Based on record review, observations, and interviews, the facility failed to ensure infection control measures, including the storage of resident equipment, were implemented during residents smoking for 1 (Resident #1) of 1 sampled resident observed for prevention of potential infection and/or the spread of infections. The findings include: Review of a facility policy titled, Cleaning and Disinfection of Resident-Care items and Equipment dated September 2022, indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. A review of an admission Record indicated the facility admitted Resident #1 with diagnoses that included cerebral palsy and Parkinson's disease. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/07/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 9 (08-12 indicates moderately impaired). Review of Resident #1's Care Plan initiated: 06/15/2015, with a revision date of 01/02/2024, revealed Resident #1was a smoker and was at risk for injury. The Care Plan indicated Resident #1 was to use a special ashtray that holds their cigarette and that if the resident does not use it, the cigarette will break. On 01/22/2025 at 3:30 PM, this surveyor observed the smoking area for the residents. This surveyor observed an assistive device called clip on ash tray with a remote tube which was used to extend amount of space between the resident and cigarette. The device was exposed and left unattended on a table in the smoking area. On 01/23/2025 at 9:30 AM, this surveyor observed the smoking area for the residents. This surveyor observed the assistive device exposed and left unattended. On 01/23/2025 at 11:45 AM, this surveyor observed residents smoking in the designated area. The Restorative Certified Nursing Assistant, (RCNA) picked the device up off the table and without cleaning it, handed it to Resident #1. Resident #1 placed the device in their mouth and used it. On 01/23/2025 at 11:44 AM, the RNCA was asked if the smoking device had been cleaned before it was handed to Resident #1. She stated it had not been but that she should have cleaned it since it had been left lying on the table and anyone could touch it. On 01/23/2025 at 12:10 PM, during an interview, the Director of Nursing (DON) was asked if the smoking device that belonged to Resident #1 should have been left outside unattended and if it should have been cleaned before it was handed to Resident #1. The DON stated that the device should be stored in a plastic bag and kept at the nurse's station and that it should be cleaned before and after Resident #1 used it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure that the environment was clean and sanitary to provide a homelike environment on the secured unit. This failed practice had the potential to affect all 20 residents who resided in the secure unit. The findings are: A review of the facility policy Housekeeping Cleaning Guidelines indicated: a. Corridors and Public Areas: (including dining rooms, day rooms, lobby, activity areas, therapy areas etc.) Dust mopping, (including corners and edges) daily, damp/wet mop daily, scrubbing of resilient tile as scheduled. b. Corridors and Public Areas: (including dining rooms, day rooms, lobby, activity areas, therapy areas etc.) 3. Check/dust horizontal areas daily, 4. check/dust/clean vertical services daily, 16. Public area deep clean (light fixtures, vents, cubicle curtains/tracks, air/heat units, fire alarms, extinguishers, call lights/devices, baseboards, room corners, edges, ceiling corners etc.) monthly. c. Patient Room Cleaning: 3. Check/dust horizontal surfaces daily, 4. Check/dust/clean vertical surfaces daily, 15. Patient room deep cleaning (light fixtures, vents, cubicle curtains/tracks, air/heat units, room corners, edges, ceiling corners, etc.) monthly. d. Corridors/Public area dust all surfaces and furnishings. Patient Rooms dust all surfaces and furniture and furnishings. A review of the [Facility Name] Floor Tech Job Description indicated, Job Summary: Under general direction, clean and maintain all carpeted and hard surfaces in the facility, perform preventative maintenance on special floor equipment. On 01/21/2025 at 11:50 AM, this surveyor observed in room [ROOM NUMBER], cobwebs behind the television on top of the closet unit, and above the air conditioner unit, and the paint was peeling and bubbling, exposing the dry wall under the window. On 01/21/2025 at 12:00 PM, this surveyor observed that a light in the hallway on the secure unit was out, making the area around the nurse's station dim. This surveyor observed that two light covers in the dining room, closest to the television, were covered in brown splatters, and the inside contained dead insects and debris. On 01/21/2025 at 12:30 PM, this surveyor observed the inside area of the handrails in the hallway of the secure unit contained debris, dried matter, and dead insects. This surveyor observed, at the end of the hallway, was a light cover with what appears to be webs on the left side of the light cover, the inside of the light cover contained debris and dead insects. The vents in the hallway were covered in a thick layer of fine brown particles. This surveyor observed that along the edges of the hallway the tiles were discolored in a gray, black matter with debris on top of them. This surveyor observed that this same discoloration of tiles was located in the rooms around the edge of closets. On 01/21/2025 at 12:40 PM, this surveyor observed residents wandering up and down the hallway touching the handrails. On 01/22/2025 at 9:00 AM, this surveyor observed that the light covers, the handrails, the vents, the floors, and the observations in room [ROOM NUMBER] had not changed. On 01/22/2025 at 9:30 AM, this surveyor observed residents wandering up and down the hallway touching the handrails. On 01/22/2025 at 1:00 PM, this surveyor observed a brown, wet splatter on the floor of the hallway. On 01/22/2025 at 3:00 PM, this surveyor observed that the previous brown splatter on the floor of the hallway had dried and become sticky. On 01/23/2025 at 9:00 AM, this surveyor observed the brown, sticky splatter remained on the floor. On 01/23/2025 at 9:15 AM, this surveyor observed that the light covers, the handrails, the vents, the floors, and the observations in room [ROOM NUMBER] had not changed. On 01/23/2025 at 9:20 AM, this surveyor observed Housekeeper (HK) #2 cleaning the dining room. HK #2 changed gloves without washing hands when wiping down tables. When mopping the floors HK #2 stopped at the edge of the dining room, and did not mop in front of the nurse's station. HK #2 moved to room [ROOM NUMBER] on the hall, rolled the cart right next to the splatter in the hallway and did not clean it up. HK #2 switched gloves between sweeping and wiping hard surfaces without washing hands. HK #2 then proceeded to clean room [ROOM NUMBER], but did not mop the floor in the bathroom. On 01/23/2025 at 10:00 AM, during an interview HK #2 stated that they have worked in the facility for two months and usually only have two housekeepers for the building. HK #2 stated that they do not have a floor tech currently and when they have time, they buff the hallways when there is less traffic. HK #2 stated that they do two deep cleans a week, and they usually work together with other housekeepers on them. HK#2 grimaced when asked if they felt short staff then nodded and stated, it can be difficult some days to get it done but I do the best I can and clean how I was taught to. HK#2 then stated if I do not finish, I will pick up where I left off the next day. On 01/23/2025 at 11:50 AM, during an interview, HK#3 stated they had worked here three years and that they cannot always do the floor tech duties, but they are used to the amount of work. HK #3 stated they only have two housekeepers on duty, but did have three scheduled to keep up with floor tech duties. With budget constraints they were told only two people could be scheduled at a time. HK #3 stated they would like to get the hallway floors clean again. HK#3 stated they were not sure if the facility was still hiring for a floor tech then stated that they sometimes feel like they are short staffed depending on what they come into when cleaning the rooms. On 01/23/2025 at 2:00 PM, this surveyor observed the shower room on the unit, in the upper left-hand corner black, gray circular spots are observed on the ceiling. The vent was covered in a thick layer of fine brown particles. The walls of the shower were observed to be covered in brown matter, on the floor in the right-hand corner the grout and tiles are covered in a layer of brown matter. On 01/23/2025 at 2:47 PM, during an interview the Infection Preventionist (IP) stated the importance of a clean environment was infection control, the residents deserved a clean environment to live in. Then stated they were looking for a floor tech but with it being a temporary position, as they will not need one at the new facility, the position had not been filled. On 01/23/2025 at 3:18 PM, Maintenance stated the procedure for reporting maintenance issues was with the logbook. Maintenance then stated that the shower room had not been reported to him and that it looked like mold was in the corner of the shower room. Then stated that they needed to check that out immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure maintenance was in place to maintain and prevent broken and exposed wall plug outlets, broken trim on walls, holes in sheet rock, wall nail holes, and leaky toilet rims in resident rooms to maintain a safe, clean, and homelike environment in Hall 1 of eleven (11) Resident rooms. The findings are: On 01/02/2023, at 12:20 PM, environmental rounds were made in the facility rooms, the following were observed: a. Standing in the entrance of room eight (8), wall trim behind the headboard on the left, is located on the floor. In addition, the 4-plug wall outlet is separated from the sheetrock, exposing 1/2 inch across the top of the wall plate. A 2-plug wall outlet on the right side of the wall, is separated from the sheetrock exposing 1/2 inch across the top of the wall plate. b. Standing in the entrance of room ten (10), behind the entrance door, is a hole in the sheetrock approximately (12 x 12 cm [centimeters]). In addition, the bathroom toilet has black-gray colored residue against the base rim. The standalone double closet doors against the right side will not safely close. c. Standing at the entrance of room sixteen (16), the left side of the upper wall, had ten (10) wall nails holes, approximately (1 x 1 cm). The right side of the room had two (2) 2-plug wall outlets, separated from the sheetrock, exposing 1/2 in across the top of the wall plate. d. On 01/02/24 at 12:37 PM, Resident #8 stated My toilet is leaking and has been for ages now. The Surveyor asked Resident #8 if she had told someone. Resident #8 answered, Yes, they just wrap a towel around it, but it still leaks. It is a slipping hazard for me. I've also seen roaches in the facility, but I don't have any now. e. On 01/04/24 at 9:26 AM, the Surveyor accompanied the Maintenance Supervisor to to observe Resident #8's toilet in bathroom. The Surveyor asked if Maintenance was aware the toilet was leaking. The Maintenance Supervisor answered, I replaced the flange yesterday. The Surveyor asked the Maintenance Supervisor how long the toilet had been leaking. The Maintenance Supervisor stated, I don't know. f. On 01/02/24 at 05:25 PM, the Surveyor observed the faucet continuously dripping in the sink in room [ROOM NUMBER]-A. The faucet would not turn off. g. On 01/04/24 at 9:20 AM, the Surveyor accompanied Maintenance to room [ROOM NUMBER]-A and asked if he knew about the leaky faucet. Maintenance stated, I've ordered two of those. This is an old building. The Surveyor asked how long these faucets last. Maintenance stated, This building is very old. Everything here is old and needs to be repaired. The Surveyor asked how does Maintenance know when repairs are needed to be done. Maintenance stated, They let me know. I have a book that I write everything down in. The Surveyor observed that the sink continued to drip a continuous, steady stream of water. During an interview and tour of Hall 1 on 01/04/2023, at 11:10 am, with the Maintenance Supervisor (MS) #1, in response to the question, are you aware of the residents wall trim that fell in room [ROOM NUMBER], and the left and right separated electrical wall covers, [and] in room [ROOM NUMBER], the wall hole behind the door, black-gray residue on the toilet rim base and the non-closing double door closet ? The MS #1, stated I was not aware of the fallen wall trim, separated electrical wall covers, black-gray toilet rim base, and closet broken doors and I was not aware of the hole behind the door, and will repair this as soon as possible. In response to the question, are you aware of the holes in the wall and the separated and exposed wall covers? MS #1 stated, I have not been back in this Hall, as they have been in quarantine. The policy Maintenance Service (Revised December 2009) received on 1/04/2024, at 10:08 PM, from the Administrator, read in part . The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, maintaining a schedule of maintenance service [and] a copy will be provided to each department director so that appropriate scheduling can be made without interruption of services to the residents. In addition, the Maintenance Director is responsible for maintaining the following reports: Inspection of building, work order requests, maintenance schedules.

Based on observation, record review and interview, the facility failed to ensure medications were given within a timely manner to avoid adverse effects on resident's condition and ensure that medications were administrated without unnecessary interruptions, for 2 (Resident #7 and #44) sampled residents. This failed practice had the potential to affect 51 residents who were dependent on the nurses for medication administration. The findings are: 1. Resident #7 [R#7] had diagnosis Hemiplegia ( weakness or paralysis on one side of the body) and Hemiparesis ( weakness of one side of the body) following unspecified Cerebrovascular Disease affecting Left Non-Dominant side. a. On 01/02/24 at 12:11 p. m., R #7 stated, My night medications [meds] are always late, I get them around 11 p. m. I have filed a grievance because on 12/19/23 I didn't get them until 2:00 a.m. I don't think they are short-staffed; I think the nurses just don't do their jobs. b. Review of the grievance filed by R#7 on 12/19/23 documented .Nature of Grievance: didn't get her night times meds until 2 am . Resolution: Verified medications were not administered on time. Nurse received written warning and educated on med pass administration . c. On 01/04/24 at 3:34 p.m., the Director of Nurses [DON] was asked about the grievance involving Resident #7. The DON said I did an investigation and resident's meds were late. I asked the nurse that worked that night why the resident ' s meds were late. The nurse said they were busy, and meds were given late. That nurse was written up and educated. d. On 01/04/24 at 3:34 p.m., the DON was asked, what is the importance of giving medications at the time that are prescribed? The DON said, It can back everything up. Like if morning meds are given late then the other meds will either be late or given to close together. 2. Resident #44 (R#44) had Diagnoses of Diabetes Mellitus Type 2 and End Stage Renal Disease. a. A Physicians Order dated 12/13/23 documented, Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 15 unit subcutaneously with meals related to Type 2 Diabetes Mellitus with complications. Hold if BS [blood sugar] is less than 200 b. A Physicians Order dated 12/14/23 documented, Inject 70 unit subcutaneously in the morning related to Type 2 Diabetes Mellitus with complications. c. A Care Plan initiated 8/29/22 documented, .Diabetes medication as ordered by doctor . d. On 1/3/24 at 9:30 AM, the Surveyor observed the Licensed Practical Nurse (LPN) #1 administer 7 units of Lispro injection [named]pen, and 15 units of Humalog Regular Insulin injection to R #44 during morning medication pass. e. On 1/3/23 at 09:36 AM The Surveyor observed the LPN #1 administer 70 units of Toujeo Max solo start injection insulin to R #44 f. The Survey readiness book provided by the Administrator on 1/2/23 at 11:00 AM documented under Medication Times, 0800 for morning medications. g. On 1/3/23 during morning medication pass between 0836 - 0945 AM, the Surveyor observed LPN #3 doing glucose checks, blood pressure checks, and lung assessments to address needs reported to her during medication pass by staff. h. On 1/3/23 at 9:37 AM The Surveyor asked the LPN#1 why the Humalog insulin was late and why it wasn't given with R #44 breakfast. The LPN #1 stated, We've been having a little trouble getting his insulin schedule right. It sometimes upsets his stomach, so we don't give it until later. The Surveyor asked if medications were always running this late in the mornings. LPN#1 answered, You've seen the interruptions this morning. We normally have 3 nurses. Today we only have 2. It's just hard to get it all done with all of the interruptions. If there are 2 nurses, we have a med tech on each side. Today there are no med techs. The Surveyor asked if they were often short-staffed. The LPN answered, Today we are.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Young, [NAME] 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 with a maintenance program in place to prevent broken, exposed wall plug outlets, broken wall trim, holes in sheet rock, wall nail holes and leaky toilets in resident's rooms to maintain a safe, clean, and homelike environment. These failed practices had the potential to affect 51 residents who reside in the facility. The findings are: 1. A Recertification survey was conducted on 01/05/2024 at the facility. During this survey, the team identified concerns with food services, food storage, and hand hygiene when preparing and serving food in a sanitary manner and concerns with infection control. A. The Plan of Correction with a completion date of 10/22/2022 documented: This Plan of Correction is to be considered as an allegation of Compliance. Step #1: Corrective Action: On 10/6/22, upon notification of deficient practice, Administrator/designee and Maintenance Director observed bathroom of Resident #3 and #16. The Maintenance Director immediately began repairs of bathroom of Resident #3 and #16 to ensure proper usage of bathrooms. Step #2: Identification of others with the potential of being affected: On 10/6/22, Administrator/designee instructed Maintenance Director to inspect each bathroom of all residents to ensure each bathroom was in good repair and proper usage to ensure no other residents had the potential to be affected. Any negative findings were corrected immediately. Step #3: To ensure deficient practice does not recur: On 10/6/22, Administrator/designee in-serviced Maintenance Director on ensuring that all areas of the facility were in good repair by visual observations and reviewing of submitted maintenance work orders during daily rounds and that all repairs are completed immediately. Step #4: Monitoring: Administrator/designee, will review and sign off on all Maintenance Director work orders and maintenance log sheet to ensure all reported repairs have been completed in a timely manner. The Maintenance Director will conduct daily visual observations of building 5 x weekly x 4 weeks or until substantial compliance is achieved. Work orders, location and completion dates will be documented on the Maintenance Log Sheet. Any negative findings will be corrected immediately with verification by the Administrator/designee. Step #5: QA: Maintenance Director/designee will present all findings to monthly QA committee for further review and recommendations. On 01/05/24 at 10:34 AM, the Administrator was interviewed. The Surveyor asked, how does the QAPI team obtain and use feedback from residents, their representatives, or staff to identify high-risk, high-volume, or problem prone issues as well as opportunities for improvement? The Administrator stated, We use our startup 9 AM meeting. Problems are discussed during that time. I&A, weights, IP situations, etc. track through monthly QA (Quality Assurance) meetings. Falls are our QAPI focus this year. A QAPI Plan provided by the Administrator during entrance conference on 01/02/24 at 10:15 am documented .II. Purpose Statement: The purpose of QAPI in our facility .Continuous quality improvement involves a review of the processes involved in delivering various components of care and service, analyzing ways in which these processes can be improved . The Facility Assessment Tool provided by the Administrator during entrance conference on 01/02/24 at 10:15 am documented .483.75 (c) QAPI Program Feedback, data systems, and monitoring .483.75 (e) QAPI Program activities .

Based on observation, interview and record review, the facility failed to ensure staff did not leave medications unattended on a secured unit. The findings are: During observation on 10/4/23 at 11:16 AM, a resident was sitting in the day room at a table with two other residents on the secured unit. The resident had a cup of water and a medication cup with four pills on a table in front of her. There was a total of four residents in the day room. During interview on 10/4/23 at 11:27 AM, Licensed Practical Nurse (LPN) #1 came into the day room. The Surveyor asked LPN #1 should a cup of medications be on a table unsupervised with residents in the day room? LPN #1 said she gave the resident her morning medications and she does not how the medications got on the table. During interview on 10/4/23 at 11:32 AM, the Director of Nursing (DON) confirmed a cup of medications should not have been left on a table in a secured unit unsupervised. Review on 10/4/23 at 3:18 PM of facility policy titled Administering Medications showed, medications shall be administered in a safe and timely manner and as prescribed. Review on 10/5/23 at 9:30 AM of facility policy titled Storage of Medications showed, the facility shall store all drugs and biologicals in a safe, secure, and orderly manner.

Based on observation, record review, and interview, the facility to ensure food was prepared by methods that maintained the flavor and encourage good nutritional intake for the residents who received regular diets and mechanical soft diets and pureed diets 1 of 1 meal observed These failed practice had the potential to affect 46 residents who received regular diets, 14 residents who required mechanical soft diets and 6 residents on pureed diets, according to lists provided by the Dietary Supervisor on 1/10/23. The findings are: 1. The grievance log for 11/28/22 documented, Food not appetizing nor taste good but notify just on weekends. 11/28/22 Inservice education report documented, Encourage dietary staff to season food according to recipe. 2. The facility recipe for baked ziti with meat sauce documented for 60 servings, use ½ (half) cup of pure vegetable oil, 3/8 cup of herb fresh rosemary, 20 cloved chopped garlic, 3/8 cup of Italian seasoning with no Msg (Monosodium Glutamate), 2 1/8 lb (pounds) of [named] whole milk. a. On 1/09/23 at 9:08 AM, a pot that contained 2 logs of hamburger meat was on the stove. There were no seasonings on the meat. Dietary Employee #1 flipped the meat items with a spatula. She added parsley flakes on the meat. She peeled 7 onions, chopped, and placed them on ground beef. There were no other spices added to the ground beef. b. On 1/09/23 at 9:35 AM, Dietary Employee #1 poured pasta in a pot water on the stove. There was no seasoning added in the water. Dietary Employee #1 drained the unseasoned pasta and poured it into 2 pans. She added ground beef that was cooked with parsley flasks and onions. She added a can and half of marinara sauce on each pan of pasta and meat. She mixed the content, sprinkled the top of each food content with shredded cheese. She placed the two pans of pasta with sauce in the oven to be baked and served to the residents for lunch. The above ingredients listed were not added in the baked ziti. 3. The facility recipe for Italian vegetable blend documented for 60 servings. Add 3/8 cup of solids pure vegetable margarine and 1 ¼ tablespoon of salt. Dietary Employee #1 poured a 25 pound of vegetable blend in a pot. She added water and placed it on the stove. She poured the pureed unseasoned Italian vegetable blend in a pan that was on the steam table to be served to the residents for lunch. There was no seasoning added to the vegetable blend. a. On 1/09/23 at 10:38 AM, Dietary Employee #1 poured squash in a pot, added water, and placed it on the stove to cook. She poured the unseasoned squash in a pan and placed on the steam table to be served to the residents who do not like Italian vegetable blend. b. On 1/09/23 at 11:38 AM, Dietary Employee #2 placed a pot of water on the stove and boiled. She added potato flakes, stirred, and poured the content in a pan. She covered the pan with foil and placed it in the oven. No seasoning was added to the mashed potatoes. c. On 9/09/23 at 1:03 PM, a taste tray that consisted of regular Italian vegetable blend, pureed Italian vegetable blend, squash, mashed potatoes and pureed pasta was obtained. The Dietary Supervisor tasted the food items and stated, pasta without sauce was bland, regular Italian vegetable blend had no seasoning. It needs some seasoning. Pureed pasta was gross, no seasoning, squash was tasteless and pureed Italian vegetable blend was bland. d. On 1/09/23 at 1:45 PM, Resident #5 was sitting in a Geri-chair in the dining room. PRD in chair. She wears a hand roll on her left hand. She was well-groomed. She was served regular pasta, regular Italian vegetable blend, salt 1, pepper 2 packets, and an 8 oz (ounce) cup of coffee. The Surveyor asked, How was your meal? She stated, It was good. The Surveyor asked, Is the food cooked and how does it taste? Do you serve a variety of foods? She stated, The vegetables were unflavored. e. On 1/09/23 at 1:53 PM, the Surveyor asked Dietary Employee #1, what was the reason that the food items prepared and served to the residents for lunch were not seasoned? She stated, I didn't know we could add some salt and pepper, because we have residents who are on no added salt diets. But I used parsley flakes and onions on ground beef. f. On 1/09/23 at 1:58 PM, the Surveyor asked Dietary Employee #2, what was the reason why she prepared the mashed potatoes with no seasoning? She stated, we were behind, and I was in a hurry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure Physician's orders for wound care treatment were processed and implemented to prevent complications and infection for 1 resident (Resident #1) of 3 sampled residents (R #1, R #2, R #3). The findings are: 1. Resident #1 was admitted on [DATE] and had diagnoses of Peripheral Vascular Disease and Osteomyelitis. The Minimum Data Set (MDS) with an Assessment Reference Date of 8/27/22 documented the resident scored 15(13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive assistance with transfers, toileting, and personal hygiene. a. A 7/1/22 the revised care plan documented, .The resident had an arterial/ischemic ulcer of bilat feet and toes r/t [related to] poor circulation . The resident will be free from infection or complications related to arterial ulcer through review date . Keep the feet clean and dry . b. A 11/1/22 The Physician's Orders documented, .Cleanse vascular ulcers to bilateral feet with wound cleanser and 4x4s, pat dry with 4x4s. Apply wound gel daily. Every day shift c. On 11/10/22 at 8:52 am, Resident #1 was seen by [named] facility. In the HPI [History of Present Illness] section of the visit it documented, [Resident #1] seen today for f/u [follow up] wound care visit. She has no complaints today. She is non-compliant w[with]/treatment but understands her wounds should be dry . In the Assessment/Plan section of the visit it documented, .encouraged compliance with wound care today. Start betadine to all wounds. Discussed importance of keeping her wounds clean and dry to prevent infection . d. On 11/16/22 The Physician's Orders documented, Cleanse vascular ulcer to right medial foot with wound cleanser and 4x4s, pat dry with 4x4s. Paint with betadine daily. Every day shift and as needed; Cleanse vascular ulcer to right 4th [fourth] toe with wound cleanser and 4x4s, pat dry with 4x4s. Paint with betadine daily. Every day shift and as needed; Cleanse vascular ulcer to left great toe with wound cleanser and 4x4s, pat dry with 4x4s. Paint with betadine daily. Every day shift and as needed; Cleanse vascular ulcer to left dorsal foot with wound cleanser and 4x4s, pat dry with 4x4s. Paint with betadine daily. Every day shift and as needed . e. On 11/16/22 at 09:40 am, Resident #1 was in the bathroom cleaning herself up after toileting. She transferred herself to her wheelchair and wheeled into her room. She was clean and well groomed. She had wounds on both feet. The 4th [fourth] toe on her right foot had an ulcer on the top of the toe that had a small amount of clear drainage with a light yellow/white appearance in the wound bed. She had another wound on her right foot that was dry. She had 2 wounds on her left foot, one on the top of her foot that had scabbed around the edges with a white center that appeared dry, and one on her left great toe that was scabbed. None were covered by dressings. She reported that she went to [named] clinic and was told by the doctor that was looking at her hip that he would not operate on her hip until she had a skin graft on the wound on the top of her left foot. She reported that the white center of the wound is a tendon. She stated, I've been trying to get Licensed Practical Nurse (LPN #1) down here to do something about them and she says that she will, but she doesn't come. The Surveyor asked, Do you see wound care doctors for your wounds? She replied, Yes, about every 3 weeks. f. On 11/17/22 at 09:10 am, The Surveyor asked the [named] Physician to look at the progress notes from the 11/10/22 on-site visit and asked, Is there an order associated with this visit? She replied, Yes, it is here in the plan. The Surveyor asked, Is it the start betadine to all wounds? She replied, Yes. The Surveyor asked, When was this order for betadine intended to be started? The Physician replied, The day it was written. The Surveyor asked, So on the tenth of November? She replied, Yes. The Surveyor asked, What is the process in which your orders are processed and implemented? She replied, Well, the nursing home keeps the original, I make a copy and turn it into the clinic, and it is put into the medical record there. The original goes to (LPN #1). I don't have anything to do with getting it into EHR [Electronic Health Record]. The Surveyor asked, Who is supposed to put it into EHR? She replied, I give it to (LPN #1). The Surveyor asked if she was aware that the order for betadine written on 11/10/22 had not been implemented until 11/16. She stated, I found out today. g. On 11/17/22 at 09:43 am, The Surveyor asked Licensed Practical Nurse (LPN) #1, On 11/10/22 when the [named] Physician was here and saw [Resident #1], Did she round by herself or did you round with her? LPN #1 replied, I rounded with her. The Surveyor asked to look at the visit notes and asked, What orders were written for [Resident #1] on 11/10/22? LPN #1 replied, Start Betadine to all wounds. The Surveyor asked LPN #1, Who's responsibility is it to process the orders? LPN #1 replied, Mine. The Surveyor asked LPN #1, Why wasn't the order processed? She replied, It should have been. The Surveyor asked, Why wasn't it? She replied, [Resident #1] has been non-compliant in the past with betadine. She says it makes her wounds too dry. The Surveyor asked LPN #1, What does it say the purpose for the betadine is in the physician's visit notes? She replied, To keep wounds clean and dry and prevent infection. The Surveyor asked, Does [Resident #1] have a history of osteomyelitis? LPN #1 replied, Yes. The Surveyor asked, Was she hospitalized in September and received IV (intravenous) Antibiotics? She replied, Yes. The Surveyor asked, What could happen if Physician's Orders aren't processed and implemented? She replied, A delay in treatment and potential infection. h. On 11/18/22 at 10:40 am, The Director of Nursing (DON) was asked to look at the [named Medical Facility] visit from 11/10/22. The Surveyor asked the Director of Nursing (DON), If you were given this from the doctor, would you interpret that as an order? She replied, Yes, I would have probably clarified the order but yes. The Surveyor asked, What would you do next? She replied, I would have updated the order in the resident's chart. The Surveyor asked, What could happen by not processing and implementing the order? She replied, She could get an infection and even become septic. i. On 11/18/22 at 09:10 am, The Minimum Data Set Coordinator (MDSC) provided a document titled, Wound Care that documented, .Preparation 1. Verify that there is a physician's order for this procedure .

Based on observation, record review, and interview, the facility failed to ensure that the use of Bi-pap (Bilateral Positive Airway Pressure) was documented on the Comprehensive Minimum Data Set (MDS) for 1 (Resident #16) of 1 sampled resident who had a Physician's Order for Bi-pap as documented on a list provided by the Nurse Consultant on 10/5/22 at 10:32 AM. The findings are: 1. Resident #16 had a diagnosis of Obstructive Sleep Apnea (OSA). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/20/22 documented a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). He did not use oxygen while a resident. a. A Physician's Order dated 1/11/22 documented, May have Bi-pap at night and PRN (as needed). IPAP (Inspiratory Positive Airway Pressure) 14, EPAP (Expiratory Positive Airway Pressure) 8, O2 [oxygen] @ (at) 2 LPM [liters per minute] bled in every evening shift related to obstructive sleep apnea. b. A Physician's Order dated 1/11/22 documented, Cleanse Bi-pap with warm water and soap. Let dry. Every day shift AND as needed. c. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/22 documented no use of C-pap or Bi-pap while a resident. Resident #16's Care Plan does not document the use of Bi-pap. d. The Policy titled, Resident Assessments which was provided by the Nurse Consultant on 10/5/22 at 10:32 AM documented, . A Comprehensive Assessment includes . completion of the Minimum Data Set . Completion of the Care Area Assessment (CAA) process, and development of the comprehensive care plan . e. On 10/03/22 at 12:11 PM, Resident #16's Bi-pap mask was lying on the nightstand and not in a bag. f. On 10/04/22 at 12:12 PM, Resident #16's Bi-pap mask was lying on the nightstand and not in bag. g. On 10/05/22 at 08:24 AM, Resident #16's Bi-pap mask was lying on the nightstand and not in a bag. h. On 10/06/22 09:19 AM, The Surveyor asked the Director of Nursing (DON), does Resident #16 have a Bi pap? She answered, Yes he has an order for at night and as needed. The Surveyor asked, what is the correct way to store the mask when it is not in use? She answered, It should be in a bag. The Surveyor asked, is the use of the Bi-pap documented on the comprehensive MDS? She answered, No. The Surveyor asked, is the use of the Bi-pap be documented on the Care Plan? She answered, No. The Surveyor asked, should the use of the Bi-pap be documented on the Comprehensive MDS and the Care Plan? She answered, Yes.

Based on record review and interview, the facility failed to ensure that an oral medication for pain was administered, to prevent pain for 1 resident (Resident #4) of 8 sampled residents (R#4, R#11, R#16, R#19, R#39, R#54, R#45, R#308.) who are dependent on staff for medications from the North Medication cart as documented on a list provided by the Director of Nursing on 10/5/22. The findings are: 1.Resident #4 had a diagnosis of E1.40-Type 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY UNSPECIFIED, M79.7-FIBROMYALGIA, M10.9-GOUT, UNSPECIFIED The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/21/2022 documented the resident scored a 15 (13-15 indicates Cognitively intact) on the Brief Interview for Mental Status (BIMs). She was on a scheduled pain medication regimen. 2. Physicians Orders documented Hydrocodone-Acetaminophen Tablet 10-325 MG [milligrams] *Controlled Drug* Give 1 tablet by mouth four times a day related to FIBROMYALGIA (M79.7) 3. The Care Plan dated 9/30/22 documented, . PROBLEM The resident has acute pain r/t [related to] Fibromyalgia, .INTERVENTIONS- Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. [Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), Registered Nurse (RN)] . 4. On 10/3/22 at 11:08 AM during initial rounds, Resident #4 stated, I'm glad ya'll are here, I haven't been getting all my medications and yesterday (10/2/22) I didn't get any of my noon medications. 5. On 10/4/22 during Record Review, the October 2022 Medication Administration Record (MAR) documented that Hydrocodone was to be given at 0500, 1100, 1700 and 2200. There was no documentation that the 11AM dose was administered. 6. On 10/5/22 at 11:30 AM, The Surveyor informed the Director of Nursing (DON) that resident #4 had voiced that she did not receive her medications on10/2/22. The DON stated, I found out this morning that she didn't get her medications yesterday. 7. ON 10/5/22 at12:15 PM, The Surveyor asked LPN #2 if she gave resident #4's medication on 10/2/2022? LPN#2 stated, Yes. Did you give her, her Noon medications? LPN #2 stated, No, she was out for church, I didn't know she was back. The Surveyor asked if the signature on the narcotic book for 12 PM was hers? LPN #2 stated No. 8. On 10/5/22 at 11:45AM The Surveyor asked Certified Nurse Assistant (CNA) #4, did you work the North Hall on 10/2/22? She answered, Yes. The Surveyor asked, Were you aware of Resident #4 not getting her medication at Noon? She answered, Yes, she was rolling up the hall mad because she had gotten back from church and had not gotten her main med. I asked her if she wanted me to tell the nurse and she told me no that she was going to do that herself. 9. On 10/5/22 at 12:05 PM, The Surveyor asked CNA #3, did you work the North Hall on 10/2/22? She answered, Yes. The Surveyor asked, Were you aware of Resident #4 not getting her medication at Noon? She answered, Yes, I sat her lunch tray up and she told me. I went right away and told (LPN#2). When I went back to pick up her lunch tray, she still had not gotten it, so I went again to tell (LPN#2) I told her twice. 10. The Surveyor asked LPN #2, why did you give Resident #4 her noon meds but not her Hydrocodone? She stated, By the time I knew she was back from church, it was too close to her next dose to give it. No one told me she was hurting. The Surveyor asked, Did you notify the MD? She stated, No 11. On 10/5/22 at 12:55 PM, The Surveyor asked Resident #4 if she was hurting during the missed medication time and she stated, Oh yes, I have bad pain when I don't get them. The Surveyor asked, on a scale of 1-10 what is your pain level with 1 being the least and 10 being the worst pain? She responded, a 9. 12. The POLICY, ADMINISTERING ORAL MEDICATIONS, provided by the nurse consultant on 10/5/22 at 2:15 PM documented, Verify that there is a physician's medication order for this procedure.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 7 residents who received pureed diets as documented on the List Dietary Supervisor provided on 10/3/2022. The findings are: 1. On 10/03/22 at 11:44 AM, Dietary Employee #2 placed servings of barbeque pulled pork into a blender, added beef broth and pureed. She poured the pureed pulled pork into a pan. She covered the pan with a piece of foil and placed it in the oven. The consistency was gritty, not smooth. 2. On 10/03/22 at 11:55 AM, Dietary Employee #2 used #8 scoop to place 7 servings of macaroni and cheese into a blender, added whole milk and pureed. On 10/03/22 at 12:02 PM, Dietary Employee #2 poured the pureed Macaroni and Cheese in a pan, covered with a piece of foil, and placed in the oven. The consistency of the pureed macaroni was lumpy, not smooth. There were pieces of macaroni visible in the mixture. 3. On 10/03/22 at 12:07 PM, Dietary Employee #2 used a 4 oz (ounce) spoon to place 7 servings of baked beans into a blender and pureed. She poured the pureed baked beans in a pan and placed in the oven. The consistency was thick, not smooth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure all areas of the building were in good repair for the bathroom of 2 (Resident #3, #16) of 2 sampled residents whose bathrooms were inspected. The findings are: 1. On 10/03/22 at 12:07 PM, Resident #3 reported that her bathroom continuously had water in the floor. Resident stated that since the water is so close to the toilet, she wasn't certain what the liquid was and that was distressing to her. A puddle of water was in the floor 6 inches from the base of the toilet. The area of liquid extended back toward the wall 2 feet and was 6 - 8 inches wide. There was an area along the left wall of the bathroom that was discolored approximately 4 feet long. On each end of the discoloration were areas where the plaster was missing from the wall. 2. On 10/03/22 at 12:30 PM, Resident #16 approached the Surveyor and stated, have you looked at my bathroom yet? Please check the bathroom. It's bad. The tile was coming up off the floor in front of the toilet. The brown plastic base board was missing from the edge of the wall to the floor and near the doorway. There was a very strong odor of urine in the bathroom. 3. A Policy titled, Maintenance Service which was provided by the Nurse Consultant on 10/5/22 at 10:32 AM documented, . Maintenance Service shall be provided to all areas of the building, grounds, and equipment . the Maintenance Director is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times . 4. On 10/04/22 at 02:38 PM, The Surveyor asked the Maintenance Director, tell me the process for making environmental rounds. He answered, When I come in every day, I check all the lights and change bulbs and ballasts. I check the bathrooms about once a week and fix toilets, etc. If there is a problem that needs fixed, they log it in my log, and I fix it. The Surveyor asked, are you aware of any issues in the bathroom in room [ROOM NUMBER]? He answered, Yes. There are 4 men who share that bathroom. There is one man who urinates on the floor in there. I'm working on that smell. I got some chemicals to get the smell out of the concrete. That tile is chipped and not a tripping hazard. The Surveyor asked, would you want to use that bathroom? He answered, No ma'am. But the housekeepers are working on the smell. The Surveyor asked, how often are the housekeepers applying the chemical? He answered, I'm not sure but I think twice a week. The Surveyor asked, how long have they been using it? He answered, About a month. The Surveyor asked, would you say the chemical is working? He answered, I'm not sure. Maybe not. 5. On 10/05/22 at 08:15 AM, The Surveyor asked Certified Nursing Assistant CNA #2, tell me about the bathroom in room [ROOM NUMBER]. She answered, It needs to be fixed. The tile. And it smells like urine. The Surveyor asked, would you want to use this bathroom? She answered, You are putting me on the spot, but no. 6. On 10/05/22 at 08:24 AM, The Surveyor asked Resident #16, has the facility done anything to get rid of the smell in your bathroom? He answered, They put shaving cream on it and something else. The Surveyor asked, has that helped the smell? He answered, No. As long as he keeps peeing on the floor it's never going to get any better. The Surveyor asked, does the condition of the bathroom bother you? He answered, Yes.

Based on observation, record review, and interview the facility failed to inform the residents and/or their representatives of a change in the COVID-19 status of the building by 5:00 PM on the next calendar day after positive test results. The failed practice had the potential to affect 63 residents according to the room/bed list provided by the Administrator on 10/03/22 at 11:10 AM. The findings are: According to a list provided by the Administrator on 10/04/22 at 9:00 AM the facility had an employee test positive for COVID-19 on 8/31/22 and 9/12/22. According to a review of the electronic medical records there were no family or resident notifications of a change in the COVID-19 status of the building which were made on 09/01/22 or 9/13/22 which would have met the requirement of resident/family notification by 5:00 PM of the next calendar day after positive results. a. On 10/06/22 at 10:10 AM, The Surveyor asked the Director of Nursing (DON) who was responsible for notifying the resident and their representatives of a change in COVID-19 status in the building. She stated .it's really a team effort. Our Infection Preventionist takes a list of all the residents and divides it up between all the department heads and we each make the calls . b. On 10/06/22 at 10:12 AM, The Nursing Consultant provided a policy entitled, Coronavirus Disease (COVID-19) - Testing Residents. The Management of Testing and Reporting #4 stated, Facility resident/responsible party/family will be notified of positive tests within the building by 5 PM the following day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that the use of a Bi-pap was documented on the Comprehensive Care Plan to meet the resident's needs for 1 (Resident #16) of 1 sampled resident who had a Physician's Order for Bi-pap (Bilateral Positive Airway Pressure) as documented on a list provided by the Nurse Consultant on 10/5/22 at 10:32 AM, and the facility, and the facility failed to ensure the use of oxygen was documented on the Care Plan for 3 (Resident #) 16, #24, #55) of 6 (Resident ##16, #24, $49, #54, #55) sampled residents who had a Physician's Order for oxygen as documented on a list provided by the Nurse Consultant on 10/5/22 at 1:34 PM. The findings are: 1. Resident #16 had a diagnosis of Obstructive Sleep Apnea (OSA). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/20/22 documented a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). He did not use oxygen while a resident. a. A Physician's Order dated 1/11/22 documented, May have Bi-pap at night and PRN (as needed). IPAP (Inspiratory Positive Airway Pressure) 14, (Expiratory Positive Airway Pressure) EPAP 8, O2 [oxygen] @ (at) 2 LPM (liters per minute) bled in every evening shift related to obstructive sleep apnea. b. A Physician's Order dated 1/11/22 documented, Cleanse bi-pap with warm water and soap. Let dry. Every day shift AND as needed. c. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/22 documented no use of C-pap or Bi-pap while a resident. d. Resident #16's Care Plan did not document the use of Bi-pap. e. The Policy titled, Care Plans, Comprehensive Person Centered which was provided by the Nurse Consultant on 10/5/22 at 10:35 AM documented, . 7. The comprehensive person-centered care plan . Describes the services that are to be furnished . which professional services are responsible for each element of care . f. On 10/03/22 at 12:11 PM, Resident #16's Bi-pap mask was lying on the nightstand and not in a bag. Photo taken at 12:11 PM. g. On 10/04/22 at 12:12 PM, Resident #16's Bi-pap mask was lying on the nightstand and not in bag. h. On 10/05/22 at 08:24 AM, Resident #16's Bi-pap mask was lying on the nightstand and not in a bag. i. On 10/06/22 at 09:19 AM The Surveyor asked the Director of Nursing, does Resident #16 have a Bi-pap? She answered, Yes he has an order for at night and as needed. The Surveyor asked, what is the correct way to store the mask when it is not in use? She answered, It should be in a bag. The Surveyor asked, is the use of the Bi-pap documented on the comprehensive MDS? She answered, No. The Surveyor asked, is the use of the Bi-pap documented on the Care Plan? She answered, No. The Surveyor asked, should the use of the Bi-pap be documented on the Comprehensive MDS and the Care Plan? She answered, Yes. 2. Resident #24 was admitted on [DATE] and acquired a diagnosis of Shortness of Breath on 7/7/22. A Quarterly Minimum Data Set with an Assessment Reference Date of 8/12/22 documents that resident requires limited assistance for toileting and personal hygiene and that resident scored a 14 (13-15 cognitively intact) on a Brief Interview for Mental Status. a. On 10/3/22 at 2:09 pm, the resident was lying in bed with eyes closed. The Oxygen was on 3 Liters per minute via nasal cannula. b. On 10/4/22 at 2:42 pm, the Record Review showed a Physician's Order dated 7/7/22 for .Oxygen every hour as needed for shortness of breath 2 Liters/Min per nasal cannula PRN (As Needed) and every shift for Shortness of Breath . c. On 10/6/22 at 9:58 am, The Surveyor asked the Director of Nursing (DON), What should the oxygen rate be set on? She stated, Whatever is prescribed by the doctor, it's per doctor orders. The Surveyor asked, Where should oxygen tubing be stored when not in use? She stated, In its bag. 3. Resident #55 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease and Shortness of Breath. A Significant Change Minimum Data Set with an Assessment Reference Date of 9/21/22 documents that resident requires extensive assistance for bed mobility, transfers, toileting, and personal hygiene and that resident scored a 3 (0-7 severe cognitive defect) on a Brief Interview of Mental Status (BIMS). a. On 10/03/22 at 12:27 pm, the resident was asleep in bed with Oxygen at 3.5 Liters per minute via nasal cannula. b. On 10/04/22 at 12:45 pm, during record review showed a physician's order dated 1/21/22 for .Oxygen as needed for Shortness of Breath for 10 days 2 liters/min per nasal cannula PRN and every shift .and showed no oxygen addressed under altered respiratory status in the care plan. c. On 10/04/22 at 1:06 pm, the resident was up for lunch with portable Oxygen. The Oxygen in the room on 3.5L and tubing laying across bed. Certified Nursing Assistant (CNA) #1 helped get her up for lunch. The Surveyor asked, Is there not a bag for her oxygen tubing in her room? She stated, Madison was supposed to get one. d. On 10/04/22 at 1:18 pm, The Surveyor asked LPN #1, What is [R#55]'s oxygen order? She stated, Her PRN (as needed) order? It's for 2 Liters per minute. The surveyor asked, Why is it on 3.5 liters on her oxygen concentrator in her room? She stated, I don't know, but I put her portable one on 2 Liters. e. A facility policy titled Oxygen Administration received by the nurse consultant on 10/05/22 documents .1. Verify that there is a physician's order for this procedure

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that a Bi-Pap mask was appropriately stored to prevent contamination and potential infection for 1 (Resident #16) of 1 sampled resident who had a Physician's Order for Bi-Pap (Bilateral Positive Airway Pressure) as documented on a list provided by the Nurse Consultant on 10/5/22 at 10:32 AM, and the facility, and the facility failed to ensure oxygen tubing was appropriately stored to prevent contamination and potential for infection for 1 (Resident #55 ) of 6 (Resident #16, #24, #49, #52, #54, #55) sampled resident who had a Physician's Order for oxygen, and the facility failed to ensure that oxygen was administered at the ordered rate for 2 (Resident #24 and #55) of 6 (Resident) #16, #24, #49, #52, #54, #55) sampled residents who had a Physician's Order for oxygen as documented on a list provided by the Nurse Consultant on 10/5/22 at 1:34 PM. The findings are: 1. Resident #16 had a diagnosis of Obstructive Sleep Apnea (OSA). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/20/22 documented a score of 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). He did not use oxygen while a resident. a. A Physician's Order dated 1/11/22 documented, May have Bi-Pap at night and PRN (as needed). IPAP (Inspiratory Positive Airway Pressure) 14, EPAP (Expiratory Positive Airway Pressure) 8, O2 @ (at) 2 LPM (liters per minute) bled in every evening shift related to obstructive sleep apnea. b. A Physician's Order dated 1/11/22 documented, Cleanse Bi-Pap with warm water and soap. Let dry. Every day shift AND as needed. c. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/11/22 documented no use of C-Pap or Bi-Pap while a resident. Resident #16's Care Plan does not document the use of Bi-pap. d. The Policy titled, CPAP/Bi PAP Support which was provided by the Nurse Consultant on 10/5/22 at 10:35 AM documented, . To promote resident comfort and safety . e. On 10/03/22 at 12:11 PM, Resident #16's Bi-pap mask was on the nightstand and not in a bag. Photo taken at 12:11 PM. f. On 10/04/22 at 12:12 PM, Resident #16's Bi-pap mask was on the nightstand and not in bag. g. On 10/05/22 at 08:24 AM, Resident #16's Bi-pap mask was on the nightstand and not in a bag. h. On 10/06/22 at 09:19 AM, The Surveyor asked the Director of Nursing, does Resident #16 have a Bi-pap? She answered, Yes he has an order for at night and as needed. The Surveyor asked, what is the correct way to store the mask when it is not in use? She answered, It should be in a bag. The Surveyor asked, is the use of the Bi-pap documented on the comprehensive MDS? She answered, No. The Surveyor asked, should use of the Bi-pap be documented on the Care Plan? She answered, No. The Surveyor asked, should the use of the Bi-pap be documented on the Comprehensive MDS and the Care Plan? She answered, Yes. 2. Resident #24 was admitted on [DATE] and acquired a diagnosis of Shortness of Breath on 7/7/22. A Quarterly Minimum Data Set with an Assessment Reference Date of 8/12/22 documents that resident requires limited assistance for toileting and personal hygiene and that resident scored a 14 (13-15 cognitively intact) on a Brief Interview for Mental Status. a. On 10/3/22 at 2:09 pm, the resident was lying in bed with eyes closed. The Oxygen was on 3 Liters per minute via nasal cannula. b. On 10/4/22 at 2:42 pm, the Record Review showed a Physician's Order dated 7/7/22 for .Oxygen every hour as needed for shortness of breath 2 Liters/Min per nasal cannula PRN (As Needed) and every shift for Shortness of Breath . c. On 10/6/22 at 9:58 am, The Surveyor asked the Director of Nursing (DON), What should the oxygen rate be set on? She stated, Whatever is prescribed by the doctor, it's per doctor orders. The Surveyor asked, Where should oxygen tubing be stored when not in use? She stated, In its bag. 3. Resident #55 was admitted with diagnoses of Chronic Obstructive Pulmonary Disease and Shortness of Breath. A Significant Change Minimum Data Set with an Assessment Reference Date of 9/21/22 documents that resident requires extensive assistance for bed mobility, transfers, toileting, and personal hygiene and that resident scored a 3 (0-7 severe cognitive defect) on a Brief Interview of Mental Status (BIMS). a. On 10/03/22 at 12:27 pm, the resident was asleep in bed with Oxygen at 3.5 Liters per minute via nasal cannula. b. On 10/04/22 at 12:45 pm, during record review showed a physician's order dated 1/21/22 for .Oxygen as needed for Shortness of Breath for 10 days 2 liters/min per nasal cannula PRN and every shift .and showed no oxygen addressed under altered respiratory status in the care plan. c. On 10/04/22 at 1:06 pm, the resident was up for lunch with portable Oxygen. The Oxygen in the room on 3.5L and tubing laying across bed. Certified Nursing Assistant (CNA) #1 helped get her up for lunch. The Surveyor asked, Is there not a bag for her oxygen tubing in her room? She stated, Madison was supposed to get one. d. On 10/04/22 at 1:18 pm, The Surveyor asked LPN #1, What is [R#55]'s oxygen order? She stated, Her PRN (as needed) order? It's for 2 Liters per minute. The surveyor asked, Why is it on 3.5 liters on her oxygen concentrator in her room? She stated, I don't know, but I put her portable one on 2 Liters. e. A facility policy titled Oxygen Administration received by the nurse consultant on 10/05/22 documents .1. Verify that there is a physician's order for this procedure

Based on observation, record review, and interview, the facility failed to ensure medications were stored and labeled properly and safely in 1 sampled resident's room (Resident #308). This failed practice had the potential to affect 4 (Resident #4, #11, #16, #308) sampled residents who were independent or supervised with locomotion on the North Hall as documented on a list provided by the Director of Nursing (DON) on 10/6/22 at 9:56 AM, and the facility failed to date multi dose Insulin bottles and Insulin pens when opened to ensure potency. This failed practice had the potential to affect 7 (Resident #4, #9, #16 #19, #26 #40, #54) sampled residents who receive Insulin from the North Hall medication cart, as documented on a list provided by the Nurse Consultant on 10/6/22 at 8:34 AM. The findings are: 1. On 10/03/22 at 12:20 PM, a bottle of Nasal Decongestant Spray and a tube of Polysporin ointment were on Resident #308's nightstand. The resident was not in the room. a. On 10/04/22 at 08:57 AM, a bottle of Nasal Decongestant Spray and a tube of Polysporin ointment were on Resident #308's nightstand. The Surveyor asked the Resident, tell me about the Nasal Decongestant Spray and Polysporin ointment? He answered, I use that when I get a nosebleed. The Surveyor asked, does the facility supply this for you? He answered, I get it myself. The Surveyor asked,; have you been assessed to self-administer your medications? He answered, I don't know. b. On 10/04/22 at 02:00 PM, review of the Medical Record for Resident #308 revealed he had no Physician's Order for Nasal Decongestant Spray or Polysporin Ointment. c. On 10/04/22 at 02:29 PM, Resident #308 did not have an assessment in the Electronic Record for self-administration of medications. He did not have a Care Plan to self-administer his medications. d. On 10/05/22 at 08:26 AM, a bottle of Nasal Decongestant Spray was on Resident #308's overbed table and a tube of Polysporin ointment was on the resident's bed. The Surveyor asked, have you used these lately? He answered, Yes. I used it last night because I had a nosebleed. The nasal spray for the nosebleed and the ointment inside my nose for dryness. They couldn't get my blood pressure down and my sinuses were stopped up on the right side. e. A Policy titled, Storage of Medications provided by the Director of Nursing (DON) on 10/05/22 at 10:50 AM documented, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Drug containers that have missing, incomplete, improper or incorrect labels shall be returned to the pharmacy for proper labeling before storing .Drugs for external use . shall be clearly marked as such . f. The Package Insert for Major Pharmaceuticals Nasal Decongestant Spray documented, .ask a doctor before use if you have .high blood pressure .if swallowed get medical help or contact the Poison Control Center immediately . g. The Package Insert for Polysporin ointment documented, .For external use only .if swallowed get medical help or contact the Poison Control Center immediately . 2. On 10/05/22 at 11:31 AM, under the supervision of Licensed Practical Nurse (LPN) #4, the North Hall Medication cart was inspected. She retrieved the keys to the Narcotic Drawer from LPN #5. She stated, She has my keys because I'm also the social worker and I do the admissions. LPN #5 gave LPN #4 the keys and they did not count narcotics when they keys were exchanged. An unlabeled bottle of Cortisporin drops was in the top drawer of the medication cart. There was one opened bottle of Novolog Insulin for Resident #16, two opened bottles of Levemir Insulin for Resident #9, 1 opened bottle of Glargine Insulin for Resident #40, 1 opened bottle of Glargine Insulin for Resident #26. None of the bottles had open dates. There was 1 opened Levemir pen for Resident #40 and 1 opened Basaglar pen for Resident #4. None of the pens had open dates. The Surveyor asked, how do you know when these were opened? She answered, There's supposed to be a date when we open them. a. A Policy titled. Insulin Storage Policy provided by the Nurse Consultant on 10/5/22 at 1:15 PM documented, . Insulin vials .Date insulin vials when first opened . b. On 10/06/22 at 08:30 AM, The Surveyor asked LPN #3, is R #308 assessed to self-administer his medications. She answered, Not to my knowledge. She looked at the electronic record and stated, No he is not. The Surveyor asked, does he have a Physician's Order for Nasal Decongestant Spray or Polysporin ointment? She answered, No. The Surveyor asked, if a resident is not assessed to self-administer medications, should they have medications in their rooms? She answered, No. The Surveyor asked, what could happen? She answered, Another resident could get them, overdose, any number of things could happen. The Surveyor asked, how long do you use insulin after you open the vial? She answered, Most are 28 days. The Surveyor asked, how do you know when the vial is opened? She answered, We write the date on the label. The Surveyor asked, if a vial of Insulin is open and there is not a date on the label, how do you know it is still useable? She answered, If I find an open vial that is not dated, I don't use it. I get another one. c. On 10/06/22 at 09:19 AM, The Surveyor asked the DON, is Resident #308 assessed to self-administer medications? She answered, No. The Surveyor asked, does he have a Physician's Order for Nasal Decongestant Spray or Polysporin ointment? She answered, No. The Surveyor asked, if a resident is not assessed to self-administer medications, should they have medications in their rooms? She answered, No. The Surveyor asked, what could happen? She answered, Another resident could get them, they could give the incorrect dose, it's just not safe. The Surveyor asked, how long do you use Insulin after you open the vial? She answered, Most are 28 days. The Surveyor asked, how do you know when the vial is opened? She answered, The nurses are supposed to date them when they open them. The Surveyor asked, if a vial of Insulin is open and there is not a date on the label, how do you know it is still useable? She answered, I've instructed the nurses to throw it away and get a new one because there is no way to know.

Based on observation and interview the facility failed to maintain a shower chair and resident bed pans in a manner as to provide a sanitary, and comfortable environment for residents. The failed practice had the ability to effect 5 (R# 9, #10, #19, #39, #54) of the 26 sampled residents who utilize the shower chair for personal hygiene and 8 (R#9, #10, #19, #26, #39, #40, #45, #54). of the 26 residents who require assistance with toileting. The findings are: 1.The following observations were made in Resident #4's room and bathroom and interviews regarding the bedpans in Resident #4's room and bathroom: a. On 10/03/22 at 11:15 AM, in Resident #4 's room, there were 2 bedpans and a face pan in the floor with used toilet paper and 1 bedpan contained a dried brown substance. b. On 10/04/22 at 09:40 AM, the bedpans remained in the floor with same substance in them. c. On 10/05/22 at 02:30 PM, the bedpans remained in the floor with the same brown substance in them. d. On 10/06/22 at 09:43 AM, the bedpans with brown substance remained in the bathroom floor. e. On 10/06/22 at 09:45 AM, The Surveyor asked Housekeeper #1, Who cleans the bedpans if they are dirty? The Housekeeper responded, Housekeeping does them. f. On 10/6/22 at 9:50 AM, The Surveyor asked Certified Nurse Assistant (CNA)#6, Who cleans the bedpans if they are dirty? The CNA responded, CNAs do. g. On 10/6/22 at 10:00 AM, The Surveyor asked the Director of Nursing (DON), who cleans the bedpans if they are dirty? The DON responded, CNAs get that up. 2. On 10/6/22 at 09:17 AM, a reclining shower chair was sitting in the North Hall. The back of the chair had a black substance that included clumps of hair along the back of the seat bottom. The edges of the flat surface and joints of the chair were covered in a dried, brownish substance. Certified Nursing Assistant #4 (CNA) stated, we have been telling them that we need something to clean that with. CNA #4 unsnapped the cushion, lifted it and revealed a dark colored substance that smelled of feces. CNA #4 continued to describe how she did not like to use this particular shower chair. She stated, when we use this one, we have to wash their butts in the bed because we can't get to them. I wish it was like this one. (She motioned toward a shower chair with a seat fashioned like a toilet seat).

Based on observation, record review, and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment. This failed practice had the potential to affect residents who received meals from the kitchen (total census:) as documented on a list provided by Dietary Supervisor on 9/8/22. The findings are: 1. On 10/03/22 at 11:24 AM, Dietary Employee #1 opened the entrance door to the kitchen and spoke to the residents and without washing her hands, she removed gloves from the glove box, placed them on her hands, contaminated the gloves. She used the gloved hands to separate the meat to be served to the residents for the lunch meal. 2. On 10/03/22 at 11:32 AM, Dietary Employee #1 opened the refrigerator and took a glass of juice by the rim and placed it on the counter. She picked up a cup of coffee and placed it on the counter. She unwrapped 2 straws, picked them up by their tips. She placed one in a glass of juice and placed the other in a cup of coffee to be served to the residents who requested coffee and or juice. 3. On 10/03/22 at 11:38 AM, Dietary Employee #2 placed a scale on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in preparing foods to be served to the residents. 4. On 10/03/22 at 11:47 AM, Dietary Employee #1 took out a box of broccoli cuts from the freezer and placed it on the counter. She turned on the sink faucet and ran water on the rag. She then turned off the faucet. She used the rag to wipe off spilled food from the counter and contaminated her hands. Without washing her hands, she picked up a pan, placed it on the counter with her fingers inside the pan. The pan was used for meat to be served to the residents for the lunch meal. 5. On 10/03/22 at 12:01 PM, Dietary Employee #1 removed all the pans that contained food items to be served for lunch from the oven and placed them on the steam table. Without washing her hands, she used her bare hands to pick up a piece of foil that was on the meat with her thumb touching the meat. 6. On 10/03/22 at 12:26 PM, Dietary Employee #1 turned on the sink faucet and washed her hands, she turned the facet off. Without washing her hands, she picked up glasses by their rims and placed them in a rubber container. The Surveyor asked, what should you have done after touching dirty objects ad before handling clean equipment? She stated, I should have washed my hands. 7. The facility's policy for hand washing provided by the Dietary Supervisor on 10/04/22, documented, Any other time deemed necessary.

Based on record review and interview the facility failed to inform the residents and/or their representatives of a change in the COVID-19 status of the building by 5:00 PM on the next calendar day after positive test results. The failed practice had the potential to affect 63 residents according to the room/bed list provided by the Administrator on 10/03/22 at 11:10 AM. The findings are: 1. According to a list provided by the Administrator on 10/04/22 at 9:00 AM, the facility had a resident test positive for COVID-19 on 07/8/22 and 07/16/22. a. According to a review of the Electronic Medical Records, there were no family or resident notifications of a change in the COVID-19 status of the building made on 07/9/22 or 07/16/22 by 5:00 PM the next calendar day. 2. According to a list provided by the administrator on 10/04/22 at 9:00 AM the facility had an employee test positive for COVID-19 on 08/31/22, and 09/12/22. a. According to a review of the electronic medical records there were no family or resident notifications of a change in the COVID-19 status of the building made on 09/01/22 or 09/13/22 by 5:00 PM the next calendar day. 3. On 10/06/22 at 10:10 AM, the Surveyor asked the Director of Nursing (DON), who is responsible for notifying the resident and their representatives of a change in COVID-19 status in the building? She stated, it's really a team effort. Our Infection Preventionist takes a list of all the residents and divides it up between all the department heads and we each make the calls. 4. On 10/06/22 at 10:12 AM, the Nursing Consultant provided a policy entitled, Coronavirus Disease (COVID-19) Testing Residents . 4. The Management of Testing & and Reporting: the Facility resident/responsible party/family will be notified of positive tests within the building by 5 PM the following day.