**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to protect the residents' privacy and dignity by failing to ensure the indwelling urinary catheter (foley catheter - a soft hollow tube, which is passed into the bladder to drain urine, for persons who cannot empty their bladder in the usual way) drainage bag was always covered for one of three sampled residents (Resident 97). This deficient practice had the potential to affect Resident 97's sense of self-worth and self-esteem. Findings: A review of the admission Record indicated Resident 97 was admitted to the facility on [DATE] with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). A review of the Minimum Data Set (MDS - resident assessment tool) dated 10/9/2024, indicated Resident 97's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 97 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 97 had an indwelling catheter. A review of Resident 97's Order Summary Report dated 12/27/2024, indicated a physician ordered foley catheter monitoring every shift. During an observation of Resident 97 on 12/27/2024 at 6:34 p.m., Resident 97 was observed with a foley catheter drainage bag with no privacy cover. Resident 97 was observed with one other roommate. During an interview with Licensed Vocational Nurse (LVN 1) on 12/27/2024 at 6:25 p.m., LVN 1 observed Resident 97's foley catheter and stated, the foley catheter drainage bag did not have any privacy cover. LVN 1 stated, not having a privacy cover could be embarrassing for a resident and LVN 1 would add a privacy bag. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:27 p.m., DON stated foley catheter collection bags needed to be covered with privacy bags, as without privacy covers the resident's privacy would be violated. A review of the facility's policy and procedure (P&P) titled, Quality of Life - Dignity, dated 1/31/2024, the P&P indicated, Demeaning practices and standard of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example: helping the resident to keep urinary catheter bags covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that one out of three sampled residents (Resident 34) were free from physical restraint by failing to ensure the use of bilateral bed siderails consent was completed per individualized assessment. This deficient practice violated resident's right to be treated with respect and dignity with the use of restraints Cross Reference: F604 Findings: A review of Resident 34's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of Resident 34's Minimum Data Set (MDS - resident assessment tool) dated 9/28/2024, indicated Resident 34's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 34 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During the initial tour of the facility and observation of Resident 34 on 12/27/2024 at 7:42 PM., Resident 34 was observed in bed, lying on a bed with a bilateral siderails up. During an interview with Resident 34's Family Member 2 (FM 2) on 12/28/2024 at 8:29 AM., FM 2 stated, Resident 34 had a previous fall incident and staff notified FM 2 bed side rails were added to Resident 34's bed to prevent the resident from falling. During an observation of Resident 34 on 12/28/2024 at 10:27 AM, Resident 34 was observed in bed, lying on a bed with a bilateral siderails up. A review of Resident 34's Order Summary Report as of 12/29/2024, indicated there was no physician order for the use of bilateral bed siderails. A review of Resident 34's electronic and paper medical chart as of 12/29/2024 indicated, a Bed Side Rail for bed enabler and mobility was in the chart with no resident's name on the form and no date signed. During an interview with Certified Nursing Assistant 1 (CNA 1) on 12/28/2024 at 4:09 PM., CNA 1 stated, Resident 34 had bilateral bed side rails in the up position to prevent the resident from falling. CNA 1 stated Resident 34 was unable to hold on to the bed side rails or reposition herself. CNA 1 stated Resident 34 required assist to reposition. During an interview with CNA 4 on 12/29/2024 at 10:57 AM, CNA 4 stated Resident 34 had a history of falls and facility staff used the bed siderails to prevent the resident from rolling and falling off the bed. CNA 1 stated Resident 34 required assistance from staff for repositioning and did not have an upper extremity strength or hand use to hold on to the bed rails for repositioning. During an interview with Licensed Vocational Nurse (LVN 3) on 12/29/2024 at 10:53 AM, LVN 3 stated side rails were used for mobility and repositioning. LVN 3 stated, Resident 34 was unable to hold on to the bed rails and or self-reposition using the bed siderails. During a concurrent interview and record review with Medical Record Director on 12/29/2024 at 12:38 PM, MRD stated there was no consent form for the bed side rails in Resident 10's current chart but there was a consent form in Resident 10's old chart. MRD stated, the consent form was not complete as it did not have a resident's name and no date indicating when the consent was signed. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:52 PM, DON stated the bed side rails were used for mobility and for repositioning. DON stated the bed side rails were not used to prevent residents from falling and bed side rails were considered a restraint if there was no physician's order and no consent on file. A review of the facility's policy and procedure (P&P) titled, Proper Use of Side Rails, dated 1/31/2024, the P&P indicated, The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to allow one of eight sampled residents (Resident 39) to retain his personal possession(s). This failure resulted in or had the potential to result in Resident 39 being angry. Findings: A review of Resident 39's admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure), and polyneuropathy (when multiple nerves become damaged). During an observation on 12/27/24 at 05:46 p.m., Resident 39 was noted in his room sitting up in bed watching TV. Resident 39 stated he has been in the facility for 8 months. Resident 39 stated since he has been residing in the facility he was missing 2 packages. Resident 39 stated he cannot remember when he did not receive the first package. Resident 39 further stated the last time his package was missing was 2 days ago. Resident 39 stated his friend sent him a package of brownies to the facility. Resident 39 was able to show the photo of where the package was delivered. The photo showed that the package was delivered to the nurse's station in the front of the facility. Resident 39 stated he was very angry that he did not receive his package from his friend because it was a Christmas gift and when she sends him gifts it meant a lot to him. Resident 39 further stated he received his mail opened approximately 3 months ago. Resident 39 stated he does not receive his mail on the weekend. A review of Resident 39's History and Physical dated 11/25/24, indicated Resident 39 had the capacity to understand and make decisions. A review of Resident 39's Scheduled Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 11/25/24 indicated Resident 39 had intact cognition (mental ability to make decisions of daily living). The same MDS further indicated Resident 39 needed moderate assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. During an interview on 12/28/24 at 03:53 p.m., Social Service Director (SSD) stated when she receives the residents' mail, she sorts the mails as soon as possible and deliver it to the residents. The SSD stated sometimes the Activity Director delivers the mail if she was not working. The SSD further stated the residents do not get mail on the weekend because the License staff do not want to be responsible because there is mail for the business office. The residents must wait until Monday to receive their mail. The SSD further stated it was the practice of the facility to give the residents their mail on the weekend due to the license staff not wanting to be responsible for the facility mail. Social Service stated the facility staff do not have a right to or is allowed to open the residents mail without the residents knowing. The SSD further stated if the resident can show proof of the delivery of his package the facility will reimburse the resident for his personal property. The SSD stated if the residents are not receiving their mail unopened, on the weekend, and not receiving their packages it can cause the residents to be sad and angry. During an interview on 12/29/24 at 12:19 p.m., the Director of Nursing (DON) stated he was not aware that Resident 39 received his mail opened, did not receive his packages and the residents were not receiving their mail on the weekend. The DON stated if the residents do not receive their mail unopened, on the weekends, and receive their packages that their friends and families send to them, the residents can become frustrated and sad. During a review of the facility's policy and procedures titled Resident Rights revised dated 12/2016, the P&P indicated: Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect, misappropriation of property, and exploitation. cc. have access to a telephone, mail, and email.

Based on observation, interview, and record review, the facility failed to ensure that one out of three sampled residents (Resident 34) were free from physical restraint by failing to ensure the physician's order for bilateral bed siderails was in placed and ensure the proper use of use rails according to facility's policy and procedure titled Proper Use of Side Rails, dated 1/31/2024. This deficient practice had the potential to result in entrapment and injury with the use of restraints. Cross Reference F552 Findings: A review of Resident 34's admission Record indicated the facility originally admitted the resident on 1/4/2024 and readmitted the resident on 3/22/2024 with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of the Minimum Data Set (MDS - resident assessment tool) dated 9/28/2024, indicated Resident 34's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 34 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During the initial tour of the facility and observation of Resident 34 on 12/27/2024 at 7:42 p.m., Resident 34 was observed in bed, lying on a bed with a bilateral siderails up. During an observation of Resident 34 on 12/28/2024 at 10:27 a.m., Resident 34 was observed in bed, lying on a bed with a bilateral siderails up. A review of Resident 34's Order Summary Report as of 12/29/2024, indicated there was no physician order for the use of bilateral bed siderails. During an interview with Certified Nursing Assistant 1 (CNA 1) on 12/28/2024 at 4:09 p.m., CNA 1 stated, Resident 34 had bilateral bed side rails up to prevent the resident from falling. CNA 1 stated, Resident 34 was unable to hold on to the bed side rails and move herself to reposition. CNA 1 stated, Resident 34 required staff assist to reposition. During an interview with Certified Nursing Assistant 4 (CNA 4) on 12/29/2024 at 10:57 a.m., CNA 4 stated, Resident 34 had history of falls and the facility used the bed siderails to prevent the resident from rolling and falling from the bed. CNA 4 stated, Resident 34 required assistance from staff for repositioning and did not have any upper extremity strength to hold on to the rail to reposition. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 12/29/2024 at 10:53 a.m., LVN 3 stated, the side rails were used for mobility and repositioning. LVN 3 stated, Resident 34 was unable to use her hands to hold on to the rails and reposition herself using the bed siderails. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:52 p.m., DON stated, the bed side rails were used for mobility and for repositioning. DON stated the bed side rails were not used to prevent residents from falling and bed side rails were considered a restraint if there were no physician's order and no consent on file. A review of the facility's policy and procedure (P&P) titled, Proper Use of Side Rails, dated 1/31/2024, the P&P indicated, The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement their policy regarding reporting of an injury of unknown source in accordance with state or federal law for one of one sampled resident (Resident 34). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injury and accidents were investigated and had the potential to place residents at further risk for injuries. Findings: A review of Resident 34's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of the Minimum Data Set (MDS - resident assessment tool) dated 9/28/2024, indicated Resident 34's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 34 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 34's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 11/12/2024, indicated a change of condition with nursing notes that stated, Resident (34) was found by Certified Nursing Assistant with lower extremity hanging from the side of bed with right knee touching the floor and resident holding onto siderails. No visible injury noted to the right knee, but the resident (Resident 34) has an open ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by a trauma) on her outer right arm. During an interview with Licensed Vocational Nurse 3 (LVN 3) on 12/28/2024 at 3:39 PM, LVN 3 stated Resident 34 was non-verbal, not able to turn independently and required assistance from staff with turning and repositioning. LVN 3 stated, Resident 34 was found hanging off the bed with an open ecchymosis on outer right arm, the incident was not witnessed by any staff or other residents. LVN 3 stated, Resident 34 was not able to verbalize and explain how she (resident 34) ended up on the floor. During an interview with Certified Nursing Assistant 1 (CNA 1) on 12/28/2024 at 4:09 PM., CNA 1 stated Resident 34 was unable to move independently and required staff assistance for repositioning. CNA 1 stated Resident 34 was also non-verbal and required staff assistance for feeding. CNA 1 stated Resident 34 had history of falling but CNA 1 did not know how Resident 34 could end up on the floor on her own as the resident did not have enough strength to move herself out of bed. During an interview with Director of Nursing (DON) on12/29/2024 at 12:55 PM, DON stated Resident 34 was not able to verbalize how she ended up dangling and on the floor. DON stated the incident was not witnessed by any staff and other residents. DON stated Resident 34 was hanging on the bed when found with an ecchymosis on her arm. DON stated the incident was not reported to the State Agency. A review of the facility policy and procedure (P&P) titled, Investigating Injuries, dated 1/31/2024, the P&P indicated, Injury of unknown source is defined as an injury that meets both of the following conditions: a. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and b. The injury is suspicious because of: (I) the extent of the injury; or (2) the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). or (3) the number of injuries observed at one particular point in time: or (4) the incidence of injuries over time . The investigation will follow the protocols set forth in our facility's established abuse investigation guidelines. A review of the facility's P&& titled, Abuse and Prevention, dated 1/31/2024, the P&P indicated, Facility shall institute procedures of identifying unusual occurrences and events, such as suspicious bruising of residents, unexplained skin tears, fractures, etc. that may constitute abuse, Such procedural guidelines shall also provide for directions of necessary investigative efforts . Facility shall ensure thorough and extensive investigation of different types of incidents including by not limited to those that may constitute abuse. Facility shall ensure reporting of all alleged and/or substantiated violations to the state agency and all other agencies as required, and to take all necessary corrective actions based on the results of the investigation. Reporting: 1. Facility administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. 2. Facility shall report the incident by calling the DHS within 24 hours of the knowledge of such incident; followed by a letter explaining the circumstances surrounding the incident. This letter shall be maintained in a separate file and made available to the Department upon request. 3. The Administrator and Director of Nurses, in the order written, shall report incidents of suspected abuse to the following agencies within twenty-four (24) hours of occurrence: 3.1. Department of Public Health Licensing and Certification. 3.2. LTC Ombudsman or designee or. 3.3. Local enforcement agency or Police Department. 3.4. Managing Physician for treatment orders as required. 3.5. Family Members/Responsible Parties or Guardians 4. Facility Administrator shall report findings of investigation to the Department within five working days of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to apply handroll to the right hand for one of four sampled residents (Resident 43). This failure had the potential to delay service and placed Resident 43 at a higher risk for further decline. Findings: A review of Resident 43's admission Record indicated Resident 43 was re-admitted to the facility on [DATE] with diagnoses including weakness (lack of strength or ability) and chronic kidney disease (a condition where the kidneys are damaged and can't filter blood properly). A review of Resident 43's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 11/20/24, indicated the resident intact cognition (mental ability to make decisions of daily living). The MDS also indicated the resident needed moderate/maximum assistance with bed mobility, transfer, dressing, eating, toilet use and personal hygiene. A review of Resident 43's Order Summary Report dated 12/1/24, indicated RNA to apply bilateral handrolls 4-6 hours per day as tolerated. During an observation on 12/27/24 06:33 p.m., Resident noted lying in bed with her eyes closed. Resident 43 was noted with handroll to left hand and noted without handroll to the right hand. During an observation on 12/28/24, at 7:16 a.m., 9:14 a.m., 11:23 a.m., and 4:49 p.m., Resident 43 had a handroll applied to her left hand but not did not have a handroll applied to her right hand. During an interview Resident 43 stated the nurse do not apply a handroll to her right hand daily. Resident 43 stated she would like to have a handroll to her right hand so that won't get stuck like the left hand. During an observation on 12/29/24 at 07:15 a.m., 9:22 a.m., and at 11:13 a.m., There was no handroll applied to Resident 43's right hand. A review of Resident 43's Restorative Nurse Assistant (RNA) Weekly Progress Note dated 12/13/24, 12/20/24, 12/27/24, did not indicate Resident 43 refused to wear right handroll. During a concurrent observation and interview on 12/29/24 at 10:23 a.m., with Restorative Nurse Assistant (RNA) 1, and License Vocational Nurse (LVN)1, Resident 43's did not have a hand roll applied to her right hand. RNA 1 he usually applied Resident 43's bilateral handrolls daily but sometimes she refuses to wear the right handroll. RNA 1 stated he did not report the refusal to wear the right handroll to the charge Nurses, and further stated he did not document Resident 43's refusal to wear the right handroll. RNA 1 further stated if the resident does not wear the handroll daily as ordered by the physician Resident 43's right hand can become contracted. During an interview on 12/29/24 10:23 a.m., LVN 1 stated RNA 1 had never reported to her that Resident 43 refused to wear right handroll. LVN 1 stated if Resident 43 do not wear her right handroll her hand can become contracted and could cause the resident pain. A review of the facility's Job Description title Restorative Nursing Assistant (RNA), dated 7/2017 indicated: Key Responsibilities: 1.Restorative Care Implementation Carry out restorative nursing programs such as range of motion (ROM) exercises, ambulation assistance, and activities of daily living (ADL) training. Assist residents with adaptive equipment and devices, ensuring proper use and safety. Monitor residents progress and report changes to the restorative nurse or nursing supervisor. 2.Documentation and reporting Accurately document restorative care activities in resident's medical records. Report changes in residents' functional abilities or behaviors to the appropriate staff.

Based on observation, interviews, and record reviews, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three sampled residents (Resident 97) by failing to ensure resident's indwelling urinary (foley) catheter (a hollow tube inserted into the bladder to drain or collect urine) was placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for Resident 97. Findings: A review of Resident 97's admission Record indicated the facility admitted the resident on 10/3/2024 with diagnoses including acute kidney failure (a condition in which the kidneys suddenly can't filter waste from the blood) and benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream). A review of the Minimum Data Set (MDS - resident assessment tool) dated 10/9/2024, indicated Resident 97's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 97 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 97 had an indwelling catheter. A review of Resident 97's Order Summary Report dated 12/27/2024, indicated a physician ordered foley catheter monitoring every shift. During a concurrent interview and observation of Resident 97 on 12/27/2024 at 6:34 p.m., Resident 97 was observed lying in bed. Resident 1 was observed with a foley catheter hanging on a moveable bed side rail placed above the level of the resident's bladder. Resident 97's foley catheter tubing was observed twisted and the urine was not flowing into the foley catheter drainage bag. Resident 97 stated, they need to place his foley catheter drainage bag in a better location as it was clumsy, and the resident was scared the foley catheter would get pulled out. During an interview with Licensed Vocational Nurse (LVN 1) on 12/27/2024 at 6:25 p.m., LVN 1 observed Resident 97's foley catheter and stated, the foley catheter bag was placed too high, and the urine was not draining in the drainage bag. LVN 1 stated, the drainage bag should have been placed below the level of the resident's bladder for gravity. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:27 p.m., DON stated the foley catheter drainage bag needed to be below the bladder to prevent infection. A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 1/31/2024, the P&P indicated, 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 observations, interviews, and record reviews, the facility failed to provide necessary respiratory care services for one of two sampled residents (Resident 10) by failing to ensure a physician's order was in place for oxygen (O2) therapy and failing to ensure the resident's humidifier (a device used to make supplemental oxygen moist) was changed per facility's policy. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: A review of Resident 10's admission record indicated the facility originally admitted the resident on 8/30/2017 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart) and chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure). A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/9/2024, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 3 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 10's Order Summary Report as of 12/29/2024, the Order summary indicated, there were no physician's orders for supplemental oxygen therapy. During a concurrent interview and observation with Resident 10 on 12/27/2024 at 6:22 p.m., Resident 10 stated, she was on oxygen therapy all the time. Resident 10 was observed with an oxygen concentrator machine at 2 liters per minute (lpm - unit of measurement) connected to a nasal cannula tubing and humidifier at bedside. Observed Resident 10's humidifier bottle was observed empty with no liquid and no bubbling was observed. During a concurrent observation and interview with Licensed Vocational Nurse (LVN 1) on 12/27/2024 at 6:25 p.m., LVN 2 observed Resident 10's humidifier bottle and confirmed by stating, Resident 10's humidifier bottle was almost empty and needed to be changed. LVN 1 further stated, there was no bubbling observed in the humidifier bottle and there was no MD's order for the resident's oxygen therapy. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:26 p.m., DON stated, the humidifier was to be replaced once a week and as needed. DON stated, if the humidifier bottle was empty, it would not provide the humidification the residents needed. A review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated 1/31/2024, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration . Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.

Based on observation, interview and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when the Registered Dietitian (RD) did not conduct a comprehensive (complete) care plan for one of two sampled residents (Resident 34) who had a significant weight loss. This failure had a potential to result in inaccurate nutrition assessment, ineffective nutrition intervention and goals for residents. Findings: A review of Resident 34's admission record indicated the facility originally admitted the resident on 1/4/2024 and readmitted the resident on 3/22/2024 with diagnoses including chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure), pressure ulcer of sacral region (the triangular bone at the base of the spine that connects the spine to the pelvis) and pressure ulcer of left hip (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). A review of the Minimum Data Set (MDS - resident assessment tool) dated 9/28/2024, indicated Resident 34's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 34 required moderate assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 34's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) dated 12/11/2024 indicated, a change of condition of a weight loss of 7 pounds (lbs. - unit of measurement) in 30 days. A review of Resident 29's weight records indicated the following weight trends: i. 8/10/2024 ii. 9/6/2024 90 lbs. iii. 11/2/2024 92 lbs. iv. 12/4/2024 85 lbs. (7.6 percent [% - unit of measurement] down in 1 month) indicative of severe weight loss. v. 12/14/2024 88 lbs. A review of Resident 34's Weight Variance Interdisciplinary (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Meetings indicated the following: i. dated 6/7/2024 indicated, Resident 34 had 17 % weight loss in 90 days. ii. dated 6/14/2024 (weight variance update) indicated, Resident 34 had 4 lbs. weight loss in one week. iii. dated 12/12/2024 indicated, Resident 34 had 7 lbs. weight loss in one month. The Weight Variance IDT Meeting did include a signature by the RD. During an interview with RD on 12/28/2024 at 2:59 p.m., RD stated, Resident 34 had significant weight loss while in the facility and most recently had a weight loss of 7 lbs. on 12/4/2024. RD stated she provided recommendations to increase boost supplement and for the physician to consider appetite stimulant, but the RD did not develop a care plan for the resident. RD stated, the CPs were developed by the nursing staff and Dietary Supervisor (DS) according to the RD's notes. RD stated, the DS could also call a physician to recommend interventions such as adding an appetite stimulant. RD stated, she did not develop a CP and only documented in the Progress Notes as it was a standard practice, along with other dietitians in the area. When asked if the RD could provide an evidence-based journal for the standard practice the RD was referring to that DS could develop a CP based on RD recommendations and call physicians for recommendations, RD stated, I don't think I can find one. RD further stated developing a CP was a time restraint for the RD and it was time consuming to develop and document in a residents' care plan. During an interview with DS on 12/28/2024 at 4:28 p.m., DS stated, she (DS) developed CPs regarding residents' diet and food preferences. DS stated, she (DS) documented residents' weight and height and if the DS noticed any significant weight loss, the DS reported the weight loss to the RD. DS confirmed by stating she (DS) did not develop a CP based on RD's notes and did not call Resident 34's physician for any recommendations such as food stimulant. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:44 p.m., DON stated, nursing could develop CPs according to RD's notes. DON stated, DS could also develop CP but according to resident's food preferences only. DON stated, DS did not have the credential to do the roles and responsibilities of an RD. DON stated, RD's response was incorrect. A review of the facility's job description titled Dietitian signed by RD on 6/27/2022, indicated Aptitude: Verbal and writing abilities necessary to communicate and work effectively with various levels of staff, residents, family members and the public, and for require written documentation or reports Specific Responsibilities: Review and assess all initial and annual Nutritional Risk Reviews and care plans initiated by Dietary Manager of Diet Technician/Clinical Manager. Review and assess all nutritional high-risk charting do charting per direction of Administrator and state regulations. A review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled NCP Step 3: Nutrition Intervention indicated Nutrition intervention goals, ideally, developed collaboratively with the client, provide the basis for monitoring progress and measuring outcomes. Planning the nutrition intervention involves: Collaborating with the client to identify goals of the intervention for each diagnosis. Implementation is the action phase and involves: Collaborating with the client to carry out the plan of care. A review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled NCP Step 4: Nutrition Monitoring and Evaluation undated, indicated During the first interaction, appropriate outcomes/indicators are selected to be monitored and evaluated at the next interaction with the client. During subsequent interactions, these outcomes /indicators are used to demonstrate the amount of progress made and weather the goals or expected outcomes are being met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide comfortable and safe temperatures in the facility for one of four residents (Resident 44). These failures had the potential to cause harm. Findings: A review of Resident 44's admission Record indicated Resident 44 was re-admitted to the facility on [DATE], with diagnoses including renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and essential hypertension (high blood pressure). A review of the Minimum Data Set (MDS, federally mandated assessment tool), dated 12/12/24, indicated Resident 44 had the capacity to understand and make decisions. Resident 44's cognition (thought process) was intact. During a concurrent observation and interview on 12/27/24 at 06:12 p.m., Resident 44 stated he layered his clothing because it was very cold in his room especially early in the morning. Resident 44 further stated it was so cold he doesn't want to get up to eat his breakfast. Resident 44 stated it made him very uncomfortable and hard to sleep at times. During an observation of the thermostat in room [ROOM NUMBER] on 12/28/24 at 07:09 a.m., the Temperature was observed to be 70. During an interview and a concurrent record review on 12/28/24 at 07:09 a.m., the Maintenance Supervisor (MS) stated he checked and recorded resident room temperatures daily and recorded them in the binder. A review of the residents' room temperature log with the MS was incomplete. The temperature log was only completed up to December 4, 2024. The last day the resident's room was checked for temperatures was on 12/4/2024 at 10:00 am. During an observation and a concurrent interview on 12/28/24 at 09:09 a.m., of room temperatures with the MS, room [ROOM NUMBER]'s temperature was 70, room [ROOM NUMBER]'s temperature was 70, and room [ROOM NUMBER]'s temperature was 24. The MS stated if the temperature in the facility was not regulated causing the residents room to be too cold, the residents can get sick and be uncomfortable. The MS further stated he cannot remember the last time the air-conditioned and heater was repaired. During an interview on 12/29/24 at 01:42 p.m., the Director of Nursing (DON) stated the staff could change the setting on the thermometer. The DON stated if the facility is too cold the residents can get very sick, catch a cold, and it can make the residents uncomfortable. During a review of the facility's policy and procedures (P&P), titled, Quality of Life-Homelike Environment, 5/2017, the P&P indicated staff shall provide person-centered care that emphasizes the residents comfort, independence, personal needs, and preferences. It further indicates comfortable and safe temperatures (71 degrees-81 degrees).

Based on interview, the facility failed to ensure mail was delivered to 4 of 11 residents (Resident 11, Resident 30, Resident 33, and Resident 41) at the resident council meeting (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life), who verbally confirmed not receiving mail on Saturdays. This had the potential to affect all 45 residents in the facility who received personal mail, denying the residents the right to receive mail. Findings: On 12/28/2024 at 10:40 AM a group of residents met to discuss the resident council meeting with surveyors. When asked whether residents received their mail on Saturdays, several residents stated they did not receive mail on Saturdays. Resident 33 stated Social Services delivered mail from Monday through Friday only. During the same meeting, Resident 41 stated the residents did not receive mail on Saturdays. During an interview on 12/28/2024 at 3:53 PM, the Social Services Director (SSD) stated the social services delivered the mail to residents Monday through Friday. The SSD stated mail delivered by the post office on the weekends was held until for Monday for the SSD to sort and then deliver to the residents. During an interview on 12/29/2023 at 1:26 PM, the Director of Nursing (DON) stated mail was delivered by SSD during the weekdays only. A review of the facility's policy and procedure titled, Resident Rights, reviewed 1/31/2024, indicated the resident has the right to communication with and access to people and services, both inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A review of Resident 42's admission information indicated Resident 42 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic pain syndrome (persistent or recurring pain that lasts for more than three months), rheumatoid arthritis (a chronic disease that causes the body's immune system to attack the joints leading to pain, swelling and stiffness) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). A review of Resident 42's chronic low back pain Care Plan, created on 7/23/2024, indicated the resident will voice a level of comfort of 0/10 (no pain). The interventions included to medicate the resident for pain as ordered and to evaluate the effectiveness of pain interventions every shift. A review of Resident 42's Quadriplegia Care plan, developed 7/24/2024, indicated the goal was for the resident to remain free of discomfort. The care plan's interventions indicated staff were to administer pain management as needed. A review of Resident 42's Minimum Data Set (MDS- a resident assessment tool), dated 10/10/2024, indicated the resident was cognitively intact. Resident 42 required partial/moderate assistance with dressing, transfer, and personal hygiene. A review of Resident 42's Physician Orders, dated 10/4/2024, indicated the physician ordered the facility to administer to Resident 42 Buprenorphine HCI Sublingual Tablet 2 MG Give 2 tablet sublingually (SL - under the tongue) every 4 hours for pain management. A review of Resident 42's November 2024 Medication Administration Record (MAR) indicated the resident did not receive the ordered dose of Buprenorphine From 11/2/2024 at 12:00 PM until 11/4/2024 at 4 PM for a total of 10 doses. From 11/10/2024 at 12 PM until 11/14/2024 at 4 PM. For a total of 21 doses. And again from 11/27/2024 at 12 PM until 11/29/2024 at 8 PM for a total of 14 doses. A review of Resident 42's Orders - Administration Notes for November 2024, indicated Resident 42 did not receive the ordered dose of Buprenorphine due to waiting for the pharmacy to deliver was from 11/1/2024 at 1:25 PM to 11/42024 at 4:11 PM, from 11/9/2024 at 10:50 PM to 11/14/2024 at 4:04 PM, from 11/27/2024 at 12:31 PM to 11/29/2024 at 2:34 PM. A review of Resident 42's Physician Orders in December indicated: - On 12/3/2024, the physician ordered Resident 42 to receive Buprenorphine HCI-Naloxone HCI Sublingual Film 2-0.5 MG (Buprenorphine HCI-Naloxone HCI Dihydrate) Give 0.5 film sublingually every 4 hours for Pain. Max Daily Amount 3 films - On 12/16/2024 indicated the facility was to Buprenorphine HCI-Naloxone HCI Sublingual (SL- under the tongue) tablet Sublingual 2-0.5 MG (Buprenorphine HCI-Naloxone HCI Dihydrate) Give 1 film sublingually every 4 hours for Pain Management. Not to exceed 6 films in 24hours. A review of Resident 42's December 2024 MAR indicated Buprenorphine HCl-Naloxone HCl Sublingual Tablet Sublingual 2-0.5 MG was not administered to the resident for 3 doses on 12/3/2024, and 16 doses not administered to the resident from 12/14/2024 at 8 AM to 12/17/2024 at 4 PM. During an interview on 12/27/2024 at 6:11 PM, Resident 42 stated I have had generalized pain for about a year. Resident 42 stated at its worst the pain level was a 10/10 (severe pain - worst pain imaginable) and at best the pain is 7/10 (moderate to severe pain). Resident 42 further the facility had administered the pain medication Buprenorphine sporadically (randomly). Resident 42 stated most recently four days had gone by without the facility administering the ordered pain medication and previously two days went by without receiving the pain medication. Resident 42 stated his pain could reach 10/10 when the pain medication was not given. During an interview on 12/28/2024 at 9:51 AM, Licensed Vocational Nurse 2 (LVN 2) stated Resident 42 was taking pain medication for chronic back pain and disk degeneration. During a concurrent record review of Resident 42's November and December 2024 MARs, LVN 2 stated Resident 42 missed doses of the ordered pain medication due to the medication not being on hand and the pharmacy not delivering the medication. LVN 2 stated the pharmacy delivered medication once a day. LVN 2 stated not receiving ordered pain medication could affect the resident's quality of life, the ability to function, and the ability to do daily activities. During an interview on 12/29/2024 at 1:27 PM, the Director of Nursing stated the pharmacy had to deliver resident's medications as soon as possible and the nurse were required to follow up with the pharmacy if a resident's pain medication was unavailable. The DON further the resident could experience inadequate pain control if pain medications were not administered as ordered. During a review of the facility's policy and procedure (P&P) titled, Administering Pain Medications, reviewed 1/31/2024, indicated staff are to administer pain medications as ordered. If there are signs or symptoms of serious adverse consequences related to narcotic (opioid) analgesics (including somnolence, delirium, respiratory depression), notify the practitioner prior to administering and staff will Report other information in accordance with facility policy and professional standards of practice. Based on observation, interview, and record review the facility failed to effectively manage a resident's pain for two out of two sampled residents (Resident 12 and Resident 42): 1. For Resident 12, the facility failed to follow directions to remove a lidocaine patch (a prescription-only topical local anesthetic) after 12 hours of application per physician's order. 2. For Resident 42, the facility failed to administer Buprenorphine HCI (medication used to help relieve severe ongoing pain) Sublingual Tablet 2 MG Give 2 tablet sublingually (SL - under the tongue) every 4 hours for pain management per physician order. These deficient practices placed the residents at risk of inadequate pain relief and the possibility to experience health complications from their medication therapy. Findings: A. A review of Resident 12's admission record indicated the facility originally admitted the resident on 5/7/2022 and readmitted the resident on 9/24/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), chronic systolic congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and chronic pain (pain that lasts longer than three months). A review of the Minimum Data Set (MDS - resident assessment tool) dated 12/16/2024, indicated Resident 12's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 34 required supervision from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). A review of Resident 12's Order Summary Report, dated 10/10/2024, indicated physician ordered, Lidocaine External Patch 4 percent (% - unit of measurement)- apply to left shoulder topically one time a day for pain management *remove after 12 hours*, scheduled at 9:00 AM. A review of Resident 12's Care Plan (CP) for lidocaine patch for pain management, revised on 12/17/2024, the CP indicated a goal of medication will be effective for pain management until next review date with interventions including to administer medication as ordered: Lidoderm (lidocaine) patch 5%, apply to skin topically every 12 hours. remove patches after 12 hours. During a medication pass observation and interview with Licensed Vocational Nurse (LVN 3) on 12/29/2024 at 9:10 AM for Resident 12, LVN 2 applied one lidocaine patch on Resident 12's left shoulder and removed the old lidocaine patch from the resident's left shoulder. LVN 3 stated, there should have been a lidocaine patch on Resident 12's shoulder, and the patch should have been removed the night prior. LVN 2 stated, the lidocaine patch was to be removed after 12 hours of application (12/27/2024 at 9 PM) and according to the Medication Administration Record (MAR), one lidocaine patch was applied on 12/27/2024 at 9 AM. A review of Resident 12's MAR dated 12/27/2024, the MAR indicated, lidocaine patch was administered and applied to Resident 12's left shoulder on 12/27/2024 at 9:22 AM The MAR also indicated that the lidocaine patch was removed at 9:36 PM. During an interview with Director of Nursing (DON) on 12/29/2024 at 12:23 PM, DON stated, the lidocaine patch instruction was put in place for 12 hours and to remove after 12 hours. DON stated, Resident 12's lidocaine patch physician's order was not followed, and Resident 12 did not receive the appropriate physician's order for pain management.

Based on observation, interview, and record review the facility failed to follow the puree menu (foods that are smooth and pudding like consistency) and ensure nutritional needs were met when: 1. Staff served plain pureed scrambled eggs to residents on puree diet instead of pureed ham and potato casserole as indicated in the nutritional spreadsheet. 2. Scoop #16 (2 ounces ([oz] a unit of measurement) was used for puree scrambled eggs instead of #12 (3oz) scoop as indicated in the spreadsheet. This failure had the potential to result in decreased food and nutrient intake resulting in malnutrition and weight loss. Findings: 1. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated puree diets would include the following foods on the tray: Juice 4 oz Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 tsp Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 7:10 a.m. of the trayline (an area where foods were assembled on the trays), residents on puree diet received scrambled eggs. During an interview on 12/28/2024 at 10:10 a.m. with Dietary Supervisor (DS), DS stated ham and potato casserole puree was not given to residents on puree/ International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level 4 instead staff gave puree plain scrambled eggs. During an interview on 12/28/2024 at 11:55 a.m. with DS, DS stated the [NAME] should have pureed the ham and potato casserole and it should have been prepared. DS stated the staff did not tell her the reason why they did not prepare the puree casserole. DS stated puree food should be the same food as the regular diet because the amount of protein and nutrients should be the same for both diets. DS stated puree scrambled eggs and puree ham and potato casserole were not the same because the puree scrambled eggs did not have ham, potatoes, onions, and mustard. DS stated the residents on puree diet would not get enough protein and carbohydrates resulting to weight loss as a potential outcome. During an interview on 12/28/2024 at 12:04 p.m. with [NAME] 3, [NAME] 3 stated he did not make the puree ham and potato casserole because some residents did not eat ham and the renal diet (diet consistent of low sodium, low potassium, and low phosphorus foods) could not have ham, however some residents liked ham. [NAME] 3 stated he should have made the puree ham and potato casserole and separated some food for those residents who did not like ham. [NAME] 3 stated not following recipes would affect the taste causing residents not to eat. During a review of the facility's Policies and Procedures (P&P) titled Food Preparation, dated 1/31/2024, the P&P indicated Procedure: (1) The facility will use approved recipes, standardized to meet the resident's census. (2) Recipes are specific as to portion yield, methods of preparation, quantities of ingredients, and time and temperature guidelines. During a review of the facility's P&P titled Standardized Recipes, dated 1/31/2024, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods. During a review of the facility's recipe titled Recipe: Ham and Potato Casserole, dated 1/31/2024, the recipe indicated ingredients: frozen diced potatoes, shredded cheddar cheese, ham, fully cooked and chopped, large, pasteurized eggs, milk, and ground mustard. Puree: Puree following the pureed recipes om the Food Safety/Misc. section of Book#1. During a review of the facility's recipe titled Puree (IDDSI LEVEL 4) Casserole, dated 1/31/2024, the recipe indicated ingredients: casserole per recipe, warm fluid such as milk, gravy, or low sodium broth. Directions: Complete regular recipe. Measure out the total number of portions based on the portion size indicated on the cook's spreadsheet) needed for puree diet. 2. During a review of Resident 21's admission Record, the admission record indicated the facility originally admitted Resident 21 on 5/24/2019 and readmitted the resident on 4/20/2024 with diagnoses including, but not limited to, acute respiratory failure (a condition in which your blood does not have enough oxygen or has too much carbon dioxide), Type 2 diabetes mellitus (a disorder in which the body does not produce or respond normally to insulin causing blood sugar levels to be abnormally high), and hyperlipidemia (high amount of fat in the blood). During a review of Resident 21's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/24/2024, the MDS indicated Resident 21 was cognitively intact (process of thinking and reasoning) skills for daily decision making and required set-up and clean up assistance when eating. During a review of Resident 21's Order Summary Report, dated 4/20/2024, the order summary report indicated Resident 21 was ordered renal (diet consisting of low salt, low potassium and low phosphorus), no added salt ([NAS], no salt packet on the tray), consistent carbohydrate diet ([CCHO], diet with the same amount of carbohydrates per meal), regular (diet with no restriction) thin liquid consistency, double portion breakfast. During a concurrent interview and observation on 12/27/2024 at 5:35 p.m., at Resident 21's bedside, Resident 21 stated he had issues with portion sizes as the staff only gave him soup on Christmas eve and two (2) pieces of bread on Christmas day. Resident 21 stated he complained about it, but they have not done anything. During a concurrent observation and interview on 12/28/2024 at 7:17 a.m. of the trayline with DS, DS stated the staff used #16 scoops for puree scrambled egg instead of #12 scoop. DS stated the portion size the staff gave the residents for breakfast was small than what the spreadsheet indicated. DS stated the residents would not get the right calories and nutrients that the residents needed and could potentially lead to weight loss. During a review of the facility's P&P titled Portion Control, reviewed 1/31/2024, the P&P indicated To provide specific portion control information. Procedure: To be sure portions served equal portions sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilize by employees portioning the food. (1) Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed within the menus, recipe books and on menu spreadsheet. (2) Ladles are sized according to their capacity.

Based on observations, interviews, and record reviews, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet (foods that are smooth with pudding like consistency/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level four (4) received puree eggs that were dry and the puree bread and puree bran cereals were too sticky and did not fall from the spoon during a spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) This failure had a potential to result in coughing, choking (to keep from breathing the normal way) and death for 8 of 46 residents on puree/IDDSI level 4 diet. Findings: a.During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on puree diet/IDDSI] Level 4 would include the following foods in the tray: Juice 4 fluid ounces (oz, a unit of measurement) Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 teaspoon (tsp, household measurement) Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 6:59 a.m. of puree food in trayline (an area where foods were assembled), the puree bread looked sticky. During a concurrent observation and interview on 12/28/2024 at 1:35 p.m. of the puree/level 4 diet test tray (a process of tasting, temping, and evaluating the quality of food) with Dietary Supervisor (DS), DS stated the puree level 4 was for residents with swallowing problems and the food in the puree diet had to be smooth like mashed potato. DS stated the puree scrambled egg was too dry. DS performed spoon tilt test and the puree bread and puree raisin bran did not fall off from the spoon when the spoon was tilted. DS stated the puree bread, and the raisin bran was too sticky, and residents would not be able to eat or swallow the puree bread, resulting to residents not getting enough calories leading to weight loss. DS stated residents would also be at risk for aspiration and choking as a potential outcome. During a review of the facility's Policies and Procedures (P&P) titled Menu Planning, dated 1/31/2024, the P&P indicated (1) The menu service provides the seasonal menus with corresponding recipes. (4) The menus are planned to meet nutritional needs of the residents in accordance with established national guidelines, physician's diet orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of National Research council National Academy of Sciences. (8) Menus are planned to consider: (F) Texture and color of all foods in meals. Procedures: 1. The facility's diet manual and the diets ordered by the physician should mirror the nutritional care provided by the facility. 2. Menus are written for regular and therapeutic diet in compliance with the diet manual. Refer to the vendor's diet manual as needed. 3. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. During a review of the facility's Diet Manual titled Regular Pureed Diet/IDDSI level 4, dated 1/31/2024, the diet manual indicated Description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing/or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep. Detailed recipes and procedures for pureeing foods may be found in Book #1, under the Food Safety/Miscellaneous Section. All foods are prepared in a food processor or blender, except for foods, which are normally in a soft and smooth state such as pudding, ice cream, applesauce, mashed potatoes, etc. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Casserole dated 1/31/2024, the recipe indicated (5) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 1/31/2024, the recipe indicated (4) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Cold Cereal, dated 1/31/2024, the recipe indicated, (4) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished product must pass IDDSI level 4 testing requirements. During a review of the IDDSI guideline website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to meet the requirement of 80 square feet per resident in a double occupancy patient room and 100 square feet (sq. ft) per resident in a single occupancy room. There were 23 out of 24 resident rooms in the facility that did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents. Findings: A review of the facility's room waiver letter and the client accommodations analysis form completed by the facility on 3/29/2024, indicated the following 23 rooms provided less than 80 feet per resident: Rooms # Beds Room Size(ft.) Sq. Ft/Bed 3 2 138.7 69.35 4 2 138.7 69.35 5 2 138.7 69.35 6 2 138.7 69.35 7 3 150.7 50.25 8 2 138.7 69.35 9 2 138.7 69.35 10 2 138.7 69.35 11 2 138.7 69.35 12 2 138.7 69.35 14 2 138.7 69.35 15 2 138.7 69.35 16 2 138.7 69.35 17 2 138.7 69.35 18 2 138.7 69.35 19 2 138.7 69.35 20 2 138.7 69.35 21 2 138.7 69.35 22 2 138.7 69.35 23 2 138.7 69.35 24 2 138.7 69.35 25 2 138.7 69.35 The minimum square footage for a 2-bed room should be 160 Sq. Ft. The client accommodations analysis form indicated room [ROOM NUMBER] accommodated 1 resident, and rooms #3, #4, #5, #6, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25 accommodated 2 residents each and room [ROOM NUMBER] accommodated 3 residents. On 12/28/2024 at 10:40 AM a group of residents met to discuss the resident council meeting (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care, and quality of life) with surveyors. When asked whether the size of rooms negatively impacted their quality of life, or the care received Resident 11, Resident 30, Resident 33 and Resident 41 who resided in rooms with room waivers denied having any issues with care received. Observations made to the requested rooms during the annual recertification survey at the facility from 12/27/2024 to 12/29/2024, indicated there were no noted concerns with privacy, nursing care and/or safety to the residents. The evaluators observed in rooms 2, 3, 4, 5, 6,7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 that nursing staff had enough space to provide care to the residents, the curtains provided privacy for each resident, and the rooms had direct access to the corridors. During an interview on 12/29/2024 at 10:01 AM., the Director of Nursing stated the facility had a request for the continuation of the waiver for twenty-three (23) rooms, which did not meet the room size requirement of 80 square feet per resident in a double occupancy room and one hundred (100) square feet per resident in a single occupancy room in March 2024. A review of the facility policy and procedure titled, Bedrooms, reviewed 1/31/2024, indicated bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms.

Based on observations, interviews, and record reviews, the facility failed to ensure kitchen were routinely trained and possessed the necessary competencies to ensure the nutritional needs of residents were met. By failing to ensure kitchen staff: a.Followed the recipe for puree (foods that are smooth with pudding like consistency) ham and potato casserole for puree diet. b.Followed spreadsheet portion sizes for puree eggs. Residents were given two (2) ounces ([oz] a unit of measurement) instead of three (3) oz. c.Were aware of and able to verbalize the potential outcome of a dirty refrigerator and freezer during food storage. This failure had a potential to result in inadequacy of food and nutrients leading to weight loss and food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) for 46 of 46 residents who received food from the kitchen and were on Puree and regular diets (diet with no restriction). Findings: 1. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on puree diet would include the following foods in the tray: Juice 4 oz Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 tsp Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 7:10 a.m. of the trayline (an area where foods were assembled on the trays), residents on puree diet received scrambled eggs. During an interview on 12/28/2024 at 10:10 a.m. with Dietary Supervisor (DS), DS stated ham and potato casserole puree was not given to residents on puree/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level 4 instead staff gave puree plain scrambled eggs. During an interview on 12/28/2024 at 11:55 a.m. with DS, DS stated the [NAME] should have pureed the ham and potato casserole and the puree casserole should have been prepared. DS stated the staff did not tell her the reason why they did not prepare the puree casserole. DS stated puree food should be the same food on the regular diet because the amount of protein and nutrients should be the same for both diets. DS stated puree scrambled eggs and puree ham and potato casserole were not the same because the puree scrambled eggs did not have ham, potatoes, onions, and mustard. DS stated the residents on puree diet would not get enough protein and carbohydrates resulting to weight loss as a potential outcome. During an interview on 12/28/2024 at 12:04 p.m. with [NAME] 3, [NAME] 3 stated he did not make the puree ham and potato casserole because some residents did not eat ham and residents on renal diets (diet consistent of low salt, low potassium, and low phosphorus food) could not have ham, however some residents liked ham. [NAME] 3 stated he should have made the puree ham and potato casserole and separated some food for those residents who did not like ham. [NAME] 3 stated not following recipes would affect the taste of the food causing residents not to eat. [NAME] 3 stated the menu was new to him. During an interview on 12/28/2024 at 12:21 p.m. with DS, DS stated she talked to staff about recipes, spreadsheets and following the recipes unless the residents were allergic to any ingredients. DS stated she was not sure why the cook did not prepare the puree ham and potato casserole and did not follow the recipe today. DS stated she provided in-service to staff on how to read the spreadsheets and how to prepare puree food. During a review of the facility's P&P titled Standardized Recipes, dated 1/31/2024, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods. During a review of the facility's Job Description (JD) titled Cook Job Description, dated and signed on 7/15/2024 by [NAME] 3, the JD indicated POLICY: The cook prepares and serves food including texture modified and therapeutic diets according to the facility menu. The cook assists in proper receiving, storage, preparation, serving, sanitation, and cleaning procedures are followed. The cook reports to the Director of Food and Nutrition Services. The JD indicated cook qualification included knowledge of basic concepts of nutrition and diet management for regular, texture modified and therapeutic diets. Responsibilities included: Prepares food, including modified textures and therapeutic diets. Prepares food by methods that conserve nutritive value, flavor, and palatability. During a review of the facility's competency test titled Competency Test for Cooks and FNS Staff, dated 7/15/2024, the competency test included questions for food safety and sanitation but did not include following menus, spreadsheets, and recipe. b. During a concurrent observation and interview on 12/28/2024 at 7:17 a.m. of the trayline with DS, DS stated the staff used #16 scoops (2 oz) for puree scrambled egg instead of #12 scoop (3 oz). DS stated the portion size the staff gave the residents for breakfast was small than what the spreadsheet indicated. DS stated the residents would not get the right calories and nutrients the residents needed and could potentially lead to weight loss. During a review of the facility's Policies and Procedures (P&P) titled Portion Control, reviewed 1/31/2024, the P&P indicated To provide specific portion control information. Procedure: To be sure portions served equal portions sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilize by employees portioning the food. (1) Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed within the menus, recipe books and on menu spreadsheet. (2) Ladles are sized according to their capacity. During a review of the facility's JD titled Cook Job Description, dated and signed on 7/15/2024 by [NAME] 3, the JD indicated Responsibilities: Prepares, portions, and/or serves food using proper measuring equipment and serving utensils, while maintaining quality control-standards. c. During an observation on 12/27/2024 at 5:29 p.m. of the reach-in freezer, the bottom shelves had dust and food residue. During an interview on 12/27/2024 at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2) translating for [NAME] 1), [NAME] 1 stated the dirt debris from the bottom shelves was from the plastic and food. [NAME] 1 stated the freezer was cleaned every weekend with the help of his supervisor. [NAME] 1 stated it was not okay to have had dirt in the freezer due to infection control but did not know the potential outcome to the residents if freezer where food was stored was dirty. During a review of the facility's P&P titled Procedure and Refrigerated Storage, dated 1/31/2024, the P&P indicated (3) Refrigerator equipment should be routinely cleaned. During a review of the facility's JD titled Cook Job Description dated and signed by [NAME] 1 on 9/9/1992, the JD indicated Qualifications: Ability to supervise Department of Food and Nutrition Services personnel and ensure sanitary conditions in the absence of the DS. Responsibilities: (6) Assures all food items are handles properly to meet safety and sanitation standards according to State and Federal regulations. Properly stores and refrigerates necessary items.

Based on observations, interviews, and record reviews, the facility failed to prepare food by methods that conserved flavor and appearance for breakfast when: a.Ham and potato breakfast casserole was scooped instead of cutting it with a portion size of 2 ½ x 2 inches ([in] unit of measurement) as indicated in the facility's spreadsheet and was served in a bowl instead of on the plate for regular texture consistency (texture with no restriction). The plates had no garnish. b.Puree diet (foods that are smooth and pudding like consistency) /International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 received puree scrambled eggs instead of puree ham and potato breakfast casserole and the puree scrambled eggs was too dry. c.Puree wheat toast and puree raisin brand were too sticky. This failure had a potential to result in 46 of 46 facility residents being at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on regular diet would include the following foods in the tray: Juice 4 fluid ounces (oz, a unit of measurement) Raisin bran ¾ cup (c, household measurement) Ham and potato breakfast casserole 1 Wheat toast 1 slice Margarine 1 teaspoon (tsp, household measurement). Parsley sprig garnish yes Milk 8 oz a. During an observation on 12/28/2024 at 7:10 a.m. staff was using a scoop to serve ham and potato casserole for regular diet in trayline (an area where foods were assembled) service for breakfast. During a concurrent observation and interview on 12/28/2024 at 7:17 a.m. of the ham and potato casserole on the steamtable with Dietary Supervisor (DS), DS stated the staff should measure the ham and potato casserole to 2 ½ x 2 in., however they were using a scoop to serve the breakfast casserole. DS stated the way staff presented the ham and potato casserole was not appetizing as it was served in a bowl instead of putting it on the plate. DS stated the residents would not eat it and it could lead to weight loss. DS stated the food was missing garnish for presentation. DS stated the staff was rushing and that was the reason the food was not properly served. During a concurrent observation and interview on 12/28/2024 at 7:51 a.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) with DS, DS stated the regular test tray appearance needed a nicer presentation and staff should have cut the casserole as the recipe indicated. DS stated staff should have served it with parsley to make it look appetizing. During a review of the facility's Policies and Procedures (P&P) titled Food Preparation dated 1/31/2024, the P&P indicated POLICY: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Procedures: 1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific to portion yield, methods of preparation, quantities of ingredients, and time and temperature guidelines. 3. Food prepared will be sampled. The Food and Nutrition Service employee who prepares the food will sample it to be sure the food has satisfactory flavor and consistency. Use clean spoon or put a small portion of the food in a dish and taste from the dish. During a review of the facility's recipe titled RECIPE: Ham and Potato Casserole dated 1/31/2024, the recipe indicated Portion size 2 ½ x 2 inches. Size Pan 10x2x2 in.=24 servings cut 4x6. 12x20x2 in. = 48 servings. Cut 6x8 and 5x8=8 servings, cut 2x4. b. During a review of the facility's daily spreadsheet titled Winter Menus, dated 12/28/2024, the spreadsheet indicated residents on puree diet would include the following foods in the tray: Juice 4 oz Puree raisin bran ½ cup (c, household measurement) Puree ham and potato breakfast casserole 1 Puree wheat toast 1 slice or 2 oz Margarine 1 tsp Parsley sprig garnish: no Milk 8 oz During an observation on 12/28/2024 at 7:10 a.m. of the trayline, residents on puree diet received scrambled eggs. During a concurrent observation and interview on 12/28/2024 at 7:54 a.m. of the test tray, DS stated resident on puree diet were given puree scrambled eggs instead of puree ham and potato casserole. DS stated the puree eggs were dried up and needed to be moist. During an interview on 12/28/2024 at 11:55 a.m. with DS, DS stated the staff should have pureed the ham and potato casserole and it should have been prepared. DS stated the staff did not tell her why they did not prepare the puree ham and potato casserole. DS stated puree food and diet should be the same as regular diet because the amount of protein and nutrients should be the same. DS stated the regular puree scrambled eggs and casserole was not the same because it did not have the ham, potatoes, onions, and mustard. DS stated the taste of the puree eggs could have been affected causing poor food intake leading to weight loss as a potential outcome. During a review of the facility's P&P titled Standardized Recipes reviewed 1/31/2024 the P&P indicated Standardized recipes shall be developed and used in preparation of foods. (1) Only tested, standardized recipes will be used to prepared foods. (2) Standardized recipes will be adjusted to the number of portions required for a meal. (3) The Food Service Manager will maintain the recipe file and make it available to Food Services staff as necessary. (4) Recipes are periodically reviewed for revisions and updating. During a review of the facility's recipe titled RECIPE: Ham and Potato Casserole dated 1/31/2024, the recipe indicated Ingredients: frozen diced potatoes, shredded cheddar cheese, ham fully cooked and chopped, large, pasteurized eggs milk mustard, ground. The P&P indicated Puree following the pureed recipes in the Food Safety/Misc. section of Book #1. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Casserole dated 1/31/2024, the recipe indicated, Ingredients: casserole per recipe, warm fluid such as milk, gravy, or low sodium broth. If needed: stabilizer: instant potato, non-fat dry milk, breadcrumbs, toast, instant cream or rice or farina, or commercial instant food thickener. Directions (1) Complete regular recipe. Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for pureed diets. (2) Puree on a low speed to a paste consistency before adding any liquid. c. During a concurrent observation and interview on 12/28/2024 at 7:54 a.m. of the test tray with DS, DS stated the puree diet was not appetizing as the puree bread and puree raisin brand did not fall from the spoon tilt test (when scooped up with a spoon, the food should be cohesive enough to hold its shape). DS stated this means the puree bread and puree raisin brand were too sticky. DS stated the residents would not eat the puree food and would lead to weight loss as a potential outcome. During a review of the facility's recipe titled Recipe: Cinnamon Toast/Milk Toast/Wheat Toast/English Muffin dated 1/31/2024, the recipe indicated Pureed: Pureed following the pureed recipes in the Food Safety/Misc. section of Book 1. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 1/31/2024, the recipe indicated (4) The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements. During a review of the facility's recipe titled Recipe: Cold Cereal dated 1/31/2024, the recipe indicated Ingredients: cold cereal of choice. Pureed/dysphagia: Pureed following the pureed recipes in Food Safety/ Misc. section book #1. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Cold Cereal, dated 1/31/2024, the recipe indicated, (4) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished product must pass IDDSI level 4 testing requirements.

Based on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Reach-in freezer temperature was at 30 degrees Fahrenheit (°F, a scale of temperature). 2. Turkey was stored on bottom of the beef. 3.Food preparation surfaces and kitchen equipment were not cleaned and sanitized. a.Reach-in refrigerator had food and dirt debris around the gasket. b. Reach-in freezer bottom shelves had dirt and food debris. c. Ice machine filter had dust and dirt buildup. d. Hood holes were not covered and had dust particles. e. Knife storage box had dust and food spillage. f. Mixer had food debris, food splashes and was stored on the floor. g. Scoop tray had food debris. h. Juice machine racks were sticky and dusty to touch. i. Food weighing scale was sticky to touch and had dirt and dust particles. j. Resident's vending machine had dust. 4. Utensils and kitchen equipment had cracks and scratches. a. Chopping boards had scratches. b. Eight (8) resident's tray had cracks and chips. c. Can opener blade have had chip. 5. Staff personal phone was on top of juice rack. 6. Three (3) dented cans were stored with non-dented cans. 7. Yogurt and juice were stored in the resident's refrigerator beyond the expiration date. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 46 of 46 medically compromised residents who received food and ice from the kitchen. Findings: a.During a concurrent observation on 12/27/2024 at 5:28 p.m. of the reach-in freezer and interview with [NAME] 1, the reach-in freezer thermometer read 30°F and there was water dripping from the roof of the freezer. [NAME] 1 stated the reach-n freezer thermometer needed to be at 0°F to ensure the food items were frozen for infection control. During an interview on 12/27/2024 at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2 translating for [NAME] 1), the freezer temperature was at 30°F and it was not okay and needed to be maintained at 0°F for infection control. During an observation on 12/27/2024 at 6:08 p.m. of the reach-in freezer, the thermometer inside the reach-in freezer read 52°F. During an observation on 12/27/2024 at 7:27 p.m. of the reach-in freezer, the thermometer inside the reach-in freezer read 10°F. During an observation on 12/28/2024 at 6:49 a.m. of the reach-in freezer, the thermometer inside the reach-in freezer read 10°F. During a concurrent observation and interview on 12/28/2024 at 6:51 a.m. with Dietary Supervisor (DS), DS stated the freezer should be at 0°F so that the products are completely frozen. DS stated she needed to call the maintenance to check if the freezer was functioning well. DS stated residents could get sick because the food was thawed already if the freezer was not maintaining temperatures at zero or below. During a review of facility's Policies and Procedures (P&P) titled Procedure for Freezer Storage, reviewed 1/31/2024, the P&P indicated, 1. Frozen foods should be immediately stored in the freezer upon delivery. The freezer should be maintained at a temperature of 0°F or lower. b. During an observation on 12/27/2024 at 5:29 p.m. of the reach-in freezer, turkey was stored on the bottom of the meats with no trays in between. During an interview on 12/27/2024 at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2 translating for [NAME] 1), [NAME] 1 stated kitchen staff stored poultry and meat separately and there was usually tray in between. [NAME] 1 stated he did not know why all the meats were not separately stored. [NAME] 1 stated it was important to store meats separately for infection control but did not know the potential outcome to the residents if the storage of meat hierarchy (a system that organizes or ranks things) was not followed. During an interview on 12/28/2024 at 8:06 a.m. with DS, DS stated they stored pork, beef, chicken separately and ready-to eat foods on top of the shelves. DS stated chicken had to be on the bottom shelves so there would be no blood dripping to other foods. DS stated not storing chicken on the bottom shelf could cause cross-contamination. DS stated residents could get sick of foodborne sickness if meats were not stored based on hierarchy of food storage. During a review of facility's P&P titled Refrigerator Storage Chart, dated 1/31/2024, the P&P indicated, All poultry (chicken, turkey, duck, fowls: stuffing made with food that require temperature control dishes with previously cooked food (casserole) are stored at the bottom of the shelve. c. 1. During an observation on 12/27/2024 at 5:29 p.m. of the reach-in freezer, the bottom shelves had dust and food residue. During an interview on 12/27/2024 at 5:45 p.m. with [NAME] 1 and Activities Assistant 2 (AA 2), [NAME] 1 stated (AA 2 translating for [NAME] 1), [NAME] 1 stated the dirt debris from the bottom shelves was from the plastic and food. [NAME] 1 stated the freezer was cleaned every weekend with the help of his supervisor. [NAME] 1 stated it was not okay to have had dirt in the freezer due to infection control but did not know the potential outcome to the residents if freezer where food was stored was dirty. 2. During an observation on 12/27/2024 at 5:53 p.m. of the reach-in refrigerator, the reach-in refrigerator gasket had dirt residue and buildup. During a concurrent observation and interview on 12/28/2024 at 6:54 a.m. with DS, DS stated the freezer and refrigerator were cleaned every day and deep cleaned weekly. DS stated there was dirt debris in the refrigerator gasket and freezer shelves and it was not cleaned from the night prior. DS stated it was important to keep the food safe and avoid bacterial growth to prevent cross-contamination. DS stated residents could get foodborne sickness. During a review of the facility's P&P titled Procedure and Refrigerated Storage, dated 1/31/2024, the P&P indicated (3) Refrigerator equipment should be routinely cleaned. 3. During an observation on 12/27/2024 at 6:03 p.m. of the ice machine, the ice machine vent had dust and dirt buildup. During a concurrent observation and interview on 12/28/2024 at 8:08 a.m. with DS, DS stated an outside company was scheduled to go to the facility to clean the ice machine filter every six (6) months. DS stated the ice machine filter had dust and needed to be cleaned so the machine could run smoothly and produce clean ice. DS stated the potential outcome would be contamination of ice. During a review of the facility's P&P titled Ice Chest Cleaning Procedure, dated 1/31/2024, the P&P indicated All ice chest will be cleaned and sanitized before and after each use, and when contaminated or visibly soiled. 4. During an observation on 12/27/2024 at 6:10 p.m. of the kitchen hood where Cooks were cooking hot foods, the hood had two holes that were not covered and there were dust and dirt buildup. During an interview on 12/28/2024 at 8:10 a.m. with DS, DS stated the kitchen hood was an old-style hood and the open hole from the ceiling was directly over where food was cooked. DS stated it was not okay as dirt could fall in the food and there could be contamination of food as a potential outcome. 5. During an observation on 12/27/2024 at 6:11 p.m. of the knife storage box, the knife storage box had dirt debris and white food splatter. During an interview on 12/28/2024 at 8:12 a.m. with DS, DS stated the knife storage was scheduled for everyday cleaning. DS stated the storage box for knives was dusty and had food spill. DS stated kitchen staff needed to clean the storage box for knives to prevent cross-contamination. 6. During an observation on 12/27/2024 at 6:13 p.m. of the mixer, the mixer internal parts had oil residue and amber discoloration particles. During an interview on 12/28/2024 at 8:13 a.m. with DS and [NAME] 3, DS stated the mixer was used for baking desserts and cakes. [NAME] 3 stated the mixer had been used three days prior. DS stated the mixer was sticky due to food splashes and food debris. DS stated the staff needed to clean the mixer after each use to prevent cross-contamination. During a concurrent observation and interview on 12/28/2024 at 12:26 a.m. of the mixer with DS, DS stated the mixer needed to be elevated so kitchen staff could clean the floor underneath. DS stated the mixer had to be six (6) inches (in., a unit of measurement) from the floor or the mixer would be dirty. DS stated the mixer could attract pests and bacteria resulting to cross-contamination. 7. During an observation on 12/27/2024 at 6:14 p.m. of the scoop storage, the tray had white particles, dirty debris and was not covered. During an observation on 12/28/2024 at 8:17 a.m. with DS, DS stated the container with scoops was clean however there were food debris on the container, and it was not covered. DS stated the container for scoops should have been covered and clean to prevent cross-contamination of food. 8. During an observation on 12/27/2024 at 6:23 p.m. of the juice rack, the juice rack had dirt buildup and was sticky to touch. During an observation on 12/28/2024 at 8:25 a.m. with DS, DS stated the juice area and juice rack had to be cleaned every day. DS stated the juice racks had juice spilled on the racks. DS stated it was important to clean the area to prevent cross-contamination and to avoid attracting pests and flies. DS stated food poisoning and contamination would the potential outcome for residents. 9. During an observation on 12/27/2025 at 6:41 p.m. of the food weighing scale, the food weighing scale had dried up food and dirt. During an interview on 12/28/2025 at 8:36 a.m. with DS, DS stated the staff were to clean the weighing scale after each use. DS stated the weighing scale felt sticky to touch and looked like it was not cleaned after the staff used it. DS stated it was not okay not to clean the weighing scale as it could cause cross-contamination. 10. During a concurrent observation and interview on 12/28/2024 at 1:03 p.m. of the vending machine outside patio with DS, DS stated the vending machine has dust and it was not acceptable because it was used for food storage, and it could contaminate the food. During a concurrent observation and interview on 12/28/2024 at 1:18 p.m. of the food vending machine with Administrator (ADM), ADM stated the outside company refilled the drinks for the vending machine and maintenance supervisor was responsible for cleaning the vending machine. ADM stated both employees and residents used the vending machine, and it was important to maintain its cleanliness to avoid contracting diseases. ADM stated the vending machine racks were dusty and the vending machine was dusty because it was located outside. ADM stated facility staff did not have the key to the machine so they could not clean it. ADM stated even if the shelves of the vending machine were dusty, it was okay, and nothing was wrong because the food products were sealed. During a concurrent observation and interview on 12/28/2024 at 3:52 p.m. with Maintenance Supervisor (MS), MS stated the MS cleaned the outside of the vending machine but did not have the key to clean the inside. MS stated the vending machine was corroded and dusty on the inside and it was not acceptable as residents used it. MS stated the dust could get in the resident's hands, could go to the food and residents could get sick in their stomach as a potential outcome. During a concurrent observation and interview on 12/28/2024 at 3:56 p.m. of the food vending machine with Activities Assistant 1 (AA 1), AA 1 stated the food vending machine was used by staff and residents. AA 1 stated she saw residents getting food and snacks in the vending machine. AA 1 stated the vending machine was dusty and it was not acceptable as the food product could touch the resident's hands. AA 1 stated residents could get sick from getting dirty food and contaminated food as a potential outcome. During a review of the facility's P&P titled Sanitation, dated 1/31/2024, the P&P indicated, POLICY: The Food and Nutrition Services Departments shall have equipment of the type and in amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. (16) The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, lights, fixtures, and the good over stove, which will be cleaned by the maintenance staff. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6). During a review of Food Code 2022, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306. d. 1. During an observation on 12/27/2024 at 6:15 a.m. the chopping boards, the green, yellow, blue, and brown chopping boards had scratches. During an interview on 12/28/2024 at 8:20 a.m. with DS, DS stated the chopping boards were worn out and had scratches. DS stated it was not okay to use chopping boards as the food could go in the scratches and surfaces that had scratches were hard to clean. DS stated bacteria could grow on the chopping board and could go to food causing cross-contamination. 2. During an observation on 12/27/2024 at 6:25 p.m. of the dishwashing process, there were eight (8) trays that had cracks and chips. During a concurrent observation and interview on 12/28/2024 at 8:34 a.m. of the resident's tray inside the carts with DS, DS stated the trays had cracks and it was not a good representation of the facility. DS stated the food debris could go in the cracks and the surface would be hard to clean causing cross-contamination. 3. During an observation on 12/27/2024 at 6:29 p.m. of the can opener, the can opener blade had chip and crack. During an interview on 12/28/2024 at 8:30 a.m. with DS, DS stated the can opener blade had a little crack and it was not okay because the blade crack residues could go in the canned foods. DS stated the can opener blade would be hard to clean so it could get bacteria on the cracks of the can opener that could cause cross-contamination. During a review of the facility's P&P titled Sanitation dated 1/23/2024, the P&P indicated (11) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. (2) Plastic ware, China, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. During a review of Food Code 2022, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. e. During an observation on 12/27/2025 at 6:31 p.m. at the preparation areas, a cellphone was on top of the juice dispenser table. During an interview on 12/28/2024 at 8:32 a.m. with DS, DS stated there were no use of personal cellphone allowed in the kitchen and it was not okay to put cellphones on work surfaces as cellphones might be dirty and could cause cross-contamination. During a review of facility's P&P titled Cellphone Use in the Kitchen for Communication, reviewed 1/31/2024, the P&P indicated, To ensure the safe, sanitary, and efficient operation of the kitchen while allowing limited and appropriate use of cellphones for communication purposes. The use of cellphones in the kitchen is permitted under specific circumstances to facilitate necessary communication, provided it does not compromise food safety, hygiene, or the efficient functioning of the kitchen. f. During an observation on 12/28/2024 at 12:55 p.m. of the dry storage area, observed three (3) dented cans were stored with non-dented cans in the disaster supply area and dietary supply. During an interview on 12/28/2024 at 1:02 p.m. with DS, DS stated there was a designated area for dented cans so staff would not use dented cans because the food could be spoiled. DS stated residents could suffer from botulism (rare but serious condition caused by toxin that attacks the body's nerves) if they consumed food out of a dented can. During a review of the facility's P&P titled Food Storage-Dented Cans dated 1/23/2024, the P&P indicated Food in unlabeled, rusty, leaking, broken containers or cans with side seam, dents, rim dents, or swells shall not be retained or used by the facility. All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyors for refund. All leaking is to be disposed immediately. During a review of Food Code 2022, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. g. During an observation and interview on 12/28/2024 at 3:59 a.m. of the resident's refrigerator in the activity room with the Activities Director (AD), AD stated the resident's refrigerator in the activities room was used for resident's food from the outside. AD stated they could keep resident's foods for three (3) days, and they must toss it out after 3 days if not consumed. AD stated they labeled the food with name, date received to ensure there were no expired food products. AD stated the orange juice had an expiration date of 11/27/2024 and the yogurt had an expiration date of 12/24/2024. AD stated a chocolate cake and canned fruit was not labeled with name and date. AD stated residents could have a bad stomach and food poisoning as a potential outcome for consuming expired food products. During a review of the facility's P&P titled Food for Residents from Outside Sources, dated 1/31/2024, the P&P indicated (5) Prepared foods, beverages, or perishable food that requires refrigeration, can be stored for the resident in the facility kitchen, the refrigerator within the nurses' station, or resident's personal refrigerator. In Food and Nutrition Services Department, the policy on food storage will apply. Otherwise, if unopened refrigerated or frozen items will be disposed of by the expiration date on the container. If opened, the food must be sealed, dated to the date opened and disposed of in 2 days after opening. Frozen items, such as ice cream, will be disposed in 30 days. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety.

Based on observation, interviews, and record reviews, the facility failed to dispose garbage and refuse properly by not completely covering 1 (one) of 2 black dumpsters (large trash container designed to be emptied into a truck) and keeping the area free from trash like plastic cups, plastic, and other trash around the trash area. This failure had a potential to result to attract birds, flies, insects, pest and possibly spread infection to 46 of 46 facility residents. Findings: During an observation on 12/27/2024 at 6:19 a.m. of the dumpster area outside of the facility, one (1) of the dumpsters was overflowing with trash and was not completely closed. During an interview on 12/28/2024 at 8:40 a.m. with Dietary Supervisor (DS), DS stated the dumpster had to always be closed and not overflowing with trash. DS stated a dumpster was not closed or covered and could attract pest and flies. DS stated it was not a good practice to leave a dumpster open and overflowing with trash as it could potentially cause food borne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) to residents. During an interview on 12/28/2024 at 3:52 p.m. with Maintenance Supervisor (MS), MS stated the trash pickup was scheduled every Monday, Wednesday, and Friday. MS stated the trash area had to be maintained clean and the staff was to clean it daily, but he did not think cleaning was done that day (12/28/24) as there were trash in the dumpster surroundings. MS stated the dumpster bins should be washed, closed, covered, and not over filled with trash as it could attract rodents. MS stated having trash around the area would look bad in the representation of the facility and it was important to maintain it cleanliness to prevent rodents going inside the facility. MS stated resident could get a sick stomach as a potential outcome of not covering the trash. A record review of the facility's policies and procedures (P&P) titled Miscellaneous Areas dated 1/31/2024, indicated Trash Procedure: (2) Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. Trash Collection Area. The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. (1) The area must be swept and washed down by maintenance with a detergent on a regular basis. If a commercial rubbish service is not used, arrangements must be made for periodic exchange of trash bins. A review of Food Code 2017, indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. A review of Food Code 2017, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.

Based on interview record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for one of four required quarters (1st fiscal quarter due 02/14/2024) in 2023. This deficient practice had the potential to place all 45 facility residents as risk for delays in care, treatment, and services necessary to maintain physical and emotional wellbeing. Findings: A review of the facility's Certification and Survey Provider Enhanced Reporting system (CASPER: Shows the facility percentage and how the facility compares with other facilities in their state and in the nation) revealed no PBJ data had been submitted from the facility to CMS from 10/1/2023 - 12/1/2023. A review of CMS' website Staffing Data PBJ Submission website (https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission) indicated the deadlines for each reporting period were: - The 1st fiscal quarter was from 10/01/2023 through 12/31/2023, the indicated submission due date was 02/14/2024. A review of CMS Staffing Data Report with a run date of 12/23/2024, indicated the facility failed to submit data for the quarter 1 2024. During an interview with Director of Staff and Development/Infection Preventionist Nurse (DSD/IP) on 12/29/2024 at 11:39 AM, DSD/IP stated the PBJ reporting from last year (Quarter 1 2024) was completed by the facility's corporate office and it had not been not done properly and was not submitted to CMS. A review of the facility's policy and procedure (P&P) titled, Staffing, dated 1/31/2024, the P&P indicated, Direct staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, not no less than once a quarter. A review of the facility's P&P titled, Reporting Direct-Care Staffing Information (Payroll-Based Journal), dated 1/31/2024, the P&P indicated, Beginning with the fiscal quarter of 2016, direct-care staffing and census information will be reported electronically to CMS through the Pay-Based Journal (PBJ) system . Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. Dates are as follows: Fiscal Quarter: 1 - October 1 - December 31, Submission Deadline: February 14. A review of the CMS PBJ Policy Manual dated 06/01/2022, indicated Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. The Policy indicated Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline. CMS will conduct audits to assess a facility's compliance related to this requirement. The policy also indicated Facilities that do not meet these requirements will be considered noncompliant and subject to enforcement actions by CMS. Note: If a facility uses a vendor to submit information on behalf of the nursing home, the nursing home is still ultimately responsible for meeting all the requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that call button was placed within reach for two of 12 sampled residents (Residents 9 and 46). This deficient practice resulted in the residents not being able to access staff assistance as needed for Residents 9 and 46. Findings: A review of Resident 9's admission Record indicated Resident 9 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), epilepsy (a brain disorder that causes recurring, unprovoked seizures [a burst of uncontrolled electrical activity between brain cells]), and hyperlipidemia (HLD -an excess of lipids or fat in the body). A review of Resident 9's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 11/6/2023, indicated Resident 9 cognitive skills (thought processes) for daily decision making were not intact. Resident 9 needed assistance with self-care, required partial/moderate assistance on staff for activities of daily living (ADLs-shower/bath, dressing and toileting hygiene). During a concurrent observation and interview on 12/5/2023 at 8:21 a.m., with Resident 9, Resident 9's call button was observed on the nightstand. Resident 9 stated she did not know where her call button was. During a concurrent observation and interview on 12/5/2023 at 8:21 a.m., with (Licensed Vocational Nurse 1) LVN 1, LVN 1 stated Resident 9's call button was on the nightstand instead of being within reach of Resident 9 so that she can call for staff assistance when needed. LVN 1 stated potential adverse effects of not having the call button within Resident 9's reach was, a lot of things can happen, falling number one. A review of Resident 46' admission Record indicated Resident 46 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including type 2 diabetes (body's inability to process blood sugar), anxiety disorder (a mood disorder), pain in right shoulder, pain in the right hip, and chest pain. A review of Resident 46's MDS dated [DATE], indicated Resident 46 was cognitively intact for daily decision making and needed supervision with self-care, required partial/moderate assistance on staff for ADL (shower/bath, dressing and toileting hygiene). During a concurrent observation and interview on 12/5/2023 at 9:00 a.m., with Resident 46, Resident 46's call button was observed behind his bed. Resident 46 stated, the facility had not provided him with a call button and did not know what it is. During a concurrent observation and interview on 12/5/2023 at 9:15 a.m., with Certified Nurse Assistant 5 ( CNA 5), CNA 5 stated, the call light should not be behind the resident's bed and explained to the resident how to use the call button. During an interview on 12/7/2023 at 3:06 p.m., with the Director of Nursing (DON), DON stated Residents call buttons should be within reach of the residents so that can be able to reach staff for assistance. DON stated potential adverse outcome of not having the call button within reach of the resident is that residents care may not be rendered to them when needed. A review of facility's policy and procedures (P&P), titled, Answering the call Light dated 10/2010, indicated, the purpose of the procedure is to respond to the resident's request and needs .When the is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to communicate in a timely manner a residents change in condition to the physician for one of 12 sampled residents (Resident 4). This deficient practice has the potential to result in the delay in care for Resident 4. Findings: A review of Resident 4's admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included (COPD - group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure (when the lungs cannot release enough oxygen into the body which prevents the organs from properly functioning), and hypertension (hypertensive [high or raised] blood pressure). A review of Resident 4's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/22/2023, indicated Resident 4 was intact in cognitive skills (thought processes) for daily decision making and needed some help with self-care, required extensive assistance on staff for activities of daily living (ADLs-bed mobility, Transfer, dressing, personal hygiene, and toileting hygiene). A review of Resident 4's situation, background, appearance and review/notify (SBAR - a tool to facilitate prompt and appropriate communication in healthcare settings, especially amongst physicians and nurses) dated 6/21/2023, indicated Resident 4 was having increased confusion and at 7:25 p.m., a message was left for the medical doctor (MD) to call back. During a concurrent interview and record review on 12/7/2023 at 4:41 p.m., with the Director of Nursing (DON), Resident 4's SBAR dated 6/21/2023, and nursing progress noted date 6/20/2023 to 6/22/2023 were reviewed. The SBAR indicated, a message was left for the medical doctor (MD) to call back. DON stated, MD is given time to call back and if no response then call the medical director right away. DON stated there was no documented evidence in the nursing progress notes reviewed from 6/20/2023 to 6/22/2023 that the MD was notified of Resident 4's change in condition (COC - a deterioration in health, mental, or psychosocial status). DON stated potential adverse outcome of not communicating a COC to the MD could lead to further changes in COC and hospitalization. A review of facility's policy and procedures (P&P), titled, Acute Condition Changes -Clinical Protocol dated 3/2018, indicated, the nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physicians and request a prompt response (within approximately one half hour or less) .The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physical of resident refusal to be transferred to the general acute care hospital (GACH) for one of 12 sampled residents (Resident 47). This deficient practice had the potential to result in delay of care hospitalization for Resident 47. Findings: A review of Resident 47's admission Record indicated Resident 47 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included diabetes mellitus (DM -when the blood sugar is too high), and hypertensive heart disease, cerebral infarction (a result of disrupted blood floor to the brain), and personal history transient ischemic attack (TIA - a temporary blockage of blood flow to the brain). A review of Resident 47's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/23/2023, indicated Resident 47 had cognitive skills (thought processes) for daily decision making were intact. Resident 47 needed some help with self-care, required limited assistance on staff for activities of daily living (ADLs- bed mobility, Transfer, dressing, personal hygiene, and toileting hygiene). A review of Resident 47's physicians orders dated 9/12/2023 at 6:30 p.m., indicated to transfer Resident 47 to GACH for further evaluation of increase weakness increased confusion, and decline with ADL's. A review of Resident 47's nursing progress notes dated 9/12/2023 at 9:31 p.m., indicated Resident 47 refused to transfer to GACH for further evaluation and that ambulance transportation was cancelled. During a concurrent interview and record review on 12/6/2023 at 1:48 p.m., with Director of Nursing (DON), Resident 47's physicians orders dated 9/12/2023 and nursing progress noted dated 9/12/2023 to 9/13/2023 were reviewed. The physicians order indicated, Resident 47 to GACH for further evaluation of increase weakness increased confusion and decline with ADL's. DON stated there was no documented evidence in the nursing progress notes reviewed from 6/20/2023 to 6/22/2023 that the MD was notified of Resident 47's refusal to transfer to GACH. DON states the physician should have been notified of Resident 47's refusal to transfer to GACH for possible alternative treatment plan. DON stated potential adverse outcome of not communicating Resident 47's refusal to transfer to GACH could lead to further changes in condition (COC - a deterioration in health, mental, or psychosocial status) and delay in care. A review of facility's policy and procedures (P&P), titled, Charting and Documentation dated 7/2017, indicated, all services provided to the resident, progress toward the care plan goals, or any other changes in the residents medical, physical, functional, or psychosocial condition, shall be documented in the residents' medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff properly assessed and document resident's medical diagnosis listed on admission Record, (a medical record that includes past and present medical history and findings), and on Preadmission Screening and Resident Review, (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation). The deficient practice resulted in Resident 362 not receiving a PASARR II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) and subsequent follow up. Findings: A review of Resident 362's admission Record indicated, Resident 362 was admitted to the facility on [DATE] with a diagnosis of unspecified schizophrenia (a mental illness that affects your thoughts, mood, and behavior). During a concurrent interview and record review on 12/6/23 at 4:01 p.m. the Director of Nursing (DON) reviewed Resident 362's PASARR level 1 screening, dated 6/8/2021. The DON confirmed section V number 26 of the PASARR was answered no indicating the resident did not have a mental disorder. The DON stated, I am responsible for PASARR forms. The PASARR II was not completed, I missed the diagnosis from the history . The DON stated the resident could not receive appropriate care for mental illness due to the incorrect PASARR. A review of a facility policy & procedures (P&P) titled, admission Criteria, dated March2019, indicated, All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The facility conducts a Level I PASARR screen for all potential admissions to determine if the individual meets the criteria for a MD, ID, or RD. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.

Based on observation, interview, and record review, the facility failed to: 1. Ensure transportation to dialysis was arranged for one out of four sampled residents (Resident 23). 2. Document and notify the physician that Resident 23 missed dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on 9/21/2023 and 12/2/2023. This deficient practice had the potential to cause a life-threatening build of toxins in the resident's body which could cause worsening in existing medical conditions, permanent damage to organs, and death. Findings, A review of Resident 23's admission Record indicated the facility admitted the resident on 8/14/2023 with diagnoses including type 2 diabetes (a group of diseases that result in too much sugar in the blood), end stage renal disease (the gradual loss of kidney function), left hand contracture (a condition of shortening and hardening of muscles), allergic urticaria (a skin condition that causes itchy welts), hypotension (low blood pressure), anemia (low red blood cells), hyperlipidemia (elevated cholesterol), dependence on renal dialysis ( treatment for people whose kidneys are failing), benign prostatic hyperplasia (enlarged prostate gland), and lack of coordination. A review of Resident 23's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/23/2023, indicated the resident was cognitively (the mental ability to make decisions of daily living) intact. The MDS indicated the resident needed extensive two-person physical assistance with transfers, dressing, toilet use, and personal hygiene. A review of Resident 23's physician orders, dated 12/05/2023, indicated an order for hemodialysis (a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood) every Tuesday, Thursday, and Saturday. A review of Resident 23's progress notes for 9/21/2023 revealed there was no documentation indicating the resident's physician was notified of missed dialysis. A review of Resident 23's progress notes for 12/2/2023 revealed there was no documentation indicating the resident's physician was notified of missed dialysis. During an interview on 12/5/2023 at 9:00 AM, Resident 23 stated, he had missed several dialysis appointments because transportation was late or did not show up. Resident 23 stated, no one at the facility informed him (Resident 23) why the transportation was late or did not show up. During an interview on 12/5/2023 at 2:00 PM., Licensed Vocational Nurse (LVN 1) stated, Resident 23 did not go to dialysis on 9/21/2023 and 12/2/2023. LVN 1 stated there were no nursing progress notes indicating if the Medical Doctor was notified. LVN stated, it was important to notify the Medical Doctor when the resident did not go to dialysis appointments so that the doctor could recommend another option. During an interview on 12/7/2023 at 3:00 PM, the Director of Nurses (DON) stated, charge nurses were expected to call the Medical Doctor and document when a resident refused to go to dialysis. The DON stated, it was important to call the Medical Doctor to report the change of condition (refusal of dialysis) so the Medical Doctor could provide alternative recommendations. A record review of a facility policy and procedures titled, Change in a Resident's Condition or Status dated May 2017, indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The policy indicated The nurse will notify the resident's Attending Physician or physician on call when there is a refusal of treatment. A record review of a facility policy and procedures titled, Charting and Documentation revised July 2017, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide assistance for resident who required supervision while eating for one (1) of 12 sampled residents (Resident 39). This deficient practice had the potential not to meet the resident's nutritional needs, not to respect the resident's dignity, and also had the potential for weight loss and food aspiration (when something you swallow goes down the wrong way and enters your airway [windpipe] or lungs), which could lead to hospitalization and death. Findings: During an observation on 12/5/2023 at 7:39AM, Resident 39 was observed attempting to eat breakfast independently without supervision. Resident 39 looked up but not at her cereal bowl and attempted sometimes to scoop her breakfast cereal with a spoon to eat without success. A review of admission Record indicated Resident 39 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included atrial fibrillation (an type of abnormal heartbeat), dysphagia (difficulty swallowing food or liquids due to underlying disease), dysarthria (a neurogenic speech disorder that makes it difficult to form and pronounce words), anarthria (a speech impairment in which the ability to articulate speech is lost) spastic hemiplegia affecting the right side (a brain injury that causes muscle tightness and involuntary contractions in the limbs and extremities on one side of the body). A review of Resident 39's Minimum Data Set (MDS - assessment and care screening tool) dated 9/25/2023, indicated the resident was assessed to be severely cognitively (relating to mental activities such as thinking, reasoning, remembering and understanding) impaired, and required extensive assistance with bed mobility, transfer, dressing, toilet use and hygiene, and required supervision for eating. A review of Resident 39's ophthalmology (specialty in eye and vision care) consult record indicated Resident 39 had presbyopia (a gradual loss of eye's ability to focus on nearby objects). During an interview on 12/05/2023 at 7:47AM, Certified Nurse Assistant 5 (CNA 5) stated Resident 39 required supervision while eating. CNA5 stated supervision should entail staying by the resident's side as she (Resident 39) ate, and directing, cueing and coaxing to ensure adequate intake of her meals. CNA5 further stated Resident 39 was a high risk for aspiration due to her dysphagia. During an interview on 12/7/2023 at 3:13PM, the Director of Nursing (DON) stated CNAs are required to sit with a resident at bedside that requires supervision while eating. The DON further stated the potential risks of failing to supervise the resident include inadequate food intake that can cause unnecessary weight loss and malnutrition and food aspiration leading to unnecessary sickness due to a change of condition, hospitalization and even death. A review of the facility's policy and procedures titled Assistance with Meals revised July 2017, indicated facility will serve resident trays and will help residents who require assistance with eating. The policy further indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity

Based on observation, interview, and record review the facility failed to ensure a Registered Nurse (RN) was available to work for at least 8 consecutive hours a day. This deficient practice placed all 47 residents in the facility at risk for delayed care and services, missed treatments and/or medications, and a potential delay in emergency care. Findings. A review of Resident 27's admission Record indicated the facility admitted the resident on 9/29/2018 and readmitted the resident on 9/02/2020 with diagnoses including unspecified convulsions (seizures), traumatic brain injury, schizophrenia (mental disorder which leads to hallucinations, irrational thoughts, and behaviors), hypertension (high blood pressure), and major depressive disorder. A review of Resident 27's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/10/2023, indicated Resident 27's was cognitively (the mental ability to make decisions of daily living) intact. The MDS indicated Resident 27 required supervision with toilet transfers, dressing, and bathing. During an interview on 12/5/2023 at 9:00 AM, Resident 27 stated, the time she (Resident 27) had spent in the facility she (Resident 27) had not seen a Registered Nurse. The resident reported only receiving care from Certified Nurse Assistants (CNAs). The resident stated she (Resident 27) would feel safer knowing there was a Registered Nurse in the building to assess her (Resident 27) in case she had a change in condition. A review of the facility's Census and Direct Care Service Hours Per Patient Day(number of nurses on shift based on number of residents in the facility) for the month of November 2023, indicated the facility did not have a Registered Nurse on 21 out of 30 days (11/4/2023, 11/5/2023, 11/6/2023, 11/7/2023, 11/8/2023, 11/9/2023, 11/10/2023, 11/13/2023, 11/14/2023, 11/15/2023, 11/16/2023, 11/17/2023, 11/20/2023, 11/21/2023, 11/22/2023, 11/23/2023, 11/24/2023, 11/27/2023, 11/28/2023, 11/29/2023, and 11/30/2023). During an interview on 12/8/2023 at 9:00 AM, CNA5 stated, she (CNA5) worked on Saturdays, and had not seen an RN in the facility on Saturdays. CNA5 stated, sometimes the Director of Nurses (DON) was on call but would not be physically in the building. During an interview on 12/8/2023 at 9:30 AM, The Director of Staff Development (DSD) stated the facility had an on call Registered Nurse, but there was no Registered Nurse in the facility on the weekends. During an interview on 12/8/2023 at 10:00 AM, DON stated, he (DON) was on call all weekends and confirmed there was no Registered Nurse in the facility on the weekends. The DON stated it was important for a Registered Nurse to be physically in the facility to provide appropriate care and treatment to the residents. A review of a facility's policy and procedure titled Staffing dated January 2023, indicated the primary goal of this staffing policy is to ensure the delivery of high-quality care and services to residents of the nursing home while maintaining compliance with applicable laws and regulations. The staffing mix will include licensed nurses (RN, LVN), certified nursing assistants, and other necessary personnel based on resident needs. The nursing home will ensure a diverse and skilled workforce to address the unique requirements of the residents. A review of the Facility Assessment (the facility's self-evaluation of its resident population and identification of the resources needed to provide the necessary person-centered care and services the residents require) dated 10/25/2023, indicated, facility resources needed to provide competent support and care for the resident population every day and during emergencies. Nursing Services include Director of Nurses, Register Nurse, Licensed Vocational Nurse, Certified Nurse Assistant, medication aide and MDS nurse. General staffing plan to match acuity level of residents. Plan indicated, at least 1 RN per day.

Based on observation, interview, and record review the facility failed ensure medications were stored as per the facility's policy and procedures titled Storage of Medications dated 11/2020. By failing to: 1. Safely store medications for one of 12 sample residents (Resident 11). Antacid tablets (Calcium Carbonate-used to treat symptoms caused by too much stomach acid such as heartburn, upset stomach, or indigestion), Biotin, ( a B-Vitamin essential nutrient available as a dietary supplement), Vitamin D3 (A supplement that helps the body absorb calcium), Isopropyl alcohol 91% proof (A powerful agent used for disinfecting and sanitizing purposes) and Voltaren Gel (Medication used to relieve joint and muscle pain) were observed stored in Resident 11's bedside drawer. 2. Discard a bottle of Naproxen Sodium (nonsteroidal anti-inflammatory drug) 220 milligrams (mg) with 100 tablets with a labeled expiration date of 9/2023. 3. Discard two bottles of Magnesium Oxide (supplement to treat low magnesium levels in the body) 400mg with 120 tablets with a labeled expiration date of 10/2023. 4. Discard two bottles of fish oil (supplement ) 500mg with 130 soft gel capsules with a labeled expiration date of 10/2023. These deficient practices had the potential to result in unsafe medication administration, improper administration, overdose, interactions with prescribed medications, and serious injury or harm. These deficient practices also had the potential to affect medication efficacy (the power to produce the desired effect) and reduce the therapeutic (intended to treat diseases or disorders) effects of medications administered to all 47 residents in the facility. Findings: a. A review of Resident 11's admission record indicated the facility admitted the resident originally on 4/11/2023 and readmitted the resident on 11/21/2023, with diagnoses that included chronic obstructive pulmonary disease (COPD [a group of diseases that cause airflow blockage and breathing related problems]), Anemia (a condition in which the body does not have enough healthy red blood cells), schizophrenia (a mental disorder characterized by disruption in thought processes, perceptions, emotional responsiveness and social interactions), and Major depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) A review of Resident 11's Minimum Data Set (MDS - assessment and care screening tool) dated 9/11/2023, indicated the resident was assessed to be cognitively intact, and was independent with all activities of daily living. A review of Resident 11's clinical record indicated there was no documented evidence the resident was assessed for self-administration of oral (taken by mouth) medication. A review of Resident 11's physician's order dated 12/6/2023 indicated Resident 11 did not have an order for Antacid tablets, Biotin, Vitamin, Isopropyl alcohol 91% proof, and Voltaren Gel. A review of Resident 11's medication administration record (MAR) dated 12/1/2023-12/31/2023 indicated Resident 11 did not have the medications at bedside as part of her listed medication regimen. During an observation of Resident 11's room on 12/5/2023 at 10:30AM, a bottle of Antacid tablets, Biotin, Vitamin, Isopropyl alcohol 91% proof, and Voltaren Gel were observed inside Resident 11's bedside drawer. During an interview on 12/5/2023 at 10:37AM, Resident 11 stated she (Resident 11) would use the Antacid Tablets for occasional upset stomach and heart burn because the nurses took too long to bring the antacid medication. The resident stated the biotin and Vitamin D3 were supplements her (Resident 11's) daughter brought into the facility. The resident would use the Isopropyl alcohol to disinfect the nasal cannula and the Voltaren gel was for neck pain. During an interview on 12/5/2023 at 11:05AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 11 should not have medications at bedside and did not have a self-administration order (a physician's order indicating the resident was allowed to self-administer medications). LVN1 removed the medications from Resident 11's bedside drawer. During an interview on 12/7/2023, at 3 p.m., the Director of Nursing (DON) stated residents were permitted to have medications at bedside only if they had been assessed and demonstrated they (residents) could safely self-administer the medications. The DON stated potential risks for storing and taking unverified medications at bedside included physician might not have been aware of the medications, unnecessary change of conditions, hospitalizations, adverse reactions (harmful effects), poor therapeutic outcomes, and harm or death. A review of a facility's policy and procedures titled Self-Administration of Medication revised in 12/2016, indicated Residents have the right to self-administer medications if the interdisciplinary team has determined that it is safe and clinically appropriate and safe for the resident to do so. The policy indicated, Staff and Practitioner will perform a skill assessment including . the resident's: Ability to read and understand medication labels: Comprehension of the purpose and proper dosage and administration time for the medications. Ability to remove medications from a container and to ingest swallow (or otherwise administer the medications; and ability to recognize risks and major adverse consequences of the medications. b. During an observation of the facility's medication storage room on 12/06/2023 at 2:53 p.m., a bottle of Naproxen Sodium 220 mg with 100 tablets was observed with a labeled expiration date of September 2023, two bottles of Magnesium 400mg with 120 tablets were observed with a labeled expiration date of 10/2023, and two bottles of fish oil 500mg with 130 soft gel capsules were observed with a labeled expiration date of 10/2023 During an interview 12/7/2023 at 1 p.m., Licensed Vocational Nurse (LVN 2) stated central supply (department responsible for receiving, storing, and distributing medical and surgical supplies and equipment) was responsible for checking for expired medications and for disposing expired medications. LVN 2 stated it was important to check all medications for the safety of the residents. During an interview on 12/7/2023 at 3 p.m., The Director of Nurses (DON) stated the charge nurse was responsible for checking over the counter medications every month. The DON stated, administering expired medications had the potential to cause adverse effects (harmful and undesired effect resulting from a medication or intervention and procedures) and medications to be ineffective. A review of a facility's policy and procedures titled, Storage of Medications dated 11/2020, indicated the facility stored all drugs and biologicals in a safe, secure, and orderly manner. The policy indicated discontinued, outdated, or deteriorated drugs or biologicals [a class of drugs that are produced using a living system, such as a microorganism, plant cell, or animal cell] were returned to the dispensing [issuing] pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to ensure proper food handling practices by: 1. Failing to label and date when yellow jelly like substance in a container was prepared with a use by date (the last date recommended for the use of the food while at peak quality). 2. Failing to store meat product (tilapia fish fillet, pork chops, and sausage) below the vegetables. 3. Failing to discard jelly in the refrigerator that was past its use by date of 12/3/2023. Those deficient practices had the potential to result in foodborne illness (caused by consuming contaminated foods or beverages) among 48 residents who consumed food prepared by the facility kitchen. Findings: During an initial tour of the facility kitchen on 12/5/2022 at 7:24 a.m. with [NAME] 1(CK 1), there were a box of labeled pork, a box of labeled tilapia fish fillet and a plastic wrap with sausage links on the shelf above the vegetable shelf in the freezer. A container with jelly yellow like substance in the refrigerator did not have a label with the name of the substance or prepared on and use by date. There was a container labeled Jelly in the refrigerator past its use by date of 12/3/2023. During an interview on 12/5/2022 at 7:24 a.m. with CK 1, CK 1 stated meat products should not be stored above the vegetables, they (meat products) should be stored below the vegetables to prevent food borne pathogens (organisms that can cause disease). CK 1 stated all the yellow jelly like substance in the refrigerator was soup, CK 1 stated the substance should have been labeled as such with the date it was prepared and the date it should be used by. CK 1 stated the jelly in the refrigerator that was past the use by date should have been discarded, as if consumed by resident past its use by date it may cause sickness. During an interview on 12/7/2022 at 9:24 a.m. with Dietary Supervisor 1(DS 1), DS 1 stated meat products should not be placed above the vegetables when stored in the refrigerator, and this is so to prevent cross contamination of the food products which may lead to food borne illnesses. DS 1 stated all food items need to be labeled with the prepared and use by date, and food item should not be left in the refrigerator past the use by date. DS 1 stated potential adverse outcome of not labelling or leaving food past their use by date is giving food that is past its freshness which may lead to food borne illnesses. A review of the facility's policy and procedures titled Food Receiving and Storage dated 7/2014, indicated that food shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready to eat foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in a double occupancy patient room and 100 square feet (Sq.Ft) per resident in a single occupancy room. There were twenty-two (23) resident rooms in the facility that did not meet the requirement of 80 square feet per resident. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents. Findings: During the entrance conference with the facility Administrator (ADM) on 12/5/2023 at 11:00 a.m., the ADM presented a letter addressed to Department of Public Health, stating the facility had a request for the continuation of the waiver for twenty-three (23) rooms, which did not meet the room size requirement of 80 square feet per resident in a double occupancy room and one-hundred (100) square feet per resident in a single occupancy room. A review of the facility's room waiver letter and the client accommodations analysis form completed by the facility on March 30, 2023, indicated the following 23 rooms provided less than 80 feet per resident: Rooms # Beds Room Size (ft.) Sq. Ft/Bed 2 2 143 71.5 3 2 140.4 70.2 4 2 140.4 70.2 5 2 140.4 70.2 6 2 140.4 70.2 7 3 152.1 50.6 8 2 140.4 70.2 9 2 140.4 70.2 10 2 140.4 70.2 11 2 140.4 70.2 12 2 140.4 70.2 14 2 140.4 70.2 15 2 140.4 70.2 16 2 140.4 70.2 17 2 140.4 70.2 18 2 140.4 70.2 19 2 140.4 70.2 20 2 140.4 70.2 21 2 140.4 70.2 22 2 140.4 70.2 23 2 140.4 70.2 24 2 140.4 70.2 25 2 140.4 70.2 The minimum square footage for a 2-bed room should be 160 Sq. Ft. The client accommodations analysis form indicated room [ROOM NUMBER] accommodated 1 resident, and rooms #3, #4, #5, #6, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #25 accommodated 2 residents each and room [ROOM NUMBER] accommodated 3 residents. Observations made to the requested rooms during the annual recertification survey at the facility from 12/5/2023 to 12/8/2023, indicated there were no noted concerns with privacy, nursing care and/or safety to the residents. The evaluators observed in rooms 2, 3, 4, 5, 6,7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 that nursing staff had enough space to provide care to the residents, the curtains provided privacy for each resident, and the rooms had direct access to the corridors.

Based on interview and record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) data had been submitted to the Center for Medicare and Medicaid Services (CMS) for four of four required quarters (1st fiscal quarter due 02/14/2023, 2nd fiscal quarter due 05/15/2023, 3rd fiscal quarter due 8/14/2023, and 4th fiscal quarter due 11/04/2023) due in 2023. This deficient practice had the potential for low staffing in facility nursing care, leading to delay and/or lack of care, treatment, and services necessary to maintain physical and emotional well-being of residents. Findings: A review of the facility's Certification and Survey Provider Enhanced Reporting system (CASPER: Shows the facility percentage and how the facility compares with other facilities in their state and in the nation) indicated no PBJ data had been submitted from 7/1/2022 through 12/31/2023. A review of CMS' Staffing Data PBJ Submission website (https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission) indicated the deadlines for each reporting period as follows: The 1st fiscal quarter was from 10/01/2022 through 12/31/2022, the indicated submission due date was 02/14/2023. The 2nd fiscal quarter was from 01/01/2023 through 03/31/2023, the indicated submission due date was 05/15/2023. The 3rd fiscal quarter was from 04/01/2023 through 06/30/2023, the indicated submission due date was 08/14/2023. The 4th fiscal quarter was from 07/01/2023 through 09/30/2023, the indicated submission due date was 11/04/2023. During an interview with the Administrator (ADM) on 12/07/2023 at 11:00 AM., the ADM stated the person in charge of submitting the Payroll Based Journal was not available and did not know if the data had been submitted to CMS. During an interview with Business Office Manager (BOM) on 12/07/2023 at 1:00 PM., the BOM stated, the corporate Human Resources person in charge of submitting the Pay Base Journal was not available. The BOM stated if no one is available then the Business Office Manager is supposed to send the information to CMS. The BOM state she did not have any further information. The BOM stated, it is important to send the Payroll Based Journal to CMS, so they are aware of the nursing ratios in the facility. A review of the CMS PBJ Policy Manual dated 06/01/2022, indicated Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. The Policy Manual indicated Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline. CMS will conduct audits to assess a facility's compliance related to this requirement. The policy Manual also indicated Facilities that do not meet these requirements will be considered noncompliant and subject to enforcement actions by CMS. Note: If a facility uses a vendor to submit information on behalf of the nursing home, the nursing home is still ultimately responsible for meeting all the requirements. A review of the facility's policy and procedures titled, Reporting Direct-Care Staffing Information dated October 2017, indicated staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of practice to one of five sampled resident (Resident 1) by failing to ensure Resident 1 was with a responsible party when going out on pass per physician order. This deficient practice had the potential to negatively impact the delivery of care service provided to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1, was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and wheelchair dependence. A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 4/14/2023, indicated resident was moderately impaired in cognitive skill (thought processes) for daily decision making and from setup to one-person assistance with staff on activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). A review of Resident 1 ' s Order Summary Report, dated 11/5/2021, indicated that Resident 1 may go out on pass (OOP) with a responsible party for therapeutic purpose for four hours. A review of Resident 1 ' s SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) Communication Form, dated 4/20/2023, indicated Resident 1 went out of the facility without notifying the facility staff. A review of Resident 1 ' s Chart, indicated that Resident 1 signed himself out on the following dates: 4/21/2023; 4/22/2023; 4/26/2023; 5/4/2023; and 5/5/2023. During an interview with the Licensed Vocational Nurse 2 (LVN2) on 5/5/2023 at 12:33 p.m., LVN2 stated that since Resident had an episode of elopement on 4/20/2023, facility staff made Resident 1 sign himself out as OOP. During a concurrent interview and record review with the Director of Nursing (DON), on 5/5/2023 at 12:40 p.m., DON stated that Resident 1 should not be signing out on his own from the out on pass form per physician order. A review of the facility ' s policy and procedures (P&P), titled, Signing Residents Out, revised 8/2006, indicated that staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. A review of the facility ' s P&P, titled, Safety and Supervision of Residents, revised 7/2017, indicated that Resident safety and supervision and assistance to prevent accidents are facility wide priorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility failed to provide necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of five sampled resident (Resident 1) by failing to address behavioral health care needs by not providing elopement risk re-assessment; and failing to implement a person-centered care plan when Resident 1 had an episode of elopement. These deficient practices had the potential to negatively affect the delivery of behavioral health care and services to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1, was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and wheelchair dependence. A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 4/14/2023, indicated resident was moderately impaired in cognitive skill (thought processes) for daily decision making and from setup to one-person assistance with staff on activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). MDS also indicated that Resident 1 was taking anti-psychotic (classification of medication to treat psych illness) medication. A review of Resident 1 ' s Order Summary Report, dated 11/5/2021, indicated that Resident 1 may go out on pass with a responsible party for therapeutic purpose for four hours. A review of Resident 1 ' s SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. also, being used as documentation for any changes of condition) Communication Form, dated 4/20/2023, indicated Resident 1 went out of the facility without notifying the facility staff. A review of Resident 1 ' s Elopement Evaluation, dated 10/6/2021, indicated Resident 1 was not at risk for elopement. No other re-assessment was indicated in Resident 1 ' s chart. A review of Resident 1 ' s Chart, indicated missing elopement risk care plan. During a concurrent interview and record review with the Director of Staff Development/Infection Preventionist Nurse (DSD/IP) on 5/5/2023 at 12:09 p.m., DSD/IP verified and stated missing re-assessment of risk for elopement and elopement risk care plan for Resident 1. DSD/IP stated that since Resident 1 had an episode of elopement, staff must re-assess and evaluate risk for elopement and ensure elopement risk care plan will be initiated and implemented. A review of the facility ' s policy and procedures (P&P), titled, Wandering and Elopements, revised 3/2019, indicated that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. P&P also indicated that if identified as a risk for wandering, elopement or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the resident ' s safety. A review of the facility ' s P&P, titled, Comprehensive Person-Centered Care Plans, revised 12/2016, indicated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change. A review of the facility ' s P&P, titled, Behavioral Health Services, revised 2/2019, indicated that the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary behavioral assessment and monitoring to one of five sampled resident (Resident 1) by failing to accurately document Resident 1 ' s frequency of occurrences of any behavioral changes per physician order. This deficient practice had the potential to negatively affect the delivery of behavioral health care and services to Resident 1. Findings: A review of Resident 1 ' s admission Record indicated Resident 1, was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a mood disorder that causes persistent feeling of sadness and loss of interest) and wheelchair dependence. A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 4/14/2023, indicated resident was moderately impaired in cognitive skill (thought processes) for daily decision making and from setup to one-person assistance with staff on activities of daily living (ADLs-bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene). MDS also indicated that Resident 1 was taking anti-psychotic (classification of medication to treat psych illness) medication. A review of Resident 1 ' s Order Summary Report, dated 9/25/2022, indicated to give Seroquel (anti-psychotic medication) 25 milligram (mg, unit of measurement) by mouth at bedtime for psychosis as manifested by delusions due to sudden changes in mood such as irritability, impulsivity or aggression towards staff and peers. It also indicated to monitor behavior every shift for taking Seroquel as manifested by sudden changes in mood such as irritability, impulsivity or aggression towards staff and peers. A review of Resident 1 ' s Care Plan, revised on 1/24/2023, indicated that Resident 1 has a behavior problem related to psychosis manifested by delusions due to sudden changes in mood such as irritability, impulsivity or aggression towards staff and peers with interventions to monitor behavior episodes and attempt to determine underlying cause. A review of Resident 1 ' s SBAR (situation, background, appearance and review/notify- structured tool for healthcare provider that provides communication between members. Also, being used as documentation for any changes of condition) Communication Form, dated 4/20/2023, indicated Resident 1 went out of the facility without notifying the facility staff. A review of Resident 1 ' s Progress Notes, dated 4/20/2023, indicated Resident 1 was agitated, showing anger towards the staff and episode of hitting staff. A review of Resident 1 ' s Medication Administration Record (MAR), indicated no behavior issues from 4/20/2023 to 4/28/2023. A concurrent interview and record review with the Director of Nursing (DON), on 5/5/2023 at 1:32 p.m., the DON confirmed and stated missing behavioral occurrences documentation in the MAR and stated that it is important that staff document and tally episodes of behavior in order to see trends and make any necessary change for the resident. A review of the facility ' s policy and procedures (P&P), titled, Behavioral Health Services, revised 2/2019, indicated that the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. A review of the facility ' s P&P, titled, Charting and Documentation, revised 7/2017, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. P&P also indicated that the medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care.

Based on interview and record review, the facility failed to monitor and supervise one of four residents (Resident 1) to prevent falls. Resident 1 had a history of falling with fractures (A break in a bone), and osteopenia (A condition in which there is a lower-than-normal bone mass). This deficient practice resulted in Resident 1 slipping and falling from a wheelchair (WC) and sustained a left hip fracture on 3/7/2023. Resident 1 was transferred to a General Acute Care Hospital (GACH) on 3/9/2023 for further evaluation and care. Resident I had left hip surgery on 3/14/2023. Findings: A review of Resident 1's admission Record, indicated the facility originally admitted Resident 1 on 10/26/2021 and readmitted Resident 1 on 2/27/2023 with diagnoses including Alzheimer's disease (Gradual decline in memory, thinking, behavior and social skills), dementia (Loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), impulse disorder (A condition in which a person has trouble controlling emotions or behaviors), history of falling, and fracture of distal (A part of the body that is farther away from the center of the body) phalanx (Any digital bones of the hand or foot) of left finger. A review of Resident's physician order, dated 3/24/2022, timed at 11:35 a.m., indicated, May apply bed tab alarm (A system to alert staff when a resident attempts to stand up) to alert staff of unassisted transfer/ambulation. A review of Resident 1's care plan on Resident with High Risk for Falls related to gait (manner of walking)/balance (stability) problems, initiated on 3/24/2022, indicated the goal included, The resident [Resident 1] will not sustain serious injury . The resident will be free from falls. The interventions included to, Anticipate and meet the resident's needs. Remove any potential causes . The resident needs a safe environment with even floors . A review of Resident 1's care plan on Risk for Falls, initiated on 5/4/2022, indicated Resident 1 will be free of falls. The interventions included to evaluate Resident 1 fall risk on admission and as necessary (PRN). If resident is a fall risk, initiate fall risk precautions. The interventions also included, Determine resident's [Resident 2] ability to transfer. Evaluate fall risk on admission and as necessary (PRN). If resident is a fall risk, initiate fall risk precautions. Resident will have a tab alarm on the wheelchair as ordered to alert nurses of attempts to get out of the wheelchair unassisted. A review of Resident 1's Minimum Data Set (MDS- A standardized assessment and care screening tool) dated 2/1/2023, indicated Resident 1 had severely impaired cognition (Mental ability to make decisions of daily living). The MDS indicated Resident 1 required one staff physical assist with surface transfers, walking, bed mobility, locomotion [movement] on and off unit [facility], dressing and personal hygiene. The MDS indicated Resident 1 was not steady when moving from sitting to standing position, walking, turning around, surface transfer, and moving on and off the toilet. The MDS indicated Resident 1 used a wheelchair (WC) for mobility. A review of the facility's Inservice (Education) Meeting Minutes dated 2/3/2023, on Safety of a Resident, indicated, The safety of the resident is the utmost importance of our job. We have to make the environment as free from accident hazards as possible. Resident supervision is a core component of the systems approach to safety. Risk factors include: bed safety, safe lifting and movement of residents, falls . A review of Resident 1's Fall Risk Evaluation dated 2/28/2023, timed at 7:26 p.m., indicated Resident 1 score was 11 (If the total score is 10 or greater, the resident should be considered at high risk for potential falls). A review of Resident 1's care plan on Psychosocial Need (Having to do with the mental, emotional, social, and spiritual effects of a disease): Other Confusion (A decline in cognitive ability), dated 3/2/2023, indicated, Resident 1, Has episodes of confusion and disorientation (A mental state marked by confusion about time, place, or who one is) and repetitiveness R/T Alzheimer's disease. The goals included, Resident 1 will, Engage in daily routine activities safely. The interventions included, Provide . supervision. A review of Resident 1's Skilled Nursing facility Progress Note dated 3/7/2023, a physician documented Resident 1 fell in the backyard. A review of Resident 1's Radiology (X-ray) Results Report dated 3/8/2023 and timed at 1:15 p.m., indicated the reason for the study was pain in the left hip for Resident 1. The radiology results report indicated, There is a fracture (Break in a bone) involving the left greater trochanter (Hip bone) with no displacement . There is osteopenia. A review of Resident 1's General Note, dated 3/9/2023, timed at 3:21 p.m., indicated Emergency Medical Transport (EMT- Ambulance services for an emergency medical condition) was the facility but Resident 1 refused to go to GACH. A review of Resident 1's Skilled Nursing Facility (SNF)/ Nursing Facility (NF) to Hospital Transfer Form dated 3/9/2023, indicated the facility transferred Resident 1 to a hospital on 3/9/2023 at 7:10 p.m. The SNF/NF to hospital form indicated Resident 1 was a high risk for fall. A review of Resident 1's Physician Progress Notes dated 3/10/2023 timed at 10:43 a.m., indicated reason for study was pain in the left hip. The radiology Resident 1 had left greater trochanter fracture and osteopenia). A review of Resident 1's GACH history and physical (H&P) dated 3/11/2023, indicated Resident was admitted to GACH on 3/9/2023 after falling at the facility on 3/7/2023. The H&P indicated an Xray performed at the facility on 3/8/2023, confirmed Resident 1 had a fracture on the left hip and that Resident 1 had refused to go to GACH. However, the H&P further indicated Resident 1 agreed to go to GACH on 3/9/2023. A review of Resident 1's Progress Note- Therapy. Dated 3/14/2023, timed at 9:39 a.m., indicated Resident 1 was not seen because, The plan is for operating room (OR) for hip pinning. A review of Resident 1's GACH Progress Notes-Physician, dated 3/15/2023, timed at 12;21 p.m., indicated, Resident 1 was, Status post (after) hip surgery yesterday (3/14/2023). On 3/22/2023 at 1:42 pm., during an interview, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 health has slowly deteriorated (Declined). LVN 1 stated she heard that Resident 1 had unwitnessed fall on 3/4/2023 on the 3 p.m. to 11 p.m. shift. LVN 1 stated a charge nurse working the 11 p.m. to 7 a.m., shift, reported that Resident 1 complained of left hip pain, a medical doctor (MD) was notified, and a stat (now) x-rays ordered and done. LVN 1 stated Resident 1 agreed to be transferred to a GACH for evaluation of for possible fracture. LVN 1 stated Resident 1 had left hip surgery performed while at GACH. On 3/22/2023 at 2:52 p.m., during an interview, LVN 3 stated on 3/7/2023 at around 4 p.m., Certified Nursing Assistant 5 (CNA 5) notified her [LVN 3] that Resident 1 was on the grass in the patio. LVN 3 stated she found Resident 1 laying on the left on the grass. LVN 3 stated Resident 1 told her that he [Resident 1] slid from the wheelchair. On 3/22/2023 at 3:40 p.m., during an interview, the Director of Staff Development (DSD) stated CNA 5 found Resident 1 on the grass in the patio on 3/7/2023. The DSD stated Resident 1 had unwitnessed fall, stat Xray of the left hip was ordered on 3/8/2023. On 4/14/2023 at 3:09 p.m., during an interview, CNA 5 stated Resident 1 was alert but forgetful. CNA 5 stated that on 3/7/2023 at around 3p.m. and 4 p.m., she [CNA 5} was abought to put another resident's WC outside the patio when she saw Resident 1 lying on the grass area on his side next to his [Resident 1] WC. CNA 5 stated she called the charge nurse (unable to recall the staff) who responded quickly. CNA 5 stated the charge nurse assessed Resident 1 and assist Resident 1 back into the WC. CNA 5 stated no other resident or staff were around in the patio when she [CNA 5] found Resident 1 lying on the grass. CNA 5 stated, It does not matter if a nurses endorsed to her that a resident was at risk. All residents are high risk regardless. So, it is important to check on the resident all the time. On 4/14/2023 at 3:36 p.m., during a concurrent interview and record review with the Director of Nursing (DON), Resident 1's medical chart was reviewed. The DON stated Resident 1 was a high risk for fall. A review of Resident 1's facility admission Summary note dated 3/16/2023, timed at 9:58 p.m., indicated the facility readmitted Resident 1 on 3/19/2023, at 8:30 p.m. Resident 1 was noted with 1 [one] staple (A metal fastener used to hold layers of tissue together to close an incision [cut]) on the left knee, eight staples on the left hip, and five staples on the left upper thigh. A review of the facility's policy and procedures (P&P), titled, Safety and Supervision of Residents, revised 7/2017, indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 3. Employees shall be trained on potential accident hazards . on how to identify and report accident hazards and try to prevent avoidable accidents. The P&P under System Approach to Safety indicated, 2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The P&P under, Resident Risks and Environmental Hazards, indicated, . These risk factors and environmental hazards include: . c. Falls. E. Unsafe wandering. A review of the facility's policy and procedures, titled, Falls-Clinical Protocol, dated 3/2018, indicated under Assessment and Recognition 3. The staff and practitioner will review each resident's risk factors for falling and document in the medical record. A. Examples of risk factors for falling include . cognitive impairment, weakness, environmental hazards, and confusion . A review of the facility's policy and procedures, titled, Falls and Fall risk, managing, revised 3/2018, indicated, Based on previous evaluation and current data, the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications of falling . Fall Risk Factors: 1.d. obstacles in the footpath. The P&P under, General guidelines, indicated, 1. Falls are a leading cause of morbidity (The state of having an illness or medical condition) and mortality (The death rate) among elders in nursing homes. 3. Falling may be related to . environmental risk factors. A review of the facility's Falling Star Program, revised 3/1/2023, indicated under bullet point, 2. Monitoring . Monitor residents who attempt to transfer without assistance. Monitor residents who ambulate or attempt to ambulate (walk) without assistance - if resident is unable to ambulate independently. 3. Interventions: Assess resident environment and make appropriate changes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop comprehensive care plans (measurable short-term and long-term objectives and timetables to meet the needs of each resident) for two of 29 sampled residents (Residents 23 and Resident 24). This deficient practice had the potential to not identify needs and implement individualized plan of care timely for Resident 23 and Resident 24. Findings: 1.A review of the admission Record (Face Sheet), indicated the facility admitted Resident 23 on 5/24/2019, with diagnoses including end stage renal disease (ERSD, kidneys are no longer able to work as they should to meet your body's needs), Type 2 diabetes mellitus (abnormal blood sugar), and hyperlipidemia (abnormal cholesterol). A review of the Resident 23's Minimum Data Set (MDS, a standardized care and screening tool) dated 3/3/2021, indicated Resident 23 cognition (ability to understand, remember, learn and make decisions of daily living) was intact. The same MDS indicated Resident 23 required extensive assistance (ADLs, bed mobility, transfer, walking, locomotion on and off the unit, toilet use, and personal hygiene). During an interview on 4/6/21 at 11:25 a.m., Certified Nurse Assistant 1 (CNA 1) stated, Resident 23 is continent (ability to control) of bowel (stool). However, CNA 1 further stated Resident 23 wears incontinent brief. During an interview on 4/6/2021 at 11:56 a.m., Resident 23 stated, he receives physical therapy about once a week, and that he is able to stand using a front wheel walker (walk device with two front wheels). Resident 23 stated, he is aware when he has a bowel movement in his incontinent brief, and he calls the staff to change him. During an interview on 4/7/2021 at 9:15 a.m., Physical Therapy Assistant (PTA), stated, Resident 23 is involved in PT activity and requires oversight, encouragement, or cuing with minimum assist. The PTA stated staff provide guided limbs maneuvers or other non-weight bearing assistance to Resident 23. PTA stated he thinks Resident 23 is able to use a bedside commode (portable toilet). During an interview on 4/7/21, 9:20 a.m., Certified Occupational Therapy Assistant, (COTA) stated, he worked with Resident 23 to improve the resident's ADLs and muscle strength. COTA stated, he never offered Resident 23 can get up and go to the bathroom. During an interview on 4/7/2021 at 10:55 a.m., the Director of Nurses (DON) stated, the facility did not document that Resident 23 is incontinent, wears incontinent brief or bowel training was attempted. The DON further stated that the facility did not develop bowel training care plan for Resident 23. The DON stated Resident 23 may experience a decrease in quality of life. 2. A review of the admission Record indicated the facility admitted Resident 24 on 2/25/2021, with diagnoses including anxiety disorder (feelings of worry, fear that interferes with daily activities), major depressive disorder (persistent feelings of sadness, low esteem, hopelessness), and Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). A review of Resident 24's MDS, dated [DATE], indicated Resident 24's cognition was intact. The same MDS indicated Resident 24 is not steady moving from seated to standing position, walking, turning around, and surface-to-surface transfer. During an observation on 4/5/2021 at 8:59 a.m., Resident 24 had a box and a green bag on a four-wheel dolly (device to move items) at his bedside, that obstructed the path to the resident's bed. During an interview on 4/6/2021 at 1:00 p.m., Resident 24 stated that he needed to go through the items at the bedside and decide what to keep. Resident 24 stated he uses a wheelchair and was difficult at times to move around in the room and exit the room because of lack of space in his room. During an interview on 4/6/2021 at 2:15 p.m., the Director of Nurses (DON) stated, Resident 24's belongings at the bedside was a safety concern because the Resident 24 was not able to exit the room safely. The DON further stated that the facility did not develop a care plan to address the resident's belongings and dolly at the bedside. A review of the facility's policy and procedure, Care Plans, Comprehensive Person-Centered, undated, indicated, 8. The comprehensive, person-centered care plan will: .b. describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .g. incorporate identified problem areas; h. incorporate risk factors associated with identified problems; i. build on the residents strengths; .m. aid in preventing or reducing decline in the resident's functional status and/or functional levels; .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a homelike and safe environment for two of 29 sampled residents (Resident 15 and Resident 24). This deficient practice had the potential for accidents and injury for Resident 24. Findings: A review of the admission Record indicated the facility admitted Resident 24 on 2/25/2021, with diagnoses including anxiety disorder (feelings of worry, fear that interferes with daily activities), major depressive disorder (persistent feelings of sadness, low esteem, hopelessness), and Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). A review of Resident 24's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 3/3/2021, indicated Resident 24's cognition (the mental processes involved in gaining knowledge and comprehension) is intact. The same MDS indicated Resident 24 is not steady moving from seated to standing position, walking, turning around, and surface-to-surface transfer. During an observation on 4/5/2021 at 8:59 a.m., Resident 24 had a box and a green bag on a four-wheel dolly (device to move items) at his bedside, that obstructed the path to the resident's bed. During an interview on 4/6/2021 at 1:00 p.m., Resident 24 stated that he needed to go through the items at the bedside and decide what to keep. Resident 24 stated he uses a wheelchair and was difficult at times to move around in the room and exit the room because of lack of space in his room. During an interview on 4/6/2021 at 2:15 p.m., the Director of Nurses (DON) stated, Resident 24's belongings at the bedside was a safety concern because the resident experienced difficulty exiting the room safely. A review of the Facesheet (admission Record) indicated the facility admitted Resident 15 on 1/8/1998 with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), hypertension (abnormal blood pressure), and chronic pain. A review of Resident 15's MDS dated [DATE], indicated Resident 15's cognition is intact. A review of Resident 15's History and Physical (H&P) dated 2/26/2021, indicated Resident 15 has the capacity to understand and make decisions. During an observation on 4/5/2021, at 10:12 a.m., several personal belongings were spread on the floor under both sides of Resident 15's bed. The items not limited to lipstick, plastic container of cotton swabs, a reusable bag, empty opened box, box of tissues, plastic storage containers, colorful square storage containers, round plastic storage container, books, spray bottle with liquid, green bottle of lotion, plastic bags, box of candy, and other items on the ground under both sides of bed. In a concurrent interview, Resident 15 stated she needed someone to pick up her box of tissues located on the floor. In a concurrent observation at 10:22 a.m., Licensed Vocational Nurse 2 (LVN 2) responded to Resident 15's call light and picked up the resident's belongings off floor. During an interview on 4/7/21, at 11 a.m., LVN 2 stated she was shocked at the clutter in Resident 15's room. LVN 2 further stated the clutter was safety and infection control concern. A review of the facility's policy and procedures titled Personal Property, with revised date of 9/2012, indicated, Each resident's room is equipped with private closet space that includes clothes racks and shelving and that permits easy access to the resident's clotheing. A representative of the admitting office will advise the resident prior to or upon admission, as to the types amd amount of personal clothing and possessions that the resident may keep in his or her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Monitor blood sugar monitoring and administer insulin (medication to manage abnormal blood sugar) for one of 29 residents (Resident 24), and 2. Administer insulin to one of 29 residents (Resident 24). Findings: A review of the admission Record indicated the facility admitted Resident 24 on 2/25/2021, with diagnoses including anxiety disorder (feelings of worry, fear that interferes with daily activities), major depressive disorder (persistent feelings of sadness, low esteem, hopelessness), and Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). A review of Resident 24's MDS, dated [DATE], indicated Resident 24's cognition was intact. The same MDS indicated Resident 24 was not steady moving from seated to standing position, walking, turning around, and surface-to-surface transfer. During a record review on 4/6/21 at 2:35 p.m., Resident 24's medication administration record (MAR), dated 03/01/2021 through 03/31/2021, indicated, the resident's blood sugar was not monitored on 3/11/2021 before breakfast, and before lunch on 3/12/2021. In a concurrent interview, the registered nurse Supervisor (RN Sup) stated, Resident 24's blood sugar should be monitored before breakfast and lunch. During a record review on 4/6/21 at 2:42 p.m., Resident 24's Certified Nursing Assistant (CNA)-Activities of Daily Living (ADL, including walking, eating, hygiene, grooming, toileting) Tracking Form indicated, Resident 24 consumed 100 percent (%) breakfast on 3/11/21, and 100% lunch on 3/12/21. In a concurrent interview, RN Sup acknowledged and stated Resident 24 consumed 100% breakfast and 100% lunch according to the CNA-ADL Tracking form. The RN Sup further stated Resident 23's blood sugar was not monitored before meals. During a record review on 4/6/21 at 2:42 p.m., Resident 24's MAR, dated 3/01/2021 through 3/31/2021, indicated Insulin Lispro (medication to control blood sugar levels) was not administered before breakfast on 3/11/2021, or before lunch on 3/12/2021. In a concurrent interview, the RN Sup acknowledged and stated Resident 24 did not receive insulin before breakfast and before lunch. During a record review on 4/6/2021 at 2:45 p.m., Resident 24's Physician Orders dated 2/25/2021, indicated to inject 12 units (dose measurement) Insulin Lispro before meals for Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). Resident 24's Physicians Telephone Order, dated 3/17/2021, indicated to administer a one-time, 12 units of Insulin Lispro. In a concurrent interview, the RN Sup stated the one-time dose insulin order was because Resident 24's blood sugar was elevated (high). During a record review on 4/6/21 at 2:50 p.m., Resident 24's SBAR (Situation, Background, Assessment, and Request) report, dated 3/17/21, indicated Resident 24's blood sugar level was greater than 600 (normal blood sugar level is between 70-110) on 3/17/21 at 12:00 p.m. In a concurrent interview, the RN Sup acknowledged and stated Resident 24 required 12 units of Insulin Lispro for elevated blood sugar level. During a record review with the RN Supervisor on 4/6/21 at 2:52 p.m., Resident 24's MAR dated 3/17/21 did not indicate the resident received one-time dose of 12 units of Insulin. The RN Sup acknowledged and stated Resident 24 stated it was not documented that the resident received insulin on 3/17/21. A review of the facility's policy and procedures titled Documentation of Medication Administration, indicated, Documentation must include, as a minimun: method of administration .date and time of administration, reason(s) why a medication was withheld, not administered, or refused (as applicable).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure: 1. Eleven expired (outdated) medications were not available for use in one of one medication storage cabinet. 2. The emergency kit (E-Kit, a portable container of emergency drugs, medication, or supply) usage record, indicated the name of the resident who received the medication. 3. Accurate documentation of removed controlled substance (a drug which has been declared by federal or state law to be illegal for sale or use) for two of 29 sampled residents (Resident 24 and Resident 13). These deficient practices had the potentials for medication errors, diversion, ineffective therapy, and or adverse effects, detrimental to the residents' health and or conditions. Findings: 1. On 4/6/2021 at 11:07 a.m., during an observation and inspection of the medication storage cabinet located inside the rehabilitation room, licensed vocational nurse 1 (LVN 1), LVN 1 verify and stated the following had expired: a. Two bottles of Geri kot (Senokot, medication for constipation) with 1000 tablets per bottle expired March 2021. b. One bottle of Ferrous Sulfate (iron supplement) 220 milligram (mg) per 5 milliliter (ml, measurement unit) elixir (liquid) in 473 ml size expired February 2021. c. Five bottles of Magnesium Oxide (a mineral supplement) 400 mg with120 tablets per bottle. The five bottles had dark orange labels covering the expiration dates. One of 5 bottles indicated the medication expired in July 2020. LVN 1 was not able to remove the labels on the remaining 4 bottles to reveal expiration dates. d. Two bottles of Gericare One-Daily multiple vitamins (supplement) with 100 tablets per bottle, expired in February 2021. e. 1 bottle of Hy[DATE] (sodium hypochlorite 0.25%, for wound care) topical solutions, 473 ml in size, expired on 2021/01/06 (year/month/day). On 4/6/2021 at 11:27 a.m., during an interview, the director of nursing (DON) acknowledged and stated that Geri kot, Ferrous Sulfate, Magnesium Oxide, Gericare, and Hy[DATE] found in the medication storage cabinet had expired. The DON further acknowledged and stated the facility was not to determine whether the 4 bottles of magnesium oxide tablets with dark orange labels were outdated/expired. Review of the facility policy and procedure, Storage of Medications revised in November 2020, indicated . Drug containers that have missing, incomplete, improper, or incorrect labels are returned . Discontinued, outdated, or deteriorated drugs . are returned . or destroyed. 2. On 4/7/2021 at 11:12 a.m., during a review of the E-kit records with LVN 1, the E-kit Usage Slip dated 2/25/2021 timed 9:00 p.m., indicated one tablet of Augmentin (medication to treatment certain infections) 875/125 mg and two capsules of Doxycycline Hyclate (medication to treatment certain infections) were removed from the E-kit. The same E-kit Usage Slip did not indicate the name of the resident(s) who received Augmentin and Doxycycline. In a concurrent interview, the Registered Nurse Supervisor (RN Sup) stated the nurse who removed the medications, did not document the resident's name and was not know which resident received the medications. A review of the facility's undated policy and procedure titled Emergency Kit (E-Kit) Use, indicated .records will be completed according to Title 22 regulations [California Code of Regulations], which includes documentation in the E-kit Log and the E-Kit Drug card inside the kit. A review of the California Code of Regulations Title 22 § 72377(b)(C)(5) indicated Separate records of use shall be maintained for drugs administered from the supply. Such records shall include the name and dose of the drug administered, name of the patient, the date and time of administration and the signature of the person administering the dose. 3. A review of the admission Record indicated the facility admitted Resident 24 on 2/25/2021, with diagnoses including anxiety disorder (feelings of worry, fear that interferes with daily activities), major depressive disorder (persistent feelings of sadness, low esteem, hopelessness), and Type 2 diabetes mellitus with hyperglycemia (high levels of sugar in the blood). A review of Resident 24's MDS, dated [DATE], indicated Resident 24's cognition was intact. The same MDS indicated Resident 24 is not steady moving from seated to standing position, walking, turning around, and surface-to-surface transfer. During record review on 4/6/2021 at 3:0 p.m., of Resident 24's Medication Administration Record (MAR) dated 3/1/2021 to 3/31/2021, and the facility's Controlled Drug Tracking Log for March 2021, indicated the number of Oxycodone HCL (controlled medication to treat moderate to severe pain) 15 mg tablets removed from a medication cart was greater than the number of Oxycodone HCL 15 mg tablets administered to Resident 24 indicated on: 3/01/21- removed five Oxycodone HCL 15 mg tablets. However, three tablets administered. 3/12/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/15/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/16/21 - removed four Oxycodone HCL 15 mg tablets. However, one tablet administered. 3/18/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/19/21 - removed six Oxycodone HCL 15 mg tablets, However, four tablets administered. 3/20/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/21/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/22/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. 3/24/21 - removed six Oxycodone HCL 15 mg tablets. However, four tablets administered. 3/25/21 - removed six Oxycodone HCL 15 mg tablets. However, four tablets administered. 3/26/21 - removed six Oxycodone HCL 15 mg tablets. However, five tablets administered. In a concurrent interview the RN Sup stated the documented number of Oxycodone HCL 15 mg tablets administered to resident 24 and the number of medication tablets removed from the medication cart did not match and that was a discrepancy. 4. A review of the admission Record (Face Sheet), indicated the facility admitted Resident 13 on 1/25/2021 with diagnoses including: chronic obstructive pulmonary disease (inflammatory lung disease that obstructs airflow from the lungs), hyperlipidemia (high cholesterol), and hypertension (high blood pressure). A review of the MDS, dated [DATE], indicated Resident 13's cognition is intact. The MDS indicated Resident 13 needed limited assistance with bed mobility and personal hygiene, and extensive assistance with transfer and dressing. A review of Resident 24's Physician Orders dated 2/25/21, indicated to administer Oxycodone HCL 15 mg tablet, one tablet by mouth, every four hours as needed Not to Exceed (NTE) 90 mg per day for severe pain. During record review on 4/7/21 from 11:40 a.m., Resident 13's MAR dated 3/1/2021 through 3/31/21, and the facility's Controlled Drug Tracking Log dated March 2021, indicated the number of Percocet (medication to treat moderate to severe pain), 325 mg-5 mg tablets removed from the medication cart was greater than the number of tablets administered to Resident 24, indicated on: 3/01/21 - removed two tablets Percocet 325 mg-5 mg. However, one tablet administered. 3/08/21 - removed two tablets Percocet 325 mg-5 mg. However, one tablet administered 3/15/21 - removed two tablets Percocet 325 mg-5 mg. However, one tablet administered 3/16/21 - removed two tablets Percocet 325 mg-5 mg. However, one tablet administered 3/17/21 - removed one tablet Percocet 325 mg-5 mg. However, zero tablets administered 3/19/21- removed one tablet Percocet 325 mg-5 mg removed. However, zero tablets administered 3/21/21 - removed three tablets Percocet 325 mg-5 mg. However, one tablet administered 3/24/21 - removed three tablets Percocet 325 mg-5 mg. However, one tablet administered In a concurrent interview the RN Sup stated there was a discrepancy between the number of Percocet administered to Resident 13 and the number of Percocet tablets removed from the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications at bedside were properly labeled and securely stored for one of 29 sampled residents (Resident 37) and ensure the medication refrigerator at the nursing station was locked and secure. These deficient practices had the potentials of unauthorized access to medications including controlled substances, and/or medication errors, that may affect residents' health conditions. Findings 1. A review of Resident 37's admission Record, indicated the facility admitted the resident on 12/6/2019 with diagnoses including Parkinson's Disease (disorder of the central nervous system that affects movement), anxiety disorder (feelings of worry, fear that interfere with daily activities) and major depressive disorder (depressed mood and long-term loss of pleasure or interest in life). A review of Resident 37's Minimum Data Set (MDS, a standardized care screening and assessment tool) dated 3/11/2021, indicated Resident 37's cognition (ability to learn, understand, reason, and make decisions of daily living) was intact. The same MDS indicated Resident 37 required supervision with bed mobility, surface transfer, and required limited assistance with dressing, toilet use, and personal hygiene. 2. A review of the admission Record indicated the facility admitted Resident 31 on 12/10/2020 with diagnoses including hyperlipidemia (abnormal fat levels in the blood), major depressive disorder, and vascular dementia (is a loss of mental ability severe enough to interfere with normal activities of daily living). A review of Resident 31's MDS, dated [DATE], indicated Resident 31's cognition for daily decision making was moderately impaired. During an observation and concurrent interview on 4/5/2021 at 8:45 a.m., Optimum Zinc Sulfate, 220 milligrams (mg), Ascorbic Acid, 500 mg, Magnesium oxide, 400 mg, Calcium 500 mg and Vitamin D4, 400 international unit (IU), medications were observed on a common shelf between Resident 37's and Resident 31's beds and were not labelled with a resident's name. In a concurrent interview, Resident 31 stated, the medications belonged to her. During an interview on 4/5/2021 at 12:34, RN Supervisor (RN Sup) verified and stated the medications belonged to Resident 37 and that the resident self-medicates. RN Supervisor further stated the medications were not labelled with Resident 37's name. The RN Sup stated a negative outcome of not having the medications labeled is the other resident in the room may take the medications. A review of the facility's undated policy and procedure titled, Self-Administration of Medications, indicated, Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents . A review of the facility's undated policy & procedure titled, Labeling of Medication Containers, indicated, Labels for over-the-counter drugs shall include all necessary information, such as: a. The original label; b. The resident's name; c. The expiration date when applicable; and d. Directions for use and appropriate accessory/cautionary statements . 3. On 4/6/2021 at 9:05 AM, during an observation and inspection at a nursing station with Registered Nurse Supervisor (RN Sup), the refrigerator had two unlocked padlocks were hanging on the side of the refrigerator door. In a concurrent interview, RN Sup) stated the refrigerator is the medication refrigerator and was unlocked. The refrigerator had medications labeled for multiple residents, insulin (medication to manage abnormal blood sugar), controlled substances (a drug or chemical whose manufacture, possession, or use is regulated by a government), and two emergency kits (kit for emergency use medication and or supplies). A review of the facility's policy and procedure titled Storage of Medications revised November 2020, indicated .Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to prepare and administer medications have access to locked medications . Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, . containing drugs . are locked when not in use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1.Provide a sanitary environment for four of 29 sampled residents (Residents 15, 26, 28, and 35). 2.Ensure that two of two transporters (Male 1 and Male 2) practiced the facility's infection control guidelines and recommendations in the yellow zone (area in the facility where residents who are observed for signs and symptoms Coronavirus 2019 (COVID-19, a severe respiratory illness caused by a virus and spread from person to person) during COVID-19 Pandemic (a disease spreads very quickly and affects a large number of people over a wide area or throughout the world). 3.Ensure a trash can did not overflow with trash inside the room for Resident 26 and Resident 28. Theses deficient practices had the potential to spread infection and COVID-19 among residents and staff. Findings: 1.A review of the Facesheet (admission Record) indicated the facility admitted Resident 15 on 1/8/1998 with diagnoses including paraplegia (the inability to voluntarily move the lower parts of the body), hypertension (abnormal blood pressure), and chronic pain. A review of Resident 15's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 2/13/2021, indicated Resident 15's cognition (the mental processes involved in gaining knowledge and comprehension) was intact. A review of Resident 15's History and Physical (H&P) dated 2/26/2021, indicated Resident 15 has the capacity to understand and make decisions. During an observation on 4/5/2021, at 10:12 a.m., several personal belongings were spread on the floor under both sides of Resident 15's bed. The items not limited to lipstick, plastic container of cotton swabs, a reusable bag, empty opened box, box of tissues, plastic storage containers, colorful square storage containers, round plastic storage container, books, spray bottle with liquid, green bottle of lotion, plastic bags, box of candy, and other items on the ground under both sides of bed. In a concurrent interview, Resident 15 stated she needed someone to pick up her box of tissues located on the floor. In a concurrent observation at 10:22 a.m., Licensed Vocational Nurse 2 (LVN 2) responded to Resident 15's call light and picked up the resident's belongings off floor. During an interview on 4/7/21, at 11 a.m., LVN 2 stated she was shocked at the clutter in Resident 15's room. LVN 2 further stated the clutter was safety and infection control concern. During an interview on 4/7/21, at 12:28 p.m. the Director of Nursing (DON), acknowledged Resident 15's miscellaneous items and belongings on the floor and stated there is an infection control issue because of Resident 15's clutter. 2. A review of the Facesheet indicated the facility admitted Resident 4 on 10/27/2020 and readmitted Resident 4 on 3/3/2021 with diagnoses chronic (long-term) kidney disease, dependence on renal (kidney) dialysis (treatment for kidney failure to remove unwanted toxins, waste products and excess fluids from the body). Resident 4 was admitted in the yellow zone. A review of Resident 4's H&P dated 3/6/2021, indicated Resident 4 has the capacity to understand and make decisions of daily living. A review of Resident 4's MDS dated [DATE], indicated Resident 4's cognition is intact. During an observation together with the DON on 4/7/2021 at 9:33 a.m., two male staff wearing N95 masks (facepiece respirator device that filters at least 95% of airborne particles) and gloves while transporting Resident 35. The two males (Male 1 and Male 2) entered Resident 35's room in the yellow zone (unit for resident potentially exposed to COVID-19 virus) and, did not wear isolation gowns (personal protective equipment serves as a barrier between patient and caregivers from infectious droplets, fluid penetration and solids) or face shields (an item to protect the wearer's entire face from hazards such as flying objects and road debris, chemical splashes, or potentially infectious material/substances), change gloves or perform hand hygiene. Male 1 and Male 2 two then transferred Resident 35 from the gurney (a bed on a frame with wheels that is used for moving people) onto the resident's roommate bed. Male 1 touched and moved Resident 35's trash can and pulled Resident 35's privacy curtain with the same contaminated. Male 1 and Male 2 exited Resident 35's room and did not perform hand hygiene nor changed their gloves. During an interview on 4/7/21, at 9:35 a.m., the DON acknowledged that Male 1 and Male 2 did not don face shields or isolation gowns, did not change gloves, or perform hand hygiene prior to or after assisting Resident 35 located in the yellow zone. During an interview on 4/7/21, at 9:43 a.m., DON stated that Male 1 and Male 2 should follow the facility's infection control protocol. During an interview on 4/7/21, at 12:17 p.m., Infection Preventionist Nurse 1 (IPN 1) stated and confirmed that Male 1 and Male 2 transporters should follow the facility's infection control protocol and should have placed Resident 35 in the correct bed to ensure infection control was maintained. A review of the facility's policy and procedure titled, Infection Control Guidelines for All Nursing Procedures, revised on 10/2010, indicated the purpose is to provide guidelines for general infection control while caring for residents. Standard Precautions will be used in the care of all residents in all situation regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for Before and after direct contact with residents after contact with a resident's intact skin, after contact with objects In the immediate vicinity of the resident, and after removing gloves. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. A review of the facility's policy and procedure titled, COVID-19, Prevention and Control, revised on 3/8/2021, indicated, the facility follows current guidelines and recommendations for the prevention and control of COVID-19 Standard Precautions - presumes that all moist body fluids from all residents/patients are colonized or infected with one or more transmissible infectious agents. In addition to hand hygiene Standard Precautions require gowns, gloves, masks and face shields when health care personnel (HCP) anticipate that their hands, clothes, mucous membranes of the yes, nose, or mouth or skin on the face will be exposed to blood or body fluids. Standard Precautions are always used in addition to the Transmission-Based Precautions and Intensified Interventions. 3a. A review of Resident 26's admission Record, indicated the facility admitted Resident 26 on 12/1/2020, with diagnoses including: COVID-19, Type 2 diabetes mellitus (abnormal blood sugar), and hypertension. A review of Resident 26's MDS dated [DATE], indicated Resident 26's cognition was severely impaired. The MDS indicates Resident 26 needed extensive assistance with bed mobility transfer, locomotion on and off the unit, toilet use, and personal hygiene. 3b. A review of Resident 28's admission Record, indicated the facility admitted Resident 28 on 2/15/2021, with diagnoses including: COVID-19, hypertension, and major depressive disorder (a mental health disorder characterized by a persistently depressed mood and loss of interest in activities). A review of the MDS, dated [DATE], indicated Resident 28's cognition was intact. The MDS indicated Resident 28 was totally dependent with bed mobility, transfer, locomotion on and off the unit, and toilet use, and needed extensive assistance with dressing and personal hygiene. During an observation on 4/5/2021 at 8:29 a.m., a trash can with overflowing trash, a glove and gauze (wound care supply) with a red substance were on the floor next to the trash can, and gloves hanging over the side of the trash can, were observed inside Resident 26 and Resident 28's room. During an interview on 4/6/2021 at 2:18 p.m., DON stated, the trash overflowing and on the floor is not acceptable and was an infection control issue. A review of the facility's policy and procedures titled, Infection Control Guidelines for All Nursing Procedures, revised on 10/2010, indicated, Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including: The facility protocols for isolation (stanadard and transmission-based precautions). A review of the Centers of Disease Control and Prevention (CDC, US agency charged with tracking and investigating public health trends) document titled Infection Control Guidance Updated 2/23/2021, indicated CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. These practices are intended to apply to all patients, not just those with suspected or confirmed SARS-CoV-2 infection .should be worn by health care provider (HCP) for source control while in the facility and for protection during patient care encounters including N95 respirator OR a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators Eye protection should be worn during patient care encounters to ensure the eyes are also protected from exposure to respiratory secretions. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html