**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 residents reviewed for self-administration of medications, of a total sample of 51 residents, (#97). Findings: Resident #97 was admitted to the facility on [DATE] with diagnoses including left tibia fracture, muscle weakness, and polyneuropathy. A review of the Minimum Data Set admission assessment with an assessment reference date of 3/05/25 revealed resident #97 had a Brief Interview for Mental Status score of 15 out of 15, which indicated that he was cognitively intact. On 4/02/25 at 10:09 AM, resident #97 was observed lying on his back in bed watching television. His bedside table was next to his bed with various personal items, including a box of Ocusoft Retaine MGD ophthalmic emulsion that contained 28 single doses (0.01 fluid ounces). The resident said he used the eye drops for his eyes. On 4/02/25 at 10:13 AM, the resident's bedside table was observed with primary Registered Nurse (RN) D, who acknowledged the box of single-dose eye drops at resident #97's bedside. Once outside the room RN D reviewed resident #97's physician orders and acknowledged there were no orders for the eye drops resident #97 had in his possession. RN D explained that residents required a physician's order to self administer medications. RN D stated there was no order for eye drops. On 4/02/25 at 11:16 AM, the Director of Nursing stated residents should have a completed self-administration assessment and a physician's order for self administration of the medication prior to resident self-administering medications. A review of the facility's policy and procedure for Self-Administration of Medications dated 4/1/22 revealed, It is the policy of this facility that residents who wish to self-administer their medications may do so if it is determined that they are capable of doing so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a homelike interior in 1 of 28 rooms, on 1 of 2 units, (East Wing, 103). Findings: On 3/31/25 at 11:45 AM, the first drawer of a nightstand was missing in room [ROOM NUMBER]. Subsequent observations on 4/01/25 at 11:33 AM and 4/02/25 at 3:10 PM, the first drawer of the nightstand was still missing. On 4/02/25 at 3:11 PM, Certified Nursing Assistant (CNA) K explained she entered work orders to alert maintenance of needed repairs in resident's rooms. She stated the first drawer of the nightstand in room [ROOM NUMBER], had been broken for awhile and pointed to the top of a dresser where the drawer had been placed. She indicated maintenance was aware of the needed repair. On 4/02/25 at 4:45 PM, the Maintenance Director stated he was responsible for the functionality of everything in the facility. He explained the staff was supposed to enter work orders to let him know when something needed his attention. At 4:59 PM, the Maintenance Director toured room [ROOM NUMBER]. He acknowledged the drawer needed to be fixed and said it was an easy fix. He stated he had not been aware of the issue. Review of the Work Orders for room [ROOM NUMBER] from January to April 2025 did not reveal a report about broken furniture including the drawer repair. On 4/03/25 at 1:57 PM, the Administrator indicated her expectation from staff was to follow up with maintenance when things were not repaired. She stated staff needed to follow the facility process and inform maintenance electronically or verbally of repairs needed in the facility. Review of the facility's Plant Operations Administrative Overview policy issued on February 2021, revealed the General Maintenance Division functions included the installation of pre-assembled cabinetry and minor furniture repairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected Pre-admission Screening and Resident Review (PASARR) results for 2 of 5 residents reviewed for PASARR, (#6, #8), and use of insulin for 1 of 1 resident (#97) reviewed for insulin, of a total sample of 50 residents. Findings: 1. Review of resident #6's medical record revealed she was initially admitted to the facility on [DATE] and readmitted from an acute care hospital on 7/25/24. Her diagnoses included schizoaffective disorder- bipolar type, bipolar disorder, major depressive disorder and generalized anxiety disorder. Review of resident #6's annual MDS assessment with Assessment Reference Date (ARD) of 8/14/24 revealed question A1500 on Section A read, Is the resident currently considered by the state level II PASARR process to have serious mental illness (SMI) and/or intellectual disability (ID) or a related condition? The documented answer was No. Review of resident #6's medical record revealed a PASARR Level II Determination Summary Report dated 9/07/23. The section Outcome/Disposition showed Meets the state definition of Serious Mental Illness? Yes. 2. Resident #8 was readmitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, major depressive disorder and generalized anxiety disorder. Review of resident #8's annual MDS assessment with ARD of 3/31/24 revealed question A1500 on Section A read, Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answered was No. Review of resident #8's significant change in status MDS assessment with ARD of 1/15/25 revealed question A1500 on Section A read, Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? The answer was No. Review of resident #8's medical record revealed a PASARR Level II Determination Summary Report dated 10/24/2023. The section Outcome/Disposition showed Meets the state definition of Serious Mental Illness? Yes. On 4/03/25 at 12:00 PM, the MDS Lead explained she reviewed that PASARRs were present for all newly admitted residents and paid attention to any yes answers. She indicated the PASARR was important because it determined if the facility was an appropriate setting to meet the needs of residents with SMI or ID. She stated Section A of some MDS assessments had a question about PASARR. She reviewed question A1500 on resident #8's annual MDS with ARD of 3/31/24, and confirmed it was answered No. She indicated that resident #8 met the state definition of SMI and the answer on the MDS assessment should have been yes. She also reviewed the significant change in status for the MDS with ARD of 1/15/25. She stated A1500 was also answered no. She reviewed resident #6's Level 2 determination completed on 9/07/23 and the annual MDS with ARD of 8/14/24 and stated it showed A1500 answered no. The MDS Lead stated accuracy of the assessment was important. Later at 3:00 PM, the MDS Lead confirmed the three MDS assessments were coded incorrectly. The Resident Assessment Instrument (RAI) instructions for A1500 read, Review the PASARR report provided by the State if Level II screening was required . Code , yes: if PASARR Level II screening determined that the resident has a serious mental illness and/or ID/DD (intellectual disability/developmental disability) or related condition, and continue to A1510 . Review of the facility's policy titled MDS Assessments dated 4/01/22 indicated, It will be the policy of this facility to complete MDS assessments in accordance with the RAI manual guidelines. 3. Resident #97 was admitted to the facility on [DATE] with diagnoses including left tibia fracture, muscle weakness, and polyneuropathy. A review of the MDS admission assessment with an ARD of 3/05/25 revealed the resident's use of the high risk medication insulin was incorrectly assessed as yes. A review of the resident's physician orders since admission revealed no orders for insulin injections. On 4/03/25 at 1:19 PM, the MDS coordinator accessed resident #97's MDS and explained she was responsible for completing his MDS assessment. She said she reviewed the medication administration documentation before completing the MDS. She acknowledged the MDS indicated the number of days insulin injections were received during the last seven days or since admission if admission/entry or reentry if less than seven days reflected seven. The MDS coordinator printed the Medication Administration Record (MAR) for February 2025 and March 2025, and confirmed there was no documentation of insulin injections being given. The MDS coordinator stated, The resident did not receive insulin; the MDS was incorrect. Review of the Center for Medicare & Medicaid Services (CMS) RAI Version 3.0 Manual Section N: Medications. The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin, and or select medications were received by the resident. The facility's policy and procedure, MDS, dated [DATE], read, It will be the policy of this facility to complete MDS assessments in accordance with the RAI manual guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record revealed resident #23, a [AGE] year-old female, was admitted to the facility from an acute care hospital on 2/27/25 with diagnoses that included multiple rib fractures, severe protein-calorie malnutrition, diabetes, schizophrenia disorder- bipolar type, major depressive disorder, and, post-traumatic stress disorder (PTSD). The MDS admission assessment with an ARD of 3/06/25 revealed that resident #23 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated she was cognitively intact. The level I PASARR dated 2/06/25 indicated the finding was based on documented history but did not include the admission diagnoses of anxiety disorder, bipolar disorder, depressive disorder, schizoaffective disorder, and PTSD from 2/27/25. On 4/01/25 at 4:05 PM, the MDS coordinator stated she reviewed the PASARR forms upon admission to ensure their completion. She said the forms were updated as needed. The MDS Coordinator acknowledged that resident #23's PASARR did not include the diagnoses. 4/02/25 at 5:40 PM, the Administrator stated that the Assistant Director of Nursing (ADON) was responsible for PASARRs. When the facility was aware of a new admission, the ADON and Social Service Director collaborated to ensure completion of the PASARR. 4. Review of the medical record revealed resident #34, a [AGE] year-old male, was admitted to the facility from an acute care hospital on 1/29/25 with diagnoses that included Parkinsonism, major depressive disorder, schizophrenia disorder-bipolar type, and brief psychotic disorder. The MDS admission assessment with an ARD of 2/04/25 revealed that resident #34 had a BIMS score of 14/15, which indicated he was cognitively intact. The level I PASARR dated 1/14/25 indicated finding is based on documented history and medications but did not include admission diagnoses of major depressive disorder, schizophrenia disorder- bipolar type, and brief psychotic disorder from 1/29/25. On 4/01/25 at 4:05 PM, the MDS coordinator stated she reviewed the PASARR forms upon admission for completion. The forms were updated as needed. The MDS Coordinator acknowledged resident #34's PASARR did not include any diagnoses. On 4/1/25 at 4:22 PM, the Director of Nursing, (DON) explained that level I PASARRs were reviewed for completion and accuracy upon admission. The document was updated as needed to reflect the resident's medical record. 04/02/25 at 5:40 PM, the Administrator stated that the ADON was responsible for reviewing PASARRs. The Administrator said when the facility was aware of a new admission, the ADON and Social Service Director collaborated to ensure completion of the PASARR which included reviewing all PASARRs for completion and accuracy. The Facility's Policy issued 4/01/22 indicated the facility will ensure each resident in a nursing facility is screened for a mental disorder or intellectual disability prior to admission. Based on interview, and record review, the facility failed to ensure the completion and accuracy of Level I Preadmission Screening and Resident Review (PASARR) documents on admission and/or failed to make referrals for newly evident or possible mental disorders/diagnoses to evaluate the need for specialized services or alternative placement for 4 of 5 residents reviewed for PASARRs, of a total sample of 51 residents, (#49,#79, #23, and #34). Findings: 1. Review of the medical record revealed resident #49 was admitted to the facility on [DATE] from the hospital with diagnoses that included enlarged heart, hypertensive heart disease with heart failure, adjustment disorder with depressed mood, sleep disorder, pain and major depressive disorder. Resident #49's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/18/25 revealed the resident scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) which indicated he had mild cognitive impairment. The assessment revealed resident #49 felt depressed, had no behaviors nor rejection of care, and had no diagnosis of depression nor mood disorder listed as active diagnoses. Resident #49's had a Plan of Care which outlined the potential for adverse side effects related to the use of psychotropic medications, antidepressant for treatment of depression and insomnia. The plan of care also focused on the potential for or actual psychosocial wellbeing issue due to the depression diagnosis. On 4/03/25 at 4:45 PM, a review of resident #49's PASARR Level I Screen for Serious Mental Illness and/or Intellectual Disability or Related Conditions dated 2/07/25, revealed no diagnoses listed in Section A for Mental Illness or Suspected Mental Illness. 2. Resident #79 was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. His diagnoses included metabolic encephalopathy (brain dysfunction), acute and chronic respiratory failure with hypoxia (low oxygen), chronic obstructive pulmonary disease, anxiety disorder, unspecified mood disorder, major depressive disorder, brief psychotic disorder, and primary insomnia. Resident #79's Order Summary Report indicated the resident had an order for Seroquel oral tablet 25 milligrams (mg) to be given three times a day related to brief psychotic disorder and Depakote Sprinkles Oral Capsule Delayed Release 125 mg, four capsules by mouth to be given twice a day related to unspecified mood disorder. Resident #79 had a Plan of Care with the focus for the potential for adverse side effects related to the use of psychotropic medications for the treatment of psychosis. The Care Plan related to resident #79's exhibited behaviors of hallucinations, yelling at staff that they are stepping on the cat, and resident thinks he's going to work. Resident #79's PASARR Level I Screen for Serious Mental Illness and/or Intellectual Disability or Related Conditions dated 12/29/24 revealed no diagnoses listed in Section A for Mental Illness or Suspected Mental Illness. On 4/01/25 at 2:57 PM, the Social Services Director was asked if she was responsible for updating the PASARR forms and said she was not assigned and that she only started working at the facility a few weeks ago but was aware that she will be responsible for them in the future. The Nursing Home Administrator (NHA) said it was the Minimum Data Set (MDS) Coordinator who oversaw PASARR forms. On 4/01/25 at 4:05 PM, the MDS coordinator said that she reviewed the PASARR forms from the admission packet and ensured they were signed. If there was anything that needed to be updated, it would be discussed in their morning clinical meeting and addressed. For example, if it was determined by the psychiatrist that there may be a new diagnosis they will then update the forms. The MDS Coordinator was then asked about resident #79's diagnoses not listed in section A of the PASSARR Level 1 form, and explained he might have another form because he was sent out to the hospital recently and that the Director of Nursing (DON) might be working on it. She was also asked about resident #49 as well and acknowledged that diagnoses were not listed in Section A. On 4/01/25 at 4:22 PM, the DON explained that the process was to look at the forms, ensured they were correct, and updated them in the system if there was a new diagnosis. She continued to explain that she did not have access to update the PASARR forms and would find out from the NHA who was responsible. The DON also mentioned that she had only just started working at the facility for about three weeks. On 4/01/25 at 4:32 PM, the Nursing Home Administrator (NHA)explained they were in a transitional period after the Assistant Director of Nursing (ADON) resigned, and she had been responsible for updating the PASARR forms. She said the ADON had been gone for three weeks and confirmed the forms should have been updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow the physician's order for oxygen (O2) for 1 of 3 residents reviewed for O2 use, of a total sample of 50 residents, (#8). Findings: Review of resident #8's medical record revealed she was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure, congestive heart failure (CHF), anemia, and shortness of breath. Review of resident #8's significant change in status Minimum Data Set assessment with Assessment Reference Date of 1/15/25 revealed she used O2. Review of resident #8's medical record revealed a physician's order dated 12/30/24 which read, Oxygen at 2 liters/minute (LPM) continuous, via NC (nasal canula) every shift. A care plan for a potential for complications of respiratory distress related to CHF and respiratory failure was initiated on 5/17/23. The interventions included, Administer medications as ordered; observe for effectiveness and for SEs (side effects). Administer O2 as ordered. On 3/31/25 at 11:36 AM, resident #8 was lying in bed with her eyes closed, wearing a NC in her nose. The NC was connected to an O2 concentrator set at 4 LPM. A second observation on 4/01/25 at 11:36 AM, revealed resident #8's O2 concentrator was set at 3.5 LPM and later on 4/01/25 at 3:38 PM, the O2 concentrator was at 4 LPM of O2. On 4/01/25 at 3:47 PM, Licensed Practical Nurse (LPN) L stated she had five residents in her assignment using O2. She explained she checked the concentrator when she gave the medications to those residents. She indicated her assessment included ensuring the tubing was changed once a week, the NC was on the resident properly, and checking the resident's oxygen saturation. She mentioned resident #8 was not ambulatory and was always in bed. She stated the nurses were responsible for ensuring the O2 concentrator was set at the rate ordered by the physician. Later on 4/01/25 at 3:55 PM, LPN L walked into resident #8's room and checked the O2 concentrator. She acknowledged the O2 was set at 4 LPM. On 4/01/25 at 4:00 PM, the Director of Nursing (DON) checked resident #8's physician orders and confirmed the order for O2 was 2 LPM. She went to resident #8's room, confirmed the O2 was set at 3.5 LPM and changed it to 2 LPM. Later on 4/01/25 at 4:08 PM, the DON explained she expected the nurses to check the O2 concentrator at the beginning of their shift and periodically throughout their shift to ensure it was correct. She indicated it was important to follow the physician's orders accurately. Review of the facility's policy titled Oxygen Administration issued on 4/01/22 read, It is the policy of the facility to provide guidelines for safe oxygen administration. The procedure listed O2 was administered as ordered by physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain adequate communication with the dialysis center, follow the comprehensive person-centered care plan and ensure post-dialysis assessments were completed for 1 of 2 residents reviewed for dialysis, of a total sample of 51 residents, (#655). Findings: Review of the medical record revealed resident #655 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included end-stage renal disease (ESRD) with dependence on dialysis, and type 2 diabetes. Review of the Minimum Data Set Medicare 5-day assessment with Assessment Reference Date of 3/27/25 revealed resident #655's Brief Interview for Mental Status score was 11 out of 15 which indicated moderately impaired cognition. The assessment showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. The assessment revealed resident #655 required hemodialysis. Review of resident #655's care plan for hemodialysis dated 3/24/25 included complete dialysis communication tool on dialysis days and review upon return from dialysis. Monitor for bruit and thrill at shunt site. A shunt is a connection between a vein and artery that helps your body create the flow of blood it needs for dialysis to work (retrieved from https://www.bmc.org on 4/04/25). On 4/01/25 at 9:15 AM, resident #655 stated the staff did not take vital signs or check her dialysis site when she returned from dialysis. Review of the Dialysis Communication Form showed three sections, the first section was to be completed prior to leaving the facility for dialysis, the second section to be completed by the dialysis center and the third section to be completed by the facility post dialysis. Review of current physician orders revealed resident #655 went to dialysis three times per week, Monday, Wednesday and Friday. Review of the Dialysis Communication Forms revealed resident #655 went to dialysis six times between 3/21/25 and 4/02/25. The forms indicated that only one day (3/21/25) were all three sections completed by nurses. On 3/24/25 only the first page was completed, on 3/26/25 only the first and third pages were completed, the form on 3/28/25 was missing, for 3/31/25 and 4/02/25 only the first page was completed. Four of the six forms did not contain a post dialysis assessment. Review of the progress notes for that time period did not reveal any facility contact made with the dialysis center. On 4/03/25 at 11:12 AM, the Unit Manager (UM) for the west wing stated, the process for dialysis was for nurses to complete the first page of the Dialysis Communication Form, the second page should be completed by the dialysis center and the third page is completed by the nurse when the resident returned to the facility. The UM confirmed the forms were not completed for resident #655. She explained that when the dialysis center did not complete the form she would call and request the form to be completed and sent. She stated even when she called the dialysis center, often the completed form did not get sent back. She confirmed the nurse was supposed to ensure the forms were complete. The UM the nurses were educated to complete the form when the resident returned from dialysis. The policy and procedure Hemodialysis dated 4/1/22 described, The facility and the Dialysis Center should maintain regular communication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to label drugs and biologicals safely and accurately, in accordance with currently accepted professional principles for 2 of 7 residents observed for medication administration, of a total sample of 51 residents, (#305, and #7). Findings: 1. On 3/31/25 at 5:14 PM, during medication administration observation with Registered Nurse (RN) A on the [NAME] medication cart 2 it was noted that the medication on the Electronic Medication Administration Record (eMAR) indicated Eliquis 5 milligrams (mg) give 1 tablet. The label on the actual medication instructed that 10 mg of Eliquis was to be administered. RN A did not administer the medication and stated he would call the physician to clarify the order. 2. On 4/01/25 at 9:14 AM, during medication administration observation with Licensed Practical Nurse (LPN) B, on the South medication cart 2, there were discrepancies found with the medication label for two of resident #7's medications. The order on the eMAR read Sodium Chloride 1 gram and one tablet to be given. In conflict with the eMAR, the medication label indicated two tablets, one gram each of the Sodium Chloride were to be given. The second medication on the eMAR instructed nurses to give Levetiracetam (an anti-seizure medication) 1500 mg by mouth every 12 hours. However, the actual medication label indicated two 1000 mg tablets were to be given, for a total of 2000 mg of Levetiracetam. LPN B did not explain why the actual medication labels did not match the physician orders in the eMAR. She did not administer the medications and stated she would call the physician to clarify the orders. On 4/03/25 at 9:25 AM, RN C explained whenever an order was changed, she updated the order, reordered the medication, then removed the old blister pack from the cart and placed it in the return bin to the pharmacy. She explained if it was a case of where the actual medication was the same but the dosage changed, for example the new order said to give two tablets, and the old order said to give one; she would put a sticker that noted the order change on the medication label and continue to use the medication from that blister pack until the new medication came in. On 4/03/25 at 9:31 AM, RN D explained if there was a new order or a changed order, she would take the medication out of the cart to the return bin. She would then send a message to the pharmacy about the changed dosage. If she discovered that the label did not match the order, she would take the medication out of the cart. RN D said that sometimes if you could have used the same medication, you could put a sticker on that read note direction change. In a phone interview on 4/03/25 at 11:01 AM, Consultant Pharmacist G said he completed medication cart audits once a month for storage of medications and verified there were no expired medications. However, he explained he did not check the eMAR to the order to verify that the label on the medications had not changed or were correct. He said he completed a monthly review including pharmacy recommendations and was involved in the facility's Quality Assurance and Performance Improvement meeting every month. Consultant Pharmacist G indicated he audited the nurses' documentation and sent a report to the facility monthly. He stated he was unaware of any discrepancies with medication labels from the last audit and acknowledged that incorrect labels could lead to medication errors. On 4/03/25 at 12:07 PM, the Unit Manager (UM) for [NAME] way explained if an order was changed or a medication dosage was updated, she would put the new order in the computer and send it to the pharmacy. She continued that the section for updated orders allowed them to use or not use the medication on hand. The UM explained if the medication was not used, the process was to discontinue the medication, remove it from the cart and place it in the return to pharmacy bin. If they chose to use the medication on hand, the process was to place a sticker which indicated, see direction change and once the new order came in, the old blister pack was removed from the cart. On 4/03/25 at 12:15 PM, the consulting pharmacy customer representative H said via telephone if an order was changed by the physician, the new order was entered, the old one discontinued and the medication removed from the cart. They explained the facility could reuse the medication on hand, if possible, by placing a sticker for the direction change. He stated Consultant Pharmacist G was responsible for medication label to eMAR checks, and acknowledged administration inaccuracies on medication labels could lead to medication errors. On 4/03/25 at 2:34 PM, the Director of Nursing (DON) stated her expectation was that discontinued medications be removed from the medication cart and if using a medication on hand when there were order changes, the sticker for the direction change should be placed on the medication until the new medication was delivered. She confirmed any medication with a label which was different from the order should be removed. The facility's Policy on Medication/Biological Storage Issued 4/01/22 indicated in the procedure section, The Nursing staff shall be responsible for maintaining medication storage .and Drug containers that have missing, incomplete, improper or incorrect labels should be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices per infection control standards; and failed to prevent cross contamination when handling trash. Findings: On 4/02/25 at 9:49 AM, Certified Nursing Assistant (CNA) J obtained a pair of gloves from a treatment cart. He donned the gloves without performing hand hygiene and entered a resident's room to assist the wound care nurse. A few minutes later on 4/02/25 at 9:53 AM, CNA J confirmed he was supposed to perform hand hygiene when donning and doffing gloves. He explained he had forgotten to do this but said it was important for sanitation and protection of the residents. On 4/02/25 at 2:58 PM, CNA J was observed at the doorway of room [ROOM NUMBER] holding a clear, plastic bag with trash in his right hand and wearing a personal backpack while talking to a staff member who was inside the room. He then entered room [ROOM NUMBER] and continued talking to the other staff with the bag in his hand. CNA J stepped out of room [ROOM NUMBER] a few minutes later. He explained the bag contained trash he collected from a different room, room [ROOM NUMBER]. He validated he was not supposed to bring trash bag from another room into other resident rooms. On 4/02/25 at 4:35 PM, the Director of Nursing stated she expected staff to perform hand hygiene when donning and doffing gloves. She indicated staff were to discard anything they removed from a resident's room in the soiled utility room and perform hand hygiene before entering another resident's room. She acknowledged entering a resident's room with trash from another room was a problem with cross contamination and was considered a break in infection control process. Review of the facility's policy titled Hand Hygiene dated 4/01/22 read, The facility considers hand hygiene the primary means to prevent the spread of infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promote dignity and positive interactions through courteous behavior and respectful attitude by direct care staff for 1 of 4 residents reviewed for Dignity of a total sample of 44 residents, (#252). Findings: Review of the medical record revealed resident #252 was admitted to the facility on [DATE] with diagnoses including fracture of the sacrum or tailbone, Multiple Sclerosis, Parkinson's Disease, spinal stenosis, generalized muscle weakness, and history of falls. Review of the Minimum Data Set admission assessment with assessment reference date of 6/30/23 revealed resident #252 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. Review of the medical record revealed resident #252 had a care plan for self-care deficit initiated on 6/30/23. Interventions included instructions to staff to anticipate the resident's needs, use a calm approach, and explain actions during care. On 7/10/23 at 5:18 PM, resident #252 expressed concerns regarding how she was treated by staff. She stated sometimes she pressed the call light and staff either responded slowly or not at all. She said, They seem really angry. It's more important to pick up trays than change me. Resident #252 stated this morning, while two Certified Nursing Assistants (CNAs) got her dressed for a Physical Therapy session, they conversed with each other about their problems with a popular social networking website. The resident said, It's insulting to me to be ignored. On 7/11/23 at 1:12 PM, resident #252 described an incident that occurred the previous night. She stated she was asleep at about 11:00 PM when the arriving night shift staff, CNA L, awakened her during rounds. The resident stated her incontinence brief was dry and she told the CNA she did not need to be changed, but the staff member decided to change her anyway. Resident #252 stated at the end of the shift this morning, her brief was wet and CNA L placed a clean brief on her without washing or wiping the urine from her skin. On 7/11/23 at 1:19 PM, CNA N stated she was assigned to resident #252 yesterday on the 3:00 PM to 11:00 PM shift and confirmed she conducted change of shift report with CNA L at 11:00 PM. CNA N stated she informed CNA L she had changed all residents on the assignment between 8:00 PM and 9:00 PM. CNA N explained oncoming night shift CNAs usually preferred residents to be changed closer to the end of the shift, at about 10:00 PM. CNA N stated she did not see what happened inside resident #252's room last night, but she described CNA L as being in a little rush as the residents might have been changed too early for her. Review of the facility's policy and procedure for Resident Rights, Dignity, and Visitation Rights, issued on 4/01/22, revealed staff would treat residents with kindness, respect, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 7/10/23 at 1:18 PM, during tour of the [NAME] Wing, a large puddle of yellow liquid with an odor of urine was noted on the floor to the left of the toilet, in the shared bathroom between rooms #154 and #156. On 7/10/23 at 1:24 PM and 1:34 PM, the Environmental Services Director inspected the shared bathroom and confirmed there appeared to be urine on the floor. He stated he was not aware of any ongoing concerns regarding the cleanliness of the bathroom. The Environmental Services Director explained he conducted daily rounds of the facility but never noticed a problem with the bathroom. On 7/10/23 at 1:31 PM and 7/12/23 at 1:16 PM, Certified Nursing Assistant (CNA) H verified there was a problem with the cleanliness of the shared bathroom for approximately the past two weeks. She explained one of the four residents who used the shared bathroom regularly urinated everywhere. She recalled during one particular shift she had to clean up urine on the bathroom floor three times. CNA H stated the residents in room [ROOM NUMBER] used urinals at bedside to avoid using the bathroom as much as possible, and they also sometimes walked to the shower room at the end of the hallway to use the toilet. On 7/10/23 at 1:36 PM and 1:44 PM, Housekeeper M stated earlier that morning, CNA O expressed concerns about the shared bathroom and she cleaned it. Housekeeper M stated her supervisor, the Environmental Services Director, never instructed her to monitor that bathroom more closely. She explained the facility's housekeepers worked from 7:00 AM to 3:00 PM and the CNAs were responsible for cleaning up after the housekeepers left for the day. On 7/13/23 at 10:00 AM, CNA O verified on the morning of Monday 7/10/23 she informed Housekeeper M there was feces on the floor of the shared bathroom. She explained the urine noted later that day was a separate incident. On 7/10/23 at 1:38 PM, the facility's Concierge explained rooms #154 and #156 were assigned to her for Guardian Angel Rounds. Review of the form utilized for the task revealed the Concierge was responsible for identifying any concerns related to cleanliness and odors of the rooms and bathrooms. The Concierge stated during rounds, one of the residents in room [ROOM NUMBER] complained about the state of the bathroom and she told the housekeeper who cleaned it. The Concierge could not recall the date of the reported concern, nor the name of the housekeeper, but she denied it was Housekeeper M. On 7/10/23 at 1:40 PM, the [NAME] Wing Unit Manager (UM) stated he was aware one of the residents in room [ROOM NUMBER] urinated on the floor in the shared bathroom. He acknowledged the situation warranted more frequent monitoring and cleaning of the floor. The facility's policy and procedure for Environment of Care, issued on 4/01/22, revealed the facility would provide residents a safe, clean, comfortable, and homelike environment. The document indicated the facility would provide adequate housekeeping services to ensure sanitary surroundings. Based on observation, interview, and record review, the facility failed to ensure a bathroom shared by residents in 1 of 18 bathrooms on the East Wing (room [ROOM NUMBER]) and 2 of 29 rooms on the [NAME] Wing (rooms #154 & #156) were maintained in a clean and homelike condition. Findings: 1. Observations conducted on 07/10/23 at 3:10 PM, 07/11/23 at 12:17 PM, 7/12/23 at 9:29 AM, 12:52 PM, and 5:44 PM and on 07/13/23 at 10:27 AM and 1:24 PM revealed room [ROOM NUMBER] bathroom (East Wing) with 7 pink plastic wash basins stacked inside each other on the bathroom floor under a white plastic shower/commode chair. The basins were not labeled with resident names and they were not covered. A pink plastic bedpan (not labeled with resident name or covered) was inside the top wash basin. A yellow plastic fracture bedpan (not labeled with resident name or covered) had been placed in the pink bedpan. On 07/13/23 at 10:27 AM and 1:24 PM, there was a small plastic laboratory specimen collection bag with a biohazard symbol inside of the yellow fracture bedpan. The resident in room [ROOM NUMBER]-B used the bathroom. On 07/13/23 at 1:25 PM, an interview with the East Wing Unit Manager and the Assistant Director of Nursing (ADON) was conducted. The East Wing Unit Manager said she had been conducting resident room rounds which included observations of the resident's room and bathroom. She said she observed for safety issues, checked if the rooms were neat, clean, and uncluttered and were free of trash. She explained there was a Guardian Angel Rounds program in place where management staff were assigned to resident rooms and completed a form which indicated what areas were to be observed. The ADON explained the resident room rounds were conducted daily, and issues were documented on the form then submitted to the Administrator. The ADON stated, All staff are responsible for insuring the resident rooms and bathrooms are clean. Observation of room [ROOM NUMBER]'s bathroom was then conducted with the East Wing Unit Manager and the ADON The East Wing Unit Manager and the ADON confirmed the findings and they stated, Nothing is to be stored on the floors and all resident care items are to be labeled with the resident's name, placed in a plastic bag, and stored in the resident's area to prevent cross-contamination. On 07/13/23 at 1:59 PM, the Administrator identified the East Wing Unit Manager was assigned and responsible for rounds in room [ROOM NUMBER] on the East Wing. The ADON said the East Wing Unit Manager was a new employee and she had just received her room assignment on 07/13/23. Review of the Observation For Action Rounds Guardian Angel Program form revealed room and bathroom were clean and odor free, nothing was stored in bathroom (unless separated and labeled with resident/roommate identifier i.e. urinal/bedpan/graduate). Review of the facility's Disposable Resident Care Product Utilization Policy, dated 4/1/2022, read, Policy: It is the policy of the facility to ensure products utilized for the provision of personalized resident care are available, utilized appropriately and discarded when no longer needed. Procedure: . 3. Disposable resident care products can be stored in resident bedside dressers, cabinets, closets and bathrooms. If a room has more that one resident that utilizes the same disposable care product, that is reusable, it is permissible to store in the same location if the item is labeled or otherwise indicates for which resident the item is to be used. Review of the Facility Assessment last updated 10/31/2022 under General Care: revealed the facility is responsible for infection identification, containment and prevention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to appropriately record and investigate a grievance to ensure resolution in a timely manner for 1 of 1 resident reviewed for grievances, of a total sample of 44 residents, (#71). Findings: Review of the medical record revealed resident #71 was admitted to the facility on [DATE] with diagnoses including left shoulder osteoarthritis, aortic stenosis, generalized weakness, and chronic kidney disease. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/23/23 revealed resident #71 had a Brief Interview for Mental Status score of 15 out of 15 which indicated he was cognitively intact. The MDS assessment showed the resident was independent with all activities of daily living, except for supervision with dressing, and he was always continent of bowel and bladder. On 7/10/23 at 1:18 PM, resident #71 explained the main concerns that affected his life in the facility was the bad condition of his bathroom. He said, It's never clean. Since the new guy came in, none of us can really use it. Everybody knows about it. Resident #71 stated he reported the situation to Certified Nursing Assistants (CNAs) and the Concierge much more than once. He explained the CNAs knew about the problem because they saw it all the time, in addition to his complaints. Resident #71 explained the bathroom was shared by four residents including himself, and they were all affected by its condition. Observation of the shared bathroom revealed a large puddle of yellow liquid with an odor of urine on the floor to the left of the toilet. The resident said, It's like that all the time. It might not be normal to you, but I'm accustomed to it. On 7/10/23 at 1:24 PM and 1:34 PM, the Environmental Services Director inspected the shared bathroom and confirmed there appeared to be urine on the floor around the toilet. Resident #71 informed him the bathroom was like that very often and he had reported it to multiple staff including the Concierge and CNAs. The Environmental Services Director stated he was never made aware of the resident's grievance regarding the bathroom. On 7/10/23 at 1:31 PM, CNA H stated resident #71 and the other residents who used the shared bathroom complained to her and stated they were upset about the condition of the bathroom. She confirmed she reported the situation to the [NAME] Wing Unit Manager (UM) and nurses assigned to the residents. On 7/10/23 at 1:38 PM, the facility's Concierge confirmed resident #71 complained to her about the condition of his bathroom and she asked a housekeeper to clean the floor. The Concierge could not recall the date of the reported concern, nor the name of the housekeeper. She acknowledged she did not complete a grievance form regarding the issue as she believed it was resolved once the bathroom was cleaned. On 7/12/23 at 2:59 PM, the Social Services Director (SSD) explained grievance forms were accessible to anyone as they were placed in multiple locations throughout the facility. She provided a Grievance-Complaint Report dated 7/1 written by the Concierge regarding resident #71's complaint about the condition of his bathroom. The SSD stated she received the form yesterday, 7/11/23, and was not aware the resident reported concerns prior to that day. She was informed the resident stated he complained to multiple staff about the issue which began soon after a new resident was admitted to the adjoining room in the past month. The SSD acknowledged if staff followed the grievance process, the interdisciplinary team would have been notified of the concerns and conducted an investigation. On 7/12/23 at 3:02 PM, the Concierge validated she wrote the grievance form yesterday, 7/11/23. She explained she did not remember the actual date resident #71 complained about the shared bathroom so she tried to back date the document and meant to put a question mark following the date of 7/1. The Concierge stated she believed the resident expressed his concerns possibly around the first of July. On 7/12/23 at 6:06 PM, the facility's Executive Director stated the Concierge wanted to clarify her previous statements regarding resident #71's grievance about the condition of his bathroom. The Concierge stated the date of 7/1 on the grievance form she wrote was wrong and it was supposed to be 7/10, the past Monday, as that was the day she informed the housekeeper the bathroom needed to be cleaned. The Executive Director and Concierge were informed the correction would be added to the survey documentation but interviews with resident #71 and staff indicated the problem existed prior to Monday 7/10/23. They were told Housekeeper M was the staff who worked on 7/10/23, not potential housekeepers named by the Concierge, and Housekeeper M stated she discussed resident #71's bathroom with a CNA that day. Review of the facility's Grievance Log for June and July 2023 revealed no entries regarding resident #71's grievance. Review of the facility's policy and procedure for Grievances, issued on 4/01/22, revealed staff would assist residents to write formal grievances, and if expressed verbally, staff would record the grievance on the appropriate form. The policy indicated the individual who filed a grievance had the right to resolution in a reasonable timeframe, and the facility would document a written decision to include investigation findings, conclusions, and corrective actions if indicated. Review of the undated job description for Concierge revealed duties and responsibilities included reporting all complaints and grievances made by residents to a nursing supervisor or any member of management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedures for prohibition of Abuse for 1 of 4 residents reviewed for Abuse, of a total sample of 44 residents, (#252). Findings: Review of the medical record revealed resident #252 was admitted to the facility on [DATE] with diagnoses including fracture of the sacrum or tailbone, Multiple Sclerosis, Parkinson's Disease, spinal stenosis, generalized muscle weakness, and a history of falls. Review of the Minimum Data Set admission assessment with assessment reference date of 6/30/23 revealed resident #252 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. On 7/11/23 at 1:12 PM, resident #252 expressed concerns regarding a bad experience with staff on her first night in the facility that made her feel afraid. The resident stated in the morning she informed the [NAME] Wing Unit Manager (UM) that she was scared and staff were mean to her. On 7/11/23 at 1:27 PM, the [NAME] Wing UM confirmed resident #252 told him about an incident with staff which caused her to feel afraid. The [NAME] Wing UM stated he felt the Certified Nursing Assistants (CNAs) treated residents well and resident #252's fear might have been caused by her perception of the way people of other cultures expressed themselves. He explained he interviewed the resident and she clarified she did not feel like there was a physical threat to her well being. The [NAME] Wing UM stated what he understood from the resident was that the CNA was probably a little gruff. He recalled he mentioned the issue at the daily clinical meeting and it was discussed briefly, but the team decided it did not meet the criteria for Abuse or Neglect. He explained the incident was not investigated as it did not arise to the level of Abuse. On 7/11/23 at 1:33 PM, the Director of Nursing (DON) confirmed she was the facility's Abuse Coordinator but she was not sure if an allegation of Abuse for resident #252 was investigated as she had not yet started work in her current position on the day the resident was admitted . Review of the facility's log of Abuse, Neglect, and Misappropriation allegations for June and July 2023 revealed no documentation of an Abuse allegation by resident #252. On 7/11/23 at 1:41 PM, the Executive Director, Corporate Nurse, DON and the [NAME] Wing UM were informed of concerns related to the absence documentation of resident #252's allegation of possible Abuse in her medical record or on the log of reportable incidents. The Corporate Nurse was informed the resident informed the [NAME] Wing UM she felt afraid on her first night in the facility, and although he notified the interdisciplinary team (IDT), an investigation was not initiated. The Corporate Nurse validated if the resident expressed fear of an employee, the facility should conduct an investigation. On 7/13/23 at 12:05 PM, the [NAME] Wing UM was informed resident #252's electronic medical record was updated on 7/12/23 to reflect an Interdisciplinary Plan of Care Review Meeting Summary dated 6/23/23. He stated he wrote the note after the IDT discussion. The [NAME] Wing UM was reminded both he and resident #252 stated they discussed the incident on 6/24/23, the morning after she was admitted . He explained he was not aware the allegation was reportable, but had since been made aware. Review of the job description for Unit Manager dated 1/01/15 revealed he/she would review complaints and grievances made by residents and make written and oral reports to the DON. The UM was expected to report and investigate all allegations of Abuse and/or Neglect. Review of the facility's policy and procedures for Abuse, Neglect, Exploitation and Investigations, issued on 4/01/22, revealed all alleged violations of Federal or State laws would be reported immediately to the facility's Executive Director, DON, or Abuse Coordinator. The document defined Abuse as inclusive of intimidation with resulting mental anguish. The policy indicated all staff would be trained to recognize and report possible Abuse to the appropriate staff and the facility would notify State agencies and file required Federal reports. The facility would notify the attending physician and the resident's representative, and involved staff would be removed from the schedule while the facility conducted a thorough internal investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a Level 1 Preadmission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed for PASARRs of a total sample of 44 residents, (#26). Findings: Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, epilepsy, recurrent mild depressive disorder, dementia, and traumatic brain injury. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 5/22/23 revealed resident #26 was admitted to the facility from another nursing home or swing bed. The MDS assessment indicated the resident was not evaluated by a Level 2 PASARR and determined to have a serious mental illness and/or mental retardation or a related condition. PASARR is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care and that they receive necessary services in the most appropriate setting. PASARR requires that Medicaid-certified nursing facilities conduct a preliminary assessment called a Level 1 screen prior to admission, to determine whether the potential resident might have a serious mental illness or intellectual disability. Those individuals who test positive at Level I are then evaluated in depth with a Level 2 screen to determine appropriate placement and recommended services (retrieved on 7/20/23 from www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review/index.html). Review of scanned documents in resident #26's electronic medical record showed no PASARR form. On 7/12/23 at 2:33 PM, the Social Services Director (SSD) was asked if she could assist in locating resident #26's PASARR form in the electronic medical record. She reviewed the scanned documents and validated the PASARR form was not scanned into the medical record. The SSD explained the resident was admitted from another skilled nursing facility and a PASARR form should have been generated by the current facility. The Medical Records staff who shared the SSD's office was asked to check unscanned paperwork for the resident's PASARR form. The Medical Records staff searched through her papers, was not able to find the document, and left the office. On 7/12/23 at 3:34 PM, the SSD provided a PASARR Level 1 form for resident #26. The document listed the name and address of the current facility as the present location of the individual being evaluated. The form indicated the resident had mental illnesses or suspected mental illnesses (depressive disorder and post-traumatic stress disorder) and a related condition (epilepsy). The document read, Incomplete forms will not be accepted. By signing this form below, I attest that I have completed the above Level I PASARR screen for the individual to the best of my knowledge. The PASARR form was signed by Registered Nurse (RN) K and the line designated for the date was incomplete and read, 1. Review of the facility's active staff list revealed RN K was not listed as a current employee. On 7/13/23 at 9:33 AM, the Human Resources staff confirmed RN K no longer worked at the facility. She stated RN K used to be the facility's Assistant Director of Nursing (ADON) and Staff Educator before she was terminated on 1/17/21. On 7/13/23 at 9:37 AM, the Admissions Director explained residents who were admitted from other skilled nursing facilities, home or assisted living facilities (ALFs) would have PASARR forms complete in-house. She stated when resident #26 was admitted from an ALF in May 2023, the facility did not have an ADON, so the Director of Nursing (DON) would have completed the form. The Admissions Director showed an email dated 5/15/23 at 1:46 PM that she sent to all department heads including the Executive Director, the DON, and SSD, with detailed information regarding the resident's transition to long-term care. The email read, He will need a PASARR. The Admissions Director stated when the Medical Records staff informed her yesterday that there was no PASARR form for resident #26, she told her she sent the email to the DON. On 7/13/23 at 10:30 AM, the DON verified resident #26's PASARR Level 1 form was not dated and never uploaded into the electronic medical record. She was asked if she could explain how the document was signed by RN K who was terminated more than two years prior to the resident's admission. The DON stated she had no idea how old the form was or where it came from. On 7/13/23 at 11:08 AM, the SSD stated she found the PASARR form in a box on the [NAME] Wing nurses' station, The facility's policy and procedure for Role of Admissions and Social Services in PASARR, issued on 4/10/22, revealed the facility would ensure each resident was screened for a mental disorder or intellectual disability prior to admission. The policy indicated the PASARR Level 1 form would be scanned into the electronic medical record or maintained in a specified tracking mechanism.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan that reflected person-centered care related to assistance with toileting for 1 of 3 residents reviewed for activities of daily living (ADLs), of a total sample of 44 residents, (#250). Findings: Review of the medical record revealed resident #250 was admitted to the facility on [DATE] with diagnoses including brain cancer, left side paralysis, and generalized muscle weakness. Review of the Nursing admission assessment dated [DATE] showed resident #250 was oriented to person, place, time, and situation. the document indicated the resident expressed personal care and lifestyle preferences that the facility would honor as able. The assessment showed resident #250 required assistance from staff for toileting and did not have a urinary catheter. On 7/10/23 at 5:35 PM, resident #250 explained he was continent of urine and on admission to the facility, he informed staff he required assistance with placement of the urinal as his left arm was paralyzed. Resident #250 stated since being in the facility, Certified Nursing Assistants (CNAs) informed him he needed to use an incontinence brief and they would change him after he urinated in the brief. Review of resident #250's medical record revealed a baseline care plan for assistance with ADLs was initiated on 7/03/23. The goal noted the resident would have his ADL needs met. The interventions instructed nursing staff to assist and provide ADL care and support as needed. The baseline care plan did not include information regarding the resident's request to use a urinal instead of an incontinence brief for voiding. A baseline care plan for expressed personal care and lifestyle preferences was initiated on 7/03/23, but was noted to be resolved, and it had no interventions listed. Review of the CNA care plan or [NAME] showed at the time resident #250 was interviewed on 7/10/23, there were no person-centered care instructions regarding use of a urinal for toileting. On 7/12/23 at 12:44 PM, the [NAME] Wing Unit Manager (UM) recalled he met with resident #250 on the morning after he was admitted to the facility. He confirmed the resident expressed a preference to be assisted to use a urinal and he thought he updated the [NAME] with that information on the same day. Review of the [NAME] with the [NAME] Wing UM and the Director of Nursing (DON) revealed the document now included instructions for a toileting plan that involved prompting the resident every two hours and cuing him with a urinal. The DON was asked to review the baseline nursing care plans for this intervention and she was not able to locate it. On 7/13/23 at 3:36 PM, the Minimum Data Set (MDS) Licensed Practical Nurse (LPN) validated resident #250 never had a person-centered baseline care plan developed for incontinence and/or toileting. She was informed a new intervention regarding use of a urinal was discovered on the CNA [NAME] although there was no related baseline care plan. The MDS LPN reviewed the resident's electronic medical record and noted the intervention was added to the [NAME] by the Regional Nurse on 7/10/23. The MDS LPN explained if staff placed items on the [NAME] without entering an order, progress note, other documentation, or verbally communicating with her, she would not be aware of the need to include it in the baseline care plan. Review of the facility's policy and procedures for Baseline Care Plans, issued on 4/01/22, revealed the facility would develop and implement a baseline care plan within 48 hours of admission that included instructions necessary to meet residents' person-centered care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan to address dental care and services required by 1 of 2 residents reviewed for dental services, out of a total sample of 44 residents, (#26). Findings: Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including arthritis of both knees, type 2 diabetes, legal blindness, and a history of falls. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 5/22/23 revealed resident #26 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. The document showed the resident had no obvious or likely cavity or broken natural tooth. On 7/11/23 at 11:18 AM, resident #26 pointed to his left lower jaw and stated he had a broken tooth. The brown, jagged surface of an obviously broken and possibly decayed lower left tooth was clearly visible during conversation with the resident. Review of the resident's comprehensive care plan as of 7/11/23 revealed no care plan focus, goals, or interventions related to dental issues. On 7/12/23 at 2:33 PM, the Social Services Director (SSD) stated she was not aware of any dental concerns for resident #26. She reviewed the resident's medical record and confirmed the admission nursing assessment and the initial MDS assessment showed resident #26 had no dental issues. When the SSD was informed the resident did not have a dental care plan, she began to type on her computer keyboard and said, He did not have a dental care plan, but I just put one in. On 7/13/23 at 3:16 PM, the MDS Licensed Practical Nurse (LPN) stated resident #26's broken tooth should have been identified by the admission nurse and/or the MDS nurse who conducted the admission assessment. She verified if nurses had noted the resident's broken tooth, an appropriate care plan would have been initiated. Review of the facility's policy and procedure for Comprehensive Assessments and Care Plans, issued on 4/01/22, revealed the facility would conduct a comprehensive and accurate assessment of a resident's needs and goals which would include his/her dental status. The policy indicated the results of the assessment would be used to develop and implement a comprehensive person-centered care plan for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care related to shaving, bathing, and nail care to maintain good grooming and personal hygiene for 2 of 3 residents reviewed for ADL care, out of a total sample of 44 residents, (#26 & #250). Findings: 1. Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including arthritis of both knees, type 2 diabetes, legal blindness, and a history of falling. Resident #26 had a care plan for self-care deficit with dressing, grooming, and bathing initiated on 5/17/23. The goal was the resident would have a clean, neat appearance. Interventions instructed staff to assist the resident with keeping his nails short, shaped, and clean, and provide hands on assistance with dressing, grooming, and bathing as needed. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 5/22/23 revealed resident #26 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. The document revealed the resident required extensive assistance from one staff for personal hygiene tasks. The MDS assessment indicated during the look back period, resident #26 did not reject care such as assistance with ADLs that was necessary to achieve his goals for well being. Review of the [NAME] Wing shower schedule showed resident #26 was scheduled for baths during the evening shift on Mondays, Wednesdays, and Fridays. On 7/11/23 at 9:46 AM, resident #26 stated his last shower was about two weeks ago and he did not receive regular full bed baths as an alternative. When asked if staff provided sponge baths to include his face and underarms, he said, Nothing like that. Resident #26 stated he did not know if there were scheduled shower days as the staff told residents when it was time for a shower. He said, The last time somebody told me about a shower I waited, but they never came back. On 7/11/23 at 9:50 AM, resident #26's fingernails on both hands were noted to be approximately one third of an inch long and dirty. There was dark brown material noted underneath all fingernails. The resident stated he did not like his fingernails long and wanted staff to keep them trimmed. The resident had a significant amount of long, curly, unkempt facial hair and he confirmed he did not like his beard to look the way it did. On 7/11/23 at 9:52 AM, the [NAME] Wing Unit manager (UM) confirmed resident #26's fingernails were dirty and too long. He acknowledged the resident's nail care should have been completed by staff. Resident #26 informed the [NAME] Wing UM that when his nails were long, they get nasty. The resident told the [NAME] Wing UM he did not like to have that much facial hair. He explained he would like the hair on his cheeks and under his neck to be shaved, but he wanted to keep a neatly trimmed moustache and beard. The [NAME] Wing UM acknowledged it was within a CNA's job description to perform those ADL tasks for resident #26. Review of resident #26's medical record revealed documentation by the [NAME] Wing UM related showers and ADL care. Progress notes dated 6/12/23 and 7/01/23 revealed the resident was showered by CNA and nail care was performed. On 7/12/23 at 2:24 PM, the [NAME] Wing UM validated he documented on showers and nail care provided by staff although he did not observe completion of the tasks. He explained his documentation reflected information provided by CNAs. The [NAME] Wing UM acknowledged CNAs could not have provided scheduled showers and nail care based on his observations of resident #26. On 7/13/23 at 3:16 PM, the MDS Licensed Practical Nurse (LPN) reviewed CNAs' documentation regarding baths on resident #26's ADL flowsheets. She explained between 6/14/23 and 7/07/23, staff documented the resident received four bed baths and one shower in the 3-week period. The MDS LPN confirmed on 7/11/23, she created a care plan for resident #26's refusal of showers and nail care at the request of facility management staff. The MDS LPN stated in the last two weeks, since she had returned to work, she was not made aware there was a concern with resident #26 regarding refusal of ADL care until she was asked to update the care plan. The MDS LPN validated resident #26's most recent MDS assessment showed he did not reject care. 2. Review of the medical record revealed resident #250 was admitted to the facility on [DATE] with diagnoses including brain cancer, left side paralysis, and generalized muscle weakness. Review of the Nursing admission assessment dated [DATE] showed resident #250 was oriented to person, place, time, and situation. The document indicated the resident expressed personal care and lifestyle preferences that the facility would honor as able. Resident #250 had a baseline care plan for assistance with ADLs, initiated on 7/03/23, which instructed nursing staff to assist and provide ADL care and support as needed. Review of the [NAME] Wing shower schedule showed resident #250 was scheduled for baths during the evening shift on Mondays, Wednesdays, and Fridays. On 7/10/23 at 5:43 PM, resident #250's hair appeared greasy and limp. He stated during the week he had been a resident of the facility he had not yet received a shower nor had his hair properly washed. He recalled on one occasion a staff member used a washcloth to wipe through his hair. The resident said, I would love to have a shower. He explained he understood the difficulty involved with transfers due to his disability and paralysis on one side, so he would accept regular bed baths as an alternative. The resident had a significant amount of long facial hair and stated he would like to be shaved. He explained he was not accustomed to a full-bearded look and he preferred a goatee with no hair on his cheeks. Resident #250 stated if that was a problem, he preferred to be clean-shaven. Observation of the resident's fingernails revealed they were approximately one third inch long and had a significant amount of black and dark brown substances tightly packed underneath each fingernail. Resident #250 looked at his right hand, frowned, and emphatically stated he did not like it. The resident stated when he was in the hospital he was told nursing facility staff would assist with his ADL care needs. On 7/10/23 at 5:47 PM, the [NAME] Wing UM confirmed resident #250's fingernails were too long and very dirty. He validated the resident required nail care. Resident #250 informed the [NAME] Wing UM he had not received a shower or regular baths since admission. On 7/12/23 at 12:44 PM, the Director of Nursing stated her expectation was staff would offer showers or bed baths on scheduled days and as needed. She validated the facility had equipment that made it was possible for resident #250 to have showers even if he could not stand and transfer without assistance. On 7/13/23 at 3:36 PM, the MDS LPN stated CNAs' flowsheets in resident #250's medical record showed during seven days in the facility, he had two bed baths and no showers. Review of the job description for a Certified Nursing Assistant dated 1/01/15 revealed duties and responsibilities included following work assignments and/or schedules, and assisting residents with daily bath functions, hair care, nail care, and shaving male residents. Review of the facility's policy and procedures for ADL Care and Assistance, issued on 4/01/22, revealed the facility would provide residents with ADL care and assistance to include personal hygiene and bathing, while attempting to maintain the highest practicable level of function.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure surgical wound treatments were initiated and provided for 1 of 1 resident reviewed for non-pressure skin out of a total sample of 44 residents, (#298). Findings: Review of resident #298's medical record noted he was admitted to the facility on [DATE] with diagnoses of Open Reduction and Internal Fixation (ORIF) of right lower leg fracture following motor vehicle accident, cardiac and vascular implants and grafts, metabolic encephalopathy, pain, indwelling urinary catheter, and major depressive disorder. Review of the admission Minimum Data Set assessment dated , 02/02/22 noted he was cognitively intact, having mood issues related to feeling down, depressed, hopeless, tired, and trouble concentrating. He required extensive assistance with activities of daily living, was independent with eating, had impairment with lower extremity and used a walker/wheelchair for mobility. He had an indwelling urinary catheter, no scheduled pain medications, and rarely had pain. The acute care hospital 3008 form dated 01/17/22 documented right leg surgical incision. Review of the admission Nursing assessment dated [DATE] read right ankle fracture and surgical site with ace wrap. Resident #298's plan of care initiated 01/27/22 revealed a care plan for skin impairment for surgical wound to right lower leg which was casted. The goal included healing without complications. The interventions directed nursing staff to perform wound treatments as ordered, obtain wound care physician services, and to observe wound for signs/symptoms of infection and for significant decline, and to update physician if noted. Review of the resident's physician orders dated 02/03/22 noted Orthopedic consult per patient request for right lower extremity cast. A physician order dated 02/16/22 directed staff to monitor right leg incision for signs of infection and drainage. Another physician order dated 02/16/22 read, follow up with Orthopedic Clinic (name) in 2 weeks and to fit patient with a CAM boot (According to www.physicalhealthcare.com a CAM or Controlled Ankle Moon boot is an adjustable device that limits ankle and foot movement) to right lower extremity upon back to rehabilitation. Review of the Orthopedic note dated 03/03/22 read, resident was seen in our clinic today, 03/03/22 for his orthopedic injuries. Impression: removal of external fixator right ankle, fixation right ankle, date of service 01/03/22. Plan: 1. WBAT (weight bearing as tolerated) RLE (right lowered extremity. 2. Pain control as tolerated,. 3. Physical Therapy: range of motion, gentle strengthening progressing as tolerated, and gait training with appropriate gait aids. 4. Discontinue CAM boot. 5. It appears that surgical incision is stable however patient does need daily dressing changes. He needs the wound appropriately cleansed to help with scabbing. 6. Okay to shower, 7. Follow up in clinic in 6 weeks with. A physician order dated 03/08/22 noted weight bearing as tolerated to right lower extremity. An order for wound care treatment was not written until 03/18/22, 14 days after the orthopedic recommendation. The order noted cleanse right lower extremity wounds daily with normal saline, pat dry, apply Calcium Alginate, cover with abdominal pad, wrap in rolled gauze, change daily, observe for redness, drainage, increased pain, odor, increased warmth and notify physician. Review of resident #298's March 2022 Medication Administration Record (MAR) noted wound care to right lower extremity wounds was initiated on 03/19/22, 15 days after Orthopedic recommendations. On 07/13/23 at 5:30 PM, the Regional Nurse Consultant (RNC) reviewed resident #298's Orthopedic recommendations, physician orders and MAR. She explained the process for all consults was for nurses to review all recommendations from consulting provider and to call the attending physician for approval of recommendations and initiate orders. The RNC confirmed the 03/03/22 Orthopedic recommendation for wound care had not been initiated until 03/18/22. The RNC acknowledged surgical wound treatment should have been started on 03/03/22 as per Orthopedic recommendations but were not started until 3/19/23. Review of the Facility Assessment, updated 10/31/2022, revealed the facility is competent to provide care and services for residents requiring surgical wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician orders and follow professional standards of practice related to oxygen use, monitoring oxygen levels, and replacing respiratory supplies for 1 of 3 residents reviewed for respiratory care, of a total sample of 44 residents, (#27). Findings: Review of the medical record revealed resident #27 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included respiratory failure with low oxygen levels, pneumonitis or inflammation of lung tissue due to inhalation of food or vomit, shortness of breath, and heart disease. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/06/23 revealed resident #27 had a Brief Interview for Mental Status score of 15/15, which indicated he was cognitively intact. The document showed the resident required extensive assistance from two staff members for bed mobility, dressing, and personal hygiene, and was totally dependent for transfers. The MDS assessment indicated resident #27 did not use oxygen. Review of resident #27's medical record revealed a care plan was initiated on 6/09/23 for potential for respiratory distress related to his diagnosis of chronic respiratory failure. The interventions directed nurses to check the resident's oxygen levels and administer oxygen as ordered. A care plan for potential for alteration in cardiac function, initiated on 3/29/22, indicated nurses should check the resident's oxygen levels and administer oxygen as ordered to prevent cardiovascular complications. On 7/10/23 at 1:06 PM, resident #27 was in bed with oxygen infusing at 2 liters per minute (L/min) through a nasal cannula and tubing connected to an oxygen concentrator. The resident stated he utilized oxygen at 2 L/min continuously, 24 hours daily. Observation of the oxygen tubing revealed it was not dated, and the empty humidifier bottle attached to the concentrator was dated 6/28/23. Resident #27 looked at the humidifier bottle, acknowledged it was empty, and explained he always had to remind nurses to replace the bottles when they were empty. On 7/10/23 at 1:09 PM, the [NAME] Wing Unit Manager (UM) confirmed resident #27's humidifier bottle was empty. He validated the bottle was dated 6/28/23 and the oxygen tubing was not dated. The [NAME] Wing UM explained nursing staff should replace and label oxygen tubing once weekly, and replace and date humidifier bottles once weekly and as needed when empty. On 7/10/23 at 1:11 PM, the [NAME] Wing UM stated oxygen supplies were scheduled to be replaced on Sunday nights. He was asked to review resident #27's medical record for nursing documentation from the previous shift, which was a Sunday night, related to oxygen use and supplies. The [NAME] Wing UM checked the resident's physician orders and Treatment Administration Record and stated there were no physician orders for continuous oxygen use, monitoring of oxygen levels, or for replacing oxygen supplies. The UM explained resident #27 was readmitted from the hospital on 5/30/23, but his previous oxygen orders were never resumed and there were no revised orders transcribed into the medical record. He stated either a nurse, a manager, or a supervisor would enter physician orders on readmission and he was responsible for reviewing the medical record to ensure the orders were in place. The UM said, I reviewed his orders but missed that the oxygen was missing. He stated it was unacceptable that three different nurses were in the resident's room daily and none of them checked or verified orders related to oxygen use and notes they were absent. Review of resident #27's physician orders revealed prior to observation of the resident on 7/10/23, there were no orders in place related to continuous use of oxygen at 2 L/min, the need for humidification, changing oxygen tubing weekly and as needed, and monitoring the resident's oxygen levels. On 7/12/23 at 11:29 AM, the Director of Nursing (DON) stated the facility obtained orders from the hospital when a resident was admitted , and the nurse was responsible for entering them into the electronic medical record. She explained on the morning after a resident was admitted , both UMs would reconcile the hospital discharge orders with the facility medical record to ensure accuracy. The DON confirmed humidifier bottles should be replaced when empty, and oxygen tubing should be changed every seven days. She explained in addition to nurses, a member of management staff was responsible for checking that oxygen tubing was labeled appropriately, but resident #27's missing label had not been identified. The DON stated the resident used oxygen as needed prior to his hospitalization and the concentrator had remained in his room. The DON validated oxygen use required appropriate physician orders. Review of signage posted at the [NAME] Wing nurses' station revealed instructions for nurses on the 11:00 PM to 7:00 AM shift regarding changing oxygen tubing and nebulizer equipment every Sunday night. Review of the Guardian Angel Program form which was used my management staff to identify issues during daily rounds of assigned rooms, revealed tasks included observation of oxygen tubing to ensure it was dated within the previous seven days and that concentrators were clean. The Facility assessment dated [DATE] revealed the facility could care for residents with respiratory conditions who required oxygen therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer pain medication in a timely manner for 1 of 3 residents reviewed for pain management, (#92). Findings: Review of the medical record revealed resident #92 was admitted to the facility on [DATE] with diagnoses including wedge compression fractures of the lumbar and thoracic spine, and muscle spasms. Review of the resident's Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 6/14/23 revealed he received pain medication on schedule and as needed. The resident reported occasional pain in the previous five days, and the worst pain intensity was level 6 on a 0 to 10 scale. The document showed he received opioid pain medication on 6 of 7 days in the look back period. Review of the MDS Discharge-Return Anticipated assessment with ARD of 6/24/23 revealed resident #92 continued to receive pain medication on schedule and as needed. The document showed he received opioid pain medication every day during the 7-day look back period. Review of the medical record revealed an Order Summary Report that showed resident #92 had physician orders for two tablets Acetaminophen 325 milligrams (mg) every four hours as needed for mild pain, and Hydrocodone-Acetaminophen 10-325 mg every six hours as needed for severe pain, levels 7 to 10 on a 0 to 10 scale. Resident #92 had a care plan initiated on 6/08/23 for potential or actual alteration in comfort related to muscle spasms and a history of compression fractures. The document indicated the resident was able communicate pain to staff. The goal was resident #92 would verbalize an acceptable level of comfort. The interventions included administer medication for discomfort as ordered, observe for medication effectiveness, observe for non-verbal signs and symptoms of discomfort, and evaluate the resident's pain level as needed. On 7/10/23 at 12:17 PM, resident #92 explained sometimes he had to lie in bed in pain when nurses did not administer his pain medication in a timely manner. He said, They tell me the cart is down the bottom and she is coming up the hall. I don't think I should have to wait. They should bring it in at the right time. On 7/12/23 at 9:33 AM, resident #92 stated he woke up in pain at 7:00 AM this morning. He explained his pain was so severe that he could not move. The resident stated although he asked for a pain pill at that time, he had to wait for a long time, and did not receive the medication until approximately 8:20 AM. On 7/12/23 at 10:04 AM, Registered Nurse (RN) B confirmed she was resident #92's assigned nurse. She recalled earlier that morning, the resident's assigned aide, Certified Nursing Assistant (CNA) I informed her the resident was in pain. RN B stated she completed change of shift report, counted a large number of narcotic medications in the medication cart and the medication room while she dealt with multiple interruptions, before she attended to the resident. RN B explained she got to resident #92's room at approximately 8:30 AM. She verified she did not pause during report to address resident #92's report of pain, nor ask the [NAME] Wing Unit Manager (UM) for assistance. RN B acknowledged it was not reasonable for the resident to wait more than one hour for pain medication. On 7/12/23 at 11:46 AM, the Director of Nursing (DON) stated she expected nurses to administer pain medications as ordered and when the resident needed them. The DON stated in this case, the resident was in pain, and if change of shift report was taking too long, RN B should have utilized the [NAME] Wing UM to either administer resident #92's pain medication or continue the count of narcotic medications while she did so. On 7/12/23 at 12:04 PM, CNA I recalled at about 7:00 AM that morning, resident #248 informed her he was in pain and wanted the medication hydro-something. CNA I stated she waited until the nurses were finished their report and she informed RN B of the resident's request at about 7:15 AM. Review of resident #92's Medication Administration Record revealed RN B administered Hydrocodone-Acetaminophen 10-325 mg on 7/12/23 at 8:23 AM for a pain level of 8. The facility's policy and procedure for Pain Management, issued on 4/01/22, revealed the facility would attempt to provide effective pain and comfort management. The document indicated nurses would administer pain medications according to physician orders and as requested by residents as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to maximize the effectiveness and promote optimal therapeutic effect of medication for 1 of 5 residents reviewed for medication administration, of a total sample of 44 residents, (#248). Findings: Review of the medical record revealed resident #248 was admitted to the facility on [DATE] with diagnoses including hypertension, type 2 diabetes, adult failure to thrive, and pancreatic cancer. The resident also suffered from exocrine pancreatic insufficiency, a deficiency of the pancreatic enzymes that results in the inability to digest food properly (retrieved on 7/18/23 from www.webmd.com/digestive-disorders/exocrine-pancreatic-insufficiency). On 7/10/23 at 4:50 PM, resident #248 explained some of her medications had to be given with meals. She stated her physician emphasized the importance of taking her pills at the right time, particularly those that she needed to take with meals. Resident #248 expressed concerns regarding often not receiving her medication with food. She gave the example of the medication Creon, which her physician told her to take in the middle of her meals. Review of resident #248's medical record revealed a physician's order for Creon oral capsule Delayed Release Particles 36000-114000 units, an enzyme supplement, to give one capsule with meals for exocrine pancreatic insufficiency. Review of the manufacturer's website revealed instructions to Always take Creon with a meal or snack.Take Creon exactly as your doctor tells you. (Retrieved on 7/18/23 from www.creoninfo.com/creon-dosing). The resident had a physician order for Metoprolol Tartrate 50 milligrams (mg) twice daily for high blood pressure, to be administered with or immediately following meals. The drug manufacturer's package insert read, Advise patients to take Metoprolol regularly and continuously, as directed, with or immediately following meals. (Retrieved on 7/17/23 from www.drugs.com/pro/metoprolol-tartrate-tablet.html). A physician order for Nateglinide 60 mg related to type 2 diabetes instructed nurses to administer the drug with meals. Review of the manufacturer's instructions indicated the drug should be taken exactly as directed, .usually taken 3 times daily, within 1 to 30 minutes before a meal. (Retrieved on 7/18/23 from www.drugs.com/mtm/nateglinide.html). An order for Metformin Hydrochloride 500 mg for type 2 diabetes, to be administered twice daily with food. Instructions from the manufacturer included take the drug exactly as prescribed by the physician, follow all directions on the drug label, and take Metformin with a meal (retrieved on 7/18/23 from www.drugs.com/metformin.html). Review of a posting on the [NAME] Wing indicated meal times were as follows: breakfast at 7:15 AM, lunch at 11:30 AM, and dinner at 5:15 PM. On 7/13/23 at 6:10 PM, the Certified Dietary Manager stated the meal times posted on the [NAME] Wing were actually delivery times for the main dining room. She explained meals arrived on the [NAME] Wing about 15 minutes after posted time, and later if there were no complications in the dining room. Review of Medication Administration Audit Reports for 7/09/23, 7/10/23, and 7/11/23 revealed resident #248's medications were either not scheduled or not administered according to meal times as ordered by the physician, per pharmacy instructions, and consistent with professional standards. The audit forms showed Creon capsules were scheduled for 8:00 AM, 12:00 PM, and 6:00 PM. The morning doses were administered on 7/09/23, 7/10/23. and 7/11/23 at 8:28 AM, 9:01 AM and 9:06 AM, approximately 1 to 1.5 hours after breakfast. On 7/10/23 and 7/11/23, the lunchtime doses were given at 12:42 PM and 2:04 PM respectively, approximately 1 to 2 hours after that meal. On 7/09/23, the resident received the Creon capsule at 6:46 PM, over 1 hour after dinner; and on 7/11/23, the drug was administered at 5:08 PM, before dinner. Resident #248's Nateglinide tablets were scheduled for 9:00 AM, approximately 1.5 hours after breakfast, 12:00 PM, and 5:00 PM. On 7/09/23, she received the drug at 9:08 AM, 11:46 AM, and 4:23 PM. On 7/10/23, she received the medication at 9:02 AM, 12:42 PM, and 4:37 PM. On 7/11/23, the administration times were 8:29 AM, 2:04 PM, and 5:07 PM. The resident's Metformin Hydrochloride tablets were scheduled for 9:00 AM, approximately 1.5 hours after breakfast and 5:00 PM, approximately 30 minutes before dinner. The drug was administered on 7/09/23 at 9:08 AM, on 7/10/23 at 9:01 AM, and on 7/11/23 at 8:31 AM, 1 to 1.5 hours after the meal was to be delivered. On the three dates shown on the audit reports, resident #248 received Metformin tablets approximately 0.5 to 1 hour before dinner at 4:22 PM, 4:33 PM, and 5:07 PM. The resident's Metoprolol tablets, also scheduled at 9:00 AM and 5:00 PM, were administered with the Metformin at the above times, with similar concerns related to inappropriate scheduling and/or administration relative to meal times. Review of resident #248's medical record revealed she had care plans initiated on 6/05/23 for risk for complications related to type 2 diabetes and risk for complications related to altered cardiac function. The interventions directed nurses to administer her medications as ordered. The care plans did not indicate the resident was assessed for the possibility of self-administration of medication or educated regarding keeping snacks at bedside to ensure she took her medications with food. The facility's policy and procedure for Medication Administration, issued on 4/01/22, revealed the nurses would administer medication in a timely manner and as prescribed by the physician, unless otherwise necessary. The policy indicated if a drug was given other than at the scheduled time, the nurse would document the occurrence in the medical record. On 7/12/23 at 11:22 AM, the Director of Nursing (DON) stated she expected nurses to follow physician orders and pharmacy recommendations during medication administration. She explained it was important to give medications at the correct time to ensure the worked as intended and most effectively. The DON explained on 7/10/23 when she was notified resident #248 received her medications before dinner, she had to go to the kitchen to get her a tray at about 5:15 PM as the meal cart was not yet on the [NAME] Wing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent medication errors for 1 of 5 residents reviewed during the Medication Administration task, of a total sample of 44 residents, (#248). There were 2 errors in 25 opportunities for a medication error rate of 5%. Findings: Review of the medical record revealed resident #248 was admitted to the facility on [DATE] with diagnoses including hypertension, type 2 diabetes, adult failure to thrive, and pancreatic cancer. On 7/10/23 between 4:35 PM and 4:45 PM, Registered Nurse (RN) D was observed during medication administration for resident #248. She removed the resident's pills from blister packs stored in the medication cart and administered medication including one tablet Metformin 500 milligrams (mg), one tablet Metoprolol Tartrate 50 mg, and one tablet Nateglinide 60 mg. On 7/10/23 at 4:50 PM, resident #248 explained some of her medications had to be given with meals. She stated her physician emphasized the importance of taking her pills at the right time, particularly those that she needed to take with meals. On 7/10/23 at 4:55 PM, RN D provided resident #248's medication blister packs for review. The label for Metformin 500 mg tablets indicated the drug was to be given twice daily for blood sugar control related to type 2 diabetes, and read, Take with meals. The label for Metoprolol Tartrate 50 mg tablets revealed the medication was to be administered twice daily for high blood pressure, .with or immediately following meals. The blister pack for Nateglinide 60 mg tablets indicated the medication was prescribed for high blood sugar related to type 2 diabetes and should be administered with meals, between one and thirty minutes before a meal. On 7/10/23 at 5:02 PM, RN D acknowledged she gave resident #248's medications before the evening meal and she was not sure exactly when dinner trays would arrive. RN D explained she read the medication dosage instructions as she prepared the tablets for administration, but did not read other information including instructions and warnings. On 7/10/23 at 5:03 PM, the [NAME] Wing Unit Manager (UM) was informed RN D administered resident #248's medications contrary to instructions. He reviewed the blister packs and validated Metformin and Metoprolol should be given with meals, not before. He stated the Nateglinide should be ok as dinner should arrive by 5:30 PM. On 7/10/23 at 5:55 PM, resident #248 stated she was confused because she got an early dinner tray without a meal ticket and then about 15 minutes later she received a second tray with her meal ticket. On 7/12/23 at 11:22 AM, the Director of Nursing (DON) stated she expected nurses to follow physician orders and pharmacy recommendations during medication administration. She explained it was important to give medications at the correct time to ensure the worked as intended and most effectively. The DON explained on 7/10/23 when she was notified resident #248 received her medications before dinner, she had to go to the kitchen to get her a tray at about 5:15 PM as the meal cart was not yet on the [NAME] Wing. Review of resident #248's medical record revealed a care plan for risk for complications related to type 2 diabetes was initiated on 6/05/23. The interventions directed nurses to administer her oral medication as ordered. A care plan for potential complications related to alteration in cardiac function dated 6/05/23, indicated nurses would administer medications as ordered. The facility's policy and procedure for Medication Administration, issued on 4/01/22, revealed nurses would administer medications in a timely manner and in accordance with physician orders. The document read, .the individual administering the medication should ensure that the right medication, right dosage, right time and right method of administration are verified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a prescribed ointment was appropriately labeled, and failed to maintain medication and supplies securely to prevent unauthorized access in 1 of 1 treatment cart and 1 of 2 medication carts on the [NAME] Wing. Findings: 1. On 7/10/23 at 3:06 PM, an unlocked treatment cart was observed to the left of the [NAME] Wing nurses' station. The treatment cart faced the hallway and all drawers were easily opened. Residents and staff were noted in the hallways and common area in front of the nurses' station. A staff member who worked at a computer in the nurses' station confirmed she was the Wound Nurse. On 7/10/23 at 3:09 PM, the Wound Nurse, Licensed Practical Nurse (LPN) C, stated she unlocked and checked the treatment cart at the start of the 3:00 PM shift. She acknowledged the treatment cart was supposed to be locked to prevent unauthorized access. LPN C looked around the area and stated there were four confused residents in the vicinity who could either walk or self-propel in wheelchairs. She demonstrated that the lock functioned, but she was unable to unlock the treatment cart for further review as she did not have a key. LPN C explained she had to ask one of the nurses assigned to a medication cart to unlock the treatment cart for her as Wound Nurses did not have keys. On 7/13/23 at 1:02 PM, LPN C was asked to explain her process for managing the treatment cart during wound care rounds. She stated if there was enough space in a resident's room, she took the cart inside the room. LPN C explained if there was not enough space in a room, she would leave the unlocked cart outside the room in the hallway. She acknowledged the resident's door had to be closed for privacy during wound care, so the treatment cart was not monitored if left in the hallway. Observation of the treatment cart with LPN C revealed prescription ointments intended for topical use only, and alcohol-based hand sanitizer and antiseptic skin cleansers, Hibiclens and Dakins solution, that could damage healthy skin and mucous membranes if used incorrectly. The third drawer of the treatment cart contained a partially used unlabeled tube of Santyl Collagenase ointment 250 units / gram. LPN C confirmed all ointments in the treatment cart should be appropriately labeled with a resident's name, a physician's order, and pharmacy instructions. 2. On 7/12/23 at 10:16 AM, a medication cart was observed on the [NAME] Wing in the hallway between rooms [ROOM NUMBERS]. A medication blister pack with 30 tablets of Methocarbamol 500 milligrams, a muscle relaxer, was noted on top of the cart. There were no nurses on the hallway and the medication blister pack was clearly visible and easily accessible. On 7/12/23 at approximately 10:19 AM, Registered Nurse (RN) G appeared at the far end of the hallway by the [NAME] Wing nurses' station and walked towards the medication cart. She was informed the blister pack of Methocarbamol was discovered on top of the unattended medication cart. RN G acknowledged she left the medication there as it had been discontinued and needed to be taken to the medication room. She explained she was trying to avoid making several trips to the medication room and planned to go when she had a few items. RN G verified medications should never be left unattended as anyone could pass by and take them. On 7/12/23 at 11:27 AM, the Director of Nursing stated the facility's policy regarding medication storage included never leaving medications unsecured. She confirmed medication and treatment carts should be locked at all times if the nurse is not present. Review of the facility's policy and procedure for Medication / Biological Storage, issued on 4/01/22, revealed the facility would store medications, drugs, and biologicals in a safe, secure, and orderly manner. The document indicated drug containers with missing labels should be returned to the pharmacy for replacement labels. The policy revealed compartments that contained medications and/or drugs should be locked when out of the nurse's view.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide routine dental services for 1 of 2 residents reviewed for dental care, (#26). Findings: Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including arthritis of both knees, type 2 diabetes, legal blindness, and history of falls. A Nursing admission assessment dated [DATE] showed the admission nurse evaluated resident #26's oral status and noted he wore a dental appliance and had no dental problems. A physician order dated 5/15/ 23 indicated the resident could obtain a dental consult as needed. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 5/22/23 revealed resident #26 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. The document showed he required extensive assistance from one staff member for personal hygiene such as brushing his teeth, and he did not reject care. The MDS assessment revealed resident #26 had no obvious or likely cavity or broken natural tooth. On 7/11/23 at 11:18 AM, resident #26 stated he had never heard about the facility's dental program but would like to be seen by a dentist. He pointed to his left lower jaw and stated he had a broken tooth. The brown, jagged surface of an obviously broken and possibly decayed lower left tooth was clearly visible during conversation with the resident. On 7/12/23 at 2:33 PM, the Social Services Director (SSD) stated she was not aware of any dental concerns for resident #26 . She explained the admission nurse usually went over any dental needs that residents had, and she relied on all staff to identify new dental issues and bring them to her attention. The SSD reviewed the medical record and confirmed the admission nursing assessment and the initial MDS assessment showed resident #26 had no dental issues. On 7/12/23 at 2:49 PM, the facility's Discharge Planner interviewed resident #26, verified he had a broken left lower front tooth, and stated she would start the process of arranging dental services. Review of documents provided by the SSD revealed resident #26 was seen by a dentist on the evening of 7/12/23. The dentist wrote that resident #26's tooth #22 was broken, with approximately 75% of the tooth missing, and he required a temporary filling. On 7/13/23 at 3:16 PM, the MDS Licensed Practical Nurse (LPN) verified the admission nurse should assess new residents and identify any immediate dental needs. She explained the MDS nurse was responsible for conducting an in-person assessment within every resident's first three to five days. The MDS LPN acknowledged resident #26's broken tooth should have been identified by both nurses. Review of the facility's policy and procedure for Dental Services, issued on 4/01/22, revealed the facility would ensure dental services were made available to meet residents' needs. The document indicated dental status should be established on admission and updated periodically during a resident's stay in the facility through assessments or per resident report. The policy revealed the Director of Nursing or his/her designee was responsible for notifying the SSD of the need for dental services.

Based on observation, and interview, the facility failed to ensure food was safely stored to prevent foodborne illness for residents residing in the facility. Findings: On 7/10/23 at 10:30 AM, during the initial tour of the kitchen, the upright double door refrigerator contained three plated salads wrapped in plastic with no date and a potato (maybe baked) on a plate wrapped in plastic with no date. [NAME] E stated she made the salads that morning but did not have time to put a date label on them. She did not have a comment about the potato. On a rack in the dry storage area, an opened bag of cornbread mix was wrapped in plastic and had no open/use-by date and the expiration date could not be seen. On 7/13/23 the Certified Dietary Manager stated her expectation was that any food prepared ahead of time or left over needed to be labeled with the date before it was placed in the refrigerator.If dry food was opened, it should be dated before it is put back on the shelf. She noted that all dietary staff had been educated in the past regarding labeling food with the date. Policy and Procedure for Refrigerated Storage, dated 1/01/22: Policy: Refrigerated items should be properly stored, labeled, and maintained by dietary staff. Procedure: Dietary staff will label, date, and monitor refrigerated food, including but not limited to leftovers to ensure use by use-by dates, or frozen (where applicable) or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor the right to make choices about significant aspects of activities of daily living related to preferred method of toileting (#250), and frequency and preferred method of bathing, (#9, #28, #307, #308, #252) for 6 of 8 residents reviewed for choices of a total sample of 44 residents. Findings: 1. Resident #9 was admitted to the facility on [DATE] with diagnoses to include depression, bipolar disorder, sleep apnea. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/14/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Resident #9 required limited assistance with one person for dressing, personal hygiene, and one-person physical assist for bathing. On 7/10/23 at 1:50 PM, resident # 9 stated she had not had a shower since she moved to this room. She said they brought a towel and wash cloth in for her to wash herself. Review of the medical record revealed the resident transferred to her current room on 6/25/23 and had one shower since the move with no other type of bathing noted. 2. Resident #28 was admitted to the facility on [DATE] with diagnoses of encephalopathy, and history of falls. The resident's modified quarterly MDS assessment with ARD of 5/19/23 revealed the resident was cognitively intact with a BIMS of 15 out of 15. She required limited assistance of one person for bed mobility, transfers, dressing, person hygiene, and one-person physical assist for bathing. On 7/13/23 at 4:41 PM, resident #28 stated she preferred showers but was always given a bed bath. Review of the record revealed resident #28 received a bed bath on 6/30/23, 7/03/23, 7/05/23, and 7/10/23. There was no documentation for showers noted. 3. Resident #307 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, with dependence on dialysis. On 7/11/23 at 2:00 PM, the resident stated she had not been offered a shower since admission, nor was she offered a bed bath. She said, I take myself in the bathroom and wash off. A care plan dated 7/03/23 noted resident #307 had a self-care deficit with dressing, grooming, and bathing related to generalized weakness, and limited endurance. 4. Resident #308 was admitted to the facility on [DATE] with diagnoses of encephalopathy, history of falls, and artificial hip joint. On 7/11/23 at 2:14 PM, resident #308 stated she had her first shower yesterday. She said, I have not been offered a bed bath or shower since admission. I take myself to the bathroom and wash up. The resident said it felt so good to get a shower. A care plan dated 6/30/23 read resident #308 has a self-care deficit with dressing, grooming, and bathing related to generalized weakness. On 7/12/23 at 5:18 PM, the [NAME] Wing Unit Manager stated his expectation was that residents received showers on their shower days. He stated he would also expected the Certified Nursing Assistant (CNA) be truthful about showers. He explained, In the future I will be checking behind the CNA to ensure the showers are done. He noted he spoke to residents daily and none of them told him they were not getting showers. On 7/13/23 at 1:17 PM, CNA J stated when a resident was ready to get up in the morning and it was not their shower day, she would wash them up and get them dressed. She said, if they get around independently, I give them a towel and washcloth so they can wash up. If they need help, they will ask. 4. Review of the medical record revealed resident #250 was admitted to the facility on [DATE] with diagnoses including brain cancer, left side paralysis, and generalized muscle weakness. Review of the Nursing admission assessment dated [DATE] showed resident #250 was oriented to person, place, time, and situation. The document indicated the resident expressed personal care and lifestyle preferences that the facility would honor as able. The assessment showed resident #250 required assistance from staff for toileting. On 7/10/23 at 5:35 PM, resident #250 explained he was continent of urine and said, I would like to use the urinal instead of a diaper. He stated on admission to the facility, he informed staff he required assistance with placement of the urinal as his left arm was paralyzed. However, resident #250 stated since being in the facility, CNAs informed him he needed to use an incontinence brief and they would change him after he urinated in the brief. On 7/10/23 at 5:47 PM, resident #250 informed the [NAME] Wing Unit Manager (UM) that CNAs had not been offering him a urinal per his request on admission. He reiterated his preference to not urinate in an incontinence brief. The [NAME] Wing UM retrieved the resident's urinal from the bathroom and held it for him to void. He verified the resident urinated readily, and voided approximately 500 milliliters (ml) of urine. For most people, the bladder holds between 500 and 700 ml of urine, but the urge to urinate usually occurs when it fills with 200 to 350 ml of urine (retrieved on 7/20/23 from www.my.clevelandclinic.org/health/body/25010-bladder). On 7/12/23 at 9:28 AM, resident #250 stated despite the discussion with the [NAME] Wing UM on 7/10/23, he still had not received assistance with the urinal as requested. He said, One lady came in yesterday and said she would help me. She must have got pulled off because she never came back. The resident stated when he was in the hospital he used the call light and staff came to his room to assist him with the urinal. The resident said, I have tried that here and it just doesn't happen.I know when I need to go. Sometimes it takes a minute to get started, but I know. Resident #250 emphasized he did not like to urinate in a brief as the bed got wet and it was just not what he was accustomed to doing. On 7/12/23 at 12:44 PM, the [NAME] Wing UM recalled he met with resident #250 on the morning after he was admitted to the facility. He stated the resident expressed a preference to be assisted to use a urinal and he assured him staff would be able to do that. The [NAME] Wing UM acknowledged he was aware this aspect of care was important to the resident. 5. Review of the medical record revealed resident #252 was admitted to the facility on [DATE] with diagnoses including fracture of the sacrum or tailbone, Multiple Sclerosis, Parkinson's Disease, spinal stenosis, generalized muscle weakness, and a history of falls. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 6/30/23 revealed resident #252 had a Brief Interview for Mental Status score of 13 which indicated she was cognitively intact. The document showed the resident required extensive assistance from two staff members for dressing, extensive assistance from one staff member for personal hygiene, and she was totally dependent on one staff member for bathing. Resident #252 had a care plan for self-care deficit with grooming and bathing initiated on 6/30/23. The interventions instructed staff to provide hands on assistance with dressing, grooming, and bathing as needed. Review of the [NAME] Wing shower schedule revealed resident #252 was scheduled for showers during the day shift on Mondays, Wednesdays, and Fridays. On Monday, 7/10/23 at 5:27 PM, resident #252 stated in over two weeks since admission to the facility, she received one shower and one complete bed bath. She said, That's it since I've been here. She stated on admission, she was informed she would be able to have a shower or bed bath on Mondays, Wednesdays, and Fridays. The resident explained the extent of daily care besides those two occasions was just help with changing her incontinence brief and wiping that area. She pointed to a package of disposable wipes on her overbed table and stated she used them to clean her underarms. On 7/11/23 at 11:10 AM, the resident was in bed and confirmed she wore the same T-shirt from the previous afternoon. She said, No shower yet. On 7/12/23 at 1:03 PM, the Director of Nursing stated her expectation was staff would offer either bed baths or showers according to the resident's preference on the scheduled days of the week, and additional baths as needed or requested. Review of the facility's Welcome Guide dated 1/01/23 revealed every resident had the right to self-determination and would be treated in a manner that promoted quality of life and recognized individuality. Review of the facility's policy and procedure for Resident Rights, Dignity, and Visitation Rights, issued on 4/01/22, revealed the facility would assist each resident to exercise his or her rights and provide care that was .consistent with his/her normal life habits, observing the resident's choices whenever able.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who smoked did not keep lighters or ignition materials on their person for 6 of 7 residents reviewed for smoking and failed to identify an accident hazard of a wet floor for 1 of 1 residents reviewed for accidents, out of a total sample of 44 residents,(#6, #69, #75, #50, #303, #73, #26). Findings: 1. Resident #50 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, atrial fibrillation, anxiety disorder, and type 2 diabetes. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 6/12/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status (BIMS) score of 14/15. On 7/10/23 at 1:33 PM, resident #50 said, I do smoke and I keep my cigarettes and lighter with me. On 7/11/23 at 12:51 PM, the resident stated she kept her cigarettes and lighter in her room in the drawer of the bedside table. She opened the drawer and a pack of cigarettes with a lighter were noted inside. Review of resident #50's smoking assessment dated [DATE] indicated resident #50 may smoke unsupervised in designated smoking areas. The resident may maintain own smoking material (per facility policy). Resident /resident representative/family have been informed of smoking policies and procedures. Resident #50's smoking care plan reflected the following, focus: Resident has been assessed as able to smoke independently. Resident/responsible party have been informed of the facility smoking policy. Goal: resident will adhere to the smoking policy daily through the next review date. Interventions: maintain smoking materials in designated area. 2. Resident #303 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, chronic respiratory failure, depression, and anxiety. On 7/10/23 at 2:00 PM, resident #303 said, I keep my cigarettes and lighter with me all the time. My nurse took them one time and now I keep them with me. On 7/11/23 at 1:24 PM, resident #303 was seen in the smoking area as she took cigarettes and a lighter out of a bag kept in her walker. Resident #303's smoking care plan reflected the following, focus: Resident has been assessed as able to smoke independently. Resident/responsible party have been informed of the facility smoking policy. Goal: resident will adhere to the smoking policy daily thru the next review date. Interventions: maintain smoking materials in designated area. On 7/12/23 at 05:22 PM, the [NAME] Wing Unit Manager (UM) stated the facility had confiscated so many lighters and vape pens and they end up back in here. The UM said families continued to bring them to the residents. The UM explained families and residents were educated to the smoking policy. In the past we would lock up all the cigarettes and lighters and keep them in a box and hand them out when the residents would come out to smoke but the families still brought cigarettes and lighters and gave them to the residents. Now they allow the residents to keep their cigarettes, but they are supposed to return the lighters when they come inside, but that does not always happen and again the visitors bring them. On 7/13/23 at 12:12 PM, the Administrator stated a resident was identified as a safe smoker if they could light and hold their own cigarette. He noted the smoking porch was open from 7 AM to 8 PM and residents could go out whenever they wanted during that time. The Administrator explained there was always a staff person outside, primarily assigned to the smoking porch. The cigarettes and lighters are collected and put in a bag labeled with the resident's name and are kept on the unit. He indicated the smoking material were collected because they want to be compliant with the smoking policy. It is a struggle to keep residents who smoke from getting extra cigarettes. We monitor the residents and educate the families and residents. He noted the nursing team was ultimately responsible for residents smoking and there had not been any changes to the policy in the past 90 days. Administration is ultimately responsible for making sure the policies are followed. He said there was a guardian angel program and administrative staff were assigned a group of rooms. They do daily room rounds and they look at the rooms for smoking material. Both the Director of Nursing (DON) and the Administrator stated it would be concerning if a resident had a lighter in the room as some roommates had oxygen and confused residents could access the lighters. The DON stated she did rounds on all units. On 7/13/23 at 1:09 PM, Registered Nurse (RN) G stated smoking materials were kept on the East Wing because that is where the residents go to smoke. On 7/13/23 at 1:23 PM, Licensed Practical Nurse (LPN) F stated cigarettes and lighters were kept in a lock box in the medication room. She stated if a resident wanted to smoke, they took the box outside and gave them their cigarettes and lighter if they were a safe smoker. If a resident needed assistance, we give them a cigarette and we light it for them. If they require a smoking blanket, we put it on before they smoke. She noted there was usually someone assigned to the smoking porch but if that staff person was on break, other staff took turns to supervise the residents who smoked. If they have a lighter when they come out to the porch, we are supposed to take it from they when they finished smoking. If they refuse to give it to us, we should notify the DON or Administrator. 6. Review of the medical record revealed resident #73 was originally admitted to the facility on [DATE] with diagnoses including muscular dystrophy, right side paralysis, generalized muscle weakness, and muscle spasms. Review of the MDS Annual assessment with ARD of 4/28/23 revealed resident #73 required limited assistance from one person for transfers and supervision for locomotion off the unit. He used a wheelchair for mobility, was only able to stabilize with staff assistance when he moved from a seated to standing position, and functional limitation in range of motion related to impairment on one side of his upper and lower extremities. The MDS assessment showed resident #73 currently used tobacco. Resident #73 had a care plan for smoking, initiated on 7/11/22, which indicated he was assessed as able to smoke independently and was informed of the facility's smoking policy. The goals were that he would demonstrate safe smoking practices and adhere to the smoking policy. The interventions included maintain smoking materials in the designated area and nursing staff were to redirect the resident if they observed unsafe smoking practices. Review of a Smoking Evaluation form dates 6/14/23 revealed the resident smoked cigarettes and had the cognitive, visual, and physical ability to smoke safely. The document indicated the facility deemed resident #72 as able to smoke unsupervised in the designated smoking area and he could maintain his own smoking material according to the facility's policy. The form showed the resident was informed of smoking policies and procedures. On 7/11/23 at 11:31 AM, resident #72 sat in his wheelchair on the facility's smoking porch. He stated he received education on the smoking policy when he was admitted to the facility. The resident explained his son provided cigarettes and lighters for him and he kept these items in his room. On 7/11/23 at 3:52 PM, resident #72 was in his room and showed a green and white box with cigarettes and a tan-colored lighter in the top drawer of the bedside table. On 7/12/23 at 11:06 AM, the DON explained there was always an assigned staff member on the smoking porch to hand out cigarettes and lighters. She explained the staff member would either give lighters to the residents or assist them to light their cigarettes. The DON verified residents should return lighters to the staff member and not retain lighters after smoking. On 7/12/23 at 1:01 PM, the [NAME] Wing Unit UM stated he was aware some residents had access to lighters. He explained the problem was they got lighters from outside. The UM stated when staff found residents with lighters, they retrieved them and placed them in a bag with the resident's name, which was kept on the East Wing. Review of the facility's policy and procedure for Safe Smoking, issued on 4/01/22, read, Residents that are smokers may not keep lighters/ignition material on their person or in their room unless provided by a nurse to be used during smoking opportunities. Lighters/ignition materials must be maintained at the resident's designated nurse's station or other centralized location specific for this purpose. 7. Review of the medical record revealed resident #26 was admitted to the facility on [DATE] with diagnoses including arthritis of both knees, abnormality of gait and mobility, legal blindness, and a history of falling. Review of the 5-day scheduled assessment for Medicare Part A Stay with ARD of 6/07/23 revealed resident #26 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. He required supervision for walking, extensive assistance for toilet use and personal hygiene, and used a walker and wheelchair for mobility. The MDS assessment indicated the resident was always continent of bowel and bladder. He had one fall with no injury since admission. Resident #26 had a baseline care plan initiated on admission, 5/15/23, for risk for falls. The interventions included checking the environment for trip hazards, encouraging the resident to wear well-fitting, non-slip footwear, and ensuring the CNA care plan or [NAME] reflected any special interventions needed to prevent falls, and that those approaches were implemented. The baseline care plan was resolved, and a comprehensive care plan for risk for falls related to generalized weakness, seizures, and legal blindness was initiated on 5/17/23. The goals included minimizing the resident's risk for falls with staff intervention. The interventions directed staff to keep the resident's environment clean and walkways free of clutter, and observe for use of appropriate footwear and assist as needed. On 7/10/23 at 1:18 PM, during tour of the [NAME] Wing, resident #26's bathroom revealed a large puddle of yellow liquid with an odor of urine on the floor to the left of the toilet. On 7/10/23 at 1:31 PM, CNA H was informed of the large puddle of urine on resident #26's bathroom floor. She explained there was a problem with that bathroom as it was shared by four residents in adjoining rooms, one of whom, resident #26's roommate, had dementia and would not use an incontinence brief. CNA H stated the roommate regularly went into the bathroom and urinated everywhere. She stated she had reported the situation to all the nurses she worked with and also informed the [NAME] Wing UM. She recalled during one particular shift she had to clean up urine on the floor three times. CNA H stated on two separate occasions she walked into the bathroom and almost slipped and fell in the urine on the floor. She validated resident #26 had to use that bathroom. On 7/10/23 at 1:40 PM, the [NAME] Wing UM stated residents' rooms and bathrooms were cleaned daily and as needed as any concerns were brought to the attention of staff. The [NAME] Wing UM stated he was aware resident #26's roommate urinated on the floor in the shared bathroom and he acknowledged the situation warranted more frequent monitoring and cleaning of the floor. On 7/11/23 at 11:16 AM, resident #26 stated his roommate made a mess of the bathroom. The resident explained since his roommate was admitted there was often a significant amount of urine on the floor. Resident #26 stated he did not like to walk in the urine it, but his sandals were very hard to put on without assistance so he ended up going to the bathroom without shoes. The resident stated he slipped and fell in urine on the bathroom floor within the last two to three days, and required assistance from staff to get up off the floor. Review of the Situation, Background, Appearance, Review and Notify Communication form dated 7/09/23 revealed resident #26 had a change in condition related to a fall as he was observed on his buttocks on the bathroom floor. The document indicated there was urine on the bathroom floor and to make the situation better, he was encouraged to use the urinal. On 7/12/23 at 12:29 PM, the Assistant Director of Nursing stated she was on call on 7/09/23 and received notification from resident #26's assigned nurse via text message regarding resident #26's fall in urine on the floor. She explained the resident was not injured and she verified staff cleaned up the urine. On 7/12/23 at 1:11 PM, the DON and [NAME] Wing UM stated the facility was not aware there was a fall and accident hazard related to urine on the resident #26's bathroom floor prior to his fall on 7/09/23. The DON reviewed the medical record and stated resident #26's roommate was admitted to the facility on [DATE]. On 7/12/23 at 1:16 PM, CNA H joined the interview and informed the DON and [NAME] Wing UM that over the last two weeks she had informed the nurses assigned to resident #26 and his roommate about the concern regarding urine on the bathroom floor. On 7/13/23 at 9:58 AM, resident #26 was told review of the facility's fall investigation revealed information that conflicted with his statement during an interview on 7/11/23 at 11:16 AM, in which he stated he slipped and fell in urine on the bathroom floor. The resident smiled and stated after he spoke with facility staff yesterday, he recalled that his fall occurred as a result of his knee buckling. The facility's policy and procedure for Falls, issued on 4/01/22, revealed the facility would attempt to prevent falls and injuries related to falls by identifying possible causes that were associated with or directly result in a fall. Review of the undated job description for Concierge revealed duties and responsibilities included keeping floors dry and reporting any hazardous conditions to a nursing supervisor or member of management. 3. Review of the medical record revealed resident #69 was admitted to the facility on [DATE], with diagnoses of chronic respiratory failure, congestive heart failure, chronic kidney disease and dependency on supplemental oxygen. Review of the MDS annual assessment with assessment reference date of 10/29/22 showed resident used tobacco products. Further review of MDS quarterly assessment with assessment reference date of 04/26/23 showed the resident's Brief Interview for Mental Status score was 15 which indicated she was cognitively intact, independent with supervision and set up for activities of daily living. A care initiated 10/07/22 and revised on 4/12/23 showed the resident had been assessed as able to smoke independently. Intervention revealed maintain smoking materials in designated area. A careplan focus initiated 10/30/21, revised on 02/13/23 for potential for complications of respiratory distress related to dependence on supplemental oxygen, resident chooses to smoke cigarettes with an intervention dated 10/30/21 to administer oxygen as ordered. Review of the physician order dated 8/11/22 showed oxygen at 3 liters per minute via nasal cannula every shift. Review of smoking evaluation dated 06/14/23 at 2:52 PM, revealed under maintenance of smoking materials resident#69 must request smoking materials from staff. On 07/11/23 at 11:12 AM, resident #69 was noted smoking in close proximity to Certified Nursing Assistant (CNA) P who monitored residents smoking. Resident #69 stated, she had her own cigarettes and lighter. Further observation of the smoking area did not reveal a smoking box or secure container for storage of resident's cigarettes or lighters. On 07/12/23 at 12:28 PM, resident #69 was lying in bed with oxygen infusing via nasal cannula at 3 liters per minute. She stated she had her lighter and cigarettes. She then pointed to a little black pouch on top of the small refrigerator across from the foot of her bed. She gave permission for this surveyor to look inside at the cigarettes and lighter. The pouch contained cigarettes in a green box and a lighter. She stated she kept her cigarettes and lighter with her. 07/12/23 at 10:54 AM, the DON stated a staff member was assigned to supervise the smoking area. She said resident smoking evaluation were completed quarterly, and some residents did not need to be supervised. She stated staff assisted residents with cigarettes and lighters, and no resident should have cigarette lighter with them. She stated she would have to get clarification from the regional nurse if residents could keep cigarettes and emphasized residents could not keep lighters with them. 4. Review of the medical record showed resident #75 was admitted to the facility on [DATE] with diagnoses of diabetes type 2, depressive disorder, hypertension, and nicotine dependence. Review of the MDS admission assessment with assessment reference date of 12/15/22 revealed current tobacco use. The MDS quarterly assessment with assessment reference date of 06/07/23 showed the resident's Brief Interview for Mental Status score of 13 which indicated she was cognitively intact, independent, set up only, of one person for assistance with activities of daily living. Care plan initiated 12/12/22 and revised on 4/12/23 showed focus for resident desires to smoke, has been assessed as able to smoke independently with intervention indicating smoking materials were to be maintained in designated area. Review of smoking evaluation dated 6/14/23 at 2:43 PM, showed resident must request smoking materials from staff located under maintenance of smoking materials. On 07/11/23 at 11:09 AM, resident #75 was in wheelchair at a table outside, smoking. She stated she had her own cigarettes and lighter and staff did not give them to her. 07/12/23 12:06 PM, resident was in the smoking patio. Certified Nursing Assistant (CNA) A stated less than a month ago, the facility stopped doing the smoke box for storage of residents' cigarettes and lighters. He stated yes, now we are passing out the cigarettes and lighters to the residents. 5. Review of the medical record reflected resident #6 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, nicotine dependence, hypertensive heart disease with heart failure, anxiety disorder, and osteoporosis. Review of the MDS admission assessment with assessment reference date of 01/13/23 revealed current tobacco use. The MDS quarterly assessment with assessment reference date of 04/10/23 revealed Brief Interview for Mental Status score of 15 which indicated she was cognitively intact. The assessment noted the resident required extensive to total assistance of one person with activities of daily living. A Care plan initiated 10/7/22 and revised on 7/11/23 revealed resident #6 desired to smoke, had been assessed and was able to smoke independently with intervention dated 6/16/23 to accompany resident to designated smoking area and provide supervision. A smoking evaluation dated 6/14/23 at 2:49 PM, indicated resident #6 must request smoking materials from staff. On 07/11/23 at 11:09 AM, resident #6 was in her wheelchair in the smoking patio, smoking. She stated she had her own smoking material. On 07/13/23 at 12:12 PM, the Administrator stated everyone should be following the smoking policy and there had been no changes in the policy. He stated he was not aware staff had not been collecting cigarettes and lighters from residents after they finished smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to implement its smoking policy and procedures to provide adequate oversight of 16 smokers and ensure the safety of all residents in the facility. Findings: Cross reference F689. On 7/13/23 at 12:11 PM, the facility's Executive Director and Director of Nursing (DON) discussed the facility's protocols for safe smoking. The Executive Director explained residents who were identified as smokers on admission were evaluated by the nursing department to determine if they were physically and cognitively able to smoke safely. He stated the facility maintained an open smoking porch from 7:00 AM to 8:00 PM daily. The Executive Director stated a staff member was always assigned to the designated smoking area to attend to and monitor the smokers. He explained the assigned staff member was responsible for retrieving smoking materials when residents finished smoking and he/she would place the items in a bag labeled with the resident's name which was kept on the resident's unit. The Executive Director confirmed the staff members who were assigned to the smoking area were educated regarding collecting smoking items as the facility wanted to ensure compliance with the smoking policy. He stated nursing staff were responsible for ensuring the smoking rules were enforced. The Executive Director verified there was no change in the facility's smoking policy in the last 60 to 90 days. On 7/13/23 at approximately 12:17 PM, the survey team informed the Executive Director and DON that facility staff stated there was a change in the smoking policy that occurred less than a month ago. The Executive Director stated he was not aware of any changes. The Executive Director and DON were informed that observations and interviews conducted during the recertification survey revealed residents who smoked kept their cigarettes and lighters on their person and in their rooms, and assigned staff in the the smoking area were not collecting smoking paraphernalia. The DON stated it was concerning that residents with lighters might be in rooms with residents who utilized oxygen. The Executive Director concurred. The Executive Director denied knowledge of the information provided regarding the facility's smokers not adhering to policy and procedures. He said, That's news to me. The Executive Director validated the facility's administration was ultimately responsible for ensuring the safe smoking policy and procedures were implemented. Review of the Facility assessment dated [DATE] revealed the facility would provide person-centered care while identifying hazards and risks for residents. Review of the job description for the Administrator, revised on 1/01/15, revealed he/she was primarily responsible for the day-to-day functions of the facility to assure the highest degree of quality care was provided for residents. The Administrator was responsible for safety in the facility to include ensuring staff, residents and visitors followed established safety regulations such as smoking regulations.

Based on interview, and record review, the facility failed to demonstrate the effectiveness of the performance improvement plan for education of nursing staff and implementation of following physician orders for oxygen for 1 of 3 residents reviewed for oxygen therapy out of a total sample of 44 residents. Findings: Cross reference to F695 On 7/13/23 at 7:40 PM, during an interview with the Executive Director, and Director of Nursing (DON), the Executive Director stated that on 6/26/23, they implemented a Performance Improvement Plan (PIP) to ensure proper oxygen use. He stated education was started on 6/26/23 with nursing staff and had been ongoing along with conducting random audits. A request was made to review the in-service training along with subject matter covered and signature records of nursing staff from 6/26/23. The DON stated education was provided to nursing staff verbally on 6/26/23 and 6/27/23. The DON added that education was provided on a one to one basis with each nurse on all shifts for a total of 8 nurses. She reported there were no sign in sheet, and education was ongoing. The Executive Director stated there was a systematic change and they now have guardian angels to ensure oxygen tubing was labeled with date. He explained nursing was conducting random audits. Review of the facility Performance Improvement Plan revealed, QAA Ad Hoc meeting dated 6/6/23, initiated on 6/28/23 for systemic issue regarding physician orders not being followed for oxygen dosage administration, and oxygen tubing not changed. There was documentation of a second Ad Hoc meeting dated 7/6/23. Further review of the facility's PIP revealed Director of Nursing Services/designee target date 6/26/23 with nursing education ongoing, no ill effects of residents from audits completed on 6/26/23. Quality review of oxygen initiated on 6/26/23 with ongoing monitoring of tubing dated, bagged, changed weekly, oxygen orders entered into computer, oxygen set on correct liters, and physician orders followed (liters on device match the physician orders). Review of audits showed 15 residents audits completed with no resident name or room numbers on the audit. The Executive Director stated they only used medical record numbers on the audits. The audits were dated on 6/26/23 with sections checked for oxygen orders to be entered into the computer, oxygen saturation for shortness of breath as needed, resident care plans in place, visualize oxygen tubing bagged, dated, changed weekly, and as needed. The audit also noted, ensure oxygen is set on correct liter, device match physician order, and physician order for oxygen. The Executive Director provided one partial page of nursing signatures for education in service regarding oxygen dated 7/10/23 with subject matter for oxygen orders to be entered in the computer, oxygen saturation as needed for shortness of breath, oxygen tubing should be bagged, dated, changed weekly, & as needed, ensure the oxygen is set on the correct liter per physician order. Review of the facility employee list showed 25 LPNs and 13 RNs for total of 38 nursing staff. The DON stated she educated 8 nurses which was less than 25% of nursing staff. The Executive Director and DON stated there were no issues with the audits for residents with oxygen. Investigative findings during the week of 7/11/23-7/14/23 identified concerns regarding resident #27's readmission to the facility on 5/30/23. The resident received continuous oxygen without a physician's order and the oxygen tubing was not dated. Review of 2023 Quality Assurance and Performance Improvement (QAPI) Plan showed the purpose is to provide excellent quality care and services to the residents. The facility has a performance improvement program which systematically monitors, analyzes, and improves its performance to enhance resident quality of care and quality of life. The QAPI program focuses on systems and processes. It strives to identify gaps within these systems and processes, rather than placing blame on an individual. The plan showed under feedback, data systems, and monitoring that education and training will be offered during regularly scheduled meetings, new hire orientation, performance improvement plan development, and as needed.

Based on observation, interview, and record review the facility failed to ensure a safe and sanitary environment in the laundry department to prevent cross-contamination of facility equipment and facility linens. Findings: An observation of the laundry department was conducted with the Housekeeping/Laundry Manager, Regional Housekeeping/Laundry Manager and Administrator In Training. The laundry's soiled linen sorting area had 6 covered bins containing soiled linen, an outdoor leaf blower, a floor cleaning/buffer machine which was plugged into the electrical socket, and battery and battery charger. The Laundry Manager explained it was a soiled room used for sorting the facility's soiled linens prior to washing. The Laundry Manager and Administrator in Training stated the leaf blower, the floor machine and battery charger should not be in the soiled room to prevent cross contamination. On 07/11/23 at approximately 12:50 PM, the laundry area containing the facility's 3 washing machines revealed all 3 washing machines were currently in process of washing soiled laundry. Approximately 4 feet directly across from the washing machines were 2 uncovered soiled laundry bins which were full of soiled linens and 1 uncovered soiled laundry bin which contained residents' soiled resident personal clothing. The Laundry Manager said the laundry staff had been using the washing area to sort the soiled linens and these soiled linens were just waiting to go into the washers. The Laundry Manager explained that when the wash had completed we would bring the large blue cart from the dryer/folding room and empty the clean laundry in to the bin and take it to the dryers for processing. On 07/11/23 at 12:45 PM, the Laundry Aide explained that for efficiency she had completed pre-separation in the room with the washing machines because the other soiled room was full of new soiled bins which had just come to the department. She said she would empty the clean laundry from the washing machines and bring it in the bin to the dryers. We really should not be doing the separation in this room because we are mixing the clean laundry with the dirty laundry. Facility's (Contractor Name) Chapter 2, Linen Operations and Management Policy, not dated, read, . How the Laundry Works . Cross-contamination should be a concern in areas containing clean or soiled linen . Transporting Linen - Soiled Soiled linen mush be kept in a container and covered at all times, this includes soiled utility rooms, sorting areas, and transportation to and from those areas . Separation and Sorting of linen Separation of linen is key to preventing cross-contamination . Soiled and clean linen need to be separated from each other at all times . Sorted soiled linens enters the wash area only after making sure any clean linen is first removed from washers and taken into dryer area . Remember that soiled linen cannot be in the wash area at the same times as clean . Review of the Facility's Infection Prevention and Control Program Policy, dated 11/28/2022, read, Policy: The primary mission is to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Procedure: . 5. A system for linen handling to prevent the spread of infection to include handling, storing, processing and transporting linens .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide appropriate care and treatment, consistent with professional standards of practice, to promote wound healing and prevent worsening of wounds and pressure ulcers for 3 of 3 residents reviewed for pressure ulcers out of 5 sampled residents, (#1, #2 and #3). Findings: 1. Review of resident #1's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included stroke, subdural abscess, and neuromuscular dysfunction of the bladder. Review of resident #1's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 1/10/23 revealed he had a Brief Interview for Mental Status (BIMS) score of 15 which indicated he was cognitively intact. The MDS assessment showed resident #1 required extensive assistance from staff for bed mobility, toileting and dressing. He required limited assistance for transfers and personal hygiene. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. The assessment revealed a stage 3 pressure ulcer was present on admission. A stage 3 pressure ulcer is a full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. (CMS Appendix PP) Review of the Nursing admission Assessment dated 1/03/23 revealed resident #1 had the following skin abnormalities: right and left heels were red and boggy, a midthoracic surgical wound and a small irritation on his penis. The assessment revealed he had an indwelling catheter related to neurogenic bladder. Review of resident #1's physician's orders dated 1/5/23 read, Change wound vac dressing 3 times per week / PRN (as needed) dislodgement or malfunction every day shift Tuesday, Thursday, Saturday. The wound vac order was discontinued on 1/13/23 and a new order read, Mid back wound, cleanse with NS (normal saline), pat dry, apply Santyl to wound bed and pack with rolled gauze and Dakin's solution, cover with small abd (abdominal) bandage, silicone foam dressing and secure with [NAME] [sic] wide tape to ensure dressing stays in place once daily and PRN every day shift, please ensure this is done over the weekends and Mondays, high risk site. Another physician's order dated 1/6/23 read, Penile foreskin skin tear, cleanse with NS, pat dry and apply collagen to wound bed with Xeroform and covered [sic] with 4x4 folded gauze and secured [sic] around with tape once daily and PRN every day shift. An Initial Wound Evaluation & Management Summary note from Wound Physicians dated 1/5/23 revealed a Stage 3 pressure ulcer to the dorsalis of penis with moderate serous exudate that measured 0.8 centimeters (cm) x 3.0 cm x 0.3 cm. The treatment consisted of Xeroform gauze, collagen powder, triple antibiotic ointment, covered with gauze and tape daily. Recommendations included to use gauze to act as a barrier between the catheter and penile skin and multivitamin daily, vitamin C 500 milligrams (mg) twice a day, and zinc 220 mg daily for 14 days. The note included a post-surgical wound to the upper back, full thickness, that measured 12.5 x 3.8 x 2.1 cm with moderate serous drainage, slough 15%, granulation tissue 65%, and 20% subcutaneous, muscle. The treatment was to continue the negative wound pressure treatment (NPWT) 3 times per week. Additional recommendations included to off load wound, turn side and front to back in bed every 1-2 hours if able, and a gel cushion to the chair. Review of resident #1's care plan for wound or skin abnormality created on 1/03/23 read, Provide treatments as ordered by physician. See medication and/or treatment administration record. Review of resident #1's Treatment Administration Record (TAR) for January 2023 revealed wound care was missed on 1/23/23. There was no evidence in the medical record resident #1's wound care was performed or resident #1's refusal. 2. Review of resident #2's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on [DATE]. His diagnoses included osteomyelitis of the left ankle and foot, congestive heart failure (CHF), type 2 diabetes with foot ulcer, peripheral vascular disease, and chronic obstructive pulmonary disease. Review of resident #2's 5-day MDS assessment with ARD of 12/20/22 revealed he had a BIMS score of 13 which indicated he was cognitively intact. The MDS showed resident #2 required limited assistance for bed mobility, dressing and personal hygiene. The assessment noted no rejection of care necessary to obtain goals for his health and well-being. The assessment revealed he had diabetic foot ulcers and skin tears, and he was at risk of developing pressure ulcers. A Wound Evaluation & Management Summary note from Wound Physicians dated 2/16/23 revealed resident #2 had multiple wounds including a venous wound of the left, anterior, lateral leg; diabetic wound of the left, distal, third toe; diabetic wound of the left, dorsal, first toe; diabetic wound of the right, medial ankle; venous wound of the right, anterior, inferior leg; diabetic wound of the right, medial first toe; an unstageable DTI (deep tissue injury) of the left heel; a stage 2 pressure ulcer of the right heel and venous wound of the left, medial shin. The physician evaluation noted, Diabetes, Peripheral Artery Disease, Heart Failure are relevant conditions that contribute to wound healing and were considered. Additionally, he noted a recommendation on 1/26/23 to check albumin due to bilateral legs (b/l) edema, patient may have low albumin levels rendering Lasix ineffective; if this is the case recommend switching to bumex; wounds have deteriorated 2/2 (secondary to) to bilateral edema; 2/2 patient w (with) increased edema b/l w increased work of breathing; recommend getting a chest x ray and considering switching loop diuretic. Additional recommendations by the physician included a multivitamin daily, Vitamin C 500 mg twice a day, and Zinc 220 mg daily for 14 days. The treatment performed to resident #2's wounds were as follows: venous wound of the left, anterior, lateral leg: apply Xeroform gauze, collagen powder, viscopaste, cover with abd pad, gauze roll and ace bandage every 2 days. Apply zinc ointment to the peri wound every 2 days. diabetic wound of the left, distal, third toe: apply Betadine once daily diabetic wound of the left, dorsal, first toe: apply collagen powder, alginate calcium with silver, cover with gauze island with border once daily. Apply skin prep to the peri wound once daily. diabetic wound of the right, medial ankle: apply collagen powder, alginate calcium with silver, cover with gauze island with border once daily. Apply skin prep and zinc ointment to the peri wound once daily and PRN. venous wound of the right, anterior, inferior leg: apply Xeroform gauze, collagen powder, viscopaste, cover with abd pad, gauze roll and ace bandage every 2 days. Apply zinc ointment to the peri wound every 2 days. diabetic wound of the right, medial first toe: apply collagen powder, alginate calcium with silver, cover with gauze island with border once daily. Apply skin prep to the peri wound once daily. unstageable DTI of the left heel: apply skin prep once daily and PRN Stage 2 pressure ulcer of the right heel: apply collagen powder, alginate calcium with silver, cover with gauze island with border once daily. Apply skin prep to the peri wound once daily. venous wound of the left, medial shin: apply Xeroform gauze, collagen powder, viscopaste, cover with abd pad, gauze roll and ace bandage every 2 days. Apply zinc ointment to the peri wound every 2 days. Review of physicians orders revealed resident #2 took Furosemide 40 mg once a day for CHF since 12/19/22. The wound care orders included: 1/26/23: left 3rd toe - cleanse with NS, pat dry, apply collagen to wound bed with Santyl and triple antibiotic x 7 days, cover with border gauze dressing once daily and PRN. 2/16/23: left lower leg - cleanse with NS, pat dry, apply collagen to wound bed with Xeroform, apply zinc to remainder of lower leg then cover with abd pads and rolled gauze dressing, secure with tape once daily and PRN. 1/26/23: right great toe - cleanse with NS, pat dry, apply collagen to wound base with Santyl and triple antibiotic x 7 days with calcium alginate secured with border gauze dressing, secure with tape once daily and PRN. 2/16/23: right lower leg: cleanse with NS, pat dry, apply collagen to wound bed with Xeroform, apply zinc to remainder of lower legs then cover with abd pads and rolled gauze dressing, secure with tape once daily and PRN. The above orders did not reflect changes on treatment or new wounds documented in the Wound Physicians progress note dated 2/16/23. Review of resident #2's care plan for skin impairment created on 5/24/22 read, Administer medications for wound healing as ordered . Perform wound treatments as ordered. Review of resident #2's TAR for February 2023 revealed wound care was not documented on 2/7/23, 2/17/23 and 2/18/23. There was no evidence in the medical record the physician was notified of resident #2's missed wound care or discussion of the recommendations given by the wound physician. 3. Review of resident #3's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included non-pressure chronic ulcer of left foot, peripheral vascular disease, vitamin deficiency, rheumatoid arthritis, and metabolic encephalopathy. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 2/10/23 revealed resident #3 was ambulatory with assistance and required a 1-person assistance for transfer. The document indicated the resident was alert, oriented and followed simple instructions. The form noted his sight and hearing were impaired. The form revealed resident #3 had no pressure ulcers, lesions or wounds. Review of the Nursing admission Assessment dated 2/10/23 revealed resident #3 had the following skin abnormalities: scar on the inner left ankle and redness to both his heels. Review of a Weekly Skin Check/Nurse form dated 2/11/23 revealed resident #3 did not have a new skin impairment that had not been previously noted. Review of resident #3's Initial Wound Evaluation & Management Summary note from Wound Physicians dated 2/17/23 revealed a fungal infection of the back and a Stage 3 pressure ulcer of the right buttock with moderate serous exudate that measured 1.0 cm x 1.3 cm x 0.3 cm. The treatment for the fungal infection was Nystatin cream twice a day (BID). The treatment for the Stage 3 pressure ulcer was to apply alginate calcium with silver, collagen powder, covered with gauze island with border once daily. Zinc ointment was to be applied to to the peri wound once daily. The physician recommendations included to off-load wound, reposition per facility protocol, turn side to side in bed every 1-2 hours if able, a group-2 mattress, a multivitamin daily, Vitamin C 500 mg twice a day, and Zinc sulphate 220 mg daily for 14 days and to upgrade offloading chair cushion. Review of resident #3's physician's order dated 2/18/23 read, Stage 3 pressure wound of the right buttock. Cleanse with NS pat dry and apply collagen powder to wound bed with calcium alginate with silver cover and secure with island gauze dressing or silicone foam dressing once daily and PRN. An order for Nystatin cream started on 2/17/23 and was to be applied to the back BID for back fungal infection. Review of resident #3's care plan for wound or skin abnormality created on 2/10/23 read, Provide treatments as ordered by physician. See medication and/or treatment administration record. Review of resident #3's TAR for February 2023 revealed wound care was not performed on 2/18/23, 2/19/23 and 2/20/23. The TAR revealed the Nystatin cream was not applied during the day shift on 2/20/23. There was no evidence in the medical record the physician was notified for resident #3's missed wound care and application of the cream. There was no evidence of resident #3's refusal of care in the medical record. Review of a progress note dated 2/15/23 entered by License Practical Nurse (LPN) A revealed resident #3 was seen by the nurse during wound care rounds. LPN A noted a right buttock wound which was cleansed, patted dry, collagen and calcium alginate applied, and secured with silicone foam dressing. On 2/21/23 at 3:45 PM, the Director of Nursing (DON) explained new admissions were discussed during daily clinical meetings attended by the MDS Coordinator and the Unit Managers. She stated the facility had a wound care nurse who rounded with the wound physician weekly and entered the wound care orders in the facility's electronic system. She explained nurses were responsible for performing wound care to their assigned residents on the weekend until approximately a month ago because they had a wound care nurse for the weekends. She indicated resident #3 developed a Stage 3 pressure ulcer on the right buttock and new wound care order started on 2/18/23, which nurses signed off on the TAR when completed. She validated there was no documentation in the medical record to show nurses performed wound care on 2/18/23, 2/19/23 and 2/20/23. She explained the weekend nurse performed the wound care but did not document it. She indicated the assigned nurse should have performed wound care on 2/20/23 because the wound care nurse did not work on Mondays and all nurses were aware of his schedule and that they had to perform wound care when he was off. The DON validated the TAR did not show wound care was done for resident #2 on 2/17/23 and 2/18/23. The DON stated this did not mean it was not done just that there were holes on those days. She validated wound care was not documented as done for resident #1 on 1/15/23, 1/19/23 and 1/23/23. She said, Some nurses won't document wound care as done if they did not perform it, but others will if they see it being done. If it is not documented, it is not done. This applies to everything. On 2/21/23 at 4:37 PM, Licensed Practical Nurse (LPN) A explained he was the wound care nurse and his responsibilities included to perform daily dressing changes for pressure ulcers Stage 2 or greater, DTIs, and unstageable wounds, notifying the wound physician when a new wound was identified and obtain wound care orders to implement until the resident was evaluated by the physician. He stated he rounded with the physician and took verbal orders during rounding. He explained in the past, he used to enter the orders after rounding, but he found the physician would add or change treatments when he received the progress note. He explained since last week he waited to receive the Wound Care physician's progress notes to enter the wound care order. He noted he documented the wound care he performed by entering a skin progress note in the medical record. He indicated he also checked off the TAR when he completed the wound care. He explained resident #1 was admitted with orders for a wound vac. He stated he thought resident #1's wound to his penis was a skin tear. On 2/22/23 at 10:38 AM, LPN A explained he applied the wound vac to resident #1 on his mid back at admission. He recalled the wound vac setting was low because he read it on the hospital discharge order. He indicated the admission orders were entered by the admitting nurse. He validated the wound vac order did not include how to clean the wound, perform the dressing change, or the setting to run the wound vac. He stated he realized it could have been more thoroughly documented. LPN A stated he entered the wound care to resident #1's penis incorrectly based on what the physician told him during his visit. He reviewed the order and the Wound Care physician progress note and stated there was a possibility he (wound physician) might have said it was a skin tear then documented it as a stage 3. He agreed he could have called the physician to clarify the information he verbally received when the note did not match. He validated the order in the medical record did not include the triple antibiotic ointment and the order was not performed as ordered by the physician. He acknowledged he did not revise the order to reflect the changes made by the physician on 1/19/23. LPN A read the physicians' recommendations including offloading, using gauze as barrier to the catheter, reposition, multivitamin, vitamin C, and zinc. He explained this was a blanket order he had for all residents with wound issues. He stated he had given those recommendations to nurses to discuss with residents' primary physicians if they wanted them implemented. He indicated he did not enter those as orders because it was the resident's assigned nurse to clarify with the primary physician if those recommendations were appropriate for that resident. LPN A stated he saw resident #3 on 2/15/23 and entered a progress note with wound care he provided to resident's right buttock after obtaining a verbal order from the physician. He explained the wound care order was entered 2 days later, on 2/17/23 after resident #3 was evaluated by the wound physician. He validated a wound care order was not entered in resident #3's medical record on 2/15/23, only a progress note which did not include the verbal order from the physician. He stated there should have been a progress note on 2/16/23 for the wound care he performed that day. He said he was pretty sure he did the wound care but might not have documented it. He stated resident #2 did not have a group-2 mattress and he would have entered the order for one if he saw the order. He verified resident #3's physician orders and validated there was none for air mattress. He stated a change in condition form should have been entered by the nurse when new skin impairment was found. He confirmed there was no evidence of it in the medical record. LPN A explained he discussed with resident #2's assigned nurse the recommendation about the lab and switching diuretics. He stated STAT (immediate) labs were done on 2/2/23. He verified the lab results and stated the albumin level was low but there was no evidence in the medical record about a discussion the recommendation from the wound physician when lab results were communicated to the primary physician. He stated the DON had provided education on various topics but he could not recall specifics about any recent wound care education. He stated he must follow the physician orders. On 2/22/23 at 12:58 PM, LPN B explained the wound care nurse handled all dressing changes and the recommendation from the wound physician. She explained he entered orders for vitamins, air mattress, and wound care. She explained she documented the wound care she performed in the residents' TAR. She acknowledged she was resident #1's assigned nurse for 13 days in January. She validated she changed resident #1's wound vac on 1/10/23 and confirmed the order did not include instructions on how to clean the wound, dressing to use and suction rate to set the wound vac. She stated she did not enter a progress notes when she performed wound care, she only signed it off in the TAR. LPN B explained on 2/15/23 she was told resident #3 had a wound on his right buttock. She indicated she notified the wound care nurse but she did not assess the new wound herself. I honestly did not do the assessment because I knew (LPN A) was coming. She stated she did not document it in the medical record because she forgot about it. She explained she should have completed a skin evaluation or note when a new wound was found. She stated she was expected to notify resident #3's physician and family about the new wound but she did not. LPN B confirmed she was resident #3's assigned nurse during the 7-3 shift on 2/18/23. She confirmed she did not perform his wound care on 2/18/23 and said, I did what I could and ran out of time. She explained there was a weekend supervisor, but she was also on a cart. LPN B explained the weekend wound care nurse was also on a cart. She said, Honestly, we just missed it that day. Normally I would let the physician know and everybody know when an order was not followed. On 2/22/23 at 2:40 PM, the DON stated she generally did not look at the notes from the wound physician to compare with the orders entered when she performed audits. She explained LPN A told her the wound physician changed orders after he left the facility, so LPN A waited to receive the progress note to enter the orders. On 2/22/23 at 4:42 PM, during a telephone interview, the Wound Physician explained he entered his orders and recommendations during his visit and the note was available to the facility within minutes, on the same day he saw the resident. He explained to prevent tissue break down or help wound healing, pressure must be alleviated and offloading devices such as air mattress or repositioning every 1 to 2 hours helped. He explained during his visit, he made recommendations that were patient specific, although some were similar interventions such as Vitamin C, multivitamin, and Zinc because those help the healing process. He stated he had seen these entered as an order, and the primary physician could continue or change them. He indicated he had the ability to sign off orders entered in the medical record under his name. He explained resident #2 had horrendous congestive heart failure, was taking Lasix, and needed to be managed medically. He recommended resident #2s Lasix to be switched to Bumex which would work better. He explained if the resident had low albumin level, Lasix would not help. Review of the policy and procedure titled Wound Care dated 4/01/22 revealed Wound care procedures and treatments should be performed according to physician orders. The procedural guidelines included to Document in the clinical record when treatments are performed and to Contact the physician for additional order changes as is appropriate or to notify of skin condition changed or refusals of care. Review of the policy and procedure titled Physician and non-Physician Practitioner Orders dated 1/01/22 revealed telephone, verbal or electronic orders were to be transcribed to the appropriate placed, such as MAR/TAR in the resident's clinical record. Review of the policy and procedure titled Change in Condition dated 4/01/22 read, It will be the policy of this facility to notify the physician, family, resident, and/or responsible party . of significant changes in condition and providing treatment(s) according to the resident's wishes and physician's orders. The procedure included significant changes in skin condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure controlled medications were reconciled to promote accuracy and prevent loss for 1 of 1 resident reviewed for narcotic medication use of a total sample of 6 residents, (#6). Findings: Review of resident #6's medical record revealed he was admitted to the facility on [DATE] with diagnoses to include dementia, cancer, and anemia. The Physician Order Sheet dated 4/14 22 revealed resident #6 had an order for Oxycodone Immediate Release (IR) 10 milligrams (mg) every six hours for pain and shortness of breath. Review of a timeline written by the Weekend Nursing Supervisor revealed on 10/31/22, the facility received a blister card of Oxycodone IR 10 mg with 16 tablets for resident #6. The timeline showed on 11/01/22, the facility received two additional blister cards of Oxycodone IR 10 mg for resident #6. One pack had 10 tablets and the second card had 30 tablets. The document indicated on 11/09/22, the resident was transferred to the hospital. A narcotic count on 11/11/22 during the 3:00 PM to 11:00 PM shift showed resident #6 had received all 16 tablets from the original 16-tablet card, and there were 25 tablets remaining in the 30-tablet card and 10 tablets left in the 10-tablet card. The timeline indicated on 11/12/22, the nurse who had completed the narcotic count the previous day discovered the 10-tablet card of Oxycodone IR 10 mg was missing. She noted the card was signed out on the Shift Change Controlled Substance Inventory count Sheet by two nurses. The nurse called the Director of Nursing (DON) who instructed her to notify the Unit Manager (UM). The UM informed the nurse the card with 10 tablets Oxycodone IR 10 mg was on the DON's desk. The timeline revealed on 11/27 22 while the Weekend Nursing Supervisor worked in the dining room, she searched a cabinet for napkins and discovered an empty card labeled Oxycodone IR 10 mg for resident #6. There was no Control Sign Out Sheet found with the narcotic medication card. The timeline showed the DON was notified of the discovery at that time. On 12/05/22 at 4:10 PM, the DON stated she was never informed the card with 10 tablets Oxycodone IR 10 mg had been left on her desk on 11/11/22. The DON validated she received notification the Weekend Nursing Supervisor discovered an empty narcotic medication card in a dining room cabinet. She said, I figured a nurse laid it down with some papers, got distracted, and forgot to pick it back up. The DON explained the facility's process for disposal of empty narcotic medication cards was for nurses to shred them. She acknowledged she had neither investigated nor reported the incident because she was not aware until now that Oxycodone tablets were actually missing. On 12/05/22 at 4:10 PM, and 12/06/22 at 10:15 AM, the UM explained when residents were transferred and admitted to the hospital, the expectation was either herself or a nurse to remove their narcotic medications from the medication cart and hand them to the DON for safekeeping. The UM recalled after resident #6 was admitted to the hospital she took his narcotic medications to the DON's office and placed them on her desk. She acknowledged the DON was not in her office at that time and the door was open. The UM said, I took the narcotic card and control sheet and slid it under some papers on her desk. I went back later, and the door was closed. I knocked, did not get an answer, so I figured the DON had left for the day. The UM explained she did not follow up to verify if the DON received the narcotic medications. She noted narcotic medications were to be handed to the DON, and not left unattended on her desk. She said, Normally I would not have left them, but I was called back to the unit, and I did not want to carry them around with me. I will not make that mistake again. On 12/06/22 at 11:15 AM, the DON stated the facility could not confirm the incident with resident #6's missing Oxycodone IR 10 mg was drug diversion. She acknowledged since the facility could not locate the narcotic reconciliation sheet, it would probably be deemed drug diversion. The DON said, If I had known the meds were left on my desk, this would never have happened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident was assessed to self-administer oral pain/sleep medication and topical pain relief cream medications for 1 of 50 total sampled residents (#88). Findings: Resident #88 was admitted to the facility on [DATE] with diagnoses including-unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, and muscle weakness. The resident's quarterly Minimum Data Set assessment, with reference date of 10/08/21, revealed the resident's cognition was moderately impaired and a brief interview mental status score of 12/15. On 10/31/2021 at 11:09 AM, the medication Tylenol PM 500 milligrams, a 3 ounce tube of Aspercream, and a 3 ounce jar of Biofreeze was in a pink wash basin on the resident's tray table in her room. Resident #88 stated that the creams are for the pain in her right shoulder. She also stated her son brought the Tylenol PM because He knows I have trouble sleeping. On 11/01/2021 at 10:54 AM, the medications were again observed in the pink basin on the tray table. On 11/02/2021 at 1:35 PM, the medications were observed in the pink wash basin on the tray table. On 11/03/2021 at 12:12 PM, Registered Nurse (RN) D was informed of the medications at the resident's bedside. RN D went to resident #88's room and informed her that she would have to keep the medications locked in a secure location for her son to collect. RN D stated resident #88 was not assessed to self-administer medications. RN D stated that a resident who wants to self-administer medications must be evaluated to determine if they are safe to do so, physician orders and care plan must then be in place, and the medication would be kept in the medication cart. On 11/03/2021 at 6:56 PM, the Director of Nursing (DON) confirmed that the resident was not assessed as a resident to self-administer her medications. Resident #88's medical record did not contain documented sleep issues or assessment to self-administer medications. There were no recommendations and no order for self-administration for oral or topical medications. Review of the most recent plan of care completed on 10/02/2021 did not reveal a plan of care for self-administration of medication. The facility's policy and procedure Self-Administration of Medications, dated December 2021, read, As part of their overall evaluation, the staff and practioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident self-administered medications must be stored in a safe and secure place, which is not accessible by other residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital with diagnoses including dementia, malnutrition, diabetes, and Parkinson's disease. The MDS Quarterly Assessment with assessment reference date of 7/30/2021 revealed resident #16 had adequate hearing, clear speech and was usually understood. The document indicated she required one person to assist with set up only for eating. Resident #16's care plan was initiated on 5/13/2021 and revised on 8/13/2021 for risk of weight loss, depression and loss of dignity related to her diagnosis of end stage dementia. The goal was for dignity and autonomy to be maintained at the highest level of capacity. On 11/03/2021 at 12:39 PM, resident #16 sat in the facility dining room for lunch. CNA C stood over resident #16 and asked nearby staff, Is she a feeder?, which she then repeated three additional times. No reply was made to CNA C by other nearby staff. Outside the dining room on 11/03/21 at 12:43 PM, CNA C stated she was an agency staff member. She stated that she did not know that residents should not be called feeders. She stated that the facility never educated her on what to call residents who required feeding assistance. Review of the Nursing Home Resident's Rights In Florida packet given to residents upon admission and New Hire Education Packet included The right to be treated courteously, fairly, and with the fullest measure of dignity The facility policy and procedure titled Dining Room, revised October 2017 read, Our facility audits the food and nutrition services department regularly to ensure that residents needs are met and that dining is a safe and pleasant experience for residents. Based on observation, interview and record review, the facility failed to promote the dignity for 3 of 3 residents in a total sample of 50 residents (#92, #644 & #16). Findings: 1. Resident #92 was admitted to the facility on [DATE] with diagnoses that included dysphagia, malnutrition, type 2 diabetes, and dementia. Review of the admission Minimum Data Set (MDS) assessment, dated 10/14/2021, revealed resident #92's Brief Interview for Mental Status score of 3, which indicated severely impaired cognition. The MDS also showed resident #92 needed extensive assistance with eating. On 11/02/2021 at 1:47 PM and 2:05 PM, during lunch trays distribution, Certified Nursing Assistant (CNA) G explained she was used to getting the feeders' trays from the kitchen, but the process was done differently at this facility. CNA G indicated staff first passed all trays out to residents who are independent or need set up with meals and then helped the feeders. CNA G asked CNA H the whereabouts of resident #92's lunch tray, and said, He is a feeder, to which CNA H replied, No, he is not. When asked why she referred to resident #92 as a feeder 3 times, CNA G explained she meant the resident needed assistance eating. CNA G indicated her new hire orientation covered resident rights but did not remember if using labels to refer to the residents was mentioned during her training. CNA G stated they used the word feeder in the facility at times when referring to the residents and added, It's not a good thing. CNA G stated it was her mistake to call him that, I apologize, my mistake. On 11/02/2021 at 6:23 PM, the Human Resources Director (HRD) and the Assistant Director of Nursing/Staff Development Coordinator (ADON) explained all new hires, agency staff included, received a New Hire Education Packet. The ADON indicated the New Hire Education Packet was to be reviewed and signed by the new employee on his/her first day at the facility. On 11/03/2021 at 2:31 PM, the Director of Nursing (DON) explained residents who needed assistant while eating should be referred as Assisted Dinner and not feeders. The DON stated she did not know what was taught during the new hire orientation. On 11/03/2021 at 7:41 PM, the ADON indicated she always corrected CNAs if she heard them referring to the resident as feeder. The ADON explained the resident was to be referred as dependent or assisted dining because this was a dignity issue. The ADON explained resident rights was covered during new hire orientation. 2. Resident #644 was readmitted to the facility on [DATE] with diagnoses that included stroke, dysphagia, protein calorie malnutrition, type 2 diabetes, and adult failure to thrive. Review of the quarterly MDS assessment dated [DATE] revealed resident #644 is rarely/never understood and needed extensive assistance with eating. On 10/31/2021 at 12:15 PM during lunch trays distribution, CNA B took the untouched tray off of resident #644's overbed table. In the resident's room, CNA B said she was taking the tray back to the food cart to stay warm because the resident is a feeder and we do them last. CNA A, who was also in the room, did not try to correct CNA B for calling resident #644 a feeder. On 10/31/2021 at 12:36 PM, resident #644 was in bed with the head of bed raised for lunch and CNA A was standing on the resident's left side of the bed feeding her a mechanical soft diet of fried chicken, mashed potatoes, broccoli and apple pie. CNA A did not talk to the resident and did not sit next to her during the meal. Instead, she stood by the resident and could easily be seen from the doorway leading out into the hall.

Based on observation, interview and record review, the facility failed to maintain safe and sanitary conditions for food storage in 2 of 2 nutrition rooms (East & [NAME] Wing). Findings: 1. On 11/03/2021 at 1:07 PM, observation of the East Wing nutrition room with the Central Supply Manager revealed three cups of poured juice unlabeled and undated, and an individual container of cottage cheese past the expiration date inside the refrigerator. Food particles and a yellow substance were seen on the inside door of the refrigerator on the door shelves. No temperature log was found for the refrigerator. Food particles and trash were observed on the cabinet shelf, under the basket of snacks when it was lifted by the Central Supply Manager. She stated the kitchen was responsible for maintaining and cleaning the nutrition room. She was unsure who was responsible for the refrigerator temperature logs, but felt it was someone from the kitchen. She said the kitchen staff were supposed to clean the room and check the refrigerator when they came to replenish the nutrition room. The Central Supply Manager confirmed the unlabeled and expired items in the refrigerator and said the items should be discarded so they were not served to residents. Photographic evidence was obtained. 2. On 11/03/2021 at 1:14 PM, observation of the [NAME] Wing nutrition room refrigerator with the Central Supply Manager revealed three clear plastic bags with pizza inside labeled with a room number but not dated. One cup of nectar thick juice was inside the refrigerator unlabeled and undated. A wet paper towel was stuck to the back wall of the refrigerator. The Central Supply Manager confirmed the findings in the [NAME] Wing nutrition room and was unable to say where the refrigerator's temperature log was located. Photographic evidence was obtained. On 11/03/2021 at 4:45 PM, the Regional Certified Dietary Manager stated the managers were responsible for cleaning the nutrition rooms, but they didn't have a key, which was why it wasn't done. On 11/03/2021 at 6:45 PM, the Staff Development Coordinator (SDC) provided copies of refrigerator temperature logs for August 2021, September 2021 and October 2021, and stated the person from the kitchen who was responsible for the temperature log had been out sick. No logs for November 2021 were provided. On 11/03/2021 at 7:48 PM, tour of the East and [NAME] Wing nutrition rooms with the Staff Development Coordinator now revealed refrigerator temperature logs in both nutrition rooms. The SDC verified the East Wing Nutrition room Refrigeration Checklist temperature log for November 2021 had no entries logged for the month. Review of the policy Foods Brought by Family/Visitors, with revision date of October 2021, read, Food brought by family/visitors that is left with the resident to consume later will be labeled Containers will be labeled with the resident's name, the item and the 'use by' date Staff are directed to discard perishable foods on or before the 'use by' date. Review of the policy, Sanitization, with revision date of October 2008, revealed that all food service areas shall be maintained in a clean and sanitary manner. It further directed that, All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish counters, shelves and equipment shall be kept clean.