**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain a clean, sanitary, and comfortable environment for three of 13 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) reviewed. Specifically, the PTAC (Packaged Terminal Air Conditioner) vents were dirty. This deficient practice had the potential to compromise the health and safety of residents and staff by increasing the risk of respiratory and allergy symptoms due to inadequate air filtration and reduced fresh air circulation. Findings include: Review of the undated facility- provided document titled PTAC Preventative Maintenance Guide under the Three-Monthly PTAC Air Cleaning Tasks section revealed, 1. Air Filter Clean the filter with a vacuum or running water. 2. Vent Screen Clean or replace the vent screen. Remove the front grille and clean it with a dampened cloth Review of the undated facility-provided document titled HVAC (heating, ventilation, and air conditioning): Clean Air Filters details the following steps, At a minimum, air filters are to be replaced or thoroughly cleaned depending on the type of filter every month. Clean evaporator coils if lint build up is present. Observations on 4/1/2025 between 9:00 am and 10:00 am of the facility's PTAC air filters in resident room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] revealed that the PTAC units in these rooms had heavily soiled air filters with a thick accumulation of dust, dirt, and debris. Originally white, the air filters appeared dark gray due to trapped contaminants. When lifted for inspection, they released visible dust clouds and were clogged with a dense layer of grime. During an interview on 3/19/2025 at 9:35 am with Housekeeper II and Housekeeper JJ, they revealed that they did not clean the air filters. However, they did clean the grills, wiping them daily when they cleaned the rooms. During an interview on 4/3/2025 at 10:50 am with the Director of Housekeeping and the Director of Maintenance, they confirmed during a facility tour that maintenance was responsible for cleaning the air filters in the PTAC units. The maintenance staff cleaned the grills on the air filter covers as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, (Long Term Care [NAME] Data Set) LTC MDS and Care Plan, the facility failed to follow the care plan for one of eight residents (R) (R168) and failed to include a care plan for O2 use with interventions for one of eight R (R37) who receive (O2) therapy. The deficient practice had the potential for R168 and R37's oxygen needs to go unmet. Findings include: Review of the facility policy titled LTC MDS and Care Plan with a revision date of December 2023 revealed under the Care Plan section: It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment services, and interventions. 1. Review of the Care Plan dated 3/17/2025 for R168 revealed a focus diagnoses of emphysema/chronic obstructive pulmonary disease related to smoking. An intervention for oxygen setting revealed oxygen settings as ordered. Review of the Medication Administration order revealed the physician's order for Continuous oxygen @ (at) 2L/M Liters (L), minute (M), (Nurse is responsible for checking and maintaining Treatment Administration Record (TAR) every shift (QS). Administration Record (TAR) every shift (QS). She said she did not check the care plan, nor follow it as stated. An interview with the Director of Nursing (DON) on 4/3/2025 at 11:00 am revealed her expectations of the nurses following Doctor's orders and regulating O2 or any medication, she expected the nurses to access the Provider, change the settings when ordered, and alter the Care Plan to address those changes so that it flowed with the doctor's orders. 2. An observation on 4/1/2025 at 9:30 AM revealed and unsecured oxygen tank in Resident (R) (37), room [ROOM NUMBER]. The oxygen cylinder was noted to be in front of R 37's dresser drawers standing upright. No nasal cannula or nebulizer was attached the cylinder. A review of the physician's orders for R37 confirmed an O2 order. Review of the care plan for R37 revealed no care plan was in place for the resident's O2. An interview on 4/3/2025 at 1:40 pm with the MDS Director revealed that R37 was care planned for O2 at 3 LPM. The intervention states that on 7/5/2024, the resident was admitted to the hospital: Low O2 on 3 liters via nasal cannula (81%) admitted to room number DX: Dyspnea/COPD without exacerbation with low saturation. She verified that the resident was ordered for O2 at 2 liters. It was her expectation that care plans contained the correct information that was resident centered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, Medical Gas Cylinder Storage, the facility failed to ensure an oxygen (O2) tank was properly secured for one of five residents (R) (R37) reviewed for O2 storage. The deficient practice had the potential to result in harm or injury to the facility's residents. Findings include: Review of the facility policy titled Medical Gas Cylinder Storage dated February 2025 revealed under 2.0 General Requirements: All freestanding oxygen cylinders shall be in a rack, on a cart, in a portable cylinder holder, in a gas cylinder storage cabinet, or secured with a chain to protect them. Review of the electronic medical record (EMR) revealed that R37 was admitted to the facility with diagnoses of, but not limited to dependence on supplemental oxygen, dyspnea (shortness of breath), pneumonia (recurrent), Alzheimer's disease, chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, dementia, unspecified. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R37 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section GG (Functional Status) revealed need for supervision to partial assistance for ADLs (activities of daily living). An observation on 4/1/2025 at 9:30 am revealed an unsecured O2 tank/cylinder in R37's room, room [ROOM NUMBER]. The O2 tank was noted to be in front of R37's dresser drawers standing upright, unsecured. No nasal cannula or nebulizer were attached to the O2 cylinder. During an interview on 4/3/2025 at 11:50 am with Certified Nurse Aide (CNA BB), she stated all O2 cylinders/tanks should be secured to the chairs or stored in the supply room. She stated, When a cylinder gets empty, we take it and replace it. She confirmed there should not be an extra cylinder in resident rooms and cylinders should be stored in a rack or attached to a resident's wheelchair. She confirmed O2 cylinders were not to be stored in resident rooms. During an interview on 4/3/2025 at 1:30 pm with the Director of Nursing (DON), she stated it was her expectation for O2 cylinders to be stored in the supply room if not secured when in use by a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the EMR for R33 revealed that the resident was admitted to the facility with diagnoses that included but were not limited to paroxysmal atrial fibrillation, anemia, deep vein thrombosis (DVT), hypertension, ulcerative colitis, thyroid disorder, anxiety, depression, obstructive sleep apnea, and a multiple drug resistant organism in a wound, presence of a cardiac pacemaker, congestive heart failure, herpes zoster keratitis, Parkinsonism, chronic obstructive pulmonary disease (COPD) and insomnia. Review of the annual MDS dated [DATE] for R33 revealed in Section C (Cognitive Patterns), a BIMS score of 15, indicating intact cognition. Section J (MDS): Received as needed medication, shortness of breath (SOB) with exertion, sitting and lying flat. Resident is on oxygen (O2) therapy. Oxygen settings: O2 via nasal canula (NC) at 3 liters per minute (LPM). Observation on 4/1/2025 at 9:30 am revealed R33 lying in bed with O2 tubing on. The O2 concentrator was noted to be on and running with fluffy, brown/gray/white substance covering the filter area and the entire machine. Observation on 4/2/2025 at 8:55 am revealed R33 lying in bed with the O2 concentrator running with fluffy brown/gray/white substance covering machine and filter area. Observation on 4/3/2025 at 11:15 am revealed R33 lying in bad using the O2 concentrator, with the O2 concentrator filter covered with fluffy, light-brown and white substance. Interview on 4/3/2025 at 10:55 am with the Maintenance Director revealed the facility's policy was that housekeeping was to clean O2 concentrators weekly when O2 was in use. He also stated that the O2 provider was responsible for maintaining and changing the filter on each concentrator. He stated that his expectation was for the O2 provider to come in and complete regular cleaning and maintenance. Based on observations, resident and staff interviews, record review, and review of the facility's policies titled, Oxygen (O2) Concentrator and LTC (long term care)-Oxygen, the facility failed to ensure that residents received O2 as ordered for two of eight residents (R) (R29 and R168) receiving O2 therapy; and failed to ensure that the O2 concentrator (machine that supplies O2) was clean, sanitary, and free of sediment build-up for one of eight R (R33) receiving O2 therapy. The deficient practice had the potential to put the residents at risk for medical complications such as hypoxia, respiratory depression, and infection. Findings include: Review of the facility's policy titled Oxygen Concentrator last revised 3/5/2024 documented under Policy Explanation and Compliance Guidelines: Oxygen is administered under orders of the attending physician. Care of the Concentrator: Follow manufacturer recommendations for the frequency of cleaning filters and servicing the device, external filters will be cleaned weekly. Only trained individuals, such as the Maintenance Director or supplier, shall service the device. The Housekeeping Department Responsibilities: Clean the outside casing of the concentrator and nebulizer units during routine room cleaning with an EPA- (Environmental Protection Agency) registered disinfectant in accordance with label instructions. Review of the facility's policy titled LTC-Oxygen dated April 2025 revealed under Policy Subject: Oxygen: . 1. There must be a physician's order for oxygen use which includes the route and liter flow or specific oxygen concentration, and how long the oxygen is to be administered. Review of the electronic medical record (EMR) revealed R29 was admitted with diagnoses of, but not limited to anemia, heart failure, hypertension, diabetes mellitus, multiple sclerosis (MS). Review of the Minimum Data Set (MDS) revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section GG (Functional Abilities and Goals) revealed R29 required substantial/maximal assistance with shower/bath and tub/shower transfers, Section J (MDS) revealed shortness of breath (SOB) with exertion, sitting and lying flat. Resident is on oxygen (O2) therapy. 1. Interview/observation on 4/1/2025 at 10:45 am with R29 revealed that his O2 should be set at 3 liters per minute (LPM), and he did not change it. He went on to reveal that the staff changed his O2 tubing every Sunday, as well as the water for the humidifier. R29's O2 was observed to be set at 3 LPM, the water bottle for the humidifier was dated 3/31/2025, and there was no label/date on the tubing showing when it had been changed. Observation on 4/1/2025 at 12:15 pm, R29's O2 was set at 3 LPM, the tubing was still unlabeled. Observation on 4/3/2025 at 11:15 am revealed R29's O2 was set at 2 LPM. The O2 tubing had been changed. Interview on 4/2/2025 at 4:15 pm with the Director of Nursing (DON) revealed that it was her expectation that the physician orders be followed and if there needed to be a change, they should contact the physician to inform them if a change was needed. 3. Review of the EMR for R168 revealed he was admitted with diagnoses including but not limited to diabetes mellitus, sepsis, hypertension, and chronic obstructive pulmonary disease (COPD). Review of the admission MDS dated [DATE] for R168 revealed in Section C (Cognitive Patterns) a BIMS score was not coded; section GG indicated eating/oral hygiene was independent; shower/bath dependent; toileting hygiene, upper/lower body dressing, and personal hygiene, required assistance. Review of the care plan dated 3/17/2025 revealed a focus area where R168 removes nasal cannula and changes the oxygen setting. The interventions revealed the oxygen setting was oxygen as ordered by the physician. Review of the physician's orders for R168 revealed on 4/2/2025 at 8:50 am during medication observation with Licensed Practical Nurse (LPN) AA, the order read, Continuous oxygen @ 2L/M (liters/minute), (Nurse is responsible for checking and maintaining Treatment Administration Record (TAR) every shift (QS). LPN AA said she did not follow the care plan as ordered. When asked what she would do going forward, she said she would notify the MD (medical doctor) to get an order to cover the titration when he removed his O2 and follow the care plan. An observation of the Medication Administration Record (MAR) revealed an order on the resident's list of medication that read, Continuous oxygen 3L-4L/NC. Observe that the resident is wearing nasal cannula (NC) every 2 hours. Document oxygen saturation. The start date and time was 4/2/2025 at 12:00. The second order read, May increase oxygen to 4L if R168 has desaturation-stat episode, as needed for Shortness of Breath (SOB). The start date was 4/2/2025 (at) 12:15 PM. An observation on 4/2/2025 at 9:10 am revealed the nurse placed her meds on the overbed table and helped R168 in the bathroom. She also took an O2 tank and tubing to the bathroom because the resident was not wearing it in the bathroom. The rate was set at 3.5 LPM and she said when R168's O2 saturation dropped, they bumped it up to 4 LPM. At 9:12 am, the O2 rate was increased to 4 LPM on the concentrator. The O2 rate remained at 4 LPM on the concentrator. Review of the physician's orders for R168 revealed an order that read, Continuous oxygen 3L-4L/NC. Observe that the resident is wearing NC every 2 hours. Document oxygen saturation (O2 sat) percentage. The start date and time was 4/2/2025 at 12:00. The second order read, May increase oxygen to 4L if resident has had a desaturation stat-episode, as needed for Shortness of Breath (SOB). The start date was 4/2/2025 @ 12:15 PM. An interview on 4/3/2025 at 11:00 am with the DON revealed her expectations of the nurses following Doctor's orders and administering medications as prescribed. She said the nurses were to ensure what the resident was on exactly what was ordered. She said she expected the tubing to be labeled and dated for O2 and the humidification bottle to be labeled as well. She said she expected the used tubing to be labeled and bagged for disposal. She said if there was an issue with regulating O2 or any medication, she expected the nurse to access the Provider and change the settings when ordered.

Based on observations, staff interviews, and review of the facility's policy titled, Hand Hygiene and Policy Procedure, the facility failed to ensure the infection control process was followed for two residents (R) (R48 and R168) during medication observation. The deficient practice had the potential to spread infection to other residents, staff and visitors. Findings include: Review of the facility policy titled Hand Hygiene dated 8/4/2011 revealed under Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene. Section 2: Waterless Handwashing Products: If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed under Handwashing. Review of the facility policy titled Policy Procedure dated 3/2023 revealed under Procedure: . 3. The facility will provide personal protective equipment (PPE) to support compliance with standard and transmission-based precautions and ensure that it is readily available for staff use. Staff are required to adhere to standard precautions and use PPE according to standard precautions. An observation on 4/2/2025 at 8:42 am revealed Licensed Practical Nurse (LPN) AA drew up the heparin for R48 and cleansed the top of the vial, dialed the 2U (units) for waste in the Insulin Pen and extracted it, then dialed 5U of Lantus insulin via pen. She then pulled and set up her medication using the same gloves she drew heparin and dialed the insulin pen. An observation on 4/2/2025 at 9:10 am revealed LPN AA placed medications on the overbed table and helped R168 in the bathroom. She also took an O2 tank and tubing to the bathroom because the resident was not wearing it in the bathroom. She assisted R168 back to bed with the same gloves and gave him the fluticasone nasal spray one puff in each nostril. She then gave R168 a Spiriva inhaler one spray by mouth using the same gloves. She placed the mask for the albuterol inhaler over the nasal cannula (NC) for O2 and turned it on for 15 minutes. She then removed her gloves and sanitized her hands. An interview on 4/2/2025 at 9:30 am with LPN AA, she revealed she should have sanitized her hands and changed her gloves after she drew the injections, and before she set up her pills to avoid contamination with R48. She also said that she should have doffed (taken off) her gloves and washed her hands once she finished assisting R168 in the bathroom and before she gave her oral medication. An interview on 4/3/2025 at 11:00 am with the Director of Nursing (DON), she stated prior to the nurse giving the medication, she expected them to sanitize and/or wash their hands when taking care of residents and then giving medications. She said she expected them to change gloves between routes of medication and/or wash their hands to avoid cross-contamination.

Based on observations, staff interviews, and review of the facility policy titled, Dietary Cleaning, the facility failed to ensure that the walk-in refrigerator, the oven, and the fryer were kept clean and sanitary, in a manner that prevents foodborne illness to the residents. This deficient practice had the potential to affect 56 of 62 residents who receive food from the kitchen. Findings include: A review of the facility policy titled Dietary Cleaning revealed: Creating a kitchen cleaning policy for a long-term care facility is essential to maintaining food safety, hygiene, and overall health. Under objective: The objective of this policy is to establish clear guidelines for maintaining a clean, sanitary kitchen environment to prevent food borne illness and ensure the health and safety of residents, staff, and visitors. Under General Guideline: All kitchen surfaces, utensils, equipment, and food storage areas must be kept clean and sanitized. During an initial walk through the kitchen on 4/1/2025 at 9:00 am with the Dietary Manager (DM) the following observations were made: Both ovens had burnt food stains, the fryer had debris, and the oil was dark colored. The side of the stove by the fryer had built up dirt and greasy substance. The walk-in fridge was very dirty with food debris, the floor was unkept with debris and the shelving was rusted. The DM acknowledged that the oven and the fryer were dirty as well as the walk-in fridge. A follow up walk through on 4/2/2025 at 9:10 am of the main kitchen revealed all previous observations remained, including stains built-up by the stove. All observations were confirmed with the DM during the walk through. Interview on 4/2/2025 at 9:40 am with the DM regarding her expectation of dietary staff maintaining a clean, sanitary environment in the kitchen. She stated that she expected staff to clean the refrigerator daily and deep clean it once a week and clean the oven daily and deep clean it once a week. She also stated that the fryer should be kept clean as well. Interview on 4/3/2025 at 12:50 pm with the facility Administrator regarding her expectations of staff when it came to maintaining a clean and sanitary environment with food storage, she revealed that the kitchen staff had a cleaning schedule, and she expected staff to wipe down everything at end of the day. She stated that she expected them to follow the cleaning schedule. She stated that the walk-in refrigerator should be cleaned on a monthly rotation and if staff walked in and observed something that needed immediate attention, that it should be addressed right away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and review of the facility's policies titled, Non-Pressure Ulcers, and Treatment Administration Record (TAR), the facility failed to ensure that wound care was provided as ordered by the physician, for one of three residents (R) (RA) with venous ulcers. The deficit practice caused RA not to receive medical treatments as needed, and placed RA at risk for adverse consequences. Findings included: Review of the facility's policy titled, Non-Pressure Ulcers, dated 6/21/2021, revealed under Procedures: 3. Treatment and Management: Wound Care: A structured wound care protocol should be followed, including cleaning . dressing changes 4. Documentation: All non-pressure ulcers must be documented in the resident's medical record including the . treatments provided Review of the facility's policy titled, Treatment Administration Record (TAR), dated 6/21/2021 revealed under, 2. Recording and Documentation: All treatments must be recorded on the TAR with the exact date and time they were administered. Review of the clinical record revealed RA was admitted to the facility with diagnoses of but not limited to paroxysmal atrial fibrillation, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease (COPD), Parkinson's disease, and hypertension. Review of physician's orders and TAR's revealed that RA had a treatment order with a start date of 10/31/2024, to clean the areas to the bilateral lower legs with acetic acid-soaked gauze for approximately five minutes, pat dry, apply gentamycin ointment to the wound bed, and apply a dry dressing every shift. An additional order with a start date of 1/2/2025 documented when applying gentamycin to the wounds on the bilateral lower extremities, apply [Brand name] (non-adherent dressing) to the site, then the bordered/dry dressing every shift. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that RA was assessed with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating little to no cognitive impairment. The MDS assessment also included that RA had two venous or arterial ulcers. Review of the facility's wound report revealed that RA had a venous ulcer to the right lower leg (with onset date of 2/8/2024) and a venous ulcer to the left lower leg (with onset date of 7/16/2024). Review of the Medication Administration Records (MAR's) revealed an order entry with a start date of 3/29/2024, that documented the nurse was responsible for checking and maintaining the TAR every shift. Review of the TAR's revealed the wound treatments to the bilateral lower legs were scheduled to be provided every day, on both the day shift and the night shift. However, further review of RA's clinical record, including the TAR's, revealed no evidence that wound treatments were documented as provided as ordered and scheduled daily. Review of the TAR's revealed wound care was provided eight times in December 2024, eleven times in January 2025, and seven times in February 2025 as follows: Review of the TAR for December 2024 revealed there was no evidence that wound treatments were provided to RA's bilateral lower leg venous ulcers on the day shift on 12/24/2024, 12/29/2024 and 12/31/2024, or on the night shift on 12/3/2024, 12/5/2024, 12/8/2024, and 12/22/2024. Review of the TAR for January 2025 revealed there was no evidence that wound treatments were provided on the day shift on 1/1/2025, 1/7/2025, 1/10/2025, 1/11/2025, 1/15/2025, 1/16/2025, 1/17/2025, 1/18/2025 and 1/31/2025, or on the night shift on 1/10/2025 and 1/15/2025. Review of the TAR for February 2025 revealed there was no evidence that wound treatments were provided on the on the day shift on 2/15/2025 or on the night shift on 2/2/2025, 2/5/2025, 2/6/2025, 2/13/2025, 2/14/2025, and 2/15/2025. During an interview on 2/18/2025 at 11:30 am with the Wound Care Licensed Practical Nurse (LPN) confirmed RA had non-pressure ulcers to the bilateral legs. During an interview on 2/19/2025 at 2:05 pm with RA revealed that the wound care nurse provided wound care to her lower extremities on the day shift, but on weekends and nights it depended on who was working, if the treatments were provided. During an interview on 2/18/2025 at 2:35 pm with the Director of Nursing (DON) revealed that on weekends the Registered Nurse (RN) supervisor or medication nurse was responsible for wound care treatments. During an additional interview on 2/19/2025 at 3:15 pm with the DON revealed that wound care treatments ordered on the night shift, the nurse assigned to the resident was responsible for completing the treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to follow physician orders for one of eight residents (R) #49. Specifically, the facility failed to ensure intravenous (IV) access site was removed from resident as ordered by physician after antibiotic regime was completed. The deficient practice had the potential to increase the probability of infection to occur at the IV insertion site. Findings: Review of the electronic medical record revealed that resident (R# 49) was admitted to the facility with diagnoses that included but were not limited to cardiovascular accident, hemiplegia of left hand, hypertension, neurogenic bladder, urinary retention, foley catheter and history of recurrent urinary tract infections (UTI). Review of Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed that resident has a Brief Interview for Mental Status (BIMS) score of 15, which means the resident is cognitively intact. Section H (Bladder and Bowel) revealed that resident was utilizing an indwelling catheter during the seven day look back period of assessment. Review of the care plan dated 4/17/2023 revealed that resident had urinary incontinence/ indwelling catheter for diagnosis of neurogenic bladder, and recurrent UTIs. Review of the nurses' notes revealed that resident # 49 received IV antibiotics, between 4/14/2023 and 4/20/2023. The orders were as follows: 4/13/2023, new orders noted per the urologist, DX: multi resistant UTI. Insert IV and instill I gram of meropenem IV every 8 hours for seven days. At the completion of the treatment, discontinue the IV and restart the alternating antibiotic treatment. Obtain urine culture 3 to 5 days after the completion of the IV antibiotic treatment. Interview on 4/25/2023 at 11:31 a.m. with R#49 revealed that resident stated that he had a urinary tract infection and had received antibiotics for it. Continued interview also revealed that the antibiotics were completed, and the resident was unsure of the last dose received. Observation on 4/26/2023 at 9:15 a.m. revealed that R#49 IV was intact in the right upper arm. Interview on 4/26/2023 at 4:19 p.m. with facility Nurse Practitioner revealed that IV and the IV antibiotics were ordered by the urologist. The Practitioner stated that she would evaluate R #49 to determine continued use of the IV access. Interview on 4/26/2023 at 4:20 p.m. with Licensed Practical Nurse (LPN) AA revealed that she had not administered any IV medications during her shift and was not aware the resident had an IV. There was no notification from the off going nurse of any IV antibiotics that should be administered to R #49. Interview on 4/26/2023 at 4:35 p.m. with the MDS Coordinator revealed that the urologist for the facility had been ordering four different antibiotics to alternate weekly for the residents that have Foley catheters and that also have chronic UTIs. She stated that if an IV was placed, it was for the resident to have meropenem IV for seven days because he had drug resistant infection in his urine. Interview on 4/27/2023 at 12:30 p.m. with LPN BB revealed when a resident has an IV, flushing and maintenance of the IV would be ordered and should be on the task list for nurses to complete. Review of the task list for R #49 did not reveal IV maintenance orders. Interview on 4/27/2023 at 2:00 p.m. with Director of Nursing (DON) revealed that IVs are flushed per the MD orders. She stated that it is done before and after administrating IV medications. Dressing changes are completed per doctors' orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to ensure that oxygen (02) tubing and respiratory equipment were properly stored for two (2) of 15 residents (R) R#32 and R#35. Specifically, the facility failed to ensure that the 02 tubing for R#32 was changed weekly as ordered, the facility also failed to ensure R#35 C-PAP (Continuous Positive Airway Pressure) (ventilation in which a constant level of pressure is continuously applied to the upper respiratory tract of a person) mask was properly stored when not in use. Findings: Review of the electronic medical record (EHR) for resident R #32 revealed that the resident was admitted to the facility with diagnoses that included but are not limited to peripheral vascular disease, chronic obstructive pulmonary disease, and right upper lobe pneumonia. Review of the Physicians' orders revealed that oxygen therapy is to be routine, as needed to keep oxygen stats more than or equal to 90%. Review of the Minimum Data set (MDS) Annual assessment dated [DATE] Section C (Cognitive Patterns) revealed resident had a Brief Interview of Mental Status (BIMS) score of 15 indicating resident had no cognitive impairment. Review of care plan for R#32 initiated on 5/4/2022 revealed that resident had interventions in place for her respiratory plan of care that included evaluate the effectiveness of oxygen and respiratory therapy. Observation on 4/25/2023 at 11:00 a.m. revealed R #32 02 tubing and humidifier bottle was dated 3/19/2023. Observation on 4/26/2023 at 11:55 a.m. revealed R #32 02 tubing and humidifier bottle was dated 3/19/2023. Observation on 4/27/2023 at 10:00 a.m. revealed R #32 02 tubing and humidifier bottle was dated 3/19/2023. Observation was confirmed by Licensed Practical Nurse (LPN) BB. Review of the policy titled oxygen administration had no instructions for tubing and mask maintenance. Review of EHR for R # 35 revealed that he was admitted to the facility with diagnoses that include but are not limited to multiple sclerosis, chronic kidney disease, neurogenic bladder, obstructive sleep apnea, and anxiety. Review of the Quarterly MDS assessment dated [DATE] revealed in Section C0500 BIMS score of 15 indicating resident had no cognitive impairment. Review of the care plan for R# 35 revealed that resident has respiratory problem that includes obstructive sleep apnea that requires the use of a C-pap. Interview on 4/25/2023 at 10:45 a.m. with R #35 revealed that the c-pap machine is used at night and the staff assists him with applying and removing the c-pap mask. Further interview also revealed that resident could not recall when the staff had cleaned his c-pap mask after use. Observation on 4/26/2023 at 11:50 a.m. revealed R#35 C-pap mask was not stored and labeled properly. Interview on 4/26/2023 at 11:47 a.m. with LPN AA, revealed that the tubing for oxygen is changed by the night shift charge nurse every week on Sunday nights. Further interview also revealed that LPN AA was unsure if the respiratory equipment should be dated. Interview on 4/27/2023 at 9:50 a.m. with LPN CC revealed that oxygen tubing, nebulizer mask, and humidifier bottles are changed on Sunday nights. She stated that they are to be dated and have a bag for when they are not in use. Interview on 4/27/2023 at 1:30 p.m. with the Director of Nursing (DON) revealed that it is her expectation that oxygen tubing is changed during the night shift on Sunday evenings. The 02 tubing and the humidifier bottle should be changed and dated, and a bag should be available to place the 02 tubing in when it is not in use. Further interview also revealed that the c-pap masks are to be cleaned when they are visibly soiled and should be properly stored when not in use as well.

Based on observation and staff interviews. The facility failed to ensure the kitchen was maintained in a clean and sanitary condition. The deficient practice had the potential to affect 58 of 62 residents receiving an oral diet. Findings include: During the initial tour of the kitchen on 4/25/2023 at 9:00 a.m. the floor and walls were observed to have brown/black/and yellow stains throughout the kitchen. The main kitchen had four air condition units with dirty vents, and spider webs noted between the unit space and the window. Continued observation revealed of the window unit located in the rear of the kitchen had a white blanket positioned underneath the unit that was wet with brown stains noted. Observation on 4/25/2023 at 9:02 a.m. of the dishwasher room revealed the floor under the single compartment sink had missing and lose tile noted from the wall to the middle of the floor. The walls under the dishwashing sink had a thick black substance that was noted on the wall and around the drainage pipe that was attached to the wall. Interview on 4/25/2023 at 12:08 p.m. with the Dietary Manager revealed it is the responsibility of the kitchen staff to ensure that the main kitchen and appliances are clean and in good working order. The continued interview also revealed that it is her responsibility to ensure that the cleaning schedule is followed and completed daily. All areas of concern during the initial tour were confirmed by the dietary manager. Interview on 4/27/2023 at 11:01 a.m. with the facility maintenance director revealed he was aware of all areas of concern but did not have work orders submitted at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of the facility policies titled, LTC-Pressure Ulcers and Hand Hygiene. The facility failed to ensure that proper hand hygiene was conducted during wound care treatment for one of 10 residents (R#31). The deficient practice had the potential to increase the probability of infection risks for the resident. Findings include: Review of the facility policy titled, Hand Hygiene effective date 5/2022 revealed under: Indications for Hand Washing and Hand Antisepsis; If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands before and after patient contact. Under: Use of Gloves; Gloves should always be worn when contact with blood, body fluids, or other potentially infectious material, mucous membranes and non-intact skin could occur. Gloves do not provide complete protection and glove integrity may be compromised by long or poorly groomed nails. Review of the facility policy titled, LTC-Pressure Ulcers effective date 11/2021 revealed under Policy subject: Pressure Ulcers 4. The facility will ensure that a resident with pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Record review for R#31 revealed resident was admitted to the facility with diagnoses of atrial fibrillation, Cardiomegaly, Diabetes Mellitus, cellulitis of left lower limb, Chronic non-pressure ulcer, fracture of left fibula. Continued record review revealed admission Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) C0500 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating resident had minimal cognitive impairment. Wound Care observation on 4/26/2023 at 10:00 a.m. revealed Wound care nurse gathered supplies and proceeded to residents' room to complete wound care. A barrier was placed on the residents' bedside table and wound care supplies were placed on the barrier. The nurse applied gloves and removed the old bandage and placed it in the trash bag. New gloves were applied without washing or sanitizing hands in between. This process continued throughout the wound care procedure for R#31, the resident had four different areas for treatments to be completed. Interview on 4/26/2023 at 10:30 a.m. with Wound care nurse revealed that the proper procedure for wound care treatment is when gloves are removed the nurse is to sanitize or wash hands with soap and water between each glove change. Further interview also revealed that Wound care nurse confirmed that sanitizer was not used between glove changes. Interview on 4/26/2023 at 3:02 p.m. with the Director of Nursing (DON) revealed that the Wound Care Nurse should have sanitized her hands between glove changes while completing wound care. Further interview also revealed that the expectation is that when conducting any care for residents that gloves are to be worn and hands should be sanitized and or cleaned with soap and water between glove changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observations of R#11 on 9/28/21 at 11:44 a.m., 9/29/21 at 9:54 a.m., 09/30/21 at 9:45 a.m. revealed hair was disheveled, and fingernails were long with a thick black substance underneath the nails. Review of R#11's Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#11 has a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment and requires extensive assistance with activities of daily living (ADL). Review of R#11's care plan dated 4/29/21 revealed a problem for self-care deficit related to impaired cognition. The goal for this problem was I will remain clean, neat, and free of body odor. Further review of care plan revealed interventions which included assist with bathing as needed, oral care daily as needed, and assist with dressing, and grooming daily as needed. Interview on 9/30/21 at 11:18 a.m. with Director of Nursing (DON) revealed it is her expectation for each resident's care plan to be followed. Based on observations, record review, staff interview, and review of policy titled, Care Plans, the facility failed to develop a care plan for one of 15 sampled residents, (R) R#52) who was admitted to the facility with a diagnosis of urinary tract infection (UTI) and the facility failed to follow the care plan to ensure one of 15 sampled residents (R#11) received routine care serves with bathing and personal hygiene. Findings include: Review of facility policy titled Care Plans (dated on 6/7/21) stated It is the facilities responsibilities to adequately capture each residents baseline ability along with any changes in condition or new diagnoses that trigger risks in each resident's care plan. If changes in condition occur, care plans must be updated to reflect the changes and interventions put in place in an attempt to reduce the opportunity for further decline. 1. Record review revealed that R#52 was originally admitted to the facility on [DATE] with the following diagnoses but not limited to Foley Catheter for urine retention. Record review of R#52 's emergency room (ER) record (dated 9/22/2021) revealed that R#52 was sent out to the hospital for complaints of abdominal pain on 9/22/21. The hospital record further revealed discharge diagnoses of UTI, constipation, and abdominal extension. Record review of R#52's nurse note, dated 9/23/21 at 3:53 p.m., documented that resident returned to the facility that same day on 9/22/2021 and a new order for antibiotic Cipro was prescribed to treat her UTI infection (Ciprofloxacin 500 mg =1 tab bid (equal one tab twice a day) for 10 days start date 9/23/21). Record review of Medication Administration Record (MAR) indicated that resident started receiving Ciprofloxacin 500mg table bid for 10 days with a start date of 9/23/21 and change in order to CEPHALEXIN 500 mg tid (three times a day) for 10 days. R#52's has a comprehensive care plan for problem identified as a catheter: (initiated and dated 9/28/21) I am at risk of complications r/t use of Foley Cath. Approaches Secure F/C to prevent pulling. Observe urine for s/sx (signs or symptoms) of infection. Keep drain bag below bladder. Provide privacy bags. Refer to urologist. Notify MD (Medical Director) as needed. There was no care plan related to UTI's found. During an interview with the facility Minimum Data Set (MDS) Coordinator on 9/29/21 at 3:40 p.m. the MDS Coordinator reported being aware that R#52 returned to the facility with a diagnosis of a urinary tract infection and required antibiotic treatment services. She further stated that R#52 was discussed on Monday (9/27/21) during clinical meeting regarding the ER [DATE]) visit. She does not recall the discussing the UTI. MDS Coordinator confirmed that she failed to create a UTI care plan for the resident. During an interview on 9/30/21 at 2:01 p.m. with the Director of Nursing (DON) it was revealed that her expectation is for the licensed nurses and the MDS Coordinator to care plan all care areas. She was unaware that R#52 's care plan was not updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to ensure that care was provided for residents who are unable to carry out Activities of Daily Living (ADL) to maintain proper grooming and personal hygiene for two residents (R#11 and R#503) of 15 sampled residents. Findings Include: 1. Observations of R#11 on 9/28/21 at 11:44 a.m., 9/29/21 at 9:54 a.m., 09/30/21 at 9:45 a.m. revealed her hair was disheveled and her fingernails were long with a thick black substance underneath the nails. Review of R#11's Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#11 has a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment and requires extensive assistance with ADLs Review of the 7AM to 7 PM Bath List revealed R#11 is scheduled to get a bath on Tuesdays, Thursdays, and Saturdays. However, there is no evidence to support that R#11 received a bath on 9/18/21, 9/25/21, and 9/28/21. During interview on 9/28/21 at 11:25 a.m. with family member of R#11, concern was verbalized that the facility is not washing R#11's hair or trimming her fingernails. During interview on 9/29/21 at 10:01 a.m. with Licensed Practical Nurse (LPN) supervisor BB it was revealed all residents are on an alternating schedule with showers and bed baths. Further stated the only day that residents don't receive a bath or shower is on Sundays. LPN supervisor BB reported that residents should receive nail care and skin assessments during their daily bath or shower. 2. Observation on 9/28/21 at 10:08 a.m., 9/29/21 at 9:24 a.m., 9/29/21 at 1:29 p.m., and on 9/30/21 at 9:03 a.m., of R# 503 lying in bed, observed with long fingernails with dark substance underneath. R#503 was also observed with long bushy untrimmed hair on the face and neck. Record review revealed that R#503 admitted to the facility on [DATE], with diagnoses that included but not limited to, acute renal failure, Hypertension, Arteriosclerosis of coronary artery in patient with Hx of myocardial infarction, Colostomy status, unspecified severe protein-calorie malnutrition, attention to Gastrostomy, A-fib, UTI, Retention of urine. Review the most current comprehensive 5-day/entry Minimum Data Set (MDS) assessment dated [DATE] revealed a Basic Interview of Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. Review of the functional status documented for personal hygiene and bathing indicated R#503 required extensive to total assistance. Review of care plan included but not limited to, 1. Require extensive to total assistance with my activities of daily living (ADL) to meet daily needs. I am able to make my needs known. Interventions included but not limited to, assist with oral and grooming care as needed, provide bath per protocol, routine care rounds at frequent intervals and as needed, date initiated 9/28/21. 2. Risk for skin breakdown related to impaired mobility and weakness. Interview on 9/30/21 at 11:30 a.m. during an observation with the Director of Nursing (DON), who confirmed R# 503 had long unclipped fingernails with dark substance underneath, and long untrimmed, bushy hair on face and neck.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interview, and review of facility policy titled Aerosol Administration, the facility failed to provide proper respiratory care for one resident (R#11) of six residents receiving respiratory treatment. Findings include: Review of policy tilted Aerosol Administration dated 6/7/21 revealed, Intent: To deliver aerosol medications to restore and maintain normal function of the mucociliary escalator, improve efficiency of cough mechanism, provide bronchodilator therapy, and other medications to the airway. Purpose: 6. Empty and residual liquid and place the nebulizer in a plastic patient bag. Record review revealed R#11 was admitted to the facility on [DATE] with diagnoses including but not limited to atrial fibrillation, wheezing, and cardiac pacemaker. Review of Physicians order revealed R#11 had an order for ipratropium-albuterol 0.5 milligrams (mg)-2.5mg/3 milliliters inhalation solution every four hours as needed for wheezing via nebulizer. Observation on 9/28/21 10:19 a.m. revealed R#11's nebulizer mask was lying in a partially open drawer uncovered and not labeled. Observation on 9/29/21 10:05 a.m. revealed R#11's nebulizer mask was lying in a partially open drawer uncovered and not labeled. During interview on 9/30/21 at 11:13 a.m. with Director of Nursing it was revealed that her expectation was that nebulizer masks and tubing are labeled, bagged, and stored properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that one of five residents (R) R#505 reviewed for unnecessary medications had a proper diagnosis for the use of prescribed psychotropic medication. Findings Include: Record review revealed that R#505 admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease unspecified, acute kidney failure, history of Transient Ischemic Attack (TIA), hypothyroidism, hyperlipidemia, retention of urine requiring indwelling catheter, Foley catheter in place, unspecified dementia with behavioral disturbance. Review of the clinical record revealed a physician order for medications that included but not limited to, Risperidone 1 milligram (mg) orally/by mouth (po) every 12 hours (q12 hrs); start date 9/9/21. (Risperidone is classified as an antipsychotic primarily used to treat schizophrenia and Bipolar disorder). Review of the most current comprehensive Minimum Data Set (MDS) 5-day entry assessment dated [DATE] revealed no psychiatric or mood disorders identified as an active diagnosis. Further review revealed antipsychotic medication received four out of seven days in the look back period. Review of the initial pharmacy consult dated 9/12/21 titled, Monthly Consultant Pharmacist Report for the month of September 2021 documented, CMS-approved uses for Risperdal includes Schizophrenia, Schizo-affective disorder, Tourette's disorder, and Huntington's disease. No appropriate diagnosis for anti-psychotic usage for Risperdal. Review of the care plan in the electronic record, included but not limited to: 1. I am at risk for complications of psychotropic medication use. I am at risk for behaviors related to progression of dementia. Associated diagnoses: depression, Anxiety, Hospice Services. Interventions included, observe for medication effectiveness; give meds as ordered; obtain labs as ordered, notify physician (MD) as indicated, pharmacy consultant to review medications and make recommendations as indicated; observe for acute changes in condition, symptoms. Onset date 9/29/21. Review of the Resident Care Team (conference) Meeting documented the normal order/medication list included Risperidone 1 mg = 1 tab, every 12 hr scheduled, date 9/10/21, Status: ordered. Interview on 9/30/21 at 11:10 a.m. with the Administrator confirmed R#505 did not have any of the CMS approved usages for Risperdal on his diagnosis list. He revealed that when a resident admits to the facility, the resident may have been on some of their medications for a long time, and they don't discontinue them. Interview revealed R#505 came from the hospital and the Administrator didn't know if R#505 had additional diagnoses in his history and physical. His expectation was that residents have approved diagnoses for all their medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of facility policy titled Care Plan revealed It is the policy of Cordele Health and Rehabilitation to adequately capture each resident's baseline ability, along with other changes in condition or new diagnoses that trigger risks in each resident's care plan. Further review of this policy revealed The care plan conferences should be inclusive of members of facility's interdisciplinary team, floor staff. The resident and/or resident's responsible party should be included in Care Plan reviews. Record review revealed R#54 was admitted to the facility on [DATE] with diagnoses including but not limited to lobar pneumonia, chronic obstructive pulmonary disease, and atrial fibrillation. Review of R#54's baseline care plan revealed it was only signed by the License Practical Nurse (LPN) EE. During interview on 9/30/21 at 1:47 p.m. with Quality and Compliance Specialist revealed a care plan conference was not held with R#54 because she was in the facility for only four days before transferring to assisted living. During interview on 9/30/21 at 2:49 p.m. with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator revealed every resident is supposed to have a care plan conference within 24 to 48 hrs of admission unless discharged prior to that time frame. Further states she is not sure why a conference was not held with the R#54 and/or her family. Based on interviews, record reviews, and review of facility policy titled Care Plans, the facility failed to ensure that the baseline care plan had appropriate interventions in place for three residents (R) R#503, R#51, and R#454), was completed within 48 hours for one resident (R#503), and a care conference was held with one resident (R#54) of five residents reviewed for baseline care plan. Findings include: Review of facility policy titled Care Plans dated on 6/7/21, stated It is the facilities responsibilities to adequately capture each residents baseline ability along with any changes in condition or new diagnoses that trigger risks in each resident's care plan. 1. R#503 was a male, admitted on [DATE], Basic Interview of Mental Status (BIMS) score 12 indicating moderate cognition, Full code status. R#503 had pertinent diagnoses that included but not limited to, acute renal failure, Hypertension, Arteriosclerosis of coronary artery in patient with Hx of myocardial infarction, Colostomy status, unspecified severe protein-calorie malnutrition, attention to Gastrostomy, A-fib, UTI, Retention of urine. Interview on 9/30/21 at 10:37 a.m. with the Quality and Compliance nurse confirmed they develop the baseline within 48 hours of admission in the electronic record under EDT Resident Care Team Meeting, and they use a paper form for the baseline care plan as well. Interview and review of the document revealed the documentation dated 9/14/21 was the baseline care plan, and the care conference. The Quality and Compliance nurse verified there were no interventions listed on the baseline care plan and it was not developed within 48 hours of admission. Interview on 9/30/21 at 2:36 p.m. with the Registered Nurse (RN) MDS Coordinator revealed nursing staff collect information through admitting documents and nursing assessments, regarding problems to include on the baseline care plan, and verified they should complete within 48 hours of admission. She verified there were no interventions on the baseline care plan (paper copy), or on the electronic record, for R#503 dated 9/14/21. RN MDS Coordinator reported that they document the initial baseline care plan in their electronic system and should have everything staff needs to provide proper care until the comprehensive is developed. Interview further revealed, if a problem comes up, a nurse should know how to assess and notify the physician for interventions. Cross refer F677 2. Record review of R#51 's medical record revealed an admission date of 9/7/2021. Further record review revealed that R#51 was admitted to the facility with the following diagnoses but not limited to End Stage Renal disease (ESRD), Foley Catheter, Type 2 Diabetes Mellitus, peripheral vascular disease, coronary artery disease, and colostomy bag. During a record review of R#51's electronic baseline care plan (dated 9/7/2021) with the facility Minimum Data Set (MDS) Coordinator on 9/30/21 at 10:01 a.m. the MDS Coordinator confirmed no interventions to communicate the type of care required to address resident care services for dialysis and diabetes. The MDS Coordinator also confirmed and verified the omission of a hard copy record of a baseline care plan which was available for licensed nursing staff. During the survey on 9/30/31 at 2:00 p.m. an interview was conducted with the Senior (hospital based) MDS Coordinator who revealed that baseline care plan should have identified specific care areas. This information is put in their electronic system once the nursing staff starts to document in the record. She reported that she supervised the facility MDS program. 3. Record review of R#454 's medical record revealed an admission date of 9/21/21. R#454 was admitted with the following diagnoses but not limited to abdominal pain, bladder spasm, pressure ulcer stage 3, paraplegia, unsp perineal gangrene, suprapubic catheter, urethral fistula, and UTI. Record review of R#454's baseline care plan on 9/29/21 revealed that the facility failed to implement a baseline care plan. Interview on 9/29/2021 at 4:13 p.m. with the inhouse facility MDS Coordinator reported that she is the only MDS Coordinator in the building at this time. She confirmed and verified that R#454's electronic record did not contain a baseline care. She further stated that the licensed nurses could have developed a baseline care plan. MDS Coordinator reported that she was not aware of where to find a hard copy of the baseline care plan as well. She further stated that R#454's colostomy and foley catheter care should have been identified within 48 hours and documented on the baseline care plan with person centered interventions. An interview and record review were conducted on 9/30/21 at 9:20 a.m. with the facility MDS Coordinator who provided copy of the baseline care plan for R#454. Review of the baseline care plan revealed problems identified for the following area: Foley Cather and Colostomy bag. There were no interventions listed for each of the mentioned care area to communicate the type of care services required. She confirmed that the baseline care plan was not person centered and also did not address R#454 quarantine status and a plan of care services for Personal Protective Equipment (PPE). During an interview on 9/30/2021 at 11:05 a.m., the Director of Nursing (DON) reported that her expectations are for use of PPE and requirement for quarantine residents for suspected Covid precautions to be addressed on the resident baseline care for the resident. DON further expressed that all care plans should have person centered interventions to address the care needs of residents. Interview with Senior MDS Coordinator on 9/30/2021 at 2:34 p.m. who confirmed that both R#51 and R#454 's baseline care plans failed to provide person centered interventions to address each residents plan of care needs. She further stated that she agreed that once a problem is identified on the base line care plan those specific interventions should be listed for each underlining problem.

Based on observations, interview, and review of policy titled, Food Safety Requirements the facility failed to label and date items in the walk-in cooler and dry food pantry. There were 55 residents that received an oral diet with a census of 57 residents. Findings include: Review of the policy titled Food Safety Requirements (not dated): Policy Interpretation and Implementation revealed the following information: 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such foods will be rotated using a first in- first out system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by). An observation on 9/28/2021 at 8:39 a.m. during a brief kitchen tour with the Food Supervisor revealed the following: 1. In the walk-in cooler there was a one-gallon unlabeled or dated bag containing approximately 7 to 10 uneaten pimento cheese sandwiches. 2. In the walk-in cooler there was a serving container with pureed food that was unlabeled or dated. 3. In the dry food pantry there was one unlabeled or dated 30-gallon container of sugar. An interview with the Food Service Supervisor on 9/30/21 at 12:15 p.m. revealed it is her expectation that all staff help to properly label and store all food items. The Food Service Supervisor further expressed that all items should have been labeled with the date in which the items were received, the date in which the item expires and the date in which the item was opened.