**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases (illnesses that can be spread from one person, animal, or object to another) and infections for five of seven residents (Resident 2, 3, 4, 5, and 6) when: 1. Resident 2, 3, 4, 5, and 6's personal trash bins (a metal or plastic container used for discarding garbage) without lids located at the bedside contained used blue rubber gloves (protective coverings for the hands designed to shield against chemicals, contamination, and other harmful substances). 2. Two of six large yellow barrels (a cylindrical container) with lids labeled soiled linen (gowns, bedsheets, drawsheets, towels etc. which were exposed to fluids from the human body such as stool; fecal matter, urine, and vomit) located in the east hall contained used blue rubber gloves. These failures had the potential to expose Resident 2, 3, 4, 5, and 6, and staff to the transmission of communicable diseases and infections. Findings: During an interview on 4/9/25 at 2:34 p.m. with Resident 1, Resident 1 stated she was admitted on [DATE] after having back surgery. Resident 1 stated she was transferred to the hospital with an infection on her back on 3/26/25. Resident 1 stated the Certified Nursing Assistant (CNA) changed the roommate's briefs (adult diaper) and Resident 1 witnessed the CNA discard a pair of used blue rubber gloves into the trash bin by her bed after the care was provided. Resident 1 was unable to recall the CNA's name and the date. Resident 1 stated the trash bin did not have a lid. Resident 1 stated the trash bin had a foul odor when she went to inspect the trash bin and she found the used blue rubber gloves with stool on it. Resident 1 stated she tied the trash liner (a plastic bag covering a container) and the stool got on her hands. Resident 1 stated she reported the incident to a staff member and the facility installed a large trash bin in the room with a lid. During a review of Resident 1's admission Record (AR) , dated 4/16/25, the AR indicated Resident 1 was admitted on [DATE] with a history of Intervertebral Disc Displacement, Lumbar Region (protrusion or herniation of the cushion-like disc resting between any two of the five lumbar vertebrae; vertebrae L1 through L5 in the lower spine). During a review of Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) , dated 3/8/25, the BIMS score was 14 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). During a review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long-term care nursing facilities), dated 3/26/25, the MDS indicated Resident 1 required setup assistance (helper sets up or cleans up and resident completes activity) with toileting hygiene (the ability to maintain cleanliness after voiding or bowel movement). During a review of Resident 1's Progress Notes (PN) , dated 3/26/25, the PN indicated, . resident wants to go to hospital for her pain . resident state I have pain 10:10 (ten out of ten- pain scale used to measure the level of pain a person is experiencing with a score of zero indicating no pain up to a score of ten indicating worse pain imaginable) and I want to go to hospital. MD (Medical Doctor) notified via phone call and MD gave phone order to transfer the resident to acute care facility for further evaluation . resident transferred to [name of hospital] at 2:15 p.m. During a concurrent observation and interview on 4/16/25 at 9:45 a.m. in Resident 2's room with CNA 1, the small trash bin without a lid located next to Resident 2's bed contained a pair of used blue rubber gloves. CNA 1 stated staff were required to don (the act of putting on personal protective equipment [PPE] such as gloves, gowns, and face mask in the healthcare setting) blue rubber gloves when providing care to the residents. CNA 1 stated after the care was provided, staff were required to discard the used blue rubber gloves in a bin with a lid or in the yellow barrels labeled soiled linen in the hallway. CNA 1 stated used blue rubber gloves may contain urine and stool. CNA 1 stated the used blue rubber gloves should not have been discarded in the small trash bin by Resident 2's bed. CNA 1 stated the small trash bin next to Resident 2's bed was for Resident 2's personal use. CNA 1 stated the used blue rubber gloves should have been discarded in a trash bin with a lid to prevent cross contamination and infection. During an interview on 4/16/25 at 10:00 a.m. with the Infection Preventionist (IP), the IP stated used blue rubber gloves should be discarded in trash bins with a lid in the residents' room and soiled linen should be discarded in the yellow barrel labeled soiled linen outside the residents' room. The IP stated waste product such as urine and stool should be contained in a plastic bag and discarded in trash bins with lids. The IP stated staff were permitted to use the yellow barrels labeled soiled linen to transport waste product to the trash bins located outside the facility. The IP stated if staff discarded wasted products in the yellow barrels, it must be contained in a separate plastic bag and discarded immediately. The IP stated discarding used blue rubber gloves in the trash bins by the resident's bed and in the yellow barrels uncontained was unacceptable and can increase the transmission of diseases and the spread infection. During a concurrent observation and interview on 4/16/25 at 10:05 a.m. in the east hall with the IP, six yellow barrels labeled soiled linen with lids were lined up next to one another. One yellow barrel contained used blue rubber gloves and linen mixed together. The IP stated the soiled linen should be contained in a separate plastic bag and the used blue rubber gloves should be contained in a separate plastic bag. The IP stated it was unacceptable to mix used blue rubber gloves and soiled linen together. During a concurrent observation and interview on 4/16/25 at 10:10 a.m. in Resident 3's room with the IP and CNA 2, the small trash bin without a lid located next to Resident 3's bed contained a pair of used blue rubber gloves. CNA 2 stated used blue rubber gloves should not be discarded in Resident 3's personal trash bin and should be discarded in trash bins with lids to minimize the transmission of diseases and prevent the spread infection. The IP stated discarding the used blue rubber gloves in Resident 3's personal trash bin was unacceptable. During a concurrent observation and interview on 4/16/25 at 10:15 a.m. in Resident 4's room with the IP, the small trash bin without a lid located next to Resident 4's bed contained a pair of used blue rubber gloves. The IP stated discarding the used blue rubber gloves in Resident 4's personal trash bin was unacceptable. During a concurrent observation and interview on 4/16/25 at 10:20 a.m. in Resident 5's room with Resident 5 and the IP, the small trash bin without a lid located next to Resident 5's bed contained a pair of used blue rubber gloves. Resident 5 stated staff provided care in the morning for him with the blue rubber gloves and staff discarded the used blue rubber gloves in the trash bin after the care. The IP stated discarding the used blue rubber gloves in Resident 5's personal trash bin was unacceptable. During a concurrent observation and interview on 4/16/25 at 10:25 a.m. in Resident 6's room with the IP, the small trash bin without a lid located next to Resident 6's bed contained a pair of used blue rubber gloves. The IP stated discarding the used blue rubber gloves in Resident 6's personal trash bin was unacceptable. During a concurrent observation and interview on 4/16/25 at 10:31 a.m. Resident 7's room with CNA 3 and the IP, there was a plastic bag tied at the top with used wipes containing stool. The plastic bag was placed on the floor by the door. CNA 3 stated she had just finished providing care to Resident 7 and was going to transport the plastic bag with the used wipes in a yellow barrel labeled soiled linen to discard the plastic bag into the trash bins located outside the facility. When CNA 3 obtained the yellow barrel labeled soiled linen, there was no plastic liner inside the barrel and two pairs of used blue rubber gloves were at the bottom of the barrel. CNA 3 stated the used blue rubber gloves should have been contained in a plastic bag and discarded in the trash waste bin outside the facility to minimize the transmission of diseases and prevent the spread infection. The IP stated discarding the used blue rubber gloves in the yellow barrel uncontained was unacceptable. During an interview on 4/16/25 at 12:07 p.m. with the Laundry Staff (LS), the LS stated the laundry staff were responsible to collect the soiled linen from the yellow barrels labeled soiled linen to be washed. The LS stated there was trash and soiled linen in the barrels. The LS stated the laundry staff would have to separate the trash from the soiled linen. The LS stated she would find used blue rubber gloves in the soiled linen barrel but was contained in a plastic bag and were discarded in the gray trash bins outside the facility. The LS stated used blue rubber gloves were required to be contained in a plastic bag because they were considered dirty and could possibly have germs on them. The LS stated containing the used blue rubber gloves was required for the prevention of infection and cross contamination. During an interview on 4/16/25 at 11:00 a.m. with the Director of Maintenance (DM), the DM stated staff were required to discard used blue rubber gloves in trash bins with lids. The DM stated soiled linen barrels were dedicated for soiled linen only and gray barrels with lids will be provided in the hallway for staff to discard waste products such as used PPEs. The DM stated each room had large bins with lids and were being washed outside the facility and will be returned to each room for staff to discard waste products into. The DM stated the small trash bins located next to the residents' bedside were for residents' personal use and staff should not be discarding used blue rubber gloves or other waste products in it. The DM stated the Infection Prevention Program was required to minimize cross contamination to prevent spread of infections. During an interview on 4/16/25 at 11:10 a.m. with the IP, the IP stated Infection Prevention In-services (training and education) were provided to staff every month. The IP stated staff were in-serviced on the use of the yellow soiled linen barrels and staff were in-serviced on discarding used PPEs. The IP stated soiled linen barrels were dedicated for soiled linen only. The IP stated waste products such as used PPEs and wipes should be contained in plastic bags and discarded in a gray bin with a lid. The IP stated waste products and soiled linen should not be mixed in the soiled linen barrels without containment. The IP stated the small trash bins without a lid located next to the residents' bed were for residents' personal use and staff should not be discarding waste products and used PPEs in it. The IP stated once a blue rubber glove was used, the glove was considered contaminated and should be discarded in a gray trash bin with a lid. The IP stated the Infection Prevention Program was required to prevent infection and ensure a safe and sanitary environment for residents and staff. During an interview on 4/16/25 at 11:46 a.m. with the Director of Nursing (DON), the DON stated staff should not be mixing uncontained waste products and soiled linen together. The DON stated laundry staff could be exposed to contamination when separating linen for laundry services. The DON stated the gray bin with a lid were provided in each resident's room for dedicated waste products such as used blue rubber gloves and other used PPEs. The DON stated if staff discarded waste products in the resident's bins, the liner in the bin should be contained and emptied right away into a trash bin with a lid and the liner replaced. The DON stated all used PPEs should be discarded in a gray trash bin with a lid. The DON stated the Infection Control Program was required to prevent cross contamination and prevent spread of infection. During an interview on 4/16/25 at 12:03 p.m. with the Administrator (ADM), the ADM stated staff discarding used blue rubber gloves in the residents' personal trash bins was unacceptable and staff should be discarding the used blue rubber gloves in the proper bin with a lid for containment. The ADM stated soiled linen should be discarded in the soiled linen barrel only. The ADM stated waste products and used PPEs should be discarded in gray waste bins with lids. The ADM stated staff discarding used blue rubber gloves in the soiled linen barrel exposed laundry staff to waste product contamination and was unacceptable. The ADM stated proper bins were dedicated to discard proper waste to minimize cross contamination and minimize spread of infection. During a review of the facility's policy and procedure (P&P) titled, Policies and Practices – Infection Control , dated 10/2023, the P&P indicated, Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation: 1. This facility infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike . 2. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the facility; b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. establish guidelines for implementing isolation precautions, including standard and transmission-based precautions . 4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control . During a review of the facility's P&P titled, Waste Disposal , dated 1/2012, the P&P indicated, Policy Statement: All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner. Policy Interpretation and Implementation: 1. All infectious and regulated waste destined for disposal shall be placed in a closable leak-proof containers or bags that are color-coded or labeled as herein described. The Infection Preventionist and Environmental Services Director will ensure that waste is properly disposed of and the following rules are observed: a. If outside contamination of the container or bag is likely to occur, a second leak-proof container or bag which is closable and labeled (or color-coded) shall be placed over the outside of the first container or bag and closed to prevent leakage during handling, storage, and transport. b. Disposal of all infectious and regulated waste shall be in accordance with applicable federal, state, and local regulations . During a review of the facility's P&P titled, Laundry and Bedding, Soiled , dated 9/2022, the P&P indicated, Policy Statement: Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control. Policy Interpretation and Implementation: Handling. 1. All used laundry is handled as potentially contaminated using standard precautions (e.g., gloves and gowns when sorting). 2. Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used). 3. Leak-resistant containers or bags are used for linens or textiles contaminated with blood or body substances. 4. Sorting and rinsing of contaminated laundry at the point of use, hallways, or other open resident care spaces is prohibited. 5. Staff handle soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces, and persons. Transport: Contaminated linen and laundry bags/containers are not held close to the body or squeezed during transport. 2. There are no additional requirements (e.g., double bagging or categorizing as biohazard [any biological agent that can cause death, injury, or illness to a person]) for transporting linen from rooms where transmission-based precautions are in effect . During a professional reference review retrieved from https://www.cdc.gov/infection-control/hcp/environmental-control/regulated-medical-waste.html#:~:text=Regulated%20medical%20wastes%20are%20treated,deposited%20in%20a%20sterile%20site titled, Regulated Medical Waste, dated 1/8/24, the professional reference indicated, . 2. Categories of Medical Waste . Health-care facility medical wastes targeted for handling and disposal precautions include laboratory waste, pathology and anatomy waste (human or animal tissues, organs, and body parts removed during medical procedures), blood specimens from clinics and laboratories, blood products, and other body-fluid specimens (saliva, vomit, urine, and feces) . 3. Management of Regulated Medical Waste in Health-Care Facilities . Medical wastes require careful disposal and containment before collection and consolidation for treatment. OSHA (Occupational Safety and Health Administration; a US Department of Labor agency responsible for ensuring safe and healthy working conditions for patients and employees) has dictated initial measures for discarding regulated medical-waste items. These measures are designed to protect the workers who generate medical wastes and who manage the wastes from point of generation to disposal. A single, leak-resistant biohazard bag is usually adequate for containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded without contaminating the bag's exterior. The contamination or puncturing of the bag requires placement into a second biohazard bag. All bags should be securely closed for disposal .

Based on observation, interview, and record review, the facility failed to provide one of six sampled residents (Resident 44) the right to self-administer medications, when Resident 44 stated she wanted to keep her inhaler at bedside and the facility did not allow her to. This failure resulted in Resident 44's right to self-administer medications to be violated and had the potential to cause Resident 44 to experience difficulty breathing as a result of not having her inhaler at the bedside. Findings: During a review of Resident 44's admission Record (AR- a document which provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/8/2024, the AR indicated, Resident 44 was admitted with the following diagnoses: asthma (lung condition which causes the tubes that carry oxygen in and out of the lungs to become swollen making it difficult to breathe) and traumatic pneumothorax (when air gets trapped between the lung and chest wall after an injury making it hard to breathe). During a review of Resident 44's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 9/17/24, the MDS indicated, a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 29 had no cognitive impairment. During a concurrent observation and interview on 11/5/24 at 10:47 a.m. in Resident 44's room, Resident 44's bedside table and bedside counter were empty, no personal medications observed. Resident 44 stated she wanted to keep her albuterol (a medication which causes the tubes that deliver oxygen in the lungs to open and make breathing easier) inhaler next to her on her bedside table. Resident 44 stated she had asthma that made breathing difficult sometimes and she wanted to have her inhaler close by in case of an emergency. Resident 44 stated nurses told her she was not allowed to keep her medications in her room even though she requested During an interview on 11/07/24 at 2:27 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated he had heard Resident 44 ask licensed nurses if she could keep her inhaler at bedside. CNA 7 stated he remembered the nurses telling her no. CNA 7 stated Resident 44 used her inhaler frequently, up to three times a day. During a concurrent interview and record review on 11/07/24 at 2:37 p.m. with Registered Nurse (RN) 1, Resident 44's Order Summary Report, dated 11/7/24, was reviewed. The Order Summary Report indicated, there was no order for self-administration of Resident 44's albuterol inhaler. RN 1 stated residents were allowed to keep their inhalers at the bedside for self-administration. RN 1 stated a doctor's order needed to be obtained for Resident 44 to keep her inhaler at the bedside and self-administer the medication. RN 1 stated Resident 44 had asthma and would have benefited from keeping her inhaler close to her, she was able to follow instructions and could make her own decisions. RN 1 stated staff should not have refused Resident 44's request to keep her inhaler at bedside for self-administration. RN 1 stated it was Resident 44's right to self-administer her own medication and keep it next to her and staff should have allowed her to do so. During an interview on 11/07/24 at 5:52 a.m. With Licensed Vocational Nurse (LVN) 2, LVN 2 stated she thought residents were not allowed to keep medications with them at bedside, she had not been trained on this and was unaware of the policy. During an interview on 11/08/24 at 11:52 a.m. with the Director of Nursing (DON), the DON stated residents were allowed to store their medications at bedside if they desired to. The DON stated if a resident asked a nurse for permission to keep the medications with them, the nurse needed to obtain a doctor's order and assess whether the resident had the ability to properly self-administer. During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, dated 2001, the P&P indicated, .Residents have the right to self-administer medications if the interdisciplinary team (IDT- A group of healthcare professionals from different disciplines who work together to provide personalized care for patients) has determined that it is clinically appropriate and safe for the resident to do so . As part of the evaluation comprehensive assessment, the interdisciplinary team assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 2. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self-administration; b. The resident is able to read and understand medication labels; c. The resident can follow directions and tell time to know when to take the medication; d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff; e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication . 5. Residents who are identified as being able to self-administer medications are asked whether they wish to do so .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of practice for one of one residents (Resident 40), when Resident 40 described her waffle mattress (a pressure relief mattress overlay [on top of mattress] that's designed to be placed on top of an existing mattress to redistribute pressure from bony areas of the body, manufacturer name Air Overlay) as uncomfortable and staff did not know how to adjust the mattress. This failure resulted in Resident 40's discomfort while lying in bed and had the potential to put the resident at risk for skin breakdown. Findings: During a concurrent observation and interview on [DATE] at 2:45 p.m., with Resident 40 in her room, Resident 40 was in her bed laying on a waffle mattress (WM) that had an air pump at the foot of the bed connected to the mattress set to firm (highest setting- maximum amount of air inflating the WM). Resident 40 stated she was unable to move in bed, or walk, because of a tumor (an abnormal growth of tissue in the body that occurs when cells divide and grow more than they should, or don't die when they should) on the inside of her right lower leg that was wrapped with gauze by her ankle. Resident 40 stated, The WM made me hot, it was uncomfortable and just doesn't feel right. During a review of Resident 40's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 40 was admitted to the facility on [DATE] with a diagnosis which included Mass/Lump Right Lower Limb (leg) and Morbid Obesity (a person's weight that exceeds an individual's desirable weight by more than 100 pounds). During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function), dated [DATE], the MDS indicated, Resident 40's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 40 was cognitively intact. During a review of Resident 40's Physician Orders (PO), dated [DATE], the PO indicated, .Order date: [DATE] at 10:36 p.m. Communication Method: Phone . Order Summary: May resident have App (alternating pressure- a bed that uses air to redistribute pressure and help prevent bedsores) Mattress on to prevent skin breakdown . Confirmed by: Licensed Vocational Nurse (LVN) 3 . Ordered by: Medical Doctor (MD) 1 . During an interview on [DATE] at 4:15 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated the WM was supposed to be adjusted to the comfort level of the resident, but she did not know how to adjust the air pump to make it more comfortable for the resident. CNA 5 stated that Maintenance does that. During an interview on [DATE] at 4:20 p.m., with the Maintenance Supervisor (MS) the MS stated they only do the initial set up of the WM and after that, they do not touch it. The MS stated only the nursing staff manipulates the pump or the air mattress after set up. During an interview on [DATE] at 9:25 a.m., with the Senior Account Manager (SAM- for WM Company), the SAM stated the facility needed to follow the instructions for use in the Owner's Manual for the WM that the company provided to the facility. During a review of the Owner's Manual- [Company Name] Air Overlay (OM), not dated, the OM indicated, .Directions for Use: . 8. Decrease firmness if necessary for resident comfort, support, and immersion into the overlay for optimal pressure redistribution (moving pressure off of bony prominence's on the body). A common method for sizing an air overlay is to check to see if suitable pressure is selected by sliding one hand between the air overlay and the air/foam base under the residence buttocks. Users should be able to feel the space between their hand and the residents' buttocks with the acceptable range being 25-40 mm (millimeters- unit of measurement) (1 inch to 1 inch and a half). This handshake procedure is issued by agency for Health Care Policy and Research (AHCPR) . B) adjust the firmness by turning the dial; counterclockwise for more immersion (if too much space during hand check, too firm) or clockwise for less immersion (not enough space during hand check, too soft) . During an interview on [DATE] at 11:07 a.m., with Registered Nurse (RN) 1, RN 1 stated she was the nurse for Resident 40. RN 1 stated if Resident 40 was uncomfortable and needed the pressure of the WM fixed, she would call Maintenance to do that. RN 1 stated she did not know how to manipulate the pressure of the WM. RN 1 stated she was never trained on how to use the WM. During an interview on [DATE] at 5:43 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she was the nurse for Resident 40. LVN 3 stated she was not sure if the WM was supposed to be on firm or not. LVN 3 stated that she was never trained on how to work the waffle mattress. LVN 3 stated Resident 40 needed the mattress to prevent skin breakdown, but the mattress needed to be comfortable for her. LVN 3 stated she did not know how to make the mattress more comfortable for the resident. During an interview on [DATE] at 10:38 a.m., with the Director of Staff Development (DSD), the DSD stated Resident 40 needed the WM for immobility (inability to move herself). The DSD stated that if Resident 40 was uncomfortable, nursing staff would tell maintenance and they would fix it. The DSD stated nurses should have monitored the WM and followed the instructions for use in the owner's manual. The DSD stated she had not trained her staff on that WM. The DSD stated staff did not follow the OM and patient harm could have happened. During an interview on [DATE] at 10:59 a.m., with the Director of Nursing (DON), the DON stated the OM was not followed by facility staff. The DON stated nursing staff was referring to Maintenance for anything related to the WM and that was not the right way. The DON stated the expectation for staff would be to follow the OM instruction for use. The DON stated staff were never trained on how to properly monitor and work the WM. The DON stated that because the WM was not inflated to Resident 40's comfort level, she would be uncomfortable and skin breakdown could happen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 12 Residents (Resident 1) was assessed for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from the bed side rails (adjustable metal or rigid plastic bars in various sizes that attach to the bed, and can be placed in a guard [raised] or lowered position), had no consent (form signed by resident or family explaining the risks of side rail use), no physician order, no indication for use, and no care plans prior to the installation and use when Resident 1 had two bed rails one on both sides at the head of the bed in the guard position (a position that is intended to prevent an individual from inadvertently[accidentally] rolling out of bed). This failure had the potential to cause entrapment, serious harm, injury, or death to Resident 1. Findings: During an observation on 11/5/24 at 8:35 a.m., Resident 1 was observed in bed sleeping. Bed rails were observed raised at the head of Resident 1's bed. Fall mats were observed on the right and left side of Resident 1's bed. During a review of Resident 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 11/8/24, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Alzheimer's (a disease characterized by a progressive decline in mental abilities), anxiety disorder (disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), psychosis (a mental disorder characterized by a disconnection from reality), fracture of the left femur (a break in the thigh bone), hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and transient ischemic attack (TIA - a short period of symptoms similar to those of a stroke, caused by a brief blockage of blood flow to the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/4/24, the MDS section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 1 was severely cognitively impaired. During a review of Resident 1's medical records, the medical records indicated, Resident 1 was observed to have no documentation of a care plan for the use of bed rails, no documentation of a bed rail assessment, no physician orders for the use of bed rails, and no consent on file for the use of bed rails. During a concurrent interview and record review on 11/6/24 at 9:44 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's record was reviewed. Resident 1's record indicated, no physician orders for the use of bed rails for Resident 1, no consent on file for the use of bed rails for Resident 1, no care plan in place for the use of bed rails for Resident 1 and no bed assessment documented for the use of bed rails for Resident 1. LVN 1 stated Resident 1 should have orders, a care plan, and a bed assessment for the use of the bed rails on Resident 1's bed. LVN 1 stated Resident 1 should have had a physician order for bed rails. LVN 1 stated bed rails were considered a restrictive device. LVN 1 stated if a bed was not assessed for bed rails, the bed rails could be unsafe, and the resident could get hurt. LVN 1 stated a care plan was to ensure staff who assisted Resident 1 with turning and repositioning were using the bed rails appropriately. During a concurrent observation and interview on 11/6/24 at 9:56 a.m., in Resident 1's room, the Maintenance Assistant (MAINTA) was observed walking out of Resident 1's room with bed rails in his hands. Certified Nursing Assistant (CNA) 8 was observed fixing the blankets on Resident 1's bed with no bed rails observed on Resident 1's bed. CNA 8 stated Resident 1's bed rails were removed by the MAINTA because Resident 1 was not supposed to have them on her bed. During an interview on 11/6/24 at 10:56 a.m. with the Maintenance Supervisor (MS), the MS stated the LVNs were letting him know which resident's bed rails needed to be removed. The MS stated he did not do a bed assessment to verify the bed was appropriate for the resident's weight, or if maintenance was using the correct rails for the resident's bed. The MS stated the maintenance department would check that the installed bed rails were tight and did not move. The MS stated if the bed rails were improperly installed, they could injure the resident. The MS stated he did not do regular bed rail checks, so there was no bed rail check log. The MS stated the CNAs or nurses would let him know if there was a problem with the bed rails, then the maintenance department would check the rails. During a review of the facility's policy and procedure (P&P) titled, Bed Safety, dated 12/2007, indicated, . the resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement . to try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails .), the facility shall promote the following approaches . inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks . ensure that bed side rails are properly installed using the manufacturer's instructions .identify additional safety measures for residents who have been identified as having higher than usual risk for injury including entrapment (e.g., altered mental status .) . the maintenance department shall provide a copy of the inspections to the Administrator and report results to the QA Committee for appropriate action. Copies of the inspection results and QA Committee recommendations shall be maintained by the Administrator and/or Safety Committee . if side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative . the staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use . after appropriate review and consent . side rails may be used . side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to meet the needs of one of six residents (Resident 37) when Resident 37's lorazepam (a controlled medication used to help with anxiety, sleep, and maintain calmness) medication was administered and was not documented on the controlled substances count sheet (This document is typically used in a medical setting to ensure accurate dispensing and administration of medications, as well as to provide a record of how much of a controlled substance has been used and when). This failure had the potential for Resident 37's lorazepam to be mistakenly administered to her twice and cause Resident 37 to experience side effects from an additional dose of medication. Findings: During a review of Resident 37's admission Record (AR- a document which provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/8/2024, the AR indicated Resident 37 was admitted to the facility with the following diagnoses: major depressive disorder (mood disorder which affects how someone feels, thinks, and functions in daily life), and adjustment disorder (a mental health condition which involves an extreme emotional or behavioral response to a stressful event or change in someone's life). During an observation on 11/06/24 at 2:05 p.m., with Licensed Vocational Nurse (LVN) 1, of Resident 37's medication blister pack (a type of packaging used to hold and protect medications) the blister pack had 25 lorazepam pills. During a concurrent interview and record review on 11/06/24 At 2:05 p.m., with LVN 1, the facility's Narcotic Binder, dated 11/06/24, was reviewed. The Narcotic Binder indicated, Resident 37's last lorazepam administration on 11/06/24 at 8:00 a.m. was not documented in the binder. LVN 1 stated she had forgot to document the lorazepam administration in the Narcotics Binder and it should have been documented as soon as she removed the medication from the blister pack. LVN 1 stated the lorazepam was a controlled substance (a medication which has the potential to be abused due to its addictive properties) and nurses needed to document all controlled substances in the binder as soon as they were taken out of the blister packs. LVN 1 stated it was important to document controlled medications in the binder because it ensured the number of medications available was accurate and it ensured residents actually received their medication. During an interview on 11/7/24 at 5:49 p.m., with LVN 2, LVN 2 stated all controlled substances needed to be signed out of the Narcotics Binder after the medication had been removed from the blister pack. LVN 2 stated it was important to document all narcotics administered because it helped nurses know if the medication was given. LVN 2 stated it was necessary to have an accurate count of all narcotics because it helped to show no one had stolen the medication and no double dose of the medications were administered to the residents. During an interview on 11/08/24 at 11:52 a.m., with the Director of Nursing (DON), the DON stated LVN 1 administered the medication but forgot to sign it out on the Narcotics Binder. The DON stated nurses were supposed to sign for all controlled medications as they took them out of the blister packs. The DON stated the count for controlled medications should always be accurate. During a review of professional reference retrieved from https://www.allcarepharmacy.com/facilityresources/assets/documents/Controlled%20Substances%20Inservice.pdf , titled, Controlled Substances In-Service, undated, indicated, . Complete documentation in the narcotic book prior to administering controlled substances to the resident. Check the count with each administration to ensure accuracy. Initial the MAR after administering the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent observation and interview on 11/5/24 at 7:48 p.m., in the kitchen an open jar of garlic had a received labeled date for 10/24/24 and no open labeled date. Dietary [NAME] (DC) 1 stated the open garlic jar should have an open labeled date along with the received labeled date. DC 1 stated it was important to have an open labeled date on the garlic jar to know the shelf- life (length of time for which an item remains usable, fit for consumption). DC 1 stated kitchen staff does not keep food items longer than two weeks. DC 1 stated the open garlic jar should have been thrown away since it did not have an open labeled date. DC 1 stated kitchen staff does not want to served resident expired food. DC 1 stated serving residents expired food could have caused foodborne illness. DC 1 stated kitchen staff should have labeled the jar when the jar was opened. During an interview on 11/7/24 at 2:18 p.m., with the Interim Dietary Manager/ Registered Dietitian (IDM/RD), the IDM/RD stated the jar of garlic should have had an opened labeled date The IDM/RD stated an opened labeled date was needed to ensure the jar of garlic was not used beyond the expiration date. The IDM/RD stated using food items beyond the expiration date was putting resident at risk for foodborne illness and cross-contamination. The IDM/RD stated the staff did not follow the policy and procedure for labeling. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2023, the P&P indicated, .All the perishable food items purchased by the department of food and dining services will be stored properly .10. Leftover food or unused portions of packaged foods should be covered, labeled, and dated to assure they will be used first . 3. During an observation on 11/7/24 at 7:50 a.m,. in the kitchen with DC 1, 24 bran muffins were in the refrigerator in a sealed box missing half of the labeled date. DC 1 stated the box of bran muffins were brought out of the freezer this morning and were placed in the refrigerator. DC 1 stated she labeled the bran muffins with the date it was placed in the freezer. DC 1 stated she was not able to see the labeled date on the bran muffin and it was missing half of the labeled date. DC 1 stated the labeled date should have been on the bran muffin. DC 1 stated it was important to have the labeled date on the bran muffin to ensured residents were not served expired items. DC 1 stated, serving expired bran muffin to residents could cause residents to be sick. DC 1 stated the bran muffins could have been old and should have been thrown away. DC 1 stated kitchen staff should have labeled the bran muffin with the date it was placed in the freezer. During an interview on 11/7/24 at 2:18 p.m., with the IDM/RD, the IDM/RD stated the policy for labeling was not followed. The IDM/RD stated the bran muffins should have been thrown away when kitchen staff noticed the label date was missing. The IDM/RD stated a missing label date could have cause confusion for the kitchen staff. The IDM/RD stated labeling items was important to ensured bran muffins and other food items were opened and received and safe to consumed. The IDM/RD stated kitchen staff should have clear labeling practices. The IDM/RD stated not following the labeling practice was putting residents at risk for food borne illness. The IDM/RD stated it was the responsibility of the morning cooks or dietary manager to inspect bran muffins before serving it for breakfast. During a review of the facility's menu titled, Fall menus, dated 11/05/24, the Fall menu indicated, .Bran Muffin cupcake size 2 oz . During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control. dated 2018, the P&P indicated, .6. Frozen food should be labeled with the date it was placed in the freezer . 4. During a concurrent observation and interview on 11/5/24 at 8:28 a.m. in the pantry with DC 1 two dented tomato sauce cans were stored on the shelf ready for use. DC 1 stated she checked the storage pantry every Mondays and Thursdays for dented cans and or expired dated items. DC 1 stated she was not sure why the dented cans were still stored on the shelf for use. DC 1 stated the dented cans should have been transferred to an area to be returned to the supplier and not on the shelf for use. DC 1 stated dented cans were not good to use and had bacteria. DC 1 stated bacteria from the dented cans could have gotten residents sick. During an interview at 11/7/24 at 2:18 p.m., with the IDM/RD, the IDM/RD stated dented cans should have been moved to the designated area and not on the shelf for use. The IDM/RD stated dented cans could have botulism (a rare but serious toxin produced by bactera that disease that attacks the body when consumed) and could have gotten residents sick if served. The IDM/RD stated the dented cans should have been inspected for dents on the dated received. The IDM/RD stated kitchen staff did not follow the facilities policy. During a review of the facility's policy and procedure (P&P) tilted, Sanitation and Infection Control, dated 2018, Subject: Canned and Dry Goods Storage: Policy: All the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly .10. Canned food items should be routinely inspected for damages such as dented, bulging, or leaking cans. These items should be set aside in a designated area for return to the vendor or disposed of properly . Based on observation, interview, and record review, the facility failed to ensure the kitchen food was stored and maintained in a safe and sanitary manner when: 1. The facility failed to store food in Resident 105's room in a safe manner in accordance with the facility's policy and procedure (P&P) Foods Brought by Family/Visitors. 2. An open jar of garlic was stored in the refrigerator without an open labeled date in accordance with the facility's P&P Sanitation and Infection Control. 3. A case of bran muffins was found in the refrigerator missing half of the labeled date identifying the placed in the freezer date per the facility's P&P Sanitation and Infection Control. 4. Two dented tomato sauce cans were stored in the pantry for use and not set aside in a designated area for return to the vendor or disposed of properly per the facility's P&P Sanitation and Infection Control. These failures had the potential risk of cross contamination (process by which bacteria is transferred from one object or substance to another, with harmful effect) and exposure of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) from improperly stored and labeled food for 52 of 53 residents. Findings: 1. During a concurrent observation and interview on 11/5/24 at 9:05 a.m., in Resident 105's room with Resident 105 and Registered Nurse (RN) 1, Resident 105 had two lidded bowls, of perishable (likely to decay, spoil, or become unsafe to eat if not kept refrigerated or frozen) food on her bedside table. Resident 105 stated the food had been brought in by family members the day before. Resident 105 stated the food was hot when family brought it in to the facility, but it was cold now. RN 1 stated the food in the bowls were stew with liquid and a bread product called [NAME] (South Asian flatbread made with whole wheat flour). RN 1 stated the food containers were not labeled or dated. During a review of Resident 105's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 105 was admitted to the facility on [DATE] with a diagnosis of Pulmonary Mycobacterial Infection (a lung infection caused by a type of bacteria called mycobacteria, which are naturally found in soil and water, and can be breathed in). During a review of Resident 105's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function), dated 10/25/24, the MDS indicated Resident 105's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 13 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 105 was cognitively intact. During an interview on 11/7/24 at 5:38 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the expectation for perishable foods at the resident's bedside would be to make sure the foods were safe for the resident to eat. LVN 3 stated food that was not dry food should have been wasted after the family leaves the facility. During an interview on 11/8/24 at 9:27 a.m., with the Interim Dietary Manager/Registered Dietician (IDM/RD), the IDM/RD stated the food that was on Resident 105's bedside was perishable and needed to be consumed immediately by the resident or refrigerated. The IDM/RD stated that because the food was not labeled or stored appropriately, we can't be sure it's safe. The IDM/RD stated placing the dated labels on the food containers were important because it would prevent time and temperature abuse and potential food-borne illness (food poisoning). The IDM/RD stated if Resident 105 ate the food on 11/5/24 that she could have acquired food poisoning and potentially been sent to the hospital. The IDM/RD stated symptoms of food poisoning would be nausea, vomiting, diarrhea, weight loss and dehydration (occurs when you use or lose more fluid than you take in, and your body doesn't have enough water and other fluids to carry out its normal functions). The IDM/RD stated staff did not follow the facility policy and procedure (P&P) Foods Brought by Family/Visitors. During an interview on 11/8/24 at 11:15 a.m., with the Director of Nursing (DON), the DON stated the expectation for Resident 105's family would have been to take the food that was not eaten at the facility home when they were done visiting with the resident that day. The DON stated they do not store perishable food for the residents. The DON stated staff can't ensure that the food at Resident 105's bedside was safe to eat. The DON stated if Resident 105 had consumed the non-labeled food, that she could have gotten sick. The DON stated staff did not follow the P&P Foods Brought by Family/Visitors. During an interview on 11/8/24 at 3:28 p.m., with the Infection Preventionist (IP), the IP stated the food at the resident bedside should be considered a meal tray and taken away after the resident had eaten what she wanted. The IP stated the facility educated the family and told them whatever food was left, it needed to be taken back home with them that same day. The IP stated if the food was consumed, the resident could have been hospitalized due to a food-borne illness because the facility did not know if it were safe to eat or not. The IP stated the facility did not follow the P&P Foods Brought by Family/Visitors. During a review of facility's P&P titled, Foods Brought by Family/Visitors, dated October 2017, the P&P indicated, Policy Statement: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a home like environment with the nutritional and safety needs of residents. Policy Interpretation and Implementation: . 4. Family/visitors are asked to prepare and transport food using safe food handling practices, including a. Safe cooling and reheating processes; b. Holding temperatures; c. Preventing cross contamination with raw or undercooked foods; . 7. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility prepared food . b. Containers will be labeled with the resident's name, the item and the use by date . c. No foods requiring refrigeration will be allowed except when can be consumed immediately . 10. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than two hours will be discarded .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 23's admission Record, (AR- a document containing resident demographic information and medical diagnosis) dated 11/8/24, the AR indicated, Resident 23 was admitted to the facility on [DATE]. Resident 23's diagnosis included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), anemia (a condition where the body does not have enough healthy red blood cells), chronic kidney disease (CKD- a long-term condition that occurs when the kidneys are damaged and can't filter blood properly), bacteremia (the presence of bacteria in your blood) and pain. During a review of Resident 23's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function), dated 10/11/24, the MDS indicated Resident 23's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 12 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 23 was moderately impaired. During a concurrent observation and interview on 11/5/24 9:25 a.m., in Resident 23's room, two flies were on a curtain and a fly swatter was on the top of the nightstand. Resident 23 was asked why he had a fly swatter on the top of the nightstand and Resident 23 stated it was to kill the flies. Resident 23 stated he did not like the flies in the room and they were there often. During an interview with 11/7/24 at 4:30 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she has been employed at the facility for 11 months. CNA 4 stated during the summer the flies were more noticeable. CNA 4 stated it was not ok for flies to be in the room and flies were dirty. CNA 4 stated it was hard to keep flies out of the rooms. CNA 4 stated she has seen fly swatters in Resident 23's room multiple times. CNA 4 stated she would kill flies in Resident 23's room when she saw one. CNA 4 stated residents had complained about flies in the building. CNA 4 stated there were fly traps and fans to keep the flies out. CNA 4 stated flies were dirty, and caused infections and cross-contamination. During an interview on 11/8/24 at 11:16 a.m., with the Director of Nursing (DON), the DON stated the expectation was for the facility to be free of flies and insects. The DON stated flies in the facility could spread infections. The DON stated flies in the facility meant the pest control program they had in place was ineffective. During an interview on 11/8/24 at 2:31 p.m., with the Facility Administrator (ADM), the ADM stated flies in the facility were a constant problem. The ADM stated the flies were a legitimate concern for the facility and they could not keep the flies out. The ADM stated cross-contamination (the unintentional transfer of harmful bacteria or other microorganisms [a living thing that is so small that it can only be seen with a microscope] from one object to another) could have occurred. During an interview on 11/8/24 at 3:20 p.m., with the Infection Preventionist (IP), the IP stated flies in Resident 40's room and in the lunchroom during meals were an issue. The IP stated flies carried germs and they can cross-contaminate things. The IP stated residents at the facility were vulnerable. The IP stated the expectation for the facility was to be free from flies and for the fly traps to work at all times. The IP stated the facility needed a better plan to keep the flies from entering inside the facility. The IP stated flies in the facility increase resident's risk for infections. The IP stated the pest control program that was in place was not effective. During an interview on 11/8/24 at 3:40 p.m., with the Maintenance Supervisor (MS), the MS stated there were a lot of flies in the facility on 11/5/24. The MS stated he called a pest control company and they replaced nine fly traps that were not working in the facility. The MS stated the pest control that was currently in place was ineffective and the facility needed to have the pest control company come service more often. During a review of the Facility's Map dated 11/8/24, the map indicated, .highlighted locations throughout the facility where 9 LED fly light trap bulbs (light that attracts flies, and they get trapped in the wall unit) had been replaced. During a review of facility's policy and procedure (P&P) titled, Sanitation and Infection Control- Subject: Pest Control, dated 2018, the P&P indicated, Policy: the facility will ensure a pest control prevention program provides . inspection, treatment and prevention of . insect infestation . pest control is designed to maintain a sanitary environment which prevents contamination transmission or spread of disease by insects . Procedures: . 11. It is recommended that a pest control company be retained on a monthly basis, or more often if necessary . 3. During a concurrent observation and interview on 11/5/24 at 11:54 a.m. with the CNA/RNA, in the Activities Room, flies were observed landing on Residents 15, 26, and 251's food and landing on the residents. The CNA/RNA stated residents eating in the Activities Room were eating there for restorative dining (a program that focuses on establishing a specific dining space for residents who require greater levels of supervision and assist with eating). The CNA/RNA stated she had a fly swatter to keep the flies off the residents. The CNA/RNA was observed swishing the fly swatter over Resident 15, 26, and 251's food while the residents were eating. The CNA/RNA stated flies should not have been in the room where Residents 15, 26, and 251 were eating. The CNA/RNA stated having flies in the room was not comfortable for the residents. The CNA/RNA stated flies could get germs on the resident's food and the residents could get sick. During a review of Resident 15's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information),), dated 11/8/24, the AR indicated, Resident 15 was admitted to the facility on [DATE] with diagnoses of fracture of left femur (a break in the bone of the thigh) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 10/18/24, the MDS section C indicated Resident 15 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 15 was severely cognitively impaired. During a review of Resident 26's AR dated, 11/8/24, the AR indicated Resident 26 was admitted on [DATE] with diagnoses of fracture of lumbar vertebra, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and dysphagia (difficulty swallowing). During a review of Resident 26's MDS, dated 9/3/24, the MDS section C indicated Resident 26 had a BIMS score of 12, which indicated Resident 26 was moderately impaired. During a review of Resident 251's AR, dated 11/8/24, the AR indicated Resident 251 was admitted on [DATE] with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and dysphagia (difficulty swallowing). During a review of Resident 251's MDS, dated 10/31/24, the MDS section C indicated Resident 251 had a BIMS score of 3, which indicated Resident 251 was severely cognitively impaired. During a concurrent observation and interview on 11/5/24 at 12:12 p.m. with the Maintenance Assistant (MAINTA) in the Activities room, the MAINTA was observed checking the bug light on the wall The MAINTA stated the bug light was not on. During an interview on 11/07/24 at 5:02 p.m. with the Infection Preventionist (IP), the IP stated the maintenance department had a pest control company that performed pest control service on a regular schedule. The IP stated if anyone informed her or if she saw pests, she would inform the maintenance department. The IP stated flies were a problem for infection control. The IP stated flies put residents at risk for infection if the flies landed on the resident's food. The IP stated if the resident had a wound, the flies could land on the wound then land on other clean areas, exposing those areas to germs. The IP stated if flies landed on a resident's wound, they could lay eggs in the wound. The IP stated there should not be flies in the areas where residents were eating. During a review of the pest control company's documents titled, Service Report, dated 10/14/24, 9/30/24, and 8/22/24, the documents indicated, . fly light not working . recommend keeping doors closed when not in use to control flying activity entering facility . one fly light bulb that needs to be replaced . fly light not working . several fly lights were unplugged . During an interview on 11/8/24 at 3:29 p.m. with the Maintenance Supervisor (MS), the MS stated the fly bulbs had been out on the last three months of the pest control service reports. The MS stated the pest control program was ineffective. The MS stated the pest control company needed to come out to the facility more often to provide pest control service. During a review of the facility job description document titled, . Building & Maintenance Supervisor, dated 4/2013, the document indicated, . responsible for overall management of . maintenance . personnel to ensure a clean, safe and orderly living environment for residents . oversees . pest control . During a review of the facility's P&P titled, Pest Control, dated 5/2008, indicated, the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . maintenance services assist, when appropriate and necessary, in providing pest control services . 4. During a concurrent observation and interview on 11/7/24 at 10:56 a.m. with the Laundry Staff (LS) in the laundry room, two holes were observed in the lower back wall, open to the outside. The LS stated that the holes in the wall were not good. The LS added that if rodents or pests got into clean clothes, they could cause an infection risk to residents. During an interview on 11/7/24 at 5:02 p.m. with the Infection Preventionist (IP), the IP stated that maintenance had a regular company scheduled for pest control. The IP stated that if anyone informed her or if she saw anything related to pests, she would notify maintenance. The IP also stated that holes opening to the outside in the laundry room posed a risk for cross-contamination and infection to residents if rodents entered the room. During an interview on 11/8/24 at 3:29 p.m. with the Maintenance Supervisor (MS), the MS stated that the holes in the laundry room walls were discovered earlier that week when the laundry area was cleaned. The MS stated that there was not a work order for the repair of the holes. The MS stated that there was a risk associated with the holes opening to the outside because rodents could enter through them. The MS stated that rodents could cause cross-contamination in the laundry and pose an infection risk to residents. The MS stated that he had started the yearly inspection on 10/31/24. The MS stated that the board, which incompletely covered one of the holes, had been placed there approximately three to four months ago as a temporary fix. The MS stated that his expectation for the laundry area was for the holes to be properly covered to prevent anything from entering from the outside. During a review of the facility's policy and procedure (P&P) titled Maintenance Service, dated 12/2009, indicated that, . the maintenance department is responsible for maintaining the buildings, keeping the building in good repair and free from hazards, and providing routinely scheduled maintenance service to all areas. The maintenance director is responsible for maintaining the following records/reports: work order requests and maintenance schedules . Based on observation, interview, and record review, the facility failed to keep the environment free from insects in accordance with the facility's policy and procedure (P&P) Pest Control when flies were observed in resident rooms and in the common areas of the dinning room and activities room and had the potential for rodents to enter from two holes on the laundry room wall. These failures led to insects being observed in the facility and had the potential to allow rodents to enter the facility from the outside, posing a risk of infection to residents due to cross-contamination. Findings: 1. During a concurrent observation and interview on 11/5/24 at 10:45 a.m., with Resident 40 in her room, Resident 40 was in her bed, had a fly swatter in her hand with three flies were flying around her. Resident 40 stated she hated the flies, and they were always in her room. Resident 40 stated she was unable to move in bed, or walk, because of a tumor (an abnormal growth of tissue in the body that occurs when cells divide and grow more than they should, or don't die when they should) on the inside of her right lower leg wrapped with gauze) by her ankle. Resident 40 stated staff gave her the fly swatter to keep the flies away from the tumor. During an observation on 11/5/24 at 12:15 p.m., in the Resident Dining Room while residents were eating lunch, there were two flies flying around and an electric LED (light emitting diode [type of lighting that converts electricity to light] that attracts multiple species of flying insects while trapping them inside) fly trap on the wall that was inoperable (not working) due to not being plugged in to the wall electrical outlet (power plug). During a review of Resident 40's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 40 was admitted to the facility on [DATE] with a diagnosis which included Mass/Lump Right Lower Limb (leg) and Morbid Obesity (a person's weight that exceeds an individual's desirable weight by more than 100 pounds). During a review of Resident 40's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function), dated 9/21/24, the MDS indicated Resident 40's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 40 was cognitively intact. During an interview on 11/6/24 at 4:45 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 40 had asked her to kill flies in her room before. CNA 5 stated she had seen flies in that room and she gets the flies for her. During an interview on 11/7/24 at 6:10 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the expectation of the facility is to be free from flies. LVN 3 stated flies could put the residents at risk of infections. LVN 3 stated Resident 40 was vulnerable because she was very weak and could not move herself in bed. During an interview on 11/8/24 at 9:25 a.m., with CNA 6, CNA 6 stated she had seen flies in Resident 40's room before and they are a constant problem. CNA 6 stated in the past, she had housekeeping clean Resident 40's room because of flies, but after the cleaning she still saw flies and stated, I don't know why. During an interview on 11/8/24 at 11:16 a.m., with the Director of Nursing (DON), the DON stated the expectation was for the facility to be free from flies and insects. The DON stated flies in the facility could spread infections. The DON stated flies in the facility meant the pest control program they had in place was ineffective. During an interview on 11/8/24 at 2:31 p.m., with the Facility Administrator (ADM), the ADM stated flies in the facility was a constant problem. The ADM stated the flies were a legitimate concern for the facility and they could not keep flies out. The ADM stated cross-contamination (the unintentional transfer of harmful bacteria or other microorganisms [a living thing that is so small that it can only be seen with a microscope] from one object to another) could have occurred. During an interview on 11/8/24 at 3:20 p.m., with the Infection Preventionist (IP), the IP stated flies in Resident 40's room and in the lunchroom were an issue. The IP stated flies carry germs and they can cross-contaminate things. The IP stated residents at the facility were vulnerable. The IP stated the expectation for the facility is to be free from flies and for the fly traps to work all the time. The IP stated the facility needed a better plan to keep the flies from entering inside the facility. The IP stated flies in the facility increase resident's risk for infections. The IP stated the pest control program that was put in place was not effective. During an interview on 11/8/24 at 3:40 p.m., with the Maintenance Supervisor (MS), the MS stated there were a lot of flies in the facility on 11/5/24. The MS stated he called a pest control company to come in and they replaced nine fly traps that were not working in the facility. The MS stated the pest control they had in place was ineffective and the facility needed to have the pest control service company come in more often. During a review of the Facility's Map dated 11/8/24, the map indicated, .highlighted locations throughout the facility where 9 LED fly light trap bulbs (light that attracts flies, and they get trapped in the wall unit) had been replaced. During a review of facility's policy and procedure (P&P) titled, Sanitation and Infection Control- Subject: Pest Control, dated 2018, the P&P indicated, Policy: the facility will ensure a pest control prevention program provides . inspection, treatment and prevention of . insect infestation . pest control is designed to maintain a sanitary environment which prevents contamination transmission or spread of disease by insects . Procedures: . 11. It is recommended that a pest control company be retained on a monthly basis, or more often if necessary .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (Illnesses caused by viruses or bacteria that people spread to one another through contact with contaminated surfaces, bodily fluids, blood products, insect bites, or through the air) and infections for 53 of 54 residents when: 1. Staff stored personal lunch bags and a drink canister on top of the dining room ice-machine and not in the locker room refrigerator per the facility's policy and procedure (P&P) Cafeteria Meals, This failure had the potential for cross-contamination (process by which bacteria is transferred from one object or substance to another, with harmful effect) and exposure to foodborne illnesses (stomach illness acquired from ingesting contaminated food) for residents, staff, and visitors. 2. Resident 2's feeding tube (a flexible plastic tube placed into the stomach or bowel [intestine] to provide nutrition when a person cannot eat or drink safely by mouth) bottle of nourishment did not have a start date indicating when the bottle was hung to determine the discard date per the facility's in-service document Feeding Pump, This failure had the potential to place Resident 2 at risk of receiving an expired tube feeding exposing Resident 2 to bacteria and risk of infection. 3. Licensed Vocational Nurse (LVN) 2 did not follow proper procedure for donning the appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) and proper hand hygiene while providing direct care to Resident 2 who was on enhanced barrier precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes) per the facility's P&P Administering Medications through an Enteral Tube. This failure had the potential to place residents at risk of infection due to cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). 4. LVN 1 did not follow proper hand hygiene procedures prior to checking blood sugar levels on Resident 27 and Resident 35, and LVN 1 did not follow proper procedures for sanitizing (to reduce or eliminate pathogenic agents [such as bacteria] on surfaces) the blood glucose meter (glucometer - a device that reads the amount of sugar in the blood) after checking the blood sugar levels on Resident 27 and Resident 35 per the facility's P&P's Obtaining a Fingerstick Glucose Level, and To clean and disinfect the Meter. This failure had the potential to place Residents 27 and 35 at risk of infection due to cross-contamination. 5. Dirty Halloween Decorations were on a table in the dining room where Resident 26 was eating his lunch meal not in accordance with the Infection Control (IC) practices. This failure had the potential to place Resident 26 at risk of infection due to cross-contamination. 6. Resident 26's urine catheter (a hollow tube inserted into the bladder to drain or collect urine into a bag) bag was observed on his lap while he was eating his lunch meal not in accordance with the facilities IC practices and per the facility's P&P titled, Catheter Care, Urinary. This failure had the potential to place Resident 26 at risk of infection due to cross-contamination. Findings: 1. During a concurrent observation and interview on 11/5/24 at 2:46 p.m., in the dining room, with Dietary [NAME] (DC) 2. Three lunch bags and one drink canister was observed on top of the ice machine. DC 2 stated staff lunch bags and or drink canisters should not be stored on top of the dining room ice machine. DC 2 stated DC 1 and Dietary Services Supervisor were responsible for cleaning the ice machine. DC 2 stated staff lunch bags could have fallen into the ice machine and caused cross contamination. DC 2 stated staff lunch bags and or drink canister were not sanitary. During an interview on 11/7/24 at 2:18 p.m., with the Registered Dietitian/Interim Dietary Manager (IDM/RD), the IDM/ RD stated personal items such as lunch bags should not be stored on top of the dining room ice machine. The IDM/RD stated staff lunch bags could have bacteria on them and could have fallen into the ice machine. The IDM/RD stated there was a potential risk for cross-contamination to residents, staff and visitors that could have caused then to got sick. The IDM/RD stated staff should have stored lunch bags and canisters in the employee designated locker, refrigerators and not on top of the dining room ice machine. The IDM/RD stated staff did not followed the policy and procedure for Cafeteria Meals. During a concurrent observation and interview on 11/7/24 at 3:10 p.m., in the dining room with DC 3 , a black lunch bag was observed on top of the ice machine above a posted sign posted stating, Do not place any items on top of the ice machine! DC 3 stated staff lunch bags should not be stored on top of the ice machine. DC 3 stated the ices could have been cross contaminated from staff lunch bags and could have gotten residents infected and sick. During an interview on 11/7/24 at 6:02 p.m., with the Infection Prevention (IP), the IP stated staff lunch bags were dirty and had bacteria on them. The IP stated staff's dirty lunch bags could have fallen into the ice and caused contamination. The IP stated staff, visitors and resident were at risk for infection from drinking contaminated ice from the ice machine. The IP stated the dietary kitchen staff were responsible for making sure the ice machine was cleaned. During an interview on 11/7/24 at 6:10 p.m., with the Director of Staff Development (DSD), the DSD stated there should not have been any items on top of the ice machine. The DSD stated the staff should have stored their lunch bags and cups in the staff refrigerator. The DSD stated storing lunch bags and cups in the staff refrigerator could prevent cross-contamination and getting resident sick. The DSD stated an in-service should have been provided to the staff. During a review of the facility's policy and procedure (P&P) titled, Cafeteria Meals, dated revised 1/2008, the P&P indicated, .6. Employees need to utilize their lunch bag in the locker room and refrigerator . 2. During a concurrent observation and interview on 11/6/24 at 9:44 a.m., with LVN 1 in Resident 2's room, Resident 2 was observed dressed, and sleeping in bed. Resident 2's bottle of feeding tube nutrition was observed handing on an infusion pole undated. LVN 1 stated the feeding tube nutrition bottle should have had a date and time labeled indicating when the bottle was hung and when the feeding started. LVN 1 stated having a date and time on the feeding bottle would let nurses know when the bottle was changed. LVN 1 stated if the bottle was not changed there would be a risk of the feeding to go bad. LVN 1 stated giving Resident 2 a feeding that had gone bad would put Resident 2 at risk of getting sick. During a review of resident 2's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 11/5/24, Resident 2's AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), aphasia (a disorder that makes it difficult to speak), dysphasia (difficulty swallowing), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis(muscle weakness or partial paralysis on one side of the body) following cerebral infarction, and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 6/20/24, the MDS section C indicated, Resident 2 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of four (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 2 was severely impaired. During an interview on 11/8/24 at 11:26 a.m. with the Registered Dietician (RD), the RD stated she did not know the requirement about dating the feeding tube bottle. The RD stated she would need to check the facility's policy on dating the feeding tube bottle of nutrition when hung. During a review of the facility in-service document titled Feeding Pump, dated 6/18/24, the document indicated, . ask your nutritionist how much formula to add to the feeding bag at a time. Formula can spoil if it hangs in the bag too long . throw the bag out if it has been used for 24 hours . if you are not going to restart the feeding right away, store the feeding set in an airtight container in the refrigerator . 3. During an observation on 11/07/24 at 3:02 p.m. in Resident 2's room, Resident 2 was observed laying down in bed with her eyes open. A notice that Resident 2 was on EBP was observed on the wall above Resident 2's bed. LVN 2 was observed checking Resident 2's gastric tube (G-tube - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement by infusing 10 ml (a measure of volume in the metric system) of air into Resident 2's G-tube and listening with a stethoscope (a medical instrument for detecting sounds produced in the body that are conveyed to the ears of the listener through rubber tubing connected with a piece placed upon the area to be examined). LVN 2 placed the supplies to check Resident 2's G-tube placement and begin Resident 2's feeding on a paper towel that was placed on the windowsill next to Resident 2. Resident 2's feeding pump was observed to have a dried, caked on substance on the infusion pump where the feeding tube line was inserted. LVN 2 was observed to leave the room to get assistance with programming the infusion pump. LVN 2 was observed to not perform hand hygiene after removing her gloves and leaving Resident 2's room. LVN 2 did not don a gown prior to performing the procedure on Resident 2. During an interview on 11/7/24 at 3:23 p.m. with the Clinical Nurse Supervisor (CNS), the CNS stated EBP was for residents with wounds, G-tubes, and Foley catheters (a common type of indwelling catheter inserted into the bladder, used to drain urine). The CNS stated it was important for staff to wear a gown and do handwashing when performing procedures on residents on EBP to prevent infection. The CNS stated staff needed to wash their hands before doing resident care. The CNS stated Resident 2's infusion pump should have been cleaned each time a new bag was hung. The CNS stated a dirty pump could cause Resident 2 to get an infection. During an interview on 11/7/24 at 5:02 p.m. with the Infection Preventionist (IP), the IP stated staff needed to perform hand washing or hand hygiene with alcohol prior to performing procedures. The IP stated if the hands were soiled, or if staff touched blood, staff would need to wash their hands. The IP stated staff had to do hand hygiene prior to donning gloves. The IP stated hand hygiene was important because hands were full of germs. The IP stated if staff put gloves on without hand hygiene, germs were still spreadable and there would be the possibility for cross-contamination. The IP stated for EBP, her expectations were for staff to don gloves and a gown for high contact activities such as, hygiene, bathing, showering, changing linens, changing briefs, toilet help, g-tube access, dialysis port dressing changes, wound care, catheter care, and care of all assistive devices. The IP stated it was not acceptable to put the feeding tube (FT) supplies on a paper towel on the windowsill. The IP stated the windowsill was not clean. The IP stated placing the tube feeding supplies on the windowsill created a risk for the resident to get an infection. The IP stated if nurses saw the infusion pump was dirty when setting up an infusion, they should clean the pump. During an interview on 11/08/24 at 11:46 a.m. with the Director of Staff Development (DSD), the DSD stated for residents on EBP, staff needed to use PPE (gown and gloves) when providing direct care to the resident. During a review of Resident 2's Care Plan (CP), undated, the CP indicated, . (Resident 2) is on ENHANCED BARRIER PRECAUTIONS R/T (Related to) INVASIVE DEVICE . date initiated: 6/18/24 . donning and doffing of PPE before entering and exiting by Health care personnel . educate staff and patient about appropriately disinfect and cleaning of equipment's and environment . perform hand hygiene before and after contact with resident . During a review of the facility document titled, Medication Administration Competency Checklist for Enteral Tube, dated 10/31/24, signed by LVN 2, indicated, . (step) 1. Washed hands . placed resident in proper position . wash hands per policy . verify tube placement . attach tube to continuous feeding . wash hands per policy . document . During a review of the facility policy and procedure (P&P), titled, Administering Medications through an Enteral Tube, dated 4/2007, indicated, . steps in the procedure . wash your hands . arrange supplies in the medication room or move the medication cart outside the resident's room . place medications on the bedside table or tray . discard all disposable items into designated containers . wash your hands . 4. During an observation on 11/7/24 at 11:27 a.m. in Resident 27's room, LVN 1 was observed gathering supplies to perform a blood sugar check on Resident 27. LVN 1 placed an unopened bag of cotton balls into a basket that contained supplies for the procedure. LVN 1 did not wash her hands or perform hand hygiene prior to donning gloves. LVN 1 opened the bag of cotton balls at Resident 27's bedside and performed a blood sugar check on Resident 27 by poking his finger and placing a drop of blood on the glucometer strip. LVN 1 discarded the supplies, changed her gloves, and wiped the glucometer with a Sani wipe (a wipe containing a powerful germ-killing formula), but did not wait the two-minute dwell time (the time specified by a manufacturer that a disinfectant must be left on a surface to ensure disinfection) and placed it back into the basket of supplies containing the bag of cotton balls. LVN 1 removed her gloves, performed hand hygiene, and placed the blood sugar meter back into Resident 27's blood sugar meter bag. LVN 1 then placed the glucometer bag and bag of cotton balls back into the medication cart. LVN 1 did not wrap the glucometer with the Sani wipe for two minutes and let it air dry per policy prior to returning the glucometer to the bag. LVN 1 did not wipe the cotton ball bag with Sani wipes and let it sit for two minutes prior to returning it to the medication cart. During a review of Resident 27's AR, dated 11/8/24, the AR indicated, Resident 27 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, ( a condition where the blood sugar levels in the body are too high) and fracture of unspecified lumbar vertebra (break in the bone of the lower part of the spine). During a review of Resident 27's MDS, dated 8/19/24, the MDS section C indicated Resident 27 had a BIMS score of 15, which indicated Resident 27 was cognitively intact. During a concurrent observation and interview on 11/7/24 at 11:40 a.m. in Resident 35's room, LVN 1 was observed checking Resident 35's blood sugar. LVN 1 was observed cleaning the glucometer and leaving it in the Sani wipe for the dwell time of two minutes. LVN 1 proceeded to place the clean glucometer back into the supply basket. LVN 1 did not clean the basket prior to placing the glucometer back into the used supply basket. LVN 1 stated she did not wipe the basket, only the glucometer. During a review of Resident 35's AR, dated 11/8/24, the AR indicated Resident 35 was admitted on [DATE] with diagnoses of type 1 diabetes mellitus with hyperglycemia (elevated sugar in the blood) and psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) substance abuse. During a review of Resident 35's MDS, dated 11/5/24, the MDS section C indicated Resident 35 had a BIMS score of 15, which indicated Resident 35 was cognitively intact. During an interview on 11/7/24 at 5:02 p.m. with the IP, the IP stated staff should do hand washing or hand hygiene with alcohol prior to performing procedures. The IP stated if the hands were soiled or touched blood, staff would need wash their hands. The IP stated staff had to do hand hygiene prior to donning gloves. The IP Stated it was important to do hand hygiene because hands are full of germs. The IP stated if staff put gloves on without performing hand hygiene, germs were still spreadable and there was the possibility for cross-contamination. The IP stated it was not acceptable to put supplies that were at the resident's bed side back into the medication cart. The IP stated the supplies could have contaminated items in the cart. The IP stated her expectation for the glucometer use was to wash hands, use manufacturer instructions for Sani wipes, make a burrito with the glucometer in the Sani wipe, let sit for two minutes, then air dry. The IP stated there was a risk for infection if the hand hygiene and sanitation of supplies and reusable equipment procedures were not being followed. The IP stated she felt she would need to do monitoring more often. During an interview on 11/8/24 at 4:14 p.m. with the Director of Nursing (DON), the DON stated when staff performed blood glucose checks, staff should have washed their hands, provided resident privacy, identified the resident, explained the procedure, donned gloves, and performed the procedure. The DON stated staff should had performed hand hygiene, cleaned the meter, taken off their gloves, washed hands, wiped the meter, wrapped the glucometer, and left the glucometer wrapped inside the wipe (followed the time on manufacturer's instructions), then air dried the meter. The DON stated there was a risk of cross-contamination and spreading infection if the supplies were not properly sanitized after use. The DON stated staff should have taken what was needed out of the cotton bag to the resident's bed side. The DON stated staff should have cleaned the cotton bag before putting it back in the medication cart, after completing the same dwell time after cleaning. The DON stated taking supplies from the resident's bed side and putting them back in the medicine cart could have spread infections to other residents from cross-contamination. The DON stated her expectation was nurses should have been following the standards of practice and policies and procedures for performing glucose checks and cleaning the glucometer. The DON stated the IP observed nurses for competency. The DON stated the IP and DON were responsible for monitoring the nurses. The DON stated nurses were not monitored every day. During a review of the facility's (P&P) titled, Obtaining a Fingerstick Glucose Level, dated 2001, indicated, . equipment . disinfected blood glucose meter (glucometer) . 1-2 cotton balls . always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . wear clean gloves . discard disposable supplies in the designated containers . clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice . remove gloves . wash hands . During a review of the facility document titled, To clean and disinfect the Meter, undated, the document indicated, . wash hands thoroughly with soap and water. Wear a clean pair of gloves . with ONLY PDI Super Sani Cloth Wipes . rub the entire outside of the meter using 3 circular wiping motions . to disinfect: Using fresh wipes, make sure that all outside surfaces of the meter remain wet for 2 minutes . 5. During a concurrent observation and interview on 11/5/24 at 11:54 a.m. with the Certified Nursing Assistant/Restorative Nurse Assistant (CNA/RNA), in the Activities Room Resident 26 was observed dressed sitting in a geriatric chair (Geri-chair - a large, padded chair that is designed to help seniors with limited mobility) at a table eating his meal with dirty Halloween decorations on the table next to his food. The CNA/RNA stated the Halloween decorations should not have been on the table. The CNA/RNA stated the tables should have been cleaned after every activity. The CNA/RNA stated Resident 26 had a change in diet, so she was watching him. During a review of Resident 26's AR dated, 11/8/24, the AR indicated, Resident 26 was admitted on [DATE] with diagnoses of fracture of lumbar vertebra, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and dysphasia (difficulty swallowing). During a review of Resident 26's MDS, dated 9/3/24, the MDS section C indicated Resident 26 had a BIMS score of 12, which indicated Resident 26 was moderately impaired. During an interview on 11/8/24 at 12:15 p.m. with the IP, the IP stated the dining room tables should have been free of any non-meal items. The IP stated the tables should have been wiped down, cleaned, and disinfected after each use. The IP stated whoever was in charge of dining, and Housekeeping should have wiped down the tables. The IP stated all staff training included the frequency of cleaning before and after dining. The IP stated dirty tables and dirty items on the dining table could have caused cross-contamination of the resident's food and placed a risk of infection for the residents. The IP stated residents could get sick. During a review of the facility's job duty document titled, Janitor, dated 4/2013, the document indicated, . the job of Janitor is done for the purpose/s of maintaining an attractive, sanitary and safe facility for residents . 6. During a concurrent observation and interview on 11/5/24 at 11:54 p.m. with the CNA/RNA in the Activities Room, Resident 26 was observed eating his lunch meal with his urine catheter bag placed on his lap. The CNA/RNA stated Resident 26's catheter bag should not have been on his lap. The CNA/RNA stated the urinary catheter bag should have been hanging below Resident 26's waist, on the back of his chair. The CNA/RNA stated Resident 26 had just come back from an appointment and she wanted to hurry and get him his meal, as he had another appointment to go to. During an interview on 11/08/24 at 12:15 p.m. with the IP, the IP stated staff had foley catheter training. The IP stated the catheter should have been free of any kinks and obstructions, off floor and hung below Resident 26's waist to reduce the risk of infection. The IP stated urine could go back up to the bladder if the catheter was not hung below the waist which would increase the risk of infection. The IP stated having the catheter bag on Resident 26's lap was not acceptable. During a review of the facility's P&P titled, Catheter Care, Urinary, dated 12/2007, indicated, . the purpose of this procedure is to prevent infection of the resident's urinary tract . the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the recommended diet plan for 1 of 3 residents (Resident 1) when Resident 1 received a swallowing evaluation (a test to visualize the function of the throat and esophagus while swallowing) on 5/2/24 and the facility did not obtain the result of the swallowing evaluation until 5/17/24. This failure was not the standard of practice according to the facility's policy and procedure, titled, Referrals, Social Services, and had the potential to place Resident 1 at risk for inadequate nutritional intake. Findings: During a review of Resident 1's admission Record (AR), dated 5/26/24, the AR indicated, Resident 1 was admitted on [DATE] and had a history of Hemiplegia (paralysis of one side of the body) and Hemiparesis (one-sided muscle weakness) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side. During a review of Resident 1's Minimum Data Set (MDS – an evaluation of a resident's cognitive and functional status), dated 4/14/24, the MDS indicated the Brief Interview for Mental Status (BIMS) score (an assessment of a resident's cognitive status for memory recall) was 0 (a score of 0 – 7 indicated severe impairment, 8 – 12 indicated moderate impairment, and 13 – 15 indicated minimal to no impairment). During a review of Resident 1's MDS for Functional Abilities and Goals (FAAG), dated 4/14/24, the FAAG indicated, Resident 1 required extensive to total assistance with activities of daily living (transferring, toileting, dressing, personal hygiene, etc.) During a review of Resident 1's MDS for Swallowing/Nutritional Status (SNS), dated 4/14/24, the SNS indicated, Resident 1 had a PEG (percutaneous endoscopic gastrostomy; a surgical procedure in which a hollow tube is inserted into the stomach from the abdomen to deliver nutrition) tube. During an interview on 5/24/24 at 3:45 p.m., with Resident 1's Responsible Party (RP; the person designated to make decisions for the resident), RP stated Resident 1 had a swallow evaluation on 5/2/24 and the facility did not obtain the result of the swallow evaluation. RP stated Resident 1 pulled out his PEG tube on 5/17/24 and was transferred to the hospital. RP stated the hospital's physician called her on 5/17/24 and informed her Resident 1 passed the swallow evaluation on 5/2/24 and a puree (a pudding-like texture that is smooth and blended) diet was recommended. RP stated she declined the PEG tube be reinserted and had Resident 1 returned to the facility with the recommended diet on 5/17/24. During a review of Resident 1's XR Video Swallow Evaluation, dated 5/2/24, the evaluation indicated, Plan/Recommendations: 1. Recommend initiating a puree texture/thin diet (advance up to ground/minced texture. 2. 1:1 feeder. 3. Neutral head positioning. 4. Slow rate of intake. 5. Check for complete oral clearance. During an observation on 5/28/24 at 9:23 a.m. in Resident 1's room, Resident 1 was in bed in clean casual clothes. Resident 1's right arm was contracted (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff), was non-verbal (unable to speak), and followed simple commands. During a review of Resident 1's Progress Notes (PN), dated 5/17/24, 5/18/24, 5/19/24, and 5/20/24 the PN indicated, Resident is s/p (status post) GTUBE (gastric tube) removal, went to dining room to eat [breakfast, lunch, and dinner], resident is a feeder (required feeding assistance), ate 100% of his meal fed by the staff member, no s/s (signs or symptoms) of complication noted while swallowing the food, resident took and tolerated his meds (medications) PO (by mouth) . During an interview on 5/28/24 at 9:57 a.m., with Speech Therapist (ST; a health professional specialized in the treatment of improving the ability to talk and swallow), ST stated Resident 1 was seen on 5/25/24. ST stated a video swallow study (evaluation) was completed on 5/2/24 at the hospital, Resident 1 passed the study and was recommended a puree diet. ST stated ST was not aware of the study until 5/25/24. ST stated she assessed Resident 1's swallowing ability on 5/25/24 and the puree diet was appropriate. ST recommended Resident 1 to be on a puree diet, required to eat in the dining room to observe for aspiration, may have thin liquids (water consistency), no straws, no cup, no glass, fluids to be given only with a spoon, and 1:1 (one resident to one staff member) for all three meals while supervised. During an interview on 5/28/24 at 12:04 p.m., with Director of Nursing (DON), DON stated Resident 1's 5/2/24 swallow evaluation was obtained on 5/17/24 when the hospital called the facility to inform that Resident 1's PEG tube would not be replaced and was recommended a puree diet. DON stated licensed nurses need to make sure that paperwork was brought back from the doctor's office after a resident return from an appointment. DON stated Medical Records (department responsible for maintaining complete and accurate medical documents) was responsible to ensure that medical records were obtained from outside appointments. DON stated Medical Records staff needed to continue contacting the doctor's office until the records were obtained to confirm the results of any test. DON stated a reasonable amount of time to obtain results was within three days. DON stated the charge nurse assigned to Resident 1 on 5/2/24 should have informed Medical Records to request the result of Resident 1's swallow evaluation. DON stated if results are not obtained, residents will not receive the appropriate care. During an interview on 5/29/24 at 2:35 p.m., with Registered Nurse (RN), RN stated she was assigned to Resident 1 on 5/2/24. RN stated Certified Nursing Assistant (CNA) escorted Resident 1 to the swallow evaluation appointment on 5/2/24. RN stated Resident 1 returned to the facility with no paperwork. RN stated CNA informed her the hospital would fax (a device that transmits the copy of a document by wire or radio) the result of the swallow evaluation to the facility. RN stated she informed the Director of Social Services (SSD) to contact the hospital to obtain the results of the swallow evaluation. RN stated it was important to obtain the result of the swallow evaluation to implement the appropriate order. During an interview on 5/29/24 at 2:27 p.m., with Director of Social Services (DSS; a person designated to ensure the well-being of an individual), DSS stated on 5/2/24 RN informed her they (the hospital) were going to fax over the results of Resident 1's swallow evaluation. DSS stated RN did not ask DSS to make sure the hospital faxed the result of the swallow evaluation. DSS stated she was not responsible to follow up with hospital to ensure the result of the swallow evaluation was obtained. DSS stated the RN should have followed up with the hospital to obtain the results. DSS stated licensed nurses should have communicated with Medical Records to request pending documents. DSS stated obtaining the required documents was important to make sure the needs of the residents were met. During an interview on 5/29/24 at 2:53 p.m., with Director of Medical Records (DMR), DMR stated she was not aware Resident 1 had a swallow evaluation on 5/2/24. DMR stated licensed nurses were required to inform Medical Records to obtain pertinent (relevant) documents. DMR stated it was important to obtain the proper medical records so care would not be compromised (made vulnerable). During an interview on 5/30/24 at 10:10 a.m. with RD, RD stated the facility was required to obtain the result of the swallow evaluation on the same day in order to implement the appropriate diet so Resident 1 would receive the proper nutritional intake. During an interview on 5/30/24 at 4:30 p.m., with Administrator (ADM), ADM stated he expected staff to obtain Resident 1's swallowing evaluation within two to three days to implement the appropriate diet order, ensuring Resident 1 received adequate nutrition. ADM stated not following up on the swallow evaluation placed Resident 1 at risk for aspiration (choking) and had the potential to cause harm for inadequate nutritional intake. ADM stated the result of the swallow evaluation would have alerted the Speech Therapist to assess Resident 1 could swallow safely. ADM stated licensed nurses were required to inform Medical Records to obtain the follow-up appointment documents in order to ensure residents received the appropriate care. ADM stated the RN should have notified Medical Records and not the Director of Social Services according to facility policy and procedure to obtain the result of the swallow evaluation on 5/2/24 for Resident 1. ADM stated Medical Records was required to continue requesting the pertinent documents until the records were obtained. During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services, dated 12/08, the P&P indicated, Policy Interpretation and Implementation . 6. Any resident returning from appointments without any paperwork, Charge nurse needs to communicate with Medical records department to obtain follow-up paperwork.

Based on observation, interview and record review, the facility failed to protect the privacy of one of six sampled residents (Resident 260), when Registered Nurse (RN) 4 left the privacy curtain and door open while providing care to Resident 260 and exposed Resident 260 to public. This failure resulted in violation of Resident 260's rights to confidentiality and the potential for unauthorized access to Resident 260. Findings: During an observation on 10/16/23, at 9:30 a.m., in Resident 260's room, Resident 260 was laying in bed with eyes closed. Resident 260 was observed with a peripherally inserted central catheter (PICC-long thin tube inserted through a vein and passed through to the larger vein near the heart-used to give fluid or medication directly into a vein) on her right arm and was receiving medication from an infusion pump (medical device used to deliver fluids into a patient's body in a controlled manner). During a review of Resident 260's admission Record (AR- document which contain patient personal information), dated 10/20/23, the AR indicated Resident 260 was admitted in the facility on 10/11/23 with diagnoses which included intraspinal (inside the spine[backbone] ) abscess (pus) and granuloma (small area of inflammation [swelling]). During a concurrent observation and interview on 10/16/23, at 9:40 a.m., in Resident 260's room. RN 4, disconnected Resident 260's infusion pump and flushed (clear out) the PICC line. RN 4 did not close the privacy curtain or the door. Resident 260 was exposed to other residents, staff and visitors walking by her room. RN 4 stated she did not close the privacy curtain or the door to Resident 260's room and should have to provide privacy to Resident 260. During a concurrent observation and interview on 10/16/23, at 9:50 a.m., with Resident 260 in her room, Resident 260 was lying in bed awake. Resident 260 stated she was getting ready to go out for a smoke. Resident 260 stated she liked her door closed at all times because she did not want to be bothered. Resident 260 stated her privacy was very important, and she did not want people looking in her room at her. During an interview on 10/19/23, at 8:46 a.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated the practice was to always close the privacy curtain and door when providing care to residents. CNA 5 stated it was important to close the privacy curtain and/or doors to ensure resident's privacy. CNA 5 stated some of the resident rooms did not have privacy curtain, so it was important to close the door to ensure resident's privacy. During an interview on 10/20/23, at 10:53 a.m., with the Director of Staff Development (DSD), DSD stated the expectation was to always provide privacy to residents when providing care and procedures. DSD stated the nurse should have provided Resident 206's privacy when she disconnected the IV. During an interview on 10/20/23, at 2:16 p.m., with the Director of Nursing (DON), DON stated all residents should be provided with privacy when performing procedures or providing care. DON stated staff should make sure to provide resident their right to keep their privacy private. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/16, the P&P indicated, . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: . privacy and confidentiality .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 14) when Resident 14 did not have a care plan for the use of anticoagulant (blood thinner) medication. This failure placed Resident 14 at risk for complications from not having care needs planned by licensed nurses to determine if nursing intervention needed to be added, changed, or completed. Findings: During a concurrent observation and interview during a facility tour on 10/13/23, at 8:55 a.m., in Resident 14's room, Resident 14 was observed walking using a four prong cane from the bathroom to his bed. Resident 14 stated he had been in the facility for one month and was working with therapists. Resident was observed with clean and dry dressings to both feet. Resident 14 stated he had several of his toes amputated (surgically removed). During a review of Resident 14's clinical record titled, admission RECORD dated 10/18/23, the admission Record, indicated Resident 14 was admitted to the facility with diagnosis of atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow and blood clot formation). During a concurrent interview and record review on 10/19/23, at 1:46 p.m., with Registered Nurse (RN) 2, RN 2 stated Resident 14 was on anticoagulant medication. RN 2 reviewed Resident 14's clinical record titled, Care Plans RN 2 stated she did not find a care plan for Resident 14's use of anticoagulant medication. RN 2 stated there should have been a care plan for Resident 14's use of anticoagulant to monitor for complications like bleeding. RN 2 stated she did not find a care plan in Resident 14's clinical record to monitor for bleeding and there should have been. During a concurrent interview and record review on 10/18/23, at 3:14 p.m., with Registered Nurse (RN)3, Resident 14's electronic record was reviewed. RN 3 stated Resident 14 has an order for anticoagulant medication. RN 3 stated Resident 14 was receiving anticoagulant medication for Atrial fibrillation that was ordered on 9/18/23. RN 3 stated he was not sure if the care plan was appropriate for anticoagulant use. RN 3 stated, . It is there and we monitor for bleeding . During a concurrent interview and record review on 10/20/23, at 10:53 a.m., with the Director of Staff Development (DSD), the DSD stated care plans were very important to know a resident's goals, interventions and the care plans had to be resident-centered. Resident 14's Care Plan dated, 9/21/23 was reviewed. The care plan indicated, Focus: [NAME] has Atrial Fibrillation . Interventions: . Eliquis (brand name) Oral Tablet 5 (five) MG (milligram-unit of measurement) . DSD stated the care plan did not address Resident 14's use of anticoagulant medication, and it should have been more individualized and completed within 72 hours after admission. DSD stated there should have been a care plan for the use of anticoagulant medication in order to monitor side effects of the medication like bleeding. During an interview on 10/20/23, at 2:16 p.m., with the Director of Nursing (DON), DON stated her expectation were for a comprehensive care plan to be developed within seven days after admission. DON stated if there were new order or changed of an order, she expected a care plan to be developed and/or updated as needed. DON stated the care plan for Resident 14 should have been specific to the use of anticoagulant in order to monitor Resident 14 for signs of bleeding. During a review of the facility's policy and procedure (P&P) titled, Anticoagulation-Clinical Protocol, dated, 4/07, the P&P indicated, . The staff and physician will monitor for possible complications in individuals who are being coagulated, and will manage related problems . During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, . The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; . to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .Incorporate risk factors associated with identified problems . The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an environment free of accident hazards when: 1. Resident 11's bed rail was loose and not in good working condition which led to Resident 11's fall on 10/11/23. This failure had the potential to result in additional falls which could have result in serious injury for Resident 11. 2. Multiple handrails in the hallways were found cracked with missing end pieces and exposed sharp edges. This failure had the potential to cause injuries to residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 10/16/23, at 9:15 a.m. with Resident 111, he was sitting up in his wheelchair appropriately dressed, observed with right below knee amputee (RBKA), dry, clean dressing and wearing stump support. Resident 111 stated the bed rail wiggled because the screw was loose. Resident 111 stated he lost his balance and fell when he attempted to transfer himself, while he held on to the rail. During a review of Resident 111's admission Record, dated 10/18/23, the admission Record indicated, Resident 111 was admitted to the facility on [DATE] with diagnoses which included Orthopedic aftercare (musculoskeletal system[bones, joints, ligaments, tendons and muscles]) and absence of right leg below knee. During a review of Resident 111's, Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [mental process] and physical functional level) assessment dated [DATE], the MDS indicated Resident 111's Brief Interview for Mental Status (BIMS-screening tool used to assess resident cognitive level) score was 15 of 15 indicating Resident 111 had no cognitive impairment. During an interview on 10/18/23, at 10:42 a.m., with certified nursing assistant (CNA) 2, CNA 2 stated she was the CNA for Resident 111 and was familiar with his care. CNA 2 stated Resident 111 had a fall but was not sure of the date and did not know how Resident 111 fell. CNA 2 stated Resident 111 complained about his bed rail were loose. CNA 2 stated she reported to the maintenance department but was not sure if the maintenance took care of the bed rail. CNA 2 stated the bed rail were still loose and the screw was loose today when she started her shift in the morning. CNA 2 stated the bed rail needed to be fixed to prevent Resident 111 from falling and hurting himself. During a concurrent observation and interview on 10/18/23, at 11:45 am., with Maintenance Supervisor (MS) in Resident 111's room, two maintenance assistants were observed fixing the bedside bed rail. MS stated a CNA had notified him about the bed rail earlier in the day. MS stated the screw in the bed rail was loose and was not the right screw. The MS stated the bed rail was just fixed and the loose screw was replaced. MS stated he remembered fixing Resident 111's bed rail after Resident fell and did not know how it got broken again. The MS stated it was important to make sure all resident's equipment are in good working condition for the safety of the residents. During an interview on 10/20/23, at 11:15 a.m., with Director of Staff Development (DSD), she stated she did not know Resident 111's bed rail were loose and did not know how he fell. The DSD stated maintenance should have taken care of the bed rail when Resident 111 fell and reported his bed rail was loose. The DSD stated the bed rail should have been fixed to prevent accidents and falls. During an interview on 10/20/23, at 2:30 p.m., with the Director of Nursing (DON), the DON stated she was aware of Resident 111's bed rail were loose when he fell. The DON stated she let the MS knew about the loose side rail and he reported he had taken care of the bed rail. The DON stated she did not know how the bed rails was broken again, if the MS reported it was fixed. The DON stated it was a potential for accidents. During a review of the facility's policy and procedure (P&P), titled Bed Safety dated 12/07, the P&P indicated, . Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risk and problem .Ensure that bed side rails are properly installed . 2. During an observation on 10/18/23, at 10:45 a.m., in the main hallway, observed several hand rails with cracks, missing end caps with exposed metals on the edges. The Handrails were metal with hard plastic covers, the cracked areas of the handrails had sharp edges and the handrails ends had exposed sharp metals. During a concurrent observation and interview on 10/18/23, at a:33 a.m., with the MS, the MS inspected the handrails and stated, . I am working with the vendor and I will send them the model number of the hand rails before the end of the day today . The MS stated hand rails are a work in progress and are finding pieces that can still be used and will slowly replaced with new ones. The MS stated the maintenance department tried to take care of things but it can get busy and forgets and had to be reminded sometimes by staff. During an interview on 10/18/23, at 11:05 a.m., with CNA 5, she stated she knew the hand-rails had cracks and missing end caps. CNA 5 stated the cracked edges were sharp and the handrail ends have exposed metals that were sharp and it was just waiting for an accident waiting to happen. CNA 5 stated the residents were at risk for cutting themselves and staff also because they also used the handrails. CNA 5 stated she was not sure if she reported it to maintenance. During an interview on 10/18/23, at 2:50 p.m., with Licensed Vocational Nurse (LVN) 4, she stated the hand rails in the hallway had cracks and missing end caps. LVN 4 stated it was not safe for residents, staff and/or visitors. LVN 4 stated the residents may end up cutting themselves holding on the handrails. LVN 4 stated she did not remember if she notified the maintenance department about the hand rails. During an interview on 10/20/23, at 2:30 p.m., with the DON, the DON stated the MS was aware of the cracked hand rails and missing end caps. The DON stated she was not sure how many handrails were broken. The DON stated the maintenance department was trying to fix the hand rails. The DON stated the broken handrails with missing end caps was a potential for accidents because of the sharp edges and exposed metals. The DON stated it was not only a risk of harm to the residents but also staff and visitors. During an interview on 10/20/23, at 4:50p.m., with the Administrator (ADM), the ADM stated, . The handrails are there and we are trying to see if we can replace one hallway at a time, we do not have the fund to replace everything . ADM stated he was not aware of any reported incidents involving the handrails. During a review of the facility's P&P, titled, Accidents and Incidents-Investigating and Reporting, dated 7/17, the P&P indicated, All accidents or incident involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated . Incidents/Accident reports will be reviewed by the Safety Committee for trends related to accidents or safety hazards in the facility . During a review of the facility's P&P, titled, Maintenance Service, dated 12/09, the P&P indicated, . The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . maintaining the building in good repair and free from hazards . The maintenance director is responsible . to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 9) with an indwelling urinary catheter (a soft hollow tube which is passed into the bladder to drain urine, for persons who cannot empty their bladder) received appropriate care when Resident 9's urinary catheter bag was touching the floor on three separate occasions. This failure had the potential for Resident 9 to develop a urinary tract infection (UTI- infection in any part of the urinary system, kidneys, bladder, or urethra) which could cause sepsis (the body's overwhelming and life-threatening response to infection) and hospitalization if untreated. Findings: During a review of Resident 9's admission Record, undated, the admission record indicated, Resident 9 was admitted to the facility on [DATE] with diagnoses which included heart failure (a condition that develops when the heart cannot pump enough blood to meet the body's needs for blood and oxygen), obstructive and reflux uropathy (a condition in which the flow of urine is blocked), retention of urine (inability to urinate), and type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as fuel). During a review of Residents 9's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical function) assessment dated [DATE], indicated, Resident 9's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 03 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 9 was severely cognitively impaired. During an observation on 10/16/23 at 11:24 a.m. in Resident 9's room, Resident 9 was lying in bed with her eyes closed. Resident 9's urinary catheter was hanging on the frame of her bed in a dignity bag (a bag used to cover the urine drainage bag for privacy), the bag was touching the ground. During an observation on 10/17/23 at 3:20 p.m. at Resident 9's bedside, Resident 9's bed was in the lowest position with fall mats on the floor beside it. Resident 9's urinary catheter was in the dignity bag hung on the side of the bed. The catheter bag was folded in the dignity bag which was touching the floor. The catheter tubing was full of urine from the bag to the resident and was not draining properly. During a concurrent observation and interview on 10/17/23 at 3:22 p.m. with Certified Nursing Assistant (CNA) 1 at Resident 9's bedside, Resident 9's catheter bag was observed. CNA 1 stated Resident 9's catheter bag should not touch the ground because the floor was not clean. CNA 1 stated Resident 9's catheter could become contaminated and cause an infection. CNA 1 stated the urine was backed up in the tubing and the catheter was not draining properly. CNA 1 removed the catheter bag from the dignity bag which caused the urine to drain into the catheter bag. During a concurrent observation, interview, and record review on 10/17/23 at 3:30 p.m. with Licensed Vocational Nurse (LVN) 4, at Resident 9's bedside, Resident 9 was lying with eyes closed in bed. LVN 4 stated the urinary catheter bag should hang freely on the bed to allow the bladder to drain. LVN 4 stated the catheter and dignity bag should not have touched the floor because it was an infection control issue. LVN 4 reviewed a photo of Resident 9's catheter bag folded in the dignity bag taken on 10/17/23. LVN 4 stated she could see the catheter bag was not placed into the dignity bag correctly and was touching the floor. LVN 4 stated in the photo, there was urine in the tubing and the catheter did not look like it was draining properly. LVN 4 stated the catheter and dignity bag should not touch the ground because it was an infection control issue and could a UTI. LVN 4 stated if the catheter bag was not placed in the dignity bag correctly, the urine could back up into the kidneys and cause an infection. During a concurrent observation and interview on 10/19/23 at 10:22 a.m. with CNA 3 in Resident 9's room, Resident 9's catheter bag was observed. The catheter bag was lying face down on the floor, under her bed. CNA 3 stated the floor could contaminate the catheter and cause a urine infection. During a concurrent interview and record review on 10/19/23 at 2:35 p.m. with the Infection Preventionist (IP) photo of Resident 9's catheter from 10/16/23 was reviewed. The IP stated Resident 9's catheter bag was touching the floor. The photo taken 10/17/23 was reviewed and the IP stated it appeared the catheter bag position did not allow for draining which could cause a UTI. During a concurrent interview and record review on 10/20/23 at 2:35 p.m. with the Director of Nursing (DON) the photos of Resident 9's catheter bag were reviewed. The DON reviewed the photo from 10/16/23 and stated the catheter bag appeared to touch the floor, which could cause contamination of the catheter. The photo taken on 10/17/23 was reviewed and the DON stated the catheter did not appear to drain correctly which could have caused Resident 9 to have an infection or pain in her bladder. The DON reviewed the photo taken 10/19/23 of the catheter bag face down on the floor, the DON stated the catheter should not have been lying on the floor and should have been hung in the dignity bag. The DON stated contamination of the catheter bag could have caused an infection, weakness, increased fall risk, sepsis and obstruct (block) the kidneys. During a review of Resident 9's Order Review History Report, dated 9/18/23, the orders indicated, .Foley Catheter 16 FR with 10 CC balloon to bedside drainage . Monitor Foley Catheter Placement Q [every] shift . During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 12/2007, the P&P indicated, . The purpose of this procedure is to prevent infection of the resident's urinary tract . keep the catheter and tubing free of kinks . Be sure the catheter tubing and drainage bag are kept off the floor . Observe the resident for signs and symptoms of urinary tract infection and urinary retention [inability to empty the bladder completely] . During a review of a professional reference retrieved from https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html titled Catheter-Associated Urinary Tract Infections, dated 11/5/2015, the reference indicated, .Guideline for Prevention of Catheter-Associated Urinary Tract Infections . Proper Techniques for Urinary Catheter Maintenance . maintain unobstructed urine flow . Keep the catheter and collecting tube free from kinking . Keep the collecting bag below the level of the bladder at all times. Do rest the bag on the floor .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for one of two sampled residents (Resident 10) when Resident 10's oxygen flow rate was given at a higher rate than the physician ordered. This failure had the potential for Resident 10 to experience difficulty breathing, respiratory distress and lung damage. Findings: During a review of Resident 10's admission Record, undated, the admission record indicated, Resident 10 was admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease with heart failure (long term heart problems caused by high blood pressure), chronic obstructive pulmonary disease (COPD-chronic lung disease which damages the lungs making it difficult to breathe), type 2 diabetes mellitus (a problem in the way the body regulates and uses sugar as fuel) and asthma (long term condition affecting the airways of the lungs). During a review of Residents 10's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical function) assessment dated [DATE], indicated, Resident 10's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 10 was cognitively intact. During an observation on 10/16/23 at 11:30 a.m. at Resident 10's bedside, Resident 10 was lying in bed with her eyes closed. Resident 10 had a nasal cannula (a device that delivers extra oxygen through a tube attached from the concentrator and into the nose) on, and there was an oxygen concentrator (an electric device which separates and compresses oxygen from the air to deliver it to the patient) next to her bed. Resident 10's oxygen flow rate was set between 3.5 and 4 liters per minute (L/min-oxygen flow rate administered per minute). During a concurrent observation and interview on 10/16/23 at 12:09 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 10's room, Resident 10 was lying in bed awake. CNA 2 checked Resident 10's oxygen concentrator and stated the oxygen was set between 3.5 and 4 L/min mark. CNA 2 stated she was not sure what the concentrator should be set at, but she would check with the nurse. Resident 10 stated her oxygen flow rate should be at 2 L/min. During a concurrent observation and interview on 10/16/23 at 12:10 p.m. with Licensed Vocational Nurse (LVN) 1 at Resident 10's bedside, LVN 1 checked Resident 10's oxygen concentrator settings. LVN 1 stated the flow rate was set at between 3.5 and 4 L/min and it should be set at 2 L/min. LVN 1 stated Resident 10 was receiving oxygen for COPD. LVN 1 stated oxygen should be administered according to the physician's order. LVN 1 stated if the oxygen was not administered as the physician ordered, it could harm the resident. LVN 1 stated Resident 10 had COPD and if she received too much oxygen it could be detrimental to her health. During a review of Resident 10's Order Review History Report, dated 9/18/23, the orders indicated, .O2 @ 2L [liters per minute] via NC continuously every shift . During a concurrent interview and record review on 10/19/23 at 2:29 p.m. with the Infection Preventionist (IP), a photo of Resident 10's oxygen setting, dated 10/16/23 was reviewed. The IP stated the oxygen was set at 4 L/min. Resident 10's physician's order was reviewed, and the IP stated the orders indicated Resident 10's oxygen should be administered at 2 L/min. The IP stated if a resident received too much oxygen it could cause damage to the lungs. The IP stated the oxygen should have been administered at the rate the physician ordered. During a concurrent interview and record review on 10/20/23 at 2:35 p.m. with the Director of Nursing (DON), the photo of Resident 10's oxygen concentrator dated 10/16/23 was reviewed. The DON stated the oxygen was set between 3.5 and 4 L/min. The DON stated the physician's order was not followed and Resident 10 should have received oxygen at 2 L/min. The DON stated if a resident received too much oxygen it could cause hyperventilation (rapid or deep breathing) and affect their lungs. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, dated 10/2010, the P&P indicated, .The purpose of this procedure is to provide guidelines for safe oxygen administration . Verify that there is a physician's order . Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute . Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered . During a review of a professional reference retrieved from https://my.clevelandclinic.org/health/treatments/23194-oxygen-therapy titled Oxygen Therapy, dated 6/6/22, was reviewed. The professional reference indicated, .Supplemental oxygen therapy helps people with COPD . Low blood oxygen levels (hypoxemia) can damage organs and be life-threatening. You may need oxygen therapy for life . Oxygen therapy gives your body the oxygen it's not getting when you breathe in air . Oxygen comes in gas or liquid form . Oxygen is a medication that requires a prescription from a healthcare provider. You should only use oxygen therapy as a medical treatment. If you take in more oxygen than your body needs, it can slow your breathing and heart rate to dangerous levels . Too much oxygen can lead to oxygen toxicity or oxygen poisoning. This can happen if you accidentally take in too much supplemental oxygen . Signs of oxygen poisoning include . Chest pain . Difficulty breathing . It's critical to follow certain safety measures when you use oxygen therapy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet the pain management needs of residents consistent with professional standards of practice for one of six sampled resident (Resident 23) when Resident 23's pain was not managed effectively due to unavailability of Resident 23's Percocet (medication used to treat pain) medication from 10/17/23, 10/18/23 and 10/19/23. This failure resulted in Resident 23's experiencing avoidable pain and suffering for prolong periods of time from 10/17 through 10/19/23 which led to her inability to sleep at night and unable to received needed care due to severe pain to the areas of her body affected by pain. Findings: During a review of Resident 23's admission Record, undated, the admission record indicated, Resident 23 was admitted in the facility on 8/24/23, with diagnoses which included wedge compression fracture of lumbar vertebrae (lower back bone), and fibromyalgia (chronic disorder that causes pain and tenderness throughout the body). During a review of Residents 23's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 23's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 23 was not cognitively impaired. During a concurrent observation and interview on 10/16/23, at 9:35 a.m., with Resident 23 in Resident's room, Resident 23 was observed lying in bed, eyes open and listening to music. Resident 23 stated she was in the hospital due to a fall she had at home and sustained four fractures (break in the bone) on her back. Resident 23 stated no surgery was needed but she was being followed by a Neurosurgeon (specially trained medical doctor who treats conditions that affects the brain, spinal cord and nerves). During a concurrent observation and interview on 10/19/23, at 9:34 a.m., with Resident 23 in her room, Resident 23 stated she did not receive her prescribed pain medication until six in the morning due to the medication not being available. Resident 23 stated she was not able to sleep the last two nights due to not received the prescribed pain medication she needed. Resident 23 stated on 10/17/23, she requested her pain medication be increased because it was not helping control her pain. Resident 23 stated when she asked for the pain medication the nurse told her the pharmacy did not deliver the pain medication. During a review of Resident 23's Care Plan, undated, the CP indicated, . The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain . Percocet oral tablet 10-325 MG(milligram- unit of measurement) (Oxycodone w/ Acetaminophen). Give 1 (one) tablet by mouth every 6 (six) hours routinely . During a concurrent interview and record review on 10/19/23, at 1:46 p.m., with Registered Nurse (RN) 2, RN 2 reviewed Resident 23's clinical record and stated she worked the afternoon shift on 10/17/23 and 10/18/23 with Resident 23. RN 2 stated Resident 23's pain medication was discontinued by the morning nurse because Resident 23 requested to increase the dose and to give the medication routinely every six hours. RN 2 stated she did not administer the ordered pain medication due at six p.m., to Resident 23 because the medication was not available and it was not available in their emergency kit. RN 2 stated she did not administer the ordered pain medication to Resident 23 on 10/18/23 due at six p.m., because it was not available. RN 2 stated she called the pharmacy to inquire about Resident 12's pain medication and was advised to fax the medication order. RN 2 stated the medication was not delivered during her shift and she did not follow up with pharmacy. RN 2 stated she should have called the Medical Doctor (MD) to get an alternate pain medication while awaiting for the pharmacy to deliver the pain medication. During a phone interview on 10/19/23, at 3:49 p.m., with RN 5, she stated she worked the night of 10/17/23, with Resident 23. RN 5 stated she did not administer the pain medication due at midnight to Resident 23 because the medication was not available. RN 4 stated Resident 23 was upset because she did not receive her routine pain medication and she complained of 5-7 on a pain scale. RN 5 stated she offered Resident 23 acetaminophen which she refused, at around two a.m. in the morning Resident 23 complained of pain again and she administered acetaminophen tablets. RN 5 stated she called the pharmacy to follow-up on Resident 23's pain medication, the medication was not delivered during her shift. RN 5 stated the pain medication should have been available for Resident 23. During a phone interview on 10/19/23, at 4:03 p.m., with Pharmerica Pharmacist (PP), the PP stated a nurse called the pharmacy on 10/18/23 after midnight for a verbal request of the medication hydrocodone/acetaminophen 10/325mg every six hours routinely, the pharmacy sent the medication the morning of 10/18/23. PP stated a facility nurse called on 10/18/23, at 11pm and spoke with the on-call pharmacist and clarified the order. PP stated the order was corrected and the pain medication was dispensed on 10/19/23 and the facility should have received the medication. During a phone interview on 10/19/23, at 4:25 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated she worked night shift on 10/18/23 to 10/19/23. LVN 5 stated she did not administer the routine prescribed pain medication to Resident 23 due at midnight because it was not available. LVN 5 stated Resident 23 was mad at her because the pain medication was not available to administer. LVN 5 stated she offered to give Resident 23 acetaminophen and to send her out to general acute care hospital (GACH) but she refused. LVN 5 stated it was not right to not have the prescribed pain medication available for Resident 23. LVN 5 stated Resident 23's routine pain medication should have been available to administer as prescribed. During an interview on 10/20/23, at 2:45 p.m., with Director of Nursing (DON), the DON stated Resident 23 requested to increase her pain medication on 10/17/23, the new medication was not delivered until 10/19/23. The DON stated she did not know what happened but it was already straightened out. The DON stated it was not right the medication was not available to administer to Resident 23. The DON stated Resident 23 was receiving routine pain medication every six hours before the pain medication was increased. The DON stated after the dose was increased Resident 23 received less than the ordered dose on 10/17/23, 10/18/23 and 10/19/23, of prescribed pain medication when the order was for every six hours routinely. During a review of the facility's policy and procedure (P&P), titled, Pain Assessment and Management, dated, 3/15, the P&P indicated, .Observe the resident (during rest and movement) for physiological and behavioral (non-verbal) signs of pain . 1. Increased Blood Pressure; 2. Tachycardia; 3. Increased respirations; and 3. Diaphoresis .

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse according to facility policy and procedures (P&P) when two of four dumpsters did not have lids closed properly. This failure had the potential to attract pests and rodents which could lead to unsanitary conditions and spread of disease. Findings: During a concurrent observation and interview on 10/17/23 at 9:40 a.m. with the Certified Dietary Manager (CDM), the outside trash dumpsters were observed. Four trash dumpsters were observed, one blue dumpster for recycling and three brown dumpsters for trash. One brown dumpster was observed with one of the lids opened and a second brown dumpster with the lid partially opened due to overflowing trash. The CDM confirmed the trash dumpster lids were left open, could lead to an infestation, causing cross contamination and disease. During an interview on 10/17/23, at 1:58 p.m., with the Registered Dietician (RD), the RD stated the outside dumpsters should be completely closed, to prevent a rodent infestation, food contamination and illness. During a review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control, dated 2018, the P&P indicated .Pest Control . The facility will ensure a pest control prevention program provides a monthly inspection, treatment and prevention of vermin and insect infestation . Keep the dumpster, waste removal and trash storage areas clean and sanitized. Trash receptacles will have clean liners and be kept covered at all times . The lid of the dumpster should be closed at all times . The dumpster should not be overflowing . During a review of the facility's policy and procedures (P&P) titled Sanitation and Infection Control, dated 2018, the P&P indicated, .Waste Control and Disposal . Facility will create method of waste disposal that will create the minimum amount of inconvenience . Keep lids of outside trash dumpsters closed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a safe, functional environment for staff members and the public when: 1. The dryer door glass was broken, and the glass was replaced by a circular piece of cardboard covering the opening in the dryer door while the dryer was in use. 2. The handwashing sink's hot water in the kitchen was 163 degrees Fahrenheit (F-unit of measurement). These failures placed staff and the public's safety at risk for harm. Findings: 1. During a concurrent observation and interview on 10/19/23 at 10:41 a.m., with the Laundry Aide (LA) in the laundry room, the front load dryer had a circular piece of cardboard covering the opening in the dryer door while it was in use. The LA stated the glass on the door had broken on Thursday (10/12/23). The LA stated when the Laundry Repair Vendor (LRV) came to fix the dryer, he cut out the cardboard to use until dryer door was fixed. The LA stated the Maintenance Supervisor (MS) was aware of the carboard and approved its use. During a concurrent observation and interview on 10/19/23 at 11:00 a.m. with the MS, the cardboard covering the dryer door was observed. The MS stated the door had broken on 10/12/23 during the PM (evening) shift. The MS stated the LRV came to the facility on [DATE]. The MS stated the LRV had cut out the cardboard to use while the dryer was in use. The MS stated he did not think using the cardboard was a safety issue. During a concurrent interview and record review on 10/20/23 at 11:50 a.m. with the MS, the manufacturers manual, dated 7/21, was reviewed. The manual indicated, . WARNING indicates a potentially hazardous situation, which if not avoided could result in death or serious injury . Warning! Do not operate equipment if door glass is damaged in any way . The MS stated he had not read the manual after the door was broken. The MS stated he was unaware the manual indicated to not to use the dryer if the door was damaged. The MS stated he trusted the LRV because he was experienced. During a phone interview on 10/20/23 at 1:45 p.m. with the LRV, the LRV stated he was notified the dryer door glass was broken and came onsite the following day. The LRV stated when he arrived the dryer was operating, and the staff had a sheet wrapped around the door to cover the opening. The LRV stated he had recommended the staff should not use the dryer. The LRV stated he was concerned about the sheet covering the door because it could cause serious harm if the sheet was pulled inside due to the air flow. The LRV stated he had notified the staff to finish the load in the dryer and not use the dryer again until the door was fixed. The LRV stated the cardboard was supposed to be temporary and was a safer option than the sheet. The LRV stated the cardboard was still a safety concern. The LRV stated he had been clear with the staff about finishing the load in the dryer at the time and to not use the dryer until door was fixed. During a review of the facility's P&P titled Laundry, dated 9/2022, .Laundry equipment (e.g. washing machines, dryer) are used and maintained according to manufacturer's IFU [Instructions for Use] to prevent microbial contamination of the system and hazards . During a review of the facility's policy and procedure (P&P) titled Maintenance Service, dated 12/2009, the P&P indicated, .The Maintenance department is responsible for maintaining the buildings, rounds, and equipment in a safe and operable manner at all times . maintaining the building in good repair and free from hazards . Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned . 2. During an observation on 10/16/23 8:35 a.m. in the kitchen, the water in the handwashing sink was extremely hot and stung hands when washing. During an interview on 10/18/23 at 10:30 a.m. with the Certified Dietary Manager (CDM) and the [NAME] (CK) in the kitchen, the CDM stated the hot water on the handwashing sink was very hot. The CDM stated the kitchen's water heater was turned up to ensure the dishwasher was hot enough to sanitize dishes. The CK stated, she knew the sink temperature was hot and stated, I don't even use the hot on the sink, I only turn on the cold water to wash my hands. I'm always hot, so I prefer the cold. The CK stated she used soap when she washed her hands which gets her hands clean enough. The CK stated it would be better to wash her hands with warm water and soap to prevent germs. During a concurrent observation and interview on 10/18/23 at 10:40 a.m. with the Maintenance Supervisor (MS) in the kitchen, the MS used a cup and digital thermometer to check the sink temperature. The MS had turned on the hot water, filled the cup and checked the temperature. The MS showed the thermometer and stated it was 163 degrees Fahrenheit (F- a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees). The MS checked the water temperature three times and stated, he guessed someone could burn their hands with the water at 163 degrees. The MS stated the water heater was turned up high, so the dishwasher was hot enough. During an interview on 10/18/23 at 10:55 a.m. with Dietary Aide (DA) 1, DA 1 stated she knew the handwashing sink was hot. DA 1 stated the sink temperature was not at a safe temperature. During a review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control, the P&P indicated, .Handwashing . Hands must be properly and frequently washed to prevent cross contamination of food supplies or equipment . Follow the following steps to effectively wash hands . Turn on water slowly to a warm, comfortable temperature . During a review of the facility's policy and procedure (P&P) titled Maintenance Service, dated 12/2009, the P&P indicated, .The Maintenance department is responsible for maintaining the buildings, rounds, and equipment in a safe and operable manner at all times . maintaining the building in good repair and free from hazards . The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds and equipment are maintained in a safe and operable manner . Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned . During a review of a professional reference retrieved from https://www.cpsc.gov/s3fs-public/5098-Tap-Water-Scalds.pdf titled Avoiding Tap Water Scalds, dated 3/2012, the reference indicated, .Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to prevent the presence of rodents when rodent excrement was found in the basement dry food storage area. This failure had the potential to lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins) for residents who eat food prepared in the kitchen. Findings: During a concurrent observation and interview on 10/19/23 at 9:12 a.m. with the Certified Dietary Manager (CDM) in the basement dry food storage area, there were several mouse and rat traps along the walls. There were small brown droppings found around a mouse trap in one corner of the basement. The CDM stated they were rodent droppings which could cause food contamination and illness. During a concurrent observation, interview, and record review, on 10/19/23 at 10:31 a.m. with the Maintenance Supervisor (MS) in the basement, the MS observed brown droppings in the corner. The MS stated the facility had a pest control service monthly and as needed. The MS stated he contacted the company for a call back visit the previous week because there were signs of activity in the basement. The MS declined to specify what he had meant by activity. The MS stated the brown droppings were recent because the pest control company had been at the facility the previous week. The MS brought the last four reports from the pest control company to review. The pest control company's report dated 9/27/23 indicated, . 1 live rodent in basement glue board monitor . The pest control company's report dated 10/11/23 was reviewed. The MS stated the report indicated the company found rodent bait eaten from the bait stations, recommended the facility to repair the door gaps to limit pests and rodent activity from entering the building. The MS stated all the facility's exterior door gaps had not been repaired as recommended. During a concurrent interview and record review on 10/19/23 at 2:41 p.m., with the Infection Preventionist (IP), photos of the brown droppings in the dry food storage area were reviewed. The IP stated rodents had been in the basement, and that could pass infection to the residents. During an interview on 10/20/23 at 1:25 p.m. with the Administrator (ADM), the ADM stated the facility had an issue with pests about six to nine months previously. The ADM stated it was up to the MS to follow up with recommendations of the pest control company and make sure pests were under control. During a review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control, dated 2018, the P&P indicated .Pest Control . The facility will ensure a pest control prevention program provides a monthly inspection, treatment and prevention of vermin and insect infestation . All Department of Food and Nutrition Services personnel will be instructed on evidence of vermin and insect infestation . Any food contaminated by insects, rodents or their excrement, will be discarded. Pest control is designed to maintain a sanitary environment, which prevents contamination, transmission or spread of disease . It is recommended that a pest control company be retained on a monthly basis, or more often if necessary . During a review of the facility's P&P titled Pest Control, dated 5/2008, the P&P indicated, . Our facility shall maintain an effective pest control program . This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . Maintenance services assist, when appropriate and necessary, in providing pest control services .

Deficiency Text Not Available

Deficiency Text Not Available

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 2 of 18 sampled residents (Residents 26 and Resident 1) were free from unnecessary psychotropic (drugs that affect brain activity associated with mental processes and behavior) medications, as evidenced by: 1. For Resident 26, there was inadequate Divalproex Sodium side-effect (S/E) monitoring. 2. For Resident 1, Olanzapine was not started at the recommended dose and there was inadequate monitoring of recommended laboratory testing while on psychotropic therapy. These failures resulted in the potential for medication interactions, adverse reactions, and increased risks associated with the use of psychotropic medications that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, memory loss and toxicity. Findings: 1. During a review of the clinical record for Resident 26, the admission Record (AR) dated 10/17/2023, indicated the resident was admitted on [DATE] with diagnoses including Altered Mental Status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain.), Schizoaffective Disorder- Bipolar Type (a subtype of a very serious mental health condition called schizoaffective disorder), Depression, Major Depressive Disorder Recurrent, and Severe with Psychotic Symptoms. During a review of the clinical record for Resident 26, the Physician Order dated 10/16/2023 indicated, Divalproex Sodium Delayed Release 500 mg. Give 1 tablet by mouth one time a day for Restlessness AEB (AEB- As Evidenced By) pulling out on wound dressing related to Schizoaffective disorder, Bipolar type . During a review of the clinical record for Resident 26, the Medication Administration Record (MAR) from 10/1/2023 to 10/31/2023 indicated, Monitor for side-effects of Divalproex: nausea, vomiting, extreme drowsiness, dizziness, weakness, abdominal pain, stomach upset, rash, diarrhea, increased appetite, pain, tremor, weight gain, back pain, air loss, headache, fever loss of appetite, constipation, double/blurred vision, side-to-side eye. Every shift. Order Date 10/2/2023 . The MAR indicated that LNs on Day, Evening and Night shifts documented either an X, a check mark, or a number in the #S/E section of the MAR for each shift. During a concurrent interview and record review on 10/19/2023 at 11:03 a.m., with LVN 1, LVN 1 stated that if the side effect is present, that behavior is documented on the MAR. LVN 1 stated that if the MAR shows a checkmark, that means that the nurse is documenting that they performed the monitoring, and the checkmark means they did that. A 9 [number] documented on the MAR indicates that the nurse observed behaviors and documented using this number and the specific behavior is written in that area. LVN 1 stated that a checkmark means that they did the monitoring, and the nurse would use the 9-with a note to provide the specific behavior observed. LVN 1 stated she was not sure who documented a 0 on the MAR instead of a check mark. If check marks and numbers are being used, the LN does not know if the resident is experiencing side effects that are being monitored. LVN 1 stated that it is important to document accurately to keep track of the effects the medications are having on the resident. If they [residents] are having so many numbers of behaviors, [they] need to report to the doctor to maybe change the medication, discontinue and start another medication that isn't going to have so many S/E. During a concurrent interview and record review on 10/19/2023 at 11:03 a.m., with LVN 1, LVN 1 stated, for Resident 26, the facility ensured that the psychotropic medications (5 psychotropics) were appropriate when the facility Medical Doctor (MD) came to the facility and reviewed all the medications and ordered laboratory tests to check medication levels. LVN 1 stated that Resident 26 was admitted from a General Acute Care Hospital (GACH) where Resident 26 was taking them. LVN 1 stated that facility LN followed up with Resident 26's family about the psychotropic medications taken while at home. During a telephone interview on 10/20/2023 at 9:00 a.m., with the facility Pharmacy Consultant (PC) the PC stated that the behaviors and S/E monitoring is a work in progress. The PC stated that when they [LNs] put in the order, they must go to another section to add another row for them to have a space to chart. The PC stated most of them [facilities] have the tally [system]. The PC stated that the key indicates a checkmark indicates that the medication was administered. The PC stated they [LNs] should be on the same page: all numbers if they use a check mark to monitor it isn't clear if a behavior was observed. The PC stated that supplemental charting is often forgotten. The PC stated that the potential harm to the resident is that without consistent documentation they [LNs] can't notify the MD of changes if the documentation is not clear. The PC stated the monitoring is used by the provider [MD] to evaluate if the medication is having the desired effect. If the behaviors aren't reported accurately the provider can't make necessary changes to medications to ensure resident is getting desired therapy. 2. During a review of the clinical record for Resident 1, the AR dated 10/17/2023, indicated the resident was admitted on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks.), Dementia with Behavioral Disturbance (agitation (a mental state of extreme emotional disturbance) including verbal and physical aggression, wandering, and hoarding.), Psychosis (when people lose some contact with reality) not due to a substance; Generalized Anxiety Disorder (a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed.), Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest.), Post-Traumatic Stress Disorder (a disorder that develops in some people who have experienced a shocking, scary, or dangerous event.), Obsessive-Compulsive Personality Disorder (a long-lasting disorder in which a person experiences uncontrollable and recurring thoughts (obsessions), engages in repetitive behaviors (compulsions), or both). During a review of the clinical record for Resident 1, the Physician Order dated 11/3/2023, indicated Resident admitted to [Hospice Facility] hospice under care of [Hospice MD] on 11/3/2023 under DX (DX- diagnosis) of Alzheimer's. Call them at [telephone number] prior to ordering: Labs, PT, OT, and X-Ray. During a review of the clinical record for Resident 1, the Hospice Physician Order dated 9/15/2023, indicated Olanzapine 10 mg. Give 1 tab PO (PO- by mouth) once a day, on AM shift, for agitation. During a review of the clinical record for Resident 1, the clinical record indicated order changes for Quetiapine Fumarate from June 2023 through October 2023: Physician order dated, 6/2/2023 Quetiapine Fumarate 25 mg. Give 1 tablet by mouth one time a day . Physician order dated, 6/29/2023 at 23:23 (11:23 p.m.) Quetiapine Fumarate 50 mg. Give 1 tablet by mouth two times a day .Discontinue .Quetiapine Fumarate 25 mg Give 1 tablet by mouth one time a day . Physician order dated, 9/8/2023 15:47 (3:47 p.m.) Quetiapine Fumarate 50 mg. Give 1 tablet by mouth two times a day .Discontinue .Quetiapine Fumarate 50 mg. Give 1 tablet by mouth three times a day . Physician order dated, 10/6/2023 22:48 (10:48 p.m.) Quetiapine Fumarate 50 mg. Give 1 tablet by mouth two times a day . Discontinue. During an interview on 10/19/2023 at 11:25 a.m., with LVN 1, LVN 1 stated she does not know why Resident 1's medication was changed. LVN 1 stated Resident 1 had had an increase in behaviors. LVN 1 stated the Hospice Nurse (HN) called the Hospice MD and got an order. LVN 1 stated that in September 2023, Resident 1 behaviors were more difficult to manage with the resident being increasingly aggressive to staff and others. LVN 1 stated the behaviors being monitored while Resident 1 was taking Olanzapine were: monitor aggressive behavior AEB (AEB- as evidenced by) attempting to hit others, NPI (non-pharmacological Intervention(s)): 1- repositioning, 2-calm quiet environment, 3-dim lighting, 4-distraction- talking to resident. 5-encourage music, 6-watching tv, 7-holding on to a stuffed toy, 8-other see notes. LVN 1 stated the total behavior tally's is 42 documented between 9/1/2023-9/17/2023. LVN 1 stated she would document [on the MAR] that the assessment of the behavior/S/E with a [check] mark and then document the number of S/E in the progress note. LVN 1 stated because the medication is routine, they usually don't have a s/e monitoring. LVN 1 stated the clinical record review showed monthly behaviors were August tally of total behaviors: 26. July tally of total behaviors: 19. LVN 1 stated that Resident 1's clinical record does not show any laboratory studies were ordered. LVN 1 stated that hospice doesn't usually do all of the labs and evaluation, since on hospices they aren't doing these things and blood glucose (sugar) checks are not done because she is on Hospice service. During a telephone interview, on 10/19/2023 at 1:42 p.m., with HN, the HN stated the Hospice MD gave the order for the medication [Olanzapine] and the dose. HN stated she called the Hospice MD due to increased resident behaviors (spitting, crawling out of the bed, getting naked, hitting people). The HN stated Resident 1 had hit others [residents] legs while passing them by in the hallway. The HN stated the Hospice MD decided to take another route. The HN stated the facility Pharmacist recommended decrease in dose with titration down of Quetiapine with Olanzapine added. The HN stated that Resident 1 was on both medications for a time. The HN stated the facility Pharmacist later asked for the Quetiapine to be discontinued. The HN stated Resident 1 was admitted to hospice on 11/3/2022, we don't do labs in hospice. If labs are needed the facility needs to follow up. The HN stated in hospice, they try to discontinue all medications of this nature that require labs because they don't do labs. The HN stated that the Hospice and facility providers share the responsibility in managing resident care. During an interview on 10/19/2023 at 2:25 p.m., with the facility MD, the facility MD stated there were changes in Quetiapine throughout the months of July-Sept and then Zyprexa overlapped for a month with Seroquel and Clonazepam. The facility MD stated that it is not his practice style to order 2 psychotropics, it's a red flag. The facility MD stated, I usually will give 1 psychotropic and possibly a mood stabilizer. During an interview on 10/19/2023 at 3:24 p.m., with the RN 2, RN 2 stated the order was received from the HN, which she clarified with the facility MD and DON prior to administering. During an interview on 10/19/23 at 3:17 p.m., with the Director of Nursing (DON), the DON stated that medication behaviors are reported, monthly to the Interdisciplinary Team (IDT) and to the facility MD for his review and signature. IDT members include the DON, Social Services Director, Dietary Supervisor, Activities Director, Minimum Data Set Coordinator and the facility MD. The DON stated that with residents on Hospice, laboratory studies are not always ordered due to goal of Hospice being focused on comfort care. DON stated if a resident is on psychotropic drugs, monitoring is important. The DON stated that Hospice ordered the Olanzapine and that at one point Resident 1 was being administered both Quetiapine and Olanzapine. The DON stated she was not sure if the HN or the Hospice MD gave the order. The DON stated she called the Hospice service and questioned the 2 anti-psychotics being administered at the same time. The DON stated she got an order to discontinue the Quetiapine from the Hospice MD. During a telephone interview on 10/19/2023 at 4:00 p.m., with Hospice MD, the Hospice MD sated Resident 1 was on Quetiapine and was reported to be experiencing an increase in behaviors such as biting people, hitting, getting out of bed, risk of self-injury or injuring the care givers. The Hospice MD stated staff were reporting that Quetiapine 100 mg twice a day was not working. The Hospice MD stated there are no good alternatives for residents with Dementia and Alzheimer's. The Hospice MD stated he took Quetiapine off and tried an atypical (not normal) anti-psychotic (Olanzapine). The Hospice MD stated the clinical record may show an overlap in the Quetiapine and Olanzapine, but doesn't think so, believes record may show taper on Quetiapine and added Olanzapine. The Hospice MD stated he made a clinical decision based upon Resident 1's symptoms. The starting dose of Olanzapine 10 mg was ordered because of the fairly high dose of Quetiapine Resident 1 had been taking, with no relief, and because of this he may have started Resident 1 on the higher dose. The Hospice MD stated he was aware of the clinical risks and benefits; APA (APA- American Psychological Association) guidelines are provided but aren't always followed due to the difficulty with the Alzheimer's and Dementia diagnosis and use of anti-psychotics. The Hospice MD stated he made a clinical decision based on his clinical judgement. During an interview on 10/20/2023 at 9:00 a.m., with the facility PC, the PC stated that the recommended starting dose for a fresh new [psychiatric] patient, we start at 2.5 mg but for this resident who has a history you might start a higher dose, but not sure why he [hospice MD] started at 10 mg. Not sure why he would have started at that higher dose. The PC stated there is an increased potential for miscommunication when resident is on Hospice service. The facility is struggling with hospice services, and it's still their patient, well Hospice is taking care of the meds, the patient, the HN comes in 3 times a week, so they seem to defer to the HN and providers. The PC stated that the expectation is hospice and facility providers/staff are communicating about orders and care. The PC stated she called the facility to have Hospice discontinue one of the psychotropics and apparently, the MD discontinued the Quetiapine as a result. The PC stated she conducts resident medication reviews monthly. The PC stated she reviews, and writes a letter, but if something needs to be done right away, she calls the DON and has the DON facilitate the implementation of her recommendations. The PC stated she spoke with the DON about the duplicate psychiatric medications and her recommendation to have the order for one to be removed/clarified. The PC stated gradual increase is recommended because you want the patient to be at the lowest possible dose to prevent S/E. With a history of mental health, age of resident and high dose was taken into consideration. Communication between facility and hospice could be improved, there are issues, and it is a work in progress. During a telephone interview on 10/20/23 at 12:07 p.m., with the facility DON, the DON stated that sometimes the discussions with the PC are verbal either by telephone or while the PC is at the facility. The DON stated she discussed the duplicate psychiatric medications and that she followed the discussion with a telephone call to the Hospice MD and the Quetiapine was discontinued. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Antipsychotic Medication Use dated December 2016, indicated, Policy Statement .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review .Policy Interpretation and Implementation 2. The Attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed .17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician . During a review of the facility's (P&P) titled, Hospice Program dated July 2017, indicated, .9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including b. Changing the level of services provided when it is deemed appropriate; c. Providing medical direction, nursing, and clinical management of the terminal illness .10. In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: b. Administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care; .d. Communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, including the appropriate accessory and cautionary instructions, and the expiration date as applicable when: Licensed Nurse (LN) staff did not apply adequate labels (discard by date) on inhaler medications for 3 residents (Resident 48, Resident 26 and Resident 261) and LN staff did not ensure adequate storage of discontinued medications for 3 residents (Resident 30, Resident 36, and Resident 9). These failures increased the potential for Resident 48, Resident 26 and Resident 261 to be administered expired medication and inadequately treated for breathing difficulty and for Resident 30, Resident 36, and Resident 9 to be administered unnecessary medication. Findings: During a concurrent medication cart inspection and interview on 10/16/23 3:05 p.m., with Registered Nurse (RN) 1, inhaler medications for 3 residents (Resident 48, Resident 26 and Resident 261) were observed to be inadequately labeled. Resident 48's Advair 100 Diskus (medication for lung disease), Resident 26's ipratropium-albuterol (medication for lung disease) 200-100 mcg (microgram-unit of measure) inhaler, and Resident 261's Breyna (medication for lung disease) 160 mcg/4.5 mcg were being administered to the residents but did not have expiration dates on the inhalers. RN 1 stated that the medication dispensers should have had date opened and expiration date labels on each inhaler once each medication was removed from the manufacturer pouch. RN 1 stated the medication could not be given to resident past its expiration date; could affect the residents breathing, not getting medication as ordered due to possibly ineffective. During a review of the clinical record for Resident 48, the admission Record (AR) dated 10/17/2023, indicated the resident was admitted on [DATE] with diagnoses including Hypertensive Heart Disease with Heart Failure; Systolic (Congestive) Heart Failure. During a review of the clinical record for Resident 48, the physician order dated 9/11/2023 indicated, Fluticasone-Salmeterol) 1 puff inhale orally every 12 hours related to Unspecified Asthma, uncomplicated (A chronic disease in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breathe. Symptoms include wheezing, coughing, tightness in the chest, shortness of breath, and rapid breathing). During a review of the clinical record for Resident 48, the Medication Administration Record (MAR) dated 10/17/2023, indicated fluticasone-salmeterol diskus was being administered daily, at 8:30 a.m. and 8:30 p.m. During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for fluticasone-salmeterol diskus indicated, After removing from box and foil pouch, write the Pouch opened and Use by dates on the label on top of the device. The Use by date is 1 month from date of opening the pouch. During a review of the clinical record for Resident 26, the AR dated 10/17/2023, indicated the resident was admitted on [DATE] with diagnoses including fracture Type 2 Diabetes Mellitus (high blood sugar); Hypertension (high blood pressure); Hypertensive Heart Disease. During a review of the clinical record for Resident 26, the physician order dated 9/14/2023 indicated, Ipatropium-Albuterol Inhalation Aerosol Solution 20-100 mcg /ACT [actuation- per operation]1 puff inhale orally two time a day for wheezing. During a review of the clinical record for Resident 26, the MAR dated 10/17/2023, indicated the medication was being administered daily, at 8:00 a.m. and 5:00 p.m. During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for ipratropium-albuterol inhaler indicated, Discard 3 months after first actuation or after labeled number of actuations has been reached and locking mechanism is engaged, whichever comes first. During a review of the clinical record for Resident 261, the AR dated 10/17/2023, indicated the resident was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs.); Respiratory Failure; (Congestive) Heart Failure; Type 2 Diabetes Mellitus (high blood sugar); Hypertension (high blood pressure). During a review of the clinical record for Resident 261, the physician order dated 10/13/2023 indicated, Budesonide-Formoterol Fumarate Dihydrate [Breyna] 2 puff inhale orally two times a day related to Chronic Obstructive Pulmonary Disease, *rinse mouth with water and spit back into cup after use*. During a review of the clinical record for Resident 261, the MAR dated 10/17/2023, indicated Breyna was being administered daily, at 8:00 a.m., 5:00 p.m., and 8:00 p.m. During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for Breyna indicated, Discard inhaler after the labeled number of inhalations have been used (the dose counter will read 0) or within 3 months after removal from foil pouch. During a concurrent treatment cart inspection and interview on 10/16/2023 at 3:48 p.m., with Licensed Vocational Nurse (LVN) 2, at the East Nursing Station, multi-dose medication tubes of diclofenac 1% gel (pain medication) for Resident 30 and Resident 36 and a bottle of Nystatin (medication to treat fungal infection) topical powder for Resident 9 were observed in the treatment cart and the medication orders were found to have been discontinued. LVN 2 stated it was important to observe discontinue orders and remove discontinued medications so we don't use it accidentally. During a review of the clinical record for Resident 30, the AR dated 10/17/2023, indicated Resident 30 was admitted on [DATE] with diagnoses including Cellulitis (skin infection); Pain, Peripheral Neuropathy (when there is damage to the nerves that control automatic body functions); Type 2 Diabetes Mellitus (high blood sugar); Hypertensive Hearth Disease (changes in the heart (left ventricle, left atrium, and coronary arteries) as a result of chronic high blood pressure). During a review of the clinical record for Resident 30, the physician order dated 9/28/2023 indicated, Diclofenac Sodium (topical) apply to L [L- left] hand topically two times a day related to pain for 2 weeks (2 grams). During a review of the clinical record for Resident 30, the MAR dated 10/17/2023, indicated the medication was last administered on 9/12/2023 at 8:00 a.m. During a review of the clinical record for Resident 36, the AR dated 10/17/2023, indicated Resident 36 was admitted on [DATE] with diagnoses including Epilepsy (a neurological disorder (relating to disorders of the nervous system.) marked by sudden recurrent (occurring often or repeatedly) episodes of sensory disturbance, loss of consciousness, or convulsions (a sudden, violent, irregular movement of a limb or of the body, associated with abnormal electrical activity in the brain); fracture (break) of the fifth metatarsal (pinky) bone; pelvic pain; muscle weakness; difficulty walking. During a review of the clinical record for Resident 36, the physician order dated 8/22/2023 indicated, Diclofenac Sodium (topical) apply to 1 gram to left shoulder topically every 8 hours as needed for Pain to the left shoulder for 2 weeks. During a review of the clinical record for Resident 36, the MAR dated 10/27/2023, for the month of August 2023, indicated LN staff administered Diclofenac 1% gel to Resident 36 on 8/22/23. During a review of the clinical record for Resident 9 the AR dated 10/17/2023, indicated Resident 9 was admitted on [DATE] with diagnoses including Systolic (Congestive) Heart Failure (long-term condition in which your heart does not pump blood well enough to meet your body's needs) Type 2 Diabetes Mellitus (high blood sugar); Hypertension (high blood pressure); Hypertensive Heart Disease. During a review of the clinical record for Resident 9, the physician order dated 9/14/2023 indicated, Nystatin External Powder 100000 unit/gm (gm-gram) (Nystatin (Topical)) Apply to groin area topically every day and evening shift for redness for 14 days .Discontinue 9/14/2023 at 16:00. During a review of the clinical record for Resident 9, the MAR dated 10/27/2023, for the month of September 2023, indicated LN staff documented administration of the Nystatin topical powder to Resident 9 daily from for 12-day shifts starting 9/3/2023 through 9/14/23 and 11-evening shifts starting from 9/3/2023 through 9/13/2023. During an interview on 10/19/23 at 2:46 p.m. with the facility Director of Nursing (DON) regarding the inhaler medications not adequately labeled with discard dates observed in the medication cart, the DON stated that the discard date labeling should be on the medication device. DON stated, Pharmacy provides stickers so that we can use them to label and then take out the expired medications. The DON stated that LN staff would not know the expiration or discard by date if the inhaler did not have a discard date label and was separated from the box. The DON stated it was her expectation that LN staff remove discontinued medication from the medication and treatment cart because unnecessary medication could be given, and the potential harm to the residents could be that the expired medication would be given to the residents, resulting in inadequate treatment of their medical condition. During an interview, via telephone, on 10/20/2023 at 9:00 a.m., with the facility Pharmacy Consultant (PC), the PC stated that if LN staff did not have the box in which the inhaler was dispensed, they would have a device without an expiration date label. PC stated her expectation was for LN staff to place open and discard date on the medication device to ensure that medication being administered wasn't expired should the box and medication device become separated. The PC stated that it was important to discard discontinued medications so that expired medications are not given to residents and that residents get optimal therapy. During a review of the facility's policy and procedure (P&P) titled, Administering Medications dated April 2007, indicated, Check the expiration date on the medication label. When opening a multi-dose container, place the date on the container . During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers dated April 2019, indicated, Labels for individual resident medications include all necessary information, such as: f: The date that the medication was dispensed; .h. The expiration date when applicable . During a review of the facility's policy and procedure (P&P) titled, Storage of Medications dated November 2020, indicated, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. The toaster had a brown substance stuck on the front knobs and a yellow substance on the edge of the toaster opening and the plate warmer had a greasy brown substance and dirt along the bottom edge and there was a clean plate on top of brown flakes of food. 2. There was a plastic bag containing American cheese slices with brown debris on them and placed inside the refrigerator. 3. Two out of two dry food bins in the dry food storage area had a brown substance inside the bottom of the bin. 4. There were no airgaps (A fixture that provides back-flow prevention) under the three compartment sink and the food preparation sink. 5. There were sewage pipes overhead in the basement dry food storage area which had canned goods, and buckets of grains under them. 6. Two of four dietary staff members had their hair exposed outside of their hair nets while working in the kitchen. These failures placed 50 of 50 residents at risk for food contamination and foodborne illness. Findings: 1. During a concurrent observation and interview on 10/16/23 at 8:41 a.m. with the Certified Dietary Manager (CDM) in the kitchen, a toaster was on top of the tray line table. The toaster had a brown substance on the front knobs. The CDM confirmed the brown substance was stuck on the knobs and could not be wiped off. A cream-colored substance was observed on the edge of the toaster and the CDM stated it was butter. The CDM stated the toaster needed to be deep cleaned to prevent cross contamination and foodborne illness. A tall plate warmer was observed at the end of the tray line with brown crumbs under the clean plate on top. The base of the plate warmer was observed and there was a brown material in the crevice along the base. The CDM stated the plate warmer needed to be deep cleaned because it could cause cross contamination of food. During a concurrent interview and record review on 10/17/23 at 1:58 p.m. with the Registered Dietitian (RD), the RD stated she was from a contracted company and had been coming to the facility since June. The RD stated she performed audits of the kitchen once a month which included cleanliness. Photos of the toaster and plate warmer taken on 10/16/23 were reviewed, the RD stated, the toaster knobs and the edge of the toaster looked very dirty, which could lead to bacterial growth and cross contamination. Photos of the plate warmer taken on 10/16/23 were reviewed and the RD stated plate warmer looked bad and could contaminate the clean dishes. During a review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control, dated 2018, the P&P indicated, . Cleaning small appliances/equipment . Equipment will be cleaned and sanitized to prevent food borne illness . Toaster will be cleaned after each use . 2. During a concurrent observation and interview on 10/16/23 at 8:41 a.m. with the Certified Dietary Manager (CDM) in the kitchen, the refrigerator across from the sink contained a plastic bag of American cheese slices and some of the slices were cut in half and placed back the bag with brown debris on them. The CDM stated the cheese slices had breadcrumbs on them and should have been thrown away. During a concurrent interview and record review on 10/17/23 at 1:58 p.m. with the Registered Dietitian (RD), photos of the cheese slices taken on 10/16/23 were reviewed, the RD stated, the darkened areas on the cheese slices appeared to be breadcrumbs. The RD stated there was a potential for cross contamination and the cheese needed to be removed as soon as possible. During a review of the facility's policy and procedure (P&P) titled Food Receiving and Storage of Cold Foods, dated 2018, the P&P indicated, . All the perishable food items purchased by the department of food and dining services will be stored properly . 3. During a concurrent observation and interview on 10/16/23 at 8:41 a.m. with the Certified Dietary Manager (CDM) in the dry food storage area, two dry food bins were side by side in the basement. The CDM lifted the lid of one of the bins, there was a brown substance in the bottom of the bin and a box of thickener on top of the substance. The CDM stated the bin previously had brown sugar in it and was not properly cleaned. The second bin was checked, and it also had the brown substance in the bottom of the bin. There was a bucket of barley and a bucket of oatmeal in the bin on top of the brown substance. The CDM stated the staff should have sanitized the bins before they placed other food products inside because it could cause cross contamination and illness. During a concurrent interview and record review on 10/17/23 at 1:58 p.m. with the Registered Dietitian (RD), the photos taken of the bins on 10/16/23 were reviewed. The RD stated, the CDM had discussed the bins with her, and she was told there was brown sugar in them previously. The RD stated the bins needed to be properly cleaned before putting anything else in them because it was a huge risk for cross contamination and the residents could get sick. During a review of the facility's policy and procedure (P&P) titled Sanitation and Infection Control, dated 2018, the P&P indicated, .Cleaning small appliances/equipment . Food Storage Bins . Food storage bin will be cleaned monthly or more often if needed . It is recommended to use a clean, sanitized and air dried food storage bins for all new products and packets . 4. During a concurrent observation and interview on 10/17/23 at 9:40 a.m. with the Certified Dietary Manager (CDM) in the kitchen, the three compartment sink and food preparation sink did not have an airgap under them. The CDM stated she had worked at other facilities, and she was aware the sinks should have airgaps. During an interview on 10/17/23 at 1:58 p.m. with the Registered Dietitian (RD), the RD stated the three compartment sink and food preparation sink should both have air gaps. The RD stated the purpose of airgaps were to allow air flow so mold and mildew cannot grow. The RD stated the food could potentially be contaminated without airgaps. During a concurrent observation and interview on 10/18/23 at 10:40 a.m. with the Maintenance Supervisor (MS) In the kitchen, the three compartment sink and food preparation sink were observed. The MS stated the sinks did not have airgaps. The MS stated he did not know the purpose of the airgaps or why the facility was supposed to have them. During a professional reference review retrieved from https://www.fda.gov/media/110822/download titled Food and Drug Administration (FDA) Food Code, dated 2017, indicated, .an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch . During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system . 5. During a concurrent observation and interview on 10/19/23 at 10:31 a.m. with the Maintenance Supervisor (MS) in the basement dry food storage area, overhead pipes were observed. The MS stated there were two sewage lines overhead in the basement. The MS pointed to a large black pipe overhead, running along the ceiling adjacent to a shelving unit with lidded buckets of grains and paper products on it. The MS stated the other sewage pipe was running along the ceiling on the opposite side of the basement. During a concurrent interview and record review on 10/19/23 at 1:25 p.m. with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2018, was reviewed. The P&P indicated, .Food storage areas will be clean dry, and free of pests, contamination by condensation, leakage, sewage, or wastewater backflow and neatly arranged. Basement storerooms with overhead sewage pipes are not suited for food storage . the ADM stated, he was the owner of the facility and could change the policy and procedures. The ADM stated no food products should be stored underneath the sewage pipes in the basement dry food storage area. The ADM stated if there was a gusher from the sewage pipes, the staff would have to destroy everything in the basement. 6. During a concurrent observation and interview on 10/17/23 at 9:27 a.m. in the kitchen, Dietary Aide (DA) 1 was washing dishes. DA 1 had a hairnet on and there was hair hanging out of the hairnet around her ears and at the base of her neck. DA 1 stated there should not be hair out of the hairnet because it could fall onto clean plates and into the food. DA 1 stated the food could become cross contaminated, bacteria could get into the food and cause the residents to become ill. During a concurrent observation and interview on 10/17/23 at 9:35 a.m. in the kitchen, DA 2 was performing different tasks. DA 2 had hair hanging out of the hairnet by her ears and at base of her neck. DA 2 stated she should not have hair hanging out of the hairnet because it could cause cross contamination of food. During an interview on 10/17/23 at 9:40 a.m. with the Certified Dietary Manager (CDM), the CDM stated hairnets needed to cover all hair to prevent cross contamination and foodborne illness. During an interview on 10/17/23 at 1:58 p.m. with the Registered Dietician (RD), the RD stated when hair is outside of the hairnet, it was a risk for contamination and should not be happening. The RD stated the hair can fall into food and cause bacterial growth. During a review of the facility's policy and procedures (P&P) titled Sanitation and Infection Control, dated 2018, the P&P indicated, .Personal Hygiene . A hair net and/or head covering, which completely cover all hair, should be worn during meal preparation and service .

Deficiency Text Not Available

Based on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one of five sampled residents, (Resident 99), when a Certified Nurse Assistant (CNA) stood over Resident 99 while he was spoon fed in his bed. This failure had the potential for Resident 99 to feel disrespected and affect his dignity. Findings; During a review of the clinical record for Resident 99, the Minimum Data Set (MDS - a comprehensive assessment for functional capability), dated 11/29/21, under Section C, the Brief Interview for Mental Status (BIMS - a cognitive assessment tool) indicated a score of nine out of 15, meanin moderate impairment (0-7 severe impairment, 8-12 moderate impairment, 13-15 intact cognition). During a concurrent observation and interview on 12/7/21 at 12:14 p.m., in the room of Resident 99 with CNA 7, Resident 99 was lying in bed with the head of bed elevated. CNA 7 stood over Resident 99 and spoon fed Resident 99's meal. CNA 7 validated she stood over Resident 99 to assist him with the meal. CNA 7 stated, I usually sit down when there is a chair here. I should sit down when feeding him to be eye level with him. During an interview on 12/10/21 at 12:21 p.m., with the Director of Staff Development (DSD), the DSD stated, The CNA should sit while feeding so [Resident 99] is more comfortable. During an interview on 12/10/21 at 2:34 p.m., with CNA 7, CNA 7 stated she spoon fed Resident 99 while she stood beside his bed on 12/7/21. CNA 7 stated Resident 99 would feel more comfortable and respected if someone sat at the same level he was. CNA 7 stated she would set the bed height and sit while she fed Resident 99 but was in a hurry and did not get a chair to be able to sit down. During an interview on 12/10/21 at 2:48 p.m., with the Director of Nursing (DON), the DON stated the staff should sit next to Resident 99 to feed him while in bed with the head of bed up. The DON stated in this way Resident 99 would feel comfortable and respected. The DON stated the CNAs were trained to sit down while feeding residents. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 12/2016, the P&P indicated, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity .

Based on observation, interview and record review, the facility failed to provide the preferences for activities for one of five for one of five sampled residents (Resident 40), when Resident 40's activity choice to sit outside daily was not met. This failure resulted in the activity needs of Resident 40 to sit outside daily to be not met and could negatively affect Resident 40's physical, mental and psychosocial well being. Findings: During the initial tour of facility on 12/6/21, at 10:55 a.m., Resident 40 was observed lying in bed. Resident 40's room was dark, Television was not on. Resident 40 had her cellular phone in her hand. Resident 40 was asked what type of activities she enjoyed. Resident 40 stated, I want to go home. During an observation on 12/6/21 during lunch time in the rehab dining (a joint effort involving Speech and Occupational Therapy in collaboration with nursing staff to supervise residents while eating), Resident 40 was observed eating by herself sitting in front of the television with her back towards other residents eating in the dining room. During a concurrent interview and record review on 12/8/21, at 10:26 a.m., with the Activities Director (AD), the AD stated Resident 40 was scheduled to receive one on one activities three times a week in Resident 40's room. The AD reviewed clinical document titled, Activities Calendar for the month of 10/21, 11/21 and 12/21. The AD stated Resident 40 did not attend any group activities scheduled for the month of October 2021, and no record of a one on one room visit was provided. The AD stated for the month of November 2021, Resident 40 did not attend any scheduled group activities. The AD stated for the month of December 2021, Resident 40 attended five days of Rehab dining but did not attend scheduled group activities. The AD reviewed Resident 40's care plan dated 10/28/21, the care plan indicated Resident 40 had preferences for group activities and self directed activity. The AD stated he did not know if facility was providing and meeting Resident 40's activity preferences. The AD stated Resident 40's activity preferences should have been implemented for resident to have meaningful activity experiences. During a concurrent observation and interview on 12/10/21, at 8:29 a.m., in the east wing hallway with Resident 40. Resident 40 was sitting in her wheelchair. Resident 40 stated she was very active prior to the accident. Resident 40 stated she played soccer in middle and high school. Resident 40 stated she would like to go sit outside the facility daily when weather permits but the facility staff did not take her. Resident 40 stated she did not think the facility was meeting all her activity needs and activity preferences. Resident 40 stated she missed her family and would like to go home soon. During a concurrent interview and record review on 12/10/21, at 8:38 a.m., with activity assistant (AA), the AA stated Resident 40 liked to go sit outside and play with the facility cat. The AA stated she observed Resident 40 outside once since she was admitted in the facility. The AA stated she did not ask Resident 40 if she wanted to join activities in the morning when she brought other residents outside. The AA stated she knew the certified nurse assistants (CNAs') are encouraging residents but did not hear the CNAs' offered Resident 40 to take her outside for activities. The AA stated she did not know what Resident 40's preferences or her choices of activities were because she did not remember asking Resident 40. The AA reviewed Resident 40's activity calendar for the month of October, November, and December. The AA stated she had provided room visits to Resident 40 but did not have a documentation of Resident 40 attended group activities. The AA stated she did not know if Resident 40's activity preferences were met. During an interview on 12/10/21, at 9:18 a.m., with certified nurse assistant (CNA) 5, CNA 5 stated she had taken care of Resident 40. CNA 5 stated she took Resident 40 outside one time and did not remember if Resident 40 went outside again. CNA 5 stated she did not know if the facility activities offered were suitable for Resident 40's age because she was young. During an interview on 12/10/21, at 2:16 p.m., with Director of Nursing (DON), the DON stated activities staff needed to try and provide activities to residents based on residents' preferences. The DON stated activities staff needed to schedule different times to accommodate residents' schedules. The DON stated ten minutes a day of activities is not enough and eating lunch in the dining room was not considered activity. During a review of Resident 40's clinical record titled, Minimum Data Set (MDS- functional and cognitive abilities) assessment dated 10/2021, indicated under section F, .Interview for activity Preferences While you are at the facility .B. how important is it to you to listen to music you like? . Very important . how important is it to you to do your favorite activities? . Very important . how important is it to you to go outside to get fresh air when the weather is good? . Very important . During a review of facility document titled, Job Description: Activities Director, dated 4/2013, indicated, .Plans, organizes, supervises and directs all administrative and operational activities of the Activities Department .responsible for the ongoing developing and implementation of an activities program designed to meet the social, psychosocial and therapeutic needs of Nursing Home Residents . During a review of facility's policy and procedure titled, Policy Statement Activity Programs dated 6/2018, indicated .Policy Statement Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident . 1. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. 2. Activities offered are based on the comprehensive resident-centered assessment and the preference of each resident . 12. Individualized and group activities are provided that: .a. Reflect the schedules, choices and rights of the residents; .c. Reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the resident; .e. Incorporate family, visitor and resident ideas of desired appropriate activities .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received care according to their needs for one of five sample residents (Resident 40) when Resident 40, who is under the age of 20, was admitted on [DATE] with a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube inserted through the wall of the abdomen directly into the stomach) and a plan and physician order to discontinue the PEG tube was not followed up on. Resident 40 voiced preferences for activities and facility staff did not provide options according to her preferences. These failures resulted in Resident 40's well-being not supported and frequent verbalizing she wanted to go home with no resident-centered plan to achieve safe discharge. These failures resulted in an unnecessary extended stay in the facility. Findings: During a review of Resident 40's face sheet [a document containing resident profile information] undated, indicated Resident 40 was admitted to the facility on [DATE] for a planned rehabilitation stay. Resident 40 was admitted with diagnoses which included Person injured in collision between other specified vehicles, paranoid Schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities), Respiratory failure and traumatic brain injury (often occurs as a result of a severe sports injury or car accident. Immediate or delayed symptoms may include confusion, blurry vision, and concentration difficulty), traumatic subdural hemorrhage (caused by a head injury strong enough to burst blood vessels. This can cause pooled blood to push on the brain). During a review of the clinical record for Resident 40, the Minimum Data Set (MDS-functional and cognitive abilities) assessment, dated 10/27/21, indicated, under Section C, Brief Interview for Mental Status (BIMS) was conducted with the score of two out of 15 ((0-7 severe impairment, 8-12 moderate impairment, 13-15 intact cognition) which indicated severe impairment in cognition (memory and judgement). During a review of Resident 40's document titled, Order Summary Report, dated 12/7/21, indicated, . May have referral GI(Gastrointestinal) Peg tube . to D/C . order date 11/16/21 . During a concurrent observation and interview on 12/6/21, at 10:55 a.m., with Resident 40, Resident 40 was found in her room lying in bed, room was dark, and curtains closed. Resident 40 stated, I want to go home. Resident lifted her top and exposed her abdominal area where the PEG tube was placed. Resident 40 stated she was eating by mouth and the staff had not used the tube to give her nutrients (substance that provides nourishment essential for growth and the maintenance of life) since the date of admission, 10/20/21. During an observation on 12/6/21 during lunch time in the rehab dining, Resident 40 was observed eating by herself sitting in front of the television with her back towards other residents eating in the dining room. During an interview on 12/7/21, at 12:12 P.M., with licensed vocational nurse (LVN) 1, LVN 1 stated Resident 40 was alert and oriented and currently able to communicate with staff verbally by whispers and typing in her cell phone. LVN 1 stated Resident 40 did not speak when first admitted in the facility. LVN 1 stated Resident 40 had always been eating by mouth and did not remember using the feeding tube to give her nutrients. During an interview on 12/8/21, at 10:55 a.m., with certified nurse assistant (CNA) 6, CNA 6 stated she took care of Resident 40. CNA 6 stated Resident 40 was eating in her room for most meals. CNA 6 stated, .Resident 40 started attending rehab dining (a joint effort involving Speech and Occupational Therapy in collaboration with nursing staff to supervise residents while eating) for a couple of weeks now. CNA 6 stated Resident 40 had good appetite and usually eats all her food. CNA 6 stated Resident 40 has a feeding tube but never seen the nurse used it. During a concurrent interview and record review on 12/8/21, at 11:28 a.m., with LVN2, LVN 2 stated Resident 40's PEG tube was never used to give nutrients since admitted in the facility on 10/20/21. LVN 2 reviewed Resident 40's physician's orders dated 12/1/2021 to12/31/2021 and stated Resident 40's diet on admission was regular chopped diet and care plan for nutrition was initiated on 10/22/21. LVN 2 stated there was an order for Resident 40's PEG tube to be discontinued on 11/16/21. LVN 2 stated she did not know if there was already an appointment set for Resident 40's PEG tube to be discontinued. LVN 2 stated the social service person arranged appointments and let the nurse know the date. During a concurrent interview and record review on 12/8/21, at 11:58 a.m., with social service designee (SSD), the SSD stated one of her responsibilities was taking care of referral appointments and schedule transports. SSD stated she did not know when she received a copy of the order for the feeding tube to be discontinued. SSD stated she did not find documentation, she tried to contact the hospital. SSD stated she was able to contact the hospital on [DATE] and received the confirmation on 12/2/21. The SSD stated she should not have waited a long to contact the hospital, but she was waiting for the LVN 1 to give her information of the doctor that placed the feeding tube. The SSD stated she should have just called the hospital instead of waiting for the nurse. The SSD stated she still had not heard from the hospital and no appointment date for Resident 40's feeding tube to be removed. The SSD stated when she called the hospital it was suggested to her to send Resident 40 to the emergency room to have the PEG tube removed. The SSD stated she did not remember if she discussed the option with the administrator of the director of Nursing (DON). During an interview on 12/9/21, at 10:33 a.m., with LVN 1, LVN 1 stated she received the order to refer Resident 40 out to have the PEG tube discontinued on 11/16/21, the hospital was not contacted by SSD until 12/2/21. LVN 1 stated it should not have taken that long to act on the order. LVN 1 stated she assumed the SSD was working on getting the appointment. LVN 1 stated if Resident 40's PEG tube was removed, she may have gone home, and nursing did not have to worry about monitoring of resident trying to pull out the tube and continued to give water flushes to maintain the patency of the PEG tube. LVN 1 stated leaving the feeding tube when it was no longer needed was putting the resident at higher risk for developing infection. During a concurrent observation and interview on 12/10/21, at 8:29 a.m., with Resident 40 in the east wing hallway, Resident 40 was sitting up in her wheelchair. Resident 40 lifted her top and pulled out the tip of the PEG tube and stated she would like the tube removed so she can go home soon. Resident 40 stated she had not heard from facility staff if she had an appointment to have her feeding tube removed. Resident stated, I miss my family. Resident 40 stated she was very active prior to the accident. Resident 40 stated she played soccer in middle and high school. Resident 40 stated she would like to go sit outside of the facility daily when weather permits but the facility staff did not take her. Resident 40 stated she did not think the facility were meeting all her activity needs and activity preferences. Resident 40 stated she missed her family and would like to go home soon. During a concurrent interview and record review on 12/10/21, at 8:38 a.m., with activity assistant (AA), the AA stated Resident 40 liked to go sit outside and played with the cat. The AA stated she had only seen Resident 40 outside once since she was admitted in the facility. The AA stated she did not ask Resident 40 if she wanted to join activities in the morning when she brought other residents outside. The AA stated she knew the certified nurse assistants (CNAs') were encouraging residents but did not hear the CNAs' offered Resident 40 to take her outside for activity. The AA stated she did not know what Resident 40's preferences or her choices of activities were because she did not remember asking Resident 40. The AA reviewed Resident 40's activity calendar for the month of October, November, and December. The AA stated she had provided room visits to Resident 40 but did not have a documentation of Resident 40 attended group activities. The AA stated she did not know if Resident 40's activity preferences were met. During an interview on 12/10/21, at 9:18 a.m., with certified nurse assistant (CNA) 5, CNA 5 stated she had taken care of Resident 40. CNA 5 stated she took Resident 40 outside one time and did not remember if Resident 40 went outside again. CNA 5 stated she did not know if the facility activities offered were suitable for Resident 40's age because she was young. During an interview on 12/10/21, at 9:56 a.m., with the Physical Therapy Assistant (PTA), the PTA stated Resident 40 was working with Occupational Therapist (OT- works to improve the life skills or vocational path of their clients/patients to overcome or adapt to their functional deficiencies so they can live as independently as possible), Physical Therapist (PT- an exercise treatment for patients who have been immobilized or impaired in their movement and flexibility. Patients are rehabilitated to use their own muscles to increase flexibility and range of motion as well as to advance to higher levels of muscular strength and endurance) and the Speech Language Pathologist (SLP- treatment of people who have speech, language, and swallowing difficulties.). The PTA stated the last therapy date for PT and OT was 11/30/21 and SLP's last note was dated 11/28/21. PTA stated Resident 40's termination of service was due to Resident 40's insurance. The PTA stated there was no physician's order for RNA (Rehabilitative Nursing Aide) because Resident 40 was supposed to go home on [DATE]. The PTA stated he was surprised to see Resident 40 still in the facility on 12/6/21. The PTA stated she asked the nursing staff why Resident 40 was still in the facility and did not go home as planned on 12/4/21. The PTA stated the nursing staff told him it was because Resident 40 still had the feeding tube. The PTA stated therapy will order for Resident 40 to work with the RNA while waiting to have her feeding tube removed and continue with the progress and not lose the functions gained in therapy. During an interview on 12/10/21, at 2:16 p.m., with the DON, the DON stated her expectation was for the SSD to follow-up on referrals right away and nurse to follow-up with the SSD if nothing was being done. The DON stated there was a higher risk of developing infection the longer the feeding tube is in. The DON stated there was also a delay of Resident 40 going home and possibly some dignity issues because Resident 40 was young and maybe embarrassed to go out of her room because of the feeding tube. During a review of facility document titled, Job Description: Social Service Designee, dated 4/13, indicated, .The primary purpose of your job position is to assist in the planning, developing, organizing, implementing, evaluating and directing our Social Services Department . to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis . Coordinate social service activities with other departments as necessary . Assist in making appointments for the resident/family as requested or appropriate . During a review of facility document titled, Job Description: Floor Nurse, dated 4/13, indicated, .Cooperate with other resident services when coordinating nursing services to ensure that the resident's total regimen of care is maintained . Periodically review the resident's written discharge plan. Participate in the updating of the resident's written discharge plan as required. Assist in planning the nursing services portion of the resident's discharge plan as necessary . During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services, dated 12/2008, indicated, .1. Social services shall coordinate most resident referrals . 3. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. 4. Social services will document the referral in the resident's medical record . During a review of the facility's policy and procedure (P&P) titled, Enteral Nutrition, dated 11/18, the P&P indicated, .6. If the resident has a feeding tube placed prior to admission or returning to the facility, the provided and the interdisciplinary team will review the rationale for the placement of the feeding tube, the resident's current clinical and nutritional status, and the treatment goals and wishes of the resident. 7. The decision to continue or discontinue the use of the feeding tube is made through collaboration between the interdisciplinary team, the provider and the resident.

Based on observation, interview, and record review the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 32 opportunities during the medication pass resulted in two errors. The calcuated medication error rate was 6.25 percent. These failures resulted in: 1. Placing Resident 44 at risk for gastrointestinal (diarrhea and nausea) side effects as a result of not taking Metformin (used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes) with food. 2. Placing Resident 14 at risk of elevated phosphorous blood levels as a result of not taking Calcium Acetate (used to treat much phosphate in the blood in patients with end stage kidney disease who are on dialysis. Calcium acetate works by binding with the phosphate in the food you eat, so that it is eliminated from the body without being absorbed.) with food. Findings: 1. During a medication administration observation on 12/7/21, at 7:18 a.m., with LVN 5, in the west wing hallway, LVN 5 prepared Resident 44's medications which included Metformin (an oral medication that lower blood sugar) 1,000 milligrams (mg- unit of measurement) one tablet to be given with meals. LVN 5 administered the medications to Resident 44 with thickened (juice that is thickened) juice given before breakfast. During a concurrent observation and interview on 12/7/21, at 7:34 a.m., with LVN 5, in the west wing hallway, Resident 44 was observed to not have a breakfast tray. LVN 5 stated breakfast trays come around 7:30 a.m. During an observation on 12/7/21, at 8:05 a.m., in Resident 44's room, Resident 44 was observed to have his breakfast tray served by staff. During an interview on 12/7/21, at 9:00 a.m. with LVN 5, LVN 5 stated she was not aware that the breakfast trays came late. During a concurrent interview and record review on 12/7/21, at 10:00 a.m., with LVN 5, the facility's 2007 Nursing Drug Handbook, dated 2007 was reviewed. LVN 5 stated she has given Resident 44's Metformin before meals. LVN 5 looked the medication in the facility's drug reference that indicated .given with morning and evening meals . LVN stated she should have given the medication with Resident 44's breakfast. During an interview on 12/9/21, at 3:17 p.m., with Consultant Pharmacist, (CP), CP stated Metformin should be given to residents with food. CP stated food aids in medication absorption in the body. During a review on Resident 44's admission Record, dated 12/7/21, the admission Record indicated, Resident 44 was diagnosed with Diabetes Mellitus ( condition that occurs when the body can't use glucose (a type of sugar) normally) 11/7/18. During a review of Resident 44, Physician's Phone Order dated 4/26/18, the Physician's Phone Order indicated, .MetFORMIN HCl Tablet 500 mg Give 1 tablet by mouth two times a day related to TYPE 2 DIABETES MELLITUS with meals . During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/19, the P&P indicated, .Medications are administered in accordance with prescriber orders, including any required time frame . During a review of a professional reference review Lexicomp, the manufacturer instructions for Metformin indicated, Administer with a meal (to decrease GI upset). 2. During a medication administration observation on 12/7/21, at 7:37 a.m., with LVN 5, in the west wing hallway, LVN 5 prepared Resident 14's medications which included Calcium Acetate (medication used to treat too much phosphate in patients with end stage kidney disease) 667 mg two capsules every morning on Tuesday, Thursday and Saturday with food. LVN 5 administered the medications to Resident 14 with four ounces of water. Resident 14's breakfast tray was not in the room. During a concurrent observation and interview on 12/7/21, at 7:45 a.m., with LVN 5, in the west wing hallway, Resident 14 was observed to not have a breakfast tray. LVN 5 stated breakfast trays come around 7:30 a.m. During an observation on 12/7/21, at 7:57a.m., in Resident 14's room, Resident 14 was observed to have his breakfast tray on his bedside table. During an interview on 12/9/21, at 3:17 p.m., with CP, CP stated Calcium Acetate should be given to residents with food. CP stated food aids in calcium absorption (binds to the phosphorus in food). During a concurrent interview and record review on 12/7/21, at 9:54 a.m., with LVN 5, the facility's 2007 Nursing Drug Handbook, dated 2007 was reviewed. LVN 5 stated she has given Resident 14's Calcium Acetate before meals. LVN 5 looked the medication in the facility's drug reference that indicated .Most dialysis patients .with each meal .Tell patient to take oral calcium one to one and half hours after meals if gastrointestinal upset occurs . LVN stated she should have given the medication with Resident 14's breakfast. During a review on Resident 14's admission Record, dated 12/7/21, the admission Record indicated, Resident 14 was diagnosed with End Stage Renal Disease 2/17/19 and disorder on phosphorus metabolism 9/9/18. During a review of Resident 14, Physician's Phone Order dated 9/11/21, the Physician's Phone Order indicated, .Calcium Acetate (Phos Binder) Capsule 667 mg Give 1 capsule by mouth three times a day every Mon., Wed, Fri, Sun related to DISORDER OF POHOSPHORUS METABOLISM, UNSPECIFIED .AND Give 2 capsule by mouth one time a day every Tues, Thur, Sat related to DISORDER OF PHOSPHORUS METABOLISM . During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/19, the P&P indicated, .Medication's administration times are determined by resident need and benefit, not staff convenience . During a review of the professional reference titled, Lexicomp, the manufacturer instructions for Calcium Acetate indicated, .Oral dosage forms must be administered with meals to be effective .

Based on observation, interview, and record review the facility failed to develop resident centered care plans for four of six sampled residents (Residents 4, 13, 40, and 44) when: 1. Psychotropic medications care plans for four Residents (Residents 4, 13, 40 and 44) did not have person centered non-pharmacological interventions. 2. Psychotropic medications care plans for four Residents (Residents 4, 13, 40 and 44) did not have measurable objective goals for their behaviors. 3. Resident 40 did not have a resident centered dietary care plan addressing her weight goal and was not discussed with family member. These failures increased the potential for Residents 4, 13, 40 and 44 to not receive treatment and care according to their needs. Findings: 1. During a concurrent interview and record review on 12/8/21, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 4's care plan was reviewed. LVN 2 acknowledged Resident 4's care plan was not resident centered and did not have measurable goals. LVN 2 stated, Care plans are important, it's how we plan care that's best for patient, yes has to be patient specific Important to monitor behaviors so we can prevent issues patient has. We should reduce dose of medication if it has been a year and patient not having behavior . Important for care plan to have timeline and goal so we can see if patient is reaching specific goal in that timeline, if behavior is getting worse, we will have to raise dose, if behavior is getting better or no incident, we can reduce dose . No, there's no measurable or objective goal in the care plan for resident for yelling, hitting or covering face with blanket (Depakote - medication is used to treat seizure disorders, certain psychiatric conditions; Seroquel - medication that works in the brain to treat schizophrenia; Lexapro - a drug used to treat depression and certain anxiety disorders). During a concurrent interview and record review, on 12/08/21, at 10:37 a.m., with Director of Staff Development (DSD), Resident 44's Depakote Care Plan (DCP), dated 2/6/19, Resident 13's Haloperidol Care Plan (HCP), dated 9/3/21, and Resident 40's Behavior Problem Care Plan (BCP), dated 10/25/21, were reviewed. Resident 44's Depakote Care Plan (DCP), dated 2/6/19, the DCP indicated, .Interventions: Administer medication as ordered. Date initiated: 2/6/1/9, monitor for side effects of Depakote: nausea, vomiting, extreme drowsiness . DSD stated, there was no documentation on the care plan dated 2/6/19 that identified resident centered non-pharmacological interventions or measurable objective goals for Resident 44's behaviors. Resident 13's Haloperidol Care Plan (HCP), dated 9/3/21, the HCP indicated, .Interventions: Educated the resident/caregivers about risks, benefits, and the side effects and/or toxic symptoms of (Specify: psychoactive medication drugs being given). Date Initiated: 9/3/21. Revision on: 9/3/21 . DSD stated, there was no documentation on the care plan dated 9/3/21 that identified resident centered non-pharmacological interventions or measurable objective goals for Resident 13's behaviors. Resident 40's Behavior Problem Care Plan (BCP), dated 10/25/21, the BCP indicated, .Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated 10/25/21, Anticipate and meet the resident needs. Date Initiated: 10/25/21. Revision on: 10/25/21 . DSD stated, there was no documentation on the care plan dated 10/25/21 that identified resident centered non-pharmacological interventions or measurable objective goals for Resident 40's behaviors. During an interview on 12/9/21, at 3:11 p.m., with the Consultant Pharmacist (CP), the CP stated Residents 4, 13, 40 and 44 should have non-pharmacologic interventions and should be resident specific. The care plan should have measurable goals to see if they need to increase or decrease the medications specific to the resident. During an interview on 12/9/21, at 5:30 p.m., with the Director of Nursing (DON), the DON stated Resident 4, 13, 40 and 44 should have care plan interventions that are personal and resident centered, and they did not. The DON stated non-individualized interventions would not work on everyone because they are general and not specific to the resident. During a review of the facility's policy and procedure (P & P) titled, Care Plans, Comprehensive Person-Centered, dated December 2016, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 2. During an interview on 12/8/21, at 10:15 a.m., with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 13, 40, and 44's care plan should have person centered interventions and measurable, objective goals, and they did not. LVN 2 stated care plans would be a guide for the resident's care. During a concurrent interview and record review, on 12/8/21, at 2:23 p.m., with LVN 4, Resident 4's SCP was reviewed. The SCP indicated, .Goal: [name of Resident 4] will have no evidence of behavior problems through review date. Date Initiated: 1/28/14. Revision on 7/13/20.Target date: 2/17/22 . LVN 4 stated Resident 4's care plan did not have measurable goals and did not have current timeframes. During a review of Resident 44's DCP, dated 2/6/19, the DCP indicated, .Goal: The resident will be free of any complication r/t Depakote through review date/ Date Initiated: 2/16/19. Revision on: 8/21/20. Target Date: 2/9/22 . During a review of Resident 13's HCP, dated 9/3/21, the HCP indicated, .Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Date Initiated: 9/3/21. Revision on: 9/3/231. Target Date: 9/20/21 . During a review of Resident 40's BCP, dated 10/25/21, the BCP indicated, .Goal: The resident will have fewer episodes of behavior of pulling on gastrostomy (g-tube- is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) and putting self on floor by review date. Date Initiated: 10/25/21, Revision on: 11/17/21. Target Date: 1/20/22 . During an interview on 12/9/21, at 3:11 p.m., with the Pharmacist Consultant (PC), the PC stated Resident 4, 13, 40 & 44's care plan should have measurable goals to see if they need to increase or decrease the medications specific to the residents. During an interview on 12/9/21, at 5:30 p.m., with the DON, the DON stated residents should have measurable goals to see if the resident's behaviors have improved. The DON stated if the resident had not met the goal it would be important to adjust the goal as needed. 3. During an interview on 12/9/21, at 11:47 a.m., with RP 2, RP 2 stated she noticed Resident 40 gained weight. RP 2 stated Resident 40's normal weight was 105 pounds (lbs- unit of measure for weight). RP 2 stated 105 pounds was heavy for Resident 40. RP 2 stated Resident 40 is an extremely light eater. RP 2 stated they were not included in the care planning for Resident 40. During a concurrent interview and record review on 12/9/21, at 2:10 p.m., with the Registered Dietician (RD), Resident 40's dietary care plan was reviewed. the Dietician stated, I don't know that information for her normal weight, Body Mass Index (BMI-is a measure of body fat based on height and weight that applies to adult men and women) was under 19 which was considered underweight . A goal for weight has not been set, initial goal has been met . did not meet family member to set resident specific weight goals . not aware resident usual weight was 105 lbs. The facility Dietician acknowledged Resident 40's dietary care plan was not resident specific. During an interview on 12/9/21, at 5:30 p.m., with the DON, the DON stated care plans should be personal and resident centered. The DON stated goals should be measurable with a timeframe because of the need to revise them if the goals were not met. The DON stated interventions would not work on everyone because it is not specific to the residents. The DON stated family should be involved in care plans and staff should involve the family in those care plans to keep them person centered. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated, .The Interdisciplinary Team (IDT-a group of healthcare providers from different fields who work together or toward the same goal to provide the best care), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet professional standards of quality and follow the facility smoking policy and procedure for nine of 11 residents (Residents' 13, 25, 26, 36, 37, 41, 102, 150 and 249) when Residents 13, 25, 26, 36, 37, 41, 102, 150 and 249 did not have a physician's order to smoke. These failures resulted in Residents 13, 25, 26, 36, 37, 41, 102, 150 and 249's physicians not being aware of residents smoking practices and had the potential to result in residents' medical health to be compromised. Findings: During a concurrent interview and record review on 12/7/21, at 11:30 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the facility had several smokers and Resident 150 was one of her residents who smokes. LVN 1 reviewed Resident 150's record titled, Physician order undated, did not indicate, any physician's order for Resident 150 to smoke. LVN 1 stated she did not know if residents who smoke needed a physician order. During an interview on 12/8/21, at 11:49 a.m., with LVN 2, LVN 2 stated residents who smoke needed to have a physician order. LVN 2 stated it was to make sure residents were safe. During an interview on 12/8/21, at 3:25 p.m., with LVN 3, LVN 3 stated current residents who smoke did not have physician's orders. LVN 3 stated, It would be good to know when a resident smokes because of safety issues. LVN 3 stated residents may be taking medications that have interactions with nicotine. During a concurrent interview and record review on 12/8 /21, at 11:58 a.m., with social service designee (SSD), the SSD stated she did the smoking assessments on admission and quarterly. The SSD stated she initiated the care plan to make sure residents were safe to smoke. SSD stated the smokers did not have a physician's order. SSD stated she did not know residents needed a physician order to smoke. The SSD reviewed the minimum data set (MDS-assessment of functional and cognitive abilities) assessments and care plans for Residents' 13, 25, 26, 36, 37, 41, 102, 150 and 249. SSD stated all residents were quoted as smoker in their MDS assessments. During an interview on 12/10/21, at 10:29 a.m., with Resident 25, Resident 25 stated he smoked, and the facility kept his cigarettes and lighter at the nurse's station. Resident 25 stated the facility had scheduled smoking breaks. Resident 25 stated residents smoked with staff supervision outside at the designated smoking area. During a review of the clinical records for Resident 25, the smoking assessment dated [DATE], indicated, Resident 25 was a smoker. Resident 25's care plan dated 9/28/21 indicated Resident 25 smoked. During an interview on 12/10/21, at 10:35 a.m., with Resident 102, Resident 102 stated she smoke but had not been out since admitted in the facility on 12/5/21. Resident 102 stated the staff explained to him there was smoking schedule, smoking breaks and a designated smoking area outside of the facility to smoke with staff supervision. During a review of the clinical records for Resident 102, the smoking assessment dated [DATE] indicated, Resident 102 was a smoker. During an interview on 12/10/21, at 10:43 a.m., with Resident 37, Resident 37 stated she smoked and had no plan to quit. Resident 37 stated she had not been out to smoke since she was admitted because she did not have cigarette. During a review of the clinical records for Resident 37, the smoking assessment dated [DATE], indicated, Resident 37 was a smoker. Resident 37's care plan dated 10/20/21, indicated, Resident 37 smoked. During an interview on 12/10/21, at 10:49 a.m., with Resident 150, Resident 150 stated he smoked since he was ten years old but has not smoked since admitted in the facility because he did not have any cigarettes. Resident 150 stated he was asked by facility staff if he smoked and explained there was a smoking schedule. During a review of the clinical record for Resident 150, the smoking assessment dated [DATE], indicated, Resident 150 was a smoker. Resident 150's care plan dated 11/15/21, indicated, Resident 150 smoked. During an interview on 12/10/21, at 10:58 a.m., with Resident 13, Resident 13 stated he smoked. Resident 13 did not answer other questions asked. During a review of the clinical record for Resident 13, the smoking assessment dated [DATE], indicated, Resident 13 was a smoker. Resident 13's care plan dated 9/6/2021, indicated Resident 13 smoked. During an interview on 12/10/21, at 11:08 a.m., with Resident 41, Resident 41 refused to talk. During a review of the clinical record of Resident 41, the smoking assessment dated [DATE], indicated, Resident 41 was a smoker. Resident 41's care plan dated 1/21/21, indicated, Resident 41 smoked. During an interview on 12/10/21, at 11:09 a.m., with Resident 249, Resident 249 stated he smoked, and the facility kept his cigarettes and lighter at the nurse's station. Resident 249 stated the facility had scheduled smoking breaks. Resident 249 stated residents smoked with staff supervision outside designated smoking area. During a review of the clinical records for Resident 249, the smoking assessment dated [DATE], indicated, Resident 249 was a smoker. Resident 249's care plan dated 12/6/21, indicated, Resident 249 smoked. During an interview on 12/10/21, at 11:19 a.m., with Resident 36, Resident 36 stated he smoked, and the facility kept his cigarettes and lighter at the nurse's station. Resident 36 stated the facility had scheduled smoking breaks. Resident 36 stated residents smoked with staff supervision at the outside designated smoking area. During a review of the clinical records for Resident 36, the smoking assessment dated [DATE], indicated, Resident 36 was a smoker. Resident 36's care plan dated 10/18/21, indicated Resident 36 smoked. During an interview on 12/10/21, at 2:16 p.m., with the Director of Nursing (DON), the DON stated Residents who smoke should have a Physician's order even it was resident's choice. The DON stated resident medications could interact with the nicotine when residents smoke. The DON stated there was a risk of burning while smoking because the resident did not have a physician's order to smoke. During a review of the facility policy and procedure titled, Smoking Policy undated, indicated, .Residents will only be allowed to smoke, if they have a physician ordered approval . During a review of the facility policy and procedure titled, Physician Medication Order dated 12/2008, indicated .All drugs and biological orders shall be written, dated, and signed by the person lawfully authorized to give such order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure: 1. A physician-documented resident-specific risk rationale for not conducting the required gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) recommendation from the Consultant Pharmacist (CP) for one of six sampled residents (Resident 44). 2. Faciilty staff did not follow up after the CP identified and recommended laboratory monitoring for Risperidone (a drug used to treat certain mental disorders, such as schizophrenia and bipolar disease), Seroquel (an antipsychotic medication to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) for 4 of 6 sampled residents Resident 4, 40, 36, and 44). These failures resulted in Residents 13 and 44 being administered a psychotropic (drug that affects brain activities associated with mental processes and behavior) medication without documented clinical rationale to justify the benefit for continued dose; and increased the potential for drug interactions and adverse reactions associated with the use of psychotropic medications including but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss. Findings: 1. During a review of Resident 44's Medication Administration Record (MAR), dated 2021, the MAR indicated, Resident 44 has been on Escitalopram Exalate (a drug used to treat depression and certain anxiety disorders) Tablet 10 milligrams [mg-unit of measure] by mouth one time a day since 1/21/19. Resident 44 has been on Quetiapine Fumarate ( is a medication that works in the brain to treat schizophrenia ) Tablet 50 mg one tablet by mouth at bedtime (qhs-at bedtime) for aggressive behavior manifested by hitting others related to schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation) since 8/23/18. During a concurrent interview on and record review on 12/7/21, at 3:40 p.m. with DSD, Resident 44's Note to Attending Physician/Prescriber ([NAME]), dated 6/10/21 was reviewed. The [NAME] indicated, the Consultant Pharmacist (CP) recommended to consider a dose reduction because Resident 44's behaviors were noted occasionally. The physician response to the recommendation was: Resident with good response, maintain the current dose. The Director of Staff Development (DSD) stated there was no documentation in Resident 44's medical record that indicated the physician had documented a clinical rationale for not attempting a GDR for Seroquel. During a concurrent interview and record review on 12/8/21, at 5:17 p.m., with DSD, Resident 44's Medication Administration Record for Behaviors (MARB), dated 2021 was reviewed. The MARB indicated no hitting behaviors since 2/21. DSD stated Resident 44 did not pose a risk of endangering themselves or others. During a telephone interview on 12/9/21, at 2:57 p.m., with the CP the CP stated the pharmacist was required to review the resident's medications to see if a GDR would be indicated every year. The CP stated the physician would make the decision on whether to keep the medication the same or decrease the dose. The CP stated, I don't go to school to make a diagnosis. The CP stated the physician would perform an evaluation on the resident and would make a diagnosis. During an interview on 12/9/21, 5:51 p.m., with the Director of Nursing (DON), the DON stated the physician should not continue a antipsychotic medication without attempting a GDR if the CP had recommended a GDR. DON stated the facility should have a clinical justification if a GDR is not attempted for a resident. The DON stated the staff should check with the physician to get a justification if GDR is not attempted after the CP has made a recommendation for a GDR. During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews (MRR), dated 5/19, the P&P indicated, .The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication . During a review of the facility's P&P titled, Tapering Medications and Gradual Drug Dose Reduction, dated 4/07, the P&P indicated, Residents who use antipsychotic drugs shall receive gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs . after the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. 2. During a review of the physician's current orders indicated Resident 40 was prescribed Seroquel 50 mg twice a day for behavior of pulling the gastrostomy tube (is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) related to paranoid schizophrenia (mental disorder characterized by delusions or paranoia) 10/21/21. During a concurrent interview and record review on 12/9/21, at 12:44 p.m., with LVN 4, Resident 40's medical record for lab results were reviewed. LVN 4 stated, there was no documentation in Resident 40's medical records that indicated a laboratory results for a lipid panel (a panel of blood tests used to find abnormalities in lipids, such as cholesterol and triglycerides) thyroid stimulating hormone level (TSH-a test that measures how much of this hormone is in your blood), or a fasting glucose level for Resident 40 since admission to the facility on [DATE]. During a review of Resident 4's Physician Orders dated 7/29/20, the Physician Order indicated, to give Seroquel 100 mg daily manifested by putting herself on the floor/trying to hit others related to unspecified psychosis not due to a substance or known physiological condition. During a review of Resident 4's Physician Orders dated 7/30/21, the Physician Order indicated, Resident 4 to receive Seroquel 125 mg daily (morning) manifested by putting herself on the floor/trying to hit others related to unspecified psychosis (a mental disorder when a person loses contact with reality) not due to a substance or known physiological condition. During a concurrent interview and record review on 12/9/21, at 12:52 p.m., with LVN 4, LVN 4 stated there was no documentation in Resident 4's medical records that indicated a laboratory results for a TSH level for Resident 4. During a review of Resident 36's Physician Orders, dated 10/16/21 the Physician Orders, indicated, Resident 36 to receive Risperidone tablet 3 mg. Give 1 tablet by mouth one time a day for auditory hallucinations (hearing voices that are not present), constantly talking related to Catatonic Schizophrenia (a rare severe mental disorder characterized by significant reductions in voluntary movement or hyperactivity and agitation). During a concurrent interview and record review on 12/09/21, at 1:20 p.m., with LVN 3, LVN 3 stated there was no documentation in Resident 36's medical records that indicated a laboratory results for a Hemoglobin A1C level (a lab that that measures your average blood sugar levels over the past 3 months), or lipid panel for Resident 36. LVN 3 stated lab work would be important because the resident's medications may need to be increased or decreased depending on the lab results. During an interview on 12/9/21, at 5:35 p.m., with the DON, the DON stated obtaining lab work would be important to see the resident's baseline needs. The DON stated labs could tell if something was going on with the resident if the lab work is too high or low. During a review of Lexicomp (a professional drug reference), dated 12/14/21, indicated, monitoring parameters for Seroquel include .TSH, free T4 (thyroxine is the main hormone produced by the thyroid gland. A laboratory test can be done to measure the amount of free T4 in your blood), and thyroid clinical assessment (baseline and follow-up); fasting plasma glucose level/HbA1c (baseline; repeat 3 months after starting antipsychotic, then yearly or if symptoms of hyperglycemia develop) . fasting lipid panel (baseline; repeat 3 months after initiation of antipsychotic; if LDL level is normal, repeat at 2-5 year intervals or more frequently if clinically indicated) During a review of Lexicomp, dated 12/14/21, indicated, monitoring parameters for Risperidone include .fasting plasma glucose level/HbA1c (baseline; repeat 3 months after starting antipsychotic, then yearly); fasting lipid panel (baseline; repeat 3 months after initiation of antipsychotic; if LDL level is normal repeat at 2 to 5 year intervals or more frequently if clinical indicated) . During a review of the facility's policy and procedure (P&P) titled, Medication Regimen Reviews, dated 5/19, the P&P indicated, .An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services of practice: is not supported by medical evidence: and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of six sampled residents (Residents 44, 13, and 40) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications, as evidenced by: 1. For Resident 44, no resident-centered non-pharmacological (treatment without medications) interventions were documented prior to initiation of Seroquel (an antipsychotic medication to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) and Depakote (a medication is used to treat seizure disorders, certain psychiatric conditions); and staff administered Seroquel and Depakote without consistent indication and clinical justification for long term use. 2. For Resident 13, no resident-centered non-pharmacological (treatment without medications) interventions were documented prior to initiation of Haldol (an antipsychotic medication to treat severe mental disorder in which thought and emotions are so weak that contact is lost with external reality); and staff administered Haldol without consistent indication and clinical justification for long term use. 3. For Resident 40, no resident-centered non-pharmacological (treatment without medications) interventions were documented prior to initiation of Seroquel (an antipsychotic medication to treat severe mental disorder in which thought and emotions are so weak that contact is lost with external reality); and staff administered Seroquel without consistent indication and clinical justification for long term use. These failures resulted in unnecessary medications for the residents and had the potential for medication interactions, adverse reactions, and increased risks associated with the use of psychotropic medications that include but not limited to sedation, respiratory depression, falls, constipation, anxiety, agitation, and memory loss. Findings: 1. During a review of Resident 44's admission Record, dated 12/7/21, the admission Record indicated, Resident 44 was admitted to the facility on [DATE], with diagnoses including schizophrenia (a serious mental disorder in which people interpret reality abnormally) since 1/27/17. During a review of Resident 44's Medication Administration Record (MAR), dated 2021, the MAR indicated, Resident 44 has been on Depakote Tablet Delayed release 500 mg: Give one tablet by mouth two times a day for aggressive behaviors: yelling at others, related to schizophrenia since 8/23/18. Resident 44 has been on Escitalopram Exalate {brand for Lexapro} Tablet 10 milligrams [mg-unit of measure] by mouth one time a day since 1/21/19. Resident 44 has been on Quetiapine Fumarate {brand for Seroquel} Tablet 50 mg one tablet by mouth at bedtime (qhs-at bedtime) for aggressive behavior manifested by hitting others related to schizophrenia since 8/23/18. During a concurrent interview on and record review on 12/7/21, at 1:29 p.m. with Licensed Vocational Nurse (LVN)5, Resident 44's facility medical records were reviewed. LVN 5 stated, there was no documentation in the facility medical records that indicated non-pharmacological interventions were implemented prior to initiation of Seroquel and Depakote for Resident 44. LVN 5 stated, Before we start anyone on unnecessary med, maybe they need a distraction from the behavior not that they need to be started on medication right away. During a concurrent interview and record review on 12/7/21 at 5:17 p.m., with Director of Staff Development (DSD), Resident 44's Medication Administration Record for Behaviors (MARB), dated 2021 was reviewed. DSD acknowledged the MARB indicated Resident 44 had zero hitting behaviors since 2/21. DSD stated Resident 44 did not pose a risk of endangering themselves or others. DSD stated, .monitoring behaviors important to see if medications are working, important to give lowest effective dose psychotropics to residents to reduce side effect of medications like tardive dyskinesia [define] . During a concurrent interview and record review on 12/8/21, at 11:08 a.m., with DSD, Resident 44's facility and hospital medical records were reviewed. DSD stated, there was no documentation in Resident 44's hospital medical records that indicated Resident 44 was diagnosed with schizophrenia. DSD stated, there was no documentation in Resident 44's facility medical records that indicated Resident 44 exhibited symptoms of hallucinations or delusions. DSD stated, Yes, resident is on Depakote and Seroquel for Schizophrenia .Schizophrenia is when we hear voices, hallucinations, delusions. During an interview on 12/8/21, at 3:54 p.m., with the DSD, the DSD stated it was important to attempt a GDR because of the medications side effects like tardive dyskinesia (abnormal, recurrent, involuntary movements that may be irreversible and typically present as lateral movements of the tongue or jaw, tongue thrusting, chewing, frequent blinking, brow arching, grimacing, and lip smacking, although the trunk or other parts of the body may also be affected) could be harmful to the resident. During a telephone interview on 12/9/21, at 2:57 p.m., with the Consultant Pharmacist (CP), the CP stated the pharmacist was required to review the resident's medications to see if a GDR would be indicated every year. The CP stated the physician would make the decision on whether to keep the medication the same or decrease the dose. The CP stated, I don't go to school to make a diagnosis. The CP stated the physician would perform an evaluation on the resident and would make a diagnosis. During an interview on 12/9/21, 5:51 p.m., with the Director of Nursing (DON), the DON stated residents should have resident specific non-pharmacological interventions. DON acknowledged Resident 44 did not have a behavioral history of delusions or hallucinations from the hospital or during stay at the facility. DON stated, when we have resident and they're taking something and pharmacy recommend it doesn't meet diagnosis criteria, doctor chooses diagnosis. DON also stated the physician should not continue an antipsychotic medication without attempting a GDR if the CP had recommended a GDR. DON stated the facility should have a clinical justification if a GDR is not attempted for a resident. The DON stated the staff should check with the physician to get a justification if GDR is not attempted after the CP has made a recommendation for a GDR. During a profession reference review of Lexicomp, dated 12/14/21, the manufacturer information for Seroquel indicated, .Elderly patients have an increased risk of adverse effects to antipsychotics. In light of this risk, and relative to their small beneficial effect size in the treatment of dementia-related psychosis and behavioral disorders, patients should be evaluated for possible reversible causes before being started on an antipsychotic. Nonpharmacologic interventions should be tried before initiating an antipsychotic. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 12/16, the P&P indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. During a review of the facility's P&P titled, Tapering Medications and Gradual Drug Dose Reduction, dated 4/07, the P&P indicated, .5. The Physician will review periodically whether current medications are still necessary in their doses; for example, whether an individual's condition s or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current doe, or whether those conditions and risk could potentially be equally well managed or controlled without certain medications, or with a lower dose .10. Residents who use antipsychotic drugs shall receive gradual dose reductions . 2. During a review of Resident 13's admission Record, dated 12/8/21, the admission Record indicated, Resident 13 was admitted to the facility on [DATE] with diagnoses including schizophrenia, and dementia (illness causing personality changes and decrease mental activity, memory). During a review of Resident 13's Physician Orders, dated 10/4/21, the Physician Order indicated, Resident 13 to give Haloperidol Tablet 5 mg, 1 tablet by mouth two times a day for aggressive behaviors: trying to hit others related to schizophrenia. During a concurrent interview and record review on 12/8/21, at 2:34 p.m., with the DSD, Resident 13's record was reviewed. The DSD stated, there was no documentation in Resident 13's facility medical records that indicated Resident 13 exhibited symptoms of hallucinations or delusions. The DSD stated she could not find a consent for the Haldol started on 9/1/21. The DSD stated a psychiatric evaluation (an evaluation recommended by the multidisciplinary team and performed by a physician that specializes in mental disorders) was not done on Resident 13. During an interview on 12/9/21, at 2:58 p.m., with CP, the CP stated the physician is the one who has to make that decision to decrease the Haldol. CP stated residents should have non-pharmacological interventions that are resident specific and should have been done on Resident 13. During a concurrent observation and interview on 12/9/21, at 5:57 p.m. with the DON, the DON stated Resident 13 was diagnosed with schizophrenia at the facility and was put on Haldol. The DON stated Resident 13 was admitted to the facility from an acute care hospital and was agitated. The DON stated the physician checked off to continue the Haldol. During a professional reference review of Lexicomp, dated 12/8/21, Lexicomp indicated .Haldol .ALERT: US Boxed Warning. Increased mortality in elderly patients with dementia-related psychosis: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Although the causes of death were varied, most of the deaths appeared to be cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Haloperidol is not approved for the treatment of patients with dementia-related psychosis . During a review of the facility's P&P titled, Antipsychotic Medication Use, dated 12/16, the P&P indicated, .1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .8. Diagnoses alone do not warrant the use of antipsychotic medication . 3. During a review of Resident 40's admission Record, dated 12/8/21, the admission Record indicated, Resident 40 was admitted to the facility on [DATE] with diagnoses including: paranoid (has an irrational and obsessive distrust of others) schizophrenia on 11/10/21. During a concurrent interview and record review on 12/8/21, at 3:48 p.m., with DSD, Resident 40's Physician Order, dated 12/8/21, Medication Administration Record for Behaviors (MARB), and facility medical records were reviewed. The Physician Order indicated, referral to remove g-tube (is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) on 11/16/21. Seroquel was prescribed 10/20/21, after admission to the facility. DSD acknowledged there was no documentation in Resident 40's facility medical records that indicated non-pharmacological approaches had been attempted or failed before starting Seroquel. During a review of Resident 40's Medication Administration Record for Behaviors (MARB), dated 10/21 through 12/21, the MARB indicated, Resident 40 had three instances of behavior of pulling at her g-tube three times in 10/21, three times in 11/21. During an interview on 12/8/21, at 3:48 p.m., with the DSD, the DSD stated there was not documentation on Resident 40's psychosocial initial clinical assessment and no indication that Resident 40 had delusions or hallucinations on admission. During a concurrent observation and interview on 12/9/21, at 10:10 a.m., with Resident 40 in her room, Resident 40 was observed in bed. Resident 40 stated she wanted her g-tube removed because she wanted to go home. During an interview on 12/9/21, at 11:47 a.m., with RP 2, RP 2 stated Resident 40 did not have a history of schizophrenia before admission to the facility. RP 2 stated they were not aware of that diagnosis. During a phone interview on 12/9/21, at 3:11 p.m., with the CP, the CP stated, I don't know if resident has schizophrenia or not, I don't make decision on what patient should have, the doctor is the one making that decision. CP also stated residents should have person specific, non-pharmacologic interventions. During an interview on 12/9/21, at 3:37 p.m., with the DSD, the DSD stated, when we have resident and they're taking something and pharmacy recommend it doesn't meet diagnosis criteria, doctor chooses diagnosis. DSD also stated Resident 40 was administered Seroquel because she was agitated and pulling on her g-tube, DSD acknowledged Resident 40 did not have documented behavioral history of delusions or hallucinations. DSD stated Resident 40 had not used her g-tube since admission to the facility. DSD stated she should have the g-tube removed. During a review of the facility's P&P titled, Antipsychotic Medication Use, dated 12/16, the P&P indicated, .Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident . Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective infection control and prevention program when: 1. Two of two residents' (Residents 9 and 23) oxygen concentrator (a device that concentrates the oxygen from the air in the environment) outer coverings and filters were found with lint and dust. These failures had the potential to contribute to the increase risk of developing respiratory infections (infections that happen in the lungs, chest, sinuses, nose, and throat) for Resident 9 and 23. 2. Licensed Vocational Nurse (LVN) 6 did not sanitize a blood pressure cuff after use on Resident 24 in the west wing. This deficient practice had the potential for the development and the spread of infection to all residents in the west wing. 3. Certified Nursing Assistant (CNA) 5 picked up a call light off the floor and placed in Resident 103's hands without sanitizing it. This deficient practice had the potential to cause contamination and infection to Resident 103. Findings: 1. During an observation on 12/8/21, at 9:02 a.m., in room [ROOM NUMBER], Resident 9 was resting in bed. Resident 9 had an nasal cannula (a device used to deliver supplemental oxygen) connected to an oxygen concentrator. The oxygen concentrator outer covering and filter was observed to be covered by dust and lint. During an observation on 12/8/21, at 9:04 a.m., in room [ROOM NUMBER], Resident 23 was sleeping in bed. Resident 23 had an nasal cannula connected to an oxygen concentrator. The oxygen concentrator outer covering and filter was observed to be covered by dust and lint. During a concurrent observation and interview on 12/8/21, at 9:06 a.m., with Licensed Vocational Nurse (LVN) 1, in room [ROOM NUMBER], Resident 9 and Resident 23 were observed laying in bed. Resident 9 and Resident 23 were being given oxygen through nasal cannulas connected to oxygen concentrators. LVN 1 checked the filters on the two oxygen concentrators. The two filters were filled with dust and lint. LVN 1 stated the filters were dirty. LVN 1 stated residents receiving oxygen from oxygen concentrator with dirty filter could cause respiratory infections. LVN 1 stated using oxygen concentrator with dirty filter was not acceptable. LVN also stated the two oxygen concentrators were covered by dust and lint and could potentially cause harm to Resident 9 and Resident 23. During an interview on 12/8/21, at 11:44 a.m., with Infection Preventionist (IP, professional who ensures healthcare workers and patients are doing all the things they should to prevent infections), IP stated using oxygen concentrators with dirty outer covering and filter was not acceptable and could worsen residents respiratory status. IP stated residents being given oxygen from oxygen concentrators with dirty filters could potentially worsen the residents' fragile respiratory system (a part of the body, starting from the nose to the lungs). IP stated nurses were responsible for cleaning the oxygen concentrator outer covering and filters on a regular basis. During an interview on 12/10/21, at 11:59 a.m., with Director of Nursing (DON), DON stated using oxygen concentrators with dirty outer covering and filter was not acceptable. DON stated dirty oxygen concentrators could potentially result in cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and could compromise Resident 9 and Resident 23 fragile respiratory system. DON stated maintenance department was responsible for cleaning the oxygen concentrators outer covering and filters on a weekly basis and as needed. During a review of Resident 9's admission Record [AR], dated 12/8/21, the AR indicated, Resident 13 was admitted to the facility on [DATE] with diagnoses which included Unspecified Asthma (a respiratory condition causing difficulty in breathing). During a review of Resident 9's Order Summary Report [OSR], dated 12/8/21, the OSR indicated, a physician's order, . O2 [oxygen] at 2L (liters, unit of measurement) VIA NC [nasal cannula] CONTINOUSLY . During a review of Resident 23's admission Record, dated 12/8/21, the AR indicated, Resident 23 was admitted to the facility on [DATE] with diagnoses of Pneumonia, Unspecified Organism (lung infection caused by bacteria) and Acute Respiratory Distress (ARD, sudden condition characterized by the inability of the lungs to adequately provide oxygen into the blood). During a review of Resident 23's Order Summary Report , dated 12/8/21, the OSR indicated, a physician's order, . O2 [oxygen] at 4L VIA NC CONTINOUSLY . During a review of the facility's document titled, [Company Name] Oxygen Concentrator, User Manual, dated 2016, the manual indicated, . Cleaning the Cabinet Filter . 1. Remove the filter and clean at least once a week depending on environmental conditions. NOTE: Environmental conditions that may require more frequent cleaning of the filters include, but are not limited to: high dust, air pollutants, etc. 2. Clean the cabinet filter with a vacuum cleaner or wash in warm soapy water and rinse thoroughly. 3. Dry the filter thoroughly before reinstallation . Cleaning the Cabinet . Clean the cabinet with a mild household cleaner and non-abrasive cloth or sponge . During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 11/2018, The P&P indicated, . Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA (Occupational Safety and Health Administration, a government agency in-charge of monitoring the working conditions of workers enforcing standards, providing training, outreach, education and assistance) Bloodborne Pathogens (infectious germs that could make a person ill) Standard . 1. d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . 2. During a review of Resident 24's admission Record, dated 12/7/21, the admission Record, indicated Resident 24 was admitted to the facility on [DATE] with diagnoses including orthostatic hypotension, (a form of low blood pressure that happens when you stand up from sitting or lying down). During a review of Resident 24's Physician Phone Order, dated 11/18/21, the Physician Phone Order, indicated, .Midodrine HCl (used to treat orthostatic hypotension) tablet 5 milligrams (MG- unit of measurement) Give one table by mouth three times a day related to ORTHOSTATIC HYPOTENSION .for 30 days until finished (Hold if Systolic ( the top number of a blood pressure that measures the force your heart exerts on the walls of your arteries each time it beats) Blood Pressure is greater than 120) . During a review of Resident 24's Medication Administration Record (MAR), dated 12/21, the MAR indicated Resident 24 had a blood pressure check three times a day. During a concurrent observation and interview on 12/6/21, at 4:46 p.m., with LVN 6, at the medication cart in the west wing hallway, LVN 6 was observed to not clean the blood pressure cuff before use on Resident 24. LVN 6 was observed wiping the blood pressure cuff with {Hydrogen Peroxide (type of wipes that kill microorganisms quickly on a broad range of surfaces.) {Cleaner} Disinfectant Wipes and immediately putting the cuff back in the medication cart after checking Resident 24's blood pressure. During a concurrent interview and record review, on 12/6/21, at 5:37 p.m. with LVN 6, the manufacturer instructions for Hydrogen Peroxide Disinfectant Wipes, were reviewed. The manufacturer instructions indicated, .surface to remain wet for Hepatitis B Virus (HBV-liver infection caused by the hepatitis B virus), Hepatitis C Virus (HCV-liver infection caused by the hepatitis C virus) and Human Immunodeficiency Virus (HIV-1-type of retrovirus that attacks your body's immune system) for 30 seconds . LVN 6 picked up the disinfectant wipes and showed us the wet time (the time that a disinfectant needs to stay wet on a surface to ensure efficacy) noted on the container. LVN 6 stated she thought the wet time was until dry, but she did not wait for thirty seconds before putting the blood pressure back in the medication cart. LVN 6 stated following the manufactures directions that would have killed bacteria on the blood pressure cuff between resident use. During an interview on 12/9/21, at 5:25 p.m., with the Director of Nursing (DON), the DON stated it was important to follow manufacturer's instructions for wet times to prevent cross contamination. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 10/18, the P&P indicated, .d. Reusable items are cleaned and disinfected or sterilized (made free from bacteria or other living microorganisms) between residents . During a review of the manufacturer instructions for dwell time for the hydrogen peroxide disinfectant wipes, dated 8/17, provided by the facility, the manufacturer's instructions indicated, .These Environmental Protection Agency EPA- is an agency of the United States federal government whose mission is to protect human and environmental health-registered disinfectant wipes contain hydrogen peroxide and other ingredients to kill most bacteria and viruses on a variety of hard nonporous (material that is not able to easily absorb fluids or allow liquid to pass through) healthcare surfaces with contact times of 30 seconds or 1 minute . 3. During a concurrent observation and interview on 12/6/21 at 3:04 p.m. with Certified Nurse Assistant (CNA) 5, in Resident 103's room, the call light was observed on the floor underneath Resident 103's bed. CNA 5 picked it up and placed the call light in Resident 103's hands without sanitizing it. CNA 5 stated the call light should be clipped to the pillow or sheet next to Resident 103. During an interview on 12/8/21 at 2:59 p.m. with CNA 8, CNA 8 stated the call light should always be within Resident 103's reach. CNA 8 stated the call light should be sanitized after it has been on the floor and clipped to the bed sheet or clothes on Resident 103 to be able to reach it. During an interview on 12/8/21 at 3:06 p.m. with CNA 5, CNA 5 validated the call light for Resident 103 was on the floor and should have sanitized prior to handing it to Resident 103. CNA 5 stated the call light was contaminated and could have made Resident 103 sick. During an interview on 12/8/21 at 3:28 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated if a call light was on the floor it would have been contaminated. LVN 4 stated the call light should have been disinfected and then given to the resident. LVN 4 stated residents could become infected with germs and become sick with an infection. During an interview on 12/10/21 at 9:51 a.m. with the Director of Staff Development (DSD), the DSD stated, We need to clean and sanitize [the call light], then give it to [Resident 103]. The DSD stated the call light should be within reach of Resident 103 and attached to the sheet or pillowcase so it doesn't drop to the floor. The DSD stated if the call light was not clean it could spread infection and Resident 103 could get sick. During an interview on 12/10/21 at 2:53 p.m. with the Director of Nursing (DON), the DON stated the staff should clean the call light before it is given to [Resident 103]. The DON stated, If [the staff] are not wiping [the call light] it could spread infection causing fever or any other infection to our residents. During an interview on 12/10/21 at 4:26 p.m. with the Infection Preventionist (IP), the IP stated the staff should have cleaned the call light before it was given to Resident 103. The IP stated the call light on the floor could cause cross contamination and cause Resident 103 to become ill. During a review of Resident 103's Care Plan (CP) dated 11/25/21, the CP indicated, .The resident has an ADL Self Care Performance Deficit r/t [related to] weakness . Interventions . Encourage the resident to use bell/call light to call for assistance . During a review of the facility's P&P titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated 10/2018, the P&P indicated, The P&P indicated, . Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA (Occupational Safety and Health Administration, a government agency in-charge of monitoring the working conditions of workers enforcing standards, providing training, outreach, education and assistance) . During a review of professional reference titled, INFECTION PREVENTION & CONTROL COMMUNICATION FORM PULL CORDS AND CALL BELLS, reference retrieved from https://professionals.wrha.mb.ca/old/extranet/ipc/files/manuals/acutecare/Pull_Cords_and_Call_Bells.pdf, dated 7/2017, the professional reference indicated, .Call bells have been linked to transmission of microorganisms and outbreaks. Pull cords are not regularly changed between patients and can become easily contaminated .Microorganisms and contaminated material migrate under the button and contaminate the inside of push button call bells. Call bells have been directly implicated in hospital outbreaks. An investigation into one hospital outbreak found evidence of heavily contaminated fecal material inside of a disassembled call bell. String cords cannot be physically cleaned between patients and may harbor organisms. Improper cleaning of the physical environment has been related to transmission of many types of pathogenic organisms, e.g. C. difficile . [a germ that causes severe diarrhea and colitis -an inflammation of the colon].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were used and labeled in accordance with professional standards, including proper temperature controls, when: 1. There was no process to check temperatures of the storage areas where over the counter (OTC - medications that do not need a physician order) were kept. 2. Resident 32's bottle of eye drops was opened and did not have a sticker with a resident identifier or an open date on the medication. 3. Resident's 149's bottle of ear drops was opened and did not have a sticker with a resident identifier or an open date on the medication. 4. Resident 33's Insulin Humalog Lispro (is a fast-acting insulin that controls blood sugar around mealtimes for both type 1 and type 2 diabetes) had an expiration date of 11/30/21 and continued to be used by staff. Theses failures had the potential to decrease medication potency that could compromise the therapeutic effectiveness of stored medications and the medications for Residents 32, 149, and 33. Findings: 1. During a concurrent observation and interview on 12/6/21, at 11:02 a.m., with Registered Nurse (RN) 1, in the facility's medication storage cabinet located on the west wing, the temperature log was noted to be missing documentation for the temperatures of the medications at room temperature. RN 1 stated nobody is monitoring the temperatures of the medications at room temperature because maintenance checks the temperatures of all the room in the facility. During a concurrent observation and interview on 12/6/21, at 11:10 a.m., with RN 1, in the west wing's medication storage cabinet, Sodium Bicarbonate (is a white crystalline compound used in a solution as an antacid to treat acid indigestion and heartburn) and Phos-Nak (Sodium, Potassium, and Phosphorus Dietary Supplement) Powder Concentrate was observed to be located on the shelf in the medication storage cabinet. The bottle indicated to store the medication between 59 degrees and 86 degrees Fahrenheit (is a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees. It is represented by the symbol ° F). RN 1 stated it would be important to monitor the medications temperatures because the medications may not be good and harm the resident. During an interview on 12/9/21, at 3:15 p.m., with the Consultant Pharmacist (CP), the CP stated maintenance should have a record of temperatures for medication storage. CP stated monitor of temperature where medications are stored is important because if the temperature is too hot then the medication would not be good. During an interview on 12/9/21, at 5:23 p.m., with the Director of Nursing (DON), the DON stated the facility should be checking and keeping a temperature log for medication storage areas. The DON stated the temperature logs would be monitored daily by the DON. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 4/19, the P&P indicated, .Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls . 2. During a concurrent observation and interview on 12/06/21, at 12:28 p.m., with License Vocational Nurse [LVN] 4, during the medication cart check on east wing hallway, eye drop solution for Resident 32 that required to be dated when opened was observed to not have an expiration date/date open sticker or patient label. LVN 4 acknowledged the bottle has been opened and used to administer medication to Resident 32 but was unable to determine when the bottle was opened. LVN 4 stated there was no patient label and there's no date on there, important to have a date so know when expiration. LVN 4 stated that using a medication that could potentially cause resident 32 to develop an eye infection or cause severe side effect of medication. During a review of Resident 32's admission Records, dated, the admission Records indicated Resident 32 was admitted to the facility on [DATE]. During a review of Resident 32's Physician Phone Orders, dated 11/30/21, the Physician Phone Order indicated, .Artificial Tears Solution (eyedrops used to lubricate dry eyes and help maintain moisture on the outer surface of your eyes) 0.2-0.2-1 % (Glycerin-Hypromellose-PEG 400 [generic name for artificial tears]) Instill 1 drop in both eye every 12 hours as need for dry eyes for 3 days . During a review of Resident 1's Medication Administration Record (MAR), dated 11/1/21 to 12/6/21, the MAR, indicated a provider's order for Artificial Tears instill one drop in both eyes once daily for itching eyes was administered to Resident 32 on 11/30/21. During an interview on 12/9/21, at 3:17 p.m., with the CP, the CP stated eye drops should have a resident label on the medications for the nurse to know the correct medication was given to the correct patient. During an interview on 12/9/21, at 5:25 p.m., with the DON, the DON stated nurses should have place a resident label on Resident 32's eye drops because the medication could potentially be used on another resident causing a contamination problem. During a review of the facility's P&P titled, Storage of Medications, dated 4/19, the P&P indicated, .Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . During a review of the facility's P&P titled, Administering Medications, dated 4/19, the P&P indicated, .21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and cirle the MAR space provided for that drug and dose. 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones . 3. During a concurrent observation and interview on 12/06/21, at 12:30 p.m., with LVN 4, during the medication cart check on east wing hallway, ear drop solution for Resident 149 that required to be dated when opened was observed to not have an expiration date/date open sticker or patient label. LVN 4 acknowledged the bottle has been opened and used to administer medication to Resident 149 but was unable to determine when the bottle was opened. LVN 4 stated there was no patient label and there's no date on there, important to have a date so know when expiration. LVN 4 stated that using a medication meant for another resident could potentially cause a medication error for Resident 149. During a review of Resident 149's admission Records, dated, the admission Records indicated Resident 149 was admitted to the facility on [DATE]. During a review of Resident 149's Physician Phone Orders, dated 11/30/21, the Physician Phone Order indicated, .Debrox Solution (a medication is used to treat earwax buildup. It helps to soften, loosen, and remove the earwax) (Carbamide Peroxide [generic name for Debrox]) Instill 4 drop in right ear two times a day related to IMPACTED CERUMEN (earwax), RIGHT EAR .for 4 days **ear lavage (a method of cleaning wax out of ears) after each administration** . During a review of Resident 1's Medication Administration Record (MAR), dated 11/29/21 to 12/4/21, the MAR, indicated a provider's order for Debrox Solution (Carbamide Peroxide) Instill 4 drops in right ear two times a day was given two times a day from 11/29/21 at 5:00 p.m. through 12/4/21 at 8:00 a.m. During an interview on 12/9/21, at 3:17 p.m., with the CP, the CP stated ear drops should have a resident label on the medications for the nurse to know the correct medication was given to the correct patient. During an interview on 12/9/21, at 5:25 p.m., with the DON, the DON stated nurses should have place a resident label on Resident 149's ear drops because the medication could potentially be used on another resident causing a contamination problem. During a review of the facility's P&P titled, Storage of Medications, dated 4/19, the P&P indicated, .Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . 4. During a concurrent observation and interview on 12/06/21, at 12:45 p.m., with Licensed Vocational Nurse (LVN) 4, during the medication cart check on east wing hallway, Insulin Humalog Lispro for Resident 33 was observed to be expired. The medication was observed to have an opened date on 11/2/21 and expiration date of 11/30/21. LVN 4 stated expired medications should not be left in the medication cart. LVN 4 stated Resident 33 had received the expired insulin since 11/30/21. LVN 4 stated expired insulin could cause Resident 33's blood sugars to get out of control. LVN 4 stated expired insulin had the potential for the medication to not be as effective and Resident 33's blood sugars could be high. During a review of Resident 33's admission Records, dated, the admission Records indicated Resident 33 was admitted to the facility on [DATE]. Resident 33's diagnoses included: Type 2 Diabetes Mellitus (a condition that occurs when the body can't use glucose (a type of sugar) normallydefine) due to Underlying Condition on 4/3/17. During a review of Resident 33's Order Summary Report, dated 12/6/21, the Order Report Summary indicated, .HumaLOG Solution 100 UNIT/ML (unit of measurement) (Insulin Lispro) Inject as per sliding scale: if 151-200=2 units if 60-149=0 UNITS IF Fasting Blood Sugar (FSBS-blood sugar checked before meals) <60, RECHECK FSBS .subcutaneously before meals related to TYPE 2 DIABETES MELLITUS . During a review of Resident 1's Medication Administration Record (MAR), dated 12/1/21 to 12/6/21, the MAR, indicated a provider's order for HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject per sliding scale was given three times on 12/1/21, three times on 12/2/21, three times on 12/3/21, two times on 12/4/21, two times on 12/5/21, and two times on 12/6/21. During an interview on 12/9/21, at 3:17 p.m., with the CP, the CP stated expired medications should not be given to a resident because the medication may not be effective. During an interview on 12/9/21, at 5:25 p.m., with the DON, the DON stated Expired medications- nurses should be checking expiration date and returning the expired medication to pharmacy. The DON stated administration of expired medications could cause the medication to lose their effectiveness. During a review of the facility's P&P titled, Administering Medications, dated 4/19, the P&P indicated, .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . During a review of the professional reference titled, Lexicomp indicated, .Once punctured (in use), vials may be stored under refrigeration or at room temperature <30°C (<86°F); use within 28 days. Cartridges and prefilled pens that have been punctured (in use) should be stored at room temperatures <30°C (<86°F) and used within 28 days .

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff had the appropriate skill set to prepare meals served to the facility residents when: 1. One of two cooks (Cook 1) did not calibrate (adjust) a food thermometer correctly. 2. One of two cooks (Cook 2) did not know the correct process of handling dented canned goods. These failures had the potential to place the 50 of 50 residents (Resident 1, 3, 4, 5, 6, 7, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 36, 38, 39, 40, 41, 42, 43, 44, 45, 47, 48, 49, 50, 99, 100, 102, 103, 149, 150 and 249) who received food prepared in the kitchen at risk for foodborne illness (a disease caused by consuming contaminated food or drink). Findings: 1. During a concurrent observation and interview on 12/7/21 at 11:28 a.m., with [NAME] 1, in the kitchen area. [NAME] 1 was observed calibrating two food thermometers using the ice bath method (a process of adjusting the gauge of food thermometer). [NAME] 1 used an eight-ounce cup filled halfway with ice and water. [NAME] 1 inserted the food thermometer into the ice/water mixture with the food thermometer probe touching the bottom of the cup. [NAME] 1 stated three months ago, she was in-serviced on food thermometer calibration. During an interview on 12/8/21, at 3:29 p.m., with Dietary Supervisor (DS), DS stated [NAME] 1 did not follow the correct technique to calibrate a food thermometer using the ice bath method. DS stated the food thermometer probe should not touch the bottom of the cup. DS stated cooks should know the appropriate technique to calibrate a food thermometer using the ice bath method. During an interview on 12/9/21, at 3:55 p.m., with Registered Dietician (RD), RD stated cooks should know the appropriate technique to calibrate a food thermometer using the ice bath method. RD stated she in-serviced [NAME] 1 on 12/7/21 [before starting the lunch tray line] on how to properly calibrate a food thermometer. RD stated if thermometers were not accurate, the food temperatures tested would not be accurate, and food may not be safe to serve to facility residents. During a review of facility's document titled, In-service: Utilizing Correct Thermometers, Checking Accuracy and Calibrating, dated 10/21/21, the document indicated, .Importance of Checking Thermometer Accuracy . Thermometers need to be accurate within +/- 2 degrees. If the thermometers are not accurate, the food temperatures tested are not accurate and the food may not be safe to serve. This can lead to food-borne illness, and be life threatening for our residents . Calibrating Thermometers . Fill a container (can be an 8 oz. glass or a mug) with crushed ice . Place the thermometers in the ice bath and wait at least one minute. Be sure the stem of thermometer is submerged enough to cover the sensor portion of the probe . The document also indicated [NAME] 1 was in attendance for the In-service . During a review of facility's document titled, Job Description Cook, dated 4/2013, the document indicated, . Purpose . The primary purpose of your job position is to prepare food in accordance with current applicable federal, state and local standards, guidelines and regulations . Safety and Sanitation . Prepare food in accordance with sanitary regulations as well as our established policies and procedures . During a review of the professional reference retrieved from https://ask.usda.gov/s/article/How-do-I-calibrate-a-food-thermometer, dated 6/21/21, the reference indicated, . To use the ice water method, fill a large glass with finely crushed ice. Add clean tap water to the top of the ice and stir well. Immerse the food thermometer stem a minimum of 5 cm (centimeter, unit of measurement) into the mixture, touching neither the sides nor the bottom of the glass. Wait a minimum of 30 seconds before adjusting. Without removing the stem from the ice, hold the adjusting nut under the head of the thermometer with a suitable tool and turn the head so the pointer reads 32°F (Fahrenheit, unit of measurement) . During a review of the professional reference retrieved from Centers for Disease Control and Prevention (CDC) document titled, Food Safety, dated 10/15/21, the reference indicated, .Food is safely cooked when the internal temperature gets high enough to kill germs that can make you sick. The only way to tell if food is safely cooked is to use a food thermometer. You can't tell if food is safely cooked by checking its color and texture .Use a food thermometer to ensure foods are cooked to a safe internal temperature . 2. During an observation on 12/6/21 at 10:40 a.m., in the dry storage food area, three dented cans of 6.5 lbs (pound, unit of measurement) of peas and two dented cans of 6.6 lbs of mandarin oranges were placed in a metal rack near a stairway. During a concurrent observation and interview on 12/6/21 at 10:45 a.m., with [NAME] 2, in the dry food storage area, [NAME] 2 stated she would use the dented can goods to prepare resident's meals. [NAME] 2 stated she would not use the canned goods if they were dented and leaking. [NAME] 2 stated the menu for today does not include peas and mandarin. During an interview on 12/7/21, at 3:48 p.m., with Dietary Supervisor (DS), DS stated cooks should know the appropriate process for handling dented canned goods. DS stated canned food items should be routinely inspected for damage such as denting, bulging, or leaking . Damaged food items are set aside for return to the vendor or disposed of properly. DS stated serving food from dented cans could potentially cause foodborne illness to facility residents. During an interview on 12/8/21, at 3:48 p.m., with Registered Dietician (RD), RD stated cooks should know the appropriate process for handling dented canned goods. RD stated damaged canned goods are set aside for return to the vendor or disposed of properly. RD stated dented canned goods could be contaminated and unsafe for consumption. During a review of facility's document titled, Job Description Cook, dated 4/2013, the document indicated, . Purpose . The primary purpose of your job position is to prepare food in accordance with current applicable federal, state and local standards, guidelines and regulations . Safety and Sanitation . Prepare food in accordance with sanitary regulations as well as our established policies and procedures . During a review of facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2019, the P&P indicated, . 10. Canned food items should be routinely inspected for damage such as dented, bulging, or leaking cans. These items should be set aside in a designated area for return to the vendor or disposed properly . 17. Canned and dry foods should be stored according to Dry Goods Storage Guidelines . During a review of the professional reference retrieved from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous, dated 7/17/2019, the reference indicated, . Is food in damaged cans dangerous? . NEVER USE food from cans that are leaking, building, or badly dented; cracked jars or jars with loose or bulging lids; canned food with foul odor; or any container that spurts liquid when opening. Such cans could contain Clostridium botulinum (bacteria that could make people sick) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were followed in the kitchen when: 1. A water leak coming from the sewage pipe was directly dripping into food items. 2. The temperatures of two of four freezers (Freezer number 3 and Freezer number 4) were 40 degrees F (Fahrenheit, unit of measurement) and 28 degrees F, respectively and not in accordance with the expected temperature of zero degrees. 3. The refrigerator and freezer used for resident and staff food was missing an inside temperature thermometer. 4. There was a wall opening in the dry food storage room measuring 3x4 inches in size. 5. Thirty-seven cases of expired water bottles were stored inside the dry food storage room. 6. One non-food grade hand sanitizer was installed next to the 3-compartment sink. 7. One of two cooks (Cook 1) was observed touching the head of measuring spoons during meal tray preparation. 8. One of two cooks (Cook 1) was observed not washing her hands in between removing and putting on a new pair of gloves. These failures had the potential to place the 50 of 50 residents (Resident 1, 3, 4, 5, 6, 7, 9, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 36, 38, 39, 40, 41, 42, 43, 44, 45, 47, 48, 49, 50, 99, 100, 102, 103, 149, 150 and 249) who received food prepared in the kitchen at risk for foodborne illness (a disease caused by consuming contaminated food or drink). Findings: 1. During a concurrent observation and interview on 12/6/21, at 10:33 a.m., with [NAME] 2, in the dry food storage room, a water leak was observed coming from the sewage pipe and directly dripping into a 4-shelf metal storage rack with food items. [NAME] 2 stated she found the leak around 5:30 a.m. [12/6/21] and she immediately notified the Dietary Supervisor (DS). [NAME] 2 stated she returned to the kitchen after reporting the incident to her supervisor and did not have a chance to relocate the metal storage rack away from the sewage leak and reorganize the dry food storage room. [NAME] 2 stated serving food from contaminated food items could potentially cause foodborne illness to facility residents. During a concurrent observation and interview on 12/6/21, at 10:36 a.m., in the dry food storage room, with [NAME] 2, [NAME] 2 validated the following food items were wet from the water dripping from the sewage pipe: a. Seven boxes of 4 oz (ounce, unit of measurement) [Brand X] apple juice b. One box of 33.8 oz [Brand X] orange juice c. Eight packages of 14.1 oz of [Brand Y] lime lite juice d. Eight packages of 14.1 oz of [Brand Y] cantaloupe juice e. 48 cans of 8 oz [Brand Z] cola f. 12 cans of 8 0z [Brand Z] diet lemon lime g. 24 cans of 8 oz [Brand Z] diet cola During a concurrent observation and interview on 12/6/21, at 11:11 a.m., in the dry food storage room, with DS, DS stated the food items affected by the water leak were no longer safe for residents consumption and would be disposed off immediately. DS stated serving food from contaminated food items could potentially cause foodborne illness. During a concurrent observation and interview on 12/6/21, at 12:30 p.m., in the dry food storage room, with Maintenance Supervisor (MS), MS stated the sewage leak started this morning [12/6/21] and a third-party vendor came earlier and fixed the source of the leak. During an interview on 12/8/21, at 11:53 a.m., with Infection Preventionist (IP, professional who ensures healthcare workers and patients are doing all the things they should to prevent infections), IP stated the sewage leak situation in the dry storage room was unacceptable. The food affected by the sewage leak should be discarded immediately and dry goods should be relocated. IP stated she would suggest storing dry goods away from the sewage pipe. IP stated serving food from contaminated food items could potentially cause gastrointestinal infections (cause by bacteria or virus, symptoms include diarrhea, vomiting, and abdominal pain). During an interview on 12/9/21, at 3:55 p.m., with Registered Dietician (RD), RD stated the food items affected by the sewage leak should be discarded immediately and dry goods should be relocated as part of the long-term plan. RD stated she would recommend to the management a different location for storing dry goods. RD stated serving food from contaminated food items could potentially make residents suffer from food poisoning. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2019, the P&P indicated, . SUBJECT: FOODBORNE ILLNESS . The Dining and Nutrition Services Department should take appropriate steps to ensure food is prepared/handled in a safe/sanitary manner to prevent any foodborne illness outbreaks . 4. The most common foodborne diseases are: . BACTERIA . Clostridium botulinum (bacteria that could make people sick) . CAUSE . Soil and unclean water carry the disease . BACTERIA . Campylobacter jejuni (bacteria that could make people sick).) . CAUSE . Contaminated water . BACTERIA . Listeria (bacteria that could make people sick) . CAUSE . cross contamination . During a professional reference review of the Food and Drug Administration (FDA, an agency in the United States federal government whose mission is to protect public health by making sure that food, cosmetics, and nutritional supplements are safe to use) 2017 Food Code Manual, dated 2017, the Manual indicated, .Section 3-305.11 Food Storage . Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food. Shoes carry contamination onto the floors of food preparation and storage areas. Even trace amounts of refuse or waste in rooms used as toilets or for dressing, storing garbage or implements, or housing machinery can become sources of food contamination. Moist conditions in storage areas promote microbial growth 2. During a concurrent observation and interview on 12/6/21, at 10:38 a.m., with [NAME] 2, in the dry food storage room, [NAME] 2 validated the freezer number 3 temperature thermometer showed 40 degrees F (Fahrenheit, unit of measurement) and with a condensation (water droplets) build up inside the entire freezer. During a concurrent observation and interview on 12/6/21, at 11:10 a.m., in the dry storage room, with Dietary Supervisor (DS), DS validated the following soft and melting food items were inside freezer number 3 and covered with moisture: a. Five packages of potato wedges a. 13 packages of English muffin b. Two packages of pancakes c. One pack of Danishes d. One pack of croissant e. Two packages of sliced pepperoni f. One pack of hamburger bread g. One large cheese pizza h. One package of meringue pie i. One package of banana muffin j. Two packages of coffee cake During a concurrent observation and interview on 12/6/21, at 11:20 a.m., with DS, in the dry food storage room, DS stated the freezer number 4 temperature thermometer showed 28 degrees F with a condensation build up. DS stated the freezer temperature should be less than or equal to zero degrees F. During a concurrent observation and interview on 12/6/21, at 11:22 a.m., in the dry storage room, with DS, DS validated the following soft and melting food items were inside freezer number 4 and covered with moisture: a. 33 packages of hotdog buns b. 12 loaves of sliced bread c. One package of tortillas d. Three packages of biscuits During an interview on 12/6/21, at 11:28 a.m., in the dry storage room, with DS, DS stated the two freezers were malfunctioning last week and was serviced by a third-party vendor. DS stated all items inside the two refrigerators were potentially not safe for consumption and should be disposed of immediately. DS stated the freezer temperature should be less than or equal to zero degrees F. DS stated serving improperly stored food items could potentially cause foodborne illness to facility residents. During an interview on 12/9/21, at 3:55 p.m., with Registered Dietician (RD), RD stated freezer temperature should be zero degrees F or below. RD stated the facility is not meeting the food code standard and the food items on Freezer number 3 and 4 should be disposed of immediately. DS stated the freezer temperature should be less than or equal to zero degrees F. (Consequences of consuming food - unsafe). During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2019, the P&P indicated, . SUBJECT: FOOD RECEIVING AND STORAGE OF COLD FOODS . Frozen food will be stored at zero degrees F or below at all times . 5. Temperatures will be logged twice daily on all refrigerators and freezers by assigned Food Service employees: Refrigerators less than or equal to 41 degrees F . Freezers less than or equal to zero degrees F . 6. All documented temperatures falling out of appropriate range should have documented action plan . During a professional reference review of the FDA 2017 Food Code Manual, dated 2017, the Manual indicated, .Section 3-305.11 Food Storage . Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food . Moist conditions in storage areas promote microbial growth 3. During a concurrent observation and interview on 12/6/21, at 4:30 p.m., with DS, in the dining area, the resident and staff refrigerator and freezer were observed with no temperature thermometer. DS stated without a temperature thermometer, the facility would not have a way to determine if the food inside the refrigerator and freezer were safe to eat. DS stated a thermometer should be placed inside the resident and staff refrigerator and freezer. During a concurrent observation and interview on 12/6/21, at 4:34 p.m., in the dining area, with DS, DS validated the following food items were inside the resident and staff freezer: a. One package of pizza roll container labelled with Resident 41's name and with an open date of 11/19/21. b. Four containers of [Brand A] frozen orange juice c. One container of [Brand B] frozen apple juice d. One container of [Brand C] vanilla ice cream, partially consumed e. One container of [Brand D] Buttermilk During a concurrent observation and interview on 12/6/21, at 4:39 p.m., in the dining area, with DS, DS validated the following food items were inside the staff and resident refrigerator: a. One gallon of [Brand E] fat free milk b. One container of potato salad, partially consumed c. One cup of [Brand F] cold drink, partially consumed d. Two containers with unknown food items e. Two lunch bags with unknow food items During an interview on 12/8/21, at 11:53 a.m., with the IP, the IP stated without a temperature thermometer it would be impossible to determine if the food inside the refrigerator and freezer were safe. IP stated a thermometer for the refrigerator and freezer should be placed immediately and a temperature log should be in place. IP stated serving food items from refrigerator without thermometer could potentially cause foodborne illness to facility residents, potentially resulting to gastrointestinal infections. During an interview on 12/9/21, at 4:00 p.m., with RD, RD stated the facility should have one temperature thermometer for the refrigerator and one temperature thermometer for the freezer. RD stated the facility is not meeting the food code standard. RD stated staff should follow the policy on food storage. RD stated serving food items from refrigerator without thermometer could potentially cause foodborne illness to residents. During a review of Resident 41's admission Record [AR], dated 12/10/21, the AR indicated, Resident 41 was admitted to the facility on [DATE] with diagnoses which included Unspecified Anemia (a condition in which the blood doesn't have enough healthy red blood cells) and Adult Failure to Thrive (a condition of poor nutrition). During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2019, The P&P indicated, . SUBJECT: FOOD RECEIVING AND STORAGE OF COLD FOODS . Frozen food will be stored at zero degrees F or below at all times . 5. Temperatures will be logged twice daily on all refrigerators and freezers by assigned Food Service employees: Refrigerators less than or equal to 41 degrees F . Freezers less than or equal to zero degrees F .6. All documented temperatures falling out of appropriate range should have documented action plan . During a professional reference review of the FDA 2017 Food Code Manual, dated 2017, the Manual indicated, .Section 3-305.11 Food Storage . Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food . Moist conditions in storage areas promote microbial growth 4. During a concurrent observation and interview on 12/6/21, at 11:31 a.m., with Maintenance Supervisor (MS), in the dry food storage room, a wall opening behind a 4-shelf metal storage rack was observed. MS stated the hole was about 3 inches x [by] 4 inches (unit of measurement) in size. MS stated the hole could be from a previous repair work and should be covered immediately to prevent rodents and pests from entering the dry food storage area. During an interview on 12/8/21, at 11:58 a.m., with the IP, the IP stated snakes, rodents and pests could enter the dry food storage room through the hole and potentially contaminate the food stored in the dry food storage room. IP stated the hole should be patched immediately and the dry food storage room should be monitored regularly for signs and symptoms of infestations. During an interview on 12/9/21, at 4:10 p.m., with RD, RD stated the hole inside the dry food storage room was not acceptable. RD stated rodents and pests could enter the dry food storage area through the hole and potentially contaminate the food stored in the dry food storage room. RD stated the hole should be covered and sealed immediately. RD stated the dry food storage room should be clean and free from pests. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2019, the P&P indicated, . SUBJECT: FOODBORNE ILLNESS . The Dining and Nutrition Services Department should take appropriate steps to ensure food is prepared/handled in a safe/sanitary manner to prevent any foodborne illness outbreaks . 1. Foodborne illness may be caused by Pathogenic bacteria, Chemicals, and/or Food contamination . 4. The most common foodborne diseases are . Salmonella . Cause . Carried to the food by sewage, employee's hands, flies, rodents, and equipment . During a professional reference review of the FDA 2017 Food Code Manual, dated 2017, the Manual indicated, .Section 6-501.111 Controlling Pests . Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments . 5. During a concurrent observation and interview on 12/6/21, at 3:29 p.m., with DS, in the dry food storage room, DS validated the presence of 13 cases of [Brand G] 1-gallon bottled water, six gallons per case, with an expiration date of 9/9/21. During a concurrent observation and interview on 12/6/21, at 3:35 p.m., with DS, in the dry food storage room, DS validated the presence of 24 cases of [Brand H] 24 oz water, 24 bottles per case, with an expiration date of 8/4/21. DS the expired bottled water were not safe for use and need to be disposed of immediately. DS stated serving expired bottled water could potentially cause foodborne illness to facility residents. During an interview on 12/9/21, at 4:10 p.m., with RD, RD stated expired bottled water bottles should be disposed of immediately. RD stated facility should have a designated staff responsible for checking the expiration date of food items stored in the dry food storage room. RD stated serving expired food items was not safe and could potentially cause foodborne illness to residents. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2019, the P&P indicated, . SUBJECT: FOODBORNE ILLNESS . The Dining and Nutrition Services Department should take appropriate steps to ensure food is prepared/handled in a safe/sanitary manner to prevent any foodborne illness outbreaks . 4. The most common foodborne diseases are: . BACTERIA . Clostridium botulinum (bacteria that could make people sick) . CAUSE . Soil and unclean water carry the disease . BACTERIA . Campylobacter jejuni (bacteria that could make people sick).) . CAUSE . Contaminated water . BACTERIA . Listeria (bacteria that could make people sick) . CAUSE . Food past its expiration date . cross contamination . 6. During a concurrent observation and interview on 12/6/21, at 3:21 p.m., with DS, in the kitchen area, a hand sanitizer dispenser containing a non-food grade sanitizer (not suitable for use on food contact surfaces or hands) was observed. The hand sanitizer dispenser was installed next to the three-compartment sink. DS stated using a non-food grade sanitizer in the kitchen area was not safe. DS stated dietary staff should wash hands and follow the facility's handwashing procedure. During an interview on 12/9/21, at 4:15 p.m., with RD, RD stated dietary staff should not use non-food grade sanitizer in the kitchen for resident's safety. RD stated non-food grade sanitizer could contaminate the food in the kitchen and could potentially cause foodborne illness to facility residents. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2019, the P&P indicated, . SUBJECT: FOODBORNE ILLNESS . The Dining and Nutrition Services Department should take appropriate steps to ensure food is prepared/handled in a safe/sanitary manner to prevent any foodborne illness outbreaks . 5. Follow these steps to prevent foodborne illness: a. Keep hands clean using the handwashing procedure . f. wash hands often and appropriately . During a review of facility's document titled, Facility In-service: How to Handwash? dated 11/8/21, the document indicated, 0. Wash hands . Wet hands with water; 1. Apply enough soap to cover all hand surfaces . 8. Rinse hands with water . During a professional reference review of the FDA 2017 Food Code Manual, dated 2017, the Manual indicated, .Section 2-301.16 Hand Antiseptics . A hand antiseptic used as a topical application, a hand antiseptic solution used as a hand dip, or a hand antiseptic soap shall . (c) A determination of generally recognized as safe (GRAS). Partial listings of substances with FOOD uses that are GRAS may be found in 21 CFR 182 -Substances Generally Recognized as Safe, 21 CFR 184 -Direct FOOD Substances Affirmed as Generally Recognized as Safe, or 21 CFR 186 - Indirect FOOD Substances Affirmed as Generally Recognized as Safe for use in contact with FOOD During a review of the professional reference retrieved from https://www.cdc.gov/handwashing/handwashing-kitchen.html, dated 5/6/2021, the reference indicated, . Your hands can spread germs in the kitchen. Some of these germs, like Salmonella (bacteria that could make people sick), can make you very sick. Washing your hands frequently with soap and water is an easy way to prevent germs from spreading around your kitchen and to other foods . Handwashing is especially important during some key times when germs can spread easily: Before, during, and after preparing any food; After handling uncooked meat, poultry, seafood, flour, or eggs; Before and after using gloves to prevent germs from spreading to your food and your hands; Before eating; After touching garbage; After wiping counters or cleaning other surfaces with chemicals; After touching pets, pet food, or pet treats; and After coughing, sneezing, or blowing your nose . 7. During a concurrent observation and interview on 12/7/21, at 11:11 a.m., with [NAME] 1, in the kitchen area, [NAME] 1 was observed touching the head of the three measuring spoons (scoop #8, scoop #12, and scoop #16) with her bare hands during meal try preparation. [NAME] 1 validated the observation and stated she was not supposed to touch the head of the measuring spoons with her bare hands. [NAME] 1 stated she probably contaminated the measuring spoons and would wash them all prior to serving meal. During an interview on 12/7/21, at 3:36 p.m., in the kitchen area, with DS, DS stated [NAME] 1 did not follow the process to ensure food was handled in a sanitary manner to prevent any foodborne illness outbreaks. DS stated [NAME] 1 should not touch the head of the measuring spoons with her bare hands during meal try preparation. DS stated the action of [NAME] 1 was not safe and could potentially cause gastrointestinal illness to facility residents. During an interview on 12/9/21, at 4:16 p.m., with RD, RD stated cooks should know the appropriate process of preparing and handling food safely. RD stated [NAME] 1 should not touch the head of the measuring spoons with her bare hands during meal try preparation. RD stated the action of [NAME] 1 was not acceptable and could potentially cause foodborne illness to residents. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2019, the P&P indicated, . SUBJECT: FOODBORNE ILLNESS . The Dining and Nutrition Services Department should take appropriate steps to ensure food is prepared/handled in a safe/sanitary manner to prevent any foodborne illness outbreaks . 1. Foodborne illness may be caused by Pathogenic bacteria, Chemicals, and/or Food contamination . 4. The most common foodborne diseases are . Salmonella . Cause . Carried to the food by sewage, employee's hands, flies, rodents, and equipment . 5. Follow these steps to prevent foodborne illness .h. Follow procedures to ensure sanitized utensils and equipment are being used . 8. During an observation on 12/7/21, at 12:31 p.m., in the kitchen area, [NAME] 1 was observed not washing her hands after removing and putting on a new pair of disposable gloves. During a concurrent observation and interview on 12/7/21, at 12:39 p.m., in the kitchen area, [NAME] 1 was observed not washing her hands after removing and putting on a new pair of disposable gloves. [NAME] 1 stated she was nervous and forgot to wash her hands after removing the disposable gloves. [NAME] 1 stated her action of not washing her hands after removing the disposable gloves was not safe and could potentially cause foodborne illness to facility residents. During an interview on 12/7/21, at 3:58 p.m., in the kitchen area, with DS, DS stated [NAME] 1 did not follow the process to ensure food was handled in a sanitary manner to prevent any foodborne illness outbreaks. DS stated [NAME] 1 did not wash her hands during meal preparation after removing the disposable gloves. During an interview on 12/9/21, at 4:18 p.m., with RD, RD stated cooks should know the appropriate process for preparing and handling food safely. RD stated [NAME] 1 should wash her hands after removing or before using a pair of disposable gloves to prevent cross contamination. RD stated the action of [NAME] 1 was not acceptable. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control, dated 2019, the P&P indicated, . SUBJECT: FOODBORNE ILLNESS . The Dining and Nutrition Services Department should take appropriate steps to ensure food is prepared/handled in a safe/sanitary manner to prevent any foodborne illness outbreaks . 5. Follow these steps to prevent foodborne illness: a. Keep hands clean using the handwashing procedure . f. wash hands often and appropriately . During a review of facility's document titled, Facility In-service: How to Handwash? dated 11/8/21, the document indicated, 0. Wash hands . Wet hands with water; 1. Apply enough soap to cover all hand surfaces . 8. Rinse hands with water . During a review of the professional reference retrieved from https://www.cdc.gov/handwashing/handwashing-kitchen.html, dated 5/6/2021, the reference indicated, . Your hands can spread germs in the kitchen. Some of these germs, like Salmonella, can make you very sick. Washing your hands frequently with soap and water is an easy way to prevent germs from spreading around your kitchen and to other foods . Handwashing is especially important during some key times when germs can spread easily: Before, during, and after preparing any food; After handling uncooked meat, poultry, seafood, flour, or eggs; Before and after using gloves to prevent germs from spreading to your food and your hands; Before eating; After touching garbage; After wiping counters or cleaning other surfaces with chemicals; After touching pets, pet food, or pet treats; and After coughing, sneezing, or blowing your nose .