**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care and services were provided for central venous access catheters, in accordance with professional standards of practice, by failing to provide necessary central venous dressing changes, for 1 of 2 residents, Resident #71, reviewed with a central venous catheter. (Photographic evidence obtained) Findings include: During an observation on 7/29/2024 at 10:00 AM Resident #71 was sitting upright in bed with a right upper arm single lumen peripherally inserted central catheter (PICC) line. The PICC line was covered by a transparent dressing which was lifting up on three sides of the dressing and had a 2 x 2 gauze under the transparent dressing. The PICC line had a date of 7/24/24 and a time of 11:00 PM documented on the dressing. During an observation on 7/29/2024 at 12:30 PM, Resident #71 had a transparent dressing covering the PICC line IV (intravenous) site on her right upper arm. There was a 2 x 2 gauze under the transparent dressing and three sides of the dressing were lifting up. The dressing was dated 7/24/24, with a time of 11:00 PM documented. Review of Resident #71's admission Record documented she was admitted to the facility on [DATE] with the following diagnoses: other acute osteomyelitis, right ankle and foot; diabetes mellitus due to underlying condition with diabetic neuropathy, type 2 diabetes mellitus with foot ulcer. Included in the admission record was documentation of an IV site/PICC line, no location of the IV site/PICC line insertion site was documented. Review of Resident #71's physician orders dated 6/21/24, read, Flush PICC line [in] right arm before and after administration of IV with 10CC (cubic centimeters) saline two times a day for osteomyelitis [in the] right foot Review of Resident #71's physician orders dated 6/24/24 read, Change IV/PICC dressing and caps weekly on 7p-7a every night shifts every Wed [Wednesday] for Prophylactic [guarding from or preventing the spread or occurrence of disease or infection]. Review of Resident #71's physician orders dated 7/25/24 read, Meropenem Intravenous Solution Reconstituted 1 GM (gram) (Meropenem). Use 1 gram intravenously two times a day for osteomyelitis [an infection in the bone] for 14 Days. During an observation on 7/30/2024 at 9:30 AM, Resident #71 was observed sitting up in bed, with her IV antibiotics, Meropenem (used to treat infections caused by bacteria), Intravenous Solution, 1 gram, infusing into the PICC line IV site in her right upper arm. The PICC line IV site was observed to be covered with a transparent dressing, with the edges lifting on three sides from her skin. There was a 2 x 2 gauze pad observed under the transparent dressing. The dressing had a date of 7/24/24 and a time of 11:00 PM documented. During an interview on 7/31/2024 at 9:55 AM, the Assistant Director of Nursing (ADON), stated, PICC line dressing changes are once a week and prn (Pro Re Nata/as needed). There should be something circular [antimicrobial sponge] at the [insertion] site. There should also be something other than Tegaderm [transparent occlusive dressing], there should be gauze or a split sponge under the Tegaderm. The only reason to change the dressing more often than once a week would be if the dressing was stained, like with blood. That's why we have the prn order. There is also an order to check the site for signs and symptoms of infection every shift. The gauze under the Tegaderm just gives something to grab when pulling off the Tegaderm. During an interview on 7/31/2024 at 10:15 AM, Staff A, Licensed Practical Nurse (LPN), stated, We do [PICC line] dressing changes every week. The kit has an occlusive dressing. The gauze in the kit is to dry the site. I only apply an occlusive (transparent) dressing. Gauze should not be under the occlusive dressing at all. If there is gauze, it should only be there, or on any wound, for 24 hours. During an interview on 7/31/2024 at 10:40 AM the Director of Nursing (DON), stated, We change the dressings on PICC lines once a week and prn, if it is saturated or loose. The dressing would have the round thing (antimicrobial disc) and the clear dressing (transparent occlusive dressing) on top. There should be no gauze. The kits have gauze, and sometimes when the line is first put in, it can be bloody and need the gauze. If there is gauze, the dressing needs to be changed within 24 hours. During an interview on 7/31/2024 at 12:15 PM, Staff A, LPN, stated, I gave her [Resident #71] morning antibiotics this week [7/29/2024, 7/30/2024, 7/31/2024]. I didn't change it [PICC line dressing] earlier this week, because I didn't think it needed to be changed. During an interview on 8/1/2024 at 11:15 AM, Staff F, LPN, stated, I took care of [Resident #71's name] last weekend [7/27/2024, 7/28/2024]. I remember she had a PICC line and was getting IV antibiotics. I gave them [the IV antibiotics] on my shift. There is usually gauze under the occlusive dressing, I had no idea it wasn't supposed to be there. During an interview on 8/1/2024 at 12:00 PM, Staff G, LPN, stated, I would have been the one to give her [Resident #71] antibiotics. I'm sure I gave the antibiotics both days [7/27/2024 and 7/28/2024]. The dressing was intact, but I did not notice there was gauze under the occlusive dressing. I didn't know the policy says there shouldn't be any gauze under the transparent occlusive dressing. I know gauze dressings are supposed to be changed every two days, but I didn't notice that there was gauze. During an interview on 8/1/2024 at 12:45 PM, the DON, stated The nurses are supposed to assess PICC sites every shift and change the dressings once a week or as needed, if the dressing is loose or soiled. There should not be any gauze. I expect the nurses to assess the insertion site and quality of the dressing and change it according to our policy. Review of the policy and procedures titled, Central Venous Catheter Care and Dressing Changes, last revised 3/2022, review date of 1/11/2024, read, Purpose - The purpose of this procedure is to prevent complications associated with therapy, including catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines - 1. Perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened or visibly soiled). 2. Maintain sterile dressing (transparent semi-permeable membrane [TSM] dressing or sterile gauze) for all central vascular access devices. The type of dressing is based on the condition of the resident and his or her preference. 3. Change the dressing if it becomes damp, loosened or visibly soiled and: a. at least every 7 days for TSM dressing; b. at least every 2 days for sterile gauze dressing (including gauze under a TSM unless the site is not obscured); or c. immediately if the dressing or site appear compromised.

Based on observation, interview, and record review, the facility staff failed to follow physician orders and ensure that oxygen was administered consistent with professional standards of practice for 3 out of 4 residents reviewed for respiratory care (Resident #27, #30 and #46) Findings include: 1. Review of Resident #27's admission record documented diagnoses that included unspecified systolic congestive heart failure, anemia unspecified, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of Resident #27's physician orders dated 9/7/2022 read, Deliver oxygen at 2L [liters]/min [minute] via nasal cannula. During an observation on 7/29/2024 at 12:34 PM Resident #27 was resting in bed, oxygen was being administered at 4 liters per minute via nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was at the head of the bed on the right side of the bed and outside of the resident's reach. During an observation on 7/30/2024 at 7:44 AM Resident #27 was resting in bed, oxygen was being administered at 4 liters per minute via nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was at the head of the bed on the right side of the bed and outside of the resident's reach. During an observation on 07/30/24 at 02:45 PM of Resident #27, conducted with Staff A, Licensed Practical Nurse (LPN), it showed oxygen was being administered at 4 liters per minute via nasal cannula that was attached to an oxygen concentrator. The oxygen concentrator was at the head of the bed on the right side of the bed and outside of the resident's reach. Staff A, LPN, during the observation, changed the oxygen administration to 3 liters per minute. During an interview on 7/30/2024 at 2:47 PM Staff A, LPN stated, That is not correct [the oxygen]. I'm not sure how it got on that high. Her orders [Resident #27] are for 2 liters and I will change that. I should check oxygen when I am administering medications. I am not aware of any reason we would have needed to change the rate of the oxygen. Review of the nursing progress notes for the period of 7/14/2024 through 07/30/2024 did not document the need to increase the oxygen administration dosage, changes in the resident's respiratory status, or notification to the physician of a change in the resident's oxygen administration rate. During an interview on 8/1/2024 at 7:30 AM the Director of Nursing (DON) stated, I expect staff to assess residents on oxygen at a minimum daily and make sure that we are following the orders for correct oxygen administration. 2. During an observation on 7/29/2024 at 12:39 PM Resident #30 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 3 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside of the reach of the resident. During an observation on 7/30/2024 at 7:48 AM Resident #30 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 3 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside the reach of the resident. Review of Resident #30's admission record which documented diagnoses that included heart failure, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus without complications, aphasia following cerebral infarction, dysphasia following cerebral infarction, and essential primary hypertension. Review of Resident #30's physician orders dated 12/20/2023 read, Continuous O2 [oxygen] at 2L [liters] via NC [nasal cannula]. Review of Resident #30's progress notes for the period of 7/19/2024 through 7/30/2024 did not provide for documentation of changes in condition, a change in respiratory status, shortness of breath, or the physician having been notified of a change in the administration of oxygen. During an observation on 7/30/2024 at 2:48 PM Staff A, LPN verified the oxygen was running at 3 liters per minute. During an interview on 7/30/2024 at 2:48 PM Staff A, LPN stated, Her orders [Resident #30] are for 2 liters of oxygen. I should check daily for what oxygen is running at. During an interview on 7/31/2024 at 9:42 AM the DON stated, The nurses should be checking oxygen every day, when they go from portable tanks to concentrators, and when they have any changes in their respiratory functioning. 3. During an observation on 7/29/2024 at 10:29 AM Resident #46 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 5 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside the reach of the resident. During an observation on 7/30/2024 at 7:43 AM Resident #46 was in bed with oxygen being administered via nasal cannula. The oxygen concentrator was set at 6 liters per minute. The oxygen concentrator was at the left side and at the head of the bed outside the reach of the resident. During an interview on 7/30/2024 at 7:44 AM Resident #46 stated, I do not change the machine, sometimes I take my oxygen off at my nose, but I can't reach the machine to change it. Review of Resident #46's admission record documented diagnoses that included acute and chronic respiratory failure, unspecified whether with hypoxia [low oxygen] or hypercapnia [high carbon dioxide], type 2 diabetes mellitus without complications, heart failure, unspecified, and essential (primary) hypertension. Review of Resident #46's physician orders dated 12/20/2023 reads, O2 at 3 L/m via nasal cannula. During an observation on 7/30/2024 at 2:44 PM Staff A, LPN verified that the oxygen was running at 6 liters per minute, During an interview on 7/30/2024 at 2:48 PM Staff A, LPN stated, It [the oxygen] is on 6 liters and should be on 4 liters. I am responsible for making sure that the oxygen is running at the right rate. We should be following physician orders for oxygen. During an interview on 8/01/2024 at 9:09 AM the DON stated, I expect staff to follow physician orders for oxygen use. They should check at least daily. Review of the policy and procedure titled, Oxygen Administration last approval date of 01/11/2024 read, Purpose: The purpose of the procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in the procedure: 13. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated.

Based on observation, interview, and policy and procedure review, the facility failed to ensure food is safely stored, covered, and/or labeled in the areas of the nutrition room and food trays delivered to the floors. Findings include: During an observation on 7/29/24 at 10:00 AM of the nutrition room on the first floor, inside the refrigerator was an open package of Bologna not dated or sealed. (Photographic evidence obtained). During an interview on 7/29/24 at 10:00 AM the Dietary Manager stated, Its dietary's responsibility to check the nourishment rooms in the morning and clean them out as needed. During an interview on 7/29/24 at 10:00 AM the Dietary Manager confirmed the bologna was not sealed in the package or dated. During an observation on 7/30/24 at 7:51 AM of the breakfast meal delivered to the first floor from main kitchen, showed half cut bananas not covered on individual resident trays. (Photographic evidence obtained). During an interview on 7/30/24 at 7:52 AM the Administrator, who walked up at the time the trays were delivered, said, I do not know why the cut bananas were not covered. During an interview on 7/30/24 at 8:10 AM the Dietary Manager stated, I am not sure why the bananas that are cut in halves are not wrapped. A request was made for the policy and procedure related to food tray delivery. During an interview on 8/1/24 at 10:14 AM the Dietary Manager stated, There is no food tray delivery policy and procedure. Review of the policy and procedure titled, Foods Brought by Family/Visitors, reviewed on January 11, 2024, read, Policy Statement: Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Policy Interpretation and Implementation: 1. Family members and visitors are asked to inform nursing staff when foods are brought for a resident. 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. a. Nonperishable foods are stored in re-sealable containers with tight fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the date. 6. The nursing staff will discard perishable foods within 3-5 days. 7. The nursing and /or food service staff will discard any foods prepared for the resident that shows obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's diet for 2 (Resident #53 and Resident #31) of 3 residents sampled for nutrition and 1 (Resident #1) of 1 residents reviewed for restraints. Findings include: 1. During an observation on 3/20/2023 at 12:35 PM, Resident #53 was sitting in her room eating independently. The resident's meal ticket read, Mechanically soft, ground meat, mashed potatoes, green bean salad, juice, and crumb cake. During an observation on 3/22/2023 at 12:40 PM, Resident #53 was sitting in her room eating independently. The resident's meal ticket read, Mechanically soft, finely chopped chicken, noodles, green beans, apple sauce, and juice. Review of the admission record documented that Resident #53 was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, dysphagia following nontraumatic intracerebral hemorrhage, aphasia following cerebral infraction, and gastro-esophageal reflux disease with esophagitis without bleeding. Review of the physician order for Resident #53 dated 11/20/2022 read, Regular diet mechanical soft texture, thin/regular consistency, Diet - Mechanical soft, thin liquids. Fortified pudding with lunch and dinner for weight loss Review of Resident #53's MDS Quarterly assessment dated [DATE] read, Section K - Swallowing/Nutritional Status, K0510 Nutrition approaches: C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids), 2. While a resident: 0. Not checked (No) During an interview on 3/22/2023 at 1:19 PM, the MDS Coordinator stated, [Resident #53's name] is on a mechanical soft diet. I probably saw the regular and did not go any further. 2. During an observation on 3/20/2023 at 12:39 PM, Resident #31 was eating independently in his room. The resident's meal ticket read, Mechanical soft, ground meat, mashed potatoes, green beans, desert and juice. During an observation on 3/22/2023 at 12:43 PM, Resident #31 was eating independently in his room. The resident's meal ticket read, Mechanical soft, finely cut chicken, noodles, apple sauce, green beans and juice. Review of the admission record documented Resident #31 was admitted to the facility on [DATE] with diagnoses including but not limited to dysphagia, dementia in other disease classified elsewhere, moderate, without behavioral disturbance, and anemia. Review of the physician order for Resident #31 dated 2/22/2023 read, Regular diet mechanical soft texture, thin/regular consistency. Review of Resident #31 MDS Medicare 5-day assessment dated [DATE] read, Section K - Swallowing/Nutritional Status, K0510 Nutrition approaches: C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids), 2. While a resident: 0. Not checked (No) During an interview on 3/22/2023 at 1:20 PM, the MDS Coordinator stated, [Resident #31's name] is on a mechanical soft diet, [the MDS] should be changed. 3. During an observation on 3/20/2023 at 9:33 AM, Resident #1 was lying in bed, with no bed rails noted. During an observation on 3/21/2023 at 10:00 AM, Resident #1 was lying in bed, with no bed rails noted. Review of the admission record documented that Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to paralytic ileus, unspecified convulsions, bipolar disorder, unspecified psychosis not due to substance or known physiological condition, anxiety disorder, schizophrenia, other specified depressive episodes, and other specified mental disorders due to known physiological. Review of the physician orders for Resident #1 on 3/22/2023 revealed no orders for bed rails. Review of Resident #1's MDS Quarterly assessment dated [DATE] read, Section P - Restraints and Alarms, P0100 Physical Restraints, Used in Bed: A. Bed Rail: 2. Used daily. During an interview on 3/22/2023 at 9:01 AM, Staff B, License Practical Nurse (LPN) stated, [Resident #1's Name] does not use any restraints. She does not have bed rails. During an interview on 3/22/2023 at 1:15 PM, the MDS Coordinator stated, [Resident #1's Name] used half rails at times. That [the MDS] is not supposed to say bed rails as restraints. Review of the policy titled Resident MDS Assessment and Care Planning Policy last reviewed on 12/15/2022 read, Purpose: To ensure facility compliance with regulations pertaining to Resident Assessment. To encourage resident and family input in assessment process. To provide interdisciplinary observation and assessment to ensure the most accurate assessment of resident functional capacity. To develop an individual Care Plan for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was newly admitted with a serious mental illness received a referral to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for 1 (Resident #53) of 6 residents reviewed for PASARR. Findings include: Review of the admission record documented Resident #53 was admitted to the facility on [DATE] with diagnoses including but not limited to schizophrenia. Review of PASARR for Resident #53 dated 5/5/2022 read, Section I: PASRR Screen Decision Making, A. MI [Mental Illness] or suspected MI (check all that apply): Schizophrenia, Section IV: PASRR Screen Completion: Individual may not be admitted to a Nursing Facility. Use this form and required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of (Check on of the following): Serious Mental Illness. Review of KEPRO (Keystone Peer Review Organization) PASRR Notice of the Need for Further Evaluation dated 5/5/2022 read, Results from your screening. There are two screening levels. You have done Level I. The results are below. Signs of a serious mental illness were found. Level II screening is needed. Results of screening will be sent to you when done. Your Level I screener will request this Level II screening. We will notify you with the result. Review of Resident #53's Minimum Data Set (MDS) Quarterly assessment dated [DATE] read, Section I Active Diagnoses, Psychiatric/ Mood Disorder: I6000. Schizophrenia. During an interview on 3/21/2023 at 9:32 AM, the Social Services Director stated, [Resident #53's Name] does not have a PASARR Level II Screening. I went into KEPRO database and was not able to find one. I do not know why they did not do it. During an interview on 3/23/2023 at 10:55 AM, the Administrator stated, My expectations is if the resident is not a provisional stay and will be long term the Level II screening should have been completed and that is part of the admission process. Review of the policy titled Resident Assessment- Coordination with PASARR Program, last reviewed 12/15/2022 reads, Policy Explanation and Compliance Guidelines: 1b. PASARR Level II - a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD (mental disorder), ID (intellectual disability) or related condition, determines the appropriate setting for individual, and recommends any specialized services and /or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care and services were provided for central venous access devices in accordance with professional standards of practice for 1 (Resident #313) of 1 residents reviewed with a central venous access devices. Findings include: During an observation on 3/20/2023 at 9:50 AM, Resident #313 was lying in bed with a single lumen midline on right upper arm dated 3/10/2023. During an interview on 3/20/2023 at 9:51 AM, Resident #313 stated, The midline was inserted in the hospital before leaving. The staff here have not changed my dressing. I have not refused any care related to my midline. Review of the admission record documented Resident #313 was admitted to the facility on [DATE] with the diagnoses including but not limited to pressure ulcer of left hip, stage 3, morbid obesity due to excess calories, vitamin D deficiency, and dietary calcium deficiency. Review of the Medical Certification For Medicaid Long-Term Care Services and Patient Transfer Form for Resident #313 dated 3/10/2023 read, V. Treatment Devices: IV/PICC (intravenous/peripherally insert central catheter) / Portacath Access-Date inserted: 3/10/2023 type: midline. Review of the physician orders for Resident #313 dated 3/19/2023 read, Change IV dressing every 7 days and as needed. Every day shift every Sat [Saturday] and every 24 hours as needed for protocol. During an interview on 3/22/2023 at 2:40 PM, the Director of Nursing stated, [Resident #313's Name] dressing was dated 3/10/2023, IV dressing should be changed every 7 days or as needed. Orders [physician] are in the system and should be followed. Review of policy titled IV Peripheral Venous Access last reviewed 12/15/2022 read, 4. IV sites shall be rotated every 7 days and as needed per facility policy. Physician's order and documentation is required.

Based on observation, interview, and record review, the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 2 of 4 sampled residents (Residents #32 and #59). Findings include: 1. During an observation on 3/20/2023 at 12:58 PM, Resident #32 was sitting in an electric wheelchair with oxygen running at 3 liters per minute via a nasal cannula. During an observation on 3/21/2023 at 8:34 AM, Resident #32 had oxygen running at 3 liters per minute via a nasal cannula. During an interview on 3/21/2023 at 8:34 AM, Resident #32 stated, It is supposed to be set at 2 liters. I do not change my oxygen setting. During an observation on 3/22/2023 at 8:19 AM, Resident #32 had oxygen running at 3 liters per minute via a nasal cannula. Review of the physician order for Resident #32 dated 6/27/22 read, Deliver Oxygen @ [at] 2 liters/minute via Cannula PRN [as needed]. During an interview on 3/22/2023 at 1:48 PM, Staff A, Licensed Practical Nurse (LPN), stated, [Resident #32's name] should be on 2 liters of oxygen and the setting they are on now reads 3.5 liters per minute. That is not correct. 2. During an observation on 3/20/2023 at 1:19 PM, Resident #59 was lying in bed, wearing a nasal cannula with oxygen running at 2 liters per minute. During an observation on 3/21/2023 at 8:18 AM, Resident #59 was lying in bed, wearing a nasal cannula with oxygen running at 2 liters per minute. During an observation on 3/22/2023 at 8:24 AM, Resident #59 had oxygen running at 2 liters per minute. During an interview on 3/22/2023 at 8:24 AM, Resident #59 stated, I don't mess with that thing [oxygen concentrator]. Review of the physician order for Resident #59 dated 10/26/2022 read; O2 [Oxygen] at 3 L/M [liters per minutes] via Nasal Cannula. During an interview on 3/22/2023 at 2:05 PM, Staff A, LPN stated, [Resident #32's name] should be at 3 liters of oxygen. The Oxygen concentrator is set on 2 liters per minute. Review of the facility policy titled Oxygen Administration, last reviewed on 12/15/2022 read, Section 1. Oxygen is administered under orders of a physician.

2. An observation of the medication room on the first floor on 10/4/2021 at 9:30 AM with Staff H, Licensed Practical Nurse (LPN), showed the floors had a brown film with multiple spots of a dark brown substance. There was trash overflowing from the trash can onto the floor. The floor had a layer of debris behind the door of the medication room. The sink had four silver color pouches on the left side. There was a tan/yellow brown substance on the bottom of the sink and around the drain. The other side had several partial stickers stuck on the bottom of the sink, with a brown dark tan substance on the sink bottom and around the drain. There was a dark brown substance around the sink handles, and the counters had multiple stains that were brown dried circular rings. During an interview on 10/4/2021 at 9:35 AM, Staff H, Registered Nurse (RN), stated, The housekeepers need to be in here with someone. I'm not sure how frequently it is cleaned. There are old stickers on the bottom of the sink. It does have some stuff on the bottom of the sink, and the counters have old coffee cup marks on them. An observation of the medication room on the second floor on 10/4/2021 at 9:45 AM showed the left side sink basin had a tan/brown substance on the bottom and around the drain. The right side of the sink basin contained five silver pouches. The bottom of the sink had a sticky brown substance, and the faucet area had a brown substance around the handles. The floor had multiple dark brown stains that were able to come off with water and dust that could be removed. There was a storage closet with the handle covered with tape that had brown stains on it. During an interview on 10/4/2021 at 9:55 AM, Staff H, RN, stated, The sink needs to be cleaned. The tape on the handle is dirty, and I do not know why it is on there. The floor really needs to be cleaned. During an interview on 10/4/2021 at 12:35 PM, the Director of Nursing (DON) stated, The stains appear to be from coffee cups. The floor really needs to be cleaned and there is dust and other things on the floor. It is very dirty. Review of the facility policy and procedure titled, Storage of Medications revised in April 2007, with an approval date 9/1/2021, read, Policy Interpretation and Implementation: . 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. 3. An observation of Resident #47's room on 10/4/2021 at 11:57 AM showed his bedroom window screen was not securely attached to the window frame. The screen was not fully attached to the bottom of the screen frame and there was a gap between the screen frame and window frame. Resident #47's window was observed to be cranked open (Photographic evidence obtained). During an interview on 10/4/2021 at 11:58 AM, Resident #47 stated, My window screen is not tight against my window and I like my windows cranked open. Bugs can crawl or fly into my window. An observation of Resident #47's room on 10/5/2021 at 8:39 AM showed the window screen was not securely attached to the window frame and the screen was not fully attached to the bottom of the screen frame. During an interview on 10/5/2021 at 8:40 AM, Resident #47 stated, Bugs could come in the window with the screen open like that. Based on observation, record review, and interview, the facility failed to provide a safe, clean, comfortable and homelike environment for 13 of 48 sampled residents, Residents #15, #3, #12, #14, #16, #54, #52, #37, #40, #20, #6, #25, and #47, for 1 of 2 common living areas, and 2 of 2 medication storage rooms. Findings: 1. During the initial tour on 10/4/2021 at approximately 9:30 AM with Staff A, Certified Nursing Assistant (CNA), observation of Resident #15's room showed the mattress was about 6 inches short of the bed frame, which left an open area revealing the steel frame with the springs. The exposed area measured approximately 6 inches by 36 inches (Photographic evidence obtained). During an interview on 10/4/2021 at 9:35 AM, Resident #15 stated, They removed a wedge that was in that area and never brought the wedge back. During a tour of the facility on 10/6/2021 beginning at 8:30 AM with the Director of Plant Operations, an observation showed three dirty ceiling light diffusers in the lobby at the front door, a chair with the fabric completely worn through in the large common living television room area on the first floor. There were rusted door jambs observed pulling away from the walls in the rooms for Residents #3, #12, #14, #16, and #54. Resident #52's bathroom showed fecal matter in clumps on the floor. In Resident #37's room, there was a dirty, brown stained privacy curtain. Resident #40's room had an uneven patched area with a hole from the middle of the wall to the baseboard, behind the door. Resident #20's wall behind the door had a panel for utilities, which was secured to the wall with black tape. In the hall on the second floor outside of Resident #53's room, there was a dirty ceiling light diffuser with a crack about 10 inches long. Resident #6's room had a dirty privacy curtain and the overbed table had a 3 inch by 4 inch piece of the laminate finish missing. The missing laminate caused an exposure of unfinished wood. The sinks in Residents #25 and #47's rooms showed the water drained very slowly out of the sinks. During an interview on 10/6/2021 at 9:35 AM, the Director of Plant Operations verified the mattress in Resident #15's room did not fit the bed properly. She verified the door jambs, baseboards and walls needed repair. She stated the overbed table needed to be replaced. She verified the slow drains in the sinks in Resident #25 and #47's rooms, the fecal matter on the floor in Resident #52's room, and the dirty privacy curtains in Residents #37 and #6's rooms. Review of the Maintenance Logs since 9/5/2021 revealed one white paper in a binder with different handwritten phrases for complaints. The forms were no longer in use. There were no entries for the dirty, worn television chair, taped wall panel, cracked and dirty light diffusers, the overbed table missing a section of laminate, holes in the walls, dirty floors and privacy curtains. Review of the facility policy and procedure titled, Cleaning and Disinfecting of Environmental Surfaces read, Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens standard. During an interview on 10/6/2021 at 12:00 PM, the Administrator stated, The staff should be noting issues in the log at the nurse's station. This is part of their Guardian Angel Program.

Based on observation, record review, and interview, the facility failed to ensure each resident received adequate assistance to prevent accidents while transfer for 1 of 3 sampled residents, Resident #14, in a total sample of 28 residents. Findings: During an interview on 10/4/2021 at approximately 11:00 AM, Resident #14 stated, My transfers scare me. I am worried because they move me from side to side and the sling is uncomfortable, sometimes it hurts. The battery goes dead sometimes when I am in the process of the transfer. During an observation of Resident #14 on 10/4/2021 at 1:15 PM, Staff A, Certified Nursing Assistant (CNA), and Staff B, CNA, assisted Resident #14 to transfer from the wheelchair to the bed with the use of a Hoyer mechanical lift. Staff A and Staff B did not lock the wheelchair brakes prior to beginning the lift or at any time during the lift. Resident #14 asked, Are you sure the battery is charged? Staff A stated, Yes, it is charged this time. Remember it moves slower when it is not charged. The resident stated, Finally. During an interview on 10/4/2021 at 1:45 PM, Staff A, CNA, and Staff B, CNA, verified they did not use the locks. They stated they completed the transfer the same way they usually do. During an interview on 10/6/2021 at 9:00 AM, the Occupational Therapist verified the wheelchair locks on Resident #14's wheelchair should be locked prior to any transfers. She stated the locks can be disengaged as needed and then relocked during the transfer. Review of Resident #14's care plan dated 1/26/2021 read, Interventions: . Up in wc [wheelchair] for distance and make sure it is locked before all transfers, . Assist of 1 with mobility, assist of 2 with Hoyer lift for transfers at this time, . bed in lowest position and make sure it is locked. Review of the facility policy and procedure titled, How to Transfer Resident from a Wheelchair to a Bed, read, Instructions: . Step 2. Lock the wheels on the wheelchair and the bed (optional). Make sure the wheelchair is positioned so it is parallel to the bed, facing the foot end of the bed or at a 45-degree angle to the bed. It also should be near the middle of the bed. During an interview on 10/5/2021 at approximately 8:15 AM, the Assistant Director of Nursing verified they expect the staff to use the wheelchair locks during all the transfers. She verified the word optional in the policy was not for the wheelchair locks.

Based on observation, interview, and record review, the facility failed to ensure the residents with indwelling catheter received appropriate care and services for 2 of 5 sampled residents, Residents #19 and #24, in a total sample of 28 residents. Findings: 1. An observation of Resident #19 on 10/4/2021 at 10:56 AM showed the urinary catheter drainage bag was on the floor. Review of Resident #19's medical records revealed the resident had a diagnosis of right femoral fracture, dementia, major depression, and neurogenic bladder (a condition where there is a lack of bladder control due to a brain, spinal cord, or nerve problems). During an interview on 10/4/2021 at 11:05 AM, Staff G, Certified Nursing Assistant (CNA), stated, The catheter bag shouldn't be on the floor. I just didn't see it. His bed is low. During an interview on 10/4/2021 at 11:35 AM, Staff E, Licensed Practical Nurse (LPN), stated, The catheter bag should not be on the floor and the tubing should not be kinked. It is against our policy to have this. 2. An observation of Resident #24 on 10/4/2021 at 10:57 AM showed the urinary catheter drainage bag was on the floor and the drainage tubing was looped and kinked. Review of Resident #24's medical records revealed diagnoses including atrial fibrillation (irregular heartbeat), benign prostatic hypertrophy (an enlarge prostate gland), hypertension (high blood pressure), cervical myelopathy (a neck condition that occurs when the spinal cord becomes compressed or squeezed). During an interview on 10/4/2021 at 11:05 AM, Staff G, CNA stated, The catheter bag shouldn't be on the floor. During an interview on 10/6/2021 at 10:07 AM, the Director of Nursing (DON) stated, All catheters should be on the bed without any kinks and should not be on the floor. That is a nursing standard of practice. Review of the facility policy and procedure titled, Catheter Care, with an approval date of 9/1/2021, read, Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.

Based on observation, interview, and record review, the facility failed to ensure the residents who needed respiratory care received such care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 8 sampled residents, Resident #5, in a total sample of 28 residents. Findings: Review of Resident #5's medical records revealed diagnoses including cerebral infarction (a stroke) with left hemiplegia (paralysis of the left side of the body), seizure disorder, depression, and gastroesophageal reflux disease (a condition when stomach acid irritates the food pipe). Review of the Resident #5's physician orders read, Oxygen at 2 LPM [liters per minute] via nasal cannula as needed every shift . Order Date: 8/24/2021. An observation of Resident #5 on 10/4/2021 at 1:37 PM showed the resident was resting in bed with oxygen being administered at 4 liters via nasal cannula. An observation of Resident #5 on 10/5/2021 at 8:44 AM showed the resident was in bed with oxygen being administered at 4 liters via nasal cannula. An observation of Resident #5 on 10/6/2021 at 8:30 AM showed the resident was in bed with oxygen being administered at 4 liters via nasal cannula. During an interview on 10/6/2021 at 8:35 AM, Staff F, Licensed Practical Nurse (LPN), and the Director of Nursing (DON) verified Resident #5 was being administered oxygen at 4 liters via nasal cannula. Staff F stated, His oxygen should be running at 2 liters per minute via nasal cannula per the physician's order. He has not had any change in condition that required having his oxygen increased. He does not adjust it himself. During an interview on 10/6/2021 at 8:38 AM, the DON stated, His oxygen is at 4 liters and the nurses should assess this and make sure it is infusing at the proper rate and flow per the doctor's orders. Review of Resident #5's care plan revealed the resident was at risk for respiratory distress related to shortness of breath and obesity and chronic anxiety. The interventions included administering oxygen per orders at 2 liters via nasal cannula. Review of the facility policy and procedure titled, Oxygen Administration with an approval date of 9/1/2021 read, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of the physician, except in the case of an emergency. In such cases oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control.

Based on record review and interview, the facility failed to ensure residents that received Medicaid benefits were notified when the amount in the resident's account reached $200 less than the SSI (Supplemental Security Income) resource limit for 2 of 3 residents, Residents #24 and #3, in a total sample of 28 residents. Findings: Review of Resident #24's trust account activity beginning on 3/8/2021 revealed a balance of $2,765.89. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 4/5/2021 revealed a balance of $1,981.99. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 6/9/2021 was $1,805.14. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 7/2/2021 was $1,935.21. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 8/3/2021 was $2,065.29. There was no documentation showing the resident was notified his account was over the eligible limit. The account balance on 9/3/2021 was $2,117.14. There was no documentation showing the resident was notified his account was over the eligible limit. There was no documentation of the resident being notified of the account balance prior to the account reaching the eligibility limit of $200.00. There was no documentation in the record of the resident's representative being notified of the account balances. Review of Resident #3's trust account activity beginning on 9/10/2021 revealed a balance of $1,845.23. There was no documentation of the resident or the resident's representative being notified the account was over the $200.00 eligibility limit. During an interview on 10/7/2021 at 7:45 AM, Staff I, Business Office Manager, stated, I have looked through his [Resident #24's] file and there are no notices that the resident was notified that he was over or within the $200.00 dollars of his allowable limit. I did not send a notification to [Resident #3's name] about being within the $200.00 limit and I should have. Review of the facility policy titled, Resident Trust Fund Policy regarding Notification of Responsible Party of near Medicaid Eligibility Limits with an approval date of 9/1/2021 read, The Business Office Manager, or designee, will provide a letter to the resident, (or resident's responsible party), notifying them when the residents trust account balance is nearing $200 of the allowable the [Sic.] Medicaid limit, or exceeding the allowable limit, for funds in the account. Review of the facility policy titled, Resident Trust Fund Policy & Reconciliation Requirements read, General Guidelines: . 11. A resident and/or responsible party who receive Medicaid benefits will be notified when their trust account balance reaches $1,800.00.

Based on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety. Findings: An observation of the nourishment room on the second floor on 10/4/2021 at 1:45 PM with the Dietary Manager showed the ice machine had a black substance on the bottom edge of the baffle (ice guard) (Photographic evidence obtained). During an interview on 10/4/2021 at 1:46 PM, the Dietary Manager stated, The ice machine is to be cleaned twice a month. This one needs to be cleaned. An observation of the nourishment room on the first floor on 10/4/2021 at 1:53 PM with the Dietary Manager showed the ice machine had a black substance on the baffle (ice guard) and the microwave had used paper towels on the bottom surface and food particles on the top and side surfaces of the microwave (Photographic evidence obtained). During an interview on 10/4/2021 at 1:54 PM, the Dietary Manager confirmed the microwave should have been cleaned after use and stated, The ice machine is to be cleaned twice a month also. This one needs to be cleaned. Review of the facility policy titled, Sanitation of Ice Machine reviewed on 9/21/2021 read, Policy: It is the policy of this facility that the ice machine shall be sanitized twice monthly by dietary . Sanitation: 5. All equipment is cleaned as needed.