Based on observation, interview, and record review, the facility failed to allow one out of 15 Residents (Resident 42) to exercise their right to self-determination when Resident 42 was not provided nutrition in accordance with their preferences. This failure had the potential to result in Residents 42 feeling upset and disrespected. Findings: During a review of Resident 42's admission Record, printed 3/13/25, the record indicated Resident 42 was admitted to the facility in December 2024 with a diagnosis of protein-calorie malnutrition and depression. During a concurrent observation and interview on 3/10/25, at 12:36 p.m. with Resident 42, Resident 42's lunch tray was observed with one regular serving of vegetables. Resident 42 stated they were supposed to get an additional large portion of vegetables with their regular vegetables. Resident 42 stated they felt upset and disrespected that staff did not follow their food prefrences. During a concurrent observation and interview on 3/11/25, at 12:45 p.m. with Registered Dietician (RD), Resident 42's lunch tray was observed with one regular serving of vegetables. RD stated Resident 42 should have got an additional large portion of vegetables and added a large portion of vegetables. RD stated it was important to honor resident preferences. During a review of Resident 42's Lunch Tray Ticket, dated 3/10/25, the ticket indicated, Notes: Add: Large portion vegetable. During a review of Resident 42's Lunch Tray Ticket, dated 3/11/25, the ticket indicated Notes: Add: Large portion vegetable. During a review of Resident 42's Dietary Interview/Pre-Screen, dated December 2024, the interview indicated Special Preferences . Lunch . add: vegetable. During a review of the facility's policy and procedure (P&P) titled, Resident Food Preferences, dated 2001, the P&P indicated, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. During a review of the facility's P&P titled, Resident Rights, dated 2001, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . self - determination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, licensed nursing staff did not notify the doctor for changes in condition for one of 15 sampled residents (Resident 49). Staff did not report continued low food intake, pain, and low blood pressures. This failure resulted in Resident 49 becoming unresponsive with a low blood sugar and sent to the hospital emergency department where she experienced a cardiac arrest (condition when heart suddenly and unexpectedly stops beating) and died. Findings: During a review of Resident 49's clinical document, titled admission Record, the admission Record showed the facility admitted Resident 49 on 11/2/24 with diagnoses including Crohn's Disease (chronic inflammatory bowel disease). During a record review of Resident 49's clinical document Weights and Vitals Summary, dated 3/13/2025, the document indicated Resident 49's blood pressure was 74/51 on 11/30/2024. There was no documentation in the clinical record which showed the doctor had been notified. During an interview on 3/13/2025 at 9:45 a.m. with the Director of Nursing (DON), DON stated staff should have retaken the blood pressure and notified the doctor if it was still low. In a concurrent record review, the DON confirmed there was no documentation in the clinical record which showed the doctor had been notified. During a record review of the Resident 49's Nutritional Risk Assessment, dated 12/3/2024, the document showed Resident 49 was At high risk for malnutrition . During a record review of Resident 49's clinical document titled, Documentation Survey Report v2, dated December 2024, the document showed Resident 49's percentage of food intake on multiple meals between 12/1/2024 to 12/17/2025 was zero to 26% intake. There was no documentation in the clinical record which showed the doctor had been notified. During a record review of Resident 49's Nutritional Risk Assessment (Admission/Annual) - V 5.0, dated 12/13/2024, the document showed Resident 49 was Not feeling well and her roommate reported to the Registered Dietitian (RD) Resident 49 was in a lot of pain, hadn't eaten breakfast that morning and was Zoning in and out. There was no documentation which showed the RD reported this information to the licensed nursing staff or the doctor had been notified. The RD was not available to be interviewed. During an interview on 03/12/25 at 2:45 p.m. with DON, DON confirmed there was no documentation in the clinical record which showed the doctor or nurse had been notified regarding the low food intake, pain, or mental status change. The DON stated when someone is at risk for malnutrition, she expected staff to monitor the intake, observe for dehydration, and skin breakdown. The DON also stated staff should have been monitoring Resident 49's blood sugar since hypoglycemia (low blood sugar) was a potential outcome for low food intake. The DON stated signs of low blood sugar included becoming pale, sweaty, and a potential altered level of consciousness. During a record review of Resident 49's Progress Notes *New*, dated 11/1/2024 to 12/31/2024, the Progress Notes showed on 12/17/2024 at 7:04 a.m., licensed nursing staff reported Resident 49 had gotten Little to no sleep due to pain which had not been relieved by medication. There was no documentation in the clinical record which showed the doctor had been notified. During an interview on 3/12/2025 at 2:26 p.m. with DON, DON confirmed the staff had not notified the doctor regarding the unrelieved pain. Further review of document Progress Notes *New*, dated 11/1/2024 to 12/31/2024, the notes showed later that morning on 12/17/2024 at 10:50 a.m., staff found Resident 49 unresponsive with a blood sugar level of 56. (normal range: 70-100). Staff called 911 and Patient 49 was sent to the hospital emergency department (ED). During a record review of Resident 49's ED to Hosp-admission (discharged ) ., dated 12/17/2024, the record showed Resident 49 arrived at the ED with a blood pressure of 76/54 and hemoglobin of 6.5.(Hemoglobin: protein in red blood cells that is responsible for delivering oxygen to the tissues. Normal range: 12-16). Resident 49's diagnoses included septic shock and a GI bleed (septic shock: life-threating condition caused by a severe localized or system-wide infection) (GI: gastrointestinal). Resident 49 was transferred to the hospital Intensive Care Unit where she went into cardiac arrest and died. During an interview on 3/13/2025 at 10:57 a.m. with the facility's physician (MD 1), MD1 stated he could not recall if anyone had notified him regarding Patient 49's low blood pressure readings. He stated he was aware of the pain and poor appetite but that the GI team never stabilized her (GI: gastrointestinal) and that maybe a feeding tube (Feeding Tube: tube placed directly into the stomach to deliver liquid food) would have helped. MD 1 stated Resident 49 was A mess. During an interview on 3/19/2025 at 11 a.m. with the Emergency Doctor (MD 2), MD 2 stated it would have been useful to have a physician assess Patient 49 and check her blood sugar when she was described as Zoning in and out. MD 2 stated Patient 49's blood cultures from the ED showed Enterobacter (intestinal bacteria) which meant that the bacteria source for her sepsis came from the GI track. MD 2 stated, not having a proper diet can contribute to the development of a GI bleed and having a feeding tube placed would have helped. During a record review of the Resident 49's clinical document titled, Care Plan Report dated 12/13/2024, the care plan showed Resident 49 was at risk for malnutrition. Goals included Will identify physical symptoms or conditions that could lead to a decreased appetite or ability to eat. During a record review of facility's Policy and Procedures (P and P) titled, Nutritional Assessment dated 2001, the P & P showed As part of the comprehensive assessment, the nutritional assessment will be a systemic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. On multivariate analysis, there was a significant increase in mortality in patients with malnutrition. Patients with malnutrition had greater rates of sepsis events, perforation and GI bleed. On multivariate analysis, malnutrition appeared to significantly increase mortality. [Malnutrition Imparts Worse Outcomes in Patients with Diverticulitis: A Nationwide Inpatient Sample Database Study: [NAME], Ayham Khrais, [NAME] Le, Sushil Ahlawat. NIH National Library of Medicine:pubmed.ncbi.[NAME].nih.gov/35989747/]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of one sampled resident (Resident 20) reviewed for vision impairment, the facility did not assist Resident 20 in making appointments for cataract evaluation. This failure had the potential to result in worsening of visual function without treatment. Definition: Cataract, a clouding of the normally clear lens of the eye, leading to blurry and hazy vision. Cataract Evaluation, a comprehensive eye exam to assess the presence, severity, and potential impact of cataracts, as well as overall eye health, to determine the best course of treatment, which may include surgery. Ophthalmology, the branch of medicine focused on the eyes and vision, encompassing the diagnosis, treatment, and prevention of eye diseases and disorders, including surgical procedures and vision correction. Findings: During a review of Resident 20's clinical record, the admission Record indicated Resident 20 was admitted to the facility in July 2021 with diagnoses that included major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities) and hypertension (high blood pressure). Resident 20's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 12/21/24 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 15. A score of 13-15 is an indication of intact cognitive status. During a review of Resident 20's MDS dated [DATE], the MDS indicated, under Section F-Preferences for Customary Routine and Activities (an interview for activity preferences), for Resident 20, it was very important to have books, newspapers, and magazines to read and to keep up with news while in the facility. During an observation and concurrent interview on 3/10/25 at 10:51 a.m. with Resident 20, while Resident 20 watched television in the room, Resident 20 stated she could not see what was shown on the screen as it was blurry. Resident 20 stated being diagnosed with cataract by an eye doctor in the last year and was told by Social Services Director (SSD) that facility would look for a surgeon to perform surgery on her eye. Resident 20 stated she has not heard back from SSD since. During an interview on 3/11/25 at 1:23 p.m. with SSD, SSD stated Resident 20 was seen by the facility's ophthalmologist (eye doctor) in December 2024. Review of Ophthalmology Consultation dated 12/11/24 indicated Resident 20 complained of blurry vision and inability to read or see TV, and with a diagnosis of having cataract on the left eye. The ophthalmologist recommendations included referral to a specialist for cataract extraction (a surgical procedure to remove a cloudy lens [cataract] lens of the eye and, in most cases, replace it with an artificial lens) evaluation. During a review of Resident 20's Order Summary Report dated 3/12/25, the Order Summary Report indicated a physician's order dated 12/11/24 for eye consult for eye health with follow-up as indicated. During a follow-up interview on 3/11/25 at 1:39 p.m. with SSD, SSD stated she did not see the recommendation for Resident 20's referral for cataract extraction. SSD stated all the residents at the facility were seen by the facility's ophthalmologist every six months and she only looked at the six-month follow-up for Resident 20. SSD stated she has not referred Resident 20 to an eye surgeon. During a review of the facility's policy and procedure (P&P) titled Eye Care Services, undated, the P&P indicated Eye care services will be made available to residents upon request, referral, or when a clinical need is identified. Residents will receive eye care services in accordance with physician's orders .may include but are not limited to: eye exams .provision of corrective lenses, treatment for eye disease and follow-up care . Follow-up visits will be scheduled and coordinated as needed based on the results of the eye examination.

Based on interview and record review, for one of two sampled residents (Resident 24) reviewed for pain management, the facility failed to ensure pain management was provided consistent with professional standards of practice when facility did not administer pain medication to address Resident 24's severe pain. This failure had the potential to result in severe discomfort. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was admitted to the facility in April 2024 with diagnoses that included complete traumatic amputation (a surgical procedure where a limb or part of a limb is removed) at level between knee and ankle and osteomyelitis (a bone infection). During a review of Resident 24's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 2/2/25 indicated a Brief Interview for Mental Status (BIMS, a scoring system to determine resident's cognitive status in regards to attention, orientation, and ability to register and recall information) score of 14. A score of 13-15 is an indication of intact cognitive status. During an interview on 3/10/25 at 10:49 a.m. with Resident 24, Resident 24 stated having headaches and severe pain on the left amputated leg. Resident 24 described pain intensity as 10 out of 10 (on a scale of 1-10, one as the absence of pain and 10 being the worst pain). Resident 24 also stated being given pain medication that does not help much with pain relief. During a concurrent interview and record review on 3/12/25 at 12:39 p.m. with Director of Nursing (DON), Resident 24's Medication Administration Records (MARs) and Order Summary Report (OSR) were reviewed. The OSR indicated a physician's order dated 12/27/24 to give oxycodone-acetaminophen (a narcotic pain medication) 5-325 milligram (mg) 1 tablet every 4 hours as needed for moderate pain (4-6). Resident 24's January 2025 MAR indicated a physician's order to give oxycodone-acetaminophen (Percocet, a narcotic pain medication) 5-325 mg 1 tablet by mouth every 4 hours for moderate pain (4-6). The MAR for January 2025 indicated Resident 24 had severe pain (7-10) but was given pain medication indicated for moderate pain (4-6) on the following dates; 1/20/25, 1/21/25, 1/22/25, 1/23/25, 1/24/25, 1/25/25, 1/26/25, 1/27/25, 1/28/25, and 1/29/25. The MAR for February 2025 indicated Resident 24 had severe pain (7-10) but was given pain medication indicated for moderate pain (4-6) on the following dates; 2/5/25, 2/24/25 and 2/26/25. The MAR for March 2025 indicated Resident had severe pain (7-10) but was given pain medication indicated for moderate pain (4-6) on the following dates; 3/4/25, 3/9/25 and 3/10/25. DON stated the MARs did not indicate a pain medication order for when Resident 24 had severe pain. DON also stated the licensed staff should have called Resident 24's physician to request for pain medication indicated for severe pain. During a review of the Consultant Pharmacist's Medication Regimen Review (CPMRR) dated 1/20/25, the CPMRR indicated Percocet (oxycodone-acetaminophen) was administered outside of parameters (refer to the specific aspects of pain that are evaluated during assessment, including intensity and quality). The recommendation was for staff to review and reinforce proper procedure with staff. During an interview on 3/12/25 at 12:46 p.m. with Assistant Director of Nursing (ADON), ADON stated she had followed up on the medication regimen recommendation by giving in-service education to the licensed staff but did not call the doctor to request pain medication. During a concurrent interview and record review on 3/12/25 at 1:25 p.m. with DON, DON stated a new physician's order for severe pain was obtained from the physician. The OSR dated 3/12/25 indicated a new order dated 3/12/25 for oxycodone-acetaminophen 5-325 mg 2 tablets every 4 hours as needed for severe pain (7-10). During a review of the facility's policy and procedure (P&P) titled Pain Assessment and Management, undated, the P&P indicated pain management is a multidisciplinary process that includes interventions that are consistent with the resident's goals for treatment which are defined and documented in the care plan. It also indicated pain management interventions should reflect the sources, type and severity of pain. During a review of Resident 24's pain care plan last revised 4/18/24, the care plan indicated for staff to administer medications as ordered and allow time to participate in activities of daily living to minimize discomfort.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to ensure that resident bedrooms were limited to a maximum of four residents for one out of 24 rooms. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, affect resident's right to privacy, dignity and lack of sufficient space for storage of resident belongings. Findings: During an observation on 3/11/25, room [ROOM NUMBER] was occupied by five residents. During a review of the Facility's Daily Census, dated 3/10/25, the census indicated room [ROOM NUMBER] was occupied by five residents. According to the Code of Federal Regulations, Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. Bedrooms must . Accommodate no more than four residents.

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. Unlabeled, undated food items were stored in the kitchen refrigerator. 2. [NAME] (CK) 1 did not wear a beard restraint while preparing resident food. 3. Expired and moldy food items were stored in the resident refrigerator. These failures had the potential for contamination of food resulting in food borne illness for the 55 residents who received food from the kitchen and used the resident refrigerator. Findings: During an observation on 3/10/25, at 9:47 a.m. the kitchen refrigerator was observed with one covered container of unlabeled and undated onions, one covered container of unlabeled and undated peas, and one pack of undated turkey burgers. During an observation on 3/10/25, at 10:49 a.m. the resident refrigerator was observed with one opened bottle of milk with an expiration date of 3/9/25, one pack of garlic with an expiration date of 3/5/25 and one container of blueberries and strawberries dated 2/28/25 that had mold. During an observation on 3/11/25, at 12:05 p.m., in the kitchen, CK 1 was observed wearing a surgical mask that did not cover CK 1's entire beard, while preparing resident salads for lunch. During an interview on 3/12/25, at 2:55 p.m., with Registered Dietician (RD), RD stated it was important to label and date food so they could have known when they were expired. RD stated staff should have discarded food in the kitchen and resident refrigerators that were unlabeled, undated, expired and moldy to prevent cross contamination and food borne illness. RD stated CK 1 should have worn a beard restraint when CK 1 prepared resident food to prevent food borne illness. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 2001, the P&P indicated, Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2023, the P&P indicated, Subject: Food Brought in From Outside Sources . Food that does not have a manufacturer's printed dated must be thrown out 3 days from the time it was brought in. During a review of the facility's P&P titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated 2001, the P&P indicated, Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure a complete medical records when Resident 1's Treatment Administration Record (TAR) had missing signatures. This failure had the potential to result in uncoordinated care, and unnecessary, painful duplicate wound care. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility in October 2024 with diagnoses of malnutrition, cancer of the kidney, anemia (abnormally low level of red blood cells) and diabetes mellitus (condition of uncontrolled high blood sugar). During a review of Resident 1's progress notes dated 10/10/24, the progress notes indicated Resident 1 had a wound from pressure on the sacrum (large triangular bone at the base of the spine) diagnosed as a stage 4 pressure ulcer (also know as bed sore, most severe stage of a pressure sore, where the damage extends through all layers of skin and tissue, exposing underlying muscle, tendon, or bone, often with significant tissue loss and a high risk of infection). During a review of Resident 1's pressure ulcer care plan dated 10/11/24, the care plan indicated for treatments to be performed as ordered. During a review of Resident 1's Order Summary Report dated 10/13/24, the Order Summary Report indicated the treatment for Resident 1's sacrum pressure ulcer was: every day shift was to cleanse wound with normal saline, pat dry, apply santyl (ointment, treatment of choice to remove damaged tissue from chronic wounds) and cover with optifoam (type of foam dressing). During an interview on 11/22/24 at 10:20 a.m. with Resident 1, Resident 1 stated he had a wound on his buttock which needed to be cleaned and re-dressed every day. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 10/16/24, the MDS indicated Resident 1 had a score of 12 on the Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of eight to 12 is an indication of moderate impairment; a score of 13 to 15 is an indication of intact cognitive status). During a review of Resident 1's TAR for October 2024, the TAR indicated the dates, times, and initials of the nursing staff who completed wound care treatments. The TAR inidcated no entries os the data for the following dates: 10/11/24, 10/14/24, 10/15/24, 10/20/24, 10/21/24, and 10/28/24. During a telephone interview on 11/25/24 at 1:04 p.m. with Treatment Nurse (TN), TN stated TN had been on duty as the treatment nurse on the days Resident 1's TAR was missing initials in October. TN stated she had forgotten to enter the date, time and her initials after providing Resident 1's treatment. During a review of the facility's policy and procedure (P&P) titled, Wound Care, revised October 2010, the P&P indicated, after wound care was provided, The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 3. The position in which the resident was placed. 4. The name and title of the individual performing the wound care. 5. Any change in the resident's condition. 6. All assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound. 7. How the resident tolerated the procedure. 8. Any problems or complaints made by the resident related to the procedure. 9. If the resident refused the treatment and the reason (s) why. 10. The signature and title of the person recording the data. During a review of the facility's P&P titled, Charting and Documentation, undated, indicated information to be documented in the resident's medical record included treatments and services performed. The P&P also indicated the documentation of the treatments and services performed will include specific details including date and time the procedure was performed, the name and title of the individual who provided the care, and the signature and title of the individual documenting the treatment.

Based on interview and record review, the facility failed to follow the facility abuse policy and procedure to protect and prevent further potential abuse for one of four sampled residents (Resident 1) when the facility allowed Certified Nursing Assistant (CNA) 1 to continue to provide direct patient care after Resident 1 made an abuse allegation. The failure to complete a thorough investigation of CNA 1 had pushed and slapped Resident 1 ' s arm during linen change resulted in psychosocial harm for Resident 1 and the potential for physical abuse for other residents. Findings: During a record review of Resident 1 ' s admission Record dated 8/5/24, the admission record indicated Resident 1 had diagnosis of femoral shaft fracture of left femur (broken thigh bone). During a record review of Resident 1 ' s Minimum Data Set (MDS-an assessment used to guide care) dated 7/22/24, the assessment indicated Resident 1 had a Brief Interview of Mental Status exam (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status) score of 12 out of 15 and indicated mildly impaired cognition. During a review of Resident 1 ' s care plan dated 7/16/24, the care plan indicated Resident 1 is at risk for ADL [Activities of Daily Living, Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.] / mobility decline and requires .will have needs anticipated and met by staff .2 person assist with ADLs .encourage to participate in ADLs to promote independence .monitor for changes in condition or declines in ability to participate in ADLs, decreased strength, increased weakness, or changes in cognition . During a phone interview on 9/10/24, at 11:51 a.m., with Resident 1, Resident 1 stated on 8/3/24 at 3 a.m. during a change of soiled bed linen, CNA 1 pushed Resident 1 ' s arm with force and then slapped Resident 1 ' s arm, when Resident 1 told CNA 1 the linen was still wet and dirty underneath her. Resident 1 stated she yelled out in pain and reported to Licensed Vocational Nurse (LVN) that CNA 1 had slapped her. Resident 1 stated she also called 911 and reported it to the police. Resident 1 stated having CNA 1 to continue to work at the facility on that day, made her fearful of retaliation and scared. Resident 1 stated I was ready to call 911 again. During a phone interview on 9/13/24 at 11:15 a.m., with CNA 1, CNA 1 stated on 8/3/24, she was removed from caring for Resident 1 by LVN 1. CNA 1 stated she continued to work the remainder of her shift providing care to the other 20 patients. CNA 1 denied the accusation. During a phone interview on 9/13/24, at 11:26 a.m., with LVN 1, LVN 1 stated LVN 1 was the charge nurse on duty on 8/3/24. LVN 1 stated CNA 1 was providing ADL care to Resident 1 and changing the dirty linen, when Resident 1 reported CNA 1 had slapped her arm. LVN stated after the Resident 1 called the police at 3:20 a.m., LVN 1 informed the DON of the incident. LVN 1 stated the DON instructed LVN 1 to remove CNA 1 from providing care for Resident 1 but CNA 1 could continue to work providing care to the other 20 patients for the remainder of the shift. During an interview on 9/10/24, at 12:35 p.m., with the Director of Nursing (DON), the DON stated LVN 1 told the DON of Resident 1 ' s complaint of being alleged hit on 8/3/24 at 3:30 a.m., by LVN 1. The DON stated she told LVN 1 to remove the CNA 1 from Resident 1 ' s care but let CNA 1 continue to work her full shift providing care to other residents. The DON stated the abuse investigation was completed on 8/6/24. During a review of Resident 1's undated investigation summary report, the report indicated Resident 1's allegation of abuse incident was completed and signed on 8/6/24 by the DON. The report indicated it was faxed to the Department on 8/7/24. During a concurrent interview and review of the facility provided document titled Detail Time and Job undated, with the DON, the DON stated CNA 1 clocked in, and started her shift on 8/2/24 at 11:00 p.m., and clocked out for lunch break on 8/3/24 at 03:00 a.m. The DON stated CNA 1 then clocked back in on 8/3/24 at 3:31 a.m. and clocked out at the end of the shift on 8/3/24 at 8:04 a.m. The DON stated CNA 1 stayed 30 minutes overtime to write a narrative of the incident. During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating revised September 2022, the P&P indicated Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on observation, interview and record review the facility failed to ensure one of five sampled residents received treatment to maintain vision. This failure resulted in Resident 32 not being referred to an ophthalmologist for cataracts. Findings Resident 32's facesheet, dated 2/22/24, indicated he was admitted to the facility in January of 2022. Resident 32's Multi Data Set (MDS - an assessment tool used to plan care), dated 1/25/24, indicated his Brief Interview for Mental Status (an assessment tool measuring cognitive function) score was 12, which indicated he was moderately cognitively impaired. During an interview on 2/21/24 at 10:20 a.m. with Resident 32, Resident 32 stated, he had cataracts, which were supposed to have been operated on and removed. Resident 32 stated, he did not know why it was taking so long for the cataracts to be removed. During an interview on 2/22/24 at 8:25 a.m. with Resident 32, Resident 32 stated, his cataracts affected his vision. Resident 32 stated, his vision was getting worse, that he liked to watch TV and he was having a harder time seeing the picture on the TV. Resident 32 stated, he needed to have his cataracts taken out as soon as possible. During an interview on 2/22/24 at 8:34 a.m. with Social Service Designee (SSD), SSD stated, SSD scheduled optometrists' examinations of facility residents. SSD stated, Resident 32 was evaluated by the optometrist on 7/12/23. SSD stated, the optometrist gave her the Optometrist Visit Notes (OVN) for Resident 32, which indicated Resident 32 had cataracts and needed to be referred to an outside ophthalmologist. SSD stated, Resident 32 had not yet been seen by an ophthalmologist and did not yet have an appointment with an ophthalmologist. SSD stated, she faxed a referral to the ophthalmologist's office on 2/21/24 at 10:55 a.m. During an interview on 2/22/24 at 9:33 a.m. with Director of Nursing (DON), DON stated, SSD was responsible for referring Resident 32 to the ophthalmologist for his cataracts. During a review of Resident 32's OVN, dated 7/12/23, the OVN indicated, Resident 32 had cataracts in both eyes and was to be referred to an outside ophthalmologist. During a review of a facility fax cover sheet (FCS), dated 2/21/24, the FCS indicated, a referral had been faxed to ophthalmology requesting a consult for Resident 32 regarding his cataracts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one out of two medication carts (medication cart #2), the medications stored in the medication cart had all their necessary labeling identifying medication stocks on hand. Resident 21's had one medication bottle without any identifying label and another bottle had no pharmacy label and torn out manufacturer's label. This failure had a potential to affect Resident 21's health and safety when unlabeled medications were in stored in the medication cart with current medications on hand for administration. Findings: During a concurrent observation and interview on 02/22/24 at 1:52 P.M., with Registered Nurse (RN) 1, with the medication cart #2. In medication cart#2's the top drawer were two bottles that had no pharmacy labels. The bottle had a black marker with Resident 21's name and Dapsone (antibiotics and anti-inflammatory medication used to treat skin disease). The second bottle of medication had manufacturer's label that had torn area indicating the medication is Bictegravir/emtricitabine/tenofovir alafenamide - (Biktarvy- fixed-dose combination antiretroviral medication), the bottle had no resident name. During a concurrent observation and interview on 02/22/24 at 02:10 P.M., with Director of Nurses (DON), while checking Resident 21's medications, DON stated, when the resident brought their medication supplies from an outside pharmacy, the licensed nurse would verify with the resident's physician. DON stated the admitting nurse would list the medication on the log and send it for verification. After the medication was verified with the physician, they can put the medication on rotation to be administered according to the physicians order's. DON stated, the Dapsone should have not been in the medication cart. During a concurrent interview and record review on 02/22/24 at 02:37 P.M., with DON, DON reviewed Outside Pharmacy Record the log indicated there was no Dapsone on the list when Resident 21 was admitted and Biktarvy had an unknown amount listed. During a concurrent interview and record review on 2/23/24 7:31 A.M., with RN 2, RN 2 reviewed the Outside Pharmacy Record, and stated it was her initials listed when Resident 21 was admitted on [DATE], but RN 2 stated does not remember accepting the Dapsone. RN 2 stated, the amount listed on the log was three tablets of Biktarby, and not three bottles. RN 2 stated, they count the tablets when accepting the medications brought in by the resident. During a review of the facility's policy and procedure titled Medication Labeling and Storage with revision date of February 2023, indicated Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceuticals practices. 2. The medication label includes, at minimum: a. medication name (generic and/or brand); b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions . 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food safely when the low-temperature dishwasher did not have sanitizer running through it. This failure increased the residents' risk for foodborne illness. Findings During a concurrent observation and interview on 2/20/24 at 9:48 a.m. with Dietary Aide (DA) 1 and Dietary Supervisor (DS), in the kitchen, DA 1 used a test strip to check the sanitizer level in the dishwasher. The test strip did not change color. DA 1 stated, the test strip showed no sanitizer was present. During a concurrent observation and interview on 2/20/24 at 9:55 a.m. with Registered Dietician (RD), in the kitchen, RD used a test strip to check the sanitizer level in the dishwasher. The test strip did not change color. RD stated, the test strip showed no sanitizer was present. RD stated, the dishes that were previously washed would be rewashed and sanitized by hand. RD stated, that the dishwasher was a low temperature dishwasher and needed sanitizer to sanitize the dishes. RD stated, using dishes washed in a low temperature dishwasher, without sanitizer, increased the risk of the spread of food bourne illness. During a concurrent observation and interview on 2/20/24 at 10:30 a.m. with RD, in the the kitchen, RD tested the sanitizer in the dishwasher with a test strip. The test strip changed color and registered 100 ppm. RD stated, the test strip registered 100 ppm of sanitizer, which was the correct amount. RD stated, she had discovered the level of sanitizer in the bucket below the dishwasher, had gotten lower than the tube that drew the sanitizer into the dishwasher and therefore, no sanitizer was going into the dishwasher. RD stated, she pushed the tube down into the sanitizer to fix the problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had consistent weekly assessments and documentation of the pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence), and development of care plan for the pressure ulcer on the right (R) heel. This failure had the potential to result in delayed healing, and ineffective plan of care and treatment of Resident 1's pressure ulcer. Findings: During a review of Resident 1's face sheet, the face sheet indicated Resident 1 was admitted on [DATE], with diagnoses that included diabetes, chronic kidney disease, and hypertension; Resident 1 was discharged on 11/16/22. During a review of Resident1's Braden Scale Assessment (for predicting pressure sore risk), dated 10/4/22, the Braden Scale indicated, a score of 17 indicating at risk for skin breakdown. During a concurrent record review of Resident 1's medical records, and interview on 2/7/23, at 12:45 p.m., with LVN 1,LVN 1 stated she was the wound care nurse after the previous wound care nurse left in November 2022. LVN 1 stated Resident 1 had a R heel stage 4 wound and was admitted with the wound. Review of the admission assessment record for Resident 1, dated 10/4/22 indicated, Resident 1 had deep tissue injury. LVN 1 stated Resident 1 was admitted on [DATE] and discharged on 11/16/22. LVN 1 stated the wound assessments were supposed to be done weekly. When asked, LVN 1 was unable to find weekly wound assessments and documentation that indicated prior status of the resident's R heel ulcer until 10/24/22 (which had no description of the wound). When asked for the care plan, LVN 1 stated she had no access to the resident's care plan. During a concurrent record review and interview on 2/7/23, at 2:30 pm, with Director of Nursing (DON), DON confirmed the wound care assessments for Resident 1 were not done weekly. During a review of the of the Nursing skin & wound evaluation for Resident 1 dated, 10/24/22, the skin and wound evaluation indicated no documentation regarding the type of wound and location. Review of the skin & wound evaluation dated 11/1/22 did not indicate the location of the pressure ulcer, and the skin and wound evaluations dated 11/7/22, and 11/16/ 22 indicated R heel pressure ulcer stage 4, present on admission. During a review of the SNF Wound Care evaluation by the Nurse practitioner (NP) for Resident 1, dated 10/25/22, the NP wound care evaluation indicated wound 1: R lateral malleolus (the bony prominence on the lateral side of the ankle joint) unstageable pressure-induced ulcer, size 5.0 X 4.5 cm, UTD (unable to determine); [NAME]-wound: Scar. Overall Wound condition: Stable During a review of SNF Wound Care evaluation for Resident 1 by the Nurse practitioner (NP), dated 11/1/22, the NP wound care evaluation indicated she was asked by the nursing staff to evaluate and treat the patient's multiple wounds .Wound 1: R lateral malleolus unstageable pressure-induced tissue damage; Overall Wound Condition: Resolved; Plan: Continue to monitor for any reopening of the wound; Wound 2: Right heel, unstageable pressure induced tissue damage, size: 6.0 X 6.0 cm, UTD, debridement (the removal of damaged tissue or foreign objects from a wound) done. During a concurrent record review and interview on 2/7/23, at 2:40 p.m. with DON, DON states the wound care nurse oversees the care plan for Resident. DON acknowledged there was no care plan for Resident 1. During a review of Resident 1's order summary Report dated 10/4/22, with start date10/5/22, the order summary report indicated R heel deep tissue injury as needed for R heel: Cleanse with NS (Normal saline), pat dry, paint with betadine, and cover with dry dressing; R heel deep tissue injury every day shift: Cleanse with NS (Normal saline), pat dry, paint with betadine, and cover with dry dressing; During a review of Resident 1's order summary Report dated 10/26/22, with start date10/27/22, the order summary report indicated R heel stage 4 pressure ulcer as needed for soiled or missing dressing: Cleanse with NS, pat dry with betadine, and cover with dry dressing; R heel stage 4 pressure ulcer every day shift for R heel: Cleanse with NS, pat dry, paint with betadine, and cover with dry dressing. During a review of the order summary by phone , dated 10/26/22 at 12:40, the phone order summary indicated, R heel stage 4 pressure ulcer every day shift for R heel, Cleanse with NS, pat dry, apply medihoney, and cover with dry dressing AND as needed for soiled or missing dressing; Discontinue R heel Deep Tissue Injury as needed for soiled or missing dressing, Cleanse with NS, pat dry, paint with betadine, and cover with dry dressing AND every day shift for R heel. During a review of the facility's policy and procedure (P & P) titled, Pressure Injury Risk assessment dated [DATE], the P & P indicated, .Once the assessment is conducted and risk factors are identified and characterized, resident-centered care plan can be created to address the modifiable risks for pressure injuries. Repeat the risk assessment weekly for the first four weeks . Conduct a comprehensive skin assessment with every risk assessment . During a review of the facility's policy and procedure (P & P) titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated April 2018, the P & P indicated, Assessment and Recognition: 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers . 2. In addition, the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width, and depth .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care instructions were kept confidential for one of one sampled resident (Resident 8). Resident 8's care instructions were posted uncovered above her bed. This failure resulted in Resident 8's care instructions open for others not engaged in her care to read including visitors of other residents. Findings: During a review of Resident 8's admission Record, dated 6/6/22, the record indicated, Resident 8 was admitted to the facility on [DATE]. During a record review of Resident 8's Minimum Data Set (MDS- An assessment tool used to guide care) dated 5/28/22, the MDS assessment indicated, Resident 8's Brief Interview for Mental Status (BIMS) score was 10 out of 15 indicating Resident 8 had cognition impairment. During an observation on 6/6/22, at 10:37 a.m., a sign stating PT [Resident 8] able to have puree textures with meal. Does not choke or aspirate. -Speech + Language posted above Resident 8's bed. The sign was visible to Resident 346, Resident 38, and staff/ visitors going in of Resident 8's room. During an observation and interview on 6/6/22, at 11:05 a.m., with Licensed Vocation Nurse (LVN 5), assigned to the care of Resident 8 for the previous three days, LVN 5 stated, therapy placed the care instruction sign and left uncovered above Resident 8's bed. LVN 5 stated, he had seen the sign there for the last 3 days during his shifts and did not see an issue if it was left uncovered. During an interview on 6/7/22, at 12:55 p.m. with Speech Therapist (ST1), the ST 1 stated, she posted the care instructions above Resident 8's bed in 02/2022. ST 1 stated, she did not cover the care instructions as she was not aware of that requirement. During an interview on 6/6/22, at 11:07 a.m., the Director of Nursing (DON), DON stated, the care instructions sign was an alert to those involved in Resident 8's care and should not be left uncovered. During a record review of the facilities policy and procedure titled, Confidentiality of Information and Personal Privacy dated 10/2017 indicated our facility will protect and safeguard resident confidentiality and personal privacy . Access to resident personal and medical records will be limited to authorized staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two (Resident 14 and 346) of two sampled residents receiving oxygen effective oxygen therapy when Resident 14 and Resident 346 received oxygen without a doctor's order. These deficient practices may result in ineffective oxygen therapy. Findings: 1. A review of Resident 14's admission Record, dated 6/7/22, indicated Resident 14 was admitted to the facility on [DATE] with a diagnosis of right arm fracture (a break, usually in a bone). During a concurrent observation, record review and interview on 6/7/22 at 12:34 p.m., Resident 14 was in bed, receiving oxygen by a nasal cannula at 2 liters per minute (LPM- flow rate). Licensed Vocational Nurse (LVN) 2 confirmed Resident 14 was receiving oxygen at 2 LPM. LVN 2 stated, Resident 14 had been receiving oxygen for a few days. During a concurrent record review and interview on 6/7/22 at 12:40 p.m. of Resident 14's doctor's orders for the month of June 2022, with LVN 2, Resident 14's doctor's orders did not indicate order for oxygen. LVN 2 stated, there should be a doctor's orders to receive oxygen. 2. During a review of Resident 346's admission Record dated 6/6/22, the record indicated, Resident 346 was admitted to the facility on [DATE]. During an observation on 6/6/22, at 10:45 a.m., with Licensed Vocational Nurse (LVN 1), Resident 346 received O2 at 2 liters/minute (L/min.) via nasal canula. During an interview and record review on 6/6/22, at 11:00 a.m., with LVN 1, Resident 346's Medication Review report dated 6/6/22 was reviewed. LVN 1 stated, she was unable to find the physician orders for to administer O2 to Resident 346. During an interview on 6/8/22, at 1:57 p.m., with Assistant Director of Nursing (ADON), ADON stated, O2 was considered a medication and nurses at the facility were required to receive a physician order to administer O2 to Resident 346. ADON stated, administering O2 without a physician order was not under scope of nursing practice. ADON stated, a physician order for O2 must include the following: Route of administration; mode of administration such as via nasal canula/ facemask; how many L/min.; if it's continuous or intermittent; monitoring of O2 saturation; and to monitor the skin integrity related to use of nasal canula/ facemask. A review of the facility document titled, Oxygen Administration, revised October 2010, indicated Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure accuracy of medical record for one of one sampled resident (Resident 346), when a physician order to administer Oxygen (O2) was created on 6/6/22 for a two month older date, 4/4/22 without any verification. This failure resulted in inaccurate reflection of physician orders to administer O2 to Resident 346. (Cross Reference F695) Findings: During a review of Resident 346's admission Record dated 6/6/22, the record indicated Resident 346 was admitted to the facility on [DATE]. During an observation on 6/6/22, at 10:45 a.m., with Licensed Vocational Nurse (LVN 1), Resident 346 received O2 at 2 liters/minute (L/min) via nasal canula. During an interview and record review on 6/6/22, at 11:00 a.m., with LVN 1, Resident 346's Medication Review report dated 6/6/22, printed at 10:54 a.m was reviewed. LVN 1 stated, she was unable to find the physician orders to administer oxygen to Resident 346. LVN 1 stated, since she was new to facility's Electronic Health Record (EHR) system, she would request Medical Records Personnel to help her find the physician orders to administer O2 to Resident 346. During an interview and record review on 6/6/22, at 12:30 p.m., LVN 1 brought Resident 346's Order Summary Report dated 6/6/22 printed at 12:27 p.m. LVN 1 stated, the Order Summary Report showed Resident 346 had a physician order to receive Oxygen- @2 Liters/Min Via Nasal Cannula (Routine/ Continuous/ PRN) Dx SOB Goal To Maintain O2 Sats Greater Than 90%. every shift for shortness of breath since 4/4/22 [two months older date]. LVN 1 stated, facility's Medical Records Personnel was somehow able to print the order that she was not able to find earlier. During an interview and record review on 6/7/22, at 9:42 a.m., with LVN 1, Physician order for O2 dated 4/4/22, in Resident 346's EHR was reviewed. Audit details showed physician order for O2 dated 4/4/22 was Created on- 6/6/22 at 12:18 p.m. and Created by- [LVN 1]. During another interview on 6/9/22, at 10:12 a.m., LVN 1 stated, she spoke to Resident 346's physician over the phone on 6/6/22 to obtain the order to administer O2, after she was inquired about the order. LVN 1 stated, she made up 4/4/22 as the start date and did not even review Resident 346's medical record to verify if Resident 346 was actually receiving O2 since 4/4/22. During an interview with Resident 346's charge nurse LVN 6 on 6/9/22, 11:26 a.m., LVN 6 stated, Resident 346 received O2 for shortness of breath on as needed basis but she was not sure for how long she's been receiving O2 treatment. During an interview on 6/8/22, at 10:21 a.m., with the Director of Nursing (DON), DON stated, she was aware that LVN 1 backdated Resident 346's physician order to receive O2 for a two months prior date. During an interview on 6/9/22, at 9:35 a.m., the Administrator (ADM) stated he was not aware that licensed staff created physician order to provide O2 to Resident 346 on 6/6/22 for 4/4/22 start date. The ADM stated if licensed staff received the order to administer O2 in 4/2022, they were expected to put in the order in EHR in 4/2022. The ADM stated residents could miss the treatment if they did not have the order documented in the EHR. During a record review of facility's Policy and Procedure (P&P) titled Charting Errors and/or Omissions dated 12/2006, the P&P showed, Accurate medical records shall be maintained by this facility.

Based on interview and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF- ABN) to two of three sampled residents (Resident 20 and Resident 43) after they were discharged from Medicare Part A services and continued to live in the facility. This failure resulted in Resident 20 and Resident 43 not being knowledgeable about their potential liability for payment and related standard claim appeal rights. Findings: During a concurrent review and interview on 6/8/22, at 12:10 p.m., with Medical Records personnel (MR 1), Resident 20's undated SNF Beneficiary Protection Review was reviewed. MR 1 stated, Resident 20's Medicare Part A stay began on 4/20/22 and the last covered day of Part A service was 5/18/22. During a concurrent review and interview on 6/8/22, at 12:10 p.m., with Medical Records personnel (MR 1), Resident 43's undated SNF Beneficiary Protection Review was reviewed. MR 1 stated, Resident 43's Medicare Part A stay began on 2/18/22 and the last covered day of Part A services was 5/18/22. During a concurrent interview and record review on 6/8/22, at 11:44 a.m., with Social Services Director (SSD 1), Medicare Denials May 2022 binder was reviewed. SSD 1 was unable to locate SNF- ABN notices for Resident 20 and resident 43 in the binder. SSD1 stated, she was responsible for providing the beneficiary protection notices to the residents but didn't know if Resident 20 and Resident 43 needed to receive the ABN. SSD1 stated, she did not know when the ABN was given or why it should be given. SSD 1 also stated, she did not even know what an ABN was. During an interview on 6/8/22, at 1:04 p.m., Assistant Director of Nursing (ADON), ADON stated, she was helping out the Social Services Department in ensuring residents were receiving appropriate beneficiary protection notices however the SNF- ABN was new to her. ADON stated, she had not issued ABNs at this facility. During an interview on 6/9/22, at 10:06 a.m. with Administrator (ADM) stated, he was not aware about Resident 20 and 43 not receiving the SNF-ABNs and to his knowledge facility was issuing SNF-ABNs. ADM stated, facility followed the federal regulation regarding beneficiary protection notices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide needed assistance with nail care for two of two sampled residents Resident 43 and Resident 245, when Resident 43's and 245's fingernails had a dark brown black substance under their fingernail tips. This failure resulted in Residents 43 and 245 appearing poorly groomed, with the potential to spread infection. Findings: During a review of Resident 245's Minimum Data Set (MDS, an assessment tool used to direct care) (MDS), dated [DATE], the MDS indicated Resident 245 was mildly cognitively impaired and needed limited assistance for personal hygiene with one person physically assisting. and physical help in part of bathing activity. During a concurrent observation and interview, on 6/6/22, at 10:25 a.m., with Resident 245, in room [ROOM NUMBER]A, Resident 245 observed to have a black brown substance under the fingernail tips of all his right hand fingernails and under the fingernail tips of his left hand index, middle, and ring finger fingernails. Resident 245 stated, he had poop under his nails, because he had been going to bathroom too much, as a result of medication he had been given. During an interview on 6/6/22, at 10:34 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 245's fingernails were dirty, that she would clean them right away, and it was her job to clean them. During an interview on 6/6/22 at 11:50 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, Resident 245's fingernails were dirty and should have been cleaned. LVN 3 stated, LVN 3 and CNA 2 were both responsible to clean Resident 245's fingernails. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 was totally dependent on staff for bathing and needed supervision for performing personal hygiene. During a review of Resident 43's facesheet, dated June 8, 2022, the facesheet indicated, Resident 43 had hemiplegia (paralysis on one side of the body) of the left side. During a concurrent observation and interview, on 6/6/22, at 11:45 a.m., with Resident 43, in room [ROOM NUMBER] B, Resident 43 observed to have a black brown substance under the fingernail tips of his index, middle, ring finger, and pinky right hand fingernails. Resident 43 stated, he had not had a shower and would like one. During an interview on 6/6/22, at 11:55 a.m., with CNA 2, CNA 2 stated, Resident 43's fingernails were dirty, that she would clean them right away, and that it was her job to clean them. During an interview on 6/6/22 at 11:58 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, Resident 43's fingernails were dirty, and should have been cleaned. LVN 3 stated, LVN 3 and CNA 2 were both responsible to clean Resident 43's fingernails. During an interview on 6/8/22, at 9:54 a.m. with the Director of Nursing (DON), DON stated, CNAs were responsible to help residents who were dependent to do their activities of daily living (ADL), including keeping the resident's nails clean. DON stated, Resident 43's and 245's nails should have been cleaned to prevent infection and for residents' dignity. During a review of the facility's policy and procedure, titled, Fingernails/Toenails, Care of, dated Revised February 2018) , indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infection . Nail care includes daily cleaning .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medication error rate of less than 5% when five errors were observed in 35 opportunities which resulted in a 14.29% medication error rate. The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or prescribed time which may result in residents not receiving the full therapeutic effect of the medications. The errors were as follows: 1. Amlodipine [medication for management of high blood pressure] was not administered according to physician's order for Resident 30. 2. Allopurinol [medication for management of gout] was not administered according to physician's order for Resident 30. 3. Cranberry tablet [supplement to maintain a healthy urinary tract] was not administered according to physician's order for Resident 26. 4. Calcium + D3 [supplement to prevent or treat conditions caused by low calcium levels such as bone loss (osteoporosis), weak bones] for Resident 9 was unavailable and not given according to prescribed time. 5. Brimonidine 0.2% eye drop [Glaucoma medication] for Resident 2 was unavailable and not given according to prescribed time Findings: 1. During a review of admission Record, admission record indicated, Resident 30 was admitted to the facility on [DATE] with diagnoses that included hypertension, Gout [a form of arthritis characterized by severe pain, redness, and tenderness in joints], and end stage kidney disease. During a med pass observation on 6/7/22, at 8:31 AM, with Licensed Vocational Nurse 2 (LVN 2), LVN2 prepared and administered eight medications for Resident 30 including one Amlodipine tablet and one Allopurinol tablet. During a concurrent interview and record review on 6/7/22, at 2:30 PM, with LVN 2, a review of Resident 30's medical record indicated a physician order dated 5/21/22, for Amlodipine Besylate Tablet 5mg Give 2 tabs by mouth one time a day for hypertension. Hold SBP < 110, HR< 60 LVN 2 confirmed that she gave Resident 30 one tablet of Amlodipine instead of 2 tablets. LVN 2 confirmed that she gave Resident 30 one tablet of Allopurinol instead of two tablets. 2. Review of admission record indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included Diabetes, hypertension, and Acute kidney failure. During a med pass observation on 6/7/22, at 9:15 AM, with LVN 2, LVN 2 prepared and administered five medications including one cranberry tablet for Resident 26. During a concurrent interview and record review on 6/7/22, at 3PM, with LVN 2, the physician order for Resident 26 dated 10/11/21 indicated Cranberry tablet 450 mg Give 2 tablet by mouth two times a day for supplement. LVN 2 confirmed she gave Resident 26 one Cranberry tablet instead of 2 tablets 3. During a review of admission record of Resident 9, Resident 9 was admitted on [DATE] with diagnoses that included Alcohol Abuse withdrawal, unsteadiness on feet, protein-calorie malnutrition [state of inadequate intake of food (as a source of protein, calories, and other essential nutrients) occurring in the absence of significant inflammation, injury .] During a med pass observation, on 6/7/22, at 8:24 AM, with LVN 2, LVN2 prepared medications for Resident 9 for the 9 AM administration time. LVN 2 unable to find Calcium+D3 600-20 mg-mcg tab. LVN 2 stated, this is the only Resident that is taking Calcium + D3 as other Residents are taking Calcium 500 mg/200 mg. LVN 2 stated, it was supposed to be supplied by pharmacy. LVN stated, she would contact pharmacy. During a concurrent interview and record review of physician's order on 6/7/22, at 2:35 PM, with LVN 2, the physician order indicated Calcium + D 3 Tablet 600-20 mg-Mcg (Calcium Cholecalciferol) Give 1 tablet by mouth one time a day for Supplement. LVN 2 stated calcium + D 3 medication was not yet available and she would contact pharmacy again. 4. During a review of admission record of Resident 2, admission record indicated, Resident 2 on 12/18/20 with diagnoses that included Glaucoma [a group of eye conditions that damage the optic nerve, the health of which is vital for good vision], Gout, and Dementia. During a med pass observation on 6/7/22, at 3:30 PM, with LVN 2, LVN 2 prepared medications for Resident 2 for the 9 AM administration time. LVN was not able to find Brimonidine eye drops. LVN looked in the refrigerator and brought out an eye drop, opened and dated it. LVN 2 doubled checked and found out this was different eye drop (Latanoprost sol 0.005%) due at bedtime. Brimonidine eye drop was not available. LVN 2 stated, she would call pharmacy to send it. During a review of the facility's policy and procedure (P & P) titled, Administering Medications dated April 2019, the P & P indicated, Medications are administered in a safe and timely manner, and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame 5. Medication administration are administered within (1) hour of their prescribed time .21. If a drug is withheld, refused, or given at a time other than the scheduled, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose .

Based on observation, interview, and document review, the facility failed to ensure the competency of a Diet Aide who prepared physician prescribed thickened liquids. This failure had the potential for 4 residents who received thickened liquids to consume a decreased amount of fluid out of 55 residents who received food and liquids from the kitchen. Findings: During an observation and concurrent interviews with Diet Aide 1 (DA 1) and the Certified Dietary Manager 1 (CDM 1) on 6/7/22 at 12:25 p.m., showed DA 1 pumped a liquid from a plastic container into cups filled with juice. DA 1 stated he was making nectar thick juice and he pumped 3 pumps of thickener from the plastic container into each cup of juice. He placed cups of thickened juice onto resident lunch trays. On the lunch trays was a tray ticket that indicated the thickness of liquids prescribed for the resident. The tray tickets, on the trays DA 1 placed the thickened juice, indicated Nectar thick fluids. CDM 1 was asked by the surveyor if the thickened juice placed on the trays was nectar thick. She stated no, it was honey thick which was thicker than nectar thick. She placed a spoon in the juice and stated she could tell the juice was honey thick by doing the spoon test. She showed that the thickened liquid stuck to the spoon and ran off slowly. She stated the cup sizes were changed recently to 8-ounce cups which required two pumps of thickener to make nectar thick liquids. When CDM 1 said to DA 1 he should only add 2 pumps of thickener to the 8-ounce cup, he stated no, it should be 3 pumps. During a review of the manufacturer's instructions on the container of thickener dated with a use-by-date of 2/24/23, showed to make a liquid Nectar ( . Mildly Thick to add 2 strokes of thickener per 8 fluid ounces.

Based on observation, interview, and facility document review, the facility failed to serve palatable pureed food to 4 residents who received food from the kitchen out of 55 residents who received food from the kitchen. This failure had the potential for 4 residents who received a pureed diet to decrease their intake of food out of 55 residents who received food from the kitchen Findings: Review of the recipe titled Spinach au Gratin dated Week 1 Tuesday and provided as the recipe for the spinach served on 6/7/22 showed to prepare the regular texture spinach then for the Pureed diet to puree the regular spinach. Review of the document from the Diet Manual titled Puree dated 2018, showed pureed food was intended for individuals with no teeth and have difficulty with swallowing. Review of the undated recipe titled Pureed Vegetables, showed some vegetables may not require additional added liquid added to puree the vegetables. Also, if liquid is required to puree the vegetables, the amount needed may vary from vegetable to vegetable. The directions showed to complete the regular recipe then portion out the number of portions needed for the puree diets and puree on low speed to a paste consistency before added any liquid. Then if needed to add a liquid such as low sodium broth or milk. The recipe did not give water as an example of a fluid to add. The directions showed to add any liquid gradually started with small amounts and adding more if needed to achieve the desired consistency. Then to add a food thickener if needed. The directions showed the puree should reach a consistency of applesauce. An observation and concurrent interview with [NAME] 1 on 6/7/22 at 11:30 a.m., [NAME] 1 pureed food for resident lunches. She added cooked spinach which was very moist then added ½ cup of water before she looked at consistency of the spinach. She pureed the spinach with the water then added 3 teaspoons of food thickener. She stated she made all the purees the same way by adding water then food thickener. In an observation and concurrent interview with Registered Dietitian 1 (RD 1) and the Certified Dietary Manager 1 (CDM 1) on 7/7/22 at 1:24 p.m., pureed and regular textured food served for lunch was tasted on a test tray. The spinach appeared shiny, had a gummy texture, and had a very bland flavor where almost no flavor was detected. In comparison of the pureed spinach to the regular spinach, the regular spinach had more flavor and tasted like spinach. The CDM 1 stated the pureed was a little too thick. RD1 and the CDM 1 stated, the regular spinach had a little more flavor than the pureed spinach. RD 1 stated the pureed spinach needed more salt. In an interview with the CDM 1 and RD 1 on 6/8/22 at 9:56 a.m., the CDM stated the cook should follow the recipe when making the pureed food. RD 1 stated, adding water to puree food can make it bland.

Based on observation, interview and facility document review, the facility failed to ensure the competency of Registered Dietitian 1 (RD 1) and Certified Dietary Manager 1 (CDM 1) when CDM 1 and RD 1 did not provide guidance to a cook to follow recipes which resulted in unpalatable pureed food. This failure had the potential for four residents who received pureed diet to decrease their intake of food out of 55 residents who received food from the kitchen Findings: During an observation and concurrent interview with [NAME] 1 on 6/7/22 at 11:30 a.m., [NAME] 1 pureed food for resident lunches. [NAME] 1 added water to puree spinach which was already very moist, before assessing the consistency of the puree. Because the pureed spinach was too thin, [NAME] 1 then added thickener to thicken the puree. She stated she made all the purees the same way by adding water then food thickener. [NAME] 1 did not follow the recipe for pureeing vegetables (Cross-reference F804). A review of the undated recipe titled Pureed Vegetables, showed some vegetables may not require additional added liquid added to puree the vegetables. Also, if liquid is required to puree the vegetables, the amount needed may vary from vegetable to vegetable. The directions showed to complete the regular recipe then portion out the number of portions needed for the puree diets and puree on low speed to a paste consistency before added any liquid. Then if needed to add a liquid such as low sodium broth or milk. The recipe did not give water as an example of a fluid to add. The directions showed to add any liquid gradually started with small amounts and adding more if needed to achieve the desired consistency. Then to add a food thickener if needed. The directions showed the puree should reach a consistency of applesauce. During a review of the undated Job description, provided for the CDM's position, titled Dietary Manager, showed CDM 1 was responsible for supervising staff in the day-to-day operation of the kitchen. She was also to direct and participate in food preparation of food that was appetizing and was the quality to meet each resident's needs in accordance with the physician's orders. In addition, she was responsible for orienting and training staff. During a review of the job description, provided for the RD, titled Department of Food and Nutrition Services Consultant (Consultant Dietitian) job description dated 2018, showed RD 1 was responsible for evaluating and monitoring the food service department to assure that the department was providing adequate, acceptable quality food. She was also responsible for evaluating and participating in implementing in-service programs for the Department of Food and Nutrition Services. During a review of the contract Agreement to Provide Consultant Services signed by the Administrator on 8/25/21, showed RD's sole responsibility was guidance and council to the Nutrition Services Department. In addition, the RD was responsible for offering in-service education to staff as indicated by the in-service schedule or as requested. In the presence of the Certified Dietary Manager 1 (CDM 1) and Registered Dietitian 1 (RD 1) on 7/7/22 at 1:24 p.m., a test tray was done to sample the pureed spinach. The puree spinach was very bland compared to the regular textured spinach and it had a gummy texture. CDM 1 stated the puree spinach was too thick and that the regular textured spinach had more flavor. RD 1 stated the pureed spinach needed salt (Cross-reference F804). During an interview with CDM 1 and RD 1 on 6/8/22 at 9:56 a.m., CDM 1 stated, it was okay to add water when pureeing food because it was stated on the recipe. She confirmed the recipe stated to add liquids such as milk or low sodium broth and water was not on the recipe. She stated the liquids shown on the recipe were only guidelines. She also stated there were no specific directions on the recipe to show when to add liquid if needed. After reviewing the recipe, she stated it was okay to add water before assessing if the puree needed liquid added to it because adding water did not affect the nutrient content. RD 1 stated she did not see a problem with added water when pureeing food and she stated adding water could make the pureed food blander. Then she stated the cook should follow the recipe when making pureed food. Documentation was not provided to show [NAME] 1 was trained regarding following recipes and pureeing food. Documentation was also not provided to show [NAME] 1 had a competency evaluation for job duties she performed.

The facility did not handle and prepare food that prevents food born illness and cross contamination. Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food safely when: 1. The internal parts of the ice machine were not clean; 2. Walls, baseboards, ceiling areas, floor areas, cabinets, shelving, tiles under stove, and piping in the kitchen area and food storage areas were dirty and in disrepair; 3. A mechanical room was used to store food, single food service items, clean uniforms and the room was not clean and had pests; 4. Chopping boards were in poor condition and stained; 5. Resident personal items were stored with clean dishes and cooking utensils; 6. Proper hand hygiene and cleaning of soiled equipment was not practiced; 7. The food preparation sink and the 3-compartment sink did not have air-gaps (a gap of air/or separation between the floor or flood level and the drainpipe from the equipment to prevent dirty water from backing up into the equipment). These failures had the potential to cause food borne illness to highly susceptible population of 57 residents who received food from the kitchen. Findings: 1. During a concurrent observation of the inside of the ice machine and interview on 6/8/22, at 11:47 a.m., with Maintenance Supervisor 1 (MS1), observed black residue on the white plastic surface above the evaporator plate (where the water flows and ice is formed). The black residue was the length of the evaporator plate and when the water in the ice machine flowed, it flowed over the black residue. In addition, the evaporator plate cover inside surface was covered with a hard white residue. There was also a spot of pink and black residue on the inside surface of evaporator plate cover. The spot was wiped with a paper towel, and it easily wiped off. MS 1 confirmed the black residue above the evaporator plate and that and water was running over this area. A review of the facility's policy and procedure titled Sanitation dated 2012 showed All . equipment shall be kept clean . According to the 2017 Federal Food Code, food contact surfaces are to be smooth, and clean to sight and touch. In addition, the Food Code annex states ice makers, must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 2. During a concurrent observation and interview on 6/8/22, at 11:08 a.m. with Certified Dietary Manager 1 (CDM1), CDM 1 showed the kitchen area had black residues on the ceiling and above fan area. There was also black residue on the surface of the conduit tube under fan. In addition, the fan was in a framed area within the wall and the fan blades and the framed area around the fan had black residue. There was also a spiderweb on the ceiling close to the fan, above the door. CDM 1 stated, Maintenance cleans the ceilings, the area behind fan and the black residue looked like grease. As the observation of the kitchen continued, the surface of the shelving under preparation table, that held cooking equipment, had rough painted areas and peeled paint exposed wood. The shelving above the preparation table had a strip of wood on the underside which was loose and created a gap between wood and the shelf. A vertical pipe connected to preparation table and alongside of oven hood had chipped paint. CDM1 stated, exposed wood was absorbent and difficult to clean. CDM1 confirmed the peeling paint is potential for physical contamination. As the observation continued, tiles under stove were loose, cracked, and broken with brown residue build-up. CDM1 stated, the cracked tiles were difficult to maintain cleanliness, not safe for staff, and pests could get into cracked areas. The observation of the kitchen continued and baseboards in dry storage room had peeled paint and exposed wood. In addition, the baseboards behind the reach-in refrigerators and freezers which were visible had brown and black residue build-up. CDM1 stated, she was aware that there was exposed wood and stated it could not be cleaned. She also said both refrigerator and freezer could be pulled out and cleaned behind, however, the baseboards could not be cleaned because of absorbent material. During a review of the facility's policy and procedure titled Sanitation dated 2001, the policy indicated, the food service area was to be maintained in a clean and sanitary manner and all kitchen areas were to be kept clean and protected from insects. All counters and shelves were to be kept clean, maintained in good repair and were to be free from breaks, corrosions, open seams, cracks, and chipped areas that could affect use or proper cleaning. According to the 2017 Federal Food Code, floors, walls, wall coverings, and ceilings are to be constructed so they are smooth and easily cleanable. Nonfood-contact surfaces are to be free of unnecessary lodges, projections, and crevices and constructed to allow easy cleaning and to facilitate maintenance. Also, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, and other debris. 3. During an observation on 6/7/22, at 10:05 a.m., in a mechanical room (a room that houses mechanical equipment such as boilers and water heaters) adjacent to the kitchen and accessed from the outside, observed there were two hot water heaters, boxes of single use items such as single use food containers, and plastic wrap, cans of food stored on a rack, employee lockers attached to a wall, as well as 2 black jackets and 2 chef coats hanging under the lockers and over boxes of single-use kitchen items. Above on the ceiling were three spiderwebs, one with a live spider. CDM1 stated, the two black jackets were staff's personal jackets and the chef's uniforms were clean and laundered uniforms. During an observation and interview on 6/7/22, at 12:10 p.m., in the mechanical room, with Dietary Aide 2 (DA2), DA2 stated, she cleaned the floor and ceiling areas but could not get to the area behind the water heaters to clean. She confirmed the ceiling had spiderwebs in multiple areas, and one had a live spider and needed to be cleaned. During an interview on 6/8/22, at 9:50 a.m., with CDM1, CDM1 stated, the mechanical room should not have spiderwebs on the ceiling. During an observation and interview on 6/8/22, at 11:40 a.m., in the mechanical room, a fuzzy black debris hung from a ledge at the upper left corner of the ceiling. The area was wiped, and black debris and dried leaves wiped off easily. CDM1 stated, the black debris should not be there and she confirmed it was mixed with leaves. During a review of the facility's P&P titled, Sanitation and Infection Control, dated 2018, the P&P indicated, 1. Food storage areas will be clean, dry, and free of pests . 13. The storeroom will be checked routinely for any evidence of pests. During a review of the facility's P&P titled, Sanitation, dated 2001, the P&P indicated, The food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. During a review of the facility's P&P titled, Department Hours, Food and Nutrition Services, dated 2001, the P&P indicated, 9. Employees are to store their personal belongings in the designated locker area. According to the 2017 Federal Food Guide, lockers or other suitable facilities shall be provided for the orderly storage of employees' clothing and other possessions. Also, cleaned and sanitized equipment, utensils, laundered linens, and single-service and single use articles are to be stored in a clean and dry location where they are not exposed to splash, dust or other contamination, and are not to be stored in a locker room or mechanical room. In addition, food may not be stored in a locker room or in a mechanical room. According to the 2017 Federal Food Code, perimeter walls and roofs of a food establishment shall effectively protect the establishment from weather and the entry of insects. 4. During a concurrent observation and interview on 6/6/22, at 9:26 a.m., during the initial tour of the kitchen, observed there were green and white cutting boards that had black marks and smudges, faded green color, and deep cuts on the surface. Kitchen Staff 1 (KS1) stated, the boards needed replacement because it is dirty and cuts on the boards may cause cross contamination. During a review of the facility's P&P titled Sanitation dated 2001, the P&P indicated all utensils and equipment were to be kept clean, maintained in good repair, and were to be free from corrosions, open seams, and cracks that could affect use or proper cleaning. According to the 2017 Federal Food Code, food contact surfaces are to be smooth, free from inclusions, pits, and similar imperfections and are to be smooth and clean to sight and touch. Also, according to the Food Code Annex, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 5. During a concurrent observation and interview on 6/6/22, at 9:24 a.m., during the initial tour of the kitchen, observed a resident's ring and a pair of eyeglasses on a rack with clean dishes. Dietary Aide 1 (DA1) stated, the items came from a resident's soiled breakfast tray. DA1 stated, the rack with clean dishes was a clean area and not supposed to have other items in clean area as this could cause cross contamination. During a review of the facility's P&P titled, Sanitation, dated 2001, the P&P indicated the food service area was to be maintained in a clean and sanitary manner and that all kitchen areas were to be kept clean. In addition, all utensils, shelves and equipment were to be kept clean. According to the 2017 Federal Food Code, cleaned and sanitized equipment may not be stored under sources of contamination. In addition, the Food Code Annex states in order to have active managerial control over personal hygiene and cross-contamination, certain control measures have to be implemented in all phases of operation. One control measure mentioned is the prevention of cross-contamination of clean and sanitized food-contact surfaces with soiled utensils, etc. 6. During a concurrent observation in the kitchen and interview on 6/7/22, at 11:35 a.m., observed DA2 sliced cake and placed pieces of cake in plastic containers for lunch. DA2 picked up a label dater and dropped it on the ground. DA2 picked it up with gloved hands and dated the plastic containers holding the sliced cake. DA2 placed the label dater on the food preparation table and carried the dated containers of sliced cake to a reach-in refrigerator and placed the cake in the refrigerator. Then DA2 used a sanitizer to wipe down the preparation table and wiped around the label dater. DA2 did not change her gloves and perform hand hygiene after picking up the label dater off the floor. During an an interview with RD1, on 6/7/22, at 12:30 p.m., RD1 stated, label dater that was dropped on the floor, should be sanitized, and staff should have washed hands and changed gloves. According to the 2017 Federal Food Guide, Proper handwashing to help prevent the transfer of viruses, bacteria, or parasites from hands to food . Prevention of cross-contamination of ready-to-eat food or clean and sanitized food-contact surfaces with soiled cutting boards, utensils, aprons, etc., or raw animal foods. According to the 2017 Federal Food Code, food employees are to wash hands after handling soiled equipment or utensils, during food preparation, as often as necessary to remove contamination and to prevent cross contamination when changing tasks, before donning gloves to initiate a task that involves working with food, and after engaging in other activities that contaminate the hands. In addition, if used, single-use gloves are to be used for only one task such as working with ready-to-eat food, and discarded when damaged or soiled, or when interruptions occur in the operation. The Food Code also shows equipment food-contact surfaces and utensils shall be cleaned at any time during the operation when contamination may have occurred. 7. During an observation and concurrent interview on 6/8/22 at 11:40 a.m., in the kitchen, observed food preparation sink with a drain pipe that led directly into the wall. There was no visible air gap. In addition, the 3-compartment sink had a drain pipe that was plumbed directly into the floor with do air-gap. MS1 confirmed there were no air-gaps for the food preparation sink and the 3-compartment sink. According to the 2017 Federal Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

Based on observation, interview and record review, the facility failed to follow standard precautions to prevent the spread of infection when following was noted: 1. Resident 346's Oxygen (O2) tubing was on the floor for almost eight feet from the O2 concentrator to the toilet seat in the bathroom. Certified Nursing Assistant (CNA 1) used her feet to move the O2 tubing when O2 tubing got caught under the bathroom door. 2. Housekeeper (HK 2) folded clean linens closely touching body. These failures had the potential for cross contamination and potential spread of infections in the facility. Findings: 1. During an observation on 6/6/22, at 10:34 a.m., Resident 346's O2 connecting tube was observed on the floor next to her bed. Resident 346 was receiving O2 at 2 liters per minute. During an observation on 6/6/22, at 10:40 a.m., Resident 346 walked to the bathroom with the assistance of Certified Nurse's assistant (CNA 1). CNA 1 left oxygen the concentrator next to Resident 346's bed and the oxygen tubing was stretched across the room from the bed to the bathroom, dragged on the floor for about seven feet. CNA 1 assisted Resident 346 to sit on the toilet seat and closed the bathroom door. O2 tubing was caught under the bathroom door and CNA 1 used her foot to kick the tubing out of the way. During an interview on 6/6/22, at 10:44 a.m., with CNA 1, CNA 1 stated, Resident 346 required continuous O2 and staff did not disconnect O2 tubing if she is going short distance, such as to the bathroom, where the tubing could reach. During an interview on 6/6/22 at 10:46 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated, having Resident 346's oxygen tubing dragging across the floor from the bed to the bathroom placed Resident 346 at risk of infection from any type of germs on the floor. LVN 1 stated, Resident 346 could get sick from germs going into her respiratory tract but could not specify what types of infections. During a record review of the facilities policy and procedure titled, Policies and Practices- Infection Control, dated 10/2018,showed The objectives of our infection control policies and practices are to: prevent, detect, investigate, and control infections in the facility . 2. During a concurrent observation and interview on 6/9/22, at 9:17 a.m., in the linen folding area just outside the laundry room, Housekeeper (HK) 2 was observed holding clean linens and clothes against HK2's body while folding them. HK 2 stated, HK2 had held clean linens and clothes against HK 2's body while folding them. During an interview on 6/9/22, at 9:25 a.m., with Housekeeping Supervisor (HKSP), HKSP stated, clean clothes and linens were contaminated when they touched HK 2's body while being folded, which could lead to the spread of infection. HKSP stated, HKSP would do an inservice on folding clean clothes and linens. During an interview on 6/9/22, at 11:50 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, HK 2 should not have held the clean linens and clothes against HK 2's body when folding them, because touching the clean clothes and linens to HK 2's body contaminated them, which had the potential to spread infection. During a review of the facility's policy and procedure (P&P), titled, Departmental (Environmental Services) - Laundry and Linen, the P&P indicated, 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts.