**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for one resident (#4) of two residents reviewed for PASARRs. Findings included: A review of Resident #4‘s admission Record revealed an original admission date of 9/13/2018, and a re-admission date of 8/10/2025 with diagnoses to include psychoactive substance abuse, primary insomnia, post-traumatic stress disorder (PTSD) - 2/7/2024, major depressive disorder, and generalized anxiety disorder. A review of Resident #4‘s Active Orders revealed the following: Antianxiety Medication-every shift. Start date 3/13/2025. Antidepressant Medication-every shift. Start date 3/13/2025. Sedative/Hypnotic Medication-every shift. Start date 3/13/2025. Zolpidem Tartrate Tablet 10 mg (milligrams) give 1 tablet by mouth at bedtime for difficulty sleeping. Start date 8/18/2025 A Review of Resident #4‘s Level I PASRR, dated 6/22/2020, under Section I-Part A MI (Mental Illness) or suspected MI, indicated anxiety disorder and depressive disorder. A review of Section IV: PASRR Screen Completion revealed the following was marked, No diagnosis or suspicion of Serious Mental Illness or intellectual Disability indicated. Level II PASRR evaluation not required. A review of Resident #4's Quarterly Minimum Data Set (MDS), dated [DATE], Section N - Medications, revealed the following to include: antianxiety, hypnotic and opioid. Further review of the Quarterly MDS, dated [DATE], Section C - Cognitive Patterns, revealed a Brief Interview Mental Status (BIMS) score of 15, cognitively intact. A review of Resident #4's current care plan included the following, [Resident name] uses anti-anxiety medications r/t (related to) Her diagnosis of anxiety & muscle spasms. [Resident name] has experienced trauma R/T (related to) adjustment issues affecting the following (specify areas) Feeling tense all the time, Anxiety attacks - Having trouble breathing, flash backs, spacing out, Feeling that things are unreal, Memory problems, bad car accidents, bad accident at work, natural disasters, physical abuse as a child/spousal abuse, forced sexual contact as a child/husband, attacked by gun by husband, sudden death of a family member, sudden loss of home/possessions, death of a close friend. 2/19/25 current triggers for physical abuse is arguing, loud noises, nightmares' due to being awakened out of deep sleep 2/19/25 Care plan reviewed and is current. Psycho-social Well Being Care Plan revealed [Resident name] has the Potential for alteration in psycho-social well being related to major depressive disorder and anxiety disorder On 8/20/2025 at 2:36 p.m., an interview with the DON (Director of Nursing) revealed that it is the her responsibility to check resident's diagnoses to compare the PASARR's with the medical records. She said the Admissions Director will ensure that the PASARR's are in the system. The DON explained that her process involves checking the resident's medications, and the type of diagnoses to determine if a Level II is needed. The DON revealed the previous administrator took on the role of checking PASARR's when an admission came in. The DON stated a resident review is completed when the resident has a change of condition. She stated a, New schizophrenia or PTSD diagnosis, qualifies a resident for a Level II PASRR. The DON revealed that she would have submitted for a Level II PASRR for Resident #4's specific diagnoses. The DON confirmed that Resident #4 does not have a Level II PASRR. She said Resident #4 needed one and she never thought about or recognized that PTSD was not on Resident #4‘s PASARR. A review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, dated 9/1/2023, revealed the following, The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include:a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis).b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to implement care plan interventions related to falls/accidents for one resident (#14) of three residents sampled.Findings included: On 08/18/2025 at 09:47 A. M., an interview was conducted with Resident #14. During the interview, the resident explained having experienced a fall in the cafeteria on 08/16/2025. The resident reported going out for a smoke break and fell backwards on their walker.Review of a progress note dated 08/18/2025 with a time stamp of 08:20 A. M., showed: staff observed resident sitting on the floor on buttock in front of the sink. [NAME] was behind Resident unlocked. Resident had on slide on thong sandal shoes.A progress note dated 08/16/2025 with a time stamp of 06:50 P. M., revealed: staff heard a noise. Upon checking, Resident was sitting on the floor in the dining room on buttock between a dining table & the wall. Resident's back was against the wall. [NAME] was about two feet away, unlocked. Slide on thong sandals on Resident's feet.Review of the admission record for Resident #14 revealed the resident was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type medical, major depressive disorder, muscle weakness, unsteadiness on feet, and essential (primary) hypertension. Review of an annual Minimum Data Set (MDS), with a target date of 07/24/2024, revealed in section C - the resident had a Brief Interview Mental Status (BIMS) of 12, which meant the resident's cognition was intact. Section GG of the MDS showed the resident had the capability to walk at least 150 feet independently. Review of the resident's physician orders dated 8/20/2025 revealed mood stabilizing medication Depakote, trazodone, and furosemide for edema. Review of an undated fall risk evaluation showed last dates of falls to include 08/16, 08/05, and 03/12 of 2025, with a fall risk score of 15, which indicated a fall risk.Review of Resident #14's care plan, revealed a focus of fall prevention initiated on 08/05/2022 and revised on 03/26/2025. It showed Resident #14 is at risk for falls. Resident #14 is on anti-psychotropic medications daily. The care plan showed the resident had falls as follows: 08/05/24, 03/12/2025, and 03/25/2025. The goal showed the resident will not experience injury from falls through the next review date. Interventions included: Resident to wear prior footwear, initiated 03/25/2025 and Educate Resident #14 to have proper shoes on when ambulating, initiated on 08/05/2024.On 08/21/2025 at 10:25 A. M., an interview was conducted with Staff A Registered Nurse (RN). Staff A,RN stated the resident was observed with legs in the air on 08/15. Staff A, RN stated the resident was wearing thong shoes. Staff A, RN stated the resident mentioned some back pain. On 08/20/2025 at 03:40 P. M., an interview was conducted with Staff B Licensed Practical Nurse (LPN). Staff B, LPN stated on 08/16 the resident was found in the cafeteria on the floor between a wall and table. Staff B, LPN stated the resident had thong sandals on. Staff B LPN stated Staff B LPN was unaware of the resident's care plan regarding shoes.On 08/20/2025 at 03:23 P. M., an interview was conducted with the Director of Therapy (DOT) and Staff C, Physical Therapist (PT). The DOT stated proper shoes are closed toed shoes like sneakers. The DOT stated thong sandals would not be appropriate for Resident #14. The DOT stated having attended a meeting on 08/15/2025, related to Resident #14, and the resident's shoes was not a topic of the meeting. The DOT and Staff C, PT were not aware of Resident #14's fall on 08/16.On 08/20/2025 at 02:36 P. M., an interview was conducted with the Director of Nursing (DON). The DON stated the resident had two falls, one on 08/15 and one on 08/16 of 2025. The DON stated the fall on 08/15 was unwitnessed and the resident was observed sitting on the floor. The DON stated the resident was educated to lock walker and to sit while washing hands. The DON Stated the resident had lower back pain. The DON stated the resident had on thong slide on shoes and a change of condition was not completed for the fall on 08/15. The DON stated the fall on 08/16 was unwitnessed and the resident was found sitting on the floor of the cafeteria with thong shoes on. The DON stated an IDT meeting was not completed for the resident and the care plan interventions were not reviewed or updated after the resident's falls. The DON stated thong shoes are not proper walking shoes for Resident #14.Review of a policy titled Accidents and Supervision, revised 04/01/2024 showed: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring for effectiveness and modifying interventions when necessary. Policy Explanation and Compliance Guidelines showed:3. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes: Communicating the interventions to all relevant staff b. Assigning responsibility C. Providing training as needed. d. Documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action. f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully. h. Facility-based interventions may include, but are not limited to: i. Educating staff iii. ii. Repairing the device/equipment. Developing or revising policies and procedures i. Resident-directed approaches may include: i. Implementing specific interventions as part of the plan of care ii. Supervising staff and residents, etc. iii. Facility records document the implementation of these interventions. 4. Monitoring and Modification- Monitoring is the process of evaluating the effectiveness of care plan interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently. b. Evaluating the effectiveness of interventions d. c. Modifying or replacing interventions as needed. Evaluating the effectiveness of new interventions 5. Supervision- Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision: a. Defined by type and frequency. b. Based on the individual resident's assessed needs and identified hazards in the resident environment.Review of a facility policy titled Comprehensive Care Plans, revised 01/2025 showed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to ensure residents received Activities of Daily living (ADL) care related to showers for one resident (#16) of three residents sampled.On 08/18/2025 at 09:48 A. M., an interview was conducted with Resident #16. The resident stated showers were not being provided by the facility staff. The resident stated showers were desired and requested from facility staff and the resident stated the facility staff refused to provide the showers.Review of a Certified Nursing Assistant (CNA) Kardex (a care documentation sheet showing individual resident's care needs), showed question 3 asked the type of bathing preferred. The response to type of bathing, revealed the resident was not provided preferred showers on 07/30, 08/06, 08/10, and 08/13 of 2025.Review of the admission record for Resident #16, revealed the resident was re-admitted to the facility on [DATE] with diagnoses to include muscle weakness, need for assistance with personal care, contracture right hand, and unspecified sequelae of cerebral infarctions acute neurologic.Review of a quarterly Minimum Data Set (MDS), with a target date of 06/12/2025, revealed in section C the resident had a Brief Interview Mental Status (BIMS) score of 14 out of 15, which meant the resident's cognition was intact. Section GG of the MDS showed the resident required maximal assistance with ADLs, including washing, rinsing, and drying self.Review of the resident's physician orders, dated 07/15/2025 showed skilled occupational therapy eval and treatment for 4 times a week for 60 days with focus on weakness and increased need for assistance towards ADLs.Review of Resident #16's care plan revised 09/09/2024, revealed: a focus of Resident #16 having a self-care deficit with dressing, grooming, bathing and toilet needs related to (r/t): cerebrovascular accident (CVA), Human immunodeficiency Viruses (HIV), impaired vision, generalized weakness & debility. Resident #16 participates in ADLs with cues from staff. Resident #16 chooses to use double brief for incontinence, initiated on 09/28/2020 and revised on 09/09/2024. The interventions included: provide hands on assistance with dressing, grooming, bathing as needed. A focus initiated on 09/28/2020 and revised on 06/13/2025 showed Resident #16 is at risk for complications r/t alteration in health maintenance with a diagnosis (dx), of Anemia. Interventions included: Provide increased assist with ADLs as needed for complaints of (c/o) increased fatigue/weakness, initiated on 01/07/2022.On 08/20/2025 at 11:30 A. M., an interview was conducted with Staff F, Certified Nursing Assistant (CNA). Staff F, CNA explained not knowing what N/A in Resident #16's Kardex chart meant.On 08/20/2025, at 11:59 A. M., an interview was conducted with Staff D, CNA. Staff D, CNA stated residents are scheduled to receive showers two times a week, according to the shower schedule in a book at nursing stations and in resident charts. Staff D, CNA stated residents can receive more showers than the scheduled showers and they can receive showers on different days than scheduled. Staff D, CNA reviewed the shower logs at each nursing station and stated shower sheets for dates 07/30, 08/06, 08/10, and 08/13 of 2025 could not be found for Resident #16. For the same dates, the CNA Kardex chart for Resident #16 showed N/A. Staff D, CNA stated N/A, in the resident's chart, meant the showers did not happen. On 08/20/2025 at 02:36 P. M., an interview was conducted with the Director of Nursing (DON). The DON stated residents are scheduled to receive showers on two or more days a week and residents can request more showers. The DON stated if a resident received a shower, it should be documented in the resident's chart and the shower log book. The DON stated if a shower isn't documented anywhere, it can't be stated the shower took place. The DON stated Resident #16 should receive showers on Sundays and Wednesdays. The DON stated not applicable means the resident did not receive a shower.Review of a policy titled Activities of Daily Living (ADL), implemented on 09/01/2023 showed: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.Policy Explanation and Compliance Guidelines: 2. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations, record review and interviews, the facility did not ensure food service safety standards were followed in the kitchen and in one of one nourishment rooms.Findings included: On 8/18/25 at 10:04 a.m., a tour of the kitchen was conducted with the Certified Dietary Manager. An observation of the window, above the three-compartment sink, revealed kitchen items were hanging to include pans, pots, and a long grater with a handle. Further observations of the top part of the window, where the kitchen items were hanging, had multiple black particles and debris throughout the surfaces. Another observation of that area revealed a circular kitchen item that had sharp, metal pieces inside and appeared to be for chopping food, which had dust particles throughout the surface. The CDM said it had never been used. The CDM was observed telling Staff G, Dietary Assistant (DA) to clean that area. On 8/18/25 at 10:06 a.m., an observation of the walk-in refrigerator revealed a 20-ounce Gatorade bottle, on the top shelf, behind a box of bananas. The CDM confirmed the bottle should not be there and was observed asking the dietary staff if it belonged to them. The CDM stated personal items should not be stored in there. On 8/18/25 at 10:10 a.m., an observation of inside the walk-in freezer revealed ice buildup along the top and sides of the door, as well as on top of boxes containing food items. A small mound of ice buildup was observed on the floor next to the door. The CDM said she put a work order in and has told the maintenance staff about the issue. She said the work order placed in the work order system can determine when she identified the issue. The CDM said she thinks the door does not close properly. An observation of the top part of the walk-in freezer door revealed the latch was off center compared to the walk-in refrigerator door. On 8/18/25 at 10:21 a.m., an observation of the refrigerator in the nourishment rooms revealed a 12-ounce plant-based protein shake which did not have a resident’s name or date labeled. An observation of the freezer revealed a pint of vanilla ice cream, a frozen plastic water bottle, and a 20-ounce Gatorade bottle. The CDM said she checked the refrigerator and freezer in the nourishment room on 8/15/25, and those items were not there. She said the Certified Nursing Assistants (CNAs) should have labeled the items with the resident’s name. The CDM was observed asking Staff B, Licensed Practical Nurse (LPN) who the items belonged to. Staff B, LPN answered she didn’t know and was instructed to discard the items. On 8/20/25 at 11:15 a.m., an observation of the lunch tray line was conducted. Staff G, DA was observed washing her hands in the handwashing sink area. After washing her hands, Staff G, DA was observed lifting the lid of the garbage can then went to a storage rack with clean items to retrieve a cup. At 11:25 a.m., Staff I, DA was observed touching the lid of a garbage can then putting on gloves. He was not observed performing hand hygiene before putting on gloves. Staff I, DA was observed going to the dry storage area and came back with another box of gloves that he put into the glove holder by the kitchen door. Staff I, DA was observed putting a new pair of gloves on, then went to the tray line to put beverages on the meal trays. He was not observed performing hand hygiene before placing the beverages on the meal trays. Staff I, DA was observed touching his right check while he was completing the task of putting individual bottles of milk on the meal trays. At 11:29 a.m., Staff I, DA was observed washing his hands in the handwashing sink. He was observed touching his forehand, shortly after washing his hands, and while putting items on the meal trays. At 11:36 a.m., Staff I, DA washed his hands and left the kitchen area after having touched the trays. A review of completed work orders revealed documentation for the walk-in freezer door created on 7/31/25. The notes on the work order documentation revealed the following, “Walk-in Freezer door is not closing properly … Door not closing properly and leading to ice buildup around door frame.” 2. On 8/18/2025 at 10:02 a.m., an observation of the kitchen stove revealed food was caked on the sides of the stove and on the floor of the stove. On 8/18/2025 at 10:09 a.m., an observation of the dry storage revealed an opened, half-full lemon juice bottle with no open date written on it and an expiration date of 6/27/25. The CDM confirmed that it was opened and not labeled. She said she’s not sure why the lemon-juice bottle was not stored in the refrigerator, but it should have been. On 8/20/2025 at 11:17 a.m., an observation of Staff H, [NAME] revealed she was wearing two dangling bracelets, with multiple charms on them, hanging outside of her gloved hand. Further observations of Staff H, [NAME] revealed she was stacking plates on a cart, away from the tray line, with gloves on. She was observed going to the food tray line, with the cart and plates, without completing hand hygiene and a glove change in between changing tasks. On 8/21/25 at 9:06 a.m., an interview was conducted with the Regional Director of Maintenance (DOM). He said he learned about the issue with the walk-in freezer door on Monday, 8/18/25, and has the part to fix it. He said the former maintenance staff did not make him aware of the issue. The Regional DOM said he did not expect the previous maintenance staff to notify him as he may have tried to fix the door himself and didn’t require replacement of a door, or something of that nature. On 8/21/25 at 10:08 a.m., a follow-up interview was conducted with the CDM. The CDM said when audits are conducted food item expiration dates are to be checked. Regarding the bottle of lemon juice observed in the dry storage on 8/18/25, she said if anything is expired it should be thrown out, or if an item is opened it needed to be refrigerated after use. The CDM explained the dietary staff are responsible for stocking and storing items, while the cooks check the storage areas daily. She stated she checked the stored food when she is completing orders and kitchen checks which are conducted, “About once a week.” When asked about glove and hand hygiene, the CDM explained that hands are to be washed in-between tasks and when there is a change of tasks. The CDM explained when there is a change of task, current gloves are to be disposed, hands need to be washed, then new gloves can be put on for the start of a new task. Regarding storage of staff’s personal items, the CDM said the dietary staff can have a cup with a lid and can store them in an area they are not working in. The CDM said dietary staff cannot store personal beverages in the kitchen refrigerator or freezer, as they contain items for the residents. She said staff have an area to store personal food and beverages. Regarding the freezer work order from 7/31/25, the CDM stated, “Nothing was done, to my knowledge.” She said she had been removing the ice buildup with a hammer and checking the temperature to make sure the walk-in freezer was cooling properly. The CDM stated, “When I put something in [work order system], that’s the extent of my knowledge.” She said she does not know what happens with the work order after she puts it in the work order system. For storage of resident’s food and beverage items in the nourishment room, she said the CNA or nurse should have labeled with the date and resident’s name. She said if it’s not labeled or dated, the item should be discarded. The CDM said she does not know who reviewed the nourishment refrigerator and freezer when she is not present. In regard to the food build-up on the stove and surrounding floor area, the CDM stated the cooking area is to be wiped up and cleaned daily. She said major equipment like the stove are cleaned weekly. The CDM stated that staff are to wear minimal jewelry while on shift, and “I don’t believe that hand jewelry is permitted.” On 8/21/25 at 10:29 a.m., an interview was conducted with the Director of Nursing (DON). She said the expectation for storage of resident’s items is to make sure they are in a proper container, as well as dated and labeled. She said any staff member can accept the food or beverage and put it in refrigerator/freezer. The DON said staff have been provided education on the storage of resident’s food and beverages; and it is something they reiterate. She said the kitchen manager, the night shift nurse, and CNAs should be checking the nourishment room refrigerator and freezer for proper storage to include labeling and dating of resident items. A review of the facilities Food Safety Requirements revealed the following, “Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. “Contamination” means the unintended presence of potentially harmful substances including, but not limited to microorganisms, chemicals, or physical objects. “Food service safety” refers to handling, preparing, and storing food in ways that prevent foodborne illness. 1. Food safety practices shall be followed throughout the facility’s entire food handling process. This process begins when food is received from the vendor and ends with the delivery of the food to the resident. Elements of the process include the following: . B. Storage of food in a manner that helps prevent deterioration or contamination of the food, including growth of microorganisms. C. Preparation of food, including thawing, cooking, cooling, holding, and reheating. E. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food. F. Employee hygienic practices. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon deliver/receipt and ensure timely and proper storage. Refrigerated storage – foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: . IV. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (Where applicable)/discarded . 5. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature and out of the Danger Zone. Strategies include but are not limited to: . C. Washing hands properly before distributing trays. 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. A. Staff shall wash hands in according to facility procedures. G. Staff shall keep jewelry to a minimum and cover hand or wrist jewelry with gloves when handling food.” A review of the facilities Handwashing Guidelines for Dietary Employees revealed the following, “Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility . Dietary employees shall keep their hands and exposed portions of their arms clean. Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: . B. After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. C. After hands have touched bare human body parts other than clean hands (such as face, nose, hair, etc.) . F. While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. J. After engaging in any activity that may contaminate the hands.” A review of the facility’s Dietary Employee Personal Hygiene Policy revealed the following, “Gloves are to be worn and changed appropriately to reduce the spread of infection. Employees are to keep jewelry to a minimum. Hand or wrist jewelry must be covered with gloves while handling food.” (Photographic Evidence Obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide equal access to quality care related to a dignified meal service for two (#2 and #3) of four residents sampled for dependence on staff during dining. Findings included: On 11/02/23 at approximately 11:50 a.m., Resident #2 and #3 were observed in the dining room. Resident #2 was in his wheelchair sharing a table with another resident. Resident #2's tray was observed in front of him. The resident was observed not able to feed himself. Resident #3 was observed in specialized chair sharing a table with two other residents. All the residents had trays in front of them. The other two residents were observed being assisted with their meals. Resident #3 was observed not eating or drinking while the other residents ate. Review of record showed Resident #2 was admitted to the facility on [DATE] with diagnoses to include encephalopathy, other specified disorders of the brain, hemiplegia and hemiparesis affecting left non-dominant side and Dysphagia following cerebral infarction. Review of physician orders for Resident #2 dated 11/02/23 showed the resident required a mechanical soft texture, thin liquid consistency diet. A quarterly Minimum Data Set (MDS) dated , 08/08/23 showed under Section C, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Section G showed the resident required extensive assistance for eating, with one-person physical assistance. Section K showed Resident #2 required a mechanically altered diet. Review of a care plan for Resident #2 dated 05/11/23, showed an Activities of Daily Living (ADL) related to memory loss, encephalopathy, anxiety, status post CVA (Cerebral Vascular Accident) affecting left side Interventions included provide assistance as needed with ADL task. Review of record showed Resident #3 was admitted to the facility on [DATE] with diagnoses to include unspecified fracture of shaft of humerus left arm, subsequent encounter for fracture with routine healing, unspecified dementia with unspecified severity, with other behavioral disturbance, displaced fracture of body of scapular, left shoulder, unspecified protein calorie malnutrition, epilepsy, cerebral palsy, unspecified intellectual disabilities and age-related osteoporosis with current pathological fracture. Review of physician orders for Resident #3 dated 11/02/23 showed the resident required a mechanical soft texture with thin liquid consistency for nutrition. An annual MDS dated , 06/19/23 showed under section C, Resident #3 had a BIMS score of 99, indicating significant cognitive impairment. Section G showed the resident required extensive assistance for eating, with one-person physical assistance. Section K showed Resident #2 required a mechanically altered diet. Review of a care plan for Resident #3 revised 04/15/23, showed the resident had a self-care deficit due to contractures on BLE (bilateral lower extremities), (ROM) Range of Motion that impact ADL activities. Resident #3 will feed self at times and may assist with simple tasks. Resident #3 is never understood and does not understand others. The goals showed the resident will allow staff to assist with ADLs as deemed necessary and will maintain current level of ADL functioning through the next review date. Interventions included to encourage/cue resident to participate in ADL task, to observe for decline in ADL function and report to the physician as indicated, and to provide hands on assistance as needed. On 11/02/23 at 12:10 p.m., an observation was made of Resident #2 and #3 sitting at dining room tables with other residents. Some residents in the dining room were observed to have finished eating their meals during approximately the 20-30-minute period. These two residents were waiting to be assisted with their meal. On 11/02/23 at 12:10 p.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA) who was assisting another Resident sharing a table with Resident #3. Staff A stated there were two CNAs assigned dining duty. She stated she would assist Resident #3 once she was done with the resident she was feeding. Staff A confirmed Resident #3 was dependent on staff for eating. Staff A stated, I know, they should not wait. The nurses are supposed to help. Staff A stated it was not okay with her that Resident #2 and #3 were waiting to be assisted with their meals while all the other residents were eating. On 11/02/23 at 12:13 p.m., an interview was conducted with Staff B, Registered Nurse (RN). Staff B walked into the dining room and sat next to Resident #2. She stated she was about to assist the resident with his meal. Staff B said, I understand how having the residents wait for their meal while everyone is eating is uncomfortable. She stated she did not think it was fair to the residents who were dependent on staff. She stated she did not know the residents had been waiting. On 11/02/23 at 2:51 p.m., an interview was conducted with the Director of Nursing (DON). She stated she would expect all residents to be served at the same time and if they need assistance, it should be provided at the same time. The DON stated she would expect the CNA to ask for assistance if they needed additional help. The DON said, It is not dignified to smell the food while others are eating, and one is not. I would not want that. A follow-up interview was conducted on 11/02/23 at 5:10 p.m., with the Nursing Home Administrator (NHA). The NHA stated he would expect residents who are sitting together to be served and assisted together. He said, right is right and wrong is wrong. That was wrong. The residents should not have been waiting when the others were eating. We will fix that. Review of a facility policy titled, Promoting/Maintaining Resident Dignity, dated 09/07/22, showed it is the policy of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. Under compliance guidelines the policy showed 1.) All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 5.) When interacting with a resident, pay attention to the resident as an individual. 6.) Respond to requests for assistance in a timely manner. 13.) Assist residents to participate in activities of choice. 14.) Each resident will be provided equal access to quality care regardless of diagnosis, severity of condition or payment source.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to request a Level II Pre-admission Screening and Resident Review (PASARR) for one resident (#16) with a newly diagnosed mental illness out of 14 sampled residents. Findings included: A review of Resident #16's admission Record showed Resident #16 was admitted to the facility on [DATE] with diagnoses to include cerebral palsy and paraplegia. Resident #16 was diagnosed with schizophrenia, unspecified on 01/16/23. A review of a psychiatric note dated 01/16/23 showed, Reason for today's evaluation: Consult for psychiatric evaluation for schizophrenia disorder. Results: Patient has schizophrenia start Risperdal 1 mg (milligram) PO (by mouth) BID (two times a day) for schizophrenia. A review of the physician orders for September 2023 showed: Risperidone Oral Tablet 1 MG (Risperidone) Give one tablet by mouth two times a day for Schizophrenia. A review of the care plan showed Resident #16 had a Focus Area for Antipsychotic Care Plan, initiated on 1/16/23, that showed: [Resident #16] is at risk of adverse side effects related to use of antipsychotic medications. He has a dx. (diagnosis) of Schizophrenia . A review of the Quarterly Minimum Data Set (MDS), dated [DATE], showed the use of antipsychotic medication and a diagnosis of schizophrenia. Further review of Resident #16's medical record showed the PASARR, dated 04/26/2020, documented a diagnosis of cerebral palsy. There was no other PASARR available in the medical record to show the new diagnosis of schizophrenia on 01/16/23. During an interview on 09/13/23 at 12:49 p.m., the Director of Nursing (DON) stated when a resident gets a new diagnosis like schizophrenia, after admission, it was expected for a PASARR Level II to be submitted. The DON stated she was responsible for all PASARR information in the facility. The DON stated she was on leave during the time the Level II was required to be submitted however she would have expected the staff member covering during her leave of absence would have submitted the new diagnosis for a Level II. Review of the facility's policy titled, Resident Assessment- Coordination with PASARR Program, implemented 09/07/2022, showed, Any resident who exhibits a newly evident or possible serious mental illness, intellectual disorder, or a related condition with be referred promptly to the state mental heal or intellectual disability authority for a level II resident review.

Based on observation, record review and interview the facility failed to monitor and record temperatures for the one nourishment refrigerator used for residents located at one nurses station (Nurses Station Two) of two nurses stations. Findings included: An observation on 09/13/23 at 1:30 p.m., showed a RESIDENTS ONLY refrigerator located at Nurses Station Two. The refrigerator contained food and drink for multiple residents. On the refrigerator was a temperature log for September 2023 that showed missing temperatures. The dates missing temperature checks for the month of September 2023 were as follows: (Photographic Evidence Obtained) - 09/01/23 - 09/03/23 - 09/04/23. Behind the September 2023 refrigerator temperature log was the August 2023 refrigerator temperature log. The dates missing temperature checks for the month of August 2023 were as follows: (Photographic Evidence Obtained) -08/18/23 -08/19/23 -08/20/23 -08/21/23 -08/22/23 -08/23/23 -08/24/23 -08/25/23 -08/26/23 -08/27/23 -08/28/23. During an interview on 09/13/23 at 1:36 p.m. the Assistant Director of Nursing (ADON) stated the night shift should have completed the refrigerator temperature logs nightly. The ADON confirmed the refrigerator temperature logs for August 2023 and September 2023 were incomplete. The ADON stated she would expect the temperature logs to be completed nightly and education will need to be provided to the staff. A review of the facility's policy, Resident Refrigerators, revised date 02/2023 showed Staff shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the binding arbitration agreement was understood by two residents (#13 and #34) of three residents sampled. Findings included: 1. On 9/11/2023 at 10:36 a.m., an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated all residents review and sign arbitration agreements upon admission. The NHA stated no one has declined to sign the arbitration agreement. The NHA provided a facility document titled, Facility admission Agreement, State: FLORIDA printed in the middle of the page and on the bottom left corner, admission Agreement, August 2022 version. Review of Resident #13's admission Record revealed Resident #13 was admitted on [DATE]., with diagnoses that included sepsis, chronic obstructive pulmonary disease, type 2 diabetes, hypertension encephalopathy. Review of the Minimum Data Set (MDS), dated [DATE], Section C - Cognitive Patterns revealed the Brief Interview for Mental Status (BIMS) score was 03 out of 15, indicating the resident had severe cognitive impairment. Review Resident #13's Facility admission Agreement - Facility admission Agreement, August 2022 version, and Attachments Section G & H revealed it was signed by Resident #13 and dated 6/1/2023. An interview with Resident #13 occurred on 9/13/2023 at 1:20 p.m. Resident #13 stated, I somewhat recall signing paperwork, but I was very out of it when admitted . I don't really recall anything specific. Review of Resident #13's medical record showed no evidence the resident's representative was contacted for assistance during this time. 2. Review of Resident #34's admission Record revealed Resident #34 was admitted on [DATE], with diagnoses that included type 2 diabetes, hypertension, unsteadiness on feet, other abnormalities of gait and mobility. Review of the MDS, dated [DATE], Section C - Cognitive Patterns revealed the BIMS score was 13 out of 15, indicating the resident was cognitively intact. Review of Resident #34's Facility admission Agreement, August 2022 version revealed it was signed by Resident #34 and dated 9/7/2023. An interview with Resident #34 was conducted on 9/13/2023 at 1:30 p.m. Resident #34 stated her admittance was very recent and recalls discussing the admission paperwork with the admission Director (AD). Resident #34 continued to state, no arbitration, mediation or dispute resolution was mentioned. I did not sign that. I know there was a bunch of paperwork they had me sign for treatment, etc. nothing about court or disputes. On 9/13/2023 at 1:52 p.m. an interview was conducted with the AD. The AD stated the admission paperwork included the arbitration agreement. The AD stated she explains to the resident they are waiving their rights and can decline if they want to, and their admission is not affected if they choose not to sign. The AD continued and explained how they determine if a resident can understand the agreement or not, and stated everyone is able to sign the admission agreement. The only residents that are not able to sign themselves in are those a physician has deemed incapacitated. All other residents can sign themselves. On 9/13/2023 at 5:56 p.m. an interview was conducted with the NHA and the Director of Nursing (DON). The NHA stated he would expect the residents to be given an opportunity to ask questions, and to ensure they understand they are waiving the right to go to court and instead go through arbitration. The DON stated the cognitive status of the resident should be considered to determine if the resident is able to understand the agreement. A facility policy titled, BINDING ARBITRATION AGREEMENTS, dated 2/2023, showed: Policy: this facility asks all residents to enter into an agreement for binding arbitration. We do not require binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, this facility. Policy explanation and compliance guidelines: 1. When explaining the arbitration agreement, the facility shall: b. Explain to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. c. Ensure the resident or his or her representative acknowledges that he or she understands the agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the creation, implementation and monitoring of the plan of correction for deficient practice identified during a recertification survey that was conducted 9/11/23 to 9/13/23 and was cited F761 and F880. On 11/2/23 a revisit survey was conducted, and the facility was recited F761 and F880. The facility had developed a Plan of Correction with a completion date of 10/13/23. Findings included: 1. The facility developed a plan of correction that included: Quality review was conducted on 9/14/23, by the Assistant Director of Nursing (ADON) of medication carts and supply rooms to ensure medications were labeled and stored appropriately. The facility developed a plan of correction that identified measures to be put into place or made systemic changes to ensure the practice did not recur included: Licensed nurses re-educated by the Director of Nursing (DON) regarding ensuring storage and labeling of drugs and biologicals in accordance with professional standards on 9/25/23. The plan identified newly hired licensed nurses would receive education as part of the orientation process. The Director of Nursing or designee, will conduct a quality review of medication carts and supply rooms to ensure medications are labeled, stored appropriately twice weekly x 4 weeks, then twice monthly x 2 months. The findings of these reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 or until the committee determines substantial compliance has been met. During the revisit survey conducted 11/2/23 the facility failed to ensure the medications were stored appropriately when unattended on one (#2) of two medication carts and medications with a shortened expiration life was opened were labeled with an open date on two of two medication carts. On 11/2/23 at 8:59 a.m., Staff D, Registered Nurse (RN) was observed walking away from a medication cart parked outside of Nursing Station #2, two residents were observed standing in the hallway near the cart. The medication cart was left unlocked with a bottle of Lactulose on top of it while the staff member ambulated to the vendor/employee entrance at the end of the hallway to let a visitor out the key-coded door. Staff D returned to the cart, confirmed the cart was unlocked and the bottle of Lactulose was left on top. The staff member stated I'll be sure not to do that again. On 11/2/23 at 10:28 a.m. an observation was conducted with Staff C, Licensed Practical Nurse (LPN) of Medication Cart #1. The observation revealed the following: - Opened bottle of Liquid Protein - Medical Food, dated 7/6/2023. The manufacturer instructed Discard 3 months after opening. Staff C had turned bottle over to read the unopened expiration date, unaware of the shortened shelf life once opened. - One (1) vial of opened Humalog insulin, the medication's attached label did not identify the date the vial was opened. - One (1) opened vial of Levemir, the vial's attached label did not identify when it was opened. - One (1) unopened vial of Levemir. The packaging instructed to Refrigerate and had a handwritten date of 11/2/23. - One (1) Humalog Kwik pen, the medication's attached label did not identify the date opened. The packaging identified Refrigerate and did not identify an open date on the available sticker. The printed packaging label included a handwritten date of 11/2/23. - One (1) Lantus Solostar insulin pen was opened and did not identify an open date on the medications attached label. The packaging identified an open date of 10/10/23 and the printed packaging label indicated Once opened store at room temperature for 28 days. The pen was not labeled with an expiration date. - One (1) Lantus Solostar insulin pen, which did not identify an open date on the available attached label and did not identify the date of expiration. The clear plastic bag containing the pen was labeled with an open date of 11/2/23, and the pharmacy had printed storage instructions, Once opened store a room temperature for 28 days. Neither the pens label or the the packaging label identified an expiration date. - One (1) Novolog Flexpen (insulin) undated per the medication's attached label. A packaging sticker identified the pen had been opened on 11/2/23. The pharmacy label on packaging identified Once opened store at room temp for up to 28 days. The pen did not identify an expiration date. (Photographic Evidence Obtained) Immediately following Medication Cart #1's observation, Staff C confirmed the Liquid Protein was to be discarded after 3 months and the plastic bag packaging could be destroyed leaving the insulin pens with unknown open dates. The staff member identified 3 insulin pens and one (1) vial of insulin had arrived to the facility on [DATE] (same day as observation). On 11/2/23 at 2:17 p.m., Staff C reported just taking the insulin from the refrigerator and the pens and vial, dated 11/2/23, were still cold during the observation (they were room temperature) and the package bags had been dated (with 11/2/23) due to habit. On 11/2/23 at 11:00 a.m. an observation was conducted with Staff D, Registered Nurse (RN) of Medication Cart #2. The observation revealed the following: - In the small top drawer, located under multiple insulin pens were 2 blister packages containing Azithromycin 250 milligram (mg) tablets. The packaging was worn and did not identify a residents' name. - An Insulin Lispro KwikPen was located in a plastic bag, the medication's attached label did not identify a date the medication was opened. The packaging did not identify an open date and the pharmacy label revealed Refrigerate until opened. - A Lantus Solostar insulin pen without a resident identifier on the medication and the pen was not labeled with an open or expiration date. - An opened Lantus Solostar insulin pen did not identify an open date on the medication's attached label. The packaging identified a pen was opened on 10/6/23 but did not identify an expiration date. The pharmacy label revealed Once opened store at room temperature for 28 days. - An opened bottle of Latanoprost 0.005% ophthamolic solution that was not dated. The plastic bag containing the medication identified an open date of 10/27/23 but did not reveal an expiration date. The pharmacy label identified Store opened room temp., Discard after 6 weeks (wk). - A Humalog insulin pen did not identify an opened date on the medication's attached pharmacy label. The packaging did not identify an open date however did reveal Refrigerate until opened. Once opened store at room temperature for 28 days. - A Levemir insulin pen, that was not contained in plastic bag. The medication's attached label did not identify an open date or any specific prescribing instructions. - An opened vial of Novolog. The medication's attached label did not include an open date. - An opened vial of Levemir whose attached label did not identify an open date. The packaging bottle identified an open date of 9/17/23. According to https://www.mynovoinsulin.com/insulin-products/levemir/home.html, after use the Levemir FlexPen and vial should be disposed of after 42 days, even if there is insulin left in the pen or vial. The vial of Levemir expired on 10/29/23. - An opened Novolog FlexPen. The medication's attached label did not identify an open date. The pharmacy label revealed Once opened store at room temp for 28 days. The sticker attached to the plastic bag containing the insulin pen identified an open date of 10/21/23 but did not reveal an expiration date. - The attached medication label of one (1) Lantus Solostar insulin pen did not identify an open date. The plastic bag containing the pen identified an open date of 10/31/23. The pharmacy label indicted Once opened store at room temperature for 28 days. The pen or the packaging did not identify an expiration date. - The pharmacy label attached to a Lantus Solostar pen did not reveal an open date. The plastic bag containing the pen identified an open date of 10/8/23. The pharmacy label revealed once opened the pen could be stored for 28 days at room temperature. The packaging stickers or the medication label did not reveal an expiration date. - The attached medication label for a Basaglar insulin Kwikpen identified an open date. The plastic bag containing the Kwikpen identified an open date of 10/27/23. - A box containing an open bottle of Artificial Tears Lubricant Eye Drops was located in the med cart #2. Staff C confirmed neither the box or the bottle were labeled with an open date. According to Cleveland Clinic, (https://my.clevelandclinic.org/health/drugs/18710-artificial-tears-eye-solution) Once the product is opened, most experts recommend discarding the product (Artificial Tears) after 30 days. Immediately following the observation, Staff C confirmed the findings of several insulin pens not being dated, the Artificial Tears not being dated, and the unopened bottle of Calcitonin should have been refrigerated. On 11/2/23 at 11:44 a.m., Staff C was standing at Medication Cart #2, parked in front of the nursing station, with Staff G counting narcotics located in the cart. A medication cup, containing several tablets and a large beige-colored geltab was observed sitting on the nursing station counter to the side of medication cart where Staff G was standing. Staff C noted the observation and moved around Staff G to the location, grabbed the cup, and said, those are mine. Staff C placed them on the medication cart in front of where she was standing (the opposite side of the cart). On 11/2/23 at 12:45 p.m., the Director of Nursing (DON) stated the expectation was to label the medications not just the baggies. The DON stated medications should not be stored with cleaners, medications carts should be locked when unattended, and medications should not be left on the cart when unattended. The DON reported education had been done regarding locking medication carts, the consultant pharmacist reviewed and it has been hectic week due to having a new pharmacy. The policy - Medication Storage, implemented 8/25/22, read It is the policy of this facility to ensure all medications housed on a premises will be stored in the pharmacy and or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The policy explanations and compliance guidelines identified: - All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls.- - During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/ cart. - All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each medication room. 2. The facility developed a plan of correction that included: Quality review completed by DON/designee on 9/14/23 - 9/25/23 of resident rooms, resident bathrooms, shower rooms, hallways, laundry and dining room to ensure appropriate infection control practices were being utilized to include proper hand hygiene/wearing gloves, gloves discarded appropriately, bathrooms are clean, linen was stored appropriately, washing machine is clean and proper disinfecting is utilized, clean and dirty linen areas are separate, lint filters for dryers are clean, and linen in laundry is properly covered. The facility developed a plan of correction that identified measures to be put into place or made systemic changes to ensure the practice did not recur included: The Infection Preventionist/DON/designee provided educated to staff on 9/25/23. Staff were reeducated on Infection prevention protocols including proper hand hygiene/wearing gloves, gloves discarded appropriately, bathrooms are clean, linen is stored appropriately, washing machine is clean and proper disinfecting is utilized, clean and dirty linen areas are separate, lint filters for dryers are clean, and linen in laundry is properly covered. During the revisit survey conducted 11/2/23 the facility failed to ensure clean laundry was handled in a sanitary manner and failed to ensure the clean laundry area was free from staff's personal items. On 11/2/23, beginning at 9:00 a.m., observations were made of two staff members (E and F) performing housekeeping duties throughout the facility, including resident rooms. On 11/2/23 at 2:10 p.m., Staff F was asked by other staff members to show this writer the facility's laundry area. The staff member maneuvered the housekeeping cart that was being used to outside the building to the laundry area. Staff E was observed in the clean laundry side of the area. The window of the one commercial-sized washer was full of linens and resident gowns. Staff F removed the laundry from the washer and placed it into a large gray rolling tote and Staff E rolled it into the clean laundry area. The area contained another tote with a large amount of linens in it. Staff E, with bare hands, placed the wet laundry into the dryer. The observation identified a clear container of store-bakery cookies and a paper take-out cup on top of the folding counter. Staff E identified the items belonged to her and Staff F questioned whether they could have the items there or not. Staff E folded a pink-back pad in half then tucked the end of it under her chin and folded the item. The staff member reached for another pink-back pad and repeated the process of holding the item under her chin and against personal clothing, the same gray sweatshirt with red lettering that she was wearing during housekeeping duties. Staff E and F reported the laundry aide works 5 a.m. to 1 p.m., they work from 7 a.m. to 3 p.m., and after their housekeeping duties they come back to the laundry area to finish up (with laundry). The staff members stated the facility is able to finish all the laundry during working hours. (Photographic evidence was obtained) On 11/2/23 at approximately 2:30 p.m., the Maintenance/Laundry/Housekeeping Director reported the facility has 3 laundry/housekeeping staff, the laundry aide works from 5 a.m. to 1 p.m., two housekeepers work from 7 a.m. to 3 p.m., and before the two housekeepers leave from the day they assist with laundry: folding and getting things (linens) to the carts. The M/L/H director reviewed the photo taken of the washer and stated it was normally like that (full) and confirmed it looked really full. The director reported not being trained in laundry and/or housekeeping and confirmed supervising staff in areas he had not been trained. The M/L/H director confirmed staff should not putting (clean) clothes into the washer with bare hands and stated it was not appropriate for the staff member to fold laundry while holding it up against herself. During an interview on 11/2/23 after 2:30 p.m., the Director of Nursing (DON) reviewed the photo of the washer and stated it looked full and confirmed the staff member (E) had cross-contaminated the laundry. On 11/2/23 at 5:20 p.m., the DON stated the M/L/H director and Regional Maintenance Director had educated the (laundry/housekeeping) staff. The facility policy - Handling Clean Linen, copyrighted 2023, revealed It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. The policy identified the following: - Facility linen is considered hygienically clean. The policy defined hygienically clean as rendered free of vegetative pathogens through disinfection during the laundering process. - Linens can become contaminated with pathogens from contact with intact skin or body substances, or from environmental contaminants or contaminated hands. - Do not place clean linen on the floor or other contaminated surfaces. 3. On 11/2/23 at 9:05 a.m., an observation was made of Resident #1 sitting in a specialized wheelchair in the hallway outside of nursing station #1. The resident's urinary drainage bag and tubing was observed lying on the floor under the wheelchair. The privacy bag for the urinary bag was improperly placed and allowed other residents and visitors to visualize the contents of the bags. The admission Record revealed Resident #1 was admitted on [DATE] and included diagnoses not limited to spastic quadriplegic cerebral palsy, unspecified scoliosis, and benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. The care plan for Resident #1 identified the resident had a urinary catheter related to neurogenic bladder and had a diagnosis of BPH. The interventions instructed staff to provide privacy bag to drainage bag at all times and provide catheter care to prevent Urinary Tract Infection (UTI). During an interview on 11/2/23 at 4:34 p.m., the Director of Nursing (DON) reported Resident #1 had one of one urinary catheters in the facility. The DON stated catheters should be stored in a privacy bag and off the floor. She reported she was the one who corrected (the location) of Resident #1's catheter this morning. The Centers of Disease Control and Prevention (CDC) - Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009), last reviewed: November 5, 2015, identified the proper technique of Urinary Catheter Maintenance was Do not rest the bag on the floor. This information was located at https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html. According to the Cleveland Clinic, (https://my.clevelandclinic.org/health/articles/14832-urine-drainage-bag-and-leg-bag-care), Do not place the urine bag on the floor. The policy - Infection Prevention and Control Program, reviewed/revised on 7/13/23, identified This facility has established and maintains 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 disease and infections as per accepted national standards and guidelines. - 2. All staff are responsible for following all policies and procedures related to the program. - 11a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. The facility policy - QAPI with QA and Risk Management Program, implemented 9/7/22, revealed Center should implement a specific Quality Assurance and Risk Management Program that includes collecting data under a written QAPI plan to coordinate and evaluate activities under the QAPI program meeting including the development of Performance Improvement Projects (PIPs) under the QAPI plan if necessary. The policy identified the purpose was To provide a structured process by which customer care and organizational functions are continually and systematically reviewed in the context of a quality improvement model. And so during, organizational compliance with regulatory requirements and professional standards of care should be enhanced in the achievement of center goals and objectives realized, thereby providing the foundation for positive customer outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An observation on 9/11/23 at 9:20 a.m. was conducted of the hallway on Unit Two (back hallway) and two ceiling tiles in front of Resident rooms [ROOM NUMBERS] were observed with dried large brown spots. (Photographic Evidence Obtained) An observation 9/11/23 at 8:37 a.m. of Resident room [ROOM NUMBER] revealed missing baseboards at the entrance to the room and visualized from the hallway. (Photographic Evidence Obtained) An observation on 9/11/23 at 9:15 a.m. of Resident room [ROOM NUMBER] revealed the floor baseboard and headboard were either missing or deteriorated, and the nightstand had a wood strip loose and curled up and sticking out. (Photographic Evidence Obtained) On 9/13/23 at 5:30 p.m. the Director of Nursing (DON) was observed entering Resident room [ROOM NUMBER] and inspected the nightstand with the strip sticking out and headboard with rotting wood and stated to the resident he will be getting a new nightstand and headboard. The DON confirmed this was not acceptable. An observation made on 9/11/23 at 6:33 a.m. and on 9/12/23 at 4:00 p.m. of the middle hallway between Resident rooms [ROOM NUMBERS] and revealed a metal cover was loose and made a clang when someone walked over it. The metal cover was soiled with what appeared to be grease and dirt. A screw was protruding from the middle of the metal cover. (Photographic Evidence Obtained) An observation made on 9/11/23 at 6:40 a.m. and 12:30 p.m. of the hallway outside of Resident room [ROOM NUMBER] and revealed shower chairs being stored and underneath a shower chair was a dirty washcloth. (Photographic Evidence Obtained) Additional observations made on 9/11/23 at 6:41 a.m. and 9/12/23 at 12:31 p.m. of the hallway outside of Resident room [ROOM NUMBER] revealed a portable air conditioner unit and next to this unit the floor had buildup of dirt and what appeared to be food particles. In the alcove where resident lifts were stored, a medication cup and tissue were on the floor. Outside of Resident room [ROOM NUMBER] in the middle of the hallway was what appeared to be a dried-up lizard. On the floor in front of Nurse Station 2, a brownish, sticky substance was visible on the floor. (Photographic Evidence Obtained) The bathroom between Resident rooms [ROOM NUMBERS] was observed on 9/11/23 at 7:30 a.m., 9/12/23 at 2:30 p.m., and 9/13/23 at 11:00 a.m. with yellow and brown liquid setting on the ceramic of the toilet base behind the toilet seat. At the base of the toilet was a black and brown substance surrounding it, a space between the base of the toilet and the floor was visible. (Photographic Evidence Obtained) The bathroom between Resident rooms [ROOM NUMBERS] was observed on 9/11/23 at 7:25 a.m., 9/12/23 at 2:25 p.m., and 9/13/23 at 10:45 a.m. with a brown substance at the base of the toilet, a buildup of dirt on the floor surrounding the front of the toilet. The pipes on the toilet, directly behind the toilet seat, were observed to be corroded. (Photographic Evidence Obtained) An observation made on 9/11/23 at 7:35 a.m. in Resident room [ROOM NUMBER] and Resident beds B, C, and D all had sheets that were threadbare. (Photographic Evidence Obtained) An interview was conducted with Staff D, Certified Nursing Assistant (CNA) on 9/11/23 at 7:30 a.m. in Resident room [ROOM NUMBER]. Staff D, CNA stated there are many sheets which are threadbare. Staff D, CNA stated, I should exchange and throw the threadbare linen out but there are not enough in the mornings to accomplish this. Staff D, CNA confirmed the toilet stains around the toilet in the bathroom between Resident rooms [ROOM NUMBERS]. Staff D, CNA stated many of the floors and toilets are stained. When I notice stains like this, I let the housekeeper know. I don't think they can do anything about it. An interview was conducted on 9/11/23 at 12:40 p.m. with Resident #13. Resident #13 stated the housekeeping in the facility is not very good. There seems to always be dirt and trash on the floor. Resident #13 stated it does not do much good to say anything. Resident #13 stated it would be better if the facility was cleaner. An interview was conducted on 9/11/23 at 9:40 a.m. with a Resident in room [ROOM NUMBER]. The Resident stated the floor has had black looking spots next to the bed for quite some time. An interview was conducted on 9/13/23 at 12:05 p.m. with Staff E, Housekeeping (Hkg). Staff E, Hkg confirmed the resident bathroom floors in between rooms19/20 and rooms 17/18 appeared dirty. Staff E, Hkg stated when an issue arises the staff notify the Maintenance Director (MD). I try to remind the MD although the MD is very busy. Staff E, Hkg confirmed the floors in the hallways and Resident room [ROOM NUMBER] were dirty. Staff E, Hkg stated she was not sure why the floors remain dirty they are supposed to be mopped at least one time per day. An interview was conducted on 9/13/23 at 12:15 p.m. with the Maintenance Director (MD). The MD confirmed responsibility of overseeing Maintenance and Housekeeping. The MD confirmed the staining of floors and toilets in resident bathrooms between rooms 19/20 and rooms 17/18. The MD stated there are several toilets that should be repaired. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 9/13/23 at 5:56 p.m. The NHA and the DON both stated the environment was being worked on since July 2023. They were not able to produce any documented evidence of an ongoing plan. The NHA stated his expectation was for the Maintenance Director to have been working on all these concerns and did not understand why they had not been completed. A facility policy titled, ROUTINE CLEANING AND DISINFECTION, dated 2/2023, showed: Policy: it is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Definitions: Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents or enzymatic products. Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas comma resident rooms comma and at the time of discharge. 4. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: -a. Toilet flush handles -g. Toilet seats -l. Sinks and faucets. A facility policy titled, PREVENTATIVE MAINTENANCE PROGRAM, dated 2/2023 showed: Policy: A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance (PM) is required. Required PM may be determined from manufacturers recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventive maintenance is required, the maintenance director shall decide what tasks need to be completed and how often to complete them. 4. The maintenance director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks and kept in the maintenance director 's office for at least 3 years. Based on observations, interviews, and policy reviews the facility failed to ensure a clean and homelike environment on two units (Unit 1 and Unit 2) out of two units related to cleanliness of resident areas, cluttered halls and dining room, linen supply, and an unkempt courtyard for three days (9/11/23, 9/12/23 and 9/13/23) of three days of the survey. Findings included: An observation was made on 9/11/23 at 6:37 a.m. of the Unit 2 resident hallway and revealed it to be cluttered with medical equipment to include mechanical lifts, wheelchairs, and shower chairs. An observation was made on 9/11/23 at 7:09 a.m. of the linen closest on Unit 1 and Unit 2 having no supply of linen. An observation was made on 9/11/23 at 7:15 a.m. of floors being dirty in Resident Rooms 6, 11, 15, 18, 17, and 20. The floors in these rooms were observed to remain in this condition during the survey from 9/11/23 to 9/13/23. An observation was made on 9/11/23 at 7:10 a.m. in the dining room of weight scales in the corner, boxes and a bag of clothes on the countertop, and the front of the cabinet having drip stains down the front. The top of the ice machine in the dining room was covered in dust and there was a dirty cup and glove behind the ice machine. An observation was made on 9/11/23 at 7:24 a.m. of the trash can overflowing onto the floor in Resident room [ROOM NUMBER]. An observation was made on 9/11/23 at 8:31 a.m. in Resident room [ROOM NUMBER]. The sheets on the window bed had dark stains on them, and the toilet had a brown liquid running down the front and splattered on the floor. On 9/13/23 at 5:51 p.m. the toilet and floor had not yet been cleaned in Resident room [ROOM NUMBER]. An observation was made on 9/11/23 at 8:34 a.m. of a circular fan attached to the wall at the Unit 2 Nurses' Station covered in dust. The fan remained covered in dust on 9/13/23 at 5:45 p.m. An observation was made on 9/11/23 at 12:21 p.m. in Resident room [ROOM NUMBER] of the closet door off the track. The air conditioning in the room was also broken and half the room was missing baseboards. At this time, an interview was conducted with a Resident who resided in Resident room [ROOM NUMBER]. The resident said the doors had been that way and she was unable to open the closet doors. An interview was conducted on 9/13/23 at 9:15 a.m. with the Maintenance Director. He said the facility did not have a computer tracking system for maintenance requests, but they are working on setting one up. When asked if he had a log or list of items that need to be repaired, he said he did not. The Maintenance Director said people just tell him when things need to be fixed. A follow-up interview was conducted on 9/13/23 at 6:06 p.m. with the Maintenance Director. He said he knows there are a lot of issues, and they are getting to them. He said the floors are dirty because the hallways were stripped and waxed about a month ago and that left a build up at the doors to the resident rooms. He said they haven't had a chance to do the resident rooms yet. The Division Plan Operations Director said there had been no room audits or anything in place at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and policy review the facility failed to ensure residents were free from accident hazards related to: 1. hot water temperatures were not maintained at a safe temperature in two community shower sinks (located near room [ROOM NUMBER] and room [ROOM NUMBER]) and two resident bathroom sinks (room [ROOM NUMBER] and room [ROOM NUMBER]), 2. a storage room and supply room being unlocked with multiple housekeeping and nursing supplies, 3. emergency cords missing or unable to be used in three resident bathrooms (Rooms15/16, room [ROOM NUMBER] and room [ROOM NUMBER]), 4. a bathroom light not working in one resident shared bathroom (Rooms 15/16) and 5. an air conditioning unit in disrepair and leaking in one resident room (20) for a period of three days (9/11/23, 9/12/23 and 9/13/23) of a three day survey. Findings included: On 9/11/23 at 7:45 a.m., during the initial tour it was revealed the temperature of the water in the shower room sink near Resident room [ROOM NUMBER] was hot. The Maintenance Director (MD) tried to take the temperature of the water coming from this sink with his digital thermometers (2) and both of the thermometers were not in working order. The MD left to get a different thermometer and did not return. On 9/11/23 at 8:30 a.m. two surveyors entered the shower room next to Resident room [ROOM NUMBER], after obtaining a facility digital thermometer from Staff B, Dietary Manager. The hot water was left to run in the sink for approximately 2 minutes. The thermometer was then placed in the stream of water coming from the sink faucet. The water had a temperature of 121-degree Fahrenheit. (Photographic Evidence Obtained) On 9/11/23 at 8:40 a.m. two surveyors entered the community shower room next to Resident room [ROOM NUMBER]. The hot water was left to run in the sink for approximately 2 minutes. The thermometer was then placed in the stream of water coming from the sink faucet and the temperature of 121-degree Fahrenheit displayed on the thermometer. (Photographic Evidence Obtained) On 9/11/23 at 8:45 a.m. two surveyors entered Resident room [ROOM NUMBER], and the hot water was left to run for approximately two minutes from the bathroom sink. The thermometer was then placed in the stream of water coming from the sink faucet and the temperature of 120-degree Fahrenheit displayed on the thermometer. (Photographic Evidence Obtained) On 9/11/23 at 8:50 a.m., two surveyors entered Resident room [ROOM NUMBER], and the hot water was left to run for approximately two minutes from the bathroom sink. The thermometer was then placed in the stream of water coming from the sink faucet and the temperature of 120-degrees Fahrenheit displayed on the thermometer. (Photographic Evidence Obtained) On 9/11/23 at 9:00 a.m. an interview was conducted with Staff B, Dietary Manager (DM). Staff B, DM confirmed the digital thermometer that was being utilized for hot water temperatures had been calibrated earlier in the morning. Staff B, DM calibrated the digital thermometer again, and confirmed all was within parameters. (Photographic Evidence Obtained) On 9/11/23 at 9:10 a.m. an observation of the facility's one resident hot water heater, occurred with the MD. At the bottom of the hot water heater was a dial. The dial was labeled with the letters A, B, C, and VERY HOT. The observation showed the dial to be set with an arrow pointing between the letters B and C. (Photographic Evidence Obtained) On 9/11/23 at 9:55 a.m. an interview was conducted with the MD. The MD stated water temperatures should not be greater than 115 degrees Fahrenheit. The MD stated, we like them to be between 110-115 degrees Fahrenheit. The MD stated he did not know what the temperature setting was for letters A, B, C and Very Hot on the resident hot water heater. He stated he knew that Very Hot was hot and the temperature should not be on that setting. The MD stated the temperatures were audited regularly, and stated the current temperature logs were currently unavailable for review. On 9/11/23 at 10:00 a.m. an interview was conducted with Staff G, Registered Nurse (RN). Staff G, RN stated the water does get quite hot at times. The temperatures come and go. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 9/13/23 at 5:56 p.m. The NHA stated the expectation was the water temperature to the resident locations should be between 105 to 115 degrees Fahrenheit. The NHA stated 120-degree Fahrenheit is too high. On 9/11/23 at 7:25 a.m. and at 1:40 p.m., an observation of the shared bathroom for Resident rooms [ROOM NUMBERS] revealed a sharps container hanging on the wall over the sink, with a syringe sitting in the disposal opening. The emergency call cord for the bathroom was wrapped around the grab bar next to toilet, preventing the cord from being pulled. (Photographic Evidence Obtained) On 9/11/23 at 12:30 p.m. a resident was observed in Resident room [ROOM NUMBER] self-propelling in the wheelchair and the resident confirmed she was able to utilize bathroom. An interview was conducted with the NHA and the DON on 9/13/23 at 5:56 p.m. The NHA and the DON both stated the emergency call cord should be available in all resident bathrooms and the call cords should not be wrapped around the grab bars. The residents should be able to pull the cord easily if needed. The DON stated the expectation was for sharps to be fully disposed of, not left exposed. The DON did not know why someone would not have properly disposed of the syringe, especially if the container was not full. On 9/11/23 at 8:30 a.m. an observation of the housekeeping/nursing supply closet by Resident room [ROOM NUMBER] revealed it was open. The housekeeping/nursing supply closet had bifold doors (two doors one handle that would lock and one door with no handle with locking mechanism at the top, which when not engaged both doors open). When pulling on the handle both doors opened. When opened, the housekeeping/nursing supply closet revealed bleach wipes sitting on the counter at eye level. (Photographic Evidence Obtained) An interview was conducted on 9/13/23 at 12:15 p.m. with the MD. The MD confirmed the housekeeping/nursing supply closet door should be locked. The MD continued to state the lock was working properly but the staff have removed the locking mechanism off the door without the handle. An interview was conducted with the NHA and the DON on 9/13/23 at 5:56 p.m. The NHA stated the expectation of supply closets is they all should be locked, except when in use. An observation was made on 9/11/23 at 7:40 a.m., 9/12/23 at 2:30 p.m., and 9/13/23 at 11:00 a.m. of Resident room [ROOM NUMBER]'s, air conditioner (a/c) wall unit and the wall surrounding the a/c was wet, brown, and crumbling. A lizard was seen in the blankets then ran under the wall. When looking down at the top of the a/c you could see the outside as a gap was between the unit and wall. (Photographic Evidence Obtained) An additional observation was made on 9/11/23 at 7:40 a.m. of Resident room [ROOM NUMBER]'s air conditioner (a/c) wall unit and underneath the a/c unit were two blankets that were wet. The resident in room [ROOM NUMBER] stated the a/c has been broken for over a week. I am worried about my roommate who walks to the bathroom with a walker and has a bad back, so I placed the blankets on the floor to clean up the water that had puddled on the floor, past the bathroom door. I was afraid my roommate would slip and fall. (Photographic Evidence Obtained) An interview was conducted on 9/13/23 at 12:15 p.m. with the MD. The MD stated the a/c in Resident room [ROOM NUMBER] needed to be repaired although the repair had to be completed from the outside. The MD confirmed the a/c was dripping water. An interview was conducted with the NHA and the DON on 9/13/23 at 5:56 p.m. The NHA stated the a/c should have been fixed immediately and did not know why this had not been completed. A facility policy titled, SAFE WATER TEMPERATURES, dated 3/2023, showed: Policy: it is the policy of this facility to maintain appropriate water temperatures in resident care areas. Policy explanation and compliance guidelines: 3. Thermometers will be available as needed for use by all staff period 4. Staff will report abnormal findings, such as complaints of water too cold or hot, burns or redness, or any problems with water temperatures (ex. water is painful to touch or causes redness) to the supervisor and/or maintenance staff. 5. Water temperatures will be set to a temperature of no more than 115-degree Fahrenheit, or the states allowable maximum water temperature. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. 7. Documentation of testing will be maintained for 3 years and kept in the maintenance office. An observation was made on 9/11/23 at 7:11 a.m. of a storage room on Unit 2. The door had a keypad lock, but the door was not closed all the way, allowing it to be opened by anyone. This storage room had shelves containing hand sanitizer, boxes of razors, gallon jugs of shampoo and body wash. This storage room opened to a resident hall and several residents were observed walking or self-propelling past the door. No staff were in sight of the room at that time. On 9/11/23 at 10:51 a.m. the door to the storage room on Unit 2 was observed to be partially opened. On 9/13/23 at 8:55 a.m. the door to the storage room was again observed to not be closed all the way, allowing easy access. No staff were in sight of the room. An interview was conducted on 9/11/23 at 8:53 a.m. with a resident who resided in room [ROOM NUMBER]. This resident stated the light in her bathroom had not been working and no one could see to use it at night. This bathroom was observed to be shared with the residents in room [ROOM NUMBER]. An interview was conducted on 9/11/23 at 8:55 a.m. with a resident who resided in room [ROOM NUMBER]. The resident stated there is no light in the bathroom and it hasn't worked consistently for months. She said maintenance knows and tried to fix it but it did not work. She stated staff have done nothing. She said the residents that use that bathroom have to hold it at night or they go to the bathroom in the dark. She said it is only a matter of time before someone falls. An observation was made on 9/11/23 at 8:57 a.m. of the shared bathroom for rooms [ROOM NUMBERS]. The light switch outside the door was flipped multiple times and the light in the bathroom did not come on. It was also observed that the emergency pull cord in that bathroom was missing. Review of the census showed seven residents shared the bathroom with no light and no emergency pull cord. A facility policy titled, PREVENTATIVE MAINTENANCE PROGRAM, dated 2/2023, showed: Policy: A preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if preventative maintenance (PM) is required. Required PM may be determined from manufacturers recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventive maintenance is required, the maintenance director shall decide what tasks need to be completed and how often to complete them. 4. The maintenance director shall develop a calendar to assist with keeping track of all tasks. 5. Documentation shall be completed for all tasks and kept in the maintenance director 's office for at least 3 years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the facility failed to ensure storage and labeling of drugs and biologicals in accordance with professional standards, and failed to ensure medications were secured and not accessible to residents, visitors and/or unauthorized staff for one medication cart (Station Two) of two medication carts, and for one of one treatment carts located in an unlocked medical supply room for two days ([DATE] and [DATE]) out of three days of the survey. Findings included: An observation was made upon entering the facility on [DATE] at 7:10 a.m. of an unlocked medical supply room opened to a resident hallway. (Photographic Evidence Obtained) There were no staff around this area at this time. Inside the medical supply room was an unlocked treatment cart. The first drawer of this treatment cart contained a pair of sharp scissors and a pair of blunted trauma shears (Photographic Evidence Obtained.) The second drawer contained residents' prescription medication. On [DATE] at 2:45 p.m. a column was observed with a key hanging from a nail in Nurses Station Two. An interview was conducted with Staff K, Registered Nurse (RN) at this time. Staff K, RN stated the hanging key was utilized for the medical supply room. The height of the key could be obtained from a standing adult. An observation on [DATE] at 8:53 a.m. revealed the medical supply room was opened to the resident hallway with a treatment cart unlocked. No staff were present during this observation. An observation was made of the Medication Cart for Station Two on [DATE] at 3:08 p.m. with Staff K, RN. An observation of each individual drawer in the medication cart revealed: seven loose tablets either whole or in pieces, three hearing aid cases, one metallic chain, two keys, one denture cup, one hearing aid battery, three entire pharmaceutical bubble packs in the back of the cart behind the bottom drawer, and a white bottle with no commercial label marked in a permanent marker as Fe Iron on the side and on top of the cap. Staff K, RN confirmed the bottle should have been labeled better than how it currently was presented. Staff K, RN stated the night shift usually cleans the medication cart. An interview and observation were conducted with the Director of Nursing (DON) on [DATE] at 3:47 p.m. of the medication cart for Station Two. The DON confirmed personal items for residents should not be in the medication cart and should be locked elsewhere on behalf of the residents. The DON confirmed the white bottle with only Fe Iron should have been removed, disposed of, and replaced with a new bottle from their medication room by Nurse Station Two. The bottom drawer was brought out and the three pharmaceutical dispense cards were removed. Two of the three medication bubble packs were for Baclofen for the same resident with a current up to date expiration date and the third medication bubble pack was for Benztropine with one pill remaining. The DON said the night shift will clean the carts but the expectation is that all nurses maintain their own cart. A phone interview was conducted on [DATE] at 1:40 p.m. with the Consultant Pharmacist. The Consultant Pharmacist said she conducts monthly medication cart audits and medication room inventory as well as Quality Assurance. A monthly report is provided to the DON regarding the pharmacist's findings. The pharmacist stated expiration of medication storage has been an ongoing issue and has placed that concern in her monthly reports. The Consultant Pharmacist stated she will immediately notify staff and the DON of any concerns regarding her findings. The Consultant Pharmacist stated education is provided when the incident is found and will also provide monthly in-services as well. A review of the Consultant Pharmacist Summaries, dated [DATE], and [DATE], showed: Top Three Areas of Opportunity for medication carts with undated and expired insulin pens and undated eye drops. During an observation made on [DATE] at 7:09 a.m. of the open door to the medical supply room on Unit 2 and the following was revealed: shelves containing wound cleanser, nail polish remover, anti-fungal powder, and safety pin needles. No staff were in sight of the room at that time. On [DATE] at 10:50 a.m. the medical supply room door was observed open directly to a resident hall and several residents were observed walking or self-propelling past the open door. On [DATE] at 8:53 a.m. an observation revealed the medical supply room had the door open with access to supplies. No staff were in sight of the room. An observation was made on [DATE] at 12:23 p.m. of two pills on the floor behind the door in room [ROOM NUMBER]. Staff K, RN came and picked up the pills. One of the pills was identified as Buspirone, a medication used to treat anxiety disorders, and the second pill was not identified. Staff K, RN said she didn't know how the pills got there and confirmed they should not be there. A review of a facility policy titled, Storage of Medications, revised 11/ 2020, showed the following: Policy The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls only persons authorized to prepare and administer medications have access to locked medications. . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. . 6. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. An observation on [DATE] at 7:40 a.m., showed the medication cart near Nurses Station One was unlocked and unattended. (Photographic Evidence Obtained) During an interview on [DATE] at 7:45 a.m., Staff A, Licensed Practical Nurse (LPN) stated she was responsible for the medication cart near Nurses Station One and the medication cart should have been locked before walking away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to serve food that was palatable and at an appetizing temperature for six residents (#12, #16, #38, #40, #41 and #343) of 17 residents reviewed for food services. Findings included: During an interview on 09/11/23 at 8:43 a.m., Resident #41 stated the food was cold. Resident #41 stated she talked to the lady in the kitchen about the cold food but nothing changed. Review of Resident #41's admission Record showed Resident #41 was admitted to the facility on [DATE] with the diagnoses to include type two diabetes mellitus, chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 13 (cognitively intact). During an interview on 09/11/23 at 8:45 a.m. Resident #40 stated being unhappy about the breakfast this morning and stated the eggs, sausage and toast was always served cold. Review of Resident #40's admission Record showed Resident #40 was admitted to the facility on [DATE] with diagnoses to include type two diabetes and hyperlipidemia. The Quarterly MDS, dated [DATE], showed Resident #40 had a BIMS score of 15 (cognitively intact). During an interview on 09/11/23 at 8:56 a.m., Resident #12 stated she had just finished breakfast and breakfast was cold. Resident #12 stated the eggs and sausage were always cold. Review of Resident #12's admission Record showed Resident #12 was admitted to the facility on [DATE] with diagnoses to include anemia, and adult failure to thrive. The nursing comprehensive MDS, dated [DATE], showed Resident #12 had a BIMS score of 15 (cognitively intact). During an interview on 09/11/23 at 9:07 a.m., Resident #38 stated the facility seemed to always serve the same thing over and over again and the food comes out cold. Review of Resident #38's admission Record showed Resident #38 was admitted to the facility on [DATE] with diagnoses to include encephalopathy, and major depressive disorder. The Quarterly MDS, dated [DATE], showed Resident #38 had a BIMS score of 14 (cognitively intact). During an interview on 09/11/23 at 9:17 a.m., Resident #16 stated, The food is cold, it is always cold. Review of Resident #16's admission Record showed Resident #16 was admitted to the facility on [DATE] with diagnoses to include diverticulosis of intestines. The nursing comprehensive MDS, dated [DATE], showed Resident #16 had a BIMS score of 14 (cognitively intact). During an interview on 09/11/23 at 10:04 a.m., Resident #343 stated the food could be a little warmer. Review of Resident #343's admission Record showed Resident #343 was admitted to the facility on [DATE] with diagnoses to include type two diabetes mellitus, hyperlipidemia, and anemia. The comprehensive MDS, dated [DATE], showed Resident #343 had a BIMS score of 13 (cognitively intact). Review of the facility's grievance log showed food concerns related to temperatures for the following dates: June 2023 - 06/07/23, and August 2023 - 08/22/23. The grievance on 06/07/23 showed two former residents of the facility stated the food was being served cold. The actions taken by the facility showed, Education done with dietary. to let staff know when trays are on the floor. Resolution of the grievance showed concern was resolved and now being served in a timely manner and is still warm. The grievance on 08/22/23 showed Resident #41 stated, food was cold. The actions taken by the facility showed, temp (temperature) check done on food trays. Resolution of the grievance showed concern was resolved as meals being delivered warmer. A lunch tray temperature check on 09/12/23 at 12:25 p.m. was conducted with Staff B, Cook/Dietary Manger (DM). The temperatures for the lunch tray for a mechanical soft diet showed: - Mechanical Salisbury Steak- 114.2 degrees Fahrenheit (F) - Mashed potatoes with gravy- 130.8 F - Carrots- 114.9 F - strawberries with whip cream- 63.2 F During an interview on 09/12/23 at 12:25 p.m., Staff B, DM stated hot foods should be above 135 degrees for hot foods and 40 degrees for cold foods. Staff B, DM stated, I am only in trouble when the kitchen serves food under 102 degrees so I would say that today's lunch was in a fair state. During an interview on 09/12/23 at 1:20 p.m., the Regional Registered Dietitian (RRD) stated the food at service was not about the temperatures at delivery, it is about palatability. During an additional interview on 09/13/23 at 11:00 a.m., Resident #41 stated she wrote grievances before on cold food but also had a problem with cold food being hot. Resident #41 said for example ice cream was always melted before it gets served and also [gelatin dessert] was melted. Resident #41 stated she worked in the health care field in the past and she knew the food should come out appetizing and it was not. Resident #41 stated the hot food comes out cold and the cold food comes out hot. During an additional interview on 09/13/23 at 11:12 a.m., Resident #343 stated he gets ice cold eggs so he had a box a cereal he will eat when the food wasn't good. Resident #343 also stated another complaint was he liked cold milk but the milk served was never cold it is always pretty warm. An additional observation of the tray line on 09/13/23 at 11:27 a.m. showed trays were prepped with hydration and condiments first. Milk and juices were observed on the trays at 11:27 a.m., with the first trays served to residents in the dining room was at 12:00 p.m. The second tray temperature at delivery with Staff B, DM on 09/13/23 at 12:18 p.m., showed: - Mechanical soft BBQ chicken- 114.1 F - Mechanical soft corn- 116.4 F - Baked Beans- 110.4 F - Orange juice- 70.4 F During an interview on 09/13/23 at 12:19 p.m., Staff B, DM stated the tray line prep starts with desserts, then juices are added and milk to go on the tray last before the plate of food, since milk was stored by the door. Staff B, DM stated the tray prep starts around 11:30 a.m. and the trays go out of the kitchen at 12:00 p.m. Staff B, DM was asked if orange juice served at 70.4 degrees (room temperature) was a reasonable temperature for palatability. Staff B, DM stated the food was appetizing to her and she stated again the food was above 102 degrees. During an interview on 09/13/23 at 1:19 p.m., the facility's Registered Dietitian (RD) stated she would expect the juice to be cold. The RD stated, Temperatures do not matter, it is all based on palatability and if residents like and eat the food. A review of the facility's policy, Record of Food Temperature, revised date 10/19/22 showed, 2. Hot foods will be held at 135 degrees Fahrenheit or greater. 4. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. 8. If the food temperature falls into an unsafe range, immediately follow procedure for reheating cooked food. 10. Ready to eat foods that require heating before consumption should be taken directly from a sealed container or an intact package from an approved food processing source and heated to at least 135 degree Fahrenheit for holding for hot service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The community shower room outside of Resident room [ROOM NUMBER] was observed on 9/11/23 at 7:50 a.m. and 1:00 p.m. The shower room had several dirty towels piled on the sink edge, dirty towels, lying on the floor between the sink and toilet, a basin was under the sink, half in a plastic bag. The basin had dirt and trash inside of it. A roll of toilet paper was sitting on the grab bar above the toilet. There was a pink/brownish color on the sink edge, where the sink attached to the wall. (Photographic Evidence Obtained) The community shower room outside of Resident room [ROOM NUMBER] was observed on 9/11/23 at 8:00 a.m. and 12:55 p.m. The shower room had dirty towels hanging from a pipe between the sink and the shower. (Photographic Evidence Obtained) An interview was conducted on 9/11/23 at 9:00 a.m. with Staff F, CNA. Staff F confirmed the towels in both community shower rooms should not have been there. Staff F stated each CNA was responsible for cleaning up after they were done using the shower for a resident. An observation was made on 9/13/23 at 10:30 a.m. of Staff C, CNA exiting Resident room [ROOM NUMBER] with gloves on. Staff C proceeded to remove the gloves in the middle of hallway as Staff C walked towards Nurse Station #2. Staff C disposed of the gloves in the trash and proceeded to complete hand hygiene. An interview was conducted on 9/13/23 at 10:55 a.m. with Staff C. Staff C confirmed exiting Resident room [ROOM NUMBER] with gloves on. Staff C stated this should not have happened, and gloves were not to be worn in the hallways. An interview was conducted on 9/13/23 at 5:45 p.m. with the Director of Nursing (DON)/Infection Preventionist (IP). She looked at pictures of the used medical gloves around the facility and confirmed it was not okay, and gloves should be thrown in a trash can. When asked about dirty under garments being washed by a resident in the bathroom sink and being left in a shared bathroom she said, Oh my, and agreed it was an infection concern. The DON/IP also confirmed staff should not be wearing gloves in the hall, especially coming in and out of a resident room. She stated that was unacceptable. The DON/IP reviewed pictures of the resident bathroom toilet that has been soiled with feces for three days, she said it is definitely an infection problem. The DON/IP said soiled linen should be bagged up and taken to the soiled laundry immediately and should never be left in a room or on the floor. The DON/IP was unaware of the laundry water temperature not being high enough. Review of a facility policy titled, Laundry, implemented 6/2023, showed the following: Policy: The facility launders linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. Policy Explanation and Compliance Guidelines: 3. Soiled laundry shall be kept separate form clean laundry at all times . 5. Laundry equipment will be used and maintained according to manufacturer's instructions . 7. The facility should use the fabric manufacturer's recommended laundry cycles, water temperatures and chemical detergent products: a. Wash with detergent in a water temperature of 160° (71°C)[Celsius] for at least 25 minutes. b. For laundry that is not hot water compatible, low temperature washing at 71 to 77°F [Fahrenheit] (22-25°C) plus chlorine or oxygen-activated bleach can reduce microbial contamination. 14. Items that can be used for another resident after an individual resident's use must be cleaned and disinfected between use for different residents or replaced or discarded. Review of a facility policy titled, Hand Hygiene, implemented 9/7/22, showed the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice . 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of a facility policy titled, Infection Prevention and Control Program, reviewed 7/13/23, showed the following; Policy: This facility has established and maintains 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 as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 2. All staff are responsible for following all policies and procedures related to the program . 4. Standard Precautions: b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures. c. All staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE . e. Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility and are to report problems outside of their scope to the appropriate department. 11. Linens: e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soil utility room. Soiled linens shall not be kept in the residents' room or bathroom. 15. Staff Education: b. All staff shall demonstrate competence in relevant infection control practices. c. Direct care staff shall demonstrate competence in resident care procedures established by our facility. Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed on two of two units, in the dining room, and in the laundry room, related to used medical gloves being left on the floor and ground, staff wearing gloves in the hall, laundry not being sanitized, dirty laundry being left hanging in shared resident bathrooms, and soiled linen being left in rooms. Findings included: An observation was made on 9/11/23 at 7:15 a.m. of a used medical glove on the floor outside of Resident room [ROOM NUMBER]. An observation was made on 9/11/23 at 7:19 a.m. of a used medical glove on the ground in the smoking courtyard. The glove remained on the ground on 9/12/23 at 1:19 p.m. An observation was made on 9/11/23 at 7:24 a.m. of a trash can overflowing in Resident room [ROOM NUMBER] with two used medical gloves on the floor near the sink. An observation was made on 9/11/23 at 8:31 a.m. of feces on the toilet and floor in the bathroom of Resident room [ROOM NUMBER]. On 9/13/23 at 6:13 p.m. the feces remained on the toilet and floor. An observation was made on 9/12/23 at 1:23 p.m. of a soiled washcloth in the dining room on a shelf by the television. An observation was made on 9/13/23 at 2:57 p.m., of a nurse at the Unit 1 medication cart with medical gloves on. The nurse was handling things on the cart then picked up a bag of trash, tied it up and carried it to the soiled utility room. The nurse continued to wear the gloves coming back into the hall then proceeded to enter a resident's room and came out with the same pair of gloves on. The nurse then removed the gloves and disposed of them. On 9/13/23 at 3:00 p.m., an interview was conducted with Staff L, Licensed Practical Nurse (LPN). When asked about wearing gloves in the hall, Staff L said I threw them away. When asked about putting trash away then going into a resident room Staff L added, it was just trash and regarding when he went in the resident's room, Staff L said I didn't touch anything. On 9/13/23 at 2:47 p.m., a tour of the laundry room was completed with Staff H, Certified Nursing Assistant (CNA). Upon entering the laundry room there was one commercial washing machine and one personal model washing machine. The personal model machine had dirt, hair, and debris around the opening and inside the lid. Staff H said the personal model machine was used for washing tablecloths, clothing protectors, and mops. She said staff used detergent and softener only in the machine. She confirmed no sanitizer was used in the machine. The personal model washing machine was being run on hot water, heavy soil level, normal cycle and two rinses. It was also observed there was nothing separating the soiled laundry from the clean laundry side. The plastic strips that were in place to be used as a divider were tucked behind clothing racks, so they were not covering the door opening. Staff H confirmed the plastic dividers should be down covering the door opening. When Staff H pulled the dividers down, they were stuck together and folded up. In the clean laundry side, there were two commercial dryers running. The lint filters in each were full. Staff H provided the sign off sheet saying the lint filters were cleaned hourly by the laundry manager. The lint filter sign off was completed every hour including 9/13/23 at 3:00 p.m. and 4:00 p.m., time that had not passed yet. An observation was also made of a rack of clean clothing that was not covered. The cover for the cart that should be used was folded on top with blankets piled on top of it. An interview was conducted on 9/13/23 at 3:15 p.m. with the Maintenance Director, who oversees laundry services. The Maintenance Director said he had not checked the temperature of the personal model washing machine. He was observed getting a thermometer and going to the laundry room. He disconnected the water hose and checked the temperature of the hot water running to the machine and the highest temperature reading was 145.6 degrees Fahrenheit. The Maintenance Director confirmed the personal model washing machine was used to wash table clothes, clothing protectors for residents, and mops. He stated no sanitizer was used in the machine. An interview was conducted on 9/13/23 at 3:20 p.m. with the Laundry Manager. She said she cleaned the lint traps on the dryers. She looked at how full the lint traps were and said they probably had not been cleaned since at least lunch. When asked why the sign off sheet was completed for every hour for the entire day, she said she, accidently signed them off yesterday. A follow-up interview was conducted on 9/13/23 at 6:06 p.m. with the Maintenance Director. He confirmed the hot water to the laundry was set too low and should be turned up to 165 degrees Fahrenheit. 2. An observation on 09/11/23 at 7:47 a.m., showed blue underwear hanging on a towel rack in the shared bathroom between Resident rooms [ROOM NUMBERS]. (Photographic Evidence Obtained) During an interview on 09/11/23 at 7:47 a.m., Resident #344 stated the underwear belonged to Resident #8. Resident #344 stated, Resident #8 washed them in the sink and was letting the underwear hang dry. During an interview on 09/11/23 at 8:50 a.m., Resident #8 stated the blue underwear was hers and she washed them out in the sink and left them to dry. Resident #8 stated she was being discharged tomorrow and wanted them clean for when she got discharged tomorrow. An observation on 09/11/23 at 9:17 a.m., showed a pair of used gloves on the corner of bed B in Resident room [ROOM NUMBER]. (Photographic Evidence Obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure that a care plan was developed related to behaviors for one resident (Resident #41) out of the sampled twenty-five residents. Findings included: On 07/27/21 at 10:55 a.m., Resident #41 was observed sitting at the table in the main dining room. The resident appeared calm. He was dressed for the day. Resident #41 replied yes when asked if he was ok. Resident #26 was observed in the main dining room sitting at a table during this time also. When asked was everything ok, he stated yes except for that nasty man while pointing at Resident #41 and he proceeded to use profanity related to the behaviors of Resident #41. Resident #26 stated Resident #41 was nasty and was always messing with his private parts in the front of everyone. A review of the admission Record for Resident #26 revealed that he was admitted into the facility on [DATE] with a primary diagnosis of unspecified dementia with behavioral disturbance. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderately impaired. Resident #38 was seated at the table with Resident #26. She stated, Yes he is always doing that. He shows his vagina. I mean . You know what I mean. A review of the admission Record for Resident #38 revealed that she was admitted into the facility on [DATE] with a primary diagnosis of schizophrenia. Section C Cognitive Patterns of the MDS dated [DATE] indicated that the resident had a BIMS score of 15 out of 15 indicating cognitively intact. The Activities Director was in the main dining room at this time also and confirmed the accusations. He stated that they redirect him as much as they can and take him to his room if it gets too out of hand. On 07/27/21 at 12:55 p.m., Staff D, Certified Nursing Assistant (CNA), stated that the resident was always digging in his backside, and he touches his private area. Staff D reported when the resident displays this type of behavior, she walks away. If you leave him and go back to check on him, most times he would be calm. She stated that they try to redirect him and let him know that the behavior was not appropriate. She had observed this behavior at least two times a day. On 07/27/21 at 3:12 p.m., Staff C, Licensed Practical Nurse (LPN), stated Resident #41 was a lot calmer now. She stated when he ambulates, he touches a lot. At one point he would come out in the hall and urinate instead of going into the bathroom. Staff C reported that she has gotten report that he takes his pants down, but she had not seen him do it. On 07/28/21 at 11:30 a.m., Resident #41 was observed sitting in the main dining room at the table with three other residents. The resident was observed spitting on the floor. On 07/28/21 at 11:35 a.m., the Activities Director reported that the resident displayed these behaviors all over the facility. He stated that the resident had his hands in his pants today in the main dining room and multiple residents were in the dining room at that time. The Activities Director stated Resident #41 did not expose himself, but he was digging in the front and the back with his hands in his pants causing an uproar with the other residents. He stated that the resident said he was fixing his pants when he tried to redirect him. On 07/28/21 at 2:53 p.m., Staff J, LPN Unit Manager, reported that she was not aware of Resident #41 displaying any inappropriate behaviors. A review of the admission Record reflected that Resident #41 was admitted into the facility on [DATE] with an admitting diagnosis of Alzheimer's Disease. Section C Cognitive Patterns of the quarterly Minimum Data Set (MDS) dated [DATE] indicated that Resident #41 had a BIMS score of 99 indicating that the resident was unable to complete the interview. This section also indicated that the resident had short term and long-term memory problems. Section E Behaviors indicated that Resident #41 displayed only verbal behavioral symptoms directed towards others 1 to 3 days. The resident had the following active orders as of 07/29/21: Target Behavior Monitoring for Depakote: Monitor resident for pacing and agitation; Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG- Give 1 capsule po (by mouth) two times a day for mood. A review of the Behavior Monitoring Charts for May, June, and July 2021 indicated that the resident did not display any of the mentioned behaviors. A review of the Point of Care Responses for Behavior Symptoms reflected that Resident #41 had a behavior of wandering and grabbing on three days in the last 30 days. Section 13 AIMS/Mood/Behavior of the Quarterly Nursing Comprehensive Evaluation dated 06/26/21 indicated that the resident was calm and did not have any behaviors. A review of the Progress Notes from May 2021 to current did not reflect any documentation related to the behaviors displayed by the resident. A review of the care plans revealed that Resident #41 did not have a care plan in place for behaviors. On 07/28/21 at 2:07 p.m., the Director of Nursing (DON) stated that Resident #41 likes to pick in his clothing, touches his bowel, and act as if he's finger painting with it. The DON reported that he also urinates in the corner of his room, and he spits. She stated that she cannot explain why it was not on the care plan or documented in the record, but it was reported to psych, and he made a medication adjustment. On 07/29/21 at 11:55 a.m., an interview via the phone with the psych Advanced Practice Register Nurse (APRN) revealed that he was familiar with Resident #41. He stated that Resident #41 needed redirection and he was incontinent. The psych APRN stated that Resident #41 was up at night, so he started him on Depakote. He reported that he was not aware of any inappropriate behaviors, and he was not aware of the resident urinating on the floor or digging in his pants in the front of others. The psych APRN stated that he would expect the behaviors to be documented in the medical record.

Based on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and four errors were identified for three (3) (Resident #10, #23 and #46) of six (6) residents observed. These errors constituted a medication error rate of 16 percent. Findings included: A facility provided policy titled, Administering Medications, revision date April 2019, Policy and Procedure, Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 10. The individual administering medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) before giving the medication. On 07/28/21 at 09:25 a.m., and observation was conducted of Staff A, Licensed Practical Nurses (LPN) administering medication to Resident #10. During the observation Staff A, (LPN) was seen administering Isosorbide Mononitrate ER Extended Release (ER) Tablet and Potassium Chloride Extended Release (ER) Tablet 10 MEQ. Both medication labels had written instructions of Do Not Crush. Staff A, (LPN) was observed to place the tablets in a clear packet and crushed the Extended Release (ER) medications and then place them in chocolate pudding in a clear medication cup with the other 9:00 am medications and administered them to Resident #10. An immediate interview was conducted with Staff A, (LPN), who revealed that she did realize they were extended Release (ER) medications and should not be crushed. On 07/28/2021 at 11:06 a.m., an observation of medication administration with Staff B, (LPN) was conducted with Resident #23. Staff B, (LPN) had obtained a Blood sugar reading of 278 at 10:45 a.m., prior to the observation. Staff B, (LPN), administered KwikPen U-100 Insulin (Lispro) 1-Unit Dial Insulin Pen; 100 units/milliliter (mL); six (6) units to Resident #23's in his right upper arm. Staff B, (LPN) was not observed priming the KWIKPEN with two (2) units prior to administering the insulin injection. According to manufacture instructions for Insulin Lispro Injection KwikPen http://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf, Priming Your Pen: Priming your pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. A second observation was conducted of Staff B, (LPN) performing insulin administration on Resident #46. Staff B, (LPN) indicated that she did not need to perform a Blood Sugar value before administering insulin to the resident. She administered twenty (20) Units Levemir FlexTouch Solution Pen Injector 100 Unit/ML (Insulin Detemir) to the resident. After medication administration, an immediate interview was conducted with Staff B, (LPN), and she was asked why she did not prime the insulin pen for both Resident #23 and #46 insulin injectors. Staff B, (LPN) stated You do not have to prime the pen, because when you put the top on and dial it up it retracts, so there is no need to prime the pens before dialing the insulin up. Review of manufacturer Novo Nordisk manufacturer instructions of usage and safety guidelines: https://www.novomedlink.com/content/dam/novonordisk/novomedlink/resources/generaldocuments/LevemirIFU.pdf, FlexTouch prefilled insulin pens, Priming our Levemir FlexTouch Pen: Step 7: Turn the dose selector to 2 Units Step 8: Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top, Step 9: Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. -A drop of insulin should be seen at the needle tip. -If you do not see a drop of insulin repeat Steps 7 to 9, no more than six times, -If you still do not see a drop of insulin change the needle and repeat steps 7 to 9. Record review of active physician orders for the Resident #46 revealed Levemir FlexTouch Solution Pen Injector 100 Unit/ML (Insulin Detemir) Inject 20 units subcutaneously in afternoon for Diagnosis of Type 2 Diabetes, date 4/20/2021. An interview was conducted with the Director of Nursing (DON) on 07/28/2021 at 12:17 p.m. The DON was notified of the medication administration observations made of Staff A, (LPN) and Staff B, (LPN). The DON revealed that all flex pens/insulin pens need to be primed with two (2) units before each use. She further stated that the nurse should have not crushed medications not be crushed. On 07/29/20211 at 12:08 p.m., a telephone interview was conducted with the Pharm-D, Pharmacy Consultant. The Pharmacy Consultant was informed of observations made of Staff A (LPN) and Staff B (LPN) during medication administration. The Pharmacist stated As far as crushing Extended-Release Medications, it damages the tablets and is not acceptable to crush and administer. She further revealed and stated, The insulin dose may not have been accurate without priming with two (2) units, because insulin fills the pen needle and old insulin that may have remained in the pen is gone, for a clean dose to be administered to the residents.

Based on observations, record review, and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety regarding not dating pre-made sandwiches on one of one tray observed in the walk-in refrigerator, not documenting food temperatures prior to serving for one out of eleven meals on the temperature log, and not ensuring food from an outside source was stored with a use-by date and labeled with the owners name in one of one nursing station refrigerator. Findings included: On 7/27/21 at 9:15 a.m., an initial tour of the kitchen was conducted with the Kitchen Manager (KM). A three-quarter filled tray of pre- made turkey and cheese half sandwiches was observed in the walk-in refrigerator. The observation identified that none of the sandwiches or the tray was dated as to when they were assembled. The KM confirmed that the sandwiches were undated, he picked up the tray, looked at it and stated there isn't a sticker. The KM left the walk-in refrigerator and placed a sticker with a date on the tray. An observation was conducted, on 7/28/21 at 11:30 a.m., with Staff Member I, cook, obtaining the temperatures of the food that was to be served to residents for the lunch meal. Neither the staff member nor the KM documented the temperatures of food on the log as they were obtained. Approximately half way through the process the KM started filling out the log with temperatures. As he wrote down the temperature readings for the lunch meal, it was observed that the breakfast temperatures for 7/28/21 were not documented. The KM confirmed those findings. The cook stated she had taken the temperatures but had written on a piece of paper that had been thrown away. The cook stated it's on me. On 7/29/21 at 10:56 a.m., an observation was conducted with the Director of Nursing (DON) of one of one unit refrigerator reserved for residents. A bag of green grapes were observed in grocery store plastic bag and an opened bottle of water that was not labeled with a name or date. The grapes were identified by a resident name and the date of 7/18 (eleven days prior to the observation). The items were returned to the refrigerator and the DON stated that the items should be labeled with a resident name and a date. The policy, Food Preparation, revised October 2019, indicated that all foods are prepared in accordance with the guidelines of the FDA Food Code. The policy identified that Temperature for Time/Temperature Control for Safety (TCS) foods recorded at time of service, and monitored periodically during meal service periods as indicated. The policy, Food brought by Family/Visitors, undated, indicated that Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, current date/time, and the use by date. The policy identified that the nursing staff was responsible for disposing of perishable foods on or before the use by date.