**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, policy review and staff interviews for 1 of 1 resident reviewed for choices (Resident #71), the facility failed to honor a family member's choice regarding having the resident out of bed to a chair by 11:00 AM. The findings include: Resident #71's diagnoses included early-onset Alzheimer's disease and seizure disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #71 with short-term and long-term memory impairments and noted dependence with eating, toileting, and transferring to and from a bed to a chair. The MDS further identified Resident #71 as incontinent of bladder and bowel. The care plan dated 4/22/24 identified Resident #71 had little, or no group activity involvement related to dementia and behaviors. Interventions included: assisting/escorting to activity functions and indicated resident preferred socializing with nursing staff and spouse. The care plan also noted at risk for Activities of Daily Living (ADL) self-care performance deficit related to dementia. Interventions included: transferring the resident out of bed with the assistance of two staff members and a mechanical lift. The care plan for communication problems related to dementia. Interventions included anticipating and meeting the residents' needs. A psychiatric follow-up note dated 5/1/24 identified Resident #71 was non-verbal and did not respond to his/her name or to family. Additionally, the psychiatric follow-up indicated that the resident's spouse visits daily. On 5/7/24 at 3:00 PM, an interview with (Person # 3) identified the resident does not get out of bed in the morning. Person # 3 further indicated s/he would like Resident # 71 to be get out of bed in the morning by 11:00 AM so s/he could take the resident outside for a walk when s/he visits 11:30 AM to 1:30 PM. Person #3 indicated s/he have complained and spoken to staff about this concern and the resident is still not consistently out of bed by the time s/he arrives to visit. On 5/8/24 at 9:34 AM, an observation identified the resident in bed with a gown on. An observation at 11:29 AM identified Resident # 71 in bed and dressed. An observation at 11:35 AM was made of Nurse Aide (NA#2) pushing a mechanical lift into the resident's room. A follow-up interview with Person # 2 on 5/8/24 at 11:40 AM indicated s/he arrived to visit Resident # 71 at 11:15 AM and found the resident in bed. Person # 3 further indicated that it takes time for staff to transfer the resident using the mechanical lift, which takes time away from the time s/he could spend visiting with the resident. On 5/8/24 at 2:18 PM, an interview with NA #1 indicated staff tried to put the resident in the chair at the same time every day. NA#1 indicated that around 11:00 AM the resident is regularly incontinent of urine and stool, so staff will wait for the incontinent episode before moving the resident to the chair. NA#1 further indicated if the resident is transferred to the chair before the resident's incontinent episode, the staff would have to use the mechanical lift to transfer the resident back to the bed to be cleaned and then once again to the chair. On 5/8/24, an interview with NA #2 identified NA#2 was new to the facility and unaware Resident # 71 had a specific time to get up. NA#2 indicated she started getting things ready to get the resident up out of bed when Person # 3 arrived and told her the resident should be taken out of bed to chair. NA#2 also indicated that part of her workflow is to help the residents who are ambulatory to get out of bed first and then the residents who require assistance from another staff member but have no set time to get up. On 5/8/24 at 2:31 PM, an interview with LPN#3 indicated Person # 3 arrives to visit every day around 11:00 AM or 11:15 AM and when it is warm outside, Person # 3 would take the resident outside and sit on a bench. Additionally, LPN#3 indicated the resident tends to be incontinent of stool around 11:00 AM, and if staff were to get the resident up before then the resident would be incontinent of stool while in the chair. Additionally, LPN#3 indicated when Person # 3 arrives and notices that the resident is incontinent of stool while on the chair, Person # 3 complains about the resident being cleaned. On 5/13/24 at 10:00 AM, an interview with the Director of Nursing Services (DNS) indicated staff take Resident #71 out of bed every day and staff know the resident should be out of bed before Person # 3 arrives and if Resident # 71 is still in bed with Person # 3 arrives s/he becomes upset.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review clinical records, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident # 160 and Resident #259) reviewed for abuse, the facility failed to report allegations of abuse to other regulatory agencies. The findings included: 1. Resident #160's diagnoses included pancytopenia (significant reduction in the number of almost all blood cells), alcoholic cirrhosis of liver with ascites (abnormal fluid in the abdomen) and dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #160 as cognitively intact, requiring one person to assist with bed mobility, transfers, and personal care. The RCP dated 4/17/23 identified Resident #160 as dependent on staff for meeting emotional, intellectual, physical, social needs and noted cognitive dysfunction. Interventions directed to ensure activities are compatible with physical/mental capabilities, provide assist of one with activities of daily living and to monitor report changes in cognitive function. A facility Reportable Event dated 4/22/23 at 3:29PM identified on 4/22/23 at 1:30PM Resident #160 reported to Registered Nurse, RN #4, that the charge nurse, Licensed Practical Nurse, LPN #6 last evening during the 3:00 PM-11:00 PM shift, LPN #6 told Resident #160 she wished s/he would fall, crack her/his head, and die. A nurse's note dated 4/22/2023 at 4:06 PM identified Resident #160 reported the nurse told him/ her that she wished the resident would fall and crack his/her head and die. The state agency, local law enforcement, Conservator of Estate and Advanced Practice Registered Nurse (APRN) were notified. The APRN ordered urinalysis due to confusion to rule out a urinary tract infection (UTI). A Reportable Event Summary dated 4/24/23 identified Resident #160 alleged on 4/22/23 LPN #6 threatened him/her and was verbally abusive. Resident #160 was confused, anxious and paranoid at the time. Resident # 160 verbalized all the other residents on the unit were dead. Investigation initiated immediately. LPN #6 was removed from the schedule. LPN #6 denied any verbal abuse. Resident's laboratory results revealed critical levels and abuse was not substantiated. A review of the investigative report did not include documented notification to other regulatory agencies. An interview with Person #3 at 5/10/24 at 10:14 AM identified that although allegations of abuse submitted for residents in long term care were referred to state agency for investigation, all allegations of potential abuse were required to be reported to other regulatory agencies when an incident occurs. An interview with the Director of Nursing Services (DNS) on 5/13/24 at 11:25 AM other regulatory agency was only notified if an allegation of abuse was substantiated. In the case of Resident #160, abuse was not substantiated. Rather, a symptom of a medical condition. A review of the facility policy for Abuse dated 12/2023 directed the Administrator, DNS or designee assume the responsibility for notification of the incident and preliminary internal investigation results to include the state agency and other regulatory agencies per individual state reporting requirements. Attempts to interview RN #4 and LPN #6 were unsuccessful. 2. Resident #259's diagnoses included dementia, visual hallucinations, and major depressive disorder. The care plan dated 8/30/22 identified Resident # 259 as cognitively impaired, impaired thought process related to dementia. Interventions included cueing, reorienting, and supervising as needed, keeping the resident's routine consistent, and providing as consistent caregivers as possible. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #259 with moderate cognitive impairment and noted the resident required extensive assistance from one person for dressing and personal hygiene. The resident was independent with ambulation. A facility Reportable Event dated 9/10/22 identified at 10:30 PM, Resident #259 alleged (Nurse Aide (NA#4) was rough with her/him and called the resident names during care. The Reportable Event indicated the facility notified the local police, immediately suspended NA#4 pending the investigation, consulted psychiatry, performed a body audit, and ensured two staff members provided care to the resident. The incident was reported to the state agency on 9/11/22 at 12:00 AM, within the two-hour mandatory window for initial reporting of alleged abuse. The facility's summary of the investigation dated 9/12/22 identified the facility did not have a reasonable cause to suspect abuse had occurred. A nursing progress note by the nursing supervisor (RN#5) dated 9/11/22 at 12:41AM indicated a body assessment was performed, and no injuries were noted. Additionally, the progress note indicated that police arrived, the resident's provider and family were notified, and the facility DNS was notified. On 5/9/24 and 5/10/24, attempts to contact NA#4 during the survey were unsuccessful. On 5/9/24 and 5/10/24 attempts to contact RN#5 were unsuccessful. An interview with the DNS on 5/9/24 at 2:00 PM indicated NA#4 was sent home when the allegation was first known. Additionally, the DNS indicated the allegation was not reported to other regulatory agency because the facility did not substantiate the allegation as an incident of abuse and the facility would only report to the other regulatory services if the facility's investigation concluded that abuse may have occurred. On 5/10/24 at 10:14 AM, an interview with Person #3 indicated the allegation of abuse for Resident #259 was the other regulatory agencies at Department of Social Services on 9/12/22 by the local police department. Person #3 indicated long-term care facilities are expected to report allegations of abuse within 24 hours to the other regulatory agency. A review of facility policy for abuse identified the facility would notify the state agency immediately but no later than 2 hours to report allegations of abuse. The facility abuse policy further indicated that staff would need to see state-specific guidelines for verbal notification of all abuse (alleged or confirmed) to the state health department and other regulatory agencies per individual state reporting requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, facility policy and interviews for the 2 of 2 residents (Resident # 77 and Resident #80) reviewed for oxygen, the facility failed to administer oxygen as prescribed. The findings included: 1. Resident #77 's diagnoses included Chronic Obstructive Pulmonary Disease (COPD) with (acute) exacerbation, dysphagia, and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #77 as cognitively intact and required two persons to assist in bed mobility, transfers and one person assist with eating. The MDS also indicated Resident #77 experience shortness of breath/ trouble breathing when lying flat and required oxygen therapy. The Resident care plan dated 4/13/24 for chronic respiratory failure with hypoxia. Interventions included oxygen via nasal cannula at 2-3 L per minute and to monitor for respiratory distress. A physician's order dated 4/13/24 directed oxygen at 2 or 3 liters per minute continuous via nasal cannula. Observation on 5/08/24 at 9:08 AM identified Resident # 77 in the room with nasal cannula in, however, tube was not connected to the oxygen machine. The oxygen machine was 4 liters. Interview with LPN #1 on 5/8/24 at 9:15 AM indicated Resident # 77 was connected to her/his oxygen machine when LPN # 1 did her rounds at 7:30 AM. However, LPN #1 could not explain why the resident was connected to the oxygen. LPN #1 was unable to explain why Resident# 77 oxygen was set at 4 litter. LPN #1 also indicated nursing supervisor/ APRN are allowed to set litter per physician's order. During the interview Resident #77 expressed she was experiencing shortness of breath (SOB). LPN #1 indicated when resident expresses SOB, there is an as needed order for a nebulizer to assist. After inquiry, the resident's orders were revised on 5/8/24 to reflect oxygen 4 liters when needed, titrate up as needed up to 5 liters and to keep oxygen saturation greater than 93 percent. 2. Resident #80's diagnoses included Chronic Diastolic Hear Failure, hypertensive heart disease with heart failure, and Chronic Obstructive Pulmonary Disease (COPD). A physician's order dated 3/5/24 directed to administer oxygen at 2 liters per minute via nasal cannula for shortness of breath or oxygen saturation levels of less than 90%. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #80 as severely cognitively impaired and required extensive assistance with transfers, eating and toileting. The Resident Care Plan updated on 3/19/24 identified Resident #80 had altered respiratory status/difficulty breathing. Interventions included oxygen settings via nasal cannula as ordered. Observation on 5/08/24 09:55 AM identified Resident # 80's oxygen liter flow rate was set at 4 liters. Interview and observation with LPN #2 on 5/8/24 at 10:00 AM identified Resident # 80's oxygen set at 4 liters and the order was for 2 liters. LPN #2 also was unable to explain why the oxygen level was set at 4 liters. After inquiry, LPN #2 set the resident's oxygen flow rate at 2 liters. Although requested, a facility policy for Oxygen was not provided. The Administrator indicated they do not have a policy for oxygen, the staff are directed to follow the physician's order for oxygen flow rate.

Based on observations, review of the facility grievance file, facility policy and interviews, the facility failed to ensure grievances were responded to in a timely manner regarding appropriate food temperatures for consumption. The findings include: Review of the Resident Council Minutes for 2/21/24 and 3/25/24 identified residents' reported concerns that meals were not served at the appropriate temperature. Inservice education on 4/2/24 indicated Nursing staff are aware to reheat food in the microwave when residents request or complain their food is cold or not warm enough. No plan was discussed for non-verbal residents. Interview with a resident on 5/8/24 at 1:30 PM identified food continues to arrive to units cold. Residents attribute the cold food temperatures to the delay in staff passing out the food. Observation on 5/9/24 at 12:00 PM of food identified food arriving on 2nd floor unit. Observation On 5/9/24 at 12:38 PM identified the last meal given to the resident on the 2nd floor. A temperature check of the last try was completed at 12:40 PM by surveyor and Registered Nurse (RN #3). The temperature of the meal served to a resident on 2nd floor identified the following: 123.8 degrees Fahrenheit (Normal Range Holding Food 135 degrees Fahrenheit; RN #3 temperature indicated 120 degrees Fahrenheit. On 5/9/24 at 12: 55 PM Interview with RN #3 indicated for non-verbal/ cognitively impaired residents, the facility should be able to tell if the food is cold by looking at it or hovering hand over meal to feel for temperature. On 5/9/24 at 1:15 PM Interview with Director of Nursing Services (DNS) indicated staff are responsible for ensuring foods are at the correct temperature prior to serving residents. She indicates for nonverbal/ cognitively impaired residents' staff should be able to tell if the food is at the appropriate temperature prior to serving. Interview on 5/13/24 at 10:14AM with Grievance Officer (Administrator) indicated he was aware of the concerns regarding the food temperature, and conducted an in service, on what to do for residents who complain. He indicated for non-verbal/ cognitively impaired residents, food temperatures are checked based on the temperatures of the plate or hovering their hand over it. Facility policy notes the appropriate method of testing temperatures, includes using various types of thermometers (Bimetallic Stemmed Thermometer, Thermistors, and thermocouples Thermometer) Etc. Facility policy Grievances notes in part the Grievance Officer is responsible for ensuring that all grievances are responded to in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, facility policy and interviews for one (1) sampled resident (Resident #1) who was reviewed for quality of care, the facility failed to ensure an injury of unknown origin was reported to the State Agency within the required time frame. The findings include: Resident #1's diagnoses included dementia, congestive heart failure and schizoaffective disorder. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decisions regarding tasks of daily living and required two (2) person assistance with turning and repositioning when in bed, total assistance with getting in and out of the bed and chair. The Resident Care Plan dated 11/17/22 identified Resident #1 had a self-care deficit related to confusion and dementia. Interventions directed to transfer with an assist of two (2) via the Hoyer lift. The nurse's note dated 3/10/23 at 1:00 PM identified Resident #1's right lower leg was noted to be swollen, Resident #1 was alert and verbal with no signs of discomfort, and the Supervisor was updated. The nurse's note dated 3/10/23 at 6:23 PM identified a new order was obtained for a venous ultrasound to rule out a deep vein thrombosis (DVT) and an x-ray of the right lower extremity. The Facility Reported Incident form dated 3/13/23 at 4:15 PM identified it was discovered Resident #1 had right ankle swelling, an x-ray was ordered to rule out DVT and the x-ray results revealed a right ankle fracture, etiology unknown. The report identified that the incident was reported on 3/12/23 at 8:00 PM to the State Agency. An interview with the Director of Nurses (DON) on 4/20/23 at 12:18 PM identified injuries of unknown origin were to be submitted to the State Agency within two (2) hours of discovery. The DON indicated that while she believed the supervisor may have had difficulty at the time with submission, she was unable to provide documentation that the effort to submit the injury was reported. The DON indicated she submitted the report once she was made aware. A review of the facility policy for abuse identified a two (2) hour requirement to report to Department of Public Health following identification of an injury of unknown source.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #64) reviewed for hospitalization, the facility failed to notify the Ombudsman within acceptable parameters when the resident was transferred and/or discharged to the hospital. The findings include: Resident #64's diagnoses included vascular dementia with behavioral disturbances, Alzheimer's disease, anxiety disorder, and major depressive disorder. The annual MDS assessment dated [DATE] identified Resident #64 had moderately impaired cognition with short and long term memory deficits, required extensive assistance with bed mobility, limited assistance with transfers and supervision with ambulation and utilized a walker. A nurse's note dated 12/21/21 at 3:59 AM identified that at 3:00 AM Resident #64 had increased agitation, attempted to hit staff with a rolling walker and was verbally abusive towards his/her roommate. The staff was unable to redirect the resident and the roommate was temporarily moved to another room. The note further identified that Resident #64 attempted enter the room that the roommate was moved to, the APRN was updated and an order was obtained that directed for the resident to be sent to the hospital for evaluation. Resident #64 was transferred to the hospital at 3:50 AM and the resident's responsible party was updated. A nurse's note dated 12/21/21 at 4:00 PM identified Resident #64 arrived at the facility at 2:30 PM via stretcher accompanied by two ambulance attendants. A nurse's note dated 12/23/21 at 2:26 PM identified Resident #64 was agitated and unable to understand due to a language barrier. The resident's responsible party was present and translated that Resident #64 was upset because he/she thought that his/her roommate had taken his/her sugar. Per the responsible party Resident #64 sat on the floor, yelled and refused to be assisted up off the floor. Resident #64 was transferred to the hospital at 1:15 PM for evaluation. Responsible party present and aware. A nurse's note dated 12/31/21 at 3:21 PM identified Resident #64 arrived at the facility via stretcher accompanied by two ambulance attendants. Review of the facility's tracking system utilized to send notices to the Ombudsman's office of resident transfers and discharges identified that the last notifications made to the Ombudsman was August of 2021. Interview on 2/17/22 at 1:30 PM with the Administrator identified he was unable to provide documentation that the Ombudsman was notified of the Resident #64's transfers to the hospital. He indicated that he was unaware that the Ombudsman was not notified when Resident #64 was transferred to the hospital. Interview on 2/17/22 at 1:46 PM with the Social Worker identified she had been employed with the facility for two months and was unaware that the previous Social Worker had not sent the resident transfer and discharge notices for the months of October, November or December of 2021 to the Office of the State Long-Term Care Ombudsman. She further failed to identify why she had not sent out the notices for the month of January but indicated that she would address the issue. Review of the facility's protocol addressing discharge and transfer notices identified that the forms were updated in January of 2022. It identified that the forms should be sent out timely to the correct address of the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #73) reviewed for Hospice, the facility failed to develop a comprehensive care plan to address the resident's hospice needs. The findings include: Resident #73 had diagnoses that include muscle weakness, hypertension, benign prostatic hyperplasia, adjustment disorder with mixed anxiety and depression, vascular dementia with behavioral disturbances, adult failure to thrive and major depressive disorder. A physician's order dated 1/6/22 directed for a hospice evaluation. The significant change MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required extensive assistance with ADL's, was incontinent of bowel and bladder and was receiving hospice care. Interview on 2/16/22 at 1:32 PM with RN #1 indicated the MDS Coordinator updates the care plan when there is a change in condition. Interview on 2/17/22 at 11:59 AM with RN #2 (MDS Coordinator) indicated it is her responsibility to update the care plan when there is a change in condition. Additionally, RN #2 indicated Resident #73's care plan was not updated to address hospice care and the coordination between the facility and hospice. Interview on 2/17/22 at 12:07 PM with the DNS identified the care plan is updated when there is a change in condition and it is the responsibility of the supervisors, charge nurses, social services and the MDS Coordinator to update the care plan. A review of the facility policy title Baseline/Comprehensive care person centered care plan indicated the comprehensive person centered care plan (CPCCP) will be periodically reviewed and revised by a team of qualified persons after each assessment or reassessment. Additionally, the policy identified the CPCCP will be reviewed and revised following a significant change in status and completion of significant change in MDS. The policy further states that the IDT will periodically review and revise the CPCCP based on the MDS assessment and reassessments and upon any change in status and intervention initiated will be dated at the time of the implementation. Subsequent to surveyor inquiry the care plan was updated to reflect Resident #1 was receiving hospice services.

Based on clinical record reviews, review of facility documentation and interviews for one of five sampled residents (Resident #17) reviewed for pneumococcal immunizations, the facility failed to ensure documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization and the administration of the pneumococcal vaccine. The findings include: During a review of the facility's infection control program, a sample of five residents' vaccination records were reviewed on 2/17/22 to determine immunization status for Covid-19, influenza and pneumonia. The review identified that Resident #17's consent form for the pneumococcal vaccinations was not complete and the vaccinations had not been administered. Further review identified Resident #17 was admitted to the facility in August of 2021. Interview on 2/17/22 at 10:35 AM with the IP identified Resident #17's pneumococcal immunization history was not available from his/her PCP, and the resident's family was not sure if Resident #17 had received them in the past. In addition, the IP identified that the information should have been documented in the resident's chart and a follow up should have been done. The IP further identified that it was an oversight on her part and noted that the focus of the facility at that time was on ensuring influenza and COVID-19 vaccinations were administered. She further noted that there was a push-back on the pneumococcal immunizations. The IP nurse also indicated that the RN supervisors are also expected to follow-up on the immunization status. Interview on 2/17/22 at 12:35 PM with the DNS identified that it is her expectation that during the admission's process the nursing supervisor should ask the family about the resident's vaccination status, obtain the consent, obtain the physician's order for the administration of the vaccine and pass the information along to the IP nurse. Review of the facility policy for Pneumococcal Vaccination identified that All residents admitted to the facility will be evaluated to determine if they have received Pneumococcal Vaccination upon admission, the facility will offer residents on admission the pneumococcal vaccine upon resident and/or responsible party consent. Additionally, the facility policy directed to obtain resident's vaccination history, obtain informed consent from the resident/designated representative (if resident unable to consent), obtain order from the physician and administer vaccine as per ACIP/CDC guidelines. Subsequent to surveyor inquiry, the IP nurse conducted an in-service for the nursing supervisors regarding ensuring immunization consents were appropriately filled out, refusals documented, and to follow-up routinely if consent was not obtained initially.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #28 and 45) reviewed for urinary catheter, the facility failed to ensure the resident's dignity when staff left urinary collection devices uncovered and visible. The findings include: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses that included diabetes, stroke, urinary retention, urinary tract infection, and benign prostatic hyperplasia. The quarterly MDS dated [DATE] identified Resident #28 had moderately impaired cognition, was frequently incontinent of bladder and always incontinent of bowel. Additionally, Resident #28 required extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. The care plan dated 8/13/19 identified Resident #28 had an indwelling catheter due to benign prostatic hyperplasia. Interventions included to monitor and document signs/symptoms of discomfort on urination and frequency, and intake and output as per facility policy. Position catheter bag and tubing below the level of the bladder and away from entrance room door. A physician's order dated 8/13/19 directed to utilize a 14 French 10cc balloon indwelling catheter, change the catheter drainage bag from straight drainage to leg bag when the resident gets out of bed in the morning, change from leg bag to straight drainage at bedtime, provide catheter care, and obtain a urology consult for urinary retention. Observation on 8/19/19 at 9:45 AM in the shared bathroom of Resident #28, Resident #45, and 2 other resident's, identified an unlabeled leg bag and urinal hanging on the grab bar. Observation and interview with NA #5 on 8/19/19 at 10:45 AM identified the leg bag and urinal, located in the shared bathroom, were not labeled or stored properly. Additionally, NA #5 indicated when not in use, the leg bag and urinals should be stored in the bottom draw of the resident's night stand. Observation and interview on 8/19/19 at 11:53 AM with the Infection Control Nurse, (RN #1) in the shared bathroom identified an unlabeled leg bag and urinal hanging on the grab bar. RN #1 indicated the expectation are the items should be dated and labeled when brought into a room, and stored in a bag in the night stand. Observation on 8/21/19 at 10:00 AM and 1:50 PM identified Resident #28 was in a wheelchair in his/her room. A urinary collection bag attached to Resident #28's wheelchair was visible without the benefit of a privacy cover. Observation and interview on 8/21/19 at 2:00 PM with the Charge Nurse, (LPN #3) indicated the resident's urinary collection bag should be covered for privacy. Additionally, LPN #3 indicated the resident is supposed to have a leg bag on when he/she is out of bed. Observation and interview on 8/21/19 at 2:10 PM with NA #4 indicated she was not aware of the physician's order to change the catheter drainage bag from straight drainage to leg bag when the resident gets up in the morning. Additionally, NA #4 indicated Resident #28 did not have a privacy cover on when she came in, and she did not apply a privacy cover. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, neuromuscular dysfunction of the bladder and phimosis. The quarterly MDS dated [DATE] identified Resident #45 had severely impaired cognition, required extensive assistance with bed mobility, transfers, dressing, toilet use, and hygiene. Additionally, Resident #45 ambulated in the room with supervision. A physician's order dated 7/3/19 directed an indwelling catheter 14 French 5cc balloon to straight drainage for urinary retention, change catheter drainage bag from straight drainage to leg bag upon the resident getting out of bed in the morning, and change from leg bag to straight drainage at bedtime. The care plan dated 7/3/19 identified Resident #45 had an indwelling catheter for urinary retention. Interventions included to change the catheter per physician's order, check tubing for kinks, position catheter bag and tubing below the level of the bladder and away from entrance room door. Observation on 8/19/19 at 9:45 AM in the shared bathroom of Resident #28, Resident #45, and 2 other resident's, identified hanging on the grab bar was an unlabeled leg bag and urinal. Observation and interview with NA #5 on 8/19/19 at 10:45 AM identified the leg bag and urinal, located in the shared bathroom were not labeled or stored properly. Additionally, NA #5 indicated when not in use, the leg bag and urinals should be stored in the bottom draw of the resident's night stand. Observation and interview on 8/19/19 at 11:53 AM with the Infection Control Nurse, (RN #1) indicated hanging on the grab bar was an unlabeled leg bag and urinal. RN #1 indicated the expectation are the items should be dated and labeled when brought into a room, and stored in a bag in the night stand. Observation on 8/22/19 at 10:30 AM identified Resident #45 lying in bed with a urinary catheter collection bag, which contained urine, attached to the bed frame, and visible from the hallway without the benefit of a privacy cover. Observation and interview on 8/22/19 at 10:35 AM with LPN #5 indicated Resident #45's urinary collection device was visible from hallway and did not have a privacy cover. LPN #5 indicated that the urinary collection bag should have a privacy cover, however, upon a room search, LPN #5 was unable to find a privacy cover in Resident #45's room. Review of the nurse aide electronic care card indicated to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, check tubing for kinks. Although requested, a policy on urinary catheter care, including labeling/privacy cover use and storage of urinary collection devices was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #28) required extensive assistance with transfers, the facility failed to ensure residents telephone and call bell where within reach when he/she was out of bed in the wheel chair. The findings include: Resident #28 was admitted to the facility on [DATE] with diagnoses that included a history of a stroke, generalized osteoarthritis, history of falls, major depressive disorder, difficulty in walking, and muscle weakness. The quarterly MDS dated [DATE] identified Resident #28 had moderately impaired cognition, was frequently incontinent of bladder and always incontinent of bowel. Additionally, Resident #28 required extensive assistance with bed mobility, transfers, dressing, toilet use, and hygiene. The care plan dated 8/13/19 identified Resident #28 was at risk for falls related to poor safety awareness, and had 6 falls since January 2019. Interventions included to anticipate and meet the resident's needs, be sure the call bell is within reach, encourage the resident to use the call bell for assistance as needed. Observation on 8/19/19 at 10:30 AM identified Resident #28 was seated in a wheelchair in the center of the room between the beds. The call bell was out of the resident's reach, located at the head of the bed near the pillow. The resident's telephone, with large print numbers, was out of the resident's reach on the other side of the bed near the window on the nightstand. During observation the telephone was ringing and the resident was unable to reach the telephone to answer it. Resident #28 was noted to be looking at the telephone while it was ringing. Observation on 8/20/19 at 12:15 PM identified Resident #28 was seated in a wheelchair in the center of the room between the beds, and the call bell was attached to side rail behind the resident out of his/her reach. The resident's telephone was on the other side of the bed near the window, on the nightstand. Resident #28 was not able to reach either the call bell or the phone. Observation and interview on 8/21/19 at 2:00 PM with LPN #3 identified Resident #28's call bell and telephone were out of the resident's reach. LPN #3 indicated she is not aware whether or not Resident #28 uses the telephone, however, was noted to move the call bell and phone within the resident's reach. Interview on 8/21/19 at 2:05 PM with Resident #28 indicated he/she does use the telephone once in a while when his/her family calls. Review of the nurse aide electronic care card identified to place the call bell within reach when the resident is in the room. Additionally, provide for the overall safety of all residents. The facility policy on residents' bill of rights indicates the resident has the right to reasonable access to a telephone that you can use without being overheard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interview for 1 resident (Resident #39) reviewed for advance directives, the facility failed to ensure the advanced directive consent form and resident care plan reflected resident's current wishes. The findings include: Resident #39 was admitted to the facility on [DATE] with diagnoses that included hypertension, Alzheimer's disease and anxiety. A consent form dated [DATE] identified Resident #39 met with staff who explained and discussed the potential benefits and risks of cardiopulmonary resuscitation and other means of resuscitation, the use of life support systems, and methods of artificial provision of nutrition and hydration. Resident #39's choices regarding the administration of life support systems were documented as follows; administer CPR, artificial respiration, artificially provided nutrition and hydration. A physician's order dated [DATE] identified Resident #39 was readmitted with a code status change. The order directed to discontinue the order to provide CPR and implement DNR (do not resuscitate) status. The quarterly MDS dated [DATE] identified Resident #39 had severely impaired cognition. The care plan dated [DATE] identified to honor Resident #39's advance directive (full code). Interview with RN #3 on [DATE] at 1:15 PM identified that the advance directive in the paper record (full code), the physician's code status order in the electronic medical record (DNR) and the resident care plan (full code) should all match. RN # 3 could not explain the discrepancy. Interview with the ADNS on [DATE] at 2:00 PM identified that Resident #39's code status was changed after his/her readmission to facility in March of 2019, and was now DNR. Additionally, the ADNS indicated she usually addressed the advance directives with new and readmissions, but it must have been overlooked. Interview with the DNS on [DATE] at 10:30 AM identified that it was the responsibility of the unit managers and/or supervisors to ensure the advance directives were addressed and completed on all admissions and readmissions, and the DNS indicated they should be done timely. Although requested, documentation was not provided to indicate a discussion regarding Resident #39's advanced directives change dated [DATE] took place. Review of the facility's advance directive policy identified that nursing is responsible for completing the advance directives form with the resident or family within the first 72 hours. All DNR information, including signed consent, copy of current progress note that addresses the DNR and copy of original MD order will be put together in a plastic sleeve and placed in the advance directives section. Although a consent form dated [DATE] identified Resident #39 choice regarding the administration of life support systems was to receive CPR, artificial respiration, artificially provided nutrition and hydration, a physician's order dated [DATE] identified Resident #39 was readmitted to the facility with a code status of DNR. Additionally, the clinical record lacked documentation to indicate a discussion regarding the change to Resident #39's advance directives from full code to DNR took place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility documentation, facility policy and interviews, the facility failed to ensure the environment was maintained in a clean, comfortable, and homelike manner. The findings include: Observations on 8/20/19 at 2:05 PM with the Administrator identified the following: Missing, cracked and/or chipped tiles on North One in rooms #128 and 130. Damaged and/or peeling base molding on North One in resident room [ROOM NUMBER]. Missing, cracked and/or chipped tiles on East Two in room [ROOM NUMBER]. Soiled and/or stained personal resident hampers on North One in rooms #117, 118, 119, 121, 123 and 125. Moderate amount of dust and/or debris buildup on the wall fan in the beauty salon, which was noted to be on at that time. Damaged, broken and/or debris buildup noted for wheelchairs in room [ROOM NUMBER], 117 and 127. Holes behind the headboards in rooms #117 and 130. Bathroom threshold in room [ROOM NUMBER] with chipped tiles, and black tape across, with some of the black tape missing. Window sill in room [ROOM NUMBER] has a hole present, and there is rust at the base of the inner window framing, and sill is missing compound/sheet rock. Interview with the Administrator on 8/20/19 at 2:05 PM identified he was aware of some of the issues identified and indicated there is a maintenance log on each unit to be used by staff. The Administrator indicated cleaning of the residents personal hampers is the responsibility of housekeeping on a daily basis. When hampers need to be replaced, the housekeeper will inform the Director of Environmental Services and/or the Administrator. Review of the Director of Environmental Services job description identified he/she performs periodic inspections of the building and grounds to ensure proper repair, cleanliness, and laundry service quality. The Director of Environmental Services places orders for necessary supplies in accordance with department budget, and performs other duties as needed to ensure that a clean environment is maintained. Review of the Director of Engineering/Maintenance job description identifies he/she oversees all aspects of the physical plant, mechanically and structurally, inside and out. Review of the Housekeeper job description identifies he/she is responsible for performing routine tasks to ensure the cleanliness of assigned areas of the facility. Review of the wheelchair cleaning policy indicated to scrub all parts of wheel/geri chairs with solution of heavy duty cleaner and water. Use long handed brush and green scouring pads for heavy soil. Use stainless steel polish on all chrome areas. Repeat process until all wheel/geri chairs are done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record, facility documentation, facility policy and staff interviews for 1 of 2 residents (Resident #101) reviewed range of motion, the facility failed ensure physician's orders for a splint were implemented and documented and/or that skin/circulatory assessments were completed. The findings include: Resident #101 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, muscle weakness, essential hypertension, dysphagia, and osteoarthritis. The occupational therapy evaluation dated 6/7/19 identified Resident #101 had a left hand contracture and would tolerate a left hand splint for 2 hours with no signs of redness, irritation and/or pain, in order to maintain skin integrity. The occupational therapy Discharge summary dated [DATE] recommended to utilize a left resting hand splint as per 24 hour positioning plan, with use of splint after morning care and remove at night prior to evening care. A physician's order dated 7/4/19 directed to apply a left resting hand splint after morning care and remove prior to evening care per 24 hour positioning plan. The quarterly MDS dated [DATE] identified Resident #101 had severely impaired cognition, required extensive assistance of 2 persons with bed mobility, transfers, dressing, and personal hygiene. Additionally, Resident #101 required extensive assistance of 1 person for eating and was dependent on staff for locomotion off the unit. Review of the July and August 2019 MAR/TAR dated 7/4/19 through 8/20/19 failed to reflect the left resting hand splint had been applied, and/or that skin integrity and CMS had been assessed. Review of the hand splint wearing schedule form, undated, directed staff to check the splint for cleanliness, check arm and hand for redness and swelling. Observation of Resident #101 on 8/20/19 at 9:47 AM identified the left hand and arm splint was in place. Interview with the ADNS on 8/21/19 at 9:05 AM identified that the nurse aides are responsible for the application and removal of splints. Additionally, the ADNS identified that while it was the responsibility of the nurse to complete the skin assessment, the nurse aide should check the skin and report changes to the nurse. Further, the ADNS indicated there was no documentation related to application or removal of the splint, or skin integrity and CMS assessments for the left hand/arm under the splint. Interview with NA #1 on 8/21/19 at 9:11AM identified she applies the splint to Resident #101's left hand, however does not document this in the medical record. Interview with LPN #1 on 8/21/19 at 9:31 AM identified the nurse aide is responsible for applying and removing the splint, and the nurse is responsible for completing the skin and CMS assessments. Additionally, LPN #1 identified the skin and CMS assessment was usually documented in the TAR however, she did not know why it had not been done. Further, LPN #1 identified the nurse who transcribed the order for the splint should have triggered the care plan, and TAR with the intervention to complete CMS and skin integrity assessments. Although requested, the facility did not provide a policy on splint management or CMS assessments. Review of the policy for general skin care identified casts, braces, splints must be checked for any irritation or pressure to the skin every shift and documented in the TAR. Additionally the policy identified to monitor for color, sensation and movement. Although Resident #101 had orders for a left hand splint, documentation failed to reflect the splint had been applied 7/4/19 through 8/20/19, or that skin integrity and CMS of the left hand/arm had been assessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #37 and 93) reviewed for accidents, the facility failed to ensure a seat belt used while the resident was in the wheelchair was applied according to professional standards and/or according to the physician's order to prevent an injury. The findings include: 1. Resident #37 was admitted to the facility on [DATE] with diagnoses that included dementia, cancer of an unspecified lower limb, stroke and muscle weakness. A physician's order dated 4/18/19 directed to provide Resident #37 a moderate assistance of 1 staff for toilet use. A physician's order dated 5/14/19 directed to apply a pelvic positioning belt when Resident #37 was out of bed in the wheelchair. A physical therapy note dated 6/11/19 identified Resident #37 required partial/moderate assistance for sitting to standing, chair or bed to chair transfers and toilet transfers. The quarterly MDS dated [DATE] identified Resident #37 had severely impaired cognition, required extensive assistance with transfers, bed mobility, toileting, personal hygiene and locomotion. The care plan dated 7/9/19 identified that Resident #37 was at risk for falls related to a history of stroke with left sided weakness, and a history of falls. Interventions included to anticipate and meet the resident's needs as able, and follow the facility fall protocol. Additionally, the care plan identified that Resident #37 had actual falls on the following dates 8/17/18, 9/9/18, 10/3/18, 12/22/18, 3/10/19, 5/26/19, 6/7/19, 6/8/19, 6/24/19, 6/30/19, and 7/22/19. Interventions included to place a sign on the resident's bathroom door (call for assistance), offer every 1 hour toileting assistance while awake, check to ensure that the resident is seated correctly in his/her wheelchair, assist resident out of bed to standard wheelchair, use a pelvic positioning belt and Dycem on the wheelchair cushion, awareness that patient utilizes a pelvic positioning belt. Observation on 8/19/19 at 10:30 AM identified Resident #37 self-transferred out of bed into the wheelchair, into the bathroom, onto and off of the toilet, back into the wheelchair where he/she remained without the pelvic positioning belt. Observation on 8/19/19 at 12:30 PM identified Resident #37 was seated in the wheelchair in his/her room without the benefit of the pelvic positioning belt. Observation on 8/20/19 at 11:34 AM identified Resident #37 was seated in the wheelchair in the doorway of his/her room without the benefit of the pelvic positioning belt. Observation on 8/21/19 at 10:46 AM identified Resident #37 was sitting on the edge of the wheelchair, hunched over, without the benefit of the pelvic positioning belt. Interview with RN #4 on 8/21/19 at 11:57 AM identified Resident #37 will un-clip the seat belt many times throughout the day, and will go into the bathroom or the bed without asking for help. RN #4 indicated staff posted a sign on the bathroom door to remind the resident to ask us for help, but that does not always happen. The nurse aides and nurses will check on the resident, but he/she can un-clip the belt him/herself, and then get into the bed or into the bathroom. Observation on 8/22/19 at 10:00 AM identified Resident #37 was seen in his/her wheelchair in the hallway in front of the nurse's station without the benefit of the pelvic positioning belt. Three nurse aides were noted to walk past the resident, and a nurse greeted the resident without the benefit of checking or reapplying the pelvic positioning belt. Review of the policy for accidents/incidents identified it is the responsibility of all staff to report all incidents and accidents that occur at the facility. All occurrences are investigated in a timely manner and preventive measures are initiated. Review of the facility's fall prevention program identified that the program monitors staff compliance with fall prevention measures, including the following general measures: Assist residents with transfers, ambulation and other activities as necessary and follow directions for care as indicated on the resident care flow sheets. Although a physician's order directed that Resident #37 required moderate assistance of 1 for toileting tasks and transfers, and when out of bed in his/her standard wheelchair a pelvic positioning belt was to be on, intermittent observations on 8/19/19 - 8/22/19 identified the interventions were not implemented. The observations identified Resident #37 did not have the pelvic positioning belt on, and self-transferred out of bed into the wheelchair, into the bathroom, onto and off of the toilet, and back into the wheelchair where he/she remained without the pelvic positioning belt. Additionally, the care plan failed to identify that Resident #37 was able to un-clip his/her pelvic positioning belt as per staff interview. 2 Resident #93 was admitted to the facility on [DATE] with diagnoses that included difficulty in walking, history of falls, generalized muscle weakness, and dementia without behaviors. The care plan dated 8/1/19 identified Resident #93 to be out of bed to an adaptive wheelchair per the 24 hour positioning plan with a pelvic belt at all times due to poor trunk control. Additionally, the care plan indicated to utilize floor mats at bedside, offer toileting after laxative administration, and between 2:00 PM - 3:00 PM, and every 1 hour. Further, consult physical therapy for strength and mobility, use a scoop mattress and transfer to a room closer to the nurses' station for closer observation due to falls. The admission MDS dated [DATE] identified Resident #93 had moderately impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance of 1 with bed mobility, transfers, dressing, and personal hygiene. The MDS further indicated Resident #93 required extensive assistance of 2 with toilet use. A physical therapy note dated 8/11/19 identified Resident #93 now required a tilt in space wheelchair with a pelvic positioning belt due to poor trunk control and poor tolerance upright. A physician's order dated 8/11/19 identified Resident #93 to be out of bed to an adaptive wheelchair per the 24 hour positioning plan with a pelvic belt on at all times due to poor trunk control. Observation on 8/19/19 at 9:52 AM identified Resident #93 was in the wheelchair, slightly tilted back at approximately 75 degrees, with a seat belt on, which was loose and the strap fully extended (6 - 8 inches). Interview and observation with RN #1 at that time identified RN #1 pulled the seat belt upward and out (6 - 8 inches), away from the residents body to look at its placement, placed it back on the resident's lap and indicated she does not know why Resident #93 wears a seat belt. RN #1 indicated that the seat belt is the charge nurse's responsibility. RN #1 did not adjust the seat belt. Observation and interview on 8/19/19 at 9:55 AM with PT #1, who was in Resident #93's room at that time with RN #1 present identified the seat belt is used for pelvic positioning but was not in the optimal position/length. Although PT #1 indicated the seat belt was not in the optimal position/length, she did not adjust the seat belt. Subsequently, both PT #1 and RN #1 left the room without adjusting the seat belt. Interview on 8/19/19 at 11:00 AM with PT #1 indicated the technique to ensure proper placement of a seat belt on a resident in a wheelchair is to place 3 fingers between the resident and the seat belt. If the length is more than 3 fingers, the seat belt needs to be adjusted. An initial physical restraint evaluation dated 8/19/19 at 1:30 PM, 8 days after the pelvic belt was implemented, and subsequent to surveyor inquiry, indicated Resident #93 does use a restraint, has a history of sliding out of the chair/wheelchair, and is at risk for falls if he/she slides out of the wheelchair. Additionally, the evaluation indicted the seat belt is used for trunk positioning, and does not constitute a restraint as the resident requires assistance for transfers. Observation and interview on 8/19/19 at 2:15 PM with LPN #4 indicated Resident #93 wears the seat belt because of a history of multiple falls. LPN #4 pulled on the seat belt and it extended 6 - 8 inches from resident's abdomen. LPN #4 did not adjust the seat belt and left the room. Observation and interview on 8/19/19 at 2:30 PM with the DNS indicated the seat belt was too loose. The DNS was observed to adjust the seat belt to the optimal position with RN #4 present. Review of the restraint management system guidelines indicates the facility is committed to providing a safe environment for our residents. The interdisciplinary team will evaluate the use of physical restraints and will only be utilized when they are required to treat medical symptoms and medically necessary. Restraints will not be used for convenience of the staff. It is the policy of the facility to provide each resident with appropriate evaluation and intervention regarding use of restraints in order to achieve the highest practicable level of independence for the resident through the ongoing evaluation of the continued need for the restraint and the use of the least-restrictive device. Although Resident #93 had a history multiple falls, and a restraint evaluation dated 8/19/19 indicated a history of sliding out of the chair/wheelchair, and a risk for falls if he/she slides out of the wheelchair, observation on 8/19/19 between 9:52 AM to 2:30 PM identified the residents seat belt was not in the optimal position/length, the strap was fully extended (loose) and was not fixed by staff, despite 3 staff members having observed the belt loose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #77 and 93) reviewed for intravenous (IV) therapy, the facility failed to label the IV bag and tubing according to professional standards. The findings include: 1. Resident #77 was admitted to the facility on [DATE] with diagnoses that included transient cerebral ischemic attack, diabetes, muscle weakness, hypertension and pressure ulcers. The quarterly MDS dated [DATE] identified Resident #77 had severely impaired cognition, required extensive assistance with bed mobility, transfers, dressing, toilet use, hygiene and locomotion. A physician's order dated 8/20/19 directed to initiate IV therapy of sodium chloride solution 0.9%, administer 60 ml IV every hour for pneumonia, hydration and fevers. The care plan dated 8/20/19 identified that IV therapy was initiated for hydration. Interventions included to flush the line with normal saline per protocol to maintain patency, monitor vital signs and clinical condition, schedule bloodwork, monitor site for placement and signs/symptoms of infection every shift. Observation on 8/20/19 at 9:30 AM identified the IV bag and tubing in Resident #77's room was not labeled with a date, time and/or initials. Observation and interview with LPN #3 on 8/20/19 at 9:35 AM identified the IV bag had been hung at approximately 3:45 AM and the nurse who hung it should have dated the tubing and IV bag. LPN #3 indicated the IV tubing and bag should be dated. Review of the IV policy and procedure identified to prime tubing according to manufacturer's recommendations, and label bag and tubing with date, time and initials. 2. Resident #93 was admitted to the facility on [DATE] with diagnoses that included systolic heart failure, hypertension, and chronic atrial fibrillation. The care plan dated 8/1/19 identified IV therapy for hydration and medication per physician order, schedule bloodwork, monitor vital signs and clinical condition. Additionally, monitor site for placement, signs and symptoms of infection every shift, change dressing and site every 72 hours for peripheral lines. IV line will remain patent with no signs/symptoms of infection during the review period. Monitor IV site for placement, signs/symptoms of infection every shift. The admission MDS dated [DATE] identified Resident #93 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. The MDS further indicated Resident #93 required extensive assistance of 2 with toilet use. A physician's order dated 8/16/19 directed IV for hydration; Dextrose 5 ½ normal saline with 20 milliequivalents of potassium at 50 cc per hour, 3000 cc's, for hypovolemia. May replace peripheral line as needed to start intravenous therapy fluids as ordered, monitor peripheral site for redness, swelling, drainage, any signs of infection every shift. Rotate access site every 96 hours and as needed. A nurse's note dated 8/17/19 identified a new order for IV therapy, hydration and potassium replacement. Dextrose 5 ½ normal saline with 20 milliequivalents of potassium. IV therapy nurse was called for peripheral line rotation. Right arm peripheral line patent. First bag of hydration started on 3:00 PM - 11:00 PM shift. A nurse's note dated 8/18/19 identified Resident #93 continues on IV hydration. New bag #3 started at 5:11 PM. A nurse's note dated 8/19/19 identified Resident #93 continues on IV hydration. IV line right forearm intact. Observation on 8/19/19 at 11:53 AM identified the IV bag and tubing lacked a label and date. Interview and observation with RN #1 at that time indicated the IV bag and tubing lacked a label and date. RN #1 indicated the IV bag/tubing does not have to be labeled or dated by nursing staff because they sign electronically in the medial record. Additionally, RN #1 indicated the IV tubing should be changed every 24 hours. Review of the policy on administrating an intermittent infusion indicates to label bag and tubing with date, time, and initials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 3 residents (Resident #93 and 100) reviewed for respiratory care, the facility failed to store and date respiratory equipment in accordance with professional standards and/or follow a physician's order to obtain oxygen saturations on room air. The findings include: 1. Resident #93 was admitted to the facility on [DATE] with diagnoses that included systolic heart failure, hypertension, and chronic atrial fibrillation. The care plan dated 8/1/19 identified Resident #93 had pneumonia with interventions to administer antibiotic therapy and encourage fluids. The admission MDS dated [DATE] identified Resident #93 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with bed mobility, transfers, dressing, and personal hygiene. A physician's order dated 8/13/19 directed to administer Ipratropium-albuterol solution; 1 unit 3 times a day. A physician's order dated 8/15/19 directed to administer oxygen at 2 liters per minute via nasal cannula, change oxygen tubing as needed (prn), and clean concentrator filter prn. Observation and interview on 8/19/19 at 9:50 AM with the Infection Control Nurse, (RN #1) identified although Resident #93 was using the oxygen at the time, the oxygen tubing lacked a date. Additionally, a nebulizer machine was noted on top of the nightstand, and the tubing and mask that were connected to the machine were stored in the top drawer. Additionally, the nebulizer tubing and mask lacked a date. RN #1 indicated the oxygen and nebulizer tubing should not be stored in the nightstand, it should be dated and stored in a bag. Additionally, RN #1 indicated the tubing should be changed weekly on Tuesday evening. Review of the policy on equipment changing indicated all respiratory equipment will be changed in order to prevent nosocomial infections. All equipment should be changed on a weekly basis and as well as when needed if it becomes soiled or falls on the ground. This equipment included: nasal cannulas, oxygen tubing, nebulizer treatment equipment and simple masks. 2. Resident #100 was admitted to the facility on [DATE] with diagnoses that included respiratory failure and COPD. A physician's order dated 4/29/19 directed to administer oxygen at 2 liters via nasal cannula to maintain an oxygen saturation level at 90 %. Additionally, the order directed to change the oxygen tubing and concentrator filter on Tuesdays. A physician's order dated 5/9/19 directed to ween Resident #100 off oxygen, and document oxygen saturation on room air each shift. The quarterly MDS dated [DATE] identified Resident #100 had moderately impaired cognition, required extensive assistance with bed mobility and received oxygen while a resident at the facility. The care plan dated 7/31/19 identified Resident #100 had altered respiratory status. Interventions included to administer medication/puffers as ordered, and monitor for effectiveness and side effects. Additionally, the care plan indicated to monitor for signs/symptoms of respiratory distress and report to the physician as needed. The July 2019 TAR identified that the oxygen tubing and concentrator filter was changed as ordered on 7/23 and 7/30/19. The August 2019 TAR identified that the oxygen tubing and concentrator filter was changed as ordered on 8/13/19. Observation on 8/19/19 at 10:00 AM identified Resident #100 wearing oxygen at 2 liters via nasal cannula. The oxygen tubing was dated 7/23/19, 27 days prior. Interview with the Infection Control Nurse (RN #1) on 8/19/19 at 11:00 AM identified Resident #100 should have his/her oxygen tubing changed once per week (Tuesday) during the evening shift. RN #1 further indicated that the oxygen tubing was overdue to be change. Review of the policy for equipment changing identified all respiratory therapy equipment must be changed in order to prevent nosocomial infections. All equipment should be changed on a weekly basis as well as (as needed/prn) if it becomes soiled or falls on the ground. This equipment includes but is not limited to nasal cannulas, nebulizer treatment equipment, oxygen tubing, and simple masks. Although documentation indicated that Resident #100's oxygen tubing had been changed on 7/30 and 8/13/19, observation on 8/19/19 at 10:00 AM identified Resident #100's oxygen tubing was last changed on 7/23/19, 27 days prior. Additionally, although a physician's order dated 5/9/19 directed to ween Resident #100 off oxygen, and document oxygen saturation on room air each shift, the clinical record failed to reflect this had been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #108) reviewed for dialysis, the facility failed to provide ongoing monitoring according to professional standards. The findings include: Resident #108 was admitted to the facility on [DATE] with diagnoses that included heart failure, type 2 diabetes and end stage renal disease. A physician's order dated 3/14/19 directed to check the dialysis book for any new recommendations. An APRN note dated 3/19/19 identified Resident #108 was to have an arteriovenous (av) fistula, (a surgical connection made between an artery and a vein that is used for hemodialysis) placed on Friday, 3/22/19. The 14 day MDS dated [DATE] identified Resident #108 had moderately impaired cognition, was incontinent of bowel and frequently incontinent of bladder, required extensive assistance with bed mobility, transferring, personal hygiene and toileting, and received dialysis. The care plan dated 3/19/19 identified Resident #108 required dialysis related to renal failure. Interventions included to monitor, document and report to the physician any signs of infection to the dialysis access site including redness, swelling, warmth or drainage. Discharge instructions dated 3/22/19 identified Resident #108 had a surgical procedure to create access for dialysis, and that a report had been provided to the facility. A nurse's note dated 3/23/19 at 2:08 PM identified Resident #108's dialysis port was clean and intact. An APRN note dated 3/25/19 identified Resident #108 had end stage renal disease and received hemodialysis treatments 3 times weekly. Resident #108 had a Quinton catheter (a Quinton catheter (permacath) served as an access port for hemodialysis until the av fistula healed and was able to be utilized for dialysis.) Resident #108 underwent an av fistula placement on Friday 3/22/19. Furthermore, the APRN note identified that her assessment and plan for the resident included that the Quinton catheter would be utilized for dialysis until the av fistula matured, in approximately 6 weeks. Review of the March, April and May 2019 MAR/TAR's and nurse's notes identified that although nursing documented that the Quinton catheter port dressing was checked each shift to ensure it was clean, and the site was monitored for signs and symptoms of infection, redness, swelling, drainage and pain daily, the record lacked documentation that the newly created av fistula had been monitored or assessed for bruit or thrill. Physician's order dated 6/15/19 directed removal of gauze from Resident #108's left upper arm 3 hours after returning to the facility from dialysis on Tuesday, Thursday and Saturday. A nurse's note dated 6/19/19 identified Resident #108 had a physician appointment and returned following removal of the permacath. Review of the June 2019 MAR/TAR and nurse's notes identified that although that the gauze was removed from Resident #108's arm following dialysis, the record lacked documentation that the av fistula was assessed for bruit or thrill. Review of the July 2019 MAR/TAR and nurse's notes lacked documentation that the av fistula was assessed for bruit or thrill. Review of the MAR/TAR dated 8/1/19 through 8/20/19 failed to reflect that the av fistula was assessed for bruit or thrill. A nurse's note dated 8/17/19 at 1:41 PM identified that Resident #108 returned to the facility from the dialysis center at 9:00 AM, and per dialysis, the av fistula was clotted and Resident #108 was not able to have dialysis. A physician's order dated 8/18/19 directed Resident #108 be sent to the emergency room as had not been dialyzed as scheduled. A nurse's note dated 8/20/19 at 3:42 AM identified Resident #108 returned from a fistulogram for repair of the av fistula to the left arm. Interview and review of the clinical record with LPN #2 on 8/21/19 at 2:22 PM identified that when caring for Resident #108, she would remove the dressing from the resident's arm 3 hours after dialysis. Additionally, LPN #2 identified that nursing was to read the communication book from dialysis for any documentation communicated to the facility related to the resident's care. Although LPN #2 identified that when caring for a resident with an av fistula, the fistula should be monitored for bruit and thrill to ensure it is working, she could not identify if this was a practice that was done by nursing for Resident #108, as this was not documented in the MAR or TAR. When LPN #2 was asked if she checked Resident #108's av fistula for a bruit/thrill, LPN #2 did not provide a response. Interview and review of the clinical record with the DNS on 8/21/19 at 2:29 PM identified that she was unable to identify what type of dialysis access site Resident #108 had via record review. The DNS identified that not all types of shunts require monitoring of a bruit or thrill, and requested the nursing supervisor (RN #4) to assist in the record review to determine what type of access site Resident #108 had, and/or to locate any facility documentation pertaining to monitoring of that site, and/or to answer any questions related to the resident's dialysis. Additionally, the DNS indicated there was no facility policy related to resident receiving hemodialysis. Interview and review of the clinical record with the nursing supervisor, (RN #4), on 8/21/19 at 2:50 PM identified Resident #108 had an av fistula, and the fistula should be checked every shift for a bruit and thrill to ensure patency. Additionally, RN #4 identified that nursing should document they checked for a bruit and thrill in the clinical record. Review of clinical record with RN #4 failed to reflect an order to check for a bruit and thrill or any nursing documentation that the av fistula had been monitored/assessed for a bruit and thrill. RN #4 identified that it was nursing's responsibility to ensure that the av fistula was monitored, and indicated the dialysis facility had notified the facility that Resident #108's prior av fistula had become occluded necessitating a graft. Interview with the care coordinator for dialysis center, (RN #5), on 8/22/19 at 11:11 AM identified that Resident #108 had an av fistula placed in the left arm on 3/22/19 and received outpatient dialysis 3 days a week. RN #5 identified that the expectation would be for staff to monitor the av fistula for a bruit and thrill at least daily. Additionally, RN #5 identified that Resident #108's fistula became blocked necessitating the resident have an av graft performed to provide access for continued dialysis. Interview with DNS on 8/22/19 at 11:34 AM identified that the facility did not have a dialysis policy for residents receiving hemodialysis, and indicated that nursing staff would be expected to follow the physician's orders and to follow nursing standards of care. Interview with the Staff Development Nurse, (RN #1) on 8/22/19 identified that residents with av grafts or fistulas should be monitored for a bruit and thrill to ensure patency of the graft and is part of competencies required of nursing staff. RN #1 identified that nursing staff should have been monitoring and documenting presence or absence of bruit and a thrill for Resident #108's av fistula. Although requested on 8/21/19 at 10:00 AM and on 8/24/19 at 11:34 PM, a policy for dialysis care for resident's receiving hemodialysis was not provided. Although Resident #108 required dialysis treatment due to kidney failure, the facility failed to monitor the resident's av fistula (dialysis access site). Additionally, on 8/17/19, the av fistula was no longer patent and the resident required a fistulogram.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #1) reviewed for staffing, the facility failed to ensure sufficient staffing to ensure a dependent resident's needs were met when requesting to use the bathroom. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, muscle weakness and difficulty in walking. A physician's order dated 8/10/19 directed to provide Resident #1 assistance with bed mobility and transfers, and for physical therapy to assist with gait. A bladder assessment dated [DATE] identified Resident #1 was continent of bladder and bowel in the daytime, prone to urinary tract infections, and experienced urinary incontinence at night. The care plan dated 8/12/19 identified Resident #1 had a self-care deficit due to weakness and recent hospitalizations. Interventions included to assist the resident with transfers and toilet use. The admission MDS dated [DATE] identified Resident #1 had moderately impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance with transfers and toilet use. Interview with Resident #1 on 8/19/19 at 11:00 AM identified a concern about facility staffing because often times the staff was so busy they could not assist the residents. Resident #1 identified that earlier in the morning (8/19/19), NA #2 had helped him/her get dressed and up into a wheelchair, but did not have enough time to take him/her to the bathroom because the unit was short staffed, and NA #2 needed to check on another resident. Resident #1 identified that he/she felt sorry for NA #2, but was grateful that the physical therapy aide happened to come into the room and take him/her to the bathroom. Resident #1 identified he/she had to have a bowel movement, and that if the physical therapy aide had not come in the room and taken him/her to the bathroom, he/she would have soiled him/herself. Interview on 8/19/19 at 11:11 AM with PTA #1 identified that he had been on his way to work with Resident #1 earlier in the day, and the resident requested assistance to the bathroom before going to physical therapy, so he helped the resident to the bathroom. PTA #1 identified that he was not asked by the nurse aide to take Resident #1 to the bathroom. Interview with NA #2 on 8/19/19 at 2:19 PM identified that she had been assigned to Resident #1 and had assisted the resident to get dressed and out of bed to the wheelchair earlier in the day. NA #2 identified that once the resident was up, the resident asked to go to the bathroom. NA #2 identified the resident had been to the bathroom earlier that morning, and although she should not have, she told Resident #1 the unit was short staffed and that he/she would have to wait a short while so NA #2 could assist other residents. NA #2 identified that although she did not tell the charge nurse or supervisor she needed help to assist the resident, they were aware the unit was short staffed as 2 nurse aids called out that morning, and a nurse aid left sick leaving the unit short staffed. Additionally, NA #2 identified she did not request physical therapy to help Resident #1 go to the bathroom. Interview with the Nursing Supervisor, (RN # 4) on 8/19/19 at 2:47 PM identified that the unit was short staffed on the day shift that day because 2 staff had called out necessitating floating a nurse aide scheduled to work on the first floor to the other floor supervised by the ADNS. Additionally, RN #4 identified that the unit had a nurse aide go home sick at 8:30 AM leaving the first floor unit short. RN #4 identified she had shared her staffing concerns with the scheduler, (Receptionist #1) at 9:00 AM. RN #4 did not know if Receptionist #1 was able to secure additional staff to assist the unit. RN #4 identified that the unit had 5 nurse aides and normal staffing was 6 to 7 nurse aids during the day shift. RN #4 identified that she was not aware of any resident complaints related to staffing, but was aware that the unit was short staffed. Interview with the ADNS on 8/19/19 at 2:50 PM identified that he was aware staff had called out for the day shift and indicated he and the supervisors were responsible to ensure the units were staffed appropriately. The ADNS identified that although he was aware of nursing call outs, he didn't really think about it, and did not have a conversation about the short staffing with the DNS. Interview with Receptionist #1 on 8/19/19 at 3:00 PM identified that she had been originally hired as a receptionist but was given the added responsibility of scheduling 7 weeks ago. Receptionist #1 identified that she had been told earlier in the day by RN #4 that the first floor unit was short staffed and that a nurse aide had left. Receptionist #1 indicated she did not attempt to call other staff in to work, and identified that the supervisors and DNS were also responsible to assist in calling staff in to work, but she was not aware if that had been done. Review of the Monday August 19, 2019 staffing identified that 2 nurse aides scheduled to work during the day shift called out, and 1 nurse aide left at 8:30 AM. Interview with Receptionist #1 on 8/22/19 at 10:20 AM identified that NA #3 left the facility at 8:30 AM on 8/19/19. Interview with the Administrator and DNS on 8/22/19 at 10:21 AM identified that NA #3 left work 8/19/19 at about 8:30 AM. Review of nurse aide standard of care identified that nurse aides are to toilet or offer to toilet residents every 2 to 4 hours (offer bedpan, urinal, commode or toilet as appropriate and assume an unhurried manner and allow ample time for task). Review of the facility staffing plan identified its purpose is to ensure that care is given to residents 24 hours a day, 7 days a week. Although on 8/19/19, 2 nurse aides called out, and 1 nurse aide left at 8:30 AM, leaving the first floor units short staffed, the facility failed to attempt to replace staff to ensure the needs of the residents were met. Subsequently, on 8/19/19 at 11:00 AM, Resident #1, who requested assistance to use the bathroom, was told by NA #2 she did not have enough time to take him/her to the bathroom because the unit was short staffed and she needed to check on another resident so Resident #1 would have to wait.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #28 and 45) reviewed for urinary catheter the facility failed to ensure infection control practices were followed. The findings include: 1. Resident #28 was admitted to the facility on [DATE] with diagnoses that included diabetes, stroke, retention of urine, urinary tract infection, and benign prostatic hyperplasia. The quarterly MDS dated [DATE] identified Resident #28 had moderately impaired cognition, was frequently incontinent of bladder and always incontinent of bowel. Additionally, Resident #28 required extensive assistance of 1 for bed mobility, transfers, dressing, toileting, and hygiene. The care plan dated 8/13/19 identified Resident #28 had an indwelling catheter due to benign prostatic hyperplasia. Interventions included to monitor and document signs or symptoms of discomfort on urination and frequency, and intake and output as per facility policy. Position catheter bag and tubing below the level of the bladder and away from entrance room door. A physician's order dated 8/13/19 directed to utilize a 14 French 10cc balloon indwelling catheter, change the catheter drainage bag from straight drainage to leg bag upon getting out of bed in the morning, change from leg bag to straight drainage at bedtime, and provide catheter care, and obtain a urology consult for urinary retention. Observation on 8/19/19 at 9:45 AM in the shared bathroom of Resident #28, Resident #45, and 2 other resident's, identified hanging on the grab bar was an un labeled/dated leg bag and urinal. Observation and interview with NA #5 on 8/19/19 at 10:45 AM identified the leg bag and urinal, located in the shared bathroom were not labeled or stored properly. Additionally, NA #5 indicated when not in use, the leg bag and urinals should be stored in the bottom draw of the resident's night stand. Observation and interview on 8/19/19 at 11:53 AM with the Infection Control Nurse, (RN #1) indicated hanging on the grab bar was an unlabeled/dated leg bag and urinal. RN #1 indicated the expectation are the items should be dated and labeled when brought into a room, and stored in a bag in the night stand. Interview with Infection Control Nurse (RN #1) on 8/22/19 at 11:05 AM identified she follows the environmental rounds form which indicated personal items are to be labeled and stored appropriately. Additionally, RN #1 indicated that is the policy. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses chronic kidney disease, neuromuscular dysfunction of bladder and phimosis. The quarterly MDS dated [DATE] identified Resident #45 had severely impaired cognition, required extensive assistance with bed mobility, transfers, dressing, toilet use, and hygiene. Additionally, Resident #45 ambulated in room with supervision. A physician's order dated 7/3/19 directed an indwelling catheter 14 French 5cc balloon to straight drainage for urinary retention, change catheter drainage bag from straight drainage to leg bag upon resident getting out of bed in the morning, and change from leg bag to straight drainage at bedtime. The care plan dated 7/3/19 identified Resident #45 had an indwelling catheter for urinary retention. Interventions included to change the catheter per physician order, check tubing for kinks, position catheter bag and tubing below the level of the bladder and away from entrance room door. Additionally, monitor/document signs and symptoms of urinary tract infections such as pain, burning, blood tinged urine, cloudiness, no output, and foul smell. Monitor/report foul smelling urine, pain, blood/ cloudy urine, confusion, temperature, or no urinary output. Observation on 8/19/19 at 9:45 AM in the shared bathroom of Resident #28, Resident #45, and 2 other resident's, identified hanging on the grab bar was an unlabeled/dated leg bag and urinal. Observation and interview with NA #5 on 8/19/19 at 10:45 AM identified the leg bag and urinal, located in the shared bathroom were not labeled or stored properly. Additionally, NA #5 indicated when not in use, the leg bag and urinals should be stored in the bottom draw of the resident's night stand. Observation and interview on 8/19/19 at 11:53 AM with the Infection Control Nurse, (RN #1) indicated hanging on the grab bar was an unlabeled/dated leg bag and urinal. RN #1 indicated the expectation are the items should be dated and labeled when brought into a room, and stored in a bag in the night stand. Interview with Infection Control Nurse (RN #1) on 8/22/19 at 11:05 AM identified she follows the environmental rounds form which indicated personal items are to be labeled and stored appropriately. Additionally, RN #1 indicated that is the policy. Review of the electronic nurse aide care card failed to reflect direction on cleaning and/or storage of urinary catheter bag and tubing. Although requested, a policy on urinary catheter care, including labeling and storage of urinary collection devices was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 residents (Resident #56) reviewed for food, the facility failed to ensure food was served at a safe and palatable temperature. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, hypertension and dementia. A physician's order dated 6/27/19 directed to provide Resident #56 with a general diet. The quarterly MDS dated [DATE] identified Resident #56 had intact cognition, was continent of bowel and bladder and required set up only for eating. The care plan dated 7/17/19 identified Resident #56 had a problem or potential nutritional problem related to diagnoses of dementia and hypertension. Interventions included to provide and serve diet as ordered, and for the dietician to evaluate the resident and make changes as needed. Interview with Resident #56 on 8/19/19 at 1:59 PM identified that he/she was frustrated because the food served was on the cold side instead of hot. Resident #56 identified that he/she had shared these concerns with nursing staff and also voiced concerns via the resident council meetings but continued to be served cold meals. Interviews during the survey with 2 anonymous residents indicated a concern with food being served cold. Observation of the tray line on 8/21/19 at 12:36 PM identified [NAME] #2 did not take the temperature of a tray of fish after it was removed from the oven. [NAME] #2 was observed serving the fish on the tray line to the dietary aides as they prepared resident meals. Interview and temperature check (test tray) of food with the Director of Dietary identified the test tray left the kitchen in a dietary cart with resident meals on 8/21/19 at 12:37 PM and arrived on 1 North at 12:40 PM. Following distribution of the last resident tray from the dietary cart, food temperatures were recorded: orzo 140 -141 degrees Fahrenheit (F), beets 120 F, and fish 115 F. The Director of Dietary identified that the food items were cold, and indicated that the food items should be 145 F to ensure food items are safe to consume and noted although she agreed with the temperatures obtained during testing of the food items on the test tray, she was surprised the food was cold. The Director of Dietary identified that it was her expectation that the cook take the temperature of food items before food is served on the tray line to ensure the items were cooked and not a potential cause of food borne illness. Interview with [NAME] #2 on 8/21/19 at 1:10 PM identified that she checked the temperature of the food items when she took out the initial tray of fish and documented the temperature on the temperature sheet. [NAME] #2 identified it was her practice to take the temperature of any food item that came out of the oven prior to serving it on tray line and she recalled checking the temperature of the fish prior to serving it for resident consumption. [NAME] #2 identified that the temperature of the orzo was 172 F, the beets 174 F and the fish 172 F. Interview with the Administrator on 8/21/19 at 3:07 PM identified that the Director of Dietary agreed that orzo, beets and fish from the test tray were cold. The Administrator identified that although the cook took the temperature of the food items prior to serving them on the tray line, she may not have given the thermometer enough time to reset between temping of different food items. Review of the facility dining policy identified the facility will prepare foods in a manner so as to prevent cross-contamination. The policy further identified that hot foods will be held at 140 degrees F. Review of residents' bill of rights identified that residents have the right to receive quality care and services with reasonable accommodations of individual needs and preferences, except when your health and/or safety or the safety of other individual needs would be endangered by such accommodations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility documentation, facility policy and interviews, the facility failed to maintain food preparation areas in a clean and/or sanitary manner. The findings include: 1. Observation on 8/19/19 at 9:40 AM of the kitchen with Dietary Aid #1 identified that sanitizing solution, used by kitchen staff, is obtained from a dispenser above the 3 bay sink. Dietary Aide #1 indicated the sanitizing solution is utilized in the food preparation areas by the cook staff, in the dishwashing room by the dietary aids, and there was a spray container with sanitizer located in the chemical room of the kitchen. The initial test of the solution contained in the spray bottle utilized for sanitizing surfaces in the kitchen and housed in the chemical closet contained less than 100 Parts Per Million (ppm). Dietary Aid #1 identified that he had not tested the solution on 8/19/19, and was not certain when it had last been tested. Dietary Aid #1 identified he had utilized the solution to clean surfaces in the kitchen earlier in the morning and did not know who was responsible to check the level of sanitization in the solution. Dietary Aid #1 identified he had not checked the ppm of the sanitizer for several weeks. Interview on 8/19/19 at 9:45 AM with Dietary Aid #2 identified the sanitizing solution should be 200 ppm or greater. Additionally, she had obtained the sanitizer for the cook from a dispenser in the dishwashing room earlier in the morning but had not tested it. Upon surveyor request, Dietary Aid #2 tested the sanitizing solution in a bucket obtained from the dispenser above the three bay sink in the dish room, and identified it was less than 200 ppm. Dietary Aid #2 identified this solution should be greater than or equal to 200 ppm and indicated she was not certain who was responsible for checking the level of sanitizer and noted she had not checked tit for several weeks. Interview with [NAME] #1 on 8/19/19 at 9:47 AM identified that although she had utilized the sanitizing solution in the bucket at the cook preparation table earlier in the morning, she did not test the ppm of the sanitizing solution that morning and was not certain who is responsible to test the sanitation solution. [NAME] #1 identified that Dietary Aid #2 had provided the bucket of sanitizer for her use at the beginning of the morning. At surveyor request, [NAME] #1 tested the sanitizing solution in the red bucket in the cook preparation area and it contained less than 100 ppm sanitizer. [NAME] #1 identified that the solution should be 200 ppm or greater to ensure the sanitizer would be effective in preventing food borne illnesses during the preparation of resident meals. Interview with Dietary Aid #1, #2 and [NAME] #1 on 8/19/19 at 9:50 AM identified that the level of sanitizer had not been tested on [DATE], and that staff had not tested the sanitizing solution since the most recent inspection by the local health department earlier in the summer. Dietary Aid #1, #2 and [NAME] #1 identified the sanitizer solution should have been tested to ensure it was effective as a sanitizer to prevent infection of residents. Additional testing of the sanitizing solution after emptying the solutions in the spray bottle, red bucket in the kitchen, and in the dishwashing sink, and refilling the sanitizer in the bucket identified the solution contained less than 100 ppm of the chemical sanitizing solution. Interview on 8/19/19 at 10:48 AM with Dietary Aid #2 identified that subsequent to surveyor tour of the kitchen, she had worked with the director of maintenance to ensure the tubing connecting the sanitizer solution to the sink water was not kinked. Additionally, Dietary Aid #2 identified that the facility had changed vendors for the sanitizing solution recently and she found a different brand of test strips in the Dietary office. Furthermore, Dietary Aid #2 identified that the new sanitizing solution she had prepared tested 200 ppm or greater with the new test strips. Interview on 8/20/19 at 7:57 AM with the Administrator identified that in the absence of the Director of Dietary, the cook was in charge of the kitchen. Additionally, the Administrator identified that the dishwasher was expected to check the level of sanitizer in the kitchen 3 times a day as was the facility policy, to ensure resident food was handled in in a manner to prevent food borne infection. Interview with the Director of Dietary on 8/20/19 at 8:07 AM identified that in her absence, the cook was in charge of the kitchen. The Director of Dietary identified that each morning the dishwasher is responsible to fill a container in the dish room with the sanitizer and to test it to ensure the level is 200 ppm, thereby effective in sanitizing the dish room areas. Additionally, the [NAME] is responsible to fill a bucket with sanitizing solution, and to test the sanitizer's ppm to ensure it was effective for use in the kitchen preparation areas where resident's food was prepared. The sanitizer spray bottle in the chemical room should be tested as well to ensure the ppm indicated the solution was effective in sanitizing. The Director of Dietary the sanitizing solutions should be changed at least 3 times a day. The Director of Dietary identified that the facility did not require staff to document the sanitizer solution had been tested and/or changed. Review of cook job description identified duties included storing all food items and supplies according to procedure in a safe and sanitary manner. Additionally, the cook was to operate, clean and sanitize any equipment or work surfaces according to procedure in a safe and sanitary manner. Review of the dietary aide job description identified duties included preparing, washing sanitizing and properly handling dishes, utensils or pots and pans according to procedure in a safe and sanitary manner. Additionally, the dietary aid was to operate, clean and sanitize any equipment or carts utilized according to procedure in a safe and sanitary manner. Review of facility policy for infection control identified that sanitizing solution must be changed at least 3 times a day. 2. Observation of tray line with second surveyor on 8/21/19 at 12: 20 PM identified [NAME] #1's hair net was positioned so it covered the top of her head, and just above her ears. [NAME] #1's hair protruded approximately 3 inches from under the hairnet as she assisted [NAME] #2 to plate food on the tray line. Additionally, although [NAME] #2 had a hair net in place, approximately 2 ½ inches of long wavy bangs hung on her forehead, and approximately 5 inches of hair strands were observed in front of both ears outside of the hair net, as she worked on the tray line. Dietary Aid #3 had a hair net in place and approximately 3 inches of bangs hung out of the hair net framing her face as she worked on the tray line. Interview with the Dietary Director on 8/21/19 at 1:15 PM identified that staff is expected to wear hair nets when working in the kitchen. The Director of Dietary identified her expectation was that the staff hair was contained within the hair net to ensure sanitary food service. Review of facility policy for dietary dress code identified that all employees must wear a hat, hair net, beard restraint (used as a barrier for any length of hair) when in the kitchen.