Based upon observations, interviews, and record review, the facility failed to promote dignity by not having a privacy cover for a foley catheter bag for 1 of 1 residents observed for dignity (Resident #43). The findings include: On 03/10/25 at 12:00 PM, an observation Resident #43's room was made from the hallway since the room door was opened. A foley catheter bag was observed hanging from the bed railing on the side of the bed facing the doorway. The foley catheter bag did not have a privacy cover and was noted to have approximately 300 ml of urine in the bag. Resident #43 was observed lying in bed with eyes closed, respirations even and unlabored at this time. On 03/10/25 at 03:41 PM, the catheter bag was once again observed from the hallway since the room door was open. No privacy cover was in use. The foley catheter had approximately 700 ml of dark yellow urine present. On 03/11/25 at 09:09 AM, Resident #43's room door was again open and could be observed from the hallway. The foley catheter is observed hanging from the bed rail facing the doorway with no privacy cover noted. Approximately 150 ml of yellow urine observed in the bag. On 03/11/25 at 12:00 PM and 2:40 PM, Resident #43 was observed once again with a Foley catheter bag without a privacy cover hanging from the bed railing with yellow urine noted in the catheter bag. Resident 43 denies pain and discomfort at this time. On 03/12/25 at 09:00 AM, Resident #43 is observed out of bed in the hallway sitting in a wheelchair. His foley catheter is observed without a privacy cover and the catheter tubing dragging against the floor as he maneuvers his wheelchair in the hallway. On 03/13/25 at 08:15 AM, Resident #43 was observed with all his personal belongings with him and a foley catheter observed without a privacy cover hanging from bottom of wheelchair. A staff member assisted Resident #43 to the front lobby and then to being assisted on to a transportation vehicle to go home.

Based on observations, interviews and record review, the facility failed to provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan, goals and preferences for 1 of 1 resident sampled. (Resident #73) The findings include: On 3/10/2025, there was respiratory tubing, a mask, and a nebulizer observed on the floor beside Resident #73's bed. The tubing was attached to a machine nebulizer with a sticker dated 2/26/2025. On 3/10/2025 at approximately 1:00 pm, a second observation was made and the respiratory tubing, mask and nebulizer were still on the floor beside Resident #73's bed. On 3/11/2025 approximately 08:30 am, the tubing, mask and nebulizer were in a nightstand drawer beside resident #73 bed. The tubing attach to nebulizer machine still had a sticker with a date of 2/26/2025. On 3/11/2025 approximately 12:00 pm, an interview with Staff D, a Registered Nurse, was performed. He stated that Resident #73 has respiratory treatments as needed and tubing for oxygen and respiratory treatments are changed per orders every Wednesday. On 3/12/2025 a record review of orders for respiratory treatments on 2/12/2025 revealed an order for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 inhalation inhale orally every 4 hours as needed for SOB/WHEEZING related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA (J96.11), Check oxygen saturations every shift and as needed. Per administration records, this medication has not been administered to Resident #73 since the order given on 2/12/2025. The care plan included interventions as follows: Monitor lungs sound every shift and as needed. Document every shift. On 3/13/2025 approximately 8:00 am, interview was performed with Staff C, a Licensed Practical Nurse, about the Albuterol order. Staff C stated this is ordered for residents initially on admission for 10 days. On 2/19/2025, there is documentation that Resident #73 had abnormal breath sounds but no documentation of respiratory treatments were found on that day. On 3/13/2025 at approximately 8:30 am, an interview with the Director of Nursing (DON) was performed. She explained that oxygen tubing and respiratory treatment equipment is changed every Wednesday, but the tubing for Resident #73 has not been changed because he has not had any respiratory treatments since it was ordered. The DON was also made aware that Resident #73 did not receive the Albuterol order on 2/19/25. The DON acknowledged this order should have been given.

Based upon observation, interview, and record review, the facility failed to practice infection control procedures concerning glucose monitoring for 1 of 1 residents reviewed for glucose monitoring (Resident #27) and for food handling procedures during 1 of 3 meals observed. The findings include: Glucose monitoring On 03/12/25 at approximately 1:28 PM, an observation was made of Staff D, a Registered Nurse (RN), checking Resident # 27's blood sugar using a glucometer and administering insulin. The RN did not perform hand hygiene before donning gloves to complete the blood glucose check or after doffing gloves, prior to exiting the resident's room and accessing the medication cart. The RN brought the communal tube of meter strips into the residents room but did not disinfect the communal container of meter strips prior to placing it back in the medication cart. The RN was asked if he had received training from the facility on infection control related to glucometer use. The RN replied, No training on infection control, just how to use the glucometer. A review of the facilities policy Obtaining a Fingerstick Glucose Level, dated January 2020, under Infection control protocol and safety, it reads, 2. Maintain clean technique and isolation precautions as indicated. Steps 17-19 of the procedure reads, 17. Remove gloves and discard into designated container. 18. Wash hands. 19. Clean glucose monitor with approved disinfectant before and after each resident. (photographic evidence obtained) Food handling On 3/12/25 at 11:30 am, during an observation of the dining room, Staff Member G and Staff Member I, both Certfied Nursing Assistants, were observed not sanitizing and/or washing hands in between serving residents seated in the dining room. Staff Member I was observed touching the counter top and drinking cup rims without washing her hands, then serving drinks to the residents. Staff Member G was observed entering the dining room without sanitizing or washing his hands, then proceeded to take clean cups sitting on the counter and dipping them into the pitcher of ice filling multiple cups and setting them on the counter. Staff Member I would take cups filled them with juice or tea and serve residents. When asked about hand hygiene, Staff Members G and I responded that it should take place when entering the dining room and in between each resident. Staff member G stated, I should have washed my hands when I came into the dining room prior to filling cups and assisting with the drinks. Staff member G stated that he should not have done dipped ice from the pitcher without hand hygiene. Staff Member I stated that we should have sanitized or washed our hands in between serving each resident their drinks. Both staff were aware of the sink used to wash hands and sanitizer on wall at entry door and on wall by counter where drinks were being provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Laundry area On 3/13/2025 at 11:00 AM, an observation of the laundry area was made. The area behind the washing machine and dryer had a dark color on the tiles. The sink was observed with dirt and debris and an orange stain in the sink with a dark green and blackish film around the inside of the sink. (photos obtained) The laundry area for facility linens had a blackish color film on the sink. (photo obtained) The area behind the dryers and washing machines had dust and lint observed on the floor and pipes where the detergent was sitting. The handwashing sink was observed with multiple clear plastic bags hanging next to it and a tube of caulk laying on the sink. Based on observations, interviews and record reviews, the facility failed to maintain a sanitary environment shower room environment in 1 of 4 shower rooms observed and in the laundry area. The findings include: Shower room On 3/10/25 at approximately 4:51 PM, Shower room [ROOM NUMBER] was observed with the trash can overflowing. There was a variety of opened hygiene products cluttered on the vanity next to a biohazard container. A stack of folded towels was sitting on an over bed table exposed. Observed on 3/13/25 at approximately 1:00 PM, a second observation of Shower room [ROOM NUMBER] was made with the following unsanitary conditions were noted: a dirty towel was laying on the shower bed and another towel was on the floor near the shower chair, a stack of clean towels were placed on top of an over the bed table beside an open pack of briefs, and a variety of used hygiene products were on the vanity. A biohazard container that was a third full was sitting next to the variety of hygiene products. A closet that is in the shower room was open exposing an opened cabinet that contained a variety of hygiene products, cleaning chemicals and roll of toilet paper. A small sink with 3 fingernail clippers were laying by faucet. A pair of rain boots and used gloves were underneath a black mat that was propped up against the wall had fallen over. The trash can was full. On 3/10/25 at approximately 11:45 AM during an interview with Staff J, a Licensed Practical Nurse (LPN), verified that the shower room is used all day for showers and incontinence care for residents.

Based on observations, record review, resident interview, staff interviews, and policy review, the facility failed to obtain physician orders to administer oxygen in accordance with the resident care plan for 1 of 1 sampled residents receiving oxygen therapy. (Resident #479) The findings include: Observations of Resident #479 were conducted on 12/4/23 at 11:30 AM, 12/5/23 at 2:42 PM, 12/5/23 at 4:26 PM, and 12/6/23 at 8:48 AM. During every observation, the resident was observed in bed and wearing oxygen at 3 liters per minute via nasal cannula from a concentrator. An interview was conducted with Resident #479 on 12/5/23 at 2:42 PM. At this time, the resident stated she had been wearing the oxygen since she was admitted to the facility. A review of the resident's medical record revealed an admission date of 12/1/23 and a current care plan dated 12/4/23 related to risk for complications related to Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure with a nursing intervention to administer oxygen per orders. The medical record contained no physician orders for oxygen. An interview was conducted with Employee A, a Registered Nurse, on 12/6/23 at 12:01 PM. Employee A stated the resident had been using oxygen since he first saw her on 12/2/23. An interview was conducted with the Assistant Director of Nursing (ADON) on 12/6/23 at 12:03 PM. The ADON stated the resident did not have oxygen orders and the admitting nurse should have put the order in upon admission. She stated the nurse who places the oxygen on the resident should place the order for the oxygen. A review of the policy Medication Orders (dated October 2019) reveals, .a current list of orders must be maintained in the clinical record of each resident. Oxygen orders: When recording orders for oxygen, specify: The rate of flow, route and rationale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure provision of safe and timely Activities of Daily Living (ADL) care for 2 of 2 resident hallways reviewed (100 Hall and 200 Hall). The findings include: 100 Hallway On 12/12/22 at approximately 10:52 AM, during the initial tour of the 100 hallway a strong odor similar to urine was noted. Several residents were noted sitting in wheelchairs in the hallway, but the majority of the residents remained in their beds in their rooms. A second tour of the hallway was completed on 12/12/22 at approximately 2:30 PM. The hallway continued to have a urine like odor, which was strongest outside rooms [ROOM NUMBERS]. On 12/12/22 at approximately 10:52 AM, an interview was conducted with Resident #11 who stated the staff work hard, they are busy, but they do not have enough staff. During the interview, a urine odor was noted while standing next to the resident. On 12/12/22 at approximately 3:10 PM, an interview was conducted with Resident #10 who revealed the residents are lucky they will get 2 showers a week, but it is usually just one time per week, and on the weekends, they do not get much help at all. A review of the Point of Care Activities of Daily Living (ADL) report for the date range of 8/15/22 to 9/6/22 for resident #1 revealed 20 days were coded as 8 under bathing, which indicates activity did not occur. There were 2 days noting bathing occurred. A review of the Point of Care ADL report for the date range of 11/1/22-12/14/22 for Resident #5 revealed 19 days were coded as an 8 under bathing which means activity did not occur. There were 3 days noting bathing occurred. A review of the Point of Care ADL report for the date range of 11/1/22-12/14/22 for Resident #9 revealed 22 days were coded as an 8 under bathing which means activity did not occur. There were 4 days noting bathing occurred. A review of the Point of Care ADL report for the date range of 11/1/22-12/14/22 for Resident #10 revealed 23 days were coded as an 8 under bathing which means activity did not occur. There were 2 days noting bathing occurred. A review of the Point of Care ADL report for the date range of 11/3/22-12/14/22 for Resident #11 revealed 22 days were coded as an 8 under bathing which means activity did not occur. There were 3 days noting bathing occurred. 200 Hallway On 12/12/22 at approximately 10:20 AM, a strong foul odor similar to urine and stool was noted in the 200 halls at the initiation of the initial facility tour. The door to room [ROOM NUMBER] was closed. The surveyor went into the room and met Resident #4. She was seated in a chair and appeared tired and exasperated. The odor in the room was overpowering. It smelled like urine and stool. A pair of brown and yellow stained wet soiled clothes laid on the floor close to the resident's feet. There was a yellow stained wet towel that was on the floor near the bed. A yellow stained towel laid on the bed. The bed had no sheet on it. The mattress was stained and soiled as well. The used breakfast tray was in the room from breakfast and there were no cups for water anywhere in the room (photographic evidence was obtained). The resident said: I called for help to change my brief this morning and no one came. Needed help to pull off and put pants on. I changed my own brief. I called last night for water and haven't gotten any yet. The surveyor asked Resident #4 if she ate breakfast. She replied: They did not tell me that breakfast was here this morning but I did get breakfast this morning. They still have not come to get the breakfast tray yet. The surveyor pushed the call button in the room at approximately 10:30 AM. At approximately 10:59 AM Staff Member A, Certified Nursing Assistant (CNA) entered the room. Resident #4 asked for water. Staff Member A, CNA left the room to go get water for Resident #4. A few minutes later Staff Member A, CNA returned with a cup of water. The CNA gave the resident the water and left immediately without picking up the soiled clothes, the breakfast tray or offering information about when someone would be back to assist. On 2/12/22 at approximately 1:10 PM, the soiled clothes remained on the floor of Resident #4's floor. The room still had a strong odor and the bed had not been made. An interview was conducted with Staff Member A, CNA she was asked why she did not pick up the clothes or make the bed earlier when she brought the resident water. Staff Member A, CNA explained that she was not assigned to care for the resident. She said she would get the CNA who was assigned to care for her. A review of the care plan revealed that the resident had an ADL self-care deficit and is at risk of not having needs met. The care plan indicated that Resident #4 had an end-of-life prognosis and that she should be allowed frequent rest periods during assistance with care. Additionally, it was listed that ADL needs should be anticipated and met as indicated. The care plan also listed that, Resident #4 was at risk of skin breakdown related to occasional incontinence and other diagnosis. It was recommended that staff provide incontinence care after incontinent episodes and apply barrier cream as needed. The care plan also recommended that staff assist the resident with repositioning and provide the amount of assistance or supervision necessary for toileting. Resident #4 was determined to be at risk for falls. Implementation steps related to falls prevention included keep call light within reach and keep room free from clutter. A review of Resident #4's record was conducted. Section G (Bathing) of the Minimum Data Set (MDS) revealed that the resident was scored to be totally dependent upon staff for assistance with bathing. The resident utilized a walker and a wheelchair for mobility. Section H revealed that Resident #4 was known to be frequently incontinent of bowel and bladder. Section J listed that Resident #4 had a condition that may result in a life expectancy of less than 6 months. A review of the Point of Care ADL report for the date range of 11/1/22 to 12/14/22 for Resident #4 revealed 27 days were coded as an 8 under bathing which means activity did not occur. There were 4 days noting bathing occurred. On 12/12/22 at approximately 3:08 PM, Resident #4's room continued to have a strong odor. The soiled clothes were still on the floor. The wet towel was on the floor. The bed had not been made. An interview was conducted with Staff Member B, CNA. Staff Member B, CNA and the surveyor walked to the resident's room. Staff Member B, CNA immediately began picking up soiled clothes from the floor and cleaning up the room. She said: I should have already taken care of this. She also explained that she would have to look for sheets for the bed because the mattress was larger and required special sheets. On 12/13/22 at approximately 1:30 PM, an interview was conducted with Nurse D, Licensed Practical Nurse (LPN) the nurse assigned to Resident #4 on 12/12/22. She was shown images of the unmade bed, wet soiled clothes, and towels on the floor in the room. The nurse explained that Resident #4 often urinates on the floor in the room. The flooring has been replaced in the past and that housekeeping usually goes in the room twice a day. She indicated that the room should have been more attended too. Nurse D, LPN was asked about the unmade bed, wet soiled clothes, and towels that laid on the floor all day. The nurse explained that this was a new assigned resident for Staff Member B, CNA. She explained that she expects the CNA's to do their jobs. Nurse D, LPN said: I asked her to attend to Resident#4's needs. I did not realize it needed to be itemized. The surveyor asked the Nurse D, if she had enough time to check to and see if the CNA's are completing their assignments. Nurse D responded by saying: Not 100 percent but I check on them as much as I can. Received a portion of the paper shower sheets that were requested. Many of the documents have the resident name written on them but does not indicate if a bath or shower was completed, and most of the forms did not indicate the nurse was notified if the resident refused the offer of a shower. A review of the facility Resident Census and Conditions of Residents Report (CMS form 672) revealed the facility had a census of 119 residents. The report revealed 61 of the residents required one or two person assist with bathing and 43 were dependent on staff for bathing. The report further noted 50 residents required assistance of one to two staff for toilet use, and 41 were dependent on staff. On 12/14/22 at approximately 9:21 AM, an interview was conducted with the Director of Nurses, (DON) who stated she has a CNA scheduled to perform showers, but if that CNA is pulled to the floor to work, the staff assigned to the resident will try to shower the resident or the person on the next shift would shower the resident. The DON stated the restorative CNA would be pulled to assist. The DON stated if the resident wants to shower daily, they would shower the resident daily, or baths /showers are usually given on Monday, Wednesday and Friday, or Tuesday, Thursday and Saturday. The DON stated the facility has had multiple staff call ins and stated the facility has started using CNAs from the agency in November and nurses from the agency since September. The DON revealed if a resident refuses a shower, the CNA should let the nurse know, and the nurse would talk with the resident or the family and should offer another day or time. A follow-up interview was conducted with the DON on 12/14/22 at approximately 9:21 AM, who revealed not all of the CNAs are able to document in the ADL function of the computer and stated the facility has shower sheets that are used if documentation cannot be done electronically. The DON stated the shower sheets are in boxes, and it will be cumbersome to get the shower sheets. On 12/12/22 at approximately 12:50 PM, an interview was conducted with Staff Member A, CAN, who stated, We are short staffed; We do not have time to give everyone showers when the residents are supposed to get them. We have all these lights going off but often the nurses do not help. She indicated that this has been going on for the past year but recently staffing had gotten worse. She also explained that staffing is short a few days a week when someone calls in. On 12/12/22 at approximately 2:00 PM, an interview was conducted with Staff Member C, CNA who stated, The residents complain that they are not getting showers and that staff is not answering call buttons. I am burned out on this job because we do not have enough help. On 12/12/22 at approximately 2:50 PM, an interview was conducted with Staff Member B, CNA, who stated that that they try to get everyone bathed and showered, but sometimes residents do miss their showers because there is not enough staff. She explained that they have not had the extra CNA assigned to shower duties often in the last three weeks.

Based on observations, staff interview and review of facility policies the facility failed to ensure medications were not left unattended at the resident's bedside for 1 of 5 residents sampled for unnecessary medications (Resident #20) and failed to ensure that medications were stored in locked compartments accessible only to authorized personnel for 1 of 5 medication carts observed. The findings include: Resident #20 On 6/13/22 at approximately 11:37 AM, during an interview with Resident #20, it was noted that there were two cups of pills sitting on her bedside table. A few minutes into the interview she stated, Oh, let me take my medicine, and then picked up both cups and took the medications. (Photographic evidence obtained) A review of physician orders failed to reveal an order for self-administration of medications. A review of assessments conducted by the facility failed to reveal any for self-administration of medications. A review of Resident #20's care plan failed to reveal care planning for self-administration of medications. On 6/16/22 at approximately 11:38 AM, an interview was conducted with the Administrator. At that time she stated that the nurses should not be leaving medications unattended with residents at the bedside. A review was conducted of the facility policy, Medication Administration: 7.3 Self-Administration by Resident, dated 11/2017. Under the procedures section it stated, item number 1, If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical and visual ability to carry out this responsibility, during the care planning process. Under item number 3 it stated, The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record. Unlocked Medication Cart On 6/16/22 at approximately 8:44 AM, an observation of medication pass was conducted with Licensed Practical Nurse Z. After pulling all of the medications for Resident #520, she asked another nurse to get for her Vitamin B12 500 micrograms because it was not available on the cart. On 6/16/22 at 8:46 AM staff Z, proceeded to take Resident #520's other medications to him while she waited for the other nurse to return with the Vitamin B12, and left the medication cart unlocked. Resident #520's room was located down the hall and around a corner from where the medication cart was left unattended. She returned to the cart on 6/16/22 at 8:48 AM, and she acknowledged that she should have locked the cart and that it was a mistake. On 6/16/22 at 8:52 AM, she went to take the missing B12 medication to Resident #520. She again left the medication cart unlocked and unattended while she went to the resident's room, out of the sight of the cart (Photographic evidence obtained). A review was conducted of the facility policy, Medication Administration: 7.1 General Guidelines, dated 1/2021. Under the, Procedures Section, subsection, Medication Administration, item number 17, it stated, During Administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse .The cart must be clearly visible to the personnel administering medications when unlocked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, posted menu review and policy review, the facility failed to follow the preapproved menu during 2 of 5 meal observations, failed to ensure approval was received prior to making meal substitutions, failed to keep record of those substitutions, and failed to post the daily menu in accordance with facility policy. The findings include: On 6/13/22 at approximately 12:10 PM, the posted menu outside of the facility's dining room was observed. The menu was dated for the previous Wednesday (6/8/22) and indicated lunch would consist of hamburger on bun, cucumber onion salad, [NAME] tots and oranges. An observation of the facility's lunch service revealed the residents were served ham, sweet potatoes, and collard greens. (Photographic evidence obtained) On 6/15/22 at approximately 9:11 AM, the posted menu outside of the facility's dining area room was observed. The posted menu for Wednesday (6/15/22) indicated dinner would consist of turkey pot pie, biscuit, peas and carrots. A review of the weekly menu indicated dinner on Wednesday (6/15/22) would consist of breaded fish on bun, peas and carrots, and [NAME] tots. (Photographic evidence obtained) On 6/15/22 at approximately 1:29 PM, an interview was conducted with the Registered Dietician (RD) who stated that the Manager in Training (MIT) will substitute preapproved menu items without approval. The RD stated the MIT requested she authorize a menu substitution two weeks after the substitution was made. On 6/15/22 at approximately 3:08 PM, an interview was conducted with the MIT, who stated she does not post the menu anywhere in the facility and that there are too many changes to the menu. When asked to review the facility's documentation of meal substitutions, the MIT stated, she had no record, and was not aware she needed to keep track of menu changes. A review of the facility's Dining Services Policy and Procedure dated 5/2014 revised 9/2017, Menus Policy 004 revealed: menus will be posted in the Dining Service department, dining rooms and resident/patient care areas, and menu substitutions log will be maintained on file.