Based on observations, staff and resident interviews, record review, and review of the facility policies titled Resident Rights, Dining and Meal Service, and Quality of Life-Dignity, the facility failed to ensure that dining practices supported and maintained the dignity and person-centered preferences for two of 49 sampled residents (R) (R43 and R53). This deficient practice had the potential to place R43 and R53 at risk of a decreased sense of dignity, autonomy, and person-centered care. Findings include:Review of the undated facility policy titled Resident Rights revealed the Policy Interpretation and Implementation section included, 1. b. be treated with respect, kindness, and dignity.Review of the policy titled Dining and Meal Service, revised 4/5/2024, revealed that The dining experience will be person-centered with the purpose of enhancing each individual patient's/resident's quality of life and being supportive of everyone's needs during dining.Review of the policy titled, Quality of Life-Dignity, undated, revealed under section 2. 'Treated with Dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth, and further review of section 11. Demeaning practices and standards of care that compromise dignity is prohibited.1. Review of the Quarterly Minimum Data Set (MDS) assessment for R43, dated 7/7/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident was independent with eating. 2. Review of the Quarterly MDS assessment for R53, dated 7/1/2025, revealed Section C (Cognitive Patterns) documented a BIMS score of 9 (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident was independent with eating. Observations on 9/10/2025 at 11:37 am and 5:16 pm revealed that during both lunch and dinner meals in the main dining room, all residents were observed eating directly from serving trays placed on the tables. Further observations revealed that plate warmers remained under the dishes throughout the entire meal. In an interview on 9/10/2025 at 12:19 pm, R43 revealed that meal serving trays had been used in the dining room for some time and stated she did not care for the tray or plate warmer. She stated that food gets caught between the plate and the warmer. She also stated she has never been asked if she prefers the tray.In an interview on 9/10/2025 at 2:02 pm, R53 revealed that she dislikes the serving trays and prefers the food plate to be placed directly on the table. She stated that she preferred a tray-free dining experience.In an interview on 9/10/2025 at 12:01 pm, Licensed Practical Nurse (LPN) JJ revealed that the serving trays and plate warmers stayed on the table and further stated that was how it had always been done at the facility. In an interview on 9/10/2025 at 12:06 pm, the Activities Assistant revealed that she always leaves the serving trays on the tables and had not been instructed otherwise.In an interview on 9/10/2025 at 12:10 pm, the Activities Director confirmed that serving trays were never removed and acknowledged that she wouldn't consider it home-like. She stated that it was just how it had always been done.In an interview on 9/10/2025 at 12:18 pm, the Director of Nursing (DON) confirmed that serving trays were always used and was uncertain whether they contributed to a home-like environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's policy titled Hazardous Area, Devices, and Equipment, the facility failed to ensure an environment free from hazards in three of 30 rooms on the 100 Hall. This deficient practice had the potential to place the residents residing in the rooms at increased risk of exposure to harmful substances and items. Findings include:Review of the facility's undated policy titled Hazardous Area, Devices, and Equipment revealed the Policy Interpretation and Implementation section included, 1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the Safety Committee. The Identification of Hazards section included, 1. A hazard is identified as anything in the environment that has the potential to cause injury or illness. c. sharp objects that are accessible to vulnerable residents. g. access to toxic chemicals.Observation on 9/9/2025 at 10:28 am in Resident room [ROOM NUMBER] revealed a manual razor on the resident's nightstand.Observation on 9/9/2025 at 10:41 am in Resident room [ROOM NUMBER] revealed alcohol wipes and a manual razor on the resident's nightstand, and an aerosol spray on the bedside table.Observation on 9/9/2025 at 11:47 am in Resident room [ROOM NUMBER] revealed alcohol wipes and an aerosol spray on the resident's nightstand.During a walking-through observation and interview on 9/9/2025 at 2:25 pm, Unit Manager/Licensed Practical Nurse (UM/LPN) AA confirmed the manual razors in Resident rooms [ROOM NUMBERS] were to be kept on each nursing cart or in the shower room. UM/LPN AA confirmed that the alcohol wipes and aerosol sprays in Residents' rooms [ROOM NUMBERS] should not be in the rooms. UM/LPN AA stated environmental rounds from leadership were conducted on a weekly basis, and the nurses and CNAs were expected to round daily. During an interview on 9/10/2025 at 2:27 pm, the Administrator and Director of Nursing (DON) stated that each administration personnel was assigned a room to conduct rounds to ensure hazardous products were not in the resident's room. The DON stated that if items were found, the residents were educated, and the items were removed. The Administrator confirmed the identified items should not be in residents' rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of the facility policy titled Dining and Meal Service, the facility failed to ensure one of 13 residents (R) (R117) with pureed diet orders was served a diet in accordance with the physician's orders. This deficient practice had the potential to place R117 at risk of medical complications and a diminished quality of life. Findings include:Review of the facility policy titled Dining and Meal Service, revised 4/5/2024, revealed the Policy section included, . Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutritional and special dietary needs. The Procedure section included, . 8. Food will be at the proper texture/consistency to meet everyone's needs and desires.Review of the admission Record revealed R117 was admitted to the facility on [DATE] with diagnoses including, but not limited to, type 2 diabetes with unspecified complications, Alzheimer's disease, cerebral infarction, hemiplegia, and hemiparesis.Review of the admission Minimum Data Set (MDS) for R117, dated 9/7/2025, revealed Section K (Swallowing and Nutritional Status) documented that the resident received a mechanically altered diet. Review of the Physician's Orders for R117 revealed an order dated 9/2/2025 for a reduced concentrated sweets diet, no added salt, pureed texture, and nectar consistency. Review of the resident's tray card, printed on 9/9/2025, confirmed R117's prescribed diet was pureed texture. Review of a facility-provided document titled Diet Type Report, dated 9/10/2025, revealed R117 was listed as requiring a pureed diet texture. Observation on 9/9/2025 at 12:46 pm revealed that R117 was served a regular consistency diet at the lunch meal.During an interview on 9/9/2025 at 1:21 pm, Certified Nurse Assistant (CNA) VV confirmed she delivered the lunch meal tray to R117, and it was a regular consistency meal and should have been a pureed consistency meal. During an interview on 9/10/2025 at 1:09 pm, Dietary Aide TT stated her responsibility as the final checker on the tray preparation line was to ensure that the tray and meal ticket corresponded. Dietary Aide TT acknowledged the error she made and indicated that she was moving too quickly. During an interview on 9/10/2025 at 1:13 pm, the Food Service Manager (FSM) acknowledged being aware of the error regarding the resident's meal tray and diet order, which consisted of a regular diet instead of a pureed one. The FSM indicated that the risk associated with R117 meal conflicting with the physician's order could lead to choking.

Based on observations, staff interviews, record review, and review of the facility policies titled Handwashing/Hand Hygiene and Handling of Linen, the facility failed to ensure infection control practices were followed during disposal of soiled items, resident equipment maintenance, during laundry processes, and during meal tray delivery. These deficient practices had the potential to place the residents residing in the facility at increased risk of infections due to cross-contamination. The facility census was 100. Findings Include: Review of the facility's undated policy titled “Handwashing/Hand Hygiene” revealed the “Policy Statement” stated, “This facility considers hand hygiene the primary means to prevent the spread of infections.” The “Policy Interpretation and Implementation” section included, “… 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. … 6. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.” Review of the facility's undated policy titled “Handling of Linen” revealed the “Infection Control” section included, “… 3. Never bring soiled linen into washroom while clean linen is exposed.” 1. Observation on 9/10/2025 at 9:40 am revealed Certified Nursing Assistant (CNA) LL transporting soiled linen and trash in bags through the hallway while wearing gloves. She used her gloved hand to punch in a code on a keypad to access the soiled utility room, removed her gloves, and did not perform hand hygiene. Further observation at 10:03 am revealed CNA LL discarding the soiled items without performing hand hygiene upon exiting the soiled utility room. In an interview on 9/10/2025 at 9:40 am, CNA LL confirmed she wore gloves while transporting soiled bags to the soiled utility room and touched the room's keypad with the soiled gloves. She confirmed she did not perform hand hygiene after discarding the soiled bags and removing her gloves. 2. Observations on 9/10/2025 at 11:10 am of the Laundry Room, conducted with the Environmental Services (EVS) Director, revealed more than nine open boxes of clean clothing stacked against a wall on the dirty side of the Laundry Room. Observation revealed that the clothing was overflowing from the boxes and in direct contact with the wall. Further observation revealed that one table, designated for folding clean linens, was cluttered with non-linen items, including binders, food, a microwave, drinks, and various office supplies. Food crumbs were visibly present, and clean linens were observed to be in contact with these items. In an interview on 9/10/2025 at 11:10 am, the EVS Director revealed that the clean clothing had been accumulating along the laundry room wall for over three years. She stated that staff routinely rummaged through the clothing to distribute items to residents. She acknowledged that storing clean clothing on the dirty side of the laundry area posed an infection control risk and stated she planned to relocate the items. Additionally, she confirmed that the table designated for folding clean linens should not be used for any other purpose and agreed that food, drinks, a microwave, binders, and office supplies should not be on the table. In an interview on 9/10/2025 at 5:00 pm, the Infection Preventionist (IP)/Assistant Director of Nursing (ADON) stated that staff should perform hand hygiene before and after entering resident rooms, and after removing gloves. The IP/ADON confirmed that clean clothing should not be stored on the dirty side of the laundry room, and stated that those items would then be considered contaminated and should be re-laundered. She further stated that the table designated for folding clean linens should not be used for items such as binders, food, drinks, a microwave, or office supplies. She stated that these practices were not in compliance with the standards for infection control. 3. Observations on 9/9/2025 at 12:07 pm, of the 100 Hall, revealed CNAs delivering meal trays between residents' rooms without performing hand hygiene.During an interview on 9/9/2024 at 12:19 pm, CNA BB, CNA CC, and CNA DD confirmed they did not sanitize their hands between resident rooms during meal tray delivery. They stated they were not aware that they should. During an interview on 9/10/2025 at 2:11 pm, the IP/ADON stated the staff received infection control education during orientation and monthly in-services on hand hygiene. The IP/ADON continued to state that the staff should be aware to perform hand hygiene between trays while delivering meal trays. During an interview on 9/10/2025 at 2:47 pm, the DON stated the staff should perform hand hygiene between meal tray passes on the halls and in the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that the medical record documentation was completed and/or accurate for one of three residents (R) (R2) reviewed for pressure ulcers. Findings included: A review of the electronic medical record (EMR) revealed that R2 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and unspecified diarrhea. A review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/31/2024 revealed that R2 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS assessment revealed that R2 had an unstageable pressure ulcer that was present on admission. A review of the Care Plan Report dated 6/10/2024 revealed that R2 had a pressure ulcer or potential for pressure ulcer development due to immobility. Interventions directed staff to provide weekly treatment to include measurement of each area of skin breakdown. A review of the Treatment Administration Record (TAR) dated June 2024 revealed an order entry with a start date of 6/1/2024 and an end date of 6/28/2024 that directed staff to clean R2's sacrum wound with wound cleanser, pat dry, apply skin barrier and then Santyl ointment, and secure with a silicone dressing daily. The TAR lacked documentation to indicate whether the treatment was provided on 6/1/2024, 6/2/2024, 6/4/2024, or 6/9/2024. During an interview on 4/11/2025 at 7:58 am, Licensed Practical Nurse (LPN)4 stated she was certain that she performed the sacral wound treatment for R2 on 6/4/2024 but became distracted and did not sign the TAR afterwards. She stated she was trained to document work once it was completed. During an interview on 4/15/2025 at 12:00 pm, the Administrator stated she expected all treatments to be documented after completion.

Based on observations, interviews, and a review of the facility policy titled, Floor Care, the facility failed to ensure that the shower rooms were maintained in a clean condition and free from dark brown to black fuzzy and slimy substances on the walls in two of the two halls (Hall 100 and Hall 200). Findings included: An undated facility policy titled, Floor Care, revealed, MONTHLY CARE - All bathroom ceramic tile floors should be scrubbed with a buffing machine or appropriate scrubbing brush (depending on size of the floor-- a buffing machine may not fit in smaller bathrooms). A combination of cleanser with bleach and warm water should be used when scrubbing. Bleach cleanser will help to clean and disinfect difficult-to-reach grout areas and will help prevent bacterial growth. An observation on 4/9/2025 at 4:15 pm of the shower rooms on the 100 and 200 Halls revealed dark brown to black fuzzy and slimy substances on the walls in each of the shower units near cracks in the grout/caulking. The shower rooms had a slightly musty odor. During a concurrent observation and interview on 4/9/2025 at 4:30 pm, the Maintenance Director confirmed the observation of the black substance on the shower room walls. He stated he performed monthly pressure washing and scrubbing of the walls of the shower rooms and used a sprayer to get rid of the black substance, and was not sure how those areas were missed. He stated he would shut down the shower rooms and perform cleaning. During an interview on 4/9/2025 at 5:36 pm, the Administrator stated the nursing department was responsible for tidying up the shower room after providing a shower, and maintenance was to perform a monthly deep cleaning of the shower room. She stated that monthly cleaning should include an inspection of unsanitary/unclean areas in each shower room, and that if any black-colored substance is located, the shower should be taken out of operation immediately and cleaned that day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the facility policy titled, Oxygen (O2) Administration, the facility failed to administer O2 therapy as ordered for one of 20 residents (R) (R21) receiving O2 therapy. The deficient practice had the potential to place R21 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the undated facility policy titled Oxygen Administration revealed under the section titled Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Section titled Preparation 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Under section titled Steps in the Procedure . 6. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Review of this policy also revealed that it did not include policies and procedures for maintaining O2 concentrators (machine that produces O2), proper storage of O2 devices (i.e. mask, nasal cannula (NC) and/or nasal catheter), and nursing staff responsibilities for assuring that the flow of O2 is at the level ordered. Review of the electronic medical record (EMR) revealed R21 was admitted to the facility with diagnoses including, but not limited to heart failure, morbid (severe) obesity due to excess calories, hypertension, transient cerebral ischemic attack, and sleep apnea. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating R21 was cognitively intact. Section O-Special Treatments and Programs revealed resident receives O2 therapy while a resident. Review of R21's Physician's order dated 1/9/2024 for oxygen (O2) at 2 (liters) L per (nasal canula) NC to keep O2 above 92% [percent]. Observation on 5/28/2024 at 10:00 am of R21, the resident had an O2 concentrator at bedside, turned on at 3 liters per minute (LPM). Observation on 5/29/2024 at 8:19 am, R21 was resting in a recliner chair in her room with O2 via NC in place at 3 LPM. Observation on 5/29/2024 at 2:00 pm, R21 was reclined back in a recliner chair in her room, dozing off to sleep with O2 in place via NC at 3 LPM. Staff Interview/Walking Rounds on 5/29/2024 at 2:02 pm with LPN AA confirmed that R21's O2 was at 3 LPM and immediately turned the O2 down to 2 LPM. She stated that the resident sometimes adjusts the machine herself when she feels it's not pushing out enough. She also revealed that residents that were receiving O2 were to have pulse oximetry (O2 saturation test) checks as ordered. Interview on 5/30/2024 at 10:35 am with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed that she and the Unit Managers do daily rounds and check O2 concentrators and settings of residents that are receiving O2. She stated that the nurses were primarily responsible for checking the settings of the O2. Interview on 5/30/2024 at 2:13 pm with the Director of Nursing (DON), she stated that her expectation was for nurses to follow the Physician's orders. She also revealed that the nurses were to monitor O2 levels every shift, especially when doing assessments and passing medications. She also stated that when residents were self-adjusting O2, they should be care planned for such actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility policy titled, Water Temperatures, Safety of, the facility failed to maintain a safe, clean, comfortable, homelike environment related to water temperatures above 110 degrees Fahrenheit (F) on one of two wings in the facility affecting 27 resident rooms and the shower room, and failed to change bed linen for one resident (R) (R103). The deficient practice had the potential for water over 110 degrees F to cause skin burns. Findings include: 1. Review of the undated facility policy titled Water Temperatures, Safety of, under policy Interpretation and Implementation revealed, 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 degrees F, or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e. hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. Review of undated facility document titled Job Description and Performance Evaluation-Maintenance Director revealed, 4. Ensure that the plant and equipment are properly maintained for patient/resident comfort and convenience. 8. Inspect the facility, on a regular basis, to ensure that the grounds, facility, and equipment are maintained in accordance with established policies and procedures and all hazardous areas properly identified. Review of the facility's Weekly Water Temperature logs from October 2023 to May 2024 revealed several temperatures that were above the stated 110 degree F facility policy. Review of the facility's Weekly Water Temperature logs for Wing 100 revealed within range temperatures. Observations on 5/28/2024 between 11:06 am and 11:56 am during the initial tour of the facility and screening of the residents revealed water temperatures over 110 degrees F in resident rooms on the 200 wing as follows: room [ROOM NUMBER] hot water temperature from the sink was 119.3 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.7 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.3 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 121.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 115.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.4 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.4 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.4 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.2 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.6 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.7 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 116.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 119.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.5 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 121.0 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 121.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 121.1 degrees F. room [ROOM NUMBER] hot water temperature from the sink was 120.1 degrees F. Observation on 5/28/2024 at 12:01 pm revealed the shower room sink temperature was 121.4 degrees F, shower one had a water temperature of 120.3 degrees F, and shower two had a water temperature of 119.8 degrees F. Interview on 5/28/2024 at 11:50 am with R412 in room [ROOM NUMBER], the resident stated, the water is too hot sometimes. He denied any burns or injuries from the water temperature. Interview during walking rounds on 5/28/2024 at 10:59 am with the Maintenance Director (MD), he was notified of the water feeling hot. Water temperatures were taken in all rooms on Wing 200. The MD verified that the water temperatures were high and out of compliance with the facility policy. The MD admitted that the mixing valve had been giving him issues for a couple of months and that he had been trying to regulate the water temperatures by the valves. He also revealed that he had checked temperatures last week, in the early am, and temperatures were fine. He was then asked for the temperature logs to show these temperatures. He stated that he was going to turn off the hot water immediately. Interview on 5/28/2024 at 5:48 pm with the Administrator, she was notified of the water temperature concerns and revealed that she was just made aware of the findings by the MD. She stated that the hot water to Wing 200 was currently turned off and will not be in used until the part was ordered to fix the water temperature issue. When asked what her plan was for resident care and the availability of hot/warm water, she revealed that the staff had been made aware that hot water would not be available on Wing 200 and that staff would have to get hot/warm water from Wing 100, which was not affected by the malfunctioning part. She also stated that residents would be taken to Wing 100 for showers and baths. She also revealed that she was not aware of any water temperature issues prior to the survey. She stated that the part had been ordered and was expected to arrive this week. 2. Interview on 05/28/2024 at 12:11 pm with R103 revealed that they received a shower on 5/27/2024, but staff did not change bed linens. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for R103, documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating that the resident is cognitively intact. Interview on 5/30/2024 at 1:15 pm R103 stated that staff had not changed her bed linens. Review of the Task section of electronic medical records (EMR) revealed that R103 received showers on 5/28/2024 at 9:30 pm, and on 5/29/2024 at 2:59 pm. Interview on 5/30/2024 at 1:20 pm with Certified Nursing Assistant (CNA) BB, she stated that bed sheets must be changed each time a resident received a shower. R103 was scheduled for evening showers and staff from the evening shift were responsible for changing bed linens. Interview on 5/30/2024 at 2:25 pm with DON revealed that the bed sheets should be changed on shower days. If a resident complained that sheets did not get changed after two previous showers, then this was grounds for in-service education and an employee write up. If CNAs note the need for deep bed cleaning, they would notify the Environmental Department and coordinate scheduling of the cleaning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission Record for R#52 revealed the facility admitted the resident on 6/10/22 with diagnoses of major depressive disorder and anxiety disorder. A review of the Preadmission Screening/Resident Review (PASRR) Level 1 Assessment, dated 5/6/22, revealed the screening did not reflect the resident's diagnosed mental illness. Further review of the form revealed No was documented for depressive and anxiety disorders. A review of the Minimum Data Set (MDS) dated [DATE], revealed R#52 had active diagnoses of anxiety disorder, depression, and psychotic disorder. Further review revealed the resident received antipsychotic medications on a routine basis since admission, readmission, or since the prior assessment. A review of a Care Plan, dated 6/11/22 and revised 6/17/22, revealed the facility developed a care plan for R#52's antipsychotic, antianxiety, and antidepressant medication use. During an interview on 7/19/22 at 2:46 p.m., the Director of Admissions revealed she was responsible for uploading the PASRR into the medical record. She further stated she did not review the document for accuracy and would not know if the PASRR accurately reflected the resident's diagnoses. During an interview on 7/19/22 at 4:22 p.m., the MDS Coordinator stated she was responsible for inputting resident diagnoses into their electronic medical record (EMR). She stated she may look at the front of the PASRR and compare the diagnoses with the hospital records but stated she did not know anything about the PASRR or who was responsible for completion or accuracy of the form. During an interview on 7/20/22 at 11:57 a.m., the Social Worker stated she had been told that she was responsible for PASRR's but had not received information on what her responsibility included. The Social Worker further stated she had received access to the computer system to look up PASRR's at the end of June 2022 and was still waiting for training on how to use the system. During an interview on 7/21/22 at 1:03 p.m., the Administrator stated the Social Worker was responsible to ensure that residents' PASRR Level 1 was accurate at the time of admission. The Administrator further stated the Social Worker had not received training and did not obtain access to GAMMIS (Georgia Medicaid Management Information System), the computer system where PASRR approvals were accessed, until the end of June 2022. Based on interviews, record review, and facility policy review, the facility failed to ensure the level one Preadmission Screening and Resident Review (PASRR) accurately reflected diagnosed mental illnesses for two of three sampled residents (R) (R#25 and R#52) who were reviewed for PASRR. Findings include: A review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, dated December 2017, revealed, Policy: This center 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 [sic] care and services in the most integrated setting appropriate to their needs. The Policy Explanation and Implementation section - Item 5 indicated, The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 1. A review of the admission Record for R#25 revealed the facility admitted the resident from an acute care hospital on 6/17/20 with diagnoses including bipolar disorder, anxiety disorder, and major depressive disorder. A review of a History and Physical from R#25's hospital admission on [DATE], revealed R#25 home medications included Seroquel (an antipsychotic medication prescribed to treat mental illness), sertraline (an antidepressant medication), and alprazolam (an antianxiety medication). A review of R#25's Preadmission Screening/Resident Review (PASRR) Level 1 Assessment Form, dated 6/17/20, included a question regarding whether the resident had a primary diagnosis of serious mental illness, developmental disability, or related condition. A response of No was entered for bipolar disorder, depressive disorder, and anxiety disorder. A review of R#25's admission Minimum Data Set (MDS) dated [DATE], revealed R#25 had diagnoses of bipolar disorder, anxiety disorder, and depression and received psychoactive medications on a routine daily basis. A review of a Care Plan, dated 6/17/20 and revised 1/20/22, revealed R#25 had a diagnosis of bipolar disorder and schizoaffective disorder and was on a daily antipsychotic medication. A review of R#25's active physician orders in the electronic medical record (EMR) revealed that R#25 had active orders for a mental health evaluation as needed; quetiapine fumarate (Seroquel), and to monitor for side effects or behaviors including agitation, hitting, delusions, hallucinations, aggression, and suicidal ideation. During an interview on 7/20/22 at 11:57 a.m., the Social Worker stated she did not have knowledge regarding R#25's PASRR. She stated she had been told that she was responsible for PASRR's but had not received information on what her responsibility included. The Social Worker further stated she had received access to the computer system to look up PASRR's at the end of June 2022 and was still waiting for training on how to use the system. During an interview on 7/21/22 at 1:03 p.m., the Administrator stated the Social Worker was responsible to ensure that residents' PASRR Level 1 was accurate at the time of admission. The Administrator further stated the Social Worker had not received training and did not obtain access to GAMMIS (Georgia Medicaid Management Information System), the computer system where PARSRR approvals were accessed, until the end of June 2022. The Administrator further stated she was unaware the PASRR assessment form for R#25 was not accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure reasonable efforts were made to facilitate participation of the resident's responsible party (RP) in care plan meetings for one of 3 sampled residents (R) (R#1) reviewed for care planning participation. Findings include: A review of the facility policy titled, Care Planning-Resident Participation, dated December 2017, revealed, This center supports the resident's right to be informed of, and participate in, his or her care planning and treatment (implementation of care). The Policy Explanation and Implementation section of the policy included the following: - 2. The center will encourage and assist the resident and/or resident representative to participate in choosing care and treatment options including: a. Initial decisions about treatment, b. Decisions about changes, and c. The right to refuse treatment. - 7. The center will discuss the plan of care with the resident and/or representative, and allow them to see the care plan, initially, at routine intervals, and after significant changes. A review of the R#1's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of three, indicating severe cognitive deficit. A review of R#1's clinical record revealed a copy of an invitation for the resident's RP to attend a care plan conference on 5/18/22 at 3:00 p.m., along with instructions to call a specific telephone number and extension. Review of an Interdisciplinary Care Plan Conference Record, dated 5/18/22, indicated R#1's family member was notified of the conference by letter and did not attend due to no response. During an interview with R#1's RP on 7/18/22 at 1:47 p.m., the RP stated he/she had not attended a care plan meeting since admission in December 2021. The RP stated he/she had received a letter with an invitation to a care plan meeting to be held on 5/18/22 with instructions to call a specific telephone number and extension at the appointment time, but when he/she called the number, there was no answer. The RP stated he/she had left several messages but had not received a return call. The RP was concerned that he/she was not being included in R#1's plan of care. During an interview on 7/19/22 at 2:17 p.m., the MDS Coordinator stated she kept a monthly calendar for care plan meetings and sent out invitation letters to the RPs with a phone number to call into the meeting at the specified time. The care plan meetings were scheduled upon admission and then quarterly. The MDS Coordinator stated she sent R#1's RP a letter for the care plan meeting scheduled on 5/18/22 but was not at work that week. According to the MDS Coordinator, she did not recall receiving any messages from R#1's RP and did not attempt to call the RP when she returned to work. The MDS Coordinator stated a care plan conference had not been conducted with the RP between R#1's admission and 7/19/22 but should have been. During an interview on 7/21/22 at 1:03 p.m., the Administrator stated it was her expectation that the RP should be included in the care plan conference, and if the RP did not respond to the invitation to attend, there should be a follow-up call made to the RP. The Administrator further stated she was unaware that R#1's RP had not attended a care plan conference since the date of admission, and it was her expectation that every family/RP was provided the opportunity to attend the conference to voice their concerns and ask questions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to ensure a safe discharge for one of three residents (R) (R#260) reviewed for discharge. Specifically, the facility failed to ensure the physician was notified and education of the resident/responsible party on the potential risks was documented when R#260 left the facility against medical advice (AMA). Findings include: A review of a facility policy titled, Discharging a Resident without a Physician's Approval, revised October 2012, revealed, Policy statement: A physician's order should be obtained for all discharges, unless a resident or representative is discharging himself or herself against medical advice. 1. Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident's Attending Physician will be promptly notified. 3. If the resident or representative (sponsor) insists upon being discharged without the approval of the Attending Physician, the resident or representative (sponsor) must sign a Release of Responsibility form. 5. The Director of Nursing Services, or Charge Nurse, shall inform the resident, and/or representative (sponsor) of the potential hazards involved in the early discharge of the resident and shall request that the resident remain in the facility until such time as the isolation/precautionary period has ended. A review of the admission Record for R#260 revealed the facility admitted the resident on 12/14/21 with diagnoses which included fracture of greater trochanter of right femur, falls, and diabetes mellitus. A review of the discharge Minimum Data Set (MDS), dated [DATE], revealed the staff completed the Staff Assessment for Mental Status which indicated the resident did not have memory problems and was able to make decisions independently. The MDS revealed that active discharge planning was not in progress and a referral was not needed. A review of the care plan, dated 12/15/21, revealed R#260 expressed a desire to return to the community and would discharge to the community with appropriate support services. Interventions included to contact the physician if an emergency or symptoms of decline occurred after discharge and the staff were to provide education to the resident and family on follow-up doctor appointments, prescriptions provided, diet, allergies, treatments, durable medical equipment, lifeline, hospice, and home health care services. A review of the Physician Orders revealed an order was not written for discharge. A review of the Progress Notes dated from 12/14/21 through 12/22/21 revealed on 12/22/21, the Social Services Director completed AMA discharge paperwork with the resident and family. There was no documentation the physician was notified about R#260's discharge, nor of education provided regarding the potential hazards related to discharging AMA. A review of the Unauthorized Discharge Release of Responsibility form, dated 12/22/21, revealed R#260 signed with an X, and a family member and witness signed the form. The form did not indicate the resident or representative was asked if the resident wanted to remain in the facility nor was the resident or representative provided with information about community resources that may have been needed for the safety of R#260. During an interview on 7/20/22 at 4:52 p.m., Licensed Practical Nurse (LPN) EE stated when a resident left the facility AMA, the physician, family, Director of Nursing (DON), Administrator, and the nurse on call were all notified. She stated that she did not have to notify anyone in the community when a resident left AMA. LPN EE stated when a resident left AMA it was their responsibility to seek their own care. She stated that the facility did not send the medication with the resident either; that was part of the AMA policy. She stated the social worker would try to keep the residents from discharging AMA. LPN EE did not remember R#260. During an interview on 7/21/22 at 8:37 a.m., Social Services Director (SSD) QQ stated the facility had an AMA form that was completed. She stated she would speak to the resident and responsible party to see if there was anything to do to help them. She stated the physician, nurses, and ombudsman were contacted if she knew first. SSD QQ stated the ombudsman did not provide additional guidance when notification was sent. She stated she did not speak with the ombudsman when R#260 discharged AMA. SSD QQ stated she did not contact the resident's primary care physician in the community, send referrals to any outside agencies, and did not contact Adult Protective Services (APS) when residents discharged AMA. She indicated she should contact APS for safety. She stated she offered to assist residents and responsible parties after discharge if they needed additional help. SSD QQ stated she spoke with R#260's responsible party (RP), who gave verbal permission for another family member to take the resident home because R#260 wanted to go home. She stated it was a spur-of-the-moment decision. SSD QQ stated she usually tried to encourage residents and responsible parties to stay longer. She stated the family of R#260 felt they could provide better care in the home. During an interview on 7/20/22 at 3:12 p.m., the Director of Nursing (DON) stated there were not a lot of residents who left AMA. She stated the physician, Administrator, and ombudsman were supposed to be notified when a resident left AMA. She stated APS was notified if there was a safety concern. The DON stated the resident and family were notified of the AMA policy and signed the form. She stated there was no evidence the physician was notified. During an interview on 7/21/22 at 11:18 a.m., the Administrator was not aware of the situation with R#260's discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to provide activities of daily living (ADL) care for one of three sampled residents (R) (R#97) reviewed for ADL care. Specifically, the facility failed to provide nail care for a dependent resident. Findings include: A review of a facility policy titled, Activities of Daily Living (ADL), Supporting, dated March 2018, revealed, The residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy also indicated, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming and oral care). A review of the admission Record for R#97 revealed the facility admitted the resident with diagnoses which included age-related osteoporosis and rheumatoid arthritis. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#97's Brief Interview for Mental Status (BIMS) score was 0 out of 15 which indicated severe cognitive impairment. The resident required extensive assistance with personal hygiene. A review of R#97's care plan, revised 9/27/21, revealed the resident had a self-care deficit related to having difficulty performing ADL tasks and required staff to assist the resident with ADL care. Interventions included that the resident required staff to assist and complete hygiene and grooming each day as needed. A review of the Progress Notes from 9/22/21 thru 7/20/22 revealed no documentation that R#97 refused ADL care. Review of ADL task documentation dated 6/21/22 through 7/20/22 revealed no evidence the resident refused hygiene care. During an observation on 7/18/22 at 12:48 p.m., R#97's fingernails were long and dirty. During an interview on 7/20/22 at 3:24 p.m., the Director of Nursing (DON) stated nail care was included in ADL care. During an observation at 4:04 p.m. with the DON present, the DON stated that the resident's nails should be cleaned daily and trimmed as needed. During an interview on 7/20/22 at 4:08 p.m., Certified Nurse Aide (CNA) II stated that ADL care included taking care of the resident and making sure they had everything they needed. He stated he looked at the resident's nails when they were showered. CNA II stated he had taken care of R#97 on 7/19/22. He stated he had not identified any concerns with Resident #97's hands or nails. CNA II did not know how long R#97's nails were. During an interview on 7/20/22 at 4:14 p.m., Licensed Practical Nurse (LPN) PP stated ADL care included nail care. He stated nails were clipped as needed. There was not a time frame because nails did not grow at the same rate. During an interview on 7/20/22 at 4:21 p.m., Licensed Practical Nurse/Staff Development Coordinator (LPN/SDC) JJ stated ADL care included nail care. He did not know how often nail care was provided or if there was a schedule. He stated the activity staff let the nursing staff know when a resident needed nail care. LPN/SDC JJ stated the CNAs completed nail care as needed. His expectation was if there was a problem or concern with nail care it should have been brought up at the time it was identified. LPN/SDC JJ stated R#97 did not have a diagnosis of diabetes, so a CNA or nurse could complete nail care. During an interview on 7/20/22 at 4:44 p.m., LPN/Wound Care Nurse (LPN/WCN) KK stated he had overheard the DON telling the Administrator that R#97's fingernails were long. He stated that he went into R#97's room and trimmed the resident's fingernails. LPN/WCN KK stated nail care was important because they can be uncomfortable and can grow fungus. During an interview on 7/21/22 at 10:59 a.m., the Administrator stated residents' nails should be clean and neat. She stated nail care was normally completed during shower days and as needed. The Administrator stated that was also the expectation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure oxygen was administered at the physician-order flow rate, oxygen saturation was regularly checked and documented to determine if as-needed (PRN) oxygen should be administered, and nurses accurately documented oxygen administration on the Medication Administration Record (MAR) for one of one sampled resident (R) (R#84) reviewed for oxygen use. Findings include: The facility policy for oxygen administration was requested on 7/19/22 and 7/20/22 but was not provided by the end of the survey. A review of the admission Record revealed the facility admitted R#84 on 3/22/21 and readmitted the resident on 3/16/22 with diagnoses of chronic obstructive pulmonary disease and shortness of breath. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#84 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Per the MDS, the resident had an active diagnosis of asthma, chronic obstructive pulmonary disease, or chronic lung disease. The resident had shortness of breath or trouble breathing with exertion and when lying flat and received oxygen therapy while a resident. A review of R84's Care Plan, dated 8/20/21 and revised 7/7/22, revealed the resident had chronic obstructive pulmonary disease (COPD) and used oxygen as ordered. The interventions included oxygen settings, which revealed the oxygen (O2) was to be administered via nasal cannula at two liters per minute as ordered to keep the resident's oxygen saturation greater than 92%. A review of the physician's orders in the electronic medical record revealed R#84 had an order dated 7/6/21 for oxygen at two liters per minute (LPM) via nasal cannula, to keep oxygen saturation above 92%. The directions were to administer as needed for shortness of breath. A review of the O2 Sats [Oxygen Saturation] Summary revealed the most recent check of the resident's oxygen saturation was documented on 6/30/22 and was 98% on room air. An observation on 7/18/22 at 2:38 p.m. revealed R#84 lying in bed receiving oxygen via nasal cannula. The oxygen concentrator was set to administer the oxygen to the resident at three liters per minute (LPM), instead of two LPM as ordered by the physician. A review of the July 2022 Medication Administration Report (MAR) revealed the physician's order dated 7/6/21 for oxygen at 2 LPM via nasal cannula to keep oxygen saturation above 92%; however, as of 7/19/22 at 2:01 p.m., there were no nurses' initials indicating the oxygen was administered at any time during the month of July 2022. An observation on 7/19/22 at 2:02 p.m. revealed the resident lying in bed with the head of the bed (HOB) upright. The resident was receiving oxygen via nasal cannula. The oxygen concentrator was set for three LPM instead of two LPM as ordered. An observation on 7/19/22 at 2:20 p.m. with Registered Nurse (RN) FFF revealed the resident continued to receive oxygen at three LPM. During an interview on 7/19/22 at 2:45 p.m., RN FFF revealed that oxygen saturation percentages should be documented on the MAR every shift, and if a resident fell below the physician-ordered oxygen saturation percentage, the resident should be placed on oxygen. RN FFF stated staff should continue to check the saturation and follow the order. RN FFF stated the flow rate of the oxygen should be verified with the physician's order at the time the resident was placed on oxygen. RN FFF stated a resident should not be on continuous oxygen if the order was for PRN use. RN FFF also stated there were no specific staff in charge of ensuring that oxygen saturation was checked, other than the nurse caring for the resident that day. RN FFF stated that the nurse assigned to the resident that day would be responsible for ensuring the oxygen flow rate was correct and that the oxygen was being administered per the physician's order. RN FFF stated the Certified Nursing Assistant (CNA) staff would not be able to tell if the flow rate was correct. RN FFF verified there was no documentation of oxygen saturation checks for R#84 since 6/30/22 and indicated there was no evidence of justification for the resident to be receiving oxygen currently. RN FFF also stated the nurse caring for R#84 was not following the physician's order, as the oxygen flow rate was set at 3 LPM when the order called for 2 LPM, and the oxygen saturation was not being documented to show that the oxygen was needed. During an interview on 7/19/22 at 2:55 p.m., Licensed Practical Nurse (LPN) GGG revealed she was the nurse in charge of R#84's care for the last two days. LPN GGG stated nursing staff documented oxygen saturations on the MAR, and they should be checked every shift. LPN GGG stated if the saturation was below the desired percentage, the resident was placed on oxygen per the physician's orders, and the nurse should ensure the resident was placed on the correct oxygen flow rate. LPN GGG stated R#84 was supposed to be on oxygen continuously, and she was not aware of an order for PRN oxygen. LPN GGG stated she was not aware that R#84's oxygen saturation was not being checked or that the last time it was documented as being checked was on 6/30/22. LPN GGG stated she knew that R#84's saturation was checked last week, and it was 92%, but stated there was no documentation that it was 92%, and there should have been. She did not remember who checked the resident's oxygen saturation last week. LPN GGG stated she remembered talking to another staff about R#84's oxygen saturation but did not know with whom. LPN GGG admitted she assumed R#84's flow rate was correct and that the order was for continuous oxygen and not PRN. LPN GGG stated she had not checked R#84's oxygen saturation, nor verified whether the flow rate was correct, but she should have. LPN GG stated staff should be ensuring they were following physician's orders. Per LPN GG, if a nurse thought an order should be changed, then they should contact the physician and get a new order. LPN GGG stated that should have been done for R#84, but it was not. LPN GGG stated everyone assumed R#84's oxygen order was for continuous oxygen, but she never observed on the MAR that the order was PRN. LPN GGG stated PRN orders did not pop up on the MAR, but she confirmed there was no documentation on the July 2022 MAR that O2 saturation was being checked. LPN GGG stated staff were not checking oxygen saturation, or at least they were not documenting if they were checking it. LPN GGG also stated if there was not documentation that R#84's saturation was ever below 92% percent, then there was no documented justification for R#84 to be on the oxygen. LPN GGG stated it was the floor nurse's responsibility to ensure the MARs were correct and that physician orders were being followed. During an interview on 7/20/22 at 2:58 p.m., Director of Nursing (DON) CC revealed she was not familiar with R#84's order for oxygen but stated that nursing staff should assess oxygen saturation every shift or as needed if a resident exhibited shortness of breath or difficulty breathing. The DON stated oxygen saturation should be documented under vital signs, and every time vitals were assessed, oxygen saturation should also be. The DON stated she was unaware of an issue with R#84's oxygen or a lack of documentation related to R#84's oxygen administration. The DON stated nursing staff should have followed physician's orders and reviewed the orders whenever the resident was placed on oxygen to ensure the correct oxygen flow rate was administered. During an interview on 7/21/22 at 1:29 p.m., Administrator AA revealed she expected staff to follow physician orders, ensure the correct oxygen flow rate was administered, and oxygen saturation was checked regularly. Administrator AA also stated she was familiar with R#84 and if there was a change in a R#84's care, staff should have communicated with the physician and had the order amended to meet the resident's level of care required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure communication was documented between the facility staff and dialysis staff to ensure pertinent information was being communicated for one of one residents (R) (R#60) reviewed for dialysis. Findings include: A review of R#60's admission Record revealed the resident's diagnoses included end stage renal disease, dependence on renal dialysis, type 2 diabetes mellitus with unspecified complications, type 2 diabetes mellitus with diabetic polyneuropathy, and nephrotic syndrome with unspecified morphologic changes. A review of R#60's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was receiving dialysis. A review of R#60's physician orders revealed a physician order, dated 7/12/22, for dialysis on Monday, Wednesday, and Friday. A review of the Dialysis Communication Form for R#60 for the time period of 6/1/22 through 7/18/22 revealed missing data pertinent to documentations for Section II (required documentation from the dialysis staff) and Section III (required documentation from the facility staff). Further review of Section II revealed staff were to document the resident's blood pressure and weight pre and post dialysis, medications administered, care plan changes, et cetera (etc.). For Section II (to be completed by the dialysis center) there was no information or documentation for the following dates: 6/14/22, 6/21/22, 6/23/22, and 7/2/22. In addition, on 7/6/22 and 7/9/22, the data was partially completed with missing data, including a missing dialysis staff signature for 7/6/22. Continued review of the Dialysis Communication Form for Section III (to be completed upon return from dialysis by the facility staff) revealed no documentation for 6/7/22 and 6/30/22. In addition, the form dated 7/9/22 revealed no documentation for the time returned, temperature, blood pressure, and other vitals. The form dated 7/11/22 revealed incomplete vital sign information and no staff signature. The form dated 7/13/22 revealed no information was documented related to the resident's vital signs, assessment of thrill and bruit (the feeling or sound of blood flow through the fistula) and/or mental status. During an interview on 7/21/22 at 1:46 p.m., Licensed Practical Nurse (LPN) VV stated R#60's dialysis book was sent out each time the resident attended dialysis at the dialysis clinic. She reported that the charge nurse was responsible for completing Section I and Section III on the dialysis form. LPN VV confirmed observing missing documentation on the dialysis communication form for Section II due to the dialysis staff's failure to document on the form. She reported that when this occurred, she would contact the dialysis clinic staff via phone. LPN VV stated it was important to complete the form because the form contained pertinent information which included the resident's weights, vital signs, and bruit and thrill. During an interview on 7/21/22 at 8:30 a.m., Director of Nursing (DON) CC stated the dialysis book contained the dialysis communication forms for dialysis residents, and the book went with the resident to the dialysis center. DON CC stated Section I should be completed by the Charge Nurse, Section II should be completed by dialysis center staff, and Section III should be completed by the facility nurse once the resident returned from the dialysis center. The DON stated if Section II was not completed or incomplete, the facility nursing staff should be calling the dialysis center. DON CC stated the nurse completed the vital signs after the resident returned. Per DON CC, it was important for the licensed nursing staff to document whether the vitals were taken in a sitting, lying, or standing position because it helped orthostatic (hypotension). DON CC stated it helped to identify fall risk, dizziness, and/or any dehydration concerns. DON CC stated any sudden change in fluids could result in the resident becoming orthostatic. Sometimes if the resident was orthostatic, they may need monitoring more closely. Per DON CC, it was important that the nursing staff checked the bruit or thrill to ensure the shunt was working. DON CC stated the nurse should call the dialysis center if information was incomplete because incomplete data may not identify if a change was required to the resident's plan of care, including their diet. The dialysis form provided pertinent information such as medication given, if iron was prescribed during dialysis, if the resident needed extra Colace from the iron given during their dialysis treatment or to identify any significant changes in conditions or in resident status. Per DON CC, she was not aware that this form was not completed correctly. During an interview on 7/21/22 at 9:11 a.m., Assistant Director of Nursing (ADON) HH stated her expectation was that the licensed nursing staff returned the incomplete form to the dialysis center for completion. During an interview on 7/21/22 at 1:33 p.m., the Administrator reported being unaware that facility staff and dialysis staff were not completing the dialysis communication form. The Administrator reported that her expectation was for the form to be completed by the dialysis staff and the facility staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, the facility failed to fully assess for the use of side rails/bed rails for one of three residents (R) (R#258) reviewed for accidents. Specifically, the facility failed to: - Ensure an initial safety assessment as well as on-going safety assessments were completed for the use of quarter side rails/bed rails, - Ensure a physician's order was in place for the use of quarter side rails/bed rails, - Ensure a consent was in place for the use of quarter side rails/bed rails, and - Ensure that the care plan identified the use of quarter side rails/bed rails. Findings include: A review of the facility's Proper Use of Bed Rails policy, dated June 2018, revealed, It is the policy of this center to utilize a person-centered approach to ensure each resident attains and maintains his/her highest practicable well-being in an environment that promotes independence and prohibits the use of side rails/bed rails as a physical restraint. Further review indicated the Policy Explanation and Compliance Guidelines section of the policy included the following: - 2. The center will conduct a comprehensive assessment to determine the need for side rail/bed rail usage. - 6. After alternatives have been attempted, the facility will obtain informed consent from the resident and if applicable, the resident's representative for the use of side rails/bed rails. - 9. The use of side rails/bed rails as an assistive device will be addressed in the resident's care plan and MDS [Minimum Data Set] data. A review of the admission Record for R#258 revealed the facility admitted the resident on 2/27/18 and readmitted the resident on 7/13/22 with diagnoses that included displaced intertrochanteric fracture of right femur (fracture of the thigh bone between the protrusions where the muscles attach), and dementia without behavioral disturbance. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#258's Brief Interview for Mental Status (BIMS) score was 2 out of 15, which indicated the resident had severe cognitive impairment. The MDS indicated the resident did not use side rails/bed rails. During an observation on 7/19/22 at 4:44 p.m., R#258 was in his/her room, lying in bed. The resident's bed had quarter side rail/bed rails in place. During an observation on 7/20/22 at 10:42 a.m., R#258 was in his/her room, lying in bed. The quarter side rails/bed rails were in place. A review of the care plan, revised 7/13/22, revealed the facility did not include the use of side rails/bed rails in the care plan. A review of the current physician orders revealed there was no order for the use of side rails/bed rails. A review of R#258's electronic medical record revealed there was not an initial assessment for the use of side rails/bed rails, nor were there ongoing assessments for the use of side rails/bed rails. Further review of R#258's electronic medical record revealed there was no signed consent for the use of side rails/bed rails. During an interview on 7/21/22 at 11:05 a.m., Assistant Director of Nursing (ADON) HH stated she had been in the position for three months. She stated she knew that a safety assessment had to be completed to rule out safety concerns related to side rail/bed rail use, since they could be a potential restraint. ADON HH stated she knew the resident's care plan should have identified the use of side rails/bed rails, and there should have been an order for the use of the side rails/bed rails. ADON HH stated she thought because the use of side rails/bed rails was a possible restraint, there should have also been an informed consent completed. ADON HH stated that during their morning meetings, the team discussed the use of side rails/bed rails, including whether there were concerns about their use and whether the proper assessments were completed. ADON HH stated that was all she remembered. During an interview on 7/21/22 at 11:18 a.m., Licensed Practical Nurse (LPN) KK stated he was not involved in the process for the use of side rails/bed rails. He stated from prior knowledge, the side rails/bed rails should be used as an enabler. During an interview on 7/21/22 11:36 a.m., Director of Nursing (DON) CC stated there should have been an assessment completed for the use of side rails/bed rails, and she knew they could be considered a restraint. She stated informed consent, a physician order, and care plan for use was required for the use of side rails/bed rails. DON CC stated she became aware the previous day (7/20/22) that R#258 did not have a safety assessment, physician order, informed consent, or documentation that alternate measures were explored and that the resident was not care planned for side rail/bed rail use. DON CC stated all those things should have been completed. She stated there should also be ongoing monitoring of the continued need and safety for the use of side rails/bed rails. She stated quarterly safety assessments should be completed. DON CC confirmed there was no ongoing monitoring but stated there should have been. She stated she did not know a lot about the side rail/bed rail protocol and was still learning the process. During an interview on 7/21/22 at 12:52 p.m., MDS Coordinator SS, who had been employed since 2018, stated she knew that in the past she had been told to care plan for side rails/bed rails under falls but confirmed Resident #258 was not care planned for side rails/bed rail use. She did not know the process or requirements for the use of side rails/bed rails. MDS SS confirmed that for R#258, there was no physician order, safety assessment, informed consent, or documentation that alternate measures were explored prior to using the side rails/bed rails. MDS SS stated she was unaware that ongoing assessments for side rails/bed rails should have been done but agreed that the assessments should be completed to ensure continued safe use of side rails/bed rails. She confirmed R#258 did not have continued assessments for side rail/bed rail use. During an interview on 7/21/22 at 1:35 p.m., Administrator AAA stated she knew some side rails/bed rails could be a restraint, the long ones. She knew some residents were care planned but did not know why some were not. Administrator AAA's expectation was for the staff to follow the process, which included a physician order, ensure safety assessments were completed, update the care plan to reflect side rail/bed rail use, explore alternate measures, and ensure ongoing safety monitoring was completed.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure the medication error rate was below 5%. During observations of medication administration, Licensed Practical Nurse (LPN) AAA made four medication errors out of 29 total opportunities, which resulted in a 13.79% medication error rate for two of three residents (R) (R#102 and R#45) observed. Findings include: A review of the facility policy titled, LTC (Long-Term Care) Facility's Pharmacy Services and Procedures Manual, dated 12/1/07, revealed, Prior to Medication Administration: 3.1 Facility staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident. During medication administration observations on 7/19/22, Licensed Practical Nurse (LPN) AAA was observed to administer 29 medications to three residents, R#102, R#45, and R#65. Following the medication administration observations, the physician's orders for all three residents were reviewed and compared with what was administered. 1. Review of R#102's physician's orders in the electronic medical record (EMR) revealed the resident had an order dated 12/16/19 for carbidopa-levodopa (a medication to treat Parkinson's disease), 25-100 milligrams (mg), two tablets by mouth twice daily. During observation of the medication pass on 7/19/22 at 8:07 a.m., LPN AAA administered one tablet of carbidopa/levodopa 25/100 instead of two tablets as ordered. Additionally, LPN AAA administered ibuprofen (an anti-inflammatory/pain medication) 200 mg two tablets to R#102 without a physician's order to do so. There was no documentation in the physician's orders, nor the July 2022 Medication Administration Record (MAR) for administration of ibuprofen to this resident. This resulted in in two medication errors for R#102. 2. Review of R#45's physician orders in the EMR revealed the resident had an order dated 4/29/22 for ferrous sulfate (iron supplement) 65 mg two tablets by mouth once daily. During observation of the medication pass on 7/19/22 at 8:20 a.m., LPN AAA administered one tablet of the Ferrous Sulfate 65 mg instead of two tablets as ordered. Further review of the physician's orders revealed R#45 had an order dated 11/24/21 for vitamin B12 500 micrograms (mcg), two tablets by mouth once daily. During observation of the medication pass on 7/19/22 at 8:20 a.m., LPN AAA administered one tablet of the vitamin B12 500 mcg instead of two tablets as ordered. This resulted in two medication errors for R#45. During an interview and record review on 7/19/22 at 3:26 p.m., the surveyor reviewed the MARs for R#45 and R#102 with LPN AAA. LPN AAA stated her process was to look at the MAR and double-check the medication against the order to ensure accuracy. LPN AAA further stated she believed she followed the five rights of medication administration (a nursing practice known as the Five Rights which involves verifying the correct medication, correct route, correct dose, correct patient, and correct time of administration). During an interview on 7/20/22 at 3:11 p.m., the Director of Nursing (DON) stated that during medication administration, nurses should pull up the MAR for each resident, pull the medication packages, look at the name, dose, route, et cetera, and then click on the MAR as they dispensed the medication. The DON stated the nurses should follow the six rights of medication administration (an updated version of the Five Rights which includes the correct documentation). The DON stated this was what nurses were taught in school and, We have to make sure that the residents get the right medications. During an interview on 7/21/22 at 1:20 p.m., the surveyor informed the Administrator of the medication error rate of 13.79%. The Administrator stated it was her expectation that medications were administered according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the hospice contract, the facility failed to integrate a plan of care between hospice and the facility staff in order to determine which disciplinary would provide direct care services for one of one resident (R) (R#31) reviewed for receiving hospice services. Findings include: A review of the [Hospice Agency Name] Nursing Facility Contract, with an approval date on 10/1/20, between the facility and the hospice provider revealed, 3.3. Design and Maintenance of Hospice Plan of Care. A. Nursing Facility Residents. In accordance with applicable Federal and State laws and regulation, Hospice shall develop an integrated Hospice Plan of Care for each new Residential Hospice patient in collaboration with the Nursing Facility. Promptly upon consent of the Residential Hospice Patient (or his/her legal representative), Hospice shall furnish Nursing Facility with a copy of the Hospice Plan of Care as defined in 2.6. A review of R#31's admission Record revealed the resident's diagnoses included chronic kidney disease, edema, anemia in chronic kidney disease, hypotension, and chronic respiratory failure. A review of R#31's physician's orders revealed an order to admit to hospice services dated for 3/1/22. A review of R#31's significant change Minimum Data Set (MDS), dated [DATE], revealed the resident was receiving hospice care. A record review of R#31's hospice care plan was reviewed with the Minimum Data Set (MDS) Coordinator/Register Nurse (RN) SS on 7/20/22 at 12:01 p.m The electronic version of the care plan that was provided by MDS RN SS and indicated the resident was receiving hospice services due to a diagnosis of multiple myeloma and a decline in condition was expected. The care plan was initiated 2/24/22. The interventions included to administer medications as ordered, assess the effectiveness of medication, assess for appetite changes, be aware of the grieving stages, provide patient and family with emotional support, and validate the order for advanced directive in place. The care plan revealed an omission of disciplinaries (facility staff or hospice staff) to determine which designated staff will provide services for each intervention listed. After reviewing the care plan with MDS RN SS, MDS RN SS confirmed that no disciplinaries (hospice staff or facility staff) were listed on the care plan and confirmed that the care plan was missing the hospice and facility staff disciplinary for each intervention. MDS RN SS stated she was aware of the regulation that the hospice care plan should integrate the designated disciplinary for each intervention. MDS RN SS stated the failure to list each facility staff or hospice staff responsible for each care service intervention was an oversight by her. Per MDS RN SS, the care plan should list the different disciplinary, licensed nursing staff, certified nursing assistant (CNA), dietary staff, social service, and activity staff. In addition, the hospice nurse, hospice CNA, and the hospice social worker should be incorporated in the care plan. During an interview on 7/20/22 at 3:10 p.m., the Administrator reported that her expectation was that the care plan should reflect an integration of the disciplinaries that should be involved in the resident plan of care. During an interview on 7/20/22 at 5:13 p.m., the Director of Nursing/Register Nurse (RN) CC stated her expectation was for the resident's plan of care to include which staff (facility or hospice) were to implement the interventions. She stated the MDS Coordinators are responsible for the hospice care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility checklists and training information, the facility failed to maintain a clean, comfortable, and homelike environment in resident rooms/bathrooms and a shower room on one (100 Hall) of two halls. Specifically, four resident rooms and/or bathrooms were observed to have broken tiles, exposed concrete, and/or holes in the walls, and the 100 Hall shower room was observed to have a rust-colored substance on the walls, floors, and soap holders. Findings include: A review of an undated facility document titled, Room Inspection revealed walls, paint, and cove base were listed, among multiple other items, with the option to choose whether the listed items were good, fair, or bad. There was also an area to check whether repairs were needed and to enter the date the repairs were completed. A review of an undated facility document titled, Housekeeping In-Service Training included a section titled, Bathroom Cleaning, which revealed the steps in the daily cleaning of resident and public bathrooms included: - Clean and sanitize the tub or shower (if applicable), using disinfectant cleaner. - Spot check the walls and ceilings: Clean as needed. Observations during the survey team's initial tour of the facility, conducted on 7/18/22 from 10:19 a.m. to 1:00 p.m., revealed the following: - Large holes were observed in the wall above the resident's bed in Rooms 127A and 101B. - The baseboards were pulled away from the wall and missing in some areas, exposing broken concrete behind the drywall in room [ROOM NUMBER]B. - There was a large hole in the drywall in the bathroom for room [ROOM NUMBER], revealing concrete behind the drywall. - Observation of the shower room on the 100 Hall revealed multiple tiles were missing from the walls. A rust-colored substance was observed on the walls and floors, and the soap holders were covered in a rust-colored substance that was dripping from the frame. On 7/20/22 at 8:57 a.m., observations of the facility were conducted with the Maintenance Director, the Housekeeping District Manager, and the Housekeeping Supervisor Trainee. All the above areas of concern were observed. The Maintenance Director stated the soap holders were covered in rust and needed to be replaced. He stated the soap holders could not be painted, as they were too far gone. He also indicated the shower tiles needed to be repaired/replaced and the shower stalls required a deep clean. The Maintenance Director stated that maintenance rounds were conducted daily in all resident rooms and the shower rooms. He stated he would peek in and talk to staff. The Maintenance Director further stated that he had just recently found a checklist (referring to the Room Inspection checklist) to be used when doing his room checks but had not previously used the checklist. During an interview on 7/20/22 at 9:20 a.m., the Housekeeping Supervisor Trainee stated that housekeeping was responsible for general daily cleaning to include the walls and floors. Deep cleaning was done at the request of the administrative staff, and it was usually decided during the morning meeting which rooms were to be deep cleaned. The Housekeeping Supervisor Trainee further stated they did not have the equipment to clean the grout in the bathrooms and that would be something that maintenance would do. During an interview on 7/20/22 at 4:54 p.m., the Administrator stated she did rounds on the units every morning to check on each resident but stated she was not aware of the above described conditions. The Administrator stated she would not consider the described conditions to be homelike. The Administrator stated the facility addressed issues with the rooms, such as the walls, when the rooms were vacated. The Administrator stated her expectation was that the rooms be clean and homelike for the residents, so that they felt at home in their own space.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and facility policy review, the facility failed to ensure personal protective equipment (PPE) was worn appropriately in one out of four units (the COVID-19 Isolation Unit) and housekeeping staff maintained a sanitary environment. Findings include: A review of the facility's Interim Infection Prevention and Control Recommendations to Prevention SARS-CoV-2 Spread in the Facility policy, updated 7/19/22, revealed, It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for the COVID-19 and to adhere to Federal and State/Local Public Health recommendations and CDC [Centers for Disease Control and Prevention] Guidance. Procedure: A. Infection Prevention and Control Program .2. The facility shall ensure health care personnel (HCP) have access to all necessary supplies including alcohol-based hand sanitizer with 60-95% alcohol, personal protective equipment (PPE), and supplies for cleaning and disinfection. If necessary, facility may follow CDC's guidance on Strategies to Optimize the Supply of PPE and Equipment .G. Evaluating and Managing Residents. 1. New Admission/readmission .e. Facility shall designate an Observation Unit for admissions/re-admissions for Quarantine: .HCP caring for residents with suspected infection shall use full PPE. 1. During multiple observations, the following signs were located on the zipper doors for the isolation room and COVID-19 Observation Unit. During the survey, the zipper doors were removed, and the signs were placed on or near individual rooms. The signs included: - Droplet Precautions with stop signs on both sides. The sign indicated, Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. - You Are Entering The Observation Unit. STOP. PPE required beyond this point - COVID Isolation Unit. PPE MUST Be Worn. N95/Face Shield or Goggles/Gown/Gloves - Gown, Gloves, Goggles or Face shield, N95 - PPE Must Be Worn Beyond This Point - Isolation until [blank space]. Gloves, Mask, Sugar Bags During an observation on 7/18/22 at 8:24 a.m. of the COVID Observation Unit, there was a zipper door with a cart for PPE outside the zipper door. The infection control cart did not contain gowns or face shields, and only had medium sized gloves. There were various other items in the cart to include adult briefs, personal care items, straws, sugar, and salt packets. Certified Nurse Aide (CNA) FF was observed exiting the observation unit at this time. She was wearing a mask and eye protection only. She stated she did not have to wear full PPE because they did not have any COVID-19 positive residents in the observation unit. She said the residents were only there because they were new admissions, and they were not positive. CNA FF left the unit and returned with gowns to place in the infection control cart. During an observation on 7/18/22 at 8:34 a.m., CNA KKK was in the COVID Observation Unit and was only wearing a mask and goggles. He was not wearing the proper PPE. During an observation on 7/18/22 at 11:46 a.m., Housekeeper (HSK) GG entered room [ROOM NUMBER] and was not wearing her goggles properly; they were on her head. During an observation on 7/18/22 at 11:46 a.m., CNA MM was in room [ROOM NUMBER] and was not wearing her goggles properly; they were on her head. During an observation on 7/19/22 at 1:52 p.m., CNA FF was not wearing goggles in the hallway. During an observation on 7/19/22 at 2:34 p.m., CNA FF was observed retrieving a gown on a trash bin outside of the COVID-19 Unit. She did not tie the gown and was not wearing goggles. During an observation and interview on 7/20/22 at 11:15 a.m., there were two infection control carts in the COVID Observation Unit outside room [ROOM NUMBER] and room [ROOM NUMBER]. There were also two yellow bins and a small trash can with discarded PPE. The trash can was overflowing. Assistant Director of Nursing (ADON) HH removed the items from the yellow bin and placed them in a sugar bag and then walked them to the laundry room. ADON HH then emptied the overflowing trash can and said the PPE should have been discarded in the trash can in the resident room and the yellow bins should have been in the resident rooms with sugar bags in them. On 7/20/22 at 11:29 a.m., ADON HH asked CNA FF what the process was for donning and doffing PPE and when was PPE supposed to be worn. CNA FF explained the process as sanitize hands and don the gown, mask, goggles or face shield, and gloves. She said all the items had to be removed prior to exiting the resident room. At this time, the ADON checked the infection control cart near room [ROOM NUMBER] and found the following items: - Three adult briefs, gloves that were not in the box, alcohol pads used to disinfect the yellow stethoscopes, various signs related to COVID-19, a hanger, one package of denture cleaner, straws, spoons, an antibacterial wicking sheet, one regular stethoscope, a syringe, sugar, a roll of tape, a razor, a rubber band, a roll of sugar bags for laundry, a roll of trash bags, a box of medium gloves, a blank paid time off request form, several absorbent pads, a denture cup, two disposable blood pressure cuffs, blank bath sheets, and a remote control for a television. ADON HH then checked the infection control cart near room [ROOM NUMBER] and found the following items: - A bath basin with four tubes of toothpaste, six toothbrushes, six mouth swabs, five bottles of mouthwash, hand sanitizer, creamer, two bottles of lotion, a hairbrush, a smaller basin, several mouth swabs, a deodorant body spray, two deodorant sticks, a tube of denture adhesive, aftershave, a ranch dressing packet, a tube of skin repair cream, a bag with hand sanitizer, skin protectant packets, personal care wipes, facial tissue, pepper packets, a bible, a blank inventory sheet, a suction container, one disposable blood pressure cuff and one non disposable blood pressure cuff, and salt packets. After ADON HH checked the infection control carts, ADON HH said there should have been gowns, gloves, cleaning wipes, hand sanitizer, disposable blood pressure cuffs, disposable stethoscopes, disposable thermometers, trash bags, sugar bags, face shields, and N-95 masks in the infection control carts. She said the unit manager was supposed to ensure the COVID Observation Unit infection carts were stocked with PPE. She said all staff were expected to replenish the PPE when needed. ADON HH said they had enough PPE. During an interview on 7/20/22 at 11:15 a.m., Staff Development Coordinator (SDC) JJ said he completed on-the-spot training to staff present for infection control related to the zipper doors being removed. During an interview on 7/20/22 at 3:24 p.m., Director of Nursing (DON) CC said she expected SDC JJ to provide training related to PPE. She said it should include donning and doffing PPE. She did not know how often training was completed by the SDC. DON CC said she told SDC JJ to have an in-service on 7/11/22, because of the outbreak status. She said they should be doing in-services monthly. DON CC said since they removed the barrier (zipper doors), SDC JJ, ADON HH, and herself were completing rounds to make sure the staff was aware of continued PPE usage for contact and droplet precautions. She said they ensured there was proper signage on each door in the COVID-19 Observation Unit and the COVID-19 positive room. DON CC said she reviewed the training with the CNAs and nurses to make sure they knew the proper PPE to wear, including donning and doffing. DON CC said the infection control carts should have gowns, masks, goggles, face shield, gloves, hand sanitizer, disposable stethoscope, disposable thermometers, disposable blood pressure cuffs, sugar bags, and regular trash bags in them. She said the staff were supposed to dispose of the doffed PPE in the trash can in the room before exiting the room. DON CC said the same PPE was to be worn in the COVID-19 Observation Unit as if there was a confirmed case in isolation because they were observing for suspected COVID-19, and they should treat the residents as if they had tested positive. During an interview on 7/21/22 at 11:13 a.m., Administrator AAA stated staff should have been wearing full PPE, including gowns, mask, and goggles when in the COVID-19 positive room or COVID-19 Observation Unit. She said the expectation was for the staff to don and doff PPE per policy, and she expected staff to wear all PPE when needed. Administrator AAA said PPE should have been inside of the bins that were outside of the rooms. She said the bins should include gowns and N95 masks, and each bin should have its own blood pressure cuff, stethoscope, and hand sanitizer. Administrator AAA said the bins should only have PPE equipment to be used by the staff, and other personal items should be in the resident rooms. 2. A review of the undated Housekeeping In-Service Training Resident Room Cleaning policy revealed the purpose was to provide a detailed description of the stages that are to be completed daily in the cleaning of a resident room. Daily cleaning would ensure optimum levels of cleanliness and sanitation, prohibit the spread of infection and bacteria, and maintain the outward appearance of the facility. The steps in the daily cleaning of a resident room included: 1. Empty the wastebaskets. (Each room will usually have 1 wastebasket per resident) clean and sanitize the can using disinfectant and replace the liner. 2. Clean and dust all horizontal surfaces including furniture, over-bed tables, floormats, over-bed lights, nightstands, bookshelves, etc. using a clean cloth soaked in, or sprayed with disinfectant cleaner. 3. Clean and dust all vertical surfaces including doors, door trim, molding, all rolling stock, walls, light switch plates etc. using a clean cloth soaked in or sprayed with disinfectant cleaner. 4. Dust mop floor using a dust mop with clean head (changed daily, not after each room). Pick up all debris with dust broom and lobby pan in dispose in trash bin on housekeeping cart. Be sure to dust under bed. Dust mop behind furniture on a weekly basis. 5. Damp mop floor using a clean mop head and clean water mixed with the appropriate amount of disinfectant cleaner (follow dilution ratios exactly). When mopping go along baseboards and walls first. Use figure eight side to side motion and begin in the furthest area of the room and work out toward the door. Mop water is to be changed no less than every 3 rooms or after mopping up a spill of food, urine, or feces. Mop head must also be replaced after cleaning, food, urine, or feces spills. Important information included to always wear gloves when working in a resident room, never spray any chemicals in the presence of residents or visitors, and always discard disposable gloves before exiting the resident's room. A review of the undated Housekeeping In-Service Training Bathroom Cleaning, Cleaning Resident and Public Bathrooms policy revealed the purpose was to provide a detailed description of the stages that were to be completed daily in the cleaning of a resident room. Daily cleaning would ensure optimum levels of cleanliness and sanitation, prohibit the spread of infection and bacteria, and maintain the outward appearance of the facility. The steps in the daily cleaning of a resident and public bathroom included: 1. Empty wastebasket: Clean and sanitize can, using disinfectant cleaner. Replace liner. 2. Check and refill all supplies: toilet paper, paper towels, hand soap, disposable gloves. 3. Clean and sanitize sink, including plumbing beneath sink, using disinfectant cleaner. 5. Clean and sanitize toilet (including raised toilet seats) using disinfectant cleaner. Use toilet brush for inside and cloth for the outside. 6. Clean and sanitize fixtures: mirror, dispensers, shelves, safety bars etc., using disinfectant cleaner. 9. High dust any ceiling fixtures: vents, lights, corners, and edges, etc., using the high duster with extension. 10. Dust mop floor: use dust broom and lobby pan to pick up any dirt and debris. 11. Damp mop floor: Use clean mop head and a solution of water and disinfectant cleaner (follow dilution ratios exactly). Important information included to always wear gloves when working in a resident or public restroom, never spray any chemicals in the presence of residents or visitors, and always discard disposable gloves before exiting the resident's room. During an observation on 7/20/22 at 12:18 p.m., Housekeeper (HSK) GG, who started the week prior on Monday, was cleaning an isolation room. She did not don eye protection or a face shield. She did not change gloves from the previous room cleaned prior to entering the isolation room. HSK GG entered the room, sprayed the sink, toilet, and riser in the bathroom. She exited the room to retrieve the broom and began sweeping around items. She moved two bags of trash that were on the floor toward the yellow linen bin. She opened the door to retrieve the dustpan. She exited the room with the broom and the dustpan. HSK GG retrieved two cloths and a toilet brush from the housekeeping cart and reentered the room. She cleaned the top of the toilet to the bottom and did not clean under the rim or the riser. She exited the room and doffed gloves as she was walking out of the room. She placed the cloths in a clear bag and placed them on top of the cart. HSK GG donned gloves and another cloth and reentered the room. She sprayed the sink area again and wiped as she sprayed and moved personal items around the vanity. She exited the room and retrieved another cloth, sprayed the mirror, and wiped with the cloth and then a paper towel. HSK GG exited the room with the cloth. She doffed the gloves and donned a new pair of gloves. She retrieved the mop, reentered the room, mopped around items and did not move personal items. HSK GG exited the room, removed the mop head from the handle, and placed it in a bag. She doffed her gloves and donned a new pair of gloves. She left the trash in the room. During the observation, HSK GG did not sanitize her hands, change gloves, or wear proper PPE prior to entering an isolation room. She did not take the needed items to clean the isolation room to avoid exiting and reentering the room. She did not clean all surfaces in the room for each resident. During an interview with HSK GG after she cleaned the isolation room, she stated she had one day of training and had cleaned the isolation room two times since she started. HSK GG said she was supposed to clean the isolation rooms every day. She said if she did not have time then she did not clean, or if a CNA was in the room, she did not clean the room. HSK GG said she worked from 5:30 a.m. to 2:00 p.m HSK GG said there was not a specific time to clean the isolation rooms. She explained the process of cleaning the room. She said she wore a gown, mask, and gloves and did not know if she needed to wear anything else. Once she entered the room she cleaned, the room with a multi-use disinfectant; she said she left it on for two minutes (dwell time) before wiping. She said she swept the floor and emptied the trash during that time. She said the isolation rooms were the last rooms to clean. She said she changed the mop water and mop after cleaning two to three rooms. During an interview on 7/21/22 at 11:13 a.m., Director of Nursing (DON) CC said she was not sure what the process was for cleaning rooms. She said she did not remember the dwell time for the disinfectant. The DON's expectation was all rooms were sanitized, items were moved and cleaned, sanitized, and frequently touched items were disinfected. The DON said her expectation was for all staff to don and doff all PPE and wear it properly. She said the cleaning process was important, so they did not spread germs or disease to other residents. During an interview on 7/21/22 at 11:02 a.m., Administrator AAA said the staff was trained to follow the process including sweeping the room and cleaning areas that were touched more often. She said housekeepers were taught to go from clean to dirty. Administrator AAA said the COVID-19 rooms should have been the last rooms cleaned and disinfected daily. During an interview on 7/21/22 at 10:12 a.m., Housekeeping Supervisor (HSKS) TT said housekeepers were in training for three days with someone. She said the first day they followed and watched, the second day, they followed, watched, and helped some, and the third day they cleaned and were watched. On the fourth day they were independent. HSKS TT explained the process of how to clean a resident room. She said they cleaned from clean to dirty, walked in the room, and sprayed the bathroom. The dwell time was two minutes for the multipurpose disinfectant cleaner. They sprayed the sink. She said they cleaned around personal items; they did not move personal items off the sink/vanity area. They took the trash out and changed the trash bags. She said they cleaned from the door to the bathroom. She said they cleaned the resident area before the bathroom, which included the over bed tables, dressers, and windowsills, and swept the floors. She said the bathroom was cleaned after cleaning the personal space. She said they cleaned from the top to the bottom of the toilet, used the toilet brush on the inside of the toilet bowl and rim, and then mopped out of the room. HSKS TT said one pair of gloves was used per room. One cloth was used to clean the bathroom, one cloth was used to clean the sink, and one cloth was used for personal space. She said if there were two residents in the room, three cloths were still used to clean the entire personal space of both residents. HSKS TT said the COVID-19 rooms were cleaned last, and the observation rooms were cleaned after the regular rooms were cleaned. She said the housekeeper should have cleaned the COVID-19 room last. She said the housekeeper should have worn a gown, gloves, and face mask/shield. HSKS TT said they had to don new PPE for every room. She said they should push the housekeeping cart in the room while cleaning the observation and COVID-19 rooms, and the whole cart had to be sanitized after completion. HSKS TT did not know if they were supposed to sanitize hands in between glove changes.

Based on record review and staff interviews, the facility failed to ensure that the staff designated as Dietary Manager (DM) was a Certified Dietary Manager (CDM) or had a similar food service management certification or degree. This had the potential to affect the 101 residents receiving an oral diet. Findings include: A policy was requested but not provided before the end of the survey related to the qualifications for the Dietary Manager. During a tour of the kitchen and corresponding interview on 7/18/22 at 12:00 p.m., Dietary Manager Supervisor (DM) XX confirmed having a Serv Safe Certification and a General Food Dietary Training Certificate from the State of Alabama. When the surveyor inquired if the certificate for the General Food Dietary Certification was an equivalent to the CDM Certificate, the DM answered yes. During a later interview on 7/20/22 at 10:13 a.m., DM XX reported that she started at the facility on June 30, 2022. She had only been employed for two weeks at the facility as the Dietary Manager. She retracted her statement about having a certification that was equivalent to the CDM. She reported that she was not CDM certified. She reported not enrolling in the class at this time for the CDM. In an attempt to follow up to see if DM XX received any onsite training or supervision from any Certified Dietary Manager or Registered Dietician, the Certified Dietary Managers and Registered Dietician staff who were present during the survey reported not providing training to DM XX during her two weeks of employment at the facility. In an interview on 7/20/22 at 11:09 a.m., CDM VV confirmed not providing any onsite training with the newly hired DM XX. She stated that the plan was for DM XX to come over to her facility and work with her. CDM VV stated that this training never occurred. During an interview on 7/20/22 at 11:21 a.m., CDM YY confirmed and verified not providing any onsite training for DM XX. CDM YY stated that the new protocol was for him to begin working with DM XX. During an interview on 7/20/22 at 11:25 a.m., Corporate CDM ZZ confirmed and verified not providing any onsite training to DM XX. He confirmed providing training that day to DM XX. When the surveyor inquired how many times he visited the facility to provide any oversight training, CDM ZZ reported only visiting the facility twice; once to drop off an item and the second time for only three hours. This occurred within the last three weeks. He stated that the plan was to get the newly hired DM XX in the Certified Dietary Manager Training Course (CDM). In an interview on 7/20/22 at 3:10 p.m., Administrator AAA reported being unaware that the newly hired DM XX was not a CDM. Administrator AAA reported the facility policy was that the DM was supposed to be certified upon hire. The Administrator provided conflicting information, stating that she was informed prior that DM XX was scheduled to take the CDM two weeks ago. She was not aware that DM XX did not have any training. She reported speaking to DM XX and that DM XX had informed her that she was studying to take the CDM exam. The Administrator confirmed being misinformed and was unaware that the Corporate CDM ZZ (who is the Contract Manager) was not onsite at the facility to provide training to DM XX. She reported that Corporate CDM ZZ was in the building one day to do an audit and inventory. It was during her first two weeks of working. He was there for only two days. She did not recall him being in the building all day. She had no record of him providing training to DM XX. In an interview on 7/21/22, Director of Nursing (DON) CC reported that her expectation was that the Dietary Manager was certified and met the requirement for the position in order to ensure residents' food items were good. She reported being unaware until yesterday that DM XX was not certified. In an interview on 7/21/22 at 11:17 a.m., Register Dietician (RD) NN confirmed and verified not providing onsite training for the newly hired DM, DM XX. She was not providing a check-off list of training for DM XX and was not serving as DM XX's supervisor. RD NN reported visiting the facility at least once a week. RD NN reported that on her days visiting the facility, the protocol for her visits was to complete clinical assessments for each resident. As the RD, her onsite visit included auditing the tray lines and auditing the textures of the food being prepared for the resident meals and the residents' diets. RD NN reported being aware of the newly hired DM's past work experience as a Food General Manager in a restaurant. Because of this information, she did not provide oversite training with the DM. RD NN reported that she was under the impression that the Contract Corporate Dietary Office Management and Corporate CDM ZZ was providing any training to new employees for the company. She was informed that CDM VV, who came to the facility during the survey on Tuesday 7/19/22, and Corporate CDM ZZ, who reported to the building on 7/20/22, was doing a follow-up training.

Based on interviews, observations, and review of facility menus, the facility failed to ensure that the menu was followed to ensure appropriate nutrition for the residents. This deficient practice had the potential to affect the 101 residents receiving an oral diet in the facility. Findings include: During an interview and observation of the posted calendars/menus on 7/19/22 at 1:44 p.m. with a visiting Certified Dietary Manager (CDM), CDM WW in the kitchen, CDM WW confirmed that the facility dietary staff had the wrong menu calendars posted. CDM WW stated staff should be following the spring instead of the fall menu. She reported visiting the facility today in order to assist the newly hired Dietary Manager (DM), DM XX during the survey. An observation in the kitchen of the lunch meal on 7/18/22 at 12:20 p.m. revealed the following food items on the steam table being plated for the residents: hot dogs with chili, baked beans, cole slaw, and banana bread. The items were sent out on the hall lunch tray and served in the dining room to the residents. A review of the Week-At-A-Glance Spring 2022 Week 3 menu revealed that the following food items were to be served for the resident's lunch on 7/18/22: choice of entrée, a bun, baked beans, and baked cookies. In an interview on 7/18/22 at 1:30 p.m., Cook/Dietary Aide (DA) LLL confirmed changing the food items. DA LLL reported being unaware that she was not following the menu. She reported that the facility was on the Week-At-A-Glance Fall Week 2 menu. After requesting a copy of the menu calendar from the dietary staff on 7/18/22, DA LLL provided a copy of the Week-At-A-Glance Fall Week 2 instead of the Week-At-A-Glance Spring Week 3 menu. Later the next day on 7/19/22, the facility provided copies of the menu calendars for the entire year, which included the Week-At-A-Glance for Week (Fall Week 2, Spring Week 3, and Summer Week 4). An observation in the kitchen on the tray line on 7/19/22 at 8:55 a.m. revealed the resident breakfast meal consisted of the following food items: grits, bacon, egg, and toast. There was no milk provided for the residents' breakfast meal. A review of the breakfast menu for Week-At -A-Glance Spring 2022 Week 3 revealed that the following food items should have been served for breakfast: egg of the day, sausage, French toast, cereal of choice, juice of choice, and milk. During an interview on 7/19/22 at 9:20 a.m., DA LLL stated that the kitchen did not have any milk. She stated that the truck had not made a delivery today. DA LLL stated she had not been instructed on what to do if there was no milk for residents. DA LLL provided no explanation for why the wrong food items were served for breakfast. An observation of the resident lunch meal on Tuesday, 7/19/22 at 1:00 p.m. revealed food served for the resident lunch included lemon pepper chicken, collard greens, apple sauce, peas and carrots mixed, and salad instead of the food items listed on Week-At-A-Glance Spring 2022 Week 3 menu. According to the Week-At-A-Glance Spring 2022 Week 3 for Tuesday, 7/19/22, the food items listed to be served for lunch were shrimp alfredo, garlic bread sticks, cherry cobbler, and cucumber and tomato salad. Interview with DA/Cook MMM on 7/18/22 at 1:45 p.m. revealed the reason why the menu was not followed for the lunch meal on 7/19/22 was because some of the food items for the lunch meal were substituted for last night's dinner meal (on 7/18/22). DA MMM stated the shrimp alfredo and garlic bread (food items scheduled for Tuesday, 7/19/22 lunch menu) were substituted for last night's meal. She reported that she could not serve the original Monday dinner meal based on the Week-At-A-Glance due to having a shortage of food items in the kitchen. In an interview on 7/20/22 at 9:41 a.m., Interim Administrator AA reported being unaware of the milk not being available and dietary staff being out of the milk products and groceries. She reported having a prior problem with the dietary staff running out of meals due to a shortage of food items. Interim Administrator AA reported becoming involved and speaking with some of the dietary staff about the previous issue with a suspected problem of food items being taken out or removed from the kitchen. The corporate office became involved and assisted with monitoring of grocery orders. Interim Administrator AA reported that her expectation was that the correct menu should be posted every day. In an interview on 7/20/22 at 3:10 p.m., Administrator AAA reported that her expectations were that the menu was posted in legible font size (meaning visible to residents) and that if the dietician (meaning dietary staff) changed the food items on the menu, then the dietary staff should post that menu. During the survey, a policy was requested related to following menus and there was no policy provided by the facility by the end of the survey.

Based on observations, interviews, and facility policy review, the facility failed to ensure proper labeling of food items, storage of food items, and discarding of expired food items; failed to ensure hair nets were available for use by dietary staff; and failed to ensure one floor ice milk chest freezer, one low temperature dishwasher, and one grease trap were operating properly. This had the potential to affect 101 residents who received an oral diet. Findings include: 1. A review of the facility policy titled, Procedures for Dating and Labeling, Items for Storage areas, Coolers, and Freezers, dated 3/31/21, revealed, Foods for meal service for same day service must be labeled and dated. Product name and date must be on the foods. All opened items in the storage area must have an opening date and use by date. Do not label the lid from a container, put label on the side of the container. Further review of the policy revealed Left-over foods must be discarded after 72 hours or 3 days. Continued review of the policy revealed All items in the storage area, cooler freezer, and kitchen area must have dates and labels on them. Observation in the kitchen of reach-in refrigerator #1 on 7/18/22 at 9:15 a.m. revealed the following food items were not dated and/or labeled or not stored properly, and the expired foods were not discarded: - one open bag of shredded cheese with no open date - one large pan of chipped bacon with a dark greenish substance growing on it stored in a deep aluminum waiter pan - bologna wrapped in plastic wrap, part of the commercial wrapping was removed, revealing no opening or expiration date - one cooked boiled egg in a cup with no expiration date - nine small bowls of gelatin covered with plastic wrap with no opening or expiration date - eight individual bowls of chicken soup (removed from the original container) stored in small plastic storage containers not dated or labeled - eight cups of nectar thick liquid (removed from the original container) stored in plastic cups not dated or labeled Observation in the kitchen of reach-in refrigerator #2 on 7/18/22 at 9:16 a.m. revealed no thermometer in the refrigerator to monitor the temperature to ensure the food items were kept at the recommended temperature and food items were not dated, not labeled, and not stored properly. Additionally, expired foods were not discarded. These food items included the following: - six chicken breast chunks in a large aluminum waiter pan with the top covered with plastic wrap, not dated or labeled (no cook date) - beets stored in a large aluminum waiter pan with the top covered with plastic wrap, undated and unlabeled - lunch meat turkey slices stored in a small aluminum pan covered with plastic wrap with no open date and no expiration date - carrots stored in a small aluminum pan covered with plastic wrap, undated and no expiration date available - tomato paste stored in a large plastic container undated and no expiration date - a large pan containing cooked hot dogs stored in a large aluminum waiter pan, covered with plastic wrap, undated and with no expiration date - cooked chicken noodle soup stored in a large plastic (removed from the original container), not dated - individual cheese slices stored in a dirty container, undated and no expiration date available; dark brown and white particles coated the bottom of the container - two small puddings stored in plastic storage cups (removed from the original container), not dated or labeled - a salad on a plate covered with plastic wrap, not dated and not labeled - broccoli stored in a small plastic container, undated and not labeled - spinach stored in a large plastic container with a lid labeled as mushroom, with a date of 12/07/2021 - cheese sauce stored in a large plastic container (removed from the original container,) not dated or labeled - 1/2 stick of butter not completely covered and not dated Observation in the kitchen of reach-in refrigerator #3 on 7/18/22 at 9:18 a.m. revealed the following food items not dated and not labeled or not stored properly, and with expired foods not discarded: - a container of whipped topping, no open date (with no expiration date as it was removed from the original container) - 1/2 block of cheese wrapped in plastic wrap, not dated - a large bowl of Jell-O stored in a plastic container with the top covered with plastic wrap (removed from the original container) - five spoiled tomatoes stored in a large box with two large watermelons - 1/2 bag of mixed salad that was spoiled, not dated - a large cucumber, spoiled, lying on the top rack in the refrigerator - 32 small bowls of pears stored in plastic bowls (removed from the original container), not dated During an interview on 7/18/22 at 9:58 a.m., Dietary Aide/Cook (DA) LLL stated she had received training on labeling and dating, food storage, and discarding of expired food. She stated that she was the cook for the morning shift. Per the DA LLL, she was not aware of food being unlabeled and undated until doing the observation today with the surveyor. She stated there had always been a problem with the weekend staff not labeling and dating food. The DA LLL stated she had complained about this before to the former Dietary Manager. Per DA LLL, she had spoken with the newly hired Dietary Manager about the problem. DA LLL confirmed that the white speckle food items in the bottom of the container containing the cheese slices were white cheese food particles. She described the dark green colored substances in the pan of chipped bacon as mold. During an interview on 7/18/22 at 10:01 a.m., DA NNN stated he worked for the facility at least one and a half months. He reported receiving some training on labeling and dating but training was from DA OOO and not from the Dietary Managers. He described the training as not formal training. In an interview on 7/18/22 at 1:13 p.m., DA RRR reported receiving training on labeling, dating of food, and food storage. DA RRR stated he was aware of expired food being discarded but was not sure of the date and timeframe leftover food should be discarded. In an interview on 7/20/22 at 3:10 p.m., Administrator AAA reported that her expectation was that food items were dated. In an interview on 7/21/22 at 1:00 p.m., DA QQQ stated he was hired in 2021 and confirmed receiving previous training on dating and labeling food items. DA QQQ stated he also received a refresher training this past Tuesday, 7/19/22. During an interview with the Director of Nursing (DON) on 7/21/22 at 10:35 a.m., the DON reported that her expectation was that kitchen staff followed the dietary policy. The DON continued to state that her expectation was that food items were labeled, dated, and stored correctly. 2. During a tour of the kitchen, which began on 7/19/22 at 9:10 a.m., Dietary Aides (DA) RRR and MMM were observed in the kitchen without hair nets. The staff were observed assisting with prepping food items for lunch. During an interview on 7/18/22 at 9:10 a.m., DA MMM reported that the facility had been out of hair nets for the last two days. In an interview on 7/18/22 at 1:00 p.m., Dietary Manager (DM) XX confirmed she was aware that the kitchen staff did not have hair nets for the last two days. Per DM XX, her plan was to purchase new hair nets today but was not able to purchase the hair nets on her way to work. She stated that she had planned to purchase the hair nets from a local retail store. In an interview with the Administrator on 7/20/22 at 3:10 p.m., the Administrator reported being unaware of the problem with the staff not wearing hair nets. Administrator AAA reported that her expectation was that the staff wore hair nets in the kitchen. Administrator AAA indicated they had now received hair nets from other facilities. 3. An observation on 7/18/22 at 9:22 a.m. with Dietary Aide/Cook DA LLL revealed a large floor model chest cooler/refrigerator (used as a milk freezer) located in the kitchen area. A continued observation of the floor model chest refrigerators' latch doors revealed broken latches, causing the door to not properly close. A close observation of the refrigerated chest door revealed a large gap on the side of the door preventing the door from being sealed tightly. On the bottom floor of the refrigerator was a dark thick liquid substance with food debris and lumps of a darkish brown substance. Observation of the milk cartons in the chest freezer with DA LLL revealed a total of 35 chocolate milk cartons, 101 2% cartons of milk, five Mighty Shakes, and four whole milk cartons. The milk was cool to touch and not very cold. DA LLL removed the milk from the chest. The milk was discarded by Dietary Manager (DM) XX when she arrived at work. Further observation revealed no thermometer in the chest refrigerator to monitor the temperature of the milk. In a later interview on 7/19/22 at 11:47 a.m. with the Maintenance Supervisor and DM XX, the Maintenance Supervisor and DM XX described the dark liquid substances as mold and mildew on the floor of the floor model chest freezer. Both reported being unaware of the condition of the freezer. 4. An observation was conducted in the kitchen on 7/18/22 at 9:23 a.m. of DA OOO operating the facility's low-temperature (temp) dishwasher with no sanitation solution in the large bucket. The dishwasher was not meeting the minimum wash temp of 120 degrees Fahrenheit (F). DA OOO reran the dishwasher three times and the highest the wash temperature reached was 110 degrees F. During the three attempts, the rinse temperature only reached 110 degrees F which was less than the required 140 degrees F. Additionally, during the sanitation cycle the maximum temperature obtained was 118 degrees F which was less than the required 140 degrees. DA OOO stated there were problems with the dishwasher wash cycle and not registering the required temperatures at times. DA OOO stated he was unaware of whether the dishwasher was a low temperature or a high temperature dishwasher. He stated that manufacture information related to the dishwasher operating cycles was not provided to him. Per DA OOO, the rinse temperature sometimes got up to 160 degrees F, and he was not sure of the sanitizer. He stated it may be 130 degrees F or 138 degrees F. He stated that morning it was 138 degrees F for the rinse and sanitizer. He stated he logged the dishwasher temperature every day. A review of the dishwasher revealed a label which listed the dishwasher as a low temperature dishwasher. Review of the manufacture guidelines revealed the dishwasher recommended temperatures for the wash cycle be at 120 degrees F, rinse cycle at 140 degrees F, and sanitizer at 140 degrees F. During an interview on 7/18/22 at 11:00 a.m., DM XX stated she was not sure of the model/type of dishwasher. She described the dishwasher as a regular dishwasher and was unsure what a low-temp or high-temp dishwasher was. During an interview on7/20/222 at 3:10 PM and at 4:14 p.m., Administrator AAA stated she was unaware of the dishwasher not working. She stated that the dietary staff informed her that the dishwasher needed more solutions, and she was not aware that as of today the dishwasher remained broken. Administrator AAA stated that her expectation was that staff continue to notify her if the problem with the dishwasher continued to exist. 5. An observation in the kitchen on 7/18/22 at 1:11 p.m. with the Maintenance Supervisor and DM XX revealed a puddle of dirty dark brown water on the floor, protruding from the grease trap. A continued observation revealed thick, dark, blackish, greasy substances with dirt and debris. In an interview at the time of the observation, the Maintenance Supervisor stated that this problem existed prior to December 2021. DM XX reported being aware of the problem and reported that Administrator AAA was aware. During an interview on 7/20/22 at 4:14 p.m., Administrator AAA stated she started working as the Administrator on 3/28/22. She stated she was made aware of the problem of a leakage from the grease trap in the kitchen. Per the Administrator, in April 2022, a service company was contacted to fix the problem. The root cause of the problem was clogged pipes, and the service company reported that pipes needed to be unclogged. The service company did come out to unclog the pipes and pump out the grease trap. The Administrator AAA stated the problem was resolved in April 2022. She stated she toured the kitchen two weeks ago and was unaware of a continued problem with the grease trap.

Based on observations, interviews, and review of the facility policy, the facility failed to maintain one of two facility dumpsters in a sanitary condition by ensuring the dumpster had fitted lids. Findings include: A review of the facility policy titled, Food Related Garbage and Refuse Disposal, revised October 2017, revealed Food-related garbage and refuse are disposed of in accordance with current state laws. 1. All food waste shall be kept in containers. 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. Further review of the policy revealed 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests. Continued review of the policy indicated 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. An observation on 7/18/22 at 11:58 p.m. with Dietary Manager (DM) XX, revealed the dumpster lid was unsecure and not tightly closed. The dumpster had a large gap, resulting in a large open space causing the trash not to be secure inside and allowing exposure to insects and rodents. Flies were observed swarming around the dumpster. The newly hired DM XX offered no explanation for the dumpster lid not being tightly fitted or closed. Continued observations of the dumpster were conducted throughout the survey on 7/19/22 at 10:13 a.m. and 7/20/22 at 11:59 a.m Each observation revealed the dumpster lid remained not tightly fitted and exposing a wide gap. During an interview on 7/20/22 at 9:41 a.m., Interim Administrator AA reported being made aware of the condition of the dumpster lid not tightly fitting by their visiting DM WW. Interim Administrator AA stated she had sent notifications to the company that handled the dumpster yesterday afternoon to have the dumpster replaced. She stated that Maintenance was responsible for ensuring that the dumpster lid was secure and for monitoring the dumpster for any problems. She further stated that a tightly fitted lid on the dumpster was important to prevent critters and insects from having access to the dumpster. During an interview on 7/20/22 at 3:10 p.m., Administrator AAA, stated that Maintenance was responsible to ensure the dumpster lid was tightly fitted to ensure rodents did not have access to the dumpster. The Administrator reported not being able to recall the last time she observed the dumpster area. In an interview with the Director of Nursing (DON) on 7/21/22 at 10:35 a.m., the DON reported not visiting the dumpster area. She stated her expectation was that the dumpster lid remained secure (meaning tightly fitted) to prevent access to any pests and flies.

Based on observation, staff interview, and review of the policy, Quality of Life - Dignity, the facility failed to ensure that the dignity of one resident (#207) from a sample of 67 residents was maintained as he moved back and forth on his hallway and was escorted to the therapy department while his catheter and drainage bag with its contents remained clearly visible to everyone in the vicinity. Findings include: Review of the policy, Quality of Life - Dignity last revised August 2009 revealed that residents are to be treated with dignity and respect defined as the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. The policy also stated that staff shall promote and maintain resident privacy, including bodily privacy. An observation on 6/17/19 at 11:56 a.m., Resident (R)#207 was observed to be wheeling back and forth in the hallway outside his room. The resident was observed to have a urinary catheter and drainage bag that was uncovered and attached to his wheelchair, the contents of which (clear yellow liquid) were clearly visible to staff, other residents, and visitors passing in the hallway. On 6/17/19 at 2:54 p.m., R#207 was observed to be sitting in the hallway outside his room with his urinary catheter and drainage bag and its content of yellow liquid still without a privacy bag/covering. On 6/17/19 3:22 p.m., the resident was again observed sitting in the hallway outside his room with an uncovered catheter and bag. A member of the therapy staff approached asking for the resident. The resident identified himself and, after conversing briefly with him, the therapy staff member wheeled him down his hallway and then the adjoining hallway to the therapy room where he was observed, a few minutes later, riding a stationary bike with the exposed catheter and drainage bag. During an observation on 6/17/19 at 3:40 p.m. accompanied by the Director of Nursing (DON), R#207 was observed being wheeled down the hallway back to his room after exiting the therapy room. His urinary catheter and drainage bag was still clearly visible to anyone in the vicinity. An interview on 6/17/19 at 3:42 p.m. with the DON, revealed that the facility did not use privacy bags for residents with catheters. Instead, the facility uses an opaque drainage bag through which the contents cannot be seen by onlookers. The DON also said that residents admitted to the facility frequently came with a transparent drainage bag like the one in use by the resident. However, staff are expected to change out this transparent bag to the opaque bag used by the facility as soon a possible. She was aware that R#207 was a new admission, but she was not aware that it was almost a week since he had been admitted . Staff should already have changed out his transparent catheter bag with an opaque bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospice and staff interview, the facility failed to update the code status of one resident (R) (R#37) from a full code to a do not resuscitate (DNR) in all of the resident's clinical records after the resident elected hospice services and signed a DNR form. A total of three residents were reviewed for any concerns with advance directives. Findings include: Review of R#37's clinical record revealed that she had diagnoses including peripheral vascular disease; cellulitis; pressure ulcer of the sacrum; anemia; chronic fatigue; chronic pain; diabetes; neuropathy; obesity; hypertension; hypothyroidism; hyperlipidemia; anxiety disorder; major depressive disorder; edema; COPD (chronic obstructive pulmonary disease); and heart failure. Review of R#37's Significant Change Minimum Data Set (MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 8 (a BIMS of 8 to 12 indicates moderately-impaired cognition), and that she received hospice care. Review of an Advance Directives Summary in R#37's active clinical record revealed that on [DATE], she had been informed of the right to implement Advance Directives. Review of R#37's care plans revealed for advance directives as follows: Focus: I DO NOT have any advanced directives on chart; I am a FULL CODE. Initiated [DATE], revision on [DATE]. Goal: If my heart stops beating or if I stop breathing, CPR (cardiopulmonary resuscitation) WILL BE initiated in honor with my wishes. Interventions: Advise me and or my RP (responsible party) to provide the facility with any new or updated advanced directives. Date Initiated: [DATE]. Discuss advanced directives with my (sic), my relative or RP during care plan meetings, yearly reviews and PRN (as needed). Date Initiated: [DATE]. Identify my chart with a FULL CODE sticker. Date Initiated: [DATE]. Review of R#37's current June Physician's Orders revealed that no code status was designated. Review of the Profile page in the facility's electronic health record (EHR) revealed that R#37 had a Code Status of Full Code. Review of a Hospice Allow Natural Death/Do Not Resuscitate form behind the Advance Directive tab in R#37's active paper clinical record revealed that the resident signed on [DATE] to consent and request that no resuscitative measures be initiated, and it was co-signed by a witness and Physician. Review of the exterior of R#37's paper clinical record binder revealed that there was a red DNR sticker on the outside spine. An interview with the Director of Nursing (DON) on [DATE] at 10:23 a.m., she verified that there was no Physician Order for a DNR. She stated during continued interview that because R#37 was a hospice resident, either the hospice nurse should have written a Physician Order for the DNR, or communicated with the facility nurse that a DNR had been obtained on R#37, and the facility nurse should have written the order. During interview with the DON on [DATE] at 10:50 a.m., she verified that R#37 had a status of full code in the EHR, as well as a care plan for full code. She stated during continued interview that she located a nursing note that a DNR order had been received, and did not know why the nurse didn't contact the physician and write the DNR order. Review of a nursing Health Status Note dated [DATE] at 8:29 p.m. revealed: DNR STATUS IMPLEMENTED AS OF TODAY. An interview with Registered Nurse (RN) Hospice nurse GG on [DATE] at 11:12 a.m., revealed that R#37 was admitted to hospice services on [DATE] for a diagnosis of heart failure, and that the resident expressed her wishes to be a DNR. Hospice nurse GG further stated that she obtained R#37's signature on the DNR form, and that she sat down afterwards with the facility nurse and showed her the DNR form. An interview with Licensed Practical Nurse (LPN) EE on [DATE] at 12:44 p.m., revealed that to know what a resident's code status was, she looked for the DNR sticker on the outside of the resident's chart, and the DNR or Full Code sheet kept with the resident's MARs (Medication Administration Record). Review of R#37's MARs at this time revealed that she had a DNR sheet included with them. Review of the facility's Do Not Resuscitate Order policy dated [DATE] revealed: 1. Do not resuscitate orders must be signed by the resident's Attending Physician on the Physician's Order sheet maintained in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow/implement care plan for two residents (R)#23 in relation to providing a referral to therapy after a fall with injury and R#58 in relation to insulin of 67 sampled residents. Findings include: 1. Review of R#23's care plan revealed there were interventions including a referral to therapy for possible walker on 6/11/19. Review of R #23 Nurse's Progress Notes dated 6/9/19 revealed R#23 fell with a right elbow injury and a fall noted on 6/11/19 indicated R#23 fell on face resulting in abrasions, nose bleed, and two lacerations. The Nurse's Progress Notes dated 6/11/19 revealed R#23 was taken to the emergency room for evaluation. An interview with Director of Nursing (DON) on 6/20/19 at 10:49 a.m.revealed that R#23 lost her balance, fell and was sent out to the emergency room for evaluation. She also stated there was a referral made to therapy to help prevent the resident from falls but wasn't sure if a follow-up had been made. An interview with the Director of Rehabilitation on 6/20/19 at 11:00 a.m. revealed that she had not received a referral to therapy for R#23 and that the resident would be a good candidate for therapy. She further revealed that the resident wasn't placed on a restorative program in the past because a restorative programs wasn't available. She stated the last time the resident was on physical therapy was in August 2018 and was discharged because the resident didn't gain a lot of function. The Director of Rehabilitation also stated the last time the resident was on the occupational therapy program was in May 2018 and met the goals set. 2. Review of R#58's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that she received insulin all seven days of the assessment period. Review of R#58's diabetes mellitus care plan revised on 5/9/19 revealed an intervention for diabetes medication as ordered by doctor. Review of R#58's Physician's Orders revealed an order dated 11/4/16 for Accucheck/fingerstick blood sugar (FSBS) twice daily at 6:30 a.m. and 4:30 p.m. with sliding scale coverage for diabetes mellitus. Review of the Physician's Order for sliding scale insulin dated 11/4/16 revealed to give Novolog for a blood sugar (BS) greater than 200 per the formula of (BS - 100) / 30 = # units (blood sugar minus 100 divided by 30 equals the number of units of insulin to give). Review of R#58's March through June (through 6/19/19) Medication Administration Records (MAR) revealed the incorrect amount of sliding scale insulin was documented 11 times, and there was no evidence that the FSBS was done two times. During interview with the Director of Nursing (DON) on 6/20/19 at 11:27 a.m. and 12:11 p.m., she verified the above concerns regarding the FSBS and sliding scale insulin for R#58. Cross-refer to F 684.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to revise one resident's (R) (R#57) comprehensive care plan for behaviors in a timely manner after an inpatient psychiatric hospitalization for threatening another resident, that included the resident's immediate and ongoing behavior management needs. The sample size was 67 residents. Findings include: During interview with R T and R S on 6/19/19 at 1:00 p.m., the resident stated that R#57 had recently been readmitted to the facility, and that the resident was verbally abusive and had been found with weapons in her room, including a hammer. Interview with R S at this time, they stated that they had concerns for their personal safety after R#57 was readmitted . Review of R#57's clinical record revealed that she had diagnoses including dementia without behavior disturbance, and cerebral infarction (stroke). Review of R#57's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 7 (a BIMS score between 0 and 7 indicates severe cognitive impairment). Further review of this MDS revealed that she exhibited no behaviors during the assessment period, was on no psychotropic medications, received no psychological therapy, needed extensive assistance for walking in her room, and supervision only for locomotion on and off the unit. Review of a Health Status Note dated 5/30/19 at 10:20 p.m. revealed that a CNA (Certified Nursing Assistant) reported to the nurse that R#57 threatened to kill her roommate with a hammer. R#57's roommate was interviewed and verified that R#57 had threatened to kill her with a hammer. R#57 was sent to the emergency room for a psychiatric evaluation. Review of a Health Status Note dated 5/31/19 at 2:46 p.m. revealed that R#57 was 1013'd (indicating an emergency mental health transport to a receiving facility). Review of a Health Status Note dated 6/7/19 at 7:01 p.m. revealed that R#57 returned from the hospital at 6:30 p.m. via stretcher. Review of the Behavioral Health Services Hospital Psychiatric Discharge Orders and Summary revealed that R#57 was admitted on [DATE], and had a projected discharge date of 6/7/19. Further review of this Summary revealed that to promote continued stabilization and recovery, DO: Keep follow up appointment; follow crisis safety plan; take all medications as prescribed; report worsening symptoms to physician. Review of the hospital's Patient Discharge Medication Instructions revealed that she was placed on two new psychotropic medications. Review of R#57's behavior problem care plan printed on 6/19/19, which was initiated on 2/22/18 and revised on 10/18/18, revealed that it had not been updated to reflect R#57's recent psychiatric hospitalization with discharge recommendations, the potentially dangerous items found in her room, nor the new psychotropic medications ordered for her. An interview with the Director of Nursing (DON) on 6/19/19 at 2:43 p.m., revealed that the facility did not get any discharge paperwork from the psychiatric hospital when R#57 returned to the facility except for a list of discharge medications, so it was not known what the admitting and discharge diagnoses were nor any special instructions or recommendations for the staff at the facility. During interview on 6/19/19 with CNA HH at 3:22 p.m., Licensed Practical Nurse (LPN) MM at 3:24 p.m., LPN EE at 3:25 p.m., and CNA NN at 3:31 p.m., they stated that they had not been instructed to do any special monitoring for R#57 once she returned from the hospital. An interview with the Director of Nursing (DON) on 6/19/19 at 5:08 p.m., she stated that she would think that R#57 would have her behavior care plan updated for threatening another resident. An interview with LPN MDS Coordinator II on 6/20/19 at 2:03 p.m., revealed that since R#57 already had a comprehensive care plan that included behaviors, that this existing care plan would just be updated with any changes since the resident's readmission. MDS Coordinator II stated during continued interview that MDS and the Social Services Director (SSD) were responsible for updating the behavior care plan, and because the other MDS Coordinator had been off for several days, she (MDS Coordinator II) updated R#57's behavior care plan even though she was not responsible for that resident. Review of R#57's behavior care plan revealed that it was updated on 6/20/19 to reflect a hospital return related to behaviors on 6/7/19, and had three new interventions as follows: -(As of 6-7-19) Medication adjustment as needed per MD (Medical Doctor). Date initiated 6/20/19. -(As of 6-7-19) Room change as indicated. Date initiated 6/20/19. -(As of 6-7-19) Room sweeps as needed for contraband not needed for safety. Date initiated 6/19/19. MDS Coordinator II verified during continued interview at this time that R#57's behaviors care plan was not updated until 6/19/19 and 6/20/19 to reflect the behaviors and hospitalization. Interview with the SSD at this time revealed that updating the care plan was a joint responsibility between the SSD and MDS, and did not know why R#57's care plan had not been updated immediately after her return from the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to consistently administer the ordered amount of sliding scale insulin 11 times and/or failed to provide evidence that fingerstick blood sugar (FSBS) measurements were done as ordered on two occasions between March and 6/19/19 for one resident (R) (R#58) of 67 sampled residents. Findings include: Review of R#58's clinical record revealed that she had diagnoses including diabetes mellitus. Review of R#58's Quarterly Minimum Data Set (MDS) dated [DATE] revealed that she received insulin all seven days of the assessment period. Review of R#58's diabetes mellitus care plan revised on 5/9/19 revealed an intervention for diabetes medication as ordered by doctor. Review of R#58's Physician's Orders revealed an order dated 11/4/16 for Accucheck/fingerstick blood sugar twice daily at 6:30 a.m. and 4:30 p.m. with sliding scale coverage for diabetes mellitus. Review of the Physician's Order for sliding scale insulin dated 11/4/16 revealed to give Novolog for a blood sugar (BS) greater than 200 per the formula of (BS - 100) / 30 = # units (blood sugar minus 100 divided by 30 equals the number of units of insulin to give). Review of R#58's March through June (through 6/19/19) Medication Administration Records (MAR) revealed the following concerns: 3/4/19 at 6:30 a.m.: BS 350, 8 units ordered, 11 units given. 3/18/19 at 4:30 p.m.: No evidence that the FSBS was done. 3/23/19 at 4:30 p.m.: BS 173, 0 units ordered, 2 units given. 4/14/19 at 6:30 a.m.: BS 216, 4 units ordered, nothing documented as given. 4/16/19 at 4:30 p.m.: BS 206, 4 units ordered, nothing documented as given. 4/25/19 at 6:30 a.m.: BS 205, 4 units ordered, nothing documented as given. 5/4/19 at 6:30 a.m.: BS 210, 4 units ordered, nothing documented as given. 5/9/19 at 4:30 p.m.: BS 186, 0 units ordered, 2 units given. 5/12/19 at 6:30 a.m.: BS 206, 4 units ordered, nothing documented as given. 5/15/19 at 6:30 a.m.: BS 248, 5 units ordered, nothing documented as given. 5/30/19 at 4:30 p.m.: No evidence that the FSBS was done. 6/15/19 at 4:30 p.m.: BS 236, 5 units ordered, 4 units given. 6/16/19 at 4:30 p.m.: BS 208, 4 units ordered, 2 units given. An interview with the Director of Nursing (DON) on 6/20/19 at 11:27 a.m. and 12:11 p.m., revealed that she could not speak for the individual nurses, but she verified the concerns with the sliding scale insulin as noted above for R#58. She further stated that the nurses used a conversion form (Sliding Scale Insulin Conversion Chart) kept with the resident's MAR with the amount of insulin to be given for a particular blood sugar, so that the nurses did not have to actually calculate the amount themselves. The DON further stated that for the blood sugar result of 350 on 3/4/19 at 6:30 a.m., that the physician was supposed to be contacted and may have given the nurse an order to give 11 units of insulin instead of 8, but she verified there was no evidence on the MAR or in the Nurse's Notes that this occurred. In addition, review of R#58's March Physician Telephone Orders revealed no one-time order for 11 units of insulin on 3/4/19 was found. A second interview with the DON on 6/20/19 at 2:22 p.m., she stated that they did not have a policy on sliding scale insulin, but that the nurses were just expected to follow the Physician's Order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the most current 30-day Minimum Data Set (MDS) assessment dated [DATE] for R#82 indicated extensive assist to total dependence on Activity of Daily Living, indwelling catheter, status post (s/p) hip fracture, retention of urine, no pressure injuries. Review of the care plan for R#82 revealed appropriate interventions including to secure the catheter tubing with leg strap. A review of the Physician Orders for June 2019 included but not limited to the following: Foley catheter orders in place, including Foley catheter #16 (french) FR with 10 cubic centimeters (cc) (size of catheter and size of catheter bulb) to gravity drainage, secure with leg strap, assess as needed. R#82 was previously on Macrobid 100 milligram (mg) po (by mouth) bid (twice daily) for seven days (6/7/19) and then on Augmentin 500-125 mg tablet one po bid for one week (6/17/19) for Urinary Tract Infection (UTI). Observation on 6/20/19 at 10:45 a.m. of Foley catheter care provided by Certified Nursing Assistant (CNA) CC and CNA DD revealed that the resident hollered out when the catheter tubing was being cleaned and catheter strap was not present. CNA CC stated that they usually get one from the nurse. An interview on the same day at 11:00 a.m. with the charge nurse Licensed Practical Nurse (LPN) BB revealed that resident's with a catheter should have a catheter strap. Based on observation, record review, staff interview, and review of policy, Care of Foley Catheters, the facility failed to assess for the continued use of a catheter or to obtain a physician's order for the use of said catheter after admission for one resident (R#207) and failed to ensure use of a catheter strap for one resident (#82). The sample size was 67. Findings include: 1. Review of the clinical records for Resident (R)#207 revealed he was admitted on [DATE] with diagnoses which included urinary tract infection and sepsis. A review of the admission Nursing Evaluation of 6/11/19 revealed that the resident was observed to have a Foley catheter on admission. A review of the Nursing Note dated 6/12/19 which documented that the resident had a Catheter Fr16. A further review of a Nursing Note dated 6/15/19 which documented that the resident was observed to have a foley bedside bag patent and draining straw color urine. A review of the plan of care initiated on 6/13/19 for the use of a Foley catheter with risk for complications. Among the interventions associated with this plan of care were the directives for staff to monitor for pain/discomfort due to the use of a catheter, and to provide changes of the catheter tubing and bag as ordered. An observation on 6/19/19 at 11:05 a.m. revealed the resident still had a catheter and drainage bag. A review on 6/19/19 at 11:08 a.m. of the Physician's Orders dated 6/11/19 revealed there was no Physician's Order for the resident's use of a catheter. An interview with Licensed Practical Nurse (LPN) AA on 6/19/19 at 11:10 a.m. revealed that R#207 did have a urinary catheter, and confirmed that there was no Physician's Order in the resident's records for him to have such a catheter. The LPN further revealed that when a resident is admitted with a catheter, that resident's Physician must write an order for the resident to continue using a catheter at the facility. Continued interview with LPN AA revealed that resident's Physician was away on leave at the time of the resident's admission and the resident was seen/assessed by the Nurse Practitioner during his absence. LPN AA said she did not know why an order was not written for the catheter. An interview on 6/19/19 at 3:05 p.m. with the Physician of R#207, revealed that when a resident is admitted with a catheter, then he usually has that catheter removed within a few days provided it is not a suprapubic catheter or the resident does not have a decubitus present. The Physician revealed that he could not say why this process had not taken place in the case of R#207 but he had not seen the resident before his visit that day at which time he had given an order for the catheter to be removed as soon as possible. An interview with the Director of Nursing (DON) on 6/20/19 at 2:43 p.m. revealed that when a resident is admitted with a urinary catheter, staff attempts to first discover the reason for that resident having a catheter. Once the reason for the catheter is ascertained, staff are to call the resident's Physician to see if he wants to continue with the catheter or whether to discontinue the catheter. It is her expectation that if a resident is at the facility for a week, that staff should have contacted and inform the Physician for orders to either maintain the cathether or to remove the catheter.

Based on observation, staff interviews and review of facility policies, the facility failed to ensure removal of two expired medications (Eldertonic bottle and Lorazepam pill pack) and to place an open date on one opened GeriLanta medication on one (hall two, medication cart B) of two medication carts. Findings include: Observation on 6/1919 at 10:30 am, of medication cart B on hall two revealed the following: one GeriLanta bottle with no open date (expiration date of 4/2020); one Eldertonic bottle with open date of 4/20/18 and expiration date of 5/2019; one punch card of Lorazepam 1milligram (mg) with discard date of 3/10/19 (total of six pills but none were used). An interview with Licensed Practical Nurse (LPN) EE, during the observation revealed that when a medication is opened, they place an open date on the medication and check the expiration date. An interview on 6/19/19 at 12:31 p.m. with the Director of Nursing revealed that they do not have a policy related to labeling/opening medications, but their standard of practice is that an open date is written on the medication and they follow manufactured expiration date. Review of the policy titled Administering Medication revised December 2012 revealed medications shall be administered in a safe and timely manner and as prescribed. 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.

Based on record review, facility and Dietary corporate staff interview, the facility failed to ensure that the staff designated as director of food and nutrition services was a certified dietary or food service manager or had a similar food service management certification or degree. There were 109 residents that received an oral diet. Findings include: During interview with the facility's designated Dietary Manager (DM) on 6/18/19 at 4:15 p.m., who revealed that he was ServSafe certified, but was not a Certified Dietary Manager (CDM), nor did he have a similar degree or certification in food service management. The DM stated during continued interview that he had been the DM for about a year, and planned to get his CDM, but had not enrolled in or started the course yet. An interview with the Corporate Registered Dietician (RD) KK at this time revealed that the facility contracted with company (name) to provide all of the dietary staff, and that the current DM was an internal hire for the position about a year ago, and he had previously been the Assistant DM at the facility. An interview with the designated DM on 6/19/19 at 12:32 p.m. revealed that he was told when he started the position as DM about a year ago, that he would have to take the CDM course, but was given no timeframe to start or complete it. An interview with the (contract company) (name) Regional Director of Operations JJ on 6/19/19 at 12:36 p.m. revealed that when they hired a DM, that they generally looked to see if they were ServSafe certified, as it was very hard to find a CDM in a rural area such as where the facility was located. He further stated that the corporate office had been working on getting a CDM training program through an online course or possibly a local program, but had not implemented anything yet to get their DMs certified. Regional Director of Operations JJ further stated that the DM had been enrolled in an online program at the University of North Dakota, but verified that the online course enrollment receipt was dated today (6/19/19). He further stated that because the DM had been the Assistant Food Services Director (AFSD) since 8/23/16, that they had 12 months to get him certified once he was promoted to the DM position on 4/22/18. Review of a Contract Company (name) Dietary Job Description with an approved date of 7/28/18 revealed: Job Title: Food Service Director Department: Contracted Management Food Service Qualifications to perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Must possess certification or equivalent to related job function. Review of a Employee New Hire Form revealed that the DM was originally hired on 9/6/16, with a job title of [NAME] Supervisor. Review of the DM's Employee Evaluation Annual Review dated 8/16/17 revealed that his date of hire was 9/6/17, and the job title he was being evaluated for was Cook. Continued review of the DM's employee file revealed that there was no evidence of a change in position from Cook/Cook Supervisor/Dietary Aide to either the Assistant DM or DM. An interview with the facility's Administrator on 6/20/19 at 9:51 a.m. revealed that all kitchen staff were hired by the Contract Company (name). He further stated that he did not know when the DM was originally hired and in which position he was hired for, as the DM was already there when he (the Administrator) started working at the facility. The Administrator added during continued interview that he did not know when the DM was hired into that position. An interview with the Contract Company (name) Regional Director of Operations JJ on 6/20/19 at 12:51 p.m., he verified that the only job titles in the DM's personnel file were for [NAME] and [NAME] Supervisor, but that he had been the Assistant Food Services Manager for a time. He further stated that the DM was promoted to the position of DM in April of 2018, but that there was nothing in his employee file with this information. Review of an e-mail from the Contract Company (name) Regional Director of Operations JJ to the facility's Administrator dated 6/20/19 at 12:23 p.m. revealed that since the DM was an AFSD prior to taking the DM position, that he should fall under the five year rule (to obtain certification). The facility or the Contract Company could not produce evidence that the designated DM had been promoted to the position of Assistant DM.