Based on observations and staff interviews, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect. Specifically, the facility failed to provide privacy during incontinent care for one of 40 sampled resident (R) (R132) reviewed for dignity. Findings include: Observation on 8/13/2024 at 10:00 am revealed Certified Nursing Assistant (CNA) NN providing incontinent care to R132 in his room with the privacy curtain not completely closed. The privacy curtain was observed pulled towards the end of the bed but did not circle the bottom of the bed leaving an open view of the resident to anyone entering the room. Further observation, revealed, the room door was also left open during care and the resident was observed to be naked from the waist down. Interview on 8/13/2024 at 2:41 pm with CNA NN revealed that today was her first day working at the facility. She stated that she was an Agency staff member. She stated she was unaware the door was left open and confirmed that she did not close the curtain all the way. Interview on 8/15/2024 at 12:10 pm with the Nurse Manger revealed all CNAs are required to know about residents rights. She stated during orientation the nursing staff received an in-service education on how to treat residents with dignity. She stated whenever she witness noncompliance among her staff, she schedule an education module.

Based on staff interviews, record review, and review of facility's policy title Comprehensive Care Plans, the facility failed to develop a comprehensive person-centered care plan for two residents (R) R8 and R59 that addressed the residents' peripherally inserted central catheter (PICC) line. The sample size was 40 residents. Findings include: Review of the facility's policy titled Comprehensive Care Plan dated March 2023 under the section titled, Policy revealed, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. Review of R8's electronic medical record (EMR) revealed, the resident had diagnoses that included but was not limited to type 2 diabetes mellitus with foot ulcer, vascular dementia, non-pressure chronic ulcer of right heel and midfoot, other acute osteomyelitis, depression and delirium due to known physiological mood. Review of R8's physician orders revealed, an order with order date of 8/6/2024 for Daptomycin solution reconstituted 500 mg (milligram); Use 250 mg intravenously every 24 hours for Infection until 8/27/2024. Review R8's care plan with revision date of 8/13/2024 revealed, that she was ordered antibiotic therapy Daptomycin through 8/27/2024 related to right foot osteomyelitis. Further review of the care plan revealed, there was no care plan in place that addressed the resident's PICC line. Interview on 8/15/2024 at 12:15 pm with the Minimum Data Set (MDS) Coordinator confirmed the PICC line was not on the care plan and revealed it had been added on 8/14/2024. 2. Review of R59's EMR revealed, the resident had diagnoses that included but was not limited to anemia, colostomy, chronic pain and muscle wasting. Review of R59's physician orders revealed with order date of 8/13/2024 for Invanz injection solution reconstituted 1 (one) GM (gram) (Ertapenem Sodium) Use 1 (one) gram intravenously one time a day for abscess Review of R59's care plan dated 7/30/2024 revealed that the resident had an infection (abscess) and was at risk for infection. Further review of the care plan revealed, there was no care plan in place that addressed the resident's PICC line. Interview on 8/15/2024 at 12:15pm with the MDS Coordinator confirmed that the PICC line was not on the care plan and asked if she could go ahead and add it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of facility's policies titled Resident Environmental Quality and Safe and Homelike Environment, the facility failed to maintain a clean and sanitary environment. Specifically, the filters for Heating Ventilation, and Air Conditioning (HVAC) unit vents contained visible thick grayish white dust particles that covered the filters for the residents that occupied rooms (103,100,101,104,105 and 106). This deficient practice had the potential to cause poor air quality that could lead to respiratory illness. The sample size was 40 residents. Findings include: Review of the facility's policy titled Resident Environmental Quality dated 6/24/2024, under the section titled Policy revealed, It is the policy of this facility to be designed, constructed, equipped and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Under the section titled Policy Explanation and Compliance Guidelines revealed, The facility shall: (2.) Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. Under the section titled General Guidelines: revealed, (1.) Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. Review of the facility's policy titled Safe and Homelike Environment dated 12/1/2023 under the section titled Policy revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Under the section titled Policy Explanation and Compliance Guidelines revealed, (3.) Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. Observation on 8/13/2024 at 10:45 am of room [ROOM NUMBER] revealed, both filters of the (HVAC) unit vents were covered with thick grayish white dust particles. Interview on 8/13/2024 at 10:50 with the Maintenance Director (MD) in room [ROOM NUMBER] revealed the process was for housekeeping to monitor and clean them monthly. The MD confirmed the (HVAC) units had a buildup of thick grayish white dust particles that that covered it. Observation on 8/13/2024 at 10:55 am of room [ROOM NUMBER] room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Observation on 8/13/2024 at 11:05 am room of 101 room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Observation on 8/13/2024 at 11:10 am room of 104 room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Observation on 8/13/2024 at 11:15 am room of 105 room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Observation on 8/13/2024 at 11:30 am room of 106 room revealed, both filters of the HVAC unit vents were covered with thick grayish white dust particles. Interview on 8/15/2024 on 8:32 am with Housekeeper (HK) GG revealed she check the air conditioner heater vents every couple of weeks and clean them monthly either by dusting off or rinsing if heavy dust was observed. HK GG also revealed there was no log or tracker for rooms that had been done. Interview with the Housekeeping Supervisor revealed his expectation of staff was that they clean them at least monthly. He stated that he also had a daily checklist but does not always use it.

Based on observations, staff interviews, and review of the facility's policy titled Medication Storage, the facility failed to ensure that a Schedule IV medication was secured under double lock and key for one of two medication storage rooms. This deficient practice had the potential to cause loss of controlled and other medications. The facility census was 81 residents. Findings include: Review of the facility's undated policy titled Medication Storage, under the section titled Policy Explanation and Compliance Guidelines revealed, 2. Narcotic and Controlled Substances: (a.) Schedule II drugs and back up stock of schedule III, IV and V medications are stored under double-lock and key. Observation and interview on 8/14/2024 at 1:18 pm of the medication storage room on the 400 hall with Licensed Practical Nurse (LPN) II revealed, the medication room was locked and that the nurse held the key however the refrigerator had no lock. During the observation, the refrigerated drugs were noted to have an emergency box closed with plastic tear away locks. The medications in the emergency box which was clear plastic container held Ativan 2mg (milligram) injectable. LPN II confirmed Ativan present in box however she was unsure whether it was properly secured. Interview on 8/14/2024 at 1:25 pm with facility pharmacist revealed the plastic tear away lock meets the requirement for double lock security for controlled drug storage. Interview on 8/15/2024 at 10:25 am with Director of Nursing confirms controlled substances should be kept under double lock but did not confirm what constitutes a double lock. The DON revealed the pharmacy has ordered a new container that will be bolted into the refrigerator and with a key lock that the nurses will carry a key for it.

Based on observation, staff interview, and review of the facility's policy titled, Date Marking for Food Safety, the facility failed to label and date 34 porkchops, eight chicken breast, and six hamburger patties in one of three freezers and the facility failed to discard 22 expired snack cookies on two of two pantries. In addition, the facility failed to maintain proper sanitary conditions for one of three ice machines and the facility failed to discard 140 expired 240 mL (milliliter) water bottles and four cases with six count each of one gallon sized water from the emergency water supply. The total of residents that received an oral diet was 81. Findings Include: Review of facility's undated policy titled, Date Marking for Food Safety under the section titled Policy revealed, The facility adheres to a date marketing system to ensure the safety of ready-to-eat, time/temperature control for safety food. Under the section titled Policy Explanation and Compliance Guidelines for Staffing revealed, 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or discarded. 5. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday). 6. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Manager, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed. Observation during the tour of the kitchen on 8/13/2024 at 10:33 am with Regional Manager MM revealed no labels or dates on three meat products; 34 porkchops, eight chicken breast, and six hamburger patties. These items were immediately discarded by Regional Manager MM. Observation on 8/15/2024 at 12:30 pm with [NAME] President (VP) of Clinical Services AA of two dry storage areas revealed 14 expired snack cookies: two chocolate chips and 12 lemon cookies in the main pantry. The tour concluded on the short-term rehab unit near the 400 hall whereas the second pantry revealed eight expired snack lemon cookie and a dirty ice machine. VP of Clinical Service AA and Housekeeping Supervisor HH observed and confirmed these findings. Interview on 8/15/2024 at 12:50 pm with Housekeeping Supervisor HH revealed he performed laundry and housekeeping duties. Housekeeping Supervisor HH revealed, he cleaned the ice machine located on 400 hall yesterday however, he confirmed the dirt-like substance and proceeded to shut down the ice machine to reclean. Interview on 8/15/2024 at 2:32 pm with Regional Manager MM revealed she identified why the frozen items found during initial tour were unlabeled because she obliviously orders more than the previous manager, and someone took items out the box to make space and did not label them. Regional Manager MM confirmed it was her responsibility to check dates in kitchen but was not certain who was responsible for checking pantries, but stated she would do an in-service for it. Observation on 8/15/2024 at 4:52 pm of the emergency water supply revealed a limited supply of food and four cases with six count each of one gallon sized water and 140 count of 240 ml water bottles expired. Regional Manager MM made directive to Housekeeping Supervisor HH to discard them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the policy titled Medication Storage, the facility failed to ensure that one of three medication carts was locked and secured when the cart was out of view of the nurse. The census was 62. Findings include: Review of the facility policy titled Medication Storage dated 5/4/22 revealed policy explanation and compliance guidelines: 1. a. All drugs and biologicals will be stored in a locked compartment (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. 1.c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Observation on 10/25/22 at 9:25 a.m., medication cart on 300 Hall, located between rooms [ROOM NUMBERS], was unlocked and unattended without a nurse or staff member within eyesight. Licensed Practical Nurse (LPN) AA approached the cart and verified she left the cart unlocked and unattended. She stated she had walked away to give a resident water and forgot to lock the cart. She confirmed the cart should be locked and secured when unattended. Interview on 10/27/22 at 11:15 a.m. with the Director of Nursing (DON), stated her expectations are for all medication carts to be locked and secured when left unattended. She stated the pharmacy consultants provide monthly in-services related to medication administration, medication storage and other relevant pharmacy topics.

Based on observations, record review, and interview, the facility failed to maintain sanitary conditions of the kitchen ice machine. The census was 62 residents. Findings include: Review of document provided by facility labeled Ice Machine dated June 2021, revealed supplies and procedure for cleaning the ice machine. Procedure indicated that the ice bin should be cleaned daily by wiping the interior of the ice bin or ice chute above the ice layer, including the drip edge of the ice deflector shield and around the ice bin door using a clean towel and sanitizer solution, being careful not to drop sanitizer on the ice. Observation on 10/26/22 at 10:05 a.m. and 10/27/22 at 8:00 a.m. using a white paper towel wiping the inside of the ice bin, revealed build-up of black substance in the bin of the ice machine. Review of a document provide by the Dietary Manager, titled ML-Safety and Sanitation with completion date of 10/4/2022, revealed under Score Summary for sanitation, a score of 64.71%, which indicated a corrective action plan is needed. Under sanitation, it was documented that the ice machine is to be well maintained and free from mold and foreign contaminants, maintenance records (cleaning) are to be posted on or near unit, and a master daily, weekly, and monthly cleaning schedule must be in place, posted and used routinely. Interview on 10/26/22 at 10:05 a.m. with Dietary Manager (DM), stated that he is the person that is responsible for cleaning the ice machine. He stated that it is supposed to be cleaned every week, but it has not been cleaned due to staffing issues. When asked to produce the cleaning logs, he stated that they were in storage.