**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility's policy titled, Advance Directives, the facility failed to provide written information to the resident and/or representative regarding the right to accept or refuse medical or surgical treatment for one of 30 sampled residents (R) (R3) reviewed for advance directives. This failure had the potential to deny R3 and/or representatives the opportunity to have choices and preferences with health care decisions and to formulate an Advance Directives. Findings include: Review of the facility's undated policy titled Advance Directives under the Purpose statement revealed, To establish guidelines for complying with state and federal law related to an individual's wishes and personal beliefs regarding the provision of health care at the end of life or when incapacitated. Under the section titled Advance Directive for Healthcare revealed, A written document, voluntarily executed, to make one's wishes regarding their own health care known. Review of R3's Electronic Medical Record (EMR) revealed R3 was admitted to the facility with diagnoses that included but was not limited to dementia, mental disorder due to known physiological condition, and unspecified intellectual disabilities. Review of the quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Pattern), a Brief Interview for Mental Status (BIMS) indicated R3 was rarely or never understood. Review of R3's EMR revealed a Do Not Resuscitate Order for Resident without Decision Making Capacity dated 4/11/1994. Further review of the document revealed that it did not include or show a signed acknowledgement of receipt or evidence that the facility provided R3 and/or responsible party with written information pertaining to their right to accept or refuse medical and/or surgical treatment. Interview on 12/11/2024 at 11:52 am with Licensed Practical Nurse (LPN) DD confirmed R3 did not have an Advance Directive Checklist in the clinical record and that the Do Not Resuscitate Order for Resident without Decision Making Capacity was the only evidence of an Advance Directive in R3's file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and record review, the facility failed to develop a comprehensive person-centered care plan related to language barrier communication devices and three facility acquired pressure ulcers for one out of 30 sampled residents (R) (R57). This deficient practice had the potential to affect R57's health and safety. Findings include: Review of R57's Electronic Medical Record (EMR) revealed R57 was admitted to the facility on [DATE] with diagnoses that included but was not limited to moderate Alzheimer's dementia, acute inflammatory demyelinating polyneuropathy, functional quadriplegia, generalized weakness, and three facility acquired pressure ulcers (foot anterior right, foot anterior left, sacrum reopened pressure injury). Review of R57's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed, Section B (Hearing, Speech, and Vision), R57 was usually understood and usually understands as it relates to communication; Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) of 9, which indicated R57 had moderate cognitive impairment; Section GG, (Functional Abilities and Goals), revealed R57 was dependent on a helper for assistance with activities of daily living (ADLs) and mobility; Section M (Skin Conditions), revealed R57 was at risk of pressure ulcers and had two unstageable pressure ulcers with suspected deep tissue injury. Review of R57's care plan dated 7/30/2024 indicated a focus of Cognitive/Communication Impairment with Goals that included the resident will be able to make simple decisions and communicate needs; Interventions included but not limited to all staff will ask simple, direct questions and provide simple direct information. There were no care plan interventions related to R57's language barrier and methods for R57 to communicate his needs. Further review of R57's care plan dated 7/30/2024 indicated a focus of Skin Integrity with Goals that included the resident will have no pressure areas, skin tears, or bruises. Interventions included but not limited to assisting R57 with diet and assessing skin integrity as needed. There were no care plan interventions related to R57's three facility-acquired pressure ulcers. Review of R57's Physician's Orders included but was not limited to a pain assessment every shift, acetaminophen 650 milligrams (mg) every six hours as needed, wound care daily, and Speech Therapy to eval and treat. Observation on 12/10/2024 at 9:48 am revealed R57 speaking only in spanish using a live translator. The translator stated that it was difficult to understand R57 and translate his words due to audio and the connection. Observation on 12/10/2024 at 12:19 pm in the dining room revealed, R57 sitting at a table with no communication device noted in sight. Observation on 12/11/2024 at 2:17 pm in R57's room revealed, R57 was difficult to understand using a translator. Observation on 12/12/2024 at 12:02 pm revealed, Registered Nurse (RN) FF entering R57's room without a translator device. Interview on 12/10/2024 at 9:48 am with Licensed Practical Nurse (LPN) AA revealed that she was an agency nurse and bilingual (Spanish and English), who worked with R57 sometimes. She stated that there was a tablet kept at the nurses' station with a live translator function. Interview on 12/12/2024 at 2:03 pm with Certified Nursing Assistants (CNA) GG revealed that she uses the translator device to communicate with R57 throughout the day and also uses LPN AA who was sometimes there during the week. She stated that they learn his needs based on experience of his needs and if the translator was not present, she uses nonverbal demonstrations to communicate. When asked if she feels like staff meet the resident's needs, she stated that they do the best they can in the situation. She further stated that sometimes it was difficult to understand him because they need to use the translator. Interview on 12/12/2024 at 3:10 pm with R57 using a Spanish-speaking surveyor to translate on the phone revealed that there was a staff member that speaks Spanish but when she was not there, he does his best with the little English he knows. He stated that most staff treat him with respect, but he also feels like some staff ignore him since he cannot speak English. He further stated that there was no device that he used to translate his words to staff; he has a phone that he could possibly use but it was dead. When asked if staff communicate with him frequently with the tablet, he stated no. Interview on 12/12/2024 at 3:33 pm with CNA CC and CNA EE revealed that there should be interventions regarding R57's pressure ulcers in the care plan. When asked how they know how to care for R57's pressure ulcers, they stated that they rely on shift reports. They further stated that they sometimes use the translator device kept at the nurses' station, Interview with the Minimum Data Set (MDS) Coordinator on 12/12/2024 at 3:56 pm revealed she also develops the care plans. She stated that a lot of care plan interventions are already built in based on diagnoses unless they need to be more specific as needed. When asked if she agrees that R57 needs care planned interventions for communication devices and for the facility acquired pressure ulcer care, she confirmed that the translator was key and agreed that it should be a listed intervention. She confirmed that the care plan would be the tool to get an understanding of each resident and their needs. It was revealed, a focus that addressed the facility acquired pressure ulcers, language barrier and methods of communication was added on 12/12/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled Nebulizer Machine Cleaning, the facility failed to prevent the spread of infections by not cleaning, changing or covering nebulizer equipment for one of five residents (R) (R21) receiving nebulization treatments. Findings include: Review of the facility's policy titled Nebulizer Machine Cleaning dated 7/1/2023 revealed, I. Purpose: To promote and maintain infection control when utilizing nebulizer machines .III. Policy: Nebulizer tubing will be changed once weekly and as needed (prn). Nebulizer filters must be washed or changed once weekly and prn. Review of Electronic Medical Records (EMR) revealed R21 was admitted with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD) and asthma. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Patterns): a Brief Interview of Mental Status (BIMS) of 14 which indicated R21 had intact cognition, Section I (Active Diagnosis): COPD and asthma. Review of R21's care plan dated 8/4/2023 included but not limited to Problem: COPD, Emphysema, Asthma. Goal: Resident will be free of respiratory infections and exacerbations through next review period. Intervention: Nebulization treatment PRN. Review of R21's Physician's Orders dated 9/19/2024 revealed, orders that included but not limited to: PROVENTIL 2.5 milligram (mg) /3 milliliters (mL) (0.083%) nebulizer solution 2.5 mg for acute cough every six hours PRN for wheezing. Observation on 12/10/2024 at 11:17 am revealed nebulizer face masks and equipment in drawer of R21's bedside table. The masks and equipment were not covered in bags. One face mask was dated 11/19 and the other face mask had 11/5 written on it. Observation on 12/10/2024 at 4:26 pm revealed nebulizer face masks and equipment in drawer of R21's bedside table. The masks and equipment were not covered in bags. One face mask was dated 11/19 and the other face mask had 11/5 written on it. Observation on 12/11/2024 at 9:38 am revealed nebulizer face masks and equipment in drawer of R21's bedside table. The masks and equipment were not covered in bags. One face mask was dated 11/19 and the other face mask had 11/5 written on it. Observation on 12/11/2024 at 2:38 pm revealed nebulizer face masks and equipment in drawer of R21's bedside table. The masks and equipment were not covered in bags. One face mask was dated 11/19 and the other face mask had 11/5 written on it. Record review of facility's document titled .Administrations of albuterol (PROVENTIL) 2.5 mg /3 mL (0.083 %) nebulizer solution 2.5 mg revealed, nebulization was administered to R21 up to five weeks after the 11/5 date written on the nebulization face mask and up to three weeks after the 11/19 date written on the nebulization face mask that read: Given: 2.5 mg: nebulization on 12/2/2024; Given: 2.5 mg: nebulization on 11/23/2024; Given: 2.5 mg: nebulization on 11/14/2024; Given: 2.5 mg: nebulization on 11/12/2024; Given: 2.5 mg: nebulization on11/6/2024; Given: 2.5 mg: nebulization on11/5/2024 at 9:00 pm and Given: 2.5 mg: nebulization on 11/5/2024 at 8:00 am. Interview on 12/11/2024 at 2:43 pm with Licensed Practical Nurse (LPN) HH confirmed the face masks in the drawer of R21's bedside table were not covered and had dates 11/19 and 11/5 on them. She stated the face masks should be covered in a bag and that the masks and nebulization tubing should be changed each week. She confirmed the masks and tubing were not changed each week and the dates on the tubing were correct. She stated the last time she worked on that hall was two weeks ago. LPN HH revealed, she had administered nebulization to R21 with the same face masks and tubing in R21's bedside drawer. She stated she did not change the face mask or the tubing before administering the nebulization. LPN HH further stated if the face masks, tubing and equipment were not cleaned weekly, soiled, and not covered in a bag, it could lead to infection for R21 because the items would be contaminated when they were placed in the drawer or on any surfaces that were not clean. She stated that nebulization equipment should be changed weekly because it made them free from dust, germs and keep them patent from solutions used for nebulization treatment which could harbor infection. Interview on 12/11/2024 at 2:52 pm with the Unit Manager (UM) revealed her expectation was for the equipment for nebulization, including the face masks and tubing were to be changed each Tuesday night by the night staff. She stated weekly cleaning of the nebulizer machine and changing of the equipment would reduce bacteria and infection for R21. She stated if the nebulization masks and equipment were not changed at least weekly or placed on dirty surfaces, they could accumulate dust and bacteria, and the outcome could lead to infections for the resident. Interview on 12/11/2024 at 3:38 pm with the Director of Nursing (DON) revealed, her expectations were for the nebulization masks and equipment to be placed in a bag when not in use and for the equipment to be changed weekly. The DON stated when the face mask and equipment were placed on dirty surfaces such as in the drawer of a resident's bedside table the outcome would be the resident could get sick or get an infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Infection Prevention and Control-Hand Hygiene, the facility failed to wash/sanitize hands during a wound treatment for one of two residents (R) (R38) reviewed for pressure ulcers. This deficient practice had the potential to result in complications of the wound and further impair the resident's skin integrity. Findings include: Review of facility's policy titled Infection Prevention and Control dated 7/1/2023 revealed, I. Purpose: To establish guidelines for healthcare providers and staff to perform hand hygiene . III. Policy A. Hand Washing and Hand Antisepsis . 4. Alcohol-based hand sanitizer (hospital approved with at least 60% alcohol) may be substituted for hand washing with soap and running water in the following circumstances: a. Hands are not visibly soiled. b Before and after patient contact (includes any contact with environment/equipment). c. After contact with a source that is likely to be contaminated. d. After removing gloves. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) of 12 which indicated R38 had intact cognition; Section M (Skin Condition) revealed, R38 had one or more unhealed pressure ulcer (s) at stage one or higher. Review of R38's care plan dated 10/30/2024 revealed a care plan that included, Problem: Wound Care Description: Wound to coccyx will not deteriorate over the next two weeks, Goal: Optimal wound healing without complications over the next weeks, Intervention: Perform wound care as ordered by physician. Review of R38's Physician's Orders dated 11/13/2024 revealed, Wound Care Pressure injury coccyx, clean wound with: (Never Use Peroxide) Wound Cleanser. Specific wound care instructions: Cleanse area, pat dry, apply skin prep to peri wound and pack wound with Dakins solution gauze loosely and cover with a protective dressing. Change twice a day. Observation on 12/12/2024 at 10:57 am during wound care treatment of the of coccyx for R38 revealed, Licensed Practical Nurse (LPN) HH removed soiled pair of gloves and put on clean pair of gloves without sanitizing her hands between changing gloves. During the observation, the Unit Manager (UM) came in the room and saw LPN HH removed soiled pair of gloves and put on a clean pair of gloves without sanitizing her hands. Interview on 12/12/2024 at 11:39 am with LPN HH confirmed she did not sanitize her hands after she removed the soiled pair of gloves and before putting on another pair of clean gloves. She stated infection prevention was paramount. She stated hand washing or hand sanitization should be done before, during and after resident contact. She further stated that she should have sanitized her hands after she removed the soiled pair of gloves, and she did not. She stated hands were to be sanitized before putting on clean gloves to get rid of germs and prevent infection to the residents. She stated that germs from her hands when she removed the soiled gloves could have been transferred to her clean gloves because she did not sanitize her hands, and this could cause infection to R38's wound. Interview on 12/12/2024 at 12:33 pm with the UM confirmed LPN HH did not sanitize her hands after she removed a soiled pair of gloves and before putting on a pair of clean gloves during wound care. She stated the outcome could lead to the spread of infection to the wound and to R38. Interview on 12/12/2024 at 7:17 pm with Director of Nursing (DON) revealed, her expectations were for the staff to sanitize their hands after removing gloves and before putting on a new pair of gloves. She stated when hands are not sanitized between glove change, the outcome would be problems with the residents' care and problems for the staff if the staff come in contact with contaminated substances from the residents and the residents come in contact with contaminated substances from the staff. She stated the residents could get an infection or there could be worsening of a wound if it occurs during wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, the facility failed to maintain communication between the facility and the dialysis center for one of one resident (R) R19 reviewed for dialysis. This deficiency had the potential to cause complications related to dialysis and diminished quality of life for R19. Findings include: Review of Electronic Medical Records (EMR) revealed R19 admitted with a diagnosis that included but not limited to End Stage Renal Disease (ESRD) on dialysis. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Patterns) revealed, a Brief Interview of Mental Status (BIMS) of 3 which indicated R19 was cognitively impaired; Section O (Special Treatments) revealed, R19 received dialysis. Review of R19's care plan dated 9/20/2023 revealed, Problem: Renal Failure with Dialysis with Goal of: Resident will be free of secondary infections through next review period that included, Interventions: encourage compliance with diet/fluid restrictions as ordered, monitor and record BP as ordered, DO NOT use arm with shunt to take BP, monitor shunt site for signs and symptoms (s/s) of infection, report substantial weight gain/loss to MD as ordered, administer medications related to condition of renal failure/dialysis as ordered, and monitor labs as ordered. Review of facility's document titled Dialysis (# of days) order dated 9/21/2023 revealed, R19 had dialysis three times weekly. Review of facility's document titled Long Term Care Facility Outpatient Dialysis Services Care Coordination Agreement revealed contract agreement between the dialysis center [name of dialysis center] and the facility. Review of Physician's Progress Note dated 9/19/2023 revealed, Plan: R19 had outpatient hemodialysis secured at [name of dialysis center] on Tuesdays, Thursdays, Saturdays (TTS). Review of facility's documents revealed, there was no evidence of documentation regarding communication between the facility and the dialysis center. Interview on 12/11/2024 at 1:04 pm with Licensed Practical Nurse (LPN) HH revealed, the facility had no documented communication between the nurses at the facility and the nurses at the dialysis center. She stated the nurses at the facility do not send documentation of vital signs or any information to the dialysis center when the resident goes to dialysis and the dialysis center does not communicate with the facility regarding R19's dialysis when R19 completes dialysis. LPN HH stated, the facility and the dialysis center nurses do not communicate through phone calls either. LPN HH stated, whenever there is no communication between the facility and the dialysis center the outcome would be a disjoint in care because if something happened with R19 the nurses at the facility would not know what was done at the dialysis center and the dialysis center would not know what happened with R19 at the facility. Interview on 12/11/2024 at 2:52 pm with Unit Manager (UM) confirmed there was no communication between the facility and the dialysis center. She stated when there was no communication between the facility and the dialysis center the outcome would be negative for the resident. Interview on 12/11/2024 at 3:38 pm with Director of Nursing (DON) revealed her expectation was for the facility to have a document sent with the resident to dialysis and a document sent from the dialysis center to the facility. The DON stated it would improve the communication between the facility and the dialysis center. She confirmed that at present, the facility did not have documentation of communication between nursing staff at the dialysis center and the facility. She stated the outcome would be a bad outcome for the resident when important information was not communicated between the facility and the dialysis center because the resident could miss out on important treatments and care. She further stated if something bad happened at dialysis and the nurses at the facility did not know about it the facility would not know what to treat and the resident could miss out on important care. A dialysis policy was requested from the facility but was not provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to ensure nails were trimmed and clean for one resident (R) (#54) of 26 sampled residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#54 is rarely or never understood and requires one-person total dependance with personal hygiene. The resident has diagnoses including nontraumatic brain dysfunction, diabetes mellitus and dementia. Observations on 8/26/22 at 10:05 a.m., 8/27/22 at 9:02 a.m., and 8/28/22 at 9:00 a.m. revealed R#54's nails are untrimmed, some jagged and dirty underneath the nail. Interview and observation with Certified Nursing Assistant (CNA) AA on 8/28/22 at 10:30 a.m. confirmed that R#54's nails are long, with some jagged with dirt underneath and stated they should have been trimmed. She stated there is a bath person who cuts the nails. CNA AA stated she usually carries clippers in her pocket but does not have them today. Resident was pleasant and allowed us to look at his nails and stated ok when told his nails may need to be trimmed. Interview on 8/28/22 at 10:49 a.m. with License Practical Nurse (LPN) BB revealed there is a bath person that will cut the resident's nails if the resident lets her or the CNAs on the floor can cut the nails if needed. She stated the nurses should cut the nails of the diabetic residents. Review of bath sheets revealed resident received a bath/shower on 8/2/22, 8/5/22, 8/9/22, 8/12/22, 8/23/22, and 8/26/22. There was no documentation of refusal for nail care. Interview on 8/28/22 at 12:47 p.m. with the MDS Coordinator revealed there is not a facility policy related to nail care. During an interview on 8/28/22 at 4:20 p.m., the Director of Nursing (DON) confirmed that her expectation is for nursing staff to ensure resident's nails are trimmed and cleaned as outlined in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and review of the policy titled, Oxygen Policy, the facility failed to ensure oxygen concentrators were free from dust build up and failed to ensure humidity was provided as ordered by the physician for two residents (R) (#21 and #27) reviewed of 16 residents receiving oxygen. Findings include: Review of policy titled Oxygen Policy revised 5/17/22 revealed: Used prefilled humidifier canister as ordered or indicated for long term oxygen use. Oxygen concentrator - concentrator filters are to be cleaned weekly in warm soapy water rinsed and dried. Filter will be changed as needed. 1. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#21 with a Brief Interview of Mental Status (BIMS) score of 14 indicating cognition intact. The resident receives oxygen therapy. Review of the current Physician Orders for August 2022 revealed an order for O2 (oxygen) @ (at) 2 liters via nasal cannula continuous. Change tubing and humidifier bottle every Tuesday. Change/clean filter on concentrator every Tuesday. Review of the August 2022 Medication Administration Record (MAR) revealed oxygen saturation levels are checked daily and signed off. There is no indication that the humidifier bottle and filter is cleaned every Tuesday. Observations on 8/26/22 at 10:30 a.m., 8/27/22 at 9:04 a.m., and 8/27/22 at 2:59 p.m. revealed R#21 was wearing oxygen via nasal cannula. The oxygen machine had humidity attached dated 8/16/22. There was also buildup of dust on the machine including the vents on the back. 2. Review of the Quarterly MDS dated [DATE] revealed R#27 with a BIMS score of 15 indicating cognition intact. Resident has diagnoses of nontraumatic brain injury, anemia, atrial fibrillation, dementia, anxiety, and depression. The resident receives oxygen therapy. Review of the current Physician Orders for August 2022 revealed an order for O2 @ 2 liters via. (sic) Change tubing and humidifier bottle every Tuesday. Change/clean filter on concentrator every Tuesday. Every shift for SOB (shortness of breath) usually only wears O2 at nighttime. Review of the August 2022 MAR revealed oxygen saturation levels are checked daily and signed off. There is no indication that the humidifier bottle and filter is cleaned every Tuesday. Observations on 8/26/22 at 10:47 a.m., 8/27/22 at 9:06 a.m., and 8/28/22 at 9:10 a.m. revealed R#27 had an oxygen machine with humidity attached dated 8/16/22. There was also buildup of dust on the machine including the vents on the back. The resident stated she uses the oxygen each night. Interview and observation with Licensed Practical Nurse (LPN) CC on 8/28/22 at 11:43 a.m. revealed R#27's humidity is out of date and should have been changed on Tuesdays on night shift. During further interview, she stated they should also assess and clean the oxygen concentrators and filters. She stated she will change them if they are getting low. During an interview on 8/28/22 at 4:20 p.m., the Director of Nursing (DON) confirmed that her expectation is for nursing staff to follow physician orders for humidity and cleaning/changing filters on oxygen concentrators.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to ensure two residents (R) (R#34 and R#43) were appropriately assessed and informed consent was obtained, for the use of side rails on their beds. The sample size was 26. Findings include: The bed rail/side rail policy for assessment and use was requested, but the facility was unable to provide it. 1. Review of the clinical record for R#34 revealed she was admitted to the facility on [DATE] with diagnoses include Meniere's disease, dementia, anxiety disorder, depression, and age-related physical debility. Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score that could not be determined. The resident was assessed as requiring extensive assistance from staff for bed mobility, dressing, eating, toileting, and personal hygiene. R#34 was assessed as requiring total assistance with transfers. Review of R#34 care plan for Activity of Daily Living (ADL) indicated that side rails: partial rails up to promote independence in bed mobility and to define bed parameters. Observe for injury or entrapment related to side rail use. Reposition every two hours and as necessary. Review of R#34's clinical record revealed no evidence of an assessment for the use of side rails had been completed. The clinical record also revealed no signed informed consent related to the risks and benefits of side rails was obtained from the resident's responsible party. Observation on 8/27/22 at 2:00 p.m. revealed R#34 was in her room lying in bed resting. The bed was in the low position and pushed against the wall. A fall mat was on the side of the bed and a full side rail was in the upright position. Interview on 8/28/22 at 3:10 p.m. with the Director of Nursing (DON) confirmed that R#34 does not have a signed informed consent form for the use of side rails nor a side rail assessment. The DON stated that they are in the process of having signed informed consent for new admission using side rails and current residents using side rails would have signed informed consent completed during care plan meetings. 2. Review of the clinical record for revealed R#43 was admitted to the facility on [DATE] with diagnoses to include, but not limited to, Downs syndrome, profound intellectual disabilities, and developmental disorders. Review of the resident's quarterly MDS, dated [DATE], indicated the resident was severely cognitively impaired, the BIMS score could not be determined. The resident was assessed as requiring extensive assistance from staff for bed mobility, transfers, eating, and toileting. R#43 was assessed as requiring total assistance with dressing and personal hygiene. Review of the care plan for R#43 ADL's revealed that side rails: partial rails up for safety to define bed parameters, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Continued review of R#43's clinical record revealed no assessment for the use of side rails had been completed. The clinical record also revealed no signed informed consent related to the risks and benefits of side rails was obtained from the resident's responsible party. Observation on 8/28/22 at 1:50 p.m. and on 8/29/22 at 2:05 p.m. of R#43 revealed he was in his room lying in bed with both top half side rails in the upright position. The resident was awake and playing with a stuffed teddy bear. Interview on 8/28/22 at 3:10 p.m. with the DON confirmed that R#43 does not have a signed informed consent form for the use of side rails nor a side rail assessment. Interview on 8/28/22 at 3:45 p.m. with the Administrator and Director of Nursing (DON) revealed that they are unable to provide a list of residents that use side rails.

Based on observation and staff interview, the facility failed to ensure recipes were available to follow for preparing pureed foods to avoid compromising the nutritive value for chicken ala king and peas. This deficient practice had the potential to effect 16 residents receiving a pureed diet. Findings include: Observation on 8/27/22 at 10:40 a.m. of the Dietary Manager (DM) preparing pureed chicken ala king for the lunch meal revealed he placed 15 baked chicken breasts in the food processor bowl and ground. The DM took the ground chicken breast and placed an unmeasured amount in a small rectangle steam table pan and another unmeasured amount into a blender bowl. The DM took the ground chicken in the blender bowl and added three, four-ounce ladles of prepared chicken ala king gravy. The ground chicken with gravy was then pureed to the appropriate consistency. Continued observation revealed the DM pureeing peas for the lunch meal. He placed an unmeasured about of cooked peas in the blender bowl and added six, two-ounce ladles of vegetable stock and pureed. The DM stopped blending and added another ladle of vegetable broth and continued to puree. During an interview on 8/27/22 at 10:40 a.m. the DM revealed there are no recipes for pureed food items. The DM stated that he knows about how much to put in the food processor or blender for the number of purees to serve.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interviews, the facility failed to ensure air conditioners were free from dust build up in six resident rooms (301, 306, 307, 308, 309, and 310) of 21 rooms in the west building. Findings include: Review of the facility document titled Task Specialization (housekeeper's checklist) revised 4/14/22 revealed no indication to clean the air conditioning vents in the resident rooms. Observations on 8/26/22 at 10:30 a.m., 8/27/22 at 9:04 a.m., and 8/27/22 at 2:59 p.m. revealed the air conditioner vent and slats were noted with dust build up in room [ROOM NUMBER]. Observations on 8/26/22 at 10:47 a.m., 8/27/22 at 9:06 a.m., and 8/28/22 at 9:10 a.m. revealed the air conditioner vent and slats were noted with dust build up in room [ROOM NUMBER]. Observations on 8/28/22 starting at 9:50 a.m. revealed additional rooms (rooms [ROOM NUMBER]) with dust build up on the air conditioner vents and slats. During concurrent observation and interview on 8/28/22 at 10:15 a.m., Housekeeper (HK) DD confirmed that she sees the dust on the above-mentioned vents, and she stated she can clean the air conditioners. She stated the task in not on her checklist and she did not know to clean the air conditioner vents and slats. Interview with Minimum Data Set (MDS) Coordinator on 8/28/22 at 10:20 a.m. revealed there was no policy for housekeeping services. Further interview and observation with the HK DD on 8/28/22 at 11:11 a.m. revealed that she went around to clean the vents and realized that the filters down in the air conditioners are dusty on some of the units. She does not remember them ever being cleaned. We observed room [ROOM NUMBER] and she stated there was another room on the 400 hall with more dust on the filter of the air conditioner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the policy titled, Care Plan Policy, it was determined the facility failed to ensure the development of a person-centered, comprehensive care plan for one resident (R) (R#13) related to contractures. Additionally, the facility failed to follow the person-centered care plan for two residents (R#21 and R#27) related to oxygen therapy , and one resident (R#54) related to nail care from a sample size of 26. Findings include: A review of the facility admission packet revealed an undated facility Care Plan Policy titled Care Plan Policy, which revealed a care plan would be developed for each resident. The plan would concentrate on the strengths, problems and needs of the residents. Additionally, the policy revealed that the facility would conduct an interdisciplinary quarterly care plan review for each resident. 1. A review of the medical record revealed that R#13 was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD), lupus, schizophrenia, epilepsy, polyneuropathy, dementia, atrial fibrillation (A-fib), hypertension, cerebral infarct, bipolar, dysphagia, and restless syndrome. A review of R#13's care plan revealed there was no care plan developed for the contracture of her left hand. A review of the Minimum Data Set (MDS) OBRA Quarterly Assessment, dated 5/28/22 revealed a Brief Interview for Mental Status (BIMS) Assessment revealed a score of 14. Section G-Functional Status, revealed that R#13 had a functional limitation in range of motion to an upper extremity (shoulder, elbow, wrist, or hand). An observation of R#13 on 8/26/22 at 9:52 a.m. revealed her left hand was contracted, and she had a pink splint in the palm of her left hand. She appeared to be in no pain or distress. During an interview with R#13 on 8/26/22 at 10:00 a.m., she revealed her left hand was contracted due to a stroke in 2006. She explained she had physical therapy when she first arrived in 2019 but was not currently receiving any treatment. She stated she kept the splint in her left hand and added that when her nails get long, they dig into the palm of her hand. She explained the staff are good about putting the splint back in her hand after bathing, and if she asked, the staff would cut her nails. During an interview with the MDS Coordinator on 8/28/22 at 10:51 a.m., she stated that R#13 should have been care planned for the contracture of her left hand. She stated it was an oversight. 2. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R#21 with a BIMS score of 14 indicating cognition intact. The resident receives oxygen therapy. Review of the care plan last revised 6/25/22 revealed R#21 has Emphysema/COPD (chronic obstructive pulmonary disease). Interventions include O2/2 lpm (liters per minute)- Check O2 tubing and supplies nightly and change out supplies weekly and PRN (as needed). Observations on 8/26/22 at 10:30 a.m., 8/27/22 at 9:04 a.m., and 8/27/22 at 2:59 p.m. revealed R#21 was wearing oxygen via nasal cannula. The oxygen machine had humidity bottle attached dated 8/16/22. There was also buildup of dust on the machine including the vents on the back. 3. Review of the Quarterly MDS dated [DATE] revealed R#27 with a BIMS score of 15 indicating cognition intact. Resident has diagnoses of nontraumatic brain injury, anemia, atrial fibrillation, dementia, anxiety, and depression. The resident receives oxygen therapy. Review of the care plan last revised 7/1/22 revealed R#27 has oxygen therapy r/t (related to) CHF (Congestive Heart Failure). Interventions include O2- Check O2 tubing and supplies nightly and change out supplies weekly and PRN (as needed). Observations on 8/26/22 at 10:47 a.m., 8/27/22 at 9:06 a.m., and 8/28/22 at 9:10 a.m. revealed R#27 had an oxygen machine with humidity bottle attached dated 8/16/22. There was also buildup of dust on the machine including the vents on the back. The resident stated she uses the oxygen each night. Interview and observation with Licensed Practical Nurse (LPN) CC on 8/28/22 at 11:43 a.m. revealed R#27's humidity should have been changed on Tuesdays on night shift. During further interview, she stated they should also clean the oxygen concentrators, change the filters when need and replace them if they are getting low. Interview on 8/28/22 at 4:20 p.m., the Director of Nursing (DON) confirmed that her expectation is for nursing staff to follow physician orders for humidity and cleaning/changing filters on oxygen concentrators. Cross refer to F695. 4. Review of the Quarterly MDS dated [DATE] revealed R#54 is rarely or never understood and requires one-person total dependance with personal hygiene. The resident has diagnoses including nontraumatic brain dysfunction, diabetes mellitus and dementia. Review of the care plan last revised 8/8/22 revealed R#54 has an ADL self-care performance deficit r/t limited mobility, weakness, and mild confusion and dementia. Interventions included: BATHING/SHOWERING: The resident requires assistance by 1-2 staff with bathing/showering twice weekly and as necessary. Check nail length and trim and clean on bath day and as necessary. Review of bath sheets revealed resident received a bath/shower on 8/2/22, 8/5/22, 8/9/22, 8/12/22, 8/23/22, and 8/26/22. There was no documentation of refusal for nail care. Observations on 8/26/22 at 10:05 a.m., 8/27/22 at 9:02 a.m., and 8/28/22 at 9:00 a.m. revealed R#54's nails are untrimmed, some jagged and dirty underneath the nail. Interview with the MDS Coordinator on 8/28/22 at 2:35 p.m. revealed that all nurses have access to the care plan and the CNA's have access to the [NAME] to ensure care plan interventions are followed. Any time an update is made, the nursing staff sign an in-service on the spot form to ensure they are aware of the changes. Cross refer to F677.

Based on staff interview and review of the facility policy titled, Personal Food Storage Dietary Policy, the facility failed to ensure the policy regarding resident personal food included safe reheating procedure to prevent food borne illness. This deficient practice has the potential to effect 66 residents consuming an oral diet. Findings include: Review of the policy tiled Personal Food Storage Dietary Policy with an approval date of 5/2021 and expiration date of 5/2024 revealed how to ensure safe and sanitary food storage brought by family or visitors. Continued review of the policy revealed there was not a procedure to assist nursing staff, family, or visitors with reheating food items in a sanitary manner. During an interview on 8/28/22 at 10:25 a.m., the Director of Nursing (DON) revealed that the facility does not have a policy stating the procedure for reheating food items brought in from outside by family or visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility policies titled, Uniform Dress Code, Food and Storage Policy, and Habersham Home Resident Nutrition Services Policy the facility failed to ensure the exhaust hood was clean and free from grease to prevent contamination; failed to ensure dietary staff with facial hair wore a beard restraint; failed to label and date opened food items; and failed to deliver resident meal trays in a sanitary manner on the [NAME] Wing. This deficient practice had the potential to effect 66 of 71 residents receiving an oral diet. Findings include: 1. Observation on 8/26/22 at 9:20 a.m. of the exhaust hood revealed that the filters were covered with a layer of brown, black grease like substance. A label on the exhaust hood stated the last professional cleaning was on 9/15/21. Interview on 8/26/22 at 9:20 a.m. with the Dietary Manager (DM) revealed that he has called the company that cleans the exhaust hood and they have not come yet to clean the exhaust hood. The DM stated that he knows it has been a while since the last time the exhaust hood was serviced. He revealed he is working on a monthly cleaning schedule and exhaust hood cleaning will be on the list. Interview on 8/26/22 at 9:21 a.m. with [NAME] EE revealed that occasionally they would take out the exhaust hood filters out and clean them, but stated it has not been done in a while. 2. Review of the policy titled Uniform Dress Code revised 1/22, revealed Associates working with food - restrain all facial hair with a beard net/restraint. Observation on 8/26/22 at 9:21 a.m. of [NAME] EE revealed that he had a beard with mustache and the hair on his chin was about an inch long. [NAME] EE was not wearing a mask or a beard restraint while in the food preparation area. Observation on 8/27/22 at 8:30 a.m. of [NAME] EE revealed he continued to not wear a mask or beard restraint while preparing food. Observation on 8/28/22 at 8:40 a.m. of [NAME] EE revealed he was preparing food and not wearing a beard restraint. During an interview on 8/28/22 at 8:40 a.m., the DM stated that he expects [NAME] EE to wear a beard restraint and stated that he has spoken with him about wearing one. Interview on 8/28/22 at 8:41 a.m. with [NAME] EE revealed that they ran out of beard restraints a few days ago and more need to be ordered. [NAME] EE stated that he does the ordering and has not ordered more yet. [NAME] EE stated he was under the assumption that if the facial hair was under a certain length, he did not have to wear a beard restraint. He was not aware of the policy for facial hair in the food preparation area. 3. Review of policy titled Food and Supply Storage revised 1/22, revealed - cover, label, and date unused portions and open packages. Continued review of the policy revealed Dry Storage - store food in their original packages. Food that must be opened must be stored in an approved container that have tight fitting lids. Observation on 8/26/22 at 9:25 a.m. of the meat and dairy walk-in refrigerator revealed an open bag of grated Parmesan cheese that was wrapped with no date. During an interview on 8/26/22 at 9:25 a.m. the DM confirmed the parmesan cheese did not have an open date and he expects staff to label, and date opened food items before storing. Observation on 8/26/22 at 9:30 a.m. of the produce walk-in refrigerator revealed a small metal bowl containing a shredded cabbage type salad that was not labeled or dated. Continued observation revealed a square clear plastic container containing an orange diced food item with no label or date. Other opened and undated items in the produce walk-in refrigerator included a half of a cut lemon wrapped in plastic wrap, a bag of shredded cabbage mixture wrapped in plastic wrap, and a bag of spring lettuce mix. During an interview on 8/26/22 at 9:30 a.m. the DM confirmed that the shredded cabbage mixture in the small metal bowl, plastic container contained diced mango, the cut lemon half, open bag of shredded cabbage mixture, and open bag of spring lettuce mix were all opened with no date. The DM stated that he expects staff to label and date food items before placing in walk-in refrigerator. Observation on 8/26/22 at 9:40 a.m. of the dry storage area revealed a large can of mandarin oranges was in the can rack and had a dent towards the bottom of the can. Continued observation revealed an opened bag of rice that was wrapped and undated. During an interview on 8/26/22 at 9:40 a.m., the DM confirmed that the can of mandarin oranges was dented, and staff should have removed it from the rack and placed in a separated area from the other cans. He also confirmed that the opened bag of rice did not have a date and staff should have dated before placing on shelf. Observation on 8/26/22 at 9:45 a.m. of the food preparation area revealed a metal bin with wheels labeled sugar, inside the bin was an open bag of sugar and an open bag of panko breadcrumbs, both items were undated. Continued observation revealed a white plastic bin with wheels was labeled flour, the bin was not dated when the flour was taken out of its original packaging. During an interview on 8/26/22 at 9:45 a.m., the DM confirmed that the sugar, panko breadcrumbs, and flour were in the bins and were undated. Observation on 8/28/22 at 8:32 a.m. of the meat and dairy walk-in refrigerator revealed an undated and opened five pound container of sour cream, an opened five pound bag of shredded mozzarella cheese not securely wrapped, and a cut log of deli salami meat that was about 10 inches in length and four inches in diameter that was wrapped, but not dated. During an interview on 8/28/22 at 8:32 a.m., the DM confirmed that the sour cream was open with no date, the shredded mozzarella cheese was not securely wrapped and was undated, and the cut log of deli salami did not have an open date. Observation on 8/28/22 at 8:35 a.m. of the produce walk-in refrigerator revealed an open bag of spring mix lettuce that was undated. During an interview on 8/28/22 at 8:35 a.m., the DM confirmed that the bag of spring mix lettuce was opened and undated. 4. Review of facility policy titled Habersham Home Resident Nutrition Services Policy which expired 5/2020 revealed In both units when auxiliary carts are used to serve meal trays, a dome plate cover, plastic wrap, plastic lid, or individual packaging is used to cover foods. Observation on 8/28/22 at 12:38 p.m. on the [NAME] Wing revealed Certified Nursing Assistant (CNA) FF deliver a meal tray to the resident in room [ROOM NUMBER]. The lunch tray was assembled from the kitchenette in the dining room, the plate on the tray was covered with a hard plastic dome but a clear plastic cup with a slice of apple strudel was not covered as the CNA walked down the hall. Continued observation of CNA FF revealed she delivered meal trays with uncovered apple strudel to rooms [ROOM NUMBER]. Interview on 8/28/22 at 12:52 p.m. with CNA FF revealed that she did not realize that all foods on the meal tray needed to be covered when walking down the hallway. The CNA stated that no one has told her that food items needed to be covered. During an interview on 8/28/22 at 12:54 p.m., the Administrator revealed that he expects staff to distribute meal trays in a sanitary manner which includes food items to be covered when staff are walking down the hall to resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of the policies Urinary Catheter Policy, (Insertion, Maintenance, Irrigation) and Resident's Federal and State Rights the facility failed to place a privacy bag over the indwelling Foley catheter of 3 out of 8 residents (R) (R#3, R#8, and R#127) on 1 of 2 units. Findings include: 1. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R#3 revealed in section (C) a Basic Interview for Mental Status (BIMS) score of 11/15 indicating intact cognitive responses, (E) Behaviors - None. (G) Functional Status - 2+ person physical assist. (H) Bowel and Bladder - Indwelling Foley Catheter, and always incontinent of bowel. (I) Active Diagnosis (including but not limited to) - Neurogenic bladder. (N) Medications - Antianxiety, antidepressant, diuretic, and opioid 7/7 days a week. Review of the medical record for R#3 revealed an order dated April 2, 2019 for an 18 French Catheter with 20cc Balloon. Change monthly and as needed related to malfunction. During an observation on 6/24/19 at 1:30 p.m. of R#3 in her room revealed her catheter bag to be hanging, uncovered, on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 9:12 a.m. of R#3 in her room revealed her catheter bag to be hanging, with the upper portion of the bag covered, revealing the mid and lower portion of the bag. The catheter bag was noted to be on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 11:10 a.m. of R#3 during activities revealed her to be sitting in her wheelchair with the catheter bag hanging below the back of the chair and it was noted to be uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licensed Practical Nurse (LPN)/Unit Supervisor BB she stated if a resident has a catheter, and is in the bed, she would expect the catheter bag to be covered completely and preferably hanging on the opposite side of the bed away from view of the hallway. She stated that if the resident is in a wheelchair she would expect the catheter bag to be hanging below the bladder underneath the back side of the wheelchair, off the floor, and covered. During an interview on 6/26/19 at 9:20 a.m. with Activities Coordinator/CNA AA she stated that she knows from working on the floor as a CNA that catheters should be hung below the bladder and should be covered to protect the privacy of the resident. She stated that she has had in-services regarding care of catheters related to Activities of Daily Living but nothing about privacy or where a catheter bag should be placed. During an interview on 6/26/19 at 9:25 a.m. with RN Supervisor CC she stated if a resident has a catheter she would expect nursing staff to ensure the catheter bag was placed below the bladder and that it was covered with a privacy bag. 2. Review of the Quarterly Minimum Data Set (MDS) for R#8, dated 3/23/19, section (C), revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition. (E) Behaviors - None. (G) Functional Status - Extensive one-person physical assist. (H) Bowel and Bladder - Indwelling Urinary Catheter and is frequently incontinent of bowel. (I) Active Diagnosis - (Including but not limited to) Obstructive Uropathy. (N) Medications - Antianxiety and Antidepressant 7/7 days a week. Review of the medical record for R#8 revealed an order dated October 25, 2018 for an 18 French Catheter with 30cc Balloon. Change monthly and as needed related to Obstructive Uropathy. During an observation of R#8 on 6/24/19 at 12:19 p.m., in his room, revealed his catheter bag uncovered and laying in his lap. During an observation of R#8 on 6/24/19 at 12:25 p.m. sitting in the dining room. Catheter bag noted in R#8's lap, uncovered. Catheter tubing noted to be looped up toward his left shirt pocket. During an observation on 6/24/19 at 12:40 p.m. in the dining room R#8 was served lunch. Catheter remained in his lab and the tubing remained looped up toward his left shirt pocket. During an observation on 6/24/19 at 1:00 p.m. in the dining room Activity Director/Certified Nursing Assistant (CNA) AA took R#8's tray, then R#8 propelled himself out of the dining room and down the hall. Catheter bag remained on R#8's lap, uncovered. During this time the catheter tubing was observed to be resting next to his left leg. During an observation on 6/24/19 at 1:10 p.m. in the hall revealed Registered Nurse (RN)/Supervisor CC stand in front of R#8 in the hall, speak to him momentarily, then walk away. During this time Activities Director/CNA AA escorted the resident into her office to complete section F of the MDS. With R#8's permission this surveyor observed the interview. The interview was completed at 1:25 p.m. and CNA AA took R#8 to his room. At no time did RN/Supervisor CC or CNA AA acknowledge the catheter bag in R#8's lap, that it did not have a cover, or place it below the bladder of R#8. During an observation on 6/25/19 of R#8 at 9:00 a.m. revealed him propelling wheelchair down hall with catheter bag noted hanging under chair uncovered. During an observation on 6/25/19 of R#8 at 11:15 a.m. in bed. Catheter bag noted hanging on left side of bed, uncovered, and exposed to hallway. During an observation on 6/25/19 of R#8 at 12:50 p.m. in dining room revealed his catheter bag hanging under his wheelchair uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licensed Practical Nurse (LPN)/Unit Supervisor BB she stated if a resident has a catheter, and is in the bed, she would expect the catheter bag to be covered and preferably hanging on the opposite side of the bed away from view of the hallway. She stated that if the resident is in a wheelchair she would expect the catheter bag to be hanging below the bladder underneath the back side of the wheelchair, off the floor, and covered. LPN/Unit Manager BB stated that a privacy bag should cover the whole catheter bag to insure the resident privacy. She stated that R#8 was just put on antibiotics for a Urinary Tract Infection (UTI). During an interview on 6/26/19 at 9:20 a.m. with Activities Coordinator/CNA AA she stated that she knows from working on the floor as a CNA that catheters should be hung below the bladder and should be covered to protect the privacy of the resident. She stated that she has had in-services regarding care of catheters related to Activities of Daily Living but nothing about privacy or where a catheter bag should be placed. Activity Director/CNA AA stated that she does remember seeing the catheter bag laying in R#8's lap but stated she was focused on what she was doing and just didn't think to place the bag in the correct place and stated she will definitely be more aware in the future. During an interview on 6/26/19 at 9:25 a.m. with RN Supervisor CC she stated if a resident has a catheter she would expect nursing staff to ensure the catheter bag was placed below the bladder and that it was covered with a privacy bag. She stated that if a catheter bag was observed not to be below the bladder she would expect staff to place the catheter bag below the bladder and ensure it was covered with a privacy bag. RN/Supervisor CC stated that R#8 moves his catheter around and sometimes puts it in his lap and staff remind him not to bother his bag. She stated that she remembers seeing the catheter bag in R#8's lap and stated that she had her mind on what she was doing at that time and just didn't think to place the catheter bag in the correct place but would be more mindful in the future. 3. Review of the clinical record for R#127 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to fractured pelvis, hypertension (HTN), osteoarthritis, chronic kidney disease (CKD), compression fracture lumbar vertebra, history prostate cancer, diabetes and anemia. There was no data available on Minimum Data Set (MDS) due to new admission status with entry tracking MDS dated [DATE]. Observation on 6/25/19 at 11:54 a.m. revealed resident (R) #127 sitting in his wheelchair in the hallway, across from the nurse's station on [NAME] Unit. Catheter bag was hanging from the arm of the wheelchair, above the level of the bladder. The tubing was looped over the arm rest of the chair. There was no evidence of a privacy bag covering the drainage bag. Observation on 6/26/19 at 9:06 a.m. revealed R#127 sitting in wheelchair in hallway, across from nurse's station. Catheter bag was hanging from back of wheelchair. There was no evidence of a privacy bag in use to cover drainage bag. Interview on 6/27/19 at 8:19 a.m. with Licensed Practical Nurse (LPN) LL, stated that residents with catheters, should have a privacy bag over the urine drainage collection bag. She stated that she did not notice that R#127 did not have a privacy bag over the drainage bag. Review of the Urinary Catheter Policy, (Insertion, Maintenance, Irrigation) policy revised April 2018 revealed to maintain unobstructed urine flow by keeping the collection bag below the level of the bladder, and the tubing free of kinks. Urine flow must be downhill. Keep the collection bag off the floor. Review of the policy titled Resident's Federal and State Rights dated December 2017 revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Refer to F656

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in six resident rooms on one of four halls and one of two units (402 B, 403 B, 405, 406, 407 and 409) related to dirty air conditioner face grills and scratched paint on door frame. The sample size is 39. Findings include: Observation on 6/24/19 at 10:25 a.m. revealed in room [ROOM NUMBER] B, the call light was pulled out of the wall and laying on the floor. Resident stated it has not worked since he was admitted on [DATE]. Observation on 6/24/19 at 1:43 p.m. revealed in room [ROOM NUMBER] B, no privacy curtain hanging from ceiling. Observation on 6/24/19 at 1:49 p.m. revealed in room [ROOM NUMBER], bathroom door frame with multiples patches of chipped paint. Observation on 6/24/19 at 1:52 p.m. revealed in room [ROOM NUMBER], air conditioner unit face grill dusty with small black spots, approximately two centimeters in diameter, on the slats. Observation on 6/24/19 at 1:55 p.m. revealed in room [ROOM NUMBER], air conditioner unit face grill dusty with small black spots, approximately two centimeters in diameter, on the slats. Observation on 6/24/19 at 1:58 p.m., revealed in room [ROOM NUMBER] A, the call light switch plate on wall above bed was loose and missing two screws. Observation on 6/25/19 at 12:23 p.m., revealed in room [ROOM NUMBER] the air conditioner unit face grill dusty with small black spots, approximately two centimeters in diameter, on the slats. Interview on 6/25/19 at 9:00 a.m. with Maintenance Technician NN, stated that he has been having to change several call lights, because of the ten foot long cords. He stated they get tied around the side rails and when the rails go up and down, it puts tension on the cord, causing it to break at the point of connection. Interview on 6/27/19 at 10:28 a.m. with Housekeeper II, stated that she is the only housekeeping staff for the [NAME] Unit. She stated that she cleans each resident room daily. She stated that she sweeps, mops, wet dusts with a sanitizing cleaner. She wet dusts all surface items in resident rooms, including table tops, side rails on bed, window sills, blinds, bathroom toilets, sinks and mirrors. She also empties the trash and makes sure toiletries are stocked. She stated that she does not clean the air conditioners or wipe them down. Interview on 6/27/19 at 10:30 a.m. with Housekeeping Director, stated that the Housekeeping staff are to clean residents entire room, including inspecting privacy curtains. She further stated the housekeeping staff are supposed to be wiping down the air conditioner (AC) units. She verified on walking rounds the dirty AC face grills identified during the survey in rooms 406, 407, 409, and also that room [ROOM NUMBER] bed B did not have a privacy curtain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to follow the person-centered comprehensive care plan related to privacy bags for 3 out of 8 residents (R) (R#3, R#8, and R#127) with indwelling Foley catheters on 1 of 2 units. Findings include: 1. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R#3 revealed in section (C) a Basic Interview for Mental Status (BIMS) score of 11/15 indicates intact cognitive responses. (E) Behaviors - None. (G) Functional Status - 2+ person physical assist. (H) Bowel and Bladder - Indwelling Foley Catheter, and always incontinent of bowel. (I) Active Diagnosis (including but not limited to) - Neurogenic bladder. (N) Medications - Antianxiety, antidepressant, diuretic, and opioid 7/7 days a week. Review of the care plan with an initiated date of 1/19/18 and revision date of 1/2/19 revealed R#3 has an indwelling Foley catheter. Interventions include: Position catheter bag and tubing below the level of the bladder with a privacy cover over the bag. Review of the medical record for R#3 revealed an order dated April 2, 2019 for an 18 French Catheter with 20cc Balloon. Change monthly and as needed related to malfunction. During an observation on 6/24/19 at 1:30 p.m. of R#3 in her room revealed her catheter bag to be hanging, uncovered, on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 9:12 a.m. of R#3 in her room revealed her catheter bag to be hanging, with the upper portion of the bag covered, revealing the mid and lower portion of the bag. The catheter bag was noted to be on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 11:10 a.m. of R#3 during activities revealed her to be sitting in her wheelchair with the catheter bag hanging below the back of the chair and it was noted to be uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licensed Practical Nurse (LPN)/Unit Supervisor BB she stated if a resident has a catheter, and is in the bed, she would expect the catheter bag to be covered completely and preferably hanging on the opposite side of the bed away from view of the hallway. She stated that if the resident is in a wheelchair she would expect the catheter bag to be hanging below the bladder underneath the back side of the wheelchair, off the floor, and covered and stated nursing staff know this because it is in the residents care plan. During an interview on 6/26/19 at 9:25 a.m. with RN Supervisor CC she stated if a resident has a catheter she would expect nursing staff to ensure the catheter bag was placed below the bladder and that it was covered with a privacy bag. She stated that all residents with a Foley catheter have a care plan related to privacy bags and ensuring the catheter is maintained below the bladder. 2. Review of the Quarterly Minimum Data Set (MDS) for R#8, dated 3/23/19, section (C), revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition. (E) Behaviors - None. (G) Functional Status - Extensive one-person physical assist. (H) Bowel and Bladder - Indwelling Urinary Catheter and is frequently incontinent of bowel. (I) Active Diagnosis - (Including but not limited to) Obstructive Uropathy. (N) Medications - Antianxiety and Antidepressant 7/7 days a week. Review of the care plan for R#8 revealed an Indwelling Catheter related to urinary retention and obstructive uropathy. Interventions include: change every month and as needed (prn) for dysfunction using size of Foley catheter as ordered with 30cc balloon, position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks each shift and PRN, monitor and document intake and output, monitor for signs and symptoms of discomfort on urination and frequency, monitor/record/report to Medical Doctor (MD) for signs and symptoms of Urinary Tract Infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, statlock to secure urinary catheter, change weekly and as needed (prn). Review of the medical record for R#8 revealed an order dated October 25, 2018 for an 18 French Catheter with 30cc Balloon. Change monthly and as needed related to Obstructive Uropathy. During an observation of R#8 on 6/24/19 at 12:19 p.m., in his room, revealed his Foley catheter bag uncovered and laying in his lap. During an observation of R#8 on 6/24/19 at 12:25 p.m. sitting in the dining room. Catheter bag noted in R#8's lap, uncovered. Catheter tubing noted to be looped up toward his left shirt pocket. During an observation on 6/24/19 at 12:40 p.m. in the dining room R#8 was served lunch. Catheter remained in his lab and the tubing remained looped up toward his left shirt pocket. During an observation on 6/24/19 at 1:00 p.m. in the dining room Activity Director/Certified Nursing Assistant (CNA) AA took R#8's tray, then R#8 propelled himself out of the dining room and down the hall. Catheter bag remained on R#8's lap, uncovered. During this time the catheter tubing was observed to be resting next to his left leg. During an observation on 6/24/19 at 1:10 p.m. in the hall revealed Registered Nurse (RN)/Supervisor CC stand in front of R#8 in the hall, speak to him momentarily, then walk away. During this time Activities Director/CNA AA escorted the resident into her office to complete section F of the MDS. With R#8's permission this surveyor observed the interview. The interview was completed at 1:25 p.m. and CNA AA took R#8 to his room. At no time did RN/Supervisor CC or CNA AA acknowledge the catheter bag in R#8's lap, that it did not have a cover, or place it below the bladder of R#8. During an observation on 6/25/19 of R#8 at 9:00 a.m. revealed him propelling wheelchair down hall with catheter bag noted hanging under chair uncovered. During an observation on 6/25/19 of R#8 at 11:15 a.m. in bed. Catheter bag noted hanging on left side of bed, uncovered, and exposed to hallway. During an observation on 6/25/19 of R#8 at 12:50 p.m. in dining room revealed his catheter bag hanging under his wheelchair uncovered. 3. Review of the clinical record for R#127 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to fractured pelvis, hypertension (HTN), osteoarthritis, chronic kidney disease (CKD), compression fracture lumbar vertebra, history prostate cancer, diabetes and anemia. There was no data available on Minimum Data Set (MDS) due to new admission status with entry tracking MDS dated [DATE]. Review of R#127 care plan initiated on 6/18/19 revealed resident has indwelling catheter related to obstructive uropathy. Interventions to care include change monthly and as needed (PRN) for dysfunction. Monitor each shift as per protocol. Position the catheter bag and tubing below the level of the bladder with a privacy cover over the bag. Observation on 6/25/19 at 11:54 a.m. revealed resident (R) #127 sitting in his wheelchair in the hallway, across from the nurse's station on [NAME] Unit. Catheter bag was hanging from the arm of the wheelchair, above the level of the bladder. The tubing was looped over the arm rest of the chair. There was no evidence of a privacy bag covering the drainage bag. Observation on 6/26/19 at 9:06 a.m. revealed R#127 sitting in wheelchair in hallway, across from nurse's station. Catheter bag was hanging from back of wheelchair. There was no evidence of a privacy bag in use to cover drainage bag. Interview on 6/27/19 at 8:19 a.m. with Licensed Practical Nurse (LPN) LL, stated that residents with catheters, should have a privacy bag over the urine drainage collection bag. She stated that she did not notice that R#127 did not have a privacy bag over the drainage bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews and review of the policy titled Oxygen Policy, the facility failed to ensure Oxygen concentrator filter was clean for one resident (R) (R#126). The sample size was 39. Findings include: Review of the facility policy titled Oxygen Policy revealed the policy states the facility shall provide oxygen therapy as ordered by the physician. Oxygen concentrator will be used for continuous therapy, with oxygen tanks available for emergency or temporary use. Concentrator filters are to be cleaned weekly in warm, soapy water, rinse and dried. Filters will be changed as needed. Review of the clinical record for R#126 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to metabolic encephalopathy, sepsis, dysphagia, atrial fibrillation, gastric ulcer, depression, malignant breast cancer, hypokalemia, kidney disease, hypertension (HTN) and hyperlipidemia. There was no data available on Minimum Data Set (MDS) due to new admission status with entry tracking MDS dated [DATE]. Review of R#126 care plan initiated on 6/21/19 revealed resident has oxygen therapy related to shortness of breath. Interventions to care include oxygen settings at two Liters via nasal cannula continuous to keep sats above 90%. Observation on 6/24/19 at 1:25 p.m. revealed oxygen in use via concentrator at bedside. Concentrator has external filter on right side that is covered with thick gray layer of dust. Observation on 6/25/19 at 8:25 a.m. revealed oxygen in use via concentrator. External filter remains with thick gray layer of dust. Observation on 6/26/19 at 12:51 p.m. revealed oxygen in use via concentrator. External filter continues to have thick gray layer of dust. Observation on 6/27/19 at 8:09 a.m. revealed oxygen continues to be used, delivered by concentrator. External filter remains with thick gray layer of dust. Physician's order dated June 27, 2019 revealed an order for oxygen to be administered continously for shortness of breath. Interview on 6/27/19 at 8:19 a.m. with Licensed Practical Nurse (LPN) LL stated the night shift is responsible for changing oxygen tubing, nebulizer masks and humidification bottles. She stated she is not sure whether or not it needs to be dated. She further stated that she is not sure about who is responsible for cleaning the filters on the concentrators. Interview on 6/27/19 at 8:30 a.m. with Licensed Practical Nurse (LPN) Unit Manager (UM) BB, stated that oxygen tubing, nebulizer masks and humidification bottles are changed out weekly by the night shift staff and it is done on Tuesday's, and as needed (PRN). She stated they should be dated as to when they were changed. She further stated that the filters should also be cleaned and/or changed on Tuesday by the night shift. She verified the filter on the oxygen concentrator for R#126 was dirty with gray dust.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to practice infection control policy for washing and/or sanitizing hands during wound care procedure. The facility census was 76 residents. Findings include: 1. Observation on 6/24/19 at 12:24 p.m. revealed in room [ROOM NUMBER] B, an un-bagged and unlabeled toothbrush sitting on sink counter and un-bagged and unlabeled urinal sitting on the floor beside the toilet. Observation on 6/21/19 at 1:28 p.m. revealed in room [ROOM NUMBER] A, two (2) un-bagged and unlabeled toothbrushes sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 1:50 p.m. revealed in room [ROOM NUMBER] B, one (1) un-bagged and unlabeled toothbrush sitting on sink counter and one un-bagged and unlabeled bath basin on floor under the sink. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 1:58 p.m. revealed in room [ROOM NUMBER] A, one (1) un-bagged and unlabeled toothbrush sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 2:07 p.m. revealed in room [ROOM NUMBER] B two (2) un-bagged and unlabeled toothbrushes sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/25/19 at 10:14 a.m. revealed in room [ROOM NUMBER], one (1) unbagged and unlabeled toothbrush sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/25/19 at 10:47 a.m. revealed an un-bagged and unlabeled urinal sitting on grab bar in bathroom. 2. Observation on 6/26/19 at 2:03 p.m., with Licensed Practical Nurse (LPN) wound care nurse JJ performed wound care for R#13. She gathered all materials needed for the procedure and placed them in plastic cups. She sanitized the residents over bed table and placed a barrier on the table and placed the plastic cups with supplies on the barrier. She washed her hands and donned on clean gloves and removed the old dressing. Dressing was discarded in trash can in residents room. Nurse changed her gloves, but did not wash or use hand sanitizer. She donned a clean pair of gloves and cleansed the wound on left lower leg with wound cleanser. She then laid the residents leg on a pillow that was used to prop the leg. The nurse did not place a barrier on the pillow, before laying the leg onto the pillow. She then removed her gloves, and donned a clean pair of gloves, but did not wash her hands or use hand sanitizer. After donning clean gloves, nurse placed a moistened 4X4 gauze pad over the wound surface and covered with dry 4X4 gauze pad and wrapped with roll gauze. She secured the dressing with tape, dated and initialed it. She removed her gloves, gathered the garbage bag from the residents rooms and discarded in soiled utility room. She then washed her hands after discarding the garbage. Interview on 6/26/19 with Licensed Practical Nurse (LPN) JJ stated that she uses hand sanitizer when changing her gloves multiple times during the procedure. She further stated that she was nervous during the observation and she forgot to use hand sanitizer. Interview on 6/27/19 at 8:30 a.m. with Licensed Practical Nurse Unit Manager BB, stated it is her expectation that all staff provide care to the residents as ordered. She stated that wound care should be done following Physician orders and at frequency ordered. She further stated the nurses should be wearing gloves and washing hands or using hand sanitizer between glove changes. Interview on 6/27/19 at 10:10 a.m. with Infection Control Nurse KK, stated that she comes over to the [NAME] Unit once per week. She provides educational trainings on infection control for hand washing, using gloves, and best practices for Infection Control. While she is on the [NAME] Unit, she makes walking rounds and does random spot checks for staff following infection control practices. She stated that she will walk into residents rooms, looking for proper storage of personal care equipment. She stated that she would expect the equipment to be labeled with resident's name, but not sure about whether the items need to be bagged or not. She verified on walking rounds with Director of Nursing (DON), the concerns identified during the survey. She stated that for wound care, she would expect staff to change gloves often and wash hand or sanitize between glove changes.

Based on staff interview, observation, and review of policy titled Storage of Food and Supplies the facility failed to label and date opened food items in two of the walk-in coolers, walk-in freezer; and dry food storage area; failed to ensure cleanliness of food preparation stations; failed to ensure cleanliness and proper storage of ice machine scoop. The deficiency practice had the potential to affect 27 of 29 residents receiving an oral diet. The facility census was 76. Findings include: An initial tour of the kitchen was conducted on 6/24/19 from 11:08 a.m. to 11:50 a.m. with Dietary Service Director (DSD) CC, he confirmed that he wasn't a Certified Dietary Manager (CDM) at this time and his serv -safe is currently expired and was taking 6/25/19 off from work to renew his certification. He reported the serv-safe certified personnel Registered Dietitian (RD), and himself (currently expired). The DSD confirmed they had 20 food service staff that included the staff for the Bistro, Suite One Café and the two skilled nursing facility (SNF) called the Healthcare Kitchen. He explained the main kitchen provides meals to the hospital and the two skilled nursing facility. The Suite One Café serve staff, guest and any residents in the (SNF) and hospital that desire to go there on the second floor, which is a part of the Healthcare Kitchen services. During this initial observation and interview, DSD EE acknowledged that several food items were insecurely wrapped and unlabeled located in both walk-in refrigerators and deep freezer. The DSD EE confirmed that there should labels on each container containing the flour, sugar, breadcrumbs, with scooper removed from contents. He stated that due to the high turnover of staff, it's hard to keep track and remind them of the potential hazards. Continued observations on 6/24/19 of the Healthcare Kitchen with DSD EE present included: Walk-in refrigerators revealed the following unlabeled and no dated food items 1. One large bag of Spinach with no open date or expiration date. 2. A salami sandwich meat with no open date or expiration date. 3. Sliced yellow cheese with no open date or expiration date. 4. Extra heavy mayonnaise one-gallon container with no open date or expiration date. 5. Chopped garlic container five-ounce (oz.) container with no open date or expiration date. 6. Diced tomatoes container 32 (oz.) container with no open date or expiration date. 7. String beans 10 pounds (lbs.) bag Walk-in freezer revealed the following exposed unlabeled and no open date items 1. Three- five (oz.) deep skinned tilapia fish slices uncovered and no open date or expiration date. 2. Sweet green peas with no open date or expiration date. 3. A10-inch (in.) unbaked pie shells with no open date or expiration date. 4. Pound cake with no open date or expiration date. 5. Two (2)- 2 (oz.) frozen southern biscuits with no open date or expiration date. Tour of kitchen area with DSD EE revealed four containers of dry foods. The flour and sugar were observed inside a large white rubber 100 cup partially closed storage bin. Inside the container revealed two measuring scoopers left inside the contents with no open date. The white rubber container revealed several dried dark brown, yellowish stains three inches in diameter with no odor. The rice and breadcrumbs were observed in separate clear plastic containers with no open date and scooper left inside the contents. The food preparation areas with storage shelve underneath revealed dried old food stains and dust. The ice machine chute revealed that the white scooper was left inside the machine and stuck into the frozen mass of ice. Interview on 6/24/19 at 12:05 p.m. with DSD EE revealed that staffing issues is the cause of lack in knowledge related to safe food practices. He removed the ice scooper from the ice machine and delivered it to the dishwashing station. He also reported that all staff are responsible for checking food in the refrigerator and on the shelves in the pantry to assure food is covered, labeled and not expired. He further explained that when the items are placed in the plastic storage container a label should be added to the container identifying the use date that is listed on the original package. DSD EE revealed that all items should be labeled and dated. Interview on 6/24/19 at 12:08 p.m. with RD revealed that she works full-time at the facility. She states she helps in the kitchen when needed, which includes menus audits and correction. She reports seventy-four oral diets which include two tube feedings at the facility. Observation and tour on 6/25/19 at 12:10 p.m. with, Executive Chef (EC) FF of the food pantry revealed: 1. Five 20 oz. boxes of dried pinto beans, dried lentil beans, dried navy beans with pour spout left opened and uncovered. 2. One 8 oz. bag of pasta with no open date or expiration date. 3. One 16 oz. bag of marshmallow with no open date or expiration date. Interview on 6/27/19 at 10:00 a.m. with EC FF revealed he'd been employed for 19 years with the facility. He states when handling food storage; he makes sure he rotates first in and first out. He states that all storage containers should be six inches from the ground and not against the wall. He reports all open containers should be labeled with a date and that dented/damaged can goods are returned to the supplier. He states he's never received any training from the facility on the storage of food and supplies. Interview on 6/27/19 at 10:05 a.m. with (Dietary Aide) GG, revealed she'd been employed for four years with the facility. She states she never received any formal training from the facility on the storage of food and supplies. She states when she handles any storage of food, she makes sure it in a clear container with an label including the date opened. She states food must be thrown out within five days after opening. Interview on 6/27/19 at 3:10 p.m. with DSD revealed that although he has cleaning/closing checklist for employees to follow and ensure safe food storage and handling, he hasn't been using them due to the shortage of staff. Review of an undated policy titled Food Storage and Handling revealed that is the policy of the dining service department to cover, label, date and store foods in a safe appropriate manner. Review of an undated policy titled Food Storage and Handling revealed that it is the policy of the dining service department to cover, label, date, and store foods in a safe, appropriate manner. All cooked foods, pre-packaged open containers, protein-based salads, desserts, and canned fruits are labeled, dated, and securely covered. Cooked foods are stored above raw meats, poultry, and fish, at a temperature of 41 degrees for below. Frozen food storage is defined as 10 degrees or below. All products are rotated using first-in, first out (FIFO) inventory system. Dry bulk items, such as rice, sugar, and flour, are stored in seamless containers with tight-fitting lids and are clearly labeled. Scoops should not be left in food bins. Procedure: Dating system for open foods Follow the label P&P Always securely cover food item Using a label, complete the following: Write the expiration date on the product, using the guide below Clearly write the products name Return to designated storage (refrigeration, freezer, or storeroom) Check labels daily and discard outdated foods.