**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, and provide maintenance services as necessary for residents in five (Rooms 106, 202, 402, 407 and 204) of six rooms identified with environmental concerns from a total of 62 resident rooms. The findings include: On 01/31/22 at 12:40 PM, room [ROOM NUMBER] was observed with a clogged bathroom sink that was not draining. On 01/31/22 at 11:02 AM, while touring with the Maintenance Director, three roaches were observed in room [ROOM NUMBER]'s bathroom sink. The Maintenance Director removed them with a paper towel. He stated pest control was on-site once a month and any time pests were sighted in the facility. He added that pest control would be contacted again. He also confirmed that the sink was clogged and stated he would fix it. On 02/01/22 at 11:24 AM, Resident #391 in room [ROOM NUMBER] stated the phone at his bedside was broken and so was the phone for the adjacent bed. He stated his beside television didn;t work either, so he watched the television designated for the adjacent bed. He stated he had to call the staff to change the channel for him. He added that he could not get out of his room due to the facility's quarantine policy, and he was lonely in the room by himself with dysfunctional equipment. On 02/01/22 at 11:33 AM, Resident #83 in room [ROOM NUMBER] stated there was no hot water in her bathroom sink. She added that it was inconvenient for her to take baths as she was in quarantine and could not go to the regular shower room. She also mentioned that staff did not assist her, and she had not had hot water in the bathroom sink since she was admitted . (Photographic Evidence Obtained) A review of Resident #83's medical record revealed she was admitted on [DATE]. The admission Minimum Data Set (MDS) assessment, dated 01/19/22, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points, indicating moderately impaired cognition. She required extensive assistance for bed mobility, transfers and toilet use. On 02/02/22 at 10:52 AM, Resident #90 in room [ROOM NUMBER] stated she had not had a call light since she had been in the facility, almost two weeks. She stated she told the staff and they stated they would come back, but no one ever came back. The resident denied having an alternative means to summon staff to her room. In an interview on 02/02/22 at 10:54 AM, Certified Nursing Assistant (CNA) G stated she worked for the facility through an Agency and had been at the facility for the last two days. She confirmed that she had worked with Resident #90 on both days and the resident did not have a call light. CNA G confirmed that the resident did not have an alternative means of summoning staff. When asked to explain the process for ensuring resident safety after providing care, CNA G stated the resident's call light should be within reach. She confirmed that she did not notify anyone that Resident #90 had no call light. She reiterated that she was employed as an Agency CNA and was not familiar with the facility's protocol. In an interview on 02/02/22 at 10:56 AM, Registered Nurse (RN) A stated she was familiar with Resident #90. She added that the resident was transferred from the short-term unit on 01/21/22. She stated the resident was able to make her needs known and was able to use the call light. She confirmed that the resident did not have a call light or an alternate means of summoning staff since 01/21/22. An interview was conducted on 02/02/22 at 11:00 AM with the Housekeeping Manager. He stated the maintenance department was responsible for making rounds to ensure all of the call lights were working, however, the facility had not had a Maintenance Director since 01/01/22. The Housekeeping Manager stated he was assisting as needed and had not had a chance to conduct the audits. On 02/02/22 at 11:05 AM, an interview was conducted with the Director of Nursing (DON). She stated the staff were supposed to ensure that the residents had a call light within reach at all times. She confirmed that Resident #90 was alert and oriented and able to use a call light. She added that residents were also assigned Guardian Angel staff that rounded weekly, but nothing had been reported about Resident #90's missing call light. When asked whether the facility conducted audits to ensure all call lights were present and working, she stated the maintenance department was expected to conduct those audits, but the facility had not had a maintenance person since 01/01/22. A review of Resident #90's medical record indicated that the resident was admitted to the facility on [DATE] with a primary diagnosis of cardiomyopathy. Her secondary diagnoses included chronic obstructive pulmonary disease (COPD), history of transient ischemic attack, pulmonary emboli without acute cor pulmonale, type II diabetes mellitus, long-term use of insulin, and hypertension. Her admission MDS assessment, dated 01/20/22, revealed a BIMS score of 13, indicating intact cognition. The resident was documented as totally dependent on staff for bed mobility, transfers, and toilet use. A review of Resident #90's care plan reveaeld she was at Risk for Falls related to impaired mobility. Interventions included ensuring her call light was within reach. Another tour of the facility was conducted on 02/02/22 at 2:39 PM with the [NAME] President of Maintenance. He stated the maintenance requests were added to the computer software system and all staff had access to the system and could enter a maintenance request. He stated the maintenance managers were notified of the work orders as soon as they were added in the system. These notifications were received on the maintenance managers' phones and could be accessed anytime. When asked if there were any requests for room [ROOM NUMBER], he produced maintenance requests dated 07/06/21 and 01/31/22 for no hot water and no light in the bathroom. For room [ROOM NUMBER], he produced multiple maintenance requests dated 06/22/21, 06/24/21, 12/20/21, 01/27/21 and 01/29/21 for the television not working. (Copies obtained) He confirmed that the requests were not followed up on. On 02/03/22 at 10:56 AM, the bathroom sink in room [ROOM NUMBER] was still clogged. On 02/03/22 at 11:57 AM, the Administrator confirmed that the sink was clogged and there was an odor in the room. He provided a maintenance request dated 01/08/22 which read, The water in the sink takes a long time to drain and smells very bad. A review of the facility's policy titled,Resident Environmental Quality (No implementation or revision date) revealed, It is the policy of the facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment. Policy explanation and compliance guideline: The facility must provide each resident with a nurse call system in the resident's room and toilet/bathing facilities, which relays the calls directly to a staff member or to a centralized staff work area. Establish procedure to ensure that water is available to essential area when there is a loss of normal water supply. General Guideline: 11. Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. 12. All facility staff are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. A review of the policy and procedure titled Call Bell Policy and Procedure revealed, Respond to request. If item is not available, or request questionable, get assistance from the charge nurse. Return to the resident with prompt reply. (Try to obtain item - Do not tell resident We don't have it.) Be sure call bell is operable and within resident's each before leaving the room. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 02/01/2022 at 11:08 AM, Resident #26 was observed sitting up in bed in her room. Her oxygen (O2) flow rate was set at 2.5 liters per minute (LPM). The resident was asked what the O2 flow rate should be set at, and she replied that she didn't know. On 02/02/2022 at 2:16 PM, Resident #26 was observed sitting up in a wheelchair in her room. Her O2 flow rate was set at 2 LPM. On 02/02/2022 at 2:44 PM, Licensed Practical Nurse (LPN) J confirmed the order for Resident #26's O2 flow rate was 3 LPM via nasal cannula. He stated the 11 PM - 7 AM shift nursing staff was responsible for changing the O2 tubing. He also reported that the facility nurses and CNAs were responsible for monitoring for any adverse reactions or changes in the resident's condition. LPN J entered Resident #26's room at 2:51 PM. Upon entrance, he greeted the resident and checked the placement and date on the tubing and nasal cannula. He stated he observed the O2 flow rate was set at 2 LPM and confirmed that it should have been set for 3 LPM. A medical record review revealed that Resident #26 was admitted to the facility on [DATE]. Her last readmission was on 12/3/2021. Her diagnoses included metabolic encephalopathy, type 2 diabetes mellitus, interstitial pulmonary disease, peripheral vascular disease, heart failure and atherosclerotic heart disease of the native coronary artery. A review of the February 2022 Physician's Order Sheets revealed an active order for oxygen (O2) via nasal cannula at 3 LPM, effective 12/21/2021, to be checked every shift. Interventions in the current Care Plan listed interventions which included, Administer medication as ordered and oxygen therapy per physician's orders. 3. On 02/01/2022 at 10:40 AM, Resident #29 was observed resting in bed. She had an oxygen concentrator, and her O2 flow rate was set at 2 LPM. She was receiving O2 via nasal cannula. On 02/02/2022 at 10:17 AM, Resident #29 was observed sitting up in bed in her room. She had an oxygen concentrator and her O2 flow rate was set at 2 LPM. She was receiving O2 via a nasal cannula. On 02/02/2022 at 10:22 AM, during an interview with LPN J, he stated he was familiar with Resident #29. He confirmed that Resident #29 had orders for O2 at a flow rate of 3 LPM via nasal cannula. LPN J entered Resident #29's room at 10:25 AM. He acknowledged the presence of the O2 concentrator and nasal cannula. He confirmed that the O2 flow rate was currently set at 1.9 LPM and that the order was 3 LPM. He reported that it was the responsibility of the facility nurses and CNAs to check theresidents' O2 flow rates. A record review revealed that Resident #29 was admitted to the facility on [DATE]. Her last readmission was on 11/18/2021. Resident #29 had diagnoses including encephalopathy, sarcopenia, chronic obstructive pulmonary disease (COPD), heart failure, chronic respiratory failure, and atrial fibrillation (A-Fib). A review of the February 2022 Physician's Order Sheets revealed an active order for oxygen (O2) via nasal cannula at 3 LPM, effective 12/9/2021. Interventions in the current Care Plan listed interventions which included, Give oxygen as ordered by the physician. Based on observation, resident interview, staff interview, clinical record review and facility policy and procedure review, the facility failed to 1) Implement the comprehensive person-centered care plan for one (Resident #145) when the physician-ordered, pressure-reducing foam boots for her heels were not applied, and 2) Implement the comprehensive person-centered care plan for two (Residents #26 and #29) when oxygen flow rates were not set at the physician-ordered liters per minute. Seven residents were being treated for pressure ulcers and 10 residents were receiving respiratory therapy from a total of 30 sampled residents. Failure to implement the care plan puts the resident at risk of not receiving appropriate interventions and could potentiate medical or physical complications and/or injury. The findings include: 1. During an interview with Resident #145 on 01/31/2022 at 2:00 PM, she was observed lying in bed with her covers on. She was lying on her right side. She stated she had a pressure ulcer on her bottom. The staff used pillows to position her. She needed help to reposition. She stated she had sores on her feet too. The resident did not have her feet elevated or any pressure-educing devices in place for her feet at the time of this interview. No pressure-educing devices were observed in her room. During a second interview with Resident #145 on 02/01/2022 at 9:30 AM, she was observed lying in bed on her back. Her feet were not elevated and no pressure-reducing devices were in place. When asked whether staff put foam boots on her feet or pillows under them, and would she allow that, she replied, I would if they wanted to. They don't put anything under my feet. No boots were observed in her room. A review of the medical record for Resident #145 revealed the face sheet, which read: admission date 12/30/2021. Diagnoses include osteomyelitis of vertebra, sacral region, pressure ulcer of sacral region Stage 4, type II diabetes mellitus without complications, hypothyroidism, heart disease, viral hepatitis C, chronic kidney disease, moderate protein-calorie malnutrition, adult failure to thrive, pressure ulcer of right heel unstageable, pressure ulcer of left heel unstageable, depression, gastric ulcer, cognitive/communicative deficit, muscle wasting and atrophy, essential hypertension, anemia, pain, and need for assistance with personal care. (Copy obtained) A review of the Minimum Data Set (MDS) assessment, dated 01/05/2022, revealed the resident was assessed as being at risk for pressure ulcer development; as having one Stage 4 pressure ulcer and one unstageable pressure ulcer. Pressure-reducing devices used for bed; receiving pressure ulcer/injury care. Her Brief Interview of Mental Status (BIMS) score was 14 out of a possible 15 points, indicating intact cognition. (Copy obtained) A review of the February 2022 Physician's Order Sheets, revealed an active order that read: Bilateral Prevalon boots while in bed every shift for prevention. Start date 01/20/2022. A review of the current Care Plan revealed a focus area for Pressure Ulcer to sacrum, left heel and right lateral heel. Interventions included: Bilateral Prevalon boots while in bed. (Copy obtained) During an interview with Certified Nursing Assistant (CNA) K on 02/01/2022 at 10:30 AM, she stated she was not aware that Resident #145 had Prevalon boots to apply to her feet. She had not seen them in her room. She stated she looked on the [NAME] for tasks she must accomplish, and for this resident, there was no task for applying the Prevalon boots or floating her heels. CNA K stated she thought maybe the nurse was supposed to do that. She was asked to open the electronic [NAME] for review. A review of the electronic [NAME] revealed no task to apply Prevalon boots or to float Resident #145's heels. During an interview with Licensed Practical Nurse (LPN) J on 02/01/2022 at 10:45 AM, he was asked to look at Resident #145's feet. The resident's feet were not in the Prevalon boots. The nurse stated, They are supposed to be in the boots while she is in bed. He proceeded to look for the boots. He went to the closet and took down a plastic laundry bag that was tied in a knot. He opened the bag, took out the Prevalon boots and proceeded to apply them to the resident's feet. During a third interview with Resident #145 on 02/01/2022 at 2:20 PM, she was observed with a boot on her right foot and a pillow under her left foot. She stated she was comfortable and her feet did not hurt. She stated, There is a lot the staff don't do that they are supposed to do. During an interview on 02/03/2022 at 10:00 AM with the Advanced Practice Registered Nurse (APRN) who worked for the contracted wound care provider, she stated the facility Minimum Data Set (MDS) nurse rounded with her once a week on Thursday mornings. The floor nurses performed the actual dressing changes and wound vacuum applications. She stated, I think she (Resident #145) had the wound on her heels when she came in. She reviewed her notes then stated, I saw the heel wounds on 01/06/2022 when I first saw her, and I assumed she came in with them. She read her progress notes, On 01/06/2022 when I first saw her the wound was 4 centimeters (cm) by 3 cm on the left heel. It was a deep tissue injury (DTI). She clarified the DTI was not an open wound. The standard order is to float the heels. I put it in my notes on 01/06/2022. She read her note out loud: Continue with air mattress encourage/assist in frequent repositioning/float heels. She ordered the Prevalon boots on the 01/20/2022 because the left heel had opened and was unstageable at that point and had deteriorated. She stated she could not say whether the staff were floating the resident's heels or not. She thought the wound opened on or about 01/19/2022. She clarified that unstageable meant that she could not measure and determine the depth of the wound because the wound bed could not be seen. She measured the wound circumference to be 3 cm by 1 cm. The circumference had improved but it was open at that point. She considered the left heel as having deteriorated because it was now an open wound. She confirmed that when a DTI opened it became more susceptible to infection. She stated none of the resident's wounds were infected at this point. There was stable eschar on the left heel. She did not want to debride it. (Copy obtained) A review of the Treatment Administration Record (TAR), dated January 2022, revealed: Bilateral Prevalon boots while in bed every shift for prevention. Start date 01/20/2022 - DC date - 02/01/2022. The TAR was blank on 01/21/2022 during the night shift, on 01/23/2022 during the night shift, on 01/26/2022 during the night shift, on 01/27/2022 during the night shift, and on 01/30/2022 during the day shift, indicating that the staff did not apply the Prevalon boots during those shifts. (Copy obtained) A review of the facility's policy and procedure entitled Prevention of Pressure Ulcers/Injuries, revealed: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. e. Reposition resident as indicated on the care plan. Mobility/Repositioning: 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 5. Provide support devices and assistance as needed. (Copy obtained) A review of the facility's policy and procedure entitled Process of Following Physician's Orders, revealed the purpose was: To administer all medication per physician's orders. Assigned nurse fulfills physician's order. (Copy obtained)

Based on observation, staff interviews and a review of the facility's Policy and Procedure for Nail Care, the facility failed to provide nail care for one (Resident #65) of 30 sampled residents who was dependent for activities of daily living. The findings include: An observation was conducted of Resident #65 on 02/01/22 at 10:02 a.m. She was lying in her bed and the thumb nail on her left hand was curling under with all nails approximately one and half inches or longer. The left hand was kept closed and the nails were close to digging into the palm of her hand. The resident could open her right hand, but her nails were one and half inches or longer. Resident #65 was confused but could answer simple questions. She replied yes when asked if she felt her nails needed to be cut. She also replied yes when asked if staff could cut them. Observations was conducted of Resident #65 on 02/02/22 at 10:11 a.m. and on 02/03/22 at 10:08 a.m. Her nails remained the same. A medical record review was conducted on 02/01/22, which noted an admission date of 05/29/12 with diagnoses including adult failure to thrive and and unspecified dementia without behavioral disturbances. A review of the Minimum Data Set (MDS) assessment, dated 12/24/21, revealed the resident had severely impaired cognition and required extensive assistance with personal hygiene. An interview was conducted with Registered Nurse (RN) A on 02/03/22 at 11:07 a.m. She reported that the facility's CNAs provided nail care, such as cutting, unless a resident was diabetic. In that instance, a nurse provided nail care. Activities staff also provided nail care. A podiatrist came to the facility monthly to cut residents' toe nails. RN/Unit Manager C, present at the time, reported a list of residents requiring toenail care was generated and was given to the Social Worker who provided it to the podiatrist. An interview was conducted with Certified Nursing Assistant (CNA) B on 02/03/22 at 11:45 a.m. in the shower room. Resident #65 was showered and dressed, and the CNA was combing her hair. The CNA reported the resident's nails were long, and CNA B had asked RN C/Unit Manager if she could cut them. She planned to cut the resident's nails after lunch. She confirmed the thumb nail on the left hand was curling under and the nails on the left and right hands could cut into the resident's palms when she was closing her hands, which she likes to do. The nails were approximately one and half inches long. The CNA was employed through an Agency and her assignments changed daily. She reported also asking Employee C to place this resident on the list for podiatrist. An interview was conducted with RN C/Unit Manger on 02/03/22 at 12:22 p.m. He reported seeing residents nails and talking to CNA B about cutting them. He reported Resident #65 was on hospice and hospice guided her care. The undated facility Policy and Procedure for Nail Care was reviewed and revealed: Routine cleaning and inspection of nails will be provided during Activity Daily Living (ADL) care on an ongoing basis. Routine nail care to include trimming and filing will be provided on a regular basis per individual preference. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for three (Residents #26, #29 and #391) of 10 residents receiving respiratory therapy from a total of 30 sampled residents. The findings include: 1. On 02/01/2022 at 11:08 AM, Resident #26 was observed sitting up in bed in her room. Her oxygen (O2) flow rate was set at 2.5 liters per minute (LPM). The resident was asked what the O2 flow rate should be set at, and she replied that she didn't know. On 02/02/2022 at 2:16 PM, Resident #26 was observed sitting up in a wheelchair in her room. Her O2 flow rate was set at 2 LPM. On 02/02/2022 at 2:44 PM, Licensed Practical Nurse (LPN) J confirmed the order for Resident #26's O2 flow rate was 3 LPM via nasal cannula. He stated the 11 PM - 7 AM shift nursing staff was responsible for changing the O2 tubing. He also reported that the facility nurses and CNAs were responsible for monitoring for any adverse reactions or changes in the resident's condition. LPN J entered Resident #26's room at 2:51 PM. Upon entrance, he greeted the resident and checked the placement and date on the tubing and nasal cannula. He stated he observed the O2 flow rate was set at 2 LPM and confirmed that it should have been set for 3 LPM. A medical record review revealed that Resident #26 was admitted to the facility on [DATE]. Her last readmission was on 12/3/2021. Her diagnoses included metabolic encephalopathy, type 2 diabetes mellitus, interstitial pulmonary disease, peripheral vascular disease, heart failure and atherosclerotic heart disease of the native coronary artery. A review of the February 2022 Physician's Order Sheets revealed an active order for oxygen (O2) via nasal cannula at 3 LPM, effective 12/21/2021, to be checked every shift. Interventions in the current Care Plan listed interventions which included, Administer medication as ordered and oxygen therapy per physician's orders. 2. On 02/01/2022 at 10:40 AM, Resident #29 was observed resting in bed. She had an oxygen concentrator, and her O2 flow rate was set at 2 LPM. She was receiving O2 via nasal cannula. On 02/02/2022 at 10:17 AM, Resident #29 was observed sitting up in bed in her room. She had an oxygen concentrator and her O2 flow rate was set at 2 LPM. She was receiving O2 via a nasal cannula. On 02/02/2022 at 10:22 AM, during an interview with LPN J, he stated he was familiar with Resident #29. He confirmed that Resident #29 had orders for O2 at a flow rate of 3 LPM via nasal cannula. LPN J entered Resident #29's room at 10:25 AM. He acknowledged the presence of the O2 concentrator and nasal cannula. He confirmed that the O2 flow rate was currently set at 1.9 LPM and that the order was 3 LPM. He reported that it was the responsibility of the facility nurses and CNAs to check theresidents' O2 flow rates. A record review revealed that Resident #29 was admitted to the facility on [DATE]. Her last readmission was on 11/18/2021. Resident #29 had diagnoses including encephalopathy, sarcopenia, chronic obstructive pulmonary disease (COPD), heart failure, chronic respiratory failure, and atrial fibrillation (A-Fib). A review of the February 2022 Physician's Order Sheets revealed an active order for oxygen (O2) via nasal cannula at 3 LPM, effective 12/9/2021. Interventions in the current Care Plan listed interventions which included, Give oxygen as ordered by the physician. 3. A record review for Resident #391, admitted [DATE] and readmitted on [DATE], revealed the resident had medical diagnoses including morbid obesity, history of Covid-19, and acute respiratory failure with hypoxia. A review of the 01/25/22 Minimum data set (MDS) assessment revealed that Resident #391 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. The resident was also documented as receiving oxygen. Resident #391 was observed and interviewed on 01/31/22 at 4:48 PM. He was receiving oxygen via oxygen concentrator at at flow rate of 3 liters per minute via nasal cannula. (Photographic evidence obtained) The resident denied any respiratory discomfort. Resident #391 was observed on 02/01/22 at 4:29 PM. He was observed out of bed in his wheelchair receiving oxygen via nasal cannula at a flow rate of 3.5 liters per minute. (Photographic evidence obtained) The resident denied any shortness of breath but stated he needed oxygen to help him breath. Resident #391 was observed on 02/02/22 at 1:42 PM sitting in his room on the side of his bed with his oxygen in place, at a flow rate of 3 liters per minute. A review of the February 2022 Physician's Order Sheets revealed an active order dated 01/19/22 for oxygen via nasal cannula at 4 liters per minute every shift for COPD (chronic obstructive pulmonary disease). A progress note, dated 01/20/22, indicated the resident was on oxygen at 3 liters per minute via nasal cannula. A progress note, dated 01/24/22, recorded the resident's oxygen saturation was 95% with oxygen at 3 liters per minute. A progress note, dated 01/26/22, documented the resident's oxygen saturation was 93% with oxygen at 3 liters per minute to maintain oxygen saturation above 92%. A progress note, dated 01/28/22, recorded oxygen at 3 liters per minute with an oxygen saturation of 97%. There were no changes made to the February 2022 Physician's Order Sheets regarding a change of oxygen flow rate to coincide with the progress notes reviewed. A review of the Treatment Administration Records (TARs) for January and February 2022, revealed the staff was signing for the administration of oxygen at 4 liters per minute every shift. A review of the resident's care plan documented the use of oxygen therapy related to Altered Respiratory Status. Interventions included: Administer oxygen via nasal cannula as per physician's order (dated 01/13/22). The care plan had not been updated since the resident's readmission on [DATE]. During an interview on 2/3/2022 at 10:51AM with LPN D/Unit Manager regarding the facility's policy on Oxygen Administration, the monitoring of residents receiving oxygen and the facility's policy on changing of the oxygen tubing, she stated the process began when a physician's order was received and transcribed on the TAR. The resident's oxygen saturation levels were checked daily or every shift and recorded. Oxygen tubing was changed on the 11AM - 7PM shift every Sunday, and the day shift nurses would follow-up to ensure that the tubing was changed and dated. When not in use, oxygen tubing and nebulizer tubing would be stored in plastic bags. An interview with the Director of Nursing (DON) was conducted on 02/03/22 at 11:00 AM regarding the facility's oxygen administration policy. She reported that oxygen must be ordered by a physician and the nurses signed for it each shift. She added that she had an done an in-service this same morning with her staff regarding the responsibility of the nurses on all shifts to check the rate of oxygen flow. She stated they needed to check the flow rate every shift to ensure that the resident was receiving oxygen as ordered by the physician. The facility's policy on Oxygen Administration (No effective or revision dates) revealed under the heading of Preparation: #1 Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, facility document review and facility policy and procedure review, the facility failed to ensure a member of the Interdisciplinary Team was designated to coordinate the hospice care and obtain a plan of care and physician's certification form from the hospice provider before hospice care was furnished to one (Resident #143) of two residents receiving hospice care, from a total of 30 residents in the sample. The findings include: Resident #143 was observed on 01/31/2022 at 1:32 PM lying in her bed. The hospice provider's Advanced Practice Registered Nurse (APRN) was in the room with her. She was calling out in pain, Too much pain, too much pain. Please take the pain away. It's too much, it's too much. During an interview with the hospice provider's APRN on 01/31/2022 at 1:45 PM, he stated he was in the facility seeing Resident #143 today for the first time. He did not know her well yet. He was aware that she was in a lot of pain and was adjusting her medications. He would see her again later in the week and the nurse would see her daily. He was not sure how long she had been a hospice recipient, but he thought it was a few days now. A review of the electronic medical record and the paper chart for Resident #143 on 02/01/2022 from 2:45 PM to 3:05 PM, revealed no certification for hospice services. A review of the face sheet for Resident #143 revealed she was admitted on [DATE]. Her diagnoses included: Cerebral infarction, nontraumatic intracerebral hemorrhage, dysphagia, asthma, heart failure, fracture of lower end of left femur, hypothyroidism, abnormality of gait and mobility, surgical aftercare following surgery on the nervous system, hypertension, reduced mobility, and cognitive social or emotional deficit following cerebral infarction. (Copy obtained) A review of the facility's care plan, dated 01/27/2022, revealed: Hospice: The resident and their family/caregivers have determined that the goal of care will be comfort care and hospice will be assisting in providing care along with facility staff. Care will be provided by [facility hospice provider]. Date Initiated: 01/27/2022. Goal: All care will be focused on the patient's comfort and will be collaborated with [facility hospice provider] through the remainder of their stay. Interventions: Hospice to provide a copy of current Plan of Care for collaboration of care. Date initiated: 01/27/2022. (Copy obtained) During an interview on 02/01/2022 at 3:10 PM with Medical Records Staff G, she stated she did not recall seeing a hospice certification or plan of care for Resident #143. She stated, It should be in her file. She confirmed that she had not scanned one into the electronic record. During an interview on 02/01/2022 at 3:13 PM with Unit Manager (UM) D, she stated she was not the facility coordinator of care for the hospice residents. She thought it was the Director of Nursing's (DON's) responsibility. She stated the Social Services Director coordinated the initial contact with the family, and the hospice provider and the Minimum Data Set (MDS) Coordinator wrote the care plan for the hospice services the facility provided. She was not aware of where the hospice certification and plan of care forms were. She did not recall seeing them. She did not know the hospice certification period for Resident #143. She did not know when it started. She asked, Monday [01/31/2022] was the first day they provided service to her, right? This surveyor stated the APRN from the hospice provider was interviewed on Monday 01/31/2022. She stated she did not have a care plan from the hospice provider. She stated, We have our [facility] care plan. She then asked, They have to meet with the family and certify her before providing services to her, right? Then she stated, I haven't seen one. Let me look. She did not produce the care plan or the certification form from the hospice provider. During an interview on 02/01/2022 at 3:22 PM with the Minimum Data Set (MDS) Coordinator, she stated Resident #143 was a new admission and they had not had a care plan meeting with the hospice provider yet. She had written an initial care plan for the resident to include hospice care, but she had not seen a plan of care from the hospice provider. She stated the medical records staff probably had not scanned it into the electronic medical record yet. She had not spoken to any of the hospice provider staff regarding the hospice care plan for Resident #143. During an interview on 02/01/2022 at 4:10 PM with the Regional Nurse Consultant and the Business Office Manager, the Hospice Certification and Plan of Care forms were requested. They stated they contacted the corporate office and the hospice provider to have them sent. No forms were produced by the end of the day on 02/01/2022. On 02/02/2022 at 9:45 AM, a faxed copy of the certification form and the plan of care were provided. The copy was faxed to the facility on [DATE] at 4:51 PM. (Copy obtained) A review of the Hospice Certification and Plan of Care form, dated 01/27/2022, revealed the Medical Director and the hospice physician signed the form that stated, I certify/recertify the patient is terminally ill with a life expectancy of six (6) month or less if the disease process runs its normal course. The certification period was documented as 01/27/2022 to 04/26/2022. (Copy obtained) During an interview on 02/02/2022 at 3:03 PM with the DON, she stated the Unit Managers coordinated the care and communicated with the hospice providers when they came into the building. She was informed that the Unit Manager thought it was her role as the DON to coordinate the care with the hospice providers. She stated she would have to talk with the UM. She stated there was no one person on the Interdisciplinary Team that was responsible for the coordination of the hospice care. They all have different parts of it. No one from the facility participated in care planning with the hospice provider. The facility wrote their own plan of care and hospice provided theirs. A review of the facility's policy and procedure entitled Hospice Services - Provided by External Provider (effective date 10/01/2018 revised 11/01/2019) read: It is the policy of the facility to provide Hospice Care to residents with a wide range of end stage diagnoses. Services Provided: Scheduled visits by RN Case Managers, Hospice aides who provide additional and individual comfort care, Emotional support the resident and the family, Spiritual counselors, Bereavement support, Pain and Symptom management. Criteria: A diagnosis of limited life expectancy or end-stage has been confirmed by the attending physician. Physician and family agree on a palliative course of care and no longer seek curative treatment. The attending physician must consent to Hospice care. The presence of an Advanced Directive, Has had a significant decline in functional status. General deterioration in physical condition to the extent that the benefits of available treatments are outweighed by the burden of such treatments and significant recover is likely. Referrals can be made by the request of the resident/Power of Attorney/family/Sponsor/Health Care Surrogate/Guardian to the attending physician and/or facility. Attending physician may suggest Hospice Care to the family. The Interdisciplinary Team may meet and suggest Hospice Care to the attending physician. The resident was a Hospice Care recipient prior to admission. (Copy obtained) A review of the Hospice Nursing Facility Agreement, dated 09/10/2021, revealed: Joint Responsibilities: 3.2 Communication and Access. Both parties will allow each other to 3.2.1 Access all records of Hospice Services rendered to Hospice Patients and 3.2.2 Attend and participate in the other party's Interdisciplinary Group Meetings held for the purpose of developing and evaluating the Plans of Care for Hospice Patients. 4.2 Designation of a Facility Interdisciplinary Group Member. Facility will designate a member of the Facility's Interdisciplinary group (IDG Member) who is responsible to work with Hospice personnel to coordinate care provided to the Hospice Patient. 4.2.1 Collaborating with Hospice representatives and coordinating Facility staff participation in the care planning process for those Hospice patients receiving Hospice Services. 4.2.4 Obtaining the following information from the Hospice: a. The most recent Hospice Plan of Care for each Hospice Patient. c. Physician certification of the terminal illness for each Hospice Patient. .

Based on the kitchen food service observations, nourishment room observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility when the walk-in cooler, a reach-in cooler, juice dispensing equipment and nourishment rooms were not regularly cleaned, and the floors were not maintained. Dietary staff also failed to implement the proper procedures for hand hygiene, disposable glove use and proper sanitation practices by failing to change contaminated gloves and wash their hands between glove changes during the lunch meal service. Hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial tour of the kitchen on 01/31/2022 at 10:30 AM, the walk-in cooler was observed. The storage racks were not clean. A build-up of black grime was observed on all of the shelving. (Photographic evidence obtained) Food debris and a build-up of black debris was observed on the floor in the corner of the cooler and on the fan cover. (Photographic evidence obtained) The underside of the juice dispenser was splattered with stuck-on juice. The tray had dried-on juice stuck to it. (Photographic evidence obtained) The reach-in juice cooler had dried-on juice stuck to the bottom of the cooler. (Photographic evidence obtained) The grout between the tiles in the dish room was missing in several places and some tiles were cracked/broken. (Photographic evidence obtained) During a tour of the kitchen on 02/01/2022 at 9:30 AM, the shelving, floors and fan cover of the walk-in cooler had not been cleaned. The grout in the tile was still missing. The bottom of the reach-in cooler had not been cleaned. The juice dispenser had not been cleaned. (Photographic evidence obtained) During a tour of the kitchen on 02/02/2022 at 8:55 AM, the walk-in cooler was observed. The floor and shelving had not been cleaned. The fan grate cover had not been cleaned. (Photographic evidence obtained) The bottom of the reach-in cooler had not been cleaned. The underside of the juice dispenser was splattered with stuck-on juice. During observations of the lunch meal service on 02/02/2022 from 11:55 AM to 1:00 PM, the walk-in cooler was observed. The floor and shelving had not been cleaned. The fan grate cover had not been cleaned. The bottom of the reac- in cooler had not been cleaned. The underside of the juice dispenser was splattered with stuck-on juice. [NAME] S was observed donning a pair of disposable gloves and then putting pans of food into the steam table using large heat resistant oven mitts that were stained and had food debris stuck on them. She then put the food scoops/ladles into the pans and prepared the tray line for service. She touched the steam table cutting board with the disposable gloves. She did not change her gloves. She started to plate the food at 12:03 PM. At 12:06 PM, the cook scraped mashed potatoes off of one plate back into the pan of mashed potatoes in the steam table with her gloved hand. At 12:19 PM, Dietary Aide R donned disposable gloves without washing her hands first. At 12:32 PM, the cook changed gloves without washing her hands in between. At 12:35 PM, Dietary Aide Q changed gloves without washing his hands while cutting up cucumbers at the prep table. At 12:55 PM, Dietary Aide Q opened a box of cucumbers, removed the tape on the box and put it into the large gray garbage can next to the prep table. He touched the side of the garbage can in an effort to get the sticky tape to release from his gloves. He did not doff the disposable gloves after touching the garbage/garbage can. He then picked up the cucumbers from the box and took them to the prep sink, rinsed them under running water and took them back to the prep table and proceeded to cut them with a chopping knife. He did not remove his contaminated gloves, wash his hands, and don new gloves prior to cutting up the cucumbers. Observations of the East Wing nutrition room on 02/02/2022 at 1:48 PM, revealed the cabinets under the sink were in disrepair, and there was food and debris on the bottom of the cabinets. The ice machine tray had plastic debris and a rubber band in it. The microwave appeared to be damaged and unclean on the top of the oven inside with open holes and stuck on food debris. (Photographic evidence obtained) Observations of the [NAME] Wing nutrition room on 02/02/2022 at 2:01 PM, revealed graham cracker crumbs in the corner of a drawer. (Photographic evidence obtained) During an interview with Certified Nursing Assistant (CNA) P at 2:08 PM on 02/02/2022, she stated she had only worked at this facility a few times, but her understanding was that the equipment in the nutrition rooms was all used for the residents. She got ice for the residents from the ice machine, and she heated food for the residents in the microwave. She was not sure who was responsible for cleaning the nourishment rooms. During an interview with CNA O at 2:15 PM on 02/02/2022, she stated she had worked at this facility for several months now. She confirmed that the equipment in the nutrition rooms was used for the residents. She thought the dietary staff were responsible for cleaning the nourishment rooms. During an interview with the Food Service Manager, the Food Services Consultant, and the Registered Dietician on 02/03/2022 at 1:40 PM, they were informed that the walk-in cooler, reach-in cooler, juice dispensing equipment, tile floors and nourishment rooms had not been cleaned and equipment maintained. The Food Service Manager was shown the inside of the walk-in cooler. She confirmed the build-up of food debris on the shelving and the floors. They were informed that the staff had not practiced appropriate glove use and hand hygiene during the lunch meal service on 02/02/2022. The Food Service Manager stated the staff had been trained to change gloves when they became contaminated, and wash their hands in between glove changes. She stated she would in-service the staff immediately and have the equipment cleaned. She would let the Administrator know about the grout missing in the tile floors of the dish room. A review of the Cleaning Schedule for the Dietary Department revealed the AM Aide #1 is to clean the juice machine, remove the white spouts and wash on Mondays. The aide is to conduct a detailed cleaning inside the juice cooler and throw outdated juice away. Make sure everything is dated on Thursdays. The AM Aide #2 is to wipe down juice cooler inside and out on Tuesdays. The cleaning schedule did not have a day and time for cleaning the walk-in cooler or nourishment rooms. (Copy obtained) A review of the Dietary Orientation Skills Checklist for new employees revealed the dietary staff received training on proper hand washing, glove usage, general kitchen sanitation, cleaning schedule and documentation, foodborne illness and prevention, cleaning equipment, refrigerator monitoring, and proper food storage. The checklist did not include cleaning of the nourishment rooms. The facility's policy and procedure entitled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices (No effective or revision dates) revealed: Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands during food preparation, as often as necessary to remove soiled and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. .

Based on resident interviews and a review of residents fund account for the entire facility, the facility failed to notify 7 (#5,#7, #10, #22, #24, #35, # 76) of 32 residents that their account had reached $200 less than SSI resource limit for one person specified in Section1611(a)(3) (B) of the Act. These residents were at risk of losing their Medicaid or SSI. The findings include: Interviews with Resident #16 on 2/17/20 at 12:13pm and Resident #9 on 2/17/20 at 12:33pm revealed complaints regarding their personal funds. An interview with the Business Office Manager on 2/19/20 at 11:21AM revealed that Resident #16 issue was already resolved by the facility but Resident #9 did not receive his Resident allowance of $130 after his care cost payment and Dental Insurance was deducted from his Social Security check. Interview with the Business Office Manager on 2/19/2020 at 11:21 AM revealed also that the facility became the Payee on Resident #9s Social Security account December 24, 2019. Social security letter noted that effective January 2020, his payments will no longer be sent to a financial institution. The Payee will be Heartland Health Care Center for Resident #9. He received $1,108.00 for January. Around February 3, 2020, $741,20 was his care cost payment to the facility; Dental was $106.80. The remaining $130 should have been paid into his resident funds account. However, the Office Manager failed to credit Resident #9's account with $130, but sent all the money into Heartland's account. During our interview, staff promised to do a reversal on the account and return the $130 into Resident #9's funds account by 2/20/2020 but it was not reversed until the Administrator was involved on 2/20/2020. The Business Office Manager was asked, Does the facility notify Medicaid residents when the amount in the resident's account reaches $200 of the eligibility limit? Staff stated Yes. She also said that she would involve the Social Worker in assisting the residents to spend down to prevent eligibility losses. On 2/20/2020 at 2:38PM, the Administrator was asked for a copy of the Trial Balance for all 32 residents with funds account in the facility. A review of this list revealed that 7 Residents #5,#7,#10,#22, #24, #35, and #76 were close to the limit or above the limit. An interview was conducted with the Social Service Director (Employee D) at 2:45PM on 2/20/2020 about her knowledge of the list of residents who needed to spend down their funds; she stated that the Office Manager gave her a list yesterday. She said both of them needed to work on the list. Prior to my interrogation and review, these residents could have lost their benefits.

Based on observations, record review and interview, the facility failed to provide respiratory care in accordance with physician's orders and care plan for 1 (#91) of 1 resident reviewed with ordered oxygen. The findings include: On 02/17/20 at 01:34 PM Resident #91 was observed in his room, sitting up in bed with lunch on overbed table and oxygen being administered through a nasal cannula @ 3 liters per minute using an oxygen concentrator with no date and time on the tubing. It was also observed his nebulizer mask was sitting on the bedside table, not in a labeled plastic bag. Photographic evidence was obtained. An interview was attempted with the resident but he was unable to remember what his oxygen flow rate should be. A review of his medical record revealed oxygen was ordered at 4 liters per minute via nasal cannula administered by an oxygen concentrator. On 02/18/20 at 11:23 AM, the resident was observed sitting in his wheelchair in his room with nasal cannula in place and oxygen being administered at 3 liters per minute via nasal cannula using an oxygen concentrator. (Photographic evidence obtained). On 02/18/20 at 02:46 PM, the resident was observed in his room, sitting in his wheelchair with nasal cannula on and oxygen being administered using a portable oxygen tank on the back of his wheelchair with the flow rate set on 2 liters per minute. On 02/19/20 at 09:58 AM, the resident was observed in his room, sitting in his wheelchair with oxygen being administered through a nasal canula using an oxygen concentrator and flow rate was set on 3 liters per minute. (Photographic evidence obtained). Also at this time, it was observed that the resident's nebulizer and mask were both on bedside table covered with a plastic bag which was not labeled or dated. (Photographic evidence obtained). On 2/19/2020 at 11:43 AM, a clinical record review was performed on Resident #91 which documented the medical diagnoses of cerebral infarction due to cerebral venous thrombosis, dysphagia following cerebreal infarction, need for assistance with personal care, sarcopenia, heart failure, peripheral vascular disease, occlusion and stenosis of unspecified carotid artery, major depressive disorder, chronic obstructive pulmonary disease (COPD), asthma, and gastric esophageal reflux disease (GERD). A review of the current physician's orders for Resident #91 documented the following: oxygen via nasal cannula at 4 liters per minute continuously. Ipratropium-Albuterol solution 0.5-2.5 (3) MG/3 ML 3 ml inhale orally four times a day for COPD. Budesonide-Formoteril Fumarate aerosol 160-4.5 MCG/ACT 2 puffs inhale orally two times a day for COPD; Rinse mouth after each use. Change oxygen tubing and humidifier bottle weekly on Sunday 7PM-7AM shift, change nebulizer set and tubing weekly on Sunday 7PM-7AM shift. A record review of minimum data set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 5 which indicated severely impaired cognition and documented the resident did have shortness of breath with exertion as well as shortness of breath while lying flat and had a past history of tobacco use. A review of care plan documented History of smoking in community, At risk for respiratory impairment related to asthma, CHF, COPD, pulmonary with interventions of evaluate lung sounds and vital signs as needed, report abnormalities to physician, obtain pulse oximetry and report abnormal findings, administer medications/treatments per physician orders, elevate the head of the bed, administer oxygen per physician order. A review of oxygen saturation levels was done and documented twice a day since admission. Levels range from a low of 95% on 2/18/2020 to a high of 99% on 2/12/2020 A review of the medication administration records for January and February 2020 all revealed documentation of oxygen at 4 liters per minute via nasal cannula. A review of the treatment administration records for February 2020 revealed the oxygen flow rate was checked on every shift, 7-1, 3-11 and 11-7. On 02/19/20 at 10:07 AM, an interview with Employee C, RN was conducted. Employee C was the nurse caring for Resident #91 on Monday, Tuesday and Wednesday on the 7-3 shift. She was asked how many residents she was caring for that received oxygen. She stated it changed weekly because she mainly worked on the rehabilitation unit but thought she had 3 resident's currently on oxygen. Employee C, RN was asked to verify on her medication administration record the current order for Resident #91 oxygen. Employee C, RN verified that on the current medication administration record, Resident #91 oxygen was ordered at 4 liters per minute. She was then asked to check Resident #91 oxygen concentrator and verify the current flow rate. She went into Resident #91 room and visually checked the gauzge on the front of the concentrator and confirmed the oxygen flow rate was set on 3 liters per minute. She then adjusted the oxygen flow rate up to 4 liters per minute. On 02/20/20 at 10:24 AM, a review of facilities Policy and Procedure Oxygen Administration under the heading PREPARATION OF EQUIPMENT was performed. On #3 it states For oxygen concentrator, plug in power cord, turn unit on and set flow meter to correct flow rate-extracts oxygen from room air. Ensure that exhaust filters care clean and unblocked and under the heading of COMPLETION OF PROCEDURE #2 When oxygen not in use, store oxygen tubing and nasal cannula or mask in separate, labeled plastic bag. A review of the facility Policy and Procedure Respiratory: Nebulizer Mist Therapy was also performed and under the heading of Procedure #18 Store dried nebulizer, t-piece or mask in separate, labeled, plastic bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that medications were not expired and/or stored within the right recommended conditions in three of five carts inspected for medication storage. The findings include: On [DATE] at 12:51 PM observed unopened insulin with instruction to refrigerate until open in the Split Cart (400/300 hall). (Photographic evidence obtained). In an interview at [DATE] at 12:55 PM, Staff B stated that the medication was supposed to be in the fridge. An observation on [DATE] at 01:15 PM for East wing 200 hall cart and [NAME] wing 300 hall cart, revealed expired Milk of Magnesium with expiration date [DATE] and [DATE]. Further inspection of the East wing 200 hall cart revealed three bottles of opened lactulose with no open date. In an Interview on [DATE] at 01:30 PM, Staff A, confirmed that the milk of magnesia was expired she added that she forgot to label the opened bottles of lactulose. In an interview on [DATE] at 01:35 PM, the Director of Nursing (DON) stated that the nurses were supposed to check theirs every shift and ensure that medications were not expired and were labeled. she added that she checked the cart weekly. She stated that education has been done to the employees. Record review of the policy and procedure titled Storage and Expiration dating of Drugs, Biologicals, syringes and Needles Revision date 08/2018: 4. Once any medication or biological package is opened, the Nursing Center should follow manufacturer guidelines with respect to expiration dates for opened medications. Nursing Center staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 16. Nursing Center personnel should inspect nursing storage areas for proper storage compliance on a regular scheduled basis.