Resident # 70 On 3/11/24 at approximately 11:37 AM, Resident #70 was observed from the hallway lying in bed with the catheter bag attached to the bed railing uncovered and visible. On 3/12/24 at approximately 2:53 PM, another observation was made of the catheter bag uncovered and visible to other residents in the hallway. On 3/13/24 at approximately 10:20 AM, the resident was again observed lying in the bed with eyes closed, door open to the hallway, with the catheter bag attached to the bed rail and visible from the hallway. On 3/13/24 at approximately 10:22 AM, an interview was conducted with the Risk Manager Registered Nurse. The Risk Manager confirmed that the catheter bag was visible from the hallway and indicated that it should be covered for dignity with a dignity bag. The Risk Manager went on to state that she would get that fixed right away. A review of the facility policy titled Dignity (dated December 2017), revealed under Policy, The Center must treat each Resident with respect and dignity for each Resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Under Procedure- Treat each resident with respect and dignity with regards to the following: * Personal care. Based on observations, interviews, and record review, the facility failed to honor resident's right to dignity for 2 of 2 residents sampled. (Resident #63 and #70) The findings include: Resident #63 An observation on 3/11/2024 at 12:58 PM noted Staff A, a Certified Nursing Assistant (CNA), standing while assisting Resident #63 with breakfast. On 03/14/24 at 9:00 AM, Staff A was again observed standing while assisting with feeding Resident #61. When Staff A was asked if that is the way they feed the residents, Staff A stated she isn't always standing. She was aware they are to assist residents with feeding while sitting. In an interview on 3/13/2024 at 1:28 PM with the Assistant Director of Nursing (ADON), she was asked if the staff receive training on sitting while assisting residents with feeding. She stated they did. She was then advised that Staff A was observed standing while assisting Resident #63. The ADON agreed that it was a dignity concern for the resident.

Resident #47, fingernails and toenails On 3/11/2024 at approximately 10:54 AM, an observation was made of Resident #47. Resident #47 was observed to have long fingernails on both hands and long toenails to the right foot. Resident #47's fingernails on the right hand appeared discolored and were noted to have a brown substance underneath each fingernail. Resident #47's toenails on the right foot appeared long and thick. On 3/11/2024 at approximately 10:57 AM, an interview was conducted with Resident #47, who was alert to person and place. Resident #47 was asked if he allows the staff to trim his fingernails and toenails. Resident #47 indicated he does allow the staff to trim his fingernails and toenails and indicated the staff have trimmed his fingernails on his left hand in the past, but not his fingernails on his right hand or his toenails on either foot. On 3/12/2024 at approximately 9:56 AM, another observation was made of Resident #47. Resident #47 who is alert and oriented to person and place gave verbal consent to take photographic evidence of his right hand and right foot. The resident was observed to have long fingernails on the right hand with a brown substance underneath each fingernail. The resident was also observed to have long toenails to the right foot. (photographic evidence obtained). On 3/12/2024 at approximately 2:10 PM, an interview was conducted with the ADON regarding the policy for trimming resident's fingernails and toenails. The ADON indicated the Certified Nursing Assistants (CNAs) should be trimming residents' fingernails and toenails on days the residents are given or assisted with a bath. The ADON indicated, if the resident is a known Diabetic, they are referred to podiatry for toenail trims. The ADON indicated the CNAs should be reporting to the Nurses if they are unable to trim the residents' fingernails and toenails or if the residents refuse care. On 3/13/2024, a record review was conducted for Resident #47. The record review confirmed that Resident #47 did not have a diagnosis of Diabetes Mellitus. The record review also confirmed that Resident #47 has not refused hygiene care. Based on observation, resident interview, staff interview and record review, the facility failed to provide activities of daily living assistance with finger and toenail trimming for 2 of 3 residents sampled (Resident #31 and #47). The facility also failed to facilitate Restorative Nursing services as ordered for Resident #31. The findings include: Resident #31, Toenail Care On 03/11/24 at approximately 12:36 PM, Resident #31 was observed with no socks or shoes. An observation of Resident #31 toenails noted very long toenails to both big toes and the third toe on the right foot. Resident #31 stated that she wasn't aware of the last time she had her toenails cut. A second observation of Resident #31 toenails on 03/13/24 at approximately 12:53 PM noted that the toenails had not been cut since the previous observation. On 03/13/24 at 1:25 PM, the Assistant Director of Nursing (ADON) was asked what the process was for residents to have their toenails cut. She stated if the resident is a diabetic, the podiatrist must do it. If they are not, then the nurse does it. When asked if there was a schedule or a process to ensure that the resident's toes are evaluated for need of trimming, she stated it likely should be done on their shower day, but that they really don't have a process to ensure toes were evaluated. Resident #31, Restorative Therapy A review of the medical record on 3/13/2024 noted that Resident #31 had an order for Restorative Therapy dated 12/20/2023 to utilize the arm bike for 15 minutes on Level 2, three times a week for 12 weeks. A review of the monthly intervention and task reports noted that the resident did not receive active range of motion therapy as ordered for Restorative Nursing 2-3 times a week. A review of the January 2024 intervention and tasks noted that Resident #31 received Active Range of Motion (ROM) for only 1 of 31 days in January. A review of February 2024 intervention and tasks noted Resident #31 received Active ROM for only 4 of 29 days. In an interview on 3/14/2024 at approximately 3:26 PM, Staff G, a Restorative Nurse, stated that Resident #31 was ordered for the Omni Cycle bilateral upper extremities back in December. She stated the staff have been trying to get her to utilize the machine, but the resident has refused. She stated she should have documented attempts to utilize the machine, but she neglected to do that. On 03/14/24 at 04:00 PM, Staff G returned and stated she had reviewed the order again and realized that she had entered the order incorrectly. The order was entered as a PRN order which meant as needed, as opposed to three times a week. She stated that because of the error, the staff were probably not asking Resident #31 appropriately and as frequently.

Based on observation, resident interview, staff interview and facility policy review, the facility failed to ensure proper storage of medications for 1 of 21 sampled residents (Resident #71). The findings include: On 3/11/24 at approximately 1:50 PM, medications and medication supplies were observed on the bedside table of Resident #71. No staff members were in the room. There was a 1 pound jar of Triamcinolone Acetonide Cream 0.1% sitting on the bedside table. On top of the jar was a 30 milliliter medicine cup containing a white substance. Also observed on the bedside table was an emesis basin containing a prefilled saline syringe, a multidose bottle of Artificial Tears eye drops, and 8 alcohol impregnated port protectors (used to cap off ports used for intravenous infusions). During the observation, an interview was conducted with Resident #71 regarding the medications and supplies observed on the bedside table. Resident #71 stated the emesis basin with the supplies just stays on my table for the staff to utilize. Resident #71 stated the nurses told him that he could apply the cream himself. He thought the cream was for his groin area, but stated he was unsure exactly where to apply it. Resident #71 stated he was capable of applying the cream if properly instructed, but would prefer if the nursing staff applied it. On 3/11/24 at approximately 1:57 PM, Licensed Practical Nurse (LPN) D entered Resident #71's room, and an interview was conducted regarding the storage of the medications, eye drops, saline pre-filled syringes, and alcohol impregnated port protectors. LPN D indicated the medications and supplies should be kept on the medication cart and was unaware of who left the medications and supplies on the resident's bedside table. LPN D disposed of the eye drops in the resident's trash can and removed the medications and supplies from the bedside table. On 3/11/24 at approximately 2:04 PM, an interview was conducted with Assistant Director of Nursing E (ADON E) who was asked if prefilled saline syringes are normally kept at the bedside. ADON E stated that this occurs only when the nurse is returning in a few minutes to flush the line. ADON E was asked if the eye drops, alcohol impregnated port protectors, and the anti-fungal cream should be left at the bedside. The ADON E indicated those items should not be at any bedside and that they should be kept on the medication cart. A review of the facility's policy titled, Storage of Medications, indicated drugs and biologicals are to be locked up when not in use, and trays or carts used to transport such items are not left unattended. The policy also indicated drugs and biologicals are stored in the containers in which they were received.

Based on record review, staff interview and policy review, the facility failed to ensure complete and accurate documentation on the Medication Administration Records (MARs) for for 1 of 5 residents sampled for unnecessary medication review. The findings include: A record review was conducted of Resident #49's medical record, which revealed an order written for premethrin external cream 5% (a cream often used to treat scabies) on 3/1/24. A review of the Electronic Medication Administration Record (EMAR) revealed the premethrin cream was scheduled to be given for 4 days from 3/1/24 - 3/4/24. However, there was no documentation of this cream being applied. On 3/13/24, an interview was conducted with the Director of Nursing (DON) at approximately 3:11 PM. The DON stated that she would expect this order to be documented. Later, she stated that she had followed up with the supervisor and confirmed that the resident did receive the medication. On 3/14/24 at approximately 3:02 pm, a follow up interview was conducted with the Director of Clinical Services, who confirmed that all administered medications should be documented. Review of the policy titled:Administration of Drugs dated October 2019 revealed, Policy: Drugs will be administered in a timely manner and as prescribed by the resident's attending physician or the Center's Medical Director. Under Policy Interpretation and Implementation: 4. Topical drugs used in treatments should be recorded on the resident's treatment record. 10. The nurse administering the drugs must electronically sign the resident's EMAR. Further review of Resident #49's record revealed a current plan of care for Psychotropic Medications (medications used to help manage behaviors) which included an intervention to observe and document for adverse medication side effects every shift. Upon review of the electronic medication administration record, no documentation was noted for side effect monitoring on the following dates and shifts: 3/1/24 on the day shift (7:00 AM - 3:00 PM) or the evening shift (3:00 PM to 11:00 PM), 3/2/24 on the day shift, 3/4/24 on the evening shift, 3/5/24 on the evening or night shift(11:00 PM to 7:00 AM), 3/6/24 on the evening shift, 3/7/24 on the evening shift, 3/8/24 on the evening shift, 3/11/24 on the evening shift, or 3/13/24 on the evening shift. A review of the policy Charting Errors/Omissions, November 2001, item 4 Any hole or omitted documentation is considered an error/omission. An interview was conducted with the Director of Nursing (DON) on 3/13/24 at approximately 3:34 PM. The DON indicated that it was her expectation to document every time anything is done for our residents, like giving medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** rooms [ROOM NUMBER] On 3/11/2024 at approximately 11:22 AM, an observation of room [ROOM NUMBER] was conducted . Bed A was empty and had a fitted sheet in place with a cloth pad on top of the fitted sheet. The fitted sheet had a brownish red stain and the cloth pad was yellow stained. On 3/11/2024 at approximately 1:50 PM an observation was made of Resident #71's room. The bed was noted to have red and yellowish stains on the fitted sheet. The entire fitted sheet appeared dirty. On 3/11/2024 at approximately 1:55 PM, an interview was conducted with Resident #71, who was alert and oriented. The resident was asked how often the staff change his bed sheets. The resident stated maybe once a week. The resident indicated the last time he was assisted with a bath, the staff did not change his sheets. On 3/12/2024 at approximately 10:02 AM, an observation was made of room [ROOM NUMBER]. Bed A was noted to have a several reddish stains on the fitted sheet. (photographic evidence obtained) Rooms 220, 228, 229, and 230 On 3/11/24 and 3/12/24 observations were made of rooms 220, 228, 229, and 230. The following issues were noted: 1. In room [ROOM NUMBER], the wall behind the bed had molding missing. 2. In room [ROOM NUMBER], there was a hole in the wall than sunlight could be seen through. 3. In room [ROOM NUMBER], the walls behind bed B were noted with missing paint. 4. In room [ROOM NUMBER], a hole was noted in the wall beside the window as well as a hole in the wall beside the vents. On 3/11/24 at approximately 11:30 am, an observation was conducted of the 2nd floor dining room, and again at approximately 1:52 pm, where it was observed that the dining room was being used as additional storage of beds, wheelchairs and boxes. (Photographic evidence obtained) On 3/12/24 at approximately 11:30 am, an interview was conducted with the Director of Clinical Services, who indicated that the facility has gone through a couple of maintenance workers, and have hired a new Maintenance Supervisor as well as brought in as needed maintenance staff to get the building maintenance caught back up. On 3/12/24 at approximately 3:29 pm, an interview was conducted with the Administrator and Director of Clinical Services. The Administrator indicated that, during the weekend, the staff does not have access to the outside storage area and they moved some beds and things around and placed them in the 2nd floor dining area until they were able to move them out to the storage locker yesterday afternoon. The Director of Clinical Services confirmed the beds stored in the dining area over the weekend does not make for a home like environment for dining. The policy titled Environmental Services (dated March 2022) states, Policy: It is the primary responsibility of the Housekeeping, Laundry and Maintenance Departments to ensure a safe, sanitary, orderly and comfortable environment. Under Policy Interpretation and Implementation: 6. A safe, clean, comfortable and homelike environment will be provided. Based on observation, resident and staff interviews, the facility failed to provide housekeeping and maintenance services to maintain a clean and sanitary environment for 9 of 9 rooms sampled for environment. (Rooms 112, 114, 115, 203, 207, 220, 228, 229, 230, resident #31's room and resident #71's room) The findings include: Resident #31's room and room [ROOM NUMBER] An observation of Resident #31's room was conducted on 3/11/2024 at 11:38 AM. The blinds to the window were noted to be broken with exposed edges. An interview with Resident #31 could not determine how long the blinds had been broken. An observation of the shared bathroom noted broken and stained tiles at the base of the toilet. (photographic evidence obtained) An observation of room [ROOM NUMBER] was conducted on 3/11/2024 at 11:56 AM. An observation of the shared bathroom noted a dirty shower chair, a dirty shower floor, and the room had an intense odor of urine. A tour on 3/13/2024 at 8:37 AM noted the same shower chair and also that the shower had not been cleaned and the smell of urine remained. A tour on 3/14/2024 at 8:15 AM noted the shower chair had been cleaned, but the floor remained dirty, and the intense smell of urine remained. (photographic evidence obtained) In an interview with the Assistant Director of Nursing 3/14/2024 at 10:53 AM, she concurred that the urine smell was intense in the room and the floors needed cleaning.

Based on observations, interviews, and policy review, the facility failed to follow proper hand hygiene and food handling practices during 1 of 5 observation of the kitchen. The findings include: On 3/13/2024 at approximately 11:21 AM, Dietary Staff B was wearing disposable gloves and placing frozen chicken contained in a plastic bag onto a metal baking sheet. Dietary Staff B placed the last piece of frozen chicken onto the baking sheet and walked to the garbage can to dispose of the empty plastic bag. Dietary Staff B did not use the hands-free foot pedal on the garbage can and lifted the garbage can lid with her gloved hands. Dietary Staff B returned to the prepping area and opened a new bag of frozen chicken and began placing the chicken on the baking sheet after touching two other baking sheets. Dietary Staff B did not change her gloves or wash her hands after touching the garbage can lid surface. During the observation an interview was attempted, but Dietary Staff B did not respond to questions. On 3/13/2024 at approximately 11:25 AM, an interview was conducted with the Dietary Manager. The Dietary Manager was asked about the process for hand hygiene when touching a contaminated surface with gloves hands during food preparation. The Dietary Manager indicated the process is to remove the disposable gloves, wash hands with soap and warm water, and apply new disposable gloves before returning to preparing food. On 3/13/2024 a review of the facility's policies titled Handwashing and Principle of Safe Food Handling (dated November 2017) indicated, Dietary Personnel must perform appropriate handwashing procedures under the following conditions: after handling soiled, contaminated equipment. The policies also indicated Dietary Personnel are to wash their hands with warm water and soap for 20 seconds before and after handling food.