, the ADON informed the Surveyor that there was no facility policy for nail care or oral care.

Based on observation, interview, and record review, the facility failed to provide skin treatment for 1 (Resident #18) sampled resident who had a dry red rash to the face and neck. The findings are: Resident #18 had a diagnosis of dementia with agitation. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/2023 documented the resident scored 9 (8-12 indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS) and had no skin issues. On 01/08/24 at 10:28 PM, 01/09/2024 at 9:00 AM, 01/09/2024 at 2:00 PM and 01/11/2023 at 3:00 PM, the skin on Resident #18's face was red and splotchy with white dry scaly patches noted on the right side of nose, his forehead, and chin. Resident #18's January 2024 Physician's Orders did not document any orders to treat the rash and scaly areas to the face. Resident #18's task sheet did not document a refusal of care in the past 30 days. Resident #18's Body Audit Report completed on 01/10/2024 noted no negative findings with clear skin. Resident #18's Care Plan with an initiated date of 03/08/2018 documented, .I have an ADL [activities of daily living] self-care performance deficit related to decreased mobility and dementia progression .I am dependent on staff for bathing .I require dependent assistance with personal hygiene .Report s/s [signs and/or symptoms] of hypothyroidism such as fatigue, dry skin, constipation to MD [Medical Doctor]/Practitioner .Observe/report PRN [as needed] any changes in skin status . On 01/12/2024 at 11:22 AM, the Director of Nursing (DON) was asked how often body audits are done. The DON stated, Weekly. The DON then accompanied the Surveyor to Resident #18's room to observe Resident #18's skin. The Surveyor asked if the resident was getting any treatment for the dry scaly red skin. The DON responded that she thought the resident had a treatment previously which may have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure physician's orders for cleaning the BiPAP (bilevel positive airway pressure) mask and machine were followed for 1 (Resident #16) of 1 sampled resident and an oxygen humidifier bottle was adequately filled with water and deemed safe for administration for 1 (Resident #52) of 1 sampled resident. The findings are: 1. Resident #16 had a diagnosis of Obstructive Sleep Apnea. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/23 documented a Brief Interview Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) and had a non-invasive mechanical ventilator (CPAP (continuous positive airway pressure)/BiPAP). a. A Physicians Order dated 3/23/23 noted clean BIPAP water tank & Mask with soap and water, wipe down external surface of machine, mask and tubing, allow to air dry not in direct sunlight every day shift and every 24 hours as needed . b. A Care Plan initiated 5/26/23 documented, .Clean bipap as ordered . prefers to keep mask on side table and does not like to keep mask in bag . c. A Care Plan initiated 11/17/21 documented, .has risk for altered respiratory status/difficulty breathing r/t [related to] sleep apnea . Clean bipap as ordered . prefers to keep mask on side table and does not like to keep mask in bag . d. On 01/08/24 at 02:33 PM, Resident #16 was lying in bed awake, a BIPAP mask was at bedside uncontained, resting inside of an open drawer on top of personal items, with no barrier. The Surveyor asked Resident #16 if he put the mask on and off by himself. Resident #16 stated, Yes. e. On 01/09/24 at 11:36 AM, Resident #16 was ambulating from the bathroom back to the bed after filling a water jug in the bathroom. The BIPAP mask remained uncontained and resting in the opened drawer of the nightstand. It was open to air and resting on objects and personal toiletries in the drawer. f. On 01/09/24 at 03:12 PM, Resident #16 was lying awake in bed watching TV. The BIPAP mask remained uncontained sitting on top of items in the opened drawer. The Surveyor asked Resident #16 if there was a bag to put the mask in. Resident #16 stated, They gave me one., as he sat up to find a plastic baggie in the drawer dated 10/26/23. Resident #16 placed the BIPAP mask in the bag and sat it back in the opened drawer. g. On 01/10/24 at 04:20 PM, Resident #16 was lying in bed awake wearing his BIPAP mask. The Surveyor asked Resident #16 if anyone had washed or cleaned the mask and machine today, yesterday, or any time during the week. Resident #16 stated, No. The Surveyor asked how long it had been since anyone had cleaned his BIPAP mask, tubing, and machine. Resident #16 stated, It's been about 2 weeks. h. On 01/11/24 at 09:34 AM, Resident #16 was out of the room. The BIPAP mask was lying on top of personal items in the drawer uncontained. There appeared to be specks of white particles on the clear section of the mask. At 9:57 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 to accompany the Surveyor into Resident #16's room. The Surveyor asked CNA #1 who was responsible for cleaning the BiPAP mask and equipment. CNA #1 stated, I really couldn't tell you. I hate to lie. CNA #2 entered Resident #16's room. The Surveyor asked how often the BiPAP mask and equipment were supposed to be cleaned. CNA #2 stated, I'd have to ask the nurse. The Surveyor asked why it was important to keep the BIPAP mask and machine clean. CNA #2 stated, Infection control, bacteria. The Surveyor asked what could happen if the mask and tubing was not cleaned regularly. CNA #2 stated, It could make them sick, or expose them to bad germs and bacteria. Resident #16 entered the room and sat on the edge of the bed. The Surveyor asked Resident #16 when the last time the mask and machine were cleaned. Resident #16 stated, It's been about two weeks. CNA #2 stated, Sometimes residents clean their own. The Surveyor asked Resident #16 if he cleaned his own BIPAP mask and equipment. Resident #16 stated, No. The Surveyor asked Resident #16 who normally cleans his mask and machine. Resident #16 stated, [Name]. CNA #2 stated, [Name] is the nurse on the three to eleven shift. i. On 01/11/24 at 11:09 AM, the Surveyor accompanied Registered Nurse (RN) #1 to Resident #16's room and asked how often his BIPAP mask and equipment were cleaned. RN #1 stated, His mask is wiped out every shift and air dried with vinegar and water. The Surveyor asked who does the cleaning. RN #1 stated, The day shift nurse does his. The Surveyor asked when was the last time Resident #16's mask and machine were cleaned. RN #1 stated, Yesterday. Resident #16 was standing in the room and added, They cleaned it today. The Surveyor asked who had cleaned it, and when it was cleaned. Resident #16 stated, [Name] the CNA, after you left. The Surveyor asked RN #1 who normally cleans Resident #16's mask and machine, and if CNAs are assigned that task. RN #1 stated, Usually the nurse cleans it. I'm not sure what [Name] wiped it out with this morning, but it's usually us. The Surveyor asked what could happen if the mask and machine were not cleaned on a regular basis. RN #1 stated, He can get a bad infection, bacteria, or mold. The Surveyor asked where the mask should be stored. RN #1 stated, It should be in a bag, but he uses it quite often, so we have a hard time keeping it covered. The Surveyor asked why it was important to keep it contained. RN #1 stated, So nothing can get transmitted on to him that could make him sick. Infection Control. 2. Resident #52 had a Diagnosis of Acute and Chronic Respiratory Failure, Unspecified whether with Hypoxia or Hypercapnia. A 5-Day MDS with an ARD of 12/4/23 documented a BIMS score of 8 (8-12 indicates moderate cognitive impairment) and received oxygen therapy. a. A Physician's Order dated 3/29/23 documented, .May have Oxygen 2 LPM (Liters per Minute) Via N/C (nasal cannula) as needed every shift for Oxygen Therapy . b. A Care Plan initiated 12/14/22 documented, .has altered respiratory status/difficulty breathing r/t COPD [Chronic Obstructive Pulmonary Disease] .Administer medication/treatment as ordered . Observe for s/sx [signs and symptoms] of respiratory distress and report to MD [Medical Doctor]/Nurse PRN [as needed] .O2 via nasal cannula as ordered . c. On 01/08/24 at 11:56 AM, Resident #52 was lying in bed with oxygen at 2 liters via nasal cannula. The humidifier bottle was dated 1/3/24 and was empty and swollen. The tubing was not dated. There was an empty baggie hanging from the tubing dated 1/3/23. d. On 01/09/24 at 08:46 AM, Resident #52 was lying in bed awake with oxygen at 2 liters via nasal cannula. The humidifier bottle remained empty and swollen with a date of 1/3/24. Tubing remained undated, and empty baggie dated 1/3/23 remained hanging from the tubing. e. On 01/09/24 at 02:26 PM, Resident # 52 was lying in bed asleep with oxygen at 2 liters via nasal cannula. The Humidifier bottle remained empty and swollen with a date of 1/3/24. Tubing remained undated, and empty baggie dated 1/3/23 remained hanging from tubing. f. On 01/10/24 at 01:03 PM, the Surveyor asked the Assistant Director of Nursing (ADON) if residents receiving oxygen via nasal cannula should have humidifier bottles with water in them. The ADON stated, They should, and yes, they should have water in them. The Surveyor asked how often humidifier bottles should be checked. The ADON stated, Daily, and every shift. Also, the departmentals when they are doing rounds in the morning The Surveyor asked why it was important to make sure humidifiers were checked and half full of water. The ADON stated, To make sure the nasal passages do not dry out. The Surveyor asked what could happen to residents if humidifiers are not checked or filled with water. The ADON stated, Nosebleeds from dried mucosa. g. On 01/10/24 01:33 PM, the ADON provided a policy titled, Respiratory Care, which documented, Policy .The facility will ensure residents that need respiratory care, including tracheostomy care and suctioning, will be provided consistent with professional standards of care . h. On 01/10/24 at 01:33 PM, the ADON provided documentation titled, Procedure Guidelines 10-12 Administering Oxygen by Nasal Cannula, which documented under section Equipment, .Humidifier filled with sterile water . and under Performance phase, .1. Make sure the humidifier bottle is filled to the appropriate mark .

Based on observation and record review, the facility failed to remove expired medications and note open dates on labels of opened multi-dose containers. The findings are: On 01/10/24 at 1:18 PM, while checking the medication storage room with Licensed Practical Nurse (LPN) #1, the Surveyor observed an open pint of ice cream with no open date and no resident name in the freezer section of the medication only refrigerator located under the counter in the medication room. The Surveyor asked who it belonged to. LPN #1 stated, I don't know, usually the residents have their name on theirs. The Medication refrigerator contained 6 prefilled influenza syringes with an expiration date of June 2023. On the left side of the countertop of the medication room was an open box of Budesonide inhalation solution containing 3 plastic ampules in an open foil envelope, did not contain an opened date. On a shelf on the wall to the left of the door was a plastic container containing the following expired pen injector needles 30mm (millimeter), 5mm, one - with an expiration date of May 2021, two- with an expiration date of June 2021, and 14 with an expiration date of December 2021, when the Surveyor asked if they were being used, LPN #1 stated, I don't use them because I don't have any residents who use a pen for their insulin. At 2:20 PM, while checking Medication Cart #2 there was a bottle of Latanoprost eyedrops (used for glaucoma) with an open date of 11/23/2023 and an unopened bottle which was not refrigerated. The box of Budesonide inhalation solution had instructions on the side of the container which documented, foil pouch must be dated and must be used within 2 weeks. LPN #1 was asked why is it important to for expired medications to not be used and for containers to be dated when opened? LPN #1 said, the medication could not be as effective. The facility Medication Storage Policy provided by the Administrator at 1/11/2024 at 7:50 AM documented, .Outdated .medications are immediately removed from inventory and disposed of according to procedure for medication disposal. Refrigerated medications are kept .separate from food .and employees lunches . ophthalmic, once opened, requires an expiration date shorter than the manufactures expiration date to insure medication purity and potency .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for F561 Self Determination; F645 Preadmission Screening and Resident Review (PASRR) evaluation for Mental Disorder and Intellectual Disorder, F 657 Care Plan Timing & Revision and F 812 Food Procurement, Store/Prepare/Serve and F 689 Free from Accidents/Hazards which resulted in Immediate Jeopardy. These failed practices had the potential to affect 66 residents as identified on the Resident Matrix provided by the Administrator on 01/08/24 at 09:35 am. The findings are: 1. A Recertification survey was conducted on 01/12/24 at the facility. During this survey, F561 was cited for the facility ' s failure to ensure Resident #222 received the lunch meal that he had ordered that morning. (01/08/24) A review of the facility's Plan of Correction (POC), with a correction date of 11/13/22 indicated: F561 Self-Determination Step #1 Corrective Action: 10/13/22, upon notification of deficient practice, the social/admission coordinator visited with resident #10 about compatibility issues with their current roommate, at this time, resident #10 states that things are going good with their roommate and that resident was fine. Resident was encouraged to notify the social/admissions coordinator if they were unhappy. Offered to move resident at this time and resident declined. 10/17/022 Social/admissions coordinator visited with resident #10 again today and resident stated again that everything is fine and that I am fine. At this time resident was offered to move to another room with a better suited roommate and they declined stating they were fine. Resident was then asked if they wanted to move back to the room they were in previously when it becomes available and resident stated no, I like it where I am and I don't want to move. On 10/18/2022 Resident #9 was moved to another room with a better suited roommate. Step #2 Identification of others with the potential to be affected: Resident #10 was affected from a sample of 19 residents No additional negative findings were observed at this time. Step #3 To ensure deficient practice does not recur: On 10/14/2022 All staff were in-serviced by the Administrator on F561 Self Determination reporting to ensure that the proper support and accommodation of resident goals, preferences and personal choices are being met. 10/14/2022 The social/admissions coordinator was in-serviced by the Administrator on utilizing the Grievance Log Monitoring Tool. Step #4 Monitoring: The social/admissions coordinator will review the Grievance Log and record results on the grievance log monitoring tool for unmet self-determination, needs or preferences 1 time a day, 5 times a week for 5 weeks or until compliance is verified by OLTC [Office of Long Term Care], Social/Admissions coordinator or designee will make rounds prior to care plan meetings to speak with residents to ensure needs are being met. Step #5: QA [Quality Assurance] The social/admissions coordinator will report the deficiencies and the corrections to the quarterly QA committee for further review and recommendations. 2. A Recertification survey was conducted on 01/12/24 at the facility. During this survey F645 was cited for facility's failure to ensure The Preadmission Screening and Resident Review (PASRR) evaluation process was completed for Resident #28. A review of the facility's Plan of Correction, with a correction date of 11/13/22 indicated: Step #1: Corrective Action Upon notification of the deficient practice of failure to ensure the Preadmission Screening and Resident Review (PASRR) evaluation process was completed in accordance with the state PASRR process for resident #1, the business office manager immediately instructed DON [Director of Nurses] to complete a 700 series for resident #1. 700 series was completed on 10/12/2022 by the DON and verified by the Administrator on 10/12/2022. Step #2: Identification of others with the potential to be affected: Resident #1 was affected from a sample of 11 residents who had a diagnosis of a serious mental disorder and/or intellectual disability. No additional negative findings were observed a this time. 10/12/2022 DON completed an audit of current residents that have transferred from other states, including border areas to ensure they have received authorization for the Office of Long Term Care [OLTC] Medical Needs Determination section prior to admission to our facility audit was verified by the Administrator. There were no additional negative findings observed at this time. Step #3: To ensure deficient practice does no recur: On 10/14/2022 the business office manager, assistant business office manager, MDS [Minimum Data Set] coordinator, Social/Admissions Coordinator, DON and ADON [Assistant Director of Nursing] were in-serviced by the Administrator on Procedures For Determination of Medical Need for Nursing Home Services and Bock PASRR training guide. Step #4: Monitoring: The Business office manager and the social/admissions coordinator will audit each resident's PASRR Screen at the time of admission on e time a day, five times a week for four weeks or until compliance is verified by OLTC. Step #5: QA Business office manager and Social/Admissions Coordinator will present all findings of the audits and deficiencies to the quarterly QA committee for further review and recommendations. 3. A Recertification survey was conducted on 01/12/24 at the facility. During this survey F657 was cited for the facility's failure to review and revise Resident #3's care plan in a timely manner. A review of the facility's Plan of Correction, with a correction date of 11/13/22 indicated: Step #1: Corrective Action: On 10/13/2022 Upon notification of the deficient practice of failure to ensure a comprehensive plan of care was revised for a resident who had a stage 3 pressure ulcer, to ensure that residents individual needs were met and maintained for resident #16, on 10/13/2022 the MDS coordinator revised plan of care to include actual impairment to skin integrity of stage III to left outer ankle, revised care plan verified by the Administrator. On 10/14/2022 MDS Coordinator did an audit, that was verified by the DON of current residents that are receiving wound care treatments to ensure wound care is being care planned. There were no additional negative findings observed at this time. Step #2: Identification of other with the potential to be affected: Resident #16 was affected from a sample of 4 residents who had pressure ulcers. On 10/13/2022 No additional negative findings were observed at this time. Step #3: To ensure deficient practice does not recur: On 10/14/2022 the MDS Coordinator, DON and ADON were in-serviced by the Administrator on F657 that Comprehensive Care Plans must include all wound care treatments to ensure that residents' individual needs are being met and maintained. Step #4: Monitoring: The MDS Coordinator and DON will audit and monitor for treatment orders that need to be initiated or revised in the resident's plan of care on time a day, five times a week for five weeks or until comp0liance is verified by OLTC. Step #5: QA: The MDS Coordinator will present all findings of the audits to the quarterly QA committee for further review and recommendations. 4. A Recertification survey was conducted on 01/12/24 at the facility. During this survey F689 was cited for the facility's failure to ensure fall interventions were implemented for Resident #3; and failed to ensure staff did not use defective mechanical lifts during transferring of residents. A review of the facility's Plan of Correction, with a correction date of 11/13/22 indicated: F689: Water Temperatures Step #1: Corrective Action On 10/10/2022 upon notification of the deficient practice of failure to ensure residents were not exposed to unsafe water temperatures. On 10/10/2022 Maintenance Supervisor immediately reported findings to Administrator and turned down hot water heater to a temperature that is consistent with safe temperatures as listed in F689 table 1 Time and Temperature Relationship to Serious Burns. On 10/13/2022 There were no negative findings as a result of water temperatures observed at this time. Step #2: Identification of others with the potential to be affected: Based on observation and interview, the facility failed to ensure residents were not exposed to unsafe water temperatures for 16 sample residents who were capable of reaching faucets. On 10/10/2022 Staff interviewed 25 residents for any grievances, complaints or skin concerns r/t water temperatures. On 10/10/2022 No additional negative findings were observed through the interview process at this time, verified by the Administrator. Step #3: To ensure deficient practice does not recur: On 10/10/2022 the Maintenance Supervisor was in-serviced by the Administrator on F689 Water Temperatures to ensure that resident are not exposed to unsafe water temperatures that may put them at risk for burns. Step #4: Monitoring: The Maintenance Supervisor will check water temperatures in 3 random residents' rooms and the shower room one time a day, five times a week for five weeks or until compliance is verified by OLTC at which time he will continue with the ongoing weekly hot water temperature checks. Step #5: QA: The Maintenance Supervisor will present all findings of the audits and deficiencies to the quarterly QA committee for further review and recommendations. F689: Fire Safety Equipment Step #1: Corrective Action On 10/12/2022 Upon notification of the deficient practice of failure to ensure fire safety equipment was located in the smoking areas to protect residents from the potential of injury related to fire hazards. The DON immediately reported findings to the Administrator. On 10/12/2022 Maintenance supervisor mounted a fire blanket and a fire extinguisher to the wall that is approximately 13 feet from the resident's smoking area located at the end of 200 hall. Placement was verified by the Administrator. 10/12/2022 DON audited the previous 6 months for resident that may have received burns with no negative findings observed at this time, audit verified by the Administrator. On 10/12/2022 There were no negative findings as a results of failure to ensure fire safety equipment was located in the smoking areas to protect residents from the potential of injury related to fire hazards. Step #2: Identification of others with the potential to be affected: Based on observation and interview, the facility failed to ensure fire safety equipment was located in the smoking areas to protect residents from the potential of injury related to fire hazards that had the potential to affect 14 residents who smoked in the smoking area. On 10/12/2022 No additional negative findings were observed at this time. Step #3: To ensure deficient practice does not recur: On 10/10/2022 the Maintenance Supervisor was in-serviced by the Administrator on failure to ensure fire safety equipment was located in the smoking areas to protect residents from the potential of injury related to fire hazards. We reviewed F689 Free of Accident Hazards/Supervision/Devices. 10/12/2022 Fire blanket and fire extinguisher were mounted on wall approximately 13 feet from the resident's smoking area. 10/19/2022 Maintenance Supervisor conducted an in-service with staff on Smokers' Safety with an emphasis on location of fire safety equipment added to the smoking area, proper use of fire aprons, fire blankets and fire extinguisher. Step #4: Monitoring: The Maintenance Supervisor added the new fire extinguisher to the Fire Extinguisher Maintenance Log which is an ongoing monthly monitoring system to ensure they are in place, charged and ready for use. The monitoring is then added to the Master Log of Life Safety Code Testing and Inspections. Step #5: QA: The Maintenance Supervisor will present all findings of the monitoring and deficiencies to the quarterly QA committee for further review and recommendations. 5. A Recertification survey was conducted on 01/12/24 at the facility. During this survey F812 was cited for the facility's failure to ensure food in the refrigerator was dated, labeled, and stored properly in sealed packaging to prevent growth of bacteria and the dishes were properly cleaned and sanitized. A review of the facility's Plan of Correction, with a correction date of 11/13/22 indicated: F812 Food Procurement, Store/Prepare/Serve-Sanitary Step #1 Corrective Action: on 10/10/2022 upon notification of deficient practice the Dietary Manager corrected the following as verified by the Administrator: The four cans of chicken noodle soup were verified by the vendors invoice and dated with the received by date. The one can of rotel was verified by the vendors invoice and dated with the received by date. The one open box of chocolate syrup with no received or opened by date was discarded. The red wine vinegar with a date of 7/15/20 was discarded. The white distilled vinegar dated7/21/22 with no open date was discarded. The open box of chips that had no received date was verified by the vendors invoice and dated with the received by date. The open box of BBQ packets that had no received date was verified by the vendors invoice and dated with the received by date. The open box of Honey packets that had no received date was verified by the vendors invoice and dated with the received by date. The one plastic jar of Italian dressing with no opened by date was discarded. The open plastic jar of mayonnaise with no open date was discarded. The resealable plastic bag of diced chicken dated 9/23/22 that was not sealed was discarded. Open box with bag chicken patties with ice crystals and white patches on patties not tied or seal closed were discarded. Open box with bag dinner rolls with ice crystals not tied or seal closed were discarded. Open box with cinnamon rolls not tied or seal closed were discarded. Plastic container of Ground Cumin dated 7/31/19 was discarded. Plastic container of All Spice dated 2/9/18 was discarded. Plastic container of [NAME] Pepper dated 10/06/20 was discarded. Plastic container of Rubbed Sage dated 11/17/20 was discarded. Plastic container of Lemon Pepper dated 3/13/18 was discarded. The purple liquid in the two plastic bottles with GA on the cap had no date or label in the refrigerator on the woman's secure unit was discarded. The plastic bottle of cranberry juice with no date or name in the refrigerator on the women's secure unit was discarded. The pitcher of water dated 9/6/22 in the refrigerator on the men's secure unit was emptied and taken to the kitchen to be washed. The pitcher of apple juice dated 9/19/22 in the refrigerator on the men's secure unit was emptied and taken to the kitchen to be washed. The 6 cans of soda with no name or date in the refrigerator on the men's secure unit were discarded. Step #2: Identification of other with the potential of being affected: On 10/10/2022 There were a total of 62 residents who received meals from the kitchen that had the potential to be affected, on 10/10/2022 residents were assessed, and no negative findings noted. Step #3: To ensure deficient practice does not recur: On 10/10/2022 the Dietary Manager in-serviced the dietary staff on making sure all food items are labeled with a received by and opened by date, watching for expired food items, and when taking items out of the freezer or refrigerator to ensure the bags are tied tightly. On 10/10/2022 the Dietary Manager in-serviced the dietary staff on Receiving and Storage. On 10/10/2022 All staff were in-serviced by the Dietary Manager on Storage of Food and Beverages brought by visitors. Step #4: Monitoring: Dietary Manager will monitor for food opened and not sealed or dated one time a day, five times a week for five weeks or until compliance is verified by OLTC. The Dietary Manager will monitor for expired food/spices one time a day, five times a week for five weeks or until compliance is verified by OLTC. The Dietary Manager will monitor refrigerators on the secure units for expired and unlabeled items one time a day, five times a week for five weeks or until compliance is verified by OLTC. Step #5 QA: Dietary Manager will present all findings, deficiencies, and corrections to the quarterly QA committee for further review and recommendations. 6. On 01/12/24 at 12:30 pm, the Administrator was asked, Is there a mechanism for staff to report quality concerns to the QAA committee? The Administrator stated, Staff can report to any department head or any of the QAPI members at any time there is a concern. The Administrator was asked how the facility decides which issues to work on. The Administrator stated, We discuss among members and work with each department to come up with a solution. The Administrator was asked how the facility knows that corrective action has been implemented, is effective, and improvement is occurring. The Administrator stated, The QAPI committee monitors the plan until it is corrected. If the plan isn't corrected, we continue to work on it until it improves. 7. A Quality Assurance & Performance Improvement Plan provided by the Administrator on 01/08/23 upon entry documented .Our QAPI plan addresses: Clinical Care .internal monitors for falls .Governance and Leadership .Quality topics are covered at general orientation and with on-going training .Caregivers will become and remain proficient .through training and on-going use in day to day operations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 01/10/24 at 02:43 PM, the Surveyor accompanied Housekeeper (HK) #1 to the bathroom shared by rooms [ROOM NUMBERS]. HK #1 took her bare hand and scraped the black substance from around the right faucet on the sink. The Surveyor observed a black colored liquid substance on the index finger of HK #1's right hand, and under the index fingernail as she proceeded to push the paper towel dispenser to get a towel to wipe her hand. The Surveyor asked HK #1 if there were any issues with touching the paper towel dispenser with dirty hands. HK #1 stated, Oh, I guess I shouldn't have done that. HK #1 then left the room without sanitizing, or washing her hands, stating she would come back right away and wipe the sink and clean the toilet which had brown streaks visible on the inside of the toilet bowl. On 01/10/24 at 3:21 PM, the Surveyor accompanied HK #2 to the shared bathroom of rooms [ROOM NUMBERS] and asked if gloves were worn when cleaning resident rooms. HK #2 stated, Yes, we normally do. The Surveyor noticed HK #2 was not wearing gloves. HK #1 was wearing gloves. The Surveyor asked why HK #1 was wearing gloves, and HK #2 was not. HK #2 answered, Well, we usually wear them. The Surveyor asked HK #2 if there were any issues with scraping black substance from the faucet with a bare hand, wiping it off with a paper towel, and leaving the room without washing or sanitizing, and why washing hands and sanitizing was important? HK #2 stated, Yes, that is a problem. Passing on germs or mold to residents when you touch paper towel dispensers, anything in the room, doorknobs, other residents, or anything a resident touches. 3. On 01/11/24 at 09:26 AM, the Surveyor observed oxygen tubing with a nasal cannula attached, under the door outside of Resident #53's room and extending out into the hallway. The oxygen tubing was attached to an oxygen concentrator that was turned on in Resident #53's. CNA #4 was observed walking past the room. Licensed Practical Nurse (LPN) #1 was passing morning medications on the hall 2 doors down. The Surveyor asked LPN #1 if it was sanitary to leave oxygen tubing with a nasal cannula lying on the floor. LPN #1 stated, No Ma'am. The Surveyor asked if she saw any issues with the oxygen tubing and the cannula being left on the floor in the hall. LPN #1 stated, Yes Ma'am, I do. It is contaminated now. I will get a new one and put it in a bag. The Surveyor asked what could happen to residents if oxygen tubing was not properly stored and contained. LPN #1 stated, It can cause upper respiratory infections and or pneumonia. 4. On 01/11/24 at 09:28 AM, observed 2 empty urine bottles hanging over the trash can between Resident #56's bed and the wall. The Surveyor asked LPN #1 if universal precautions were being followed by leaving empty urinals hanging from the trash can. LPN #1 stated, No, but sometimes it is the resident's preference if they request to leave it there, and its care planned. The Surveyor asked what could potentially happen if urine bottles are stored hanging from the trash can. LPN #1 stated, Potential contamination from the trash can, or urine could spill and cause smells and bacteria to grow. The Surveyor asked LPN #1 who was responsible for keeping urine bottles stored where they could not cause potential contamination. LPN #1 stated, Anybody who notices them out of place. Usually it's the CNAs. The Surveyor asked why Resident #56's had 3 urinals, one in the bathroom and 2 on the trash can. LPN #1 stated, I'm not sure. e. On 01/11/24 at 09:30 AM, Resident #56's Care Plan did not contain documentation or interventions related to the resident's preference to keep urine bottles in the room hanging over the edge of the trash can. f. On 01/11/24 at 09:40 AM, LPN#1 stopped the Surveyor on the 300 Hall and stated, I told the MDS person about the urine bottles and she is going to make sure it's added to [Resident #56's] Care Plan. Based on observation, record review, and interview, the facility failed to ensure infection control measures, including handwashing and/or glove changes between dirty and clean tasks; and residents were clean of feces after incontinent care for 1 (Resident #33) of 1 sample resident; the oxygen nasal cannula was contained for 1 (Resident #53) of 1 sampled resident; and urinals were not hanging on trash cans for 1 (Resident #56) of 1 sampled resident; and housekeeping staff performed hand hygiene/or used gloves to remove a wet black substance from the environment to prevent the spread of infection and or transmission of diseases. The findings are: 1. A review of an admission Record indicated the facility admitted Resident #33 with a diagnosis of dementia. The Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The resident was dependent for all activities of daily living (ADLs). Review of Resident #33's Care Plan, revised on 6/16/2021, revealed the resident had incontinence r/t (related to) dementia with behaviors and psychosis. Interventions included uses disposable briefs initiated on 6/16/2021; and an intervention initiated on 6/16/2021 to clean peri-area with each incontinence episode. Review of the facility policy, Peri-Care, dated May 2013, indicated, Prepare your clean area with 2 towels, 12-20 wipes and 3 pairs of gloves. Have the wipes pulled out and placed on your clean field. You need 3 pairs of gloves because you change your gloves from front to back and anytime there is a chance of cross contamination, or heavily soiled gloves. Wash your hands before you apply gloves and after you have completed care. Use 1 wipe per 1 swipe. Wipe abdomen, wipe front, sides, thighs in a downward motion. Dry area after cleansing with wipes. change gloves then turn resident, wipe top of hips, center of buttocks and each side, wipe the thighs in a downward motion. Take your soiled gloves off and wash your hands before you leave the room. Review of the facility policy, Hand Hygiene, no date, indicated, Hand hygiene is any method that removes or destroys microorganisms on hands that includes Handwashing and Alcohol Based Hand Rubs. Perform hand hygiene when: before having direct contact with patients. After contact with blood, body fluids, or excretions, mucous membranes, non-intact skin, or wound dressing. After contact with patient's intact skin. If hands will be moving from a contaminated-body site to clean-body site during patient care. After contact with inanimate objects in immediate vicinity of the patient. After removing gloves. Wash hands when: hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids or if contact with spores. Review of the facility policy, Personal Protective Equipment (PPE), no date, indicated, Gloves Procedure: Wear when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin could occur. Remove gloves after contact with a patient and / or the surrounding environment. Change gloves during patient care if the hands will move from a contaminated body site to a clean body-site. 01/09/2024 at 9:51 AM, Nursing Assistant (NA) #1 was observed to enter Resident #33's room and pulled a pair of gloves from her scrub top pocket and applied the gloves to her hands. NA #1 did not perform hand hygiene before applying gloves. On 01/09/2024 at 9:55 AM, Certified Nursing Assistant (CNA) #6 entered Resident #33's room with a mechanical lift. Observed NA #1 with gloved hands touching own body and placing gloved hands on hips. On 01/09/2024 at 9:59 AM, observed CNA #6 pull gloves from scrub top pocket and apply to hands. CNA #6 did not perform hand hygiene before applying gloves. CNA #6 and NA #1 assisted Resident #33 to a sitting position in the specialized chair. On 01/09/2024 at 10:00 AM, CNA #6 left the legs apart on the mechanical lift and did not lock the wheels on the specialized chair. CNA #6 placed the lift under Resident #33's specialized chair and assisted Resident #33 up from the chair and then lowered back into the chair. The locks on the specialized chair were not locked. On 01/09/2024 at 10:01 AM, CNA #6 and NA #1 unhooked the lift pad from the lift hooks. The head of the specialized chair was placed in a downward position so the resident was lying flat in the chair. CNA #6 and NA #1 attempted to adjust the lift pad under Resident #33. On 01/09/2024 at 10:04 AM, NA #1 removed her gloves and left the room. NA #1 did not perform hand hygiene after removing the gloves and before leaving the room. On 01/09/2024 at 10:06 AM, observed CNA #6 with the same gloved hands, assist Resident #33's roommate behind the privacy curtain. CNA #6 did not change gloves or perform hand hygiene. On 01/09/2024 at 10:08 AM, CNA #6 moved the mechanical lift under Resident #33's specialized chair. NA #1 entered the room with a glove on the left hand and applied a glove to the right hand. CNA #6 and NA #1 hooked the lift pad to the hooks on the mechanical lift. On 01/09/2024 at 10:09 AM, observed CNA #6 lift Resident #33 from the specialized chair using the mechanical lift. On 01/09/2024 at 10:10 AM, CNA #6 lowered Resident #33 to the bed. CNA #6 unhooked the lift pad from the hooks on the lift. CNA #6 did not change gloves or perform hand hygiene. On 01/09/2024 at 10:12 AM, CNA #6 and NA #1 did not change gloves and did not perform hand hygiene. CNA #6 started removing Resident #33's pants. The outside of Resident #33's pants was wet under the left buttock area. CNA #6 rolled Resident #33 over and finished pulling Resident #33's pants off. CNA #6 unfastened Resident #33's brief. Resident #33 had had a bowel movement. CNA #6 used a premoistened wet wipe and swiped back to front on the inside of Resident #33's left leg then discarded. CNA #6 used a premoistened wet wipe and swiped back to front on the inside of Resident #33's right leg then discarded. CNA #6 used a premoistened wet wipe and swiped back to front across Resident #33's pubic bone area then discarded. CNA #6 rolled Resident #33 over on her side toward the wall. There was a dried black/brown substance on Resident #33's right buttock. NA #1 used a premoistened wet wipe and swiped across Resident #33's left buttock and discarded. NA #1 used a premoistened wet wipe and swiped across Resident #33's right buttock and discarded. NA #1 used a premoistened wet wipe and wiped Resident #33's right buttock folded the wet wipe and wiped the right buttock again, removing the black/brown substance. NA #1 used a premoistened wet wipe and wiped the inside edge of Resident #33's buttocks. CNA #6 and NA #1 did not change gloves and did not perform hand hygiene. On 01/09/2024 at 10:15 AM, CNA #6 obtained a clean brief and placed behind Resident #33's buttocks. NA #1 positioned the clean brief under Resident #33. CNA #6 pulled the clean brief between Resident #33's legs and started to secure the brief. CNA #6 and NA #1 were asked if they were done. CNA #6 and NA #1 both replied, Yes. The Surveyor asked if they could use a premoistened wet wipe and wipe between Resident #33's buttocks. On 01/09/2024 at 10:16 AM, NA #1 used a premoistened wet wipe and using one swipe, swiped between Resident #33's buttocks with a return of a brown substance. NA #1 was asked if the resident was clean. NA #1 replied, No. CNA #6 instructed the NA #1 to wipe Resident #33 again. NA #1 used a premoistened wet wipe and wiped in between Resident #33's buttocks until clean using one swipe per wipe and discarding. CNA #6 and NA #1did not change gloves and did not perform hand hygiene. On 01/09/2024 at 10:17 AM, CNA #6 then applied clean pants on Resident #33 using the same dirty gloves used to complete incontinent care. CNA #6 removed her gloves and finished pulling Resident #33's pants up. On 01/09/24 at 10:19 AM, CNA #6 used alcohol gel to clean her hands. NA #1 removed her gloves and did not perform hand hygiene. On 01/09/2024 at 10:22 AM, NA #1 exited the room and did not perform hand hygiene before exiting the room. On 01/09/2024 at 10:25 AM, CNA #6 was asked how perineal (peri) care is performed on a resident. CNA #6 stated, One wipe, one swipe. CNA #6 was asked what direction. CNA #6 stated, Front to back. CNA #6 was asked why peri care should be performed on a resident in the direction from front to back. CNA #6 stated, To prevent infection. CNA #6 was asked why all feces should be cleaned from residents after an incontinent episode. CNA #6 stated, To prevent infections and sores. CNA #6 was asked when should hand hygiene be performed. CNA #6 stated, Before and after peri care. CNA #6 was asked why did you use gloves from your scrub top pocket? CNA #6 stated, I put them in my pockets and didn't realize it. CNA #6 was asked when gloves should be changed. CNA #6 stated, Before and after care. CNA #6 was asked do gloves take the place of hand hygiene. CNA #6 stated, No. On 1/11/2024 at 3:15 PM, the Infection Control Preventionist (ICP) was asked when hand hygiene should be performed and when gloves should be changed. The ICP verbally confirmed that staff should perform hand hygiene after taking gloves off, before, during, and after care, and that sanitizing hands was acceptable, and that gloves should be change when they get dirty and should be changed between clean and dirty tasks. The ICP was asked why gloves should be changed between clean and dirty tasks. The ICP stated, For the prevention of contamination. The ICP was asked why should hand hygiene be performed. The ICP stated, For the prevention of contamination. The ICP was asked why should staff ensure residents are clean of feces after incontinent care. The ICP stated, Because it could cause urinary tract infections, and skin damage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 01/08/24 at 11:27 AM, the exit door at the end of the 300 Hall had a draft, and the hinge mechanism at the top of the door was missing 2 out of 3 bolts. On 01/09/24 at 12:28 PM, the exit door at the end of the 300 Hall remained the same with 2 out of 3 bolts missing from the hinge mechanism at the top of the door. On 01/10/24 at 02:15 PM, the Surveyor observed Rooms 401- 403 shared bathroom. There was a chrome piece of a toilet paper holder observed lying on the floor next to the toilet. There was another chrome piece attached to the wall. There was a metal square with sharp edges on the wall where the chrome piece that was lying on the floor had once been attached to hold toilet paper. On 01/10/24 at 03:10 PM, the Surveyor accompanied the Maintenance Supervisor to Rooms 401 & 403 bathroom where Housekeeper (HK) #2 was cleaning the sink, and HK #1 was mopping the floor. The Surveyor asked the Maintenance Supervisor if he knew about the toilet paper holder needing repair. He stated, I didn't know about the toilet paper holder, but I've been planning on replacing that toilet since there have been problems with it leaking and staining the floor. The Surveyor asked the Maintenance Supervisor if there were any issues with the chrome pieces left on the wall. The Maintenance Supervisor stated, Well it looks like it might need to be moved back so they don't have to reach as far to get to it. The Surveyor observed that the chrome piece was no longer lying on the floor next to the toilet. The Surveyor asked HK #1 what had happened to the chrome piece. HK #1 stated, I put it on my cart out in the hallway. On 01/10/24 at 03:40 PM, the Surveyor accompanied the Maintenance Supervisor to the end of hallway on Hall 300 where he stated he had replaced the 2 screws on the top door hinge that were missing. The Surveyor asked how long it had been that way. The Maintenance Supervisor stated, I don't really know, I've been battling with that door for a long time. We replaced the hinge, put on a new alarm, and I've replaced these screws before. I think it might have just happened. Housekeeping told me about it, and I just got it fixed today. On 01/10/24 at 08:58 AM, the Assistant Director of Nursing (ADON) provided documentation entitled Record of Inservice dated 8/17/23 that documented on Page 1 under Section 1: Introduction, .Recognize potential hazards in residential, home, and community settings . and on page 8, Section 3: Conclusion, second paragraph, under Work Place Safety: The Basics, .Employees at all levels of the organization have responsibility for the safety and well-being of the individuals they serve and themselves . On 01/11/24 at 07:59 AM, the Administrator provided documentation entitled, Healthcare Services Group that documented, .No Food, Drinks, Dangerous Object on HK Cart . and under required Supplies/Tools: .Gloves . and under 7-step (washroom Cleaning), .Clean Commode/Base, Clean Skink/Pipes, Sweep, Damp Mop . On 01/11/24 at 07:50 AM, the Administrator informed the Surveyor that there was no facility policy on Maintenance, and stated, We follow the Life Safety Book. Based on observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for residents and staff on halls 300, 400, and 600. The findings are: A review of the facility's undated policy titled, Summary of Residents' [NAME] of Rights, indicated, The facility must ensure and protect the human right of every individual in residence and to that end will provide a clean healthy attractive environment wherein the resident will receive treatment without discrimination as to race, color, religion, sex, national origin, disability or source of payment. On 01/08/2024 at 12:10 PM, a strong odor of ammonia and urine was noted upon entrance into the 600 Hall secure unit. The Dayroom on the 600 Hall Secure Unit contained two vinyl brown couches with torn vinyl on the arms and seams; a nightstand with the top peeling; a brown chair with peeling vinyl exposing the foam; and a plastic over the bed table that was ripped six inches and exposing a hard plastic pointed area. Thirty six inches of baseboard was pulled away from the wall exposing the drywall, rocks, and possible bricks between the bathroom door and the area under the TV. Another baseboard, 36 inches in length, was pulled away from the wall behind a brown chair in the dayroom exposing drywall and bricks. The window seal in the dayroom had dead bugs and/or moths. A broken tile was noted outside of room [ROOM NUMBER], the corners of 4 tiles were 12 centimeters in diameter, and 0.5 centimeters deep. On 01/08/2024 at 12:26 PM, in room [ROOM NUMBER] a cloth recliner had a brown, rust stain on the seat and a yellow stain on the floor near the recliner. The room had a strong odor of ammonia and urine. On 01/08/2024 at 12:29 PM, in room [ROOM NUMBER], there was a cloth recliner. The room had a strong odor of ammonia and urine. On 01/09/2024 at 10:50 AM, upon entry onto the men's unit, a strong odor of ammonia and urine was noted. Certified Nursing Assistant (CNA) #11 was asked what the smell was on the unit. CNA #11 said a resident just had a BM (Bowel Movement). CNA #11 was asked what is the ammonia/urine smell? CNA #11 said it may be the cleaner they are using. The smell was stronger in the dayroom than at the end of the hall. CNA #11 stated, They think it's the furniture, they ordered new furniture, and it was supposed to be here last week, but now it's supposed to be here this week. On 01/10/24 at 09:03 AM, the Maintenance Logs dated 12/26/23 to 01/10/24 were reviewed with no documentation noted for the odors on the 500 or 600 secure units or the concerns observed on the 500 Hall secure unit.

Based on observation, interview and record review, the facility failed to ensure food items were labeled, dated, stored properly in sealed packaging, and the dishes were properly cleaned and sanitized, to prevent growth of bacteria, for residents who receive meals from 1 of 1 kitchen. This failed practice had the potential to affect 66 residents who receive meals from the kitchen, according to list provided by the Dietary Manager on 1/11/2024 at 3:30 p.m. The findings are: A review of the facility policy, Receiving and Storage, dated 2010, indicated all foods should be covered, labeled and dated. On 1/8/2024 at 9:55 AM, aluminum foil was observed covering the bottom shelf of the steam table. The aluminum foil was stained and had hard dried substances on it and was not clean. On 1/8/2024 at 9:57 AM, a pan of dumplings, a pan of green beans, and a pan of polish sausage was on the stove and was not covered. On 1/8/2024 at 10:00 AM, a metal cart holding clean dishes was observed in the kitchen. A metal pan with a metal rack was observed on the bottom shelf of the metal cart. The metal pan had a dried white substance in it and was not clean. On 1/8/2024 at 10:01 AM, a blue plastic rack on the bottom shelf of a metal rack containing clean dishes was observed containing bowls. The blue plastic rack had a brown dried substance and was not clean. On 01/08/24 at 10:00 AM, Dietary Employee (DE) #2 was asked what the pan on the bottom shelf of the metal rack was. DE #2 stated, It's a bread pan, it's waiting to be run through the wash. DE #2 was asked do you usually store dirty dishes with the clean dishes? DE #2 stated, Not usually, I had dirty dishes in the sink, so I stored them there. On 1/8/2024 at 10:04 AM, a package of tortilla shells with an opened date of 12/25/23 in a plastic resealable bag was not sealed. A 1/2 package of opened cream cheese in a plastic resealable bag was not sealed and did not have a date. A package of shredded cheese with an open date of 12/28/23 and a use by date of 12/26 was in a plastic resealable bag and was not sealed. A package of bologna with a date of 12/20/23 was in a plastic resealable bag that was not sealed. A package of Swiss/ American cheese with a use by date of 1/2/23 was in a plastic resealable bag was not sealed. On 01/08/2024 at 10:16 AM, there was dust and dirt observed on the ceiling and the wiring of the main refrigerator in the kitchen. The dust and dirt were easily removed by wiping it with fingers and falling onto the food. On 01/08/24 at 10:22 AM, a refrigerator in the kitchen with a sign labeled special drinks was observed with DE #2. There were 6 - 240 cc (cubic centimeters) of plastic cups with lids. The cups were not labeled with date, contents, or names.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs were met and contributed to the resident attaining or maintaining her highest practicable level of independence and well-being for 1 (Resident #39) of 16 (Resident #1, R#3, R#6, R#9, R #13, R #16, R #23, R #25, R #29, R #37, R #43, R #49, R #53, R #57, and R #261) sample selected residents who were capable of reaching their own belongings, as documented on a list provided by the DON (Director of Nursing) on 10/14/22. The findings are: Resident #39 had diagnoses of Acquired Absence of Left leg below knee, Rheumatoid Arthritis, Contusion of Right Knee, and Myocardial Infarction. Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 8/31/22 scored a 13 (13-15 Indicate Cognitively Intact) and documented use of wheelchair assistive device and one-person physical extensive assistance for transfers and bed mobility. a. On 10/10/22 at 12:55 PM, during initial screening interview, the resident reported, My briefs and clothes are up too high, so I can't reach them. I have asked them to lower the shelf so I can be able to reach my own clothes and I have asked for my refrigerator to be lower, but they said No. The Surveyor asked R#39, Who did you talked to? R#39 responded, The Administrator was the one I talked and said No. She is refusing to lower shelves for me to be able to get my own clothing and items from refrigerator. The DON stated I can't do anything about it, with no reason given. b. Resident #39 told the Surveyor to open the closet door. The Surveyor observed a bar with clothing hung on it that was out of the resident's reach. The Surveyor observed a refrigerator on the counter and R#39 demonstrated being able to reach items in the door and could not reach the back of refrigerator. c. On 10/13/22 at 01:51 PM, The Surveyor asked the DON, Are you aware of R #39 requesting her shelf and bar in her closet lowered and her refrigerator lowered, so she can reach her clothing and food and beverages herself? The DON stated, As far as the closet, I tried to find an expansion rod. I looked on [online shopping and in-store]. I keep coming up empty. As far as the refrigerator, we had thought of putting it on a smaller table, but we were worried about stability. The Surveyor asked, How long ago did she voice this request for accommodation? The DON stated, At least a month or so ago. The Surveyor asked, Should reasonable accommodations be made for residents to remain as independent as possible? The DON stated, Yes, they should. d. On 10/13/22 at 02:27 PM, The surveyor asked Administrator, Are you aware of R #39 requesting her shelf and bar in her closest lowered and her refrigerator lowered so she can reach her clothing and food and beverages herself? The Administrator stated, She [R#39] has asked for her paper towel holder to be lowered, but it's not convenient for a roommate when she was to have one, so I just went and bought her a roll of paper towels at the store and gave it to her. The Surveyor asked, What about her closet and refrigerator? The Administrator stated, I told her it [refrigerator] would have to be sitting on something. She has two small drawer units in her room, and I told her she would have to have room made on her side to fit a small new table for it, so it did not interfere if she were to have a roommate. She [R#39] never got back to me. For the closet, we are trying to find something that is not permanent like an extender piece but have had no luck. The Maintenance Employee had to even hook her light pull to her bed rail. She likes everything to be in reach, so we've had to do things for her. We try to accommodate her. The Surveyor asked, Would you consider her requests reasonable accommodations? The Administrator stated, Yes, but it is a matter of finding things and making sure they would not affect a roommate. The Surveyor asked, What is an acceptable amount of time for reasonable accommodations to be handled? The Administrator stated, Well, within a couple weeks. But we are a small town, and we don't have a [retail store], so it depends on the situation.

Based on interview and record review, facility failed to ensure the Preadmission Screening and Resident Review (PASRR) evaluation process was completed in accordance with the State PASRR process for 1 (R #1) of 11 (Resident 1, R #6, R #11, R #16, R #18, R #25, R #29, R #43, R #44, R#49, and R #57) sample residents who had a diagnosis of a Serious Mental Disorder and/or Intellectual Disability (ID), in order to ensure the resident received appropriate care and services per list provided by the Director of Nursing (DON) on 10/14/22. The findings are: Resident #1 had a diagnosis of bipolar disorder. A Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/26/22 scored a 14 (13-15 Indicate Cognitively Intact). a. On 10/11/22 at 1:13 PM, The Surveyor asked the Medical Records Employee, if she had a PASRR for R#1. The Medical Records Employee looked in the electronic record and could only locate a PASRR completed out of state. The Medical Records Employee called the Business Office Manager (BOM) to office. The Surveyor asked BOM, Was a PASRR completed for R #1? b. On 10/11/22 at 2:50 PM, The BOM informed the surveyor that a PASRR had never been submitted for R#1. The Surveyor asked, Who is responsible for completing and submitting PASRR's? The BOM stated, I'm going to tell me. I am going to do that right now. The Surveyor asked, What could be the outcome of a PASRR is not completed? The BOM stated, The resident might not be able to stay here. c. On 10/13/22 at 2:27 PM, The Surveyor asked the Administrator, Who is responsible for completing and submitting PASRRs? The Administrator stated, [BOM's name] and [SSD's name] The Surveyor asked, What could be the outcome if a PASRR is not completed for a resident? The Administrator stated, Could be denied benefits. The Surveyor asked, What else could occur if they had a Mental Health diagnosis? The Administrator stated, Denied access for treatment.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive plan of care was revised for a resident who had a Stage 3 Pressure Ulcer, to ensure that resident's individual needs were met and maintained for 1 (Resident #16) of 4 (Resident #11, R #16, R #44, and R #43) sampled case mix residents who had pressure ulcers per a list provided by the Treatment Nurse on 10/14/22. The findings are: Resident #16 with diagnoses of Stage 3 Pressure Ulcer Left Lateral Malleolus and Severe Intellectual disability. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 8/2/22 documented, the resident required 2+persons extensive assist for bed mobility, transfers extensive assist of one person for dressing, toileting, personal hygiene and was totally dependent on staff for bathing. a. On 10/11/22 at 01:56 PM, Resident (R #16) sitting in common area in a wheelchair with a dressing to her left outer ankle. b. On 10/11/22 at 02:04 PM, a revised care plan, dated 8/14/2022, did not include documentation of a Stage three Pressure Ulcer. c. A Physician's Order dated October 2022 documented, .Cleanse left outer ankle with wound cleanser, pat dry, apply hydro gel dressing to wound and cover with dry dressing every day shift . start date 7/16/22 . d. On 10/13/22 at 01:53 PM, The Surveyor observed R #16's pressure ulcer to her left outer ankle. e. On 10/13/22 at 02:18 PM, The Surveyor asked the DON (Director of Nursing), Are there Care Planned interventions documented regarding [R#16's] pressure ulcer? The DON stated, I could not find any. The Surveyor asked the DON, Should care plan include interventions for [R#16's] pressure ulcer? The DON stated, Yes. The Surveyor asked, What is a potential negative outcome of the resident's stage three pressure ulcer not being documented on the care plan? The DON stated, Poor progression with the wound. f. On 10/14/22 at 09:15 AM, the DON stated, We use the RAI (Resident Assessment Instrument) manual for our Care Plan policy. g. The RAI manual documented on page1.1 .The RAI helps nursing home staff in gathering definitive information on a resident's strengths and needs, which must be addressed in an Individualized Care Plan. It also assists staff with evaluating goal achievement and revising care plans accordingly by enabling the nursing home to track changes in the resident's status. As the process of problem identification is integrated with sound clinical interventions, the Care Plan becomes each resident's unique path toward achieving or maintaining his or her highest practical level of well-being .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a resident's self-determination was supported by providing a compatible roommate to promote psychosocial well-being for 1 (Resident #10) of 19 (Residents #1, R #3, R #9, R #10, R #11, R #13, R #16, R #18, R #23, R #29, R #34, R #37, R #43, R #44, R #49, R #53, R #57, and R #261) sample selected residents who reside with a roommate. The findings are: Resident #10 had diagnoses of Chronic Embolism and Thrombosis of unspecified Deep veins of Lower Extremities, Osteoarthritis, and Congestive Heart Failure. Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/18/22 scored a 12 (8-12 Moderate Cognitive Deficit). a. On 10/10/22 at 02:53 PM, during an initial screening interview, R #10 reported, I want a new roommate, but the nurse said she's not sure if I can have one and I have been stuck with her (pointing to roommate) for a long time now. R #10 went on to explain that she likes to watch TV (television) but her roommate does not like the TV on at all and her roommate sleeps during the day and then is up and about at night and comes and goes from the room waking R #10 up. b. On 10/13/22 at 01:45 PM, The Surveyor asked Certified Nursing Assistant (CNA)#2 if she typically works 100 halls. CNA #2 stated she does. The Surveyor asked, Have you noticed any issues between R #10 and her roommate? CNA #2 stated, I really think they are not alike. She [roommate (R #9)] sleeps most of the day and is up at night and R #10 likes a regular schedule. The only issue I know of is the TV being unplugged, I know roommate is doing it because R#10 cannot get out of bed on her own. The Surveyor asked, Have either of the residents asked for a new roommate? CNA #2 stated, Neither has mentioned it to me. 3. On 10/13/22 at 03:08 PM, The Surveyor asked CNA #4, if she typically works the 100 halls. CNA #4 stated she does. The Surveyor asked, Have you noticed any issues between R #10 and her roommate? CNA #4 stated, The only issue be a daily one. She [Resident #9] don't like the TV on or the light on. R #10 do want the TV and light on. I be like talking' to [roommate] every day. She [R #9] done unplugged the tv and I be like having' to plug it back in. The Surveyor asked if this happens daily. CNA #4 stated, This be happening' a lot each day. The Surveyor asked, Do you feel they are compatible roommates? CNA #4 stated, No ma'am. [Resident #9] has sundowners and R #10 be like awake when she [R #9] want to be sleeping'. The Surveyor asked, Have either of the ladies mentioned wanting a new roommate? CNA #4 stated, Not like I remember. The Surveyor asked, Who would you inform if a resident wanted a new roommate? CNA #4 stated, It probably be like the DON or Administrator. 4. On 10/13/22 at 03:15 PM, The Surveyor asked the Administrator, If a resident has an issue with their roommate who would they report it to? The Administrator stated, Really anyone. Their CNA, Director of Nursing (DON), Social Services Director (SSD) or me. The Surveyor asked, Are you aware of any issues between R #10 and her roommate? The Administrator stated, No, I was not aware. The Surveyor asked, Are you aware of any schedule preference issues between R #10 and her roommate? The Administrator stated, No, nothing about schedules. The Surveyor asked, Are you aware of any conflicts that R #10 and her roommate have? The Administrator stated, Nothing, should I be aware of something? The Surveyor informed Administrator of schedule and TV preference differences and the information surveyor was provided by CNAs. The Administrator stated, I will have to check into that. It surprises me that I have not been told. R #10 is usually so happy, and I didn't know she was dealing with that.

Based on Interview and Record Review, the facility failed to ensure residents that received Medicaid benefits were notified when the amount in the resident's trust account reached $200 less than the Supplement Security Income (SSI) resource limit for one person for 3 of 3 (Resident #16, R #25 and R #44) sampled selected residents who had a resident trust account with the facility. This failed practice had the potential to affect 26 residents that received Medicaid benefits and had resident trusts managed by the facility, per Trust Current Account Balance report received 10/12/22 from Business Office Manager (BOM). The findings are: a. On 10/12/22 at 04:27 PM, The Surveyor requested $200 Medicaid notification letters for R #16, R #25 and R #44 from BOM, in her office. BOM stated, I have never sent any notification letters. I just call the families or tell the residents. The Surveyor asked, Do you document your calls in [Electronic Record] or anywhere else? The BOM stated, No, but I can document them now. I will put it in this box (pointing to box labeled 'prayer box') and hope for forgiveness. The Surveyor requested Transaction history for R #16, R #25 and R #37 from BOM. b. On 10/12/22 at 04:35 PM, The Surveyor received Transaction reports from BOM. The Surveyor asked the BOM, What could be the outcome for Medicaid residents having over $2,000 in their Resident Trust account? The BOM stated, They would be kicked off Medicaid. Then they could be private pay until we resubmit a new Medicaid application. c. On 10/12/22 at 04:47 PM, The surveyor asked the Administrator, Who monitors BOM's duties? Administrator stated, That's me. The Surveyor asked, Was notification given to Medicaid residents whose trusts were within $200 of or over the Medicaid $2,000 limit? Administrator stated, Yes. The Surveyor asked, Where is the documentation of notification located? The Administrator stated, There should be in electronic record name. The Surveyor asked, What outcome could occur if Medicaid residents remain over the $2,000 limit? The Administrator stated, They could lose their benefits. d. On 10/12/22 at 09:15 PM, The surveyor reviewed transaction reports which documented R#16 and R#25 was within $200 or over the $2,000 Medicaid limit 3 of the last 12 months and 9 of the last 12 months respectively. e. On 10/14/22 at 10:02 AM, The surveyor was informed by the Director of Nursing the facility did not have a Personal Funds policy and followed the Federal Guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure residents were not exposed to unsafe water temperatures for 16 (Resident #1, R#3, R#6, R#9, R#13, R#16, R#18, R#23, R#25, R#29, R#37, R#43, R#49, R#53, R#57, & R#261) sample selected residents who were capable of reaching faucets and failed to ensure fire safety equipment was located in smoking areas to protect residents from the potential of injury related to fire hazards for 6 (Resident #29, R#36, R#43, R#49, R#55 and R#59) sampled selected residents who smoked in the smoking area outside at the end of 300 hall. This failed practice had the potential to affect 14 residents who smoked in the smoking area outside at the end of 300 hall, according to the smoking list provided by the Director of Nursing (DON) on 10/12/22. The findings are: a. On 10/10/22 at 03:01 PM, due to concern of very hot water temperature in the general bathroom on 400 halls, the Surveyor requested to accompany the Maintenance Employee and check a bathroom's water temperature at the front and end of each hall. Hall 600, the men's secure unit, was not checked due to a resident attempting to leave unit at the time. 1. At 03:03 PM, The Surveyor Maintenance Employees asked R#59 if they could go in his bathroom to check water. R#59 stated, We have plenty of hot water and not enough cold. The water temperature in room [ROOM NUMBER] registered at 123.4. In room [ROOM NUMBER], the water temperature registered at 123.3. 2. While walking to the next hall, the Maintenance Employee asked the Surveyor, What should the water temp be at? The Surveyor asked the Maintenance Employee, What should the water temperature be in the resident bathrooms? The Maintenance Employee stated, I don't know because each of you ladies gives me a different temp range. The VA lady was just here recently and said 117 was fine. a. At 03:08 PM, the water temperature in room [ROOM NUMBER] registered at 122.6 and in room [ROOM NUMBER] registered at 122.1 b. Maintenance stated as leaving the room, We have a tankless system so it will be easy to turn down. c. At 03:11 PM, the water temperature in room [ROOM NUMBER] registered at 122.1 and in room [ROOM NUMBER] registered at 120.0 d. Maintenance stated after checking room [ROOM NUMBER]'s water I can already tell I gotta turn them down. e. At 03:16 PM, the water temperature in room [ROOM NUMBER] registered at 121.6 and in room [ROOM NUMBER] registered at 121.8 f. At 03:21 PM, the water temperature in room [ROOM NUMBER] registered at 120.5 and in room [ROOM NUMBER] registered at 119.1 b. On 10/11/22 at 02:35 PM, The Surveyor asked the Administrator, What is the appropriate range for the water temperature in the resident rooms? The Administrator stated, The book says below 120 degrees. The Surveyor asked, What book are you referencing? Administrator stated, The Long-Term Care Manual. The Surveyor asked, What could be the outcome if the temperature is over 120 degrees? The Administrator stated, It could cause serious burns. The Surveyor asked, Who is responsible for checking temperatures? The Administrator stated, [Maintenance Employee] checks them. The Surveyor asked, How often does he check them? The Administrator stated, It is weekly. The Surveyor requested a copy of the logs. The Regional Consultant stated, He [Maintenance Employee] has been advised to get them around 110 [degrees]. c. On 10/11/22 at 03:22 PM, The Surveyor received copies of water temperature weekly logs for the last 120 days from Medical Records which documented water temperatures ranging from 118.4 to 121.8 degrees in bathrooms, day rooms, and showers. d. On 10/11/22 at 3:40 PM, The Surveyor observed 9 residents (3 with smoking aprons and 6 without) smoking under an awning at the smoking area outside at the end of 300 hall with 3 Certified Nursing Assistant (CNA)s providing supervision, while all smoking themselves. No fire blanket or fire extinguisher observed by surveyor. e. On 10/12/22 at 8:30 AM, The Surveyor observed 5 residents (2 wearing smoking aprons and 3 without) smoking under an awning at the smoking area and 2 residents (R#17 and R#59) smoking next to the building outside near the closed door at the end of 300 hall with 2 CNAs (CNA#1 and CNA#2) providing supervision, one of which was smoking herself. The Surveyor observed R#17 shaking while smoking and ash falling onto her lap. The Surveyor observed R#59 toss a cigarette butt into grass and propel his wheelchair to door and someone inside opened the door and let him onto the 300 hall. One of the two CNAs asked if he was going back inside, and R#59 replied Yes. The Surveyor observed no fire blanket or fire extinguisher available to staff supervising smokers. f. On 10/10/22 at 08:42 AM, The Surveyor asked CNA#1, after she completed supervising smoking, how she is aware which residents require smoking aprons? CNA#1 responded, It is care planned and charted, but we can just tell and decide by how they move. The Surveyor asked CNA#1, What is available for safety and in case of fire? CNA#1 looked around area and stated, We only have smoking aprons out here. The Surveyor asked, What else could you need in case of fire? CNA#1 stated, The closest fire extinguisher is inside down this hall by the fire alarm. (Pointing to 300 hall). g. On 10/12/22 at 08:50 AM, The Surveyor asked the Director of Nursing (DON) to accompany this surveyor to the outside smoking area, at end of 300 hall. Once outside, the Surveyor asked the DON, What requirements are needed for a smoking area? The DON stated, Well, we got smoking aprons, butt cans, ashtrays and (paused and began looking around) possibly a fire blanket. The Surveyor asked, What else would staff need in case of a fire while a resident is smoking? The DON stated, There should be a fire blanket out here. The Surveyor asked where the closest fire extinguisher was located. The DON stated, It is just down this hall (pointing to 300 hall). The Surveyor asked the DON, How do staff know which residents require smoking aprons? The DON stated, The MDS (Minimum Data Set) Coordinator does the assessment which is sent to [NAME]. The Surveyor accompanied the DON down 300 halls. The Surveyor asked the DON for Maintenance to be called to measure the distance. The DON stated, The tiles are 1 foot each. The Surveyor and DON counted tiles and found closest fire extinguisher was 42 tiles from door that leads to smoking area. h. On 10/12/22 at 10:08 AM, The Surveyor requested a list of any residents that received burns in the last 6 months from the DON. At 10:20 AM, The Surveyor received statement from DON which documented I am not aware of any resident receiving any burns in the last six months. i. On 10/12/22 at 12:40 PM, The Surveyor requested the Maintenance Employee to measure the exact distance from the fire extinguisher on 300 the hall to the closed door to the smoking area and from the fire extinguisher to the edge of the actual smoking area under the awning. The Surveyor, Maintenance Employee, and Administrator measured the distances from the fire extinguisher on 300 the hall to the closed door to the smoking area and from the fire extinguisher to the edge of the actual smoking area under the awning. The Measurements were 64 feet from closest fire extinguisher to edge of smoking area concrete slab under awning and 44 feet from closest fire extinguisher to closed door to outside that lead to smoking area. The Surveyor asked the Maintenance Employee, How long has this smoking area been used by residents? The Maintenance Employee stated, Over a year. The Maintenance Employee pointed out a fire box that contained a fire blanket and stated, I just got this fire blanket box put up here. Where does the fire extinguisher need to be? The Surveyor responded, Within 30 feet. The Maintenance Employee asked, Is next to the fire blanket, ok? The Surveyor responded, Within 30 feet. The Administrator stated, That will be fine. She [surveyor] can't tell us. j. On 10/12/22 at 1:15 PM, The Surveyor asked the Administrator, Should a fire extinguisher be accessible in the resident smoking areas? The Administrator stated, Yes they should. k. On 10/12/22 at 11:16 AM, The Surveyor received Smoking policy from consultant which documented, .policy of this facility to ensure a safe smoking environment . and .will have smoking assessment to determine if safety equipment is needed .

Based on observation, record review, and interview, the facility failed to ensure an indwelling urinary catheter collection bag was stored in a manner to prevent possible contamination and infections for 1 (Residents #43) of 3 (#37, #42, #43) sampled residents who had an indwelling urinary catheter, according to a list provided by the Director of Nursing on 10/14/2022. The findings are: Resident #43 had diagnoses of Extended spectrum beta Lactamase Resistance; personal history of Urinary Calculi; encounter for Attention to Cystostomy; Neuromuscular Dysfunction of Bladder; and Multiple Sclerosis. The Significant Change Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 09/07/2022 Q (every) documented resident scored 15 (13-15 cognitively) on the Brief Interview for Mental Status (BIMS), section H documented indwelling catheter. Physician's Orders documented, .12/30/21 Suprapubic Catheter 16 FR (French) with 5 CC (Cubic Centimeter) balloon record output every shift related to multiple sclerosis . Flush catheter with 10 CC water for discomfort or cloudy urine every 8 hours as needed .01/03/22 Change Suprapubic Catheter every 24 hours as needed for Occlusion or Leakage . Change Suprapubic Catheter every day shift starting on the 16th and ending on the 16th every month related to Multiple Sclerosis . The Comprehensive Plan of Care Documented, .has frequent Urinary Tract Infections and is on daily antibiotics. Date Initiated: 10/05/2022 .The resident's Urinary Tract Infection will resolve without complications by the review date . Give antibiotic therapy as ordered. Observe for side effects and effectiveness . has a Suprapubic Catheter Date Initiated: 09/09/2021 .will be/remain free from catheter-related trauma through review date .has Suprapubic catheter and request that the catheter bag be hung up on the trash can because it back flows. Date Initiated: 09/10/2021 .Observe for s/sx (signs/symptoms) of discomfort on urination and frequency .Observe/report pain/discomfort due to catheter .Observe/report to Nurse/MD (Medical Doctor) for s/s UTI (Urinary Tract Infection) . a. On 10/10/2022 at 11:30 a.m., Resident # 43 lying in bed, a catheter collection bag was hanging from a trashcan beside the right side of the bed with the bottom of the bag touching the floor. The tubing from the collection bag was stationed under the blanket next to the resident. The resident stated, It is care planned to be that way because when it's on the bed it does not drain properly. b. On 10/11/2022 at 2:00 p.m Resident #43 was lying in bed, a catheter collection bag was hanging from a trashcan beside the right side of the bed with the bottom of the bag touching the floor. The tubing from the collection bag was stationed under the blanket next to the resident. c. On 10/14/2022 at 8:40 a.m., Resident # 43 was lying in bed, a catheter collection bag was hanging from a trashcan beside the right side of the bed. The trashcan contained trash. The bottom of the bag was touching the floor on top of a dried yellow substance. d. On 10/14/2022 at 8:44 a.m., The Surveyor asked Certified Nursing Assistant # 5 (CNA), Do you see a problem with resident's # 43 catheter bag? CNA # 5 stated, It is hanging on the trash can. The Surveyor asked, Is there anything in it [trashcan]? CNA # 5 stated, Yes, trash. The Surveyor asked, What could happen by doing this? CNA # 5 stated, It's not sanitary and could cause an infection. e. On 10/14/2022 at 9:00 a.m., The Surveyor asked the Director of Nursing (DON), [Resident # 43]'s catheter is hanging from a trash can with trash in it. The bottom of the bag is touching the floor. Is this an issue? The DON stated, yes. The Surveyor asked, What could happen? The DON stated, It could spread germs to other residents. The Surveyor asked, If germs were spread what could happen? The DON stated, It could cause infection. The Surveyor asked, What could be done as catheter is care planned to hang from trash can? The DON stated, A barrier could be put between the bag and the floor. f. On 10/14/2022 at 12:04 p.m., The Assistant Director of Nursing provided a document with a section titled, Indwelling Urinary Catheter Care and Removal, that documented, 'Intended to prevent infection and other complications .Attach the drainage bag below bladder level to the bed frame .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure food items stored in the refrigerators, freezers, and dry goods area were sealed, labeled, and dated to prevent the potential food borne illness, failed to ensure foods in unit refrigerators were labeled and dated, and failed to ensure spices were used prior to losing flavor, potency, and color for residents who received meals from 1 of 1 kitchen. The failed practices had the potential to affect 62 residents who received meals from the kitchen (total census: 62), as documented on a statement provided by Director of Nursing (DON) on 10/14/2022 the facility had no residents NPO (No Food by Mouth). The findings are: a. On 10/10/22 at 11:45 AM, The Surveyor began the Initial tour of kitchen with Dietary Manager (DM) in the dry storage room which contained the following: - 4 chicken noodle soup cans with no received date - 1 can of Rotel with no received date - 1 open box of bottles of chocolate syrup no received or opened date. A dead roach fell off the box when it was removed from shelf. The DM stated, We just had pest control here about a week ago. - Red wine vinegar with date 7/15/20. The Surveyor asked what the date represented. The DM stated, It is the open date. No, wait. It is the received date. I will throw it away. - [NAME] Distilled Vinegar dated 7/21/22 had no open date. - 1 open box of bags of chips had no received date. - 1 open box of BBQ packets had no received date. - 1 open box of honey packets had no received date. The DM yelled out to kitchen to inform a Dietary Employee of the non-dated items. 1. At 12:06 PM, The Surveyor observed the Walk-in stainless refrigerator which contained the following: - Open plastic jar of Italian dressing 1/2 full had no open date, the date on cap was 8/30. - Open plastic jar of Mayonnaise 1/2 full had no open date, date on cap was 9/16. The Surveyor asked DM if the dates on the lids were received or opened dates. The DM stated, The dates we have on them are received dates. The DM stated, I did not know they needed an open date if they had a use by or expiration date. The Surveyor asked DM to find the use by or expiration date on the plastic jars. The DM was unable to locate any use by or expiration date on the plastic jars. 2. At 12:16 PM, The Surveyor observed Walk-in stainless Freezer which contained the following: - Ziploc bag of diced chicken dated 9/23/22 not sealed. DM stated, I am unsure if that is the received or bagged date. - Open box with bag of chicken patties with ice crystals and white patches on patties not tied or sealed closed. - Open box with bag of dinner rolls with ice crystals on rolls not tied or sealed closed. - Open box with bag of cinnamon rolls not tied or sealed closed. The DM stated, My goodness they know better. 3. At 12:22 PM, The Surveyor observed the shelf above the Robocoupe puree area which contained the following: - Plastic container of Ground Cumin 1/2 full dated 7/31/19 - Plastic container of Allspice 1/2 full dated 2/9/18 - Plastic container of [NAME] Pepper dated 10/6/20 - Plastic container of Rubbed Sage dated 11/17/20 - Plastic container of Lemon Pepper dated 3/13/18 The DM stated, Most of these we don't even use. The seasons were no longer palatable. 4. At 12:30 PM, The Surveyor observed the Refrigerator on Women's unit which contained the following: - Purple liquid in two water plastic bottles with 'GA' on cap had no date or label. - Plastic bottle of cranberry juice one half full had no date, or name. 5. At 12:35 PM, The Surveyor observed the Refrigerator on Men's unit which contained the following: - Pitcher of water dated 9/6/22 - Pitcher of Apple juice dated 9/19/22 - 2 cans of [diet soda] had no date or name - 4 cans of [soda] had no date or name The DM stated, They haven't been down here for a while to check this. A Certified Nursing Assistant (CNA) walking by stated, I think those are R#45's and R#35's. The Surveyor asked who was responsible for the items in the unit refrigerators. The DM stated, All of us are responsible. a. On 10/12/22 at 04:02 PM, The Surveyor received Storage of Food and Beverages Brought by Visitors which documented .Foods or beverages brought into the facility by guests or visitors will be labeled with the specific resident's name, room number, and dated with the current date the item is brought into the Facility for storage outside the resident's room . b. On 10/14/22 at 11:29 AM, The Surveyor received Diet, Sanitation, and Menu policy which documented .nursing facility will provide each Resident/Elder with a nourishing, palatable, well-balanced diet . and .the Nursing Facility will store, prepare, distribute, and serve food under sanitary conditions as prescribed by Serv Safe Manual .