**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and review of the facility's policy titled, Resident Personal Funds, the facility failed to provide resident trust fund account quarterly statements for two of three residents (R) (R45 and R51) reviewed. This deficient practice had the potential to place the 62 residents with trust fund accounts managed by the facility at risk of not being provided the quarterly bank statements. Findings include: Review of the facility policy titled, Resident Personal Funds, dated 1/9/2024, revealed the Policy Explanation and Compliance Guidelines section included 2. If the resident chooses to deposit personal funds with the facility, upon written authorization of a resident, the facility must act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility. The Accounting and Records section included 3. The individual financial record must be available to the resident through quarterly statements and upon request. 1. Review of R45's admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 15, which indicated R15 was cognitively intact. Review of the document titled Trial Balance, as of 2/28/2025, revealed R45 had a trust fund account that the facility manages. In an interview on 3/29/2025 at 8:00 am, R45 stated he had a trust fund account that the facility managed. The resident stated he had never received a quarterly statement from the facility. 2. Review of R51's quarterly MDS assessment, dated 2/28/2025, revealed a BIMS was assessed as 15, which indicated R51 was cognitively intact. Review of the document titled Trial Balance, as of 2/28/2025, revealed R51 had a trust fund account that the facility manages. In an interview on 3/29/2025 at 8:10 am, R51 stated he had a trust fund account that the facility managed. The resident stated if he asked the lady in the front office how much money he had, she would verbally tell him the amount in the account, but he did not receive a written quarterly statement from the facility. In an interview on 3/31/25 at 3:20 pm, the Business Office Manager (BOM) stated she was responsible for the resident trust fund account and providing the residents with their quarterly statements. The BOM confirmed that R45 and R51 had a trust fund account that the facility manages. She stated R45 and R51 statements did not go to a responsible party. The BOM stated that the quarterly statements were given to R45 and R51. The BOM stated she had no way to prove that R45 and R51 were receiving their quarterly statements. She stated that going forward, she will have the residents sign a copy and load the signed copy into the facility's electronic medical record system.

Based on staff interviews, record review, and review of the facility policy titled, Elopements and Wandering Residents, the facility failed to ensure timely reporting of resident elopement to the State Survey Agency (SSA) for two of 32 sampled residents (R) (R281 and R54). Findings include: Review of the facility policy titled, Elopements and Wandering Residents, revised 2/13/2024, revealed the Definitions section included, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The Policy Explanation and Compliance Guidelines section included, . 5. Procedure for locating missing resident: . g. Appropriate reporting requirements to the State Survey Agency shall be conducted. 1. A review of R281's quarterly Minimum Data Set (MDS) assessment, dated 6/3/2024, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 8 (indicating moderate cognitive impairment). Section E (Behaviors) documented that R281 exhibited wandering behavior four to six days during the look-back period. Review of R281's diagnoses included, but was not limited to, Alzheimer's Disease, cognitive communication deficit disorder, and depression. Review of the facility incident report dated 6/25/2024 revealed the date of the incident was documented as 6/15/2024, and the details included that R281 exited the facility through an unsecured kitchen exit door and was found kneeling outside by a vending machine. The incident was not reported to the SSA until 6/25/2024, which was 10 days after the incident occurred on 6/15/2024. 2. A review of R54's quarterly MDS assessment, dated 3/15/2024, revealed Section C (Cognitive Patterns) documented a BIMS of 8 (indicating moderate cognitive impairment). Section E (Behaviors) documented that R281 exhibited wandering behavior one to three days during the look-back period. Review of R54's diagnoses included, but was not limited to, Alzheimer's Disease with late onset and unspecified dementia with agitation. Review of the facility incident report dated 6/25/2024 revealed the date of the incident was documented as 6/15/2024, and the details included that a Certified Nurse Assistant (CNA) heard the front door alarm go off and found the resident outside, walking towards the parking lot. The incident was not reported to the SSA until 6/25/2024, which was 10 days after the incident occurred on 6/15/2024. During an interview on 3/30/2025 at 10:00 am, the Director of Nursing (DON) and current Administrator stated that the previous Administrator did not recognize the two incidents as elopements and failed to report them timely to the SSA. The Administrator stated that upon assuming duties, she immediately reported both incidents and completed the five-day investigations. The DON and Administrator further stated that facility staff were re-educated on the definition of elopement and regulatory reporting requirements.

Based on observations, resident interviews, staff interviews, and record review, the facility failed to ensure that activities of daily living (ADL) care was provided for three dependent residents (R) (R45, R46, and R65) related to nail care out of 32 sampled residents. This deficient practice had the potential to place R45, R46, and R65 at risk of feeling self-conscious about their appearance. Findings include: 1. Review of R46's admission Record revealed diagnoses of, but not limited to, muscle weakness and rheumatoid arthritis. Review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 3/12/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) was assessed as 14 (which indicated R46 was cognitively intact). Section GG (Functional Abilities and Goals) documented the resident as totally dependent for personal hygiene. Review of the resident's care plan, initiated 3/30/2025, revealed that R46 has actual impairment related to fragile skin, with a goal to be clean and well groomed. In an observation and interview on 3/29/2025 at 7:45 am, R46 was lying in bed. His right and left hands were placed on the sides of his right and left thighs. The right hand metacarpophalangeal (MCP) joint, also known as the knuckle, was hyperflexed, the proximal interphalangeal joint (PIP) that bends and extends the fingers was hyperextended, and the distal interphalangeal (DIP) close to the fingernail was hyperflexed. The left hand MCP was hyperflexed, PIP was flex, and the DIP was hyperflexed. The resident's fingernails on the right and left hand were long in length with dirt and brown debris under the nail. The resident stated he had rheumatoid arthritis. The resident further stated that he would like his nails to be cleaned and clipped. In a concurrent interview and observation on 3/30/2025 at 11:53 am, Licensed Practical Nurse (LPN) AA stated the resident's nails should be cleaned and clipped every two weeks. LPN AA confirmed that R46's nails were long and uneven, with dark brown debris. 2. Review of the R65's admission Record revealed diagnoses of, but not limited to, dementia, muscle weakness, and acute on chronic systolic (congestive) heart failure. Review of the resident's quarterly MDS assessment, dated 3/20/2025, revealed Section C (Cognitive Patterns) documented a BIMS assessed as 10 (which indicated R65 had moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented the resident required partial to moderate assistance with personal hygiene. Review of the resident's care plan, revised on 12/15/2024, revealed that R65 has actual impairment related to fragile skin, with a goal to be clean and well groomed. In an observation and interview on 3/29/2025 at 7:50 am, R65's fingernails on the right and left hand were long in length with dirt and brown debris under the nail. The resident stated he would like his fingernails to be cleaned up and clipped. In a concurrent interview and observation on 3/30/2025 at 11:54 am, LPN AA confirmed that R65 nails were long in length with dark brown debris. 3. Review of R45's admission Record revealed diagnoses of, but not limited to, contracture to the left hand, muscle weakness, and end-stage renal disease. Review of the resident's admission MDS assessment, dated 12/8/2024, revealed Section C (Cognitive Patterns) documented a BIMS of 15 (which indicated R45 was cognitively intact). Section GG (Functional Abilities and Goals) documented the resident as totally dependent for personal hygiene. Review of the resident's care plan, revised on 3/29/2025, revealed that R45 required total assistance of one to two staff for ADL care. In an observation and interview on 3/29/2025 at 8:00 am, R45's fingernails were observed to be long in length with dirt and brown debris under the nail. The resident stated that he would like his nails to be cleaned and clipped. An observation on 3/30/2025 at 11:25 am revealed R45 sitting up in the wheelchair in his room, dressed in street clothes. The resident's fingernails on the right and left hand were long in length with dirt and brown debris under the nail. During an observation on 3/30/2025 at 12:00 pm, the Director Of Nursing Service (DNS) confirmed that R45 nails were long with brown debris under the nail and needed to be clipped. In an interview on 3/30/2025 at 12:05 pm with the DNS outside of R65's room, the DNS stated the resident's nails should be clean and clipped on their scheduled bath days. The DNS stated R65 refuses to have his nails clipped and refuses baths. The DNS reviewed the resident's skin integrity care plan and confirmed that the resident's care plan did not reflect that R65 refused to have his fingernails clipped. At 12:03 pm, Certified Nursing Assistant (CNA) FF arrived with nail clippers. CNA FF asked R45 if he would his fingernails clipped, he responded that he would and allowed CNA FF to trim his fingernails. In an interview on 3/30/2025 at 1:00 pm, the Director of Nursing Service (DNS) stated the facility did not have a policy on ADLs or nail care. In an interview on 3/30/2025 at 2:40 pm, CNA FF stated the facility policy regarding nail care was for the resident's fingernails to be checked on their bath days and clipped if needed. CNA FF stated that when a resident refused ADLs, including nail care and shaving, the charge nurse should be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility's policies titled, Oxygen Concentrator, and Oxygen Administration, the facility failed to ensure that three of five residents (R) (R12, R58, and R66) reviewed for oxygen (O2) had respiratory equipment that was properly cleaned and stored. This deficient practice had the potential to place R12, R58, and R66 at risk for respiratory complications and a diminished quality of life. Findings include: Review of the facility policy titled, Oxygen Concentrator, dated 2013, revealed the Purpose section included, To provide Oxygen for therapeutic use by utilizing a concentrator that converts ambient air to a higher concentration level of oxygen. The Precautions and Hazards section included, 1. Do not operate the oxygen concentrator without the filter or with a dirty filter. The Procedure section included, . 5. Check the air inlet filter and ensure that it is in place and clean. The Daily Maintenance section included, . 3. Clean the air inlet filter PRN (as needed) and weekly. Review of the facility policy titled, Oxygen Administration, reviewed 2/14/2024, revealed the Policy Explanation and Compliance Guidelines section included, . 7. Cleaning and care of equipment shall be in accordance with facility policies for such equipment. 1. Review of R12's clinical electronic record revealed diagnoses that included, but were not limited to, unspecified asthma, chronic diastolic (congestive) heart failure, and chronic kidney disease stage 3. Review of R12's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section J (Health Conditions) documented the resident had shortness of breath when lying flat. Section O (Special Treatments, Procedures, and Programs) documented R12 received oxygen. Review of R12's Physician Orders revealed an order dated 1/3/2025 for O2 at 2 liters per minute (LPM) via a nasal cannula (NC) every shift. Observations on 3/29/2025 at 10:30 am, 3/30/2025 at 8:43 am, and 3/31/2025 at 9:01 am revealed R12 lying in bed receiving O2 therapy. Observation revealed the O2 concentrator inlet foam filter was dirty with a fuzzy grayish substance. 2. Review of R58's clinical electronic record revealed diagnoses that included, but were not limited to, major depressive disorder, recurrent, unspecified, and generalized anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating the resident had intact cognition). Section O (Special Treatments, Procedures, and Programs) did not document that R58 received oxygen. Review of R58's Physician Orders revealed an order for O2 at 2 LPM via a NC with a discontinued date of 12/13/2024. Observation on 3/29/2025 at 10:04 am in R58's room revealed an O2 concentrator at the bedside with O2 tubing and a nasal cannula lying on the floor. In an interview on 3/30/2025 at 9:13 am, R58 stated he no longer used the O2. Observation revealed that the tubing and cannula remained on the floor. Observation on 3/31/2025 at 8:55 am in R58's room revealed the O2 tubing and cannula remained on the floor. 3. Review of R66's clinical electronic record revealed diagnoses that included, but were not limited to, unspecified asthma, chronic diastolic (congestive) heart failure, chronic coronary microvascular dysfunction, and obstructive sleep apnea. Review of R66's quarterly MDS assessment, dated 1/30/2025, revealed Section C (Cognitive Patterns) documented a BIMS of 15 (indicating the resident had intact cognition). Section J (Health Conditions) documented the resident had shortness of breath when lying flat. Section O (Special Treatments, Procedures, and Programs) documented R12 used a non-invasive mechanical ventilator. Review of R66's Physician Orders revealed an order dated 3/11/2025 for ipratropium-albuterol solution 0.5-2.5 (3) milligrams (mg)/3 milliliters (ml), one vial inhale orally every six hours as needed for shortness of breath, nebulizer. Observation on 3/29/2025 at 11:08 am in R66's room revealed a nebulizer machine sitting on top of a basket of miscellaneous clothing items and located on the floor. Further observation revealed the tubing and nebulizing mask were lying on top of the machine, unbagged and exposed to the environment. In an interview and observation on 3/30/2025 at 9:10 am, the nebulizer machine, tubing, and mask remained on top of the basket with clothing, with the mask unbagged and exposed to the environment. R66 stated that she was never provided with a storage bag to cover or keep her nebulizer mask in to keep it clean from dirt or other debris. Observation on 3/31/2025 at 9:16 am revealed the nebulizer machine, tubing, and mask remained on top of the basket with clothing, with the mask unbagged and exposed to the environment. During concurrent interviews and observations on 3/31/2025 at 9:35 am, the Director of Nursing (DON) and Licensed Practical Nurse (LPN) II confirmed R66's nebulizer mask was unbagged and resting in a clothes basket, the dirty O2 concentrator inlet filter with gray fuzzy substances in R12's room, and the nasal cannula lying on the floor in R58's room. LPN II stated that the nurse was responsible for the maintenance and cleaning of the oxygen equipment on their hall. She verified that, according to R58's physician orders, his O2 therapy was discontinued in December, and the equipment should have been removed from his room. The DON confirmed that the nursing staff assigned to that resident's hall was responsible for respiratory care needs on their hall, which included cleaning of all O2 equipment. She stated the nursing staff was required to clean all the O2 concentrators' filters weekly, ensuring the nebulizer masks were stored properly when not in use, and nasal cannulas were stored in a bag when not in use. She further confirmed that if O2 therapy had been discontinued for a resident, the equipment needed to be removed immediately from their room.

Based on observations, staff interviews, and review of the facility policy titled, Hand Hygiene, the facility failed to ensure hand hygiene was performed between residents and failed to ensure shared medical equipment was sanitized between residents. The deficient practices had the potential to place residents at risk of avoidable infections due to cross-contamination. The facility census was 82. Findings: Review of the facility policy titled, Hand Hygiene, revised 2/1/2024, revealed the Policy section stated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. The Definitions section included, Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). The Policy Explanation and Compliance Guidelines section included, . 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. The Hand Hygiene attachment included, Either soap and water or ABHR for between resident contacts, after handling contaminated objects, and before preparing or handling medications. A policy was requested for the cleaning and disinfecting of shared equipment and was not provided. Observations on 3/29/2025 beginning at 10:05 am revealed Licensed Practical Nurse (LPN) AA exited a resident room, placed a piece of reuseable equipment on the medication cart, donned gloves, cleaned the equipment, removed the gloves, moved the medication cart to another location in the hallway, prepared medications for a resident, entered a code on a keypad at an exit door for a staff member, and proceeded to the resident's room and administered the medication. Observation revealed she did not perform hand hygiene between any of the tasks she completed or before entering the resident's room. Continued observation revealed she exited he resident's room, removed an electronic blood pressure cuff from her pocket, placed it on the medication cart, prepared medication for another resident, picked up the blood pressure machine, and entered another resident's room to administer medications. She exited the resident's room, placed the blood pressure machine on the medication cart, documented in the electronic medical record, and performed hand hygiene with ABHR. In an interview on 3/27/2025 at 10:25 am, LPN AA stated hand hygiene should be performed with each medication administration and after gloves were removed. She confirmed she did not perform hand hygiene each time she should have. She confirmed that a container of ABHR was available to her on the medication cart. She further confirmed she did not sanitize the blood pressure machine between residents and stated she should have. In an interview on 3/27/2025 at 1:02 pm, the Director of Health Services (DHS) stated that she expected nurses to perform hand hygiene before preparing medications, after preparing medications, after administering medications, and when gloves were removed. She further stated that blood pressure cuffs should be sanitized between residents.

Based on observations, staff interviews, and a review of the facility's policy titled, Labeling and Dating Inservice, the facility failed to ensure that expired, unlabeled, and undated food items were not stored in the freezer, refrigerator, and dry food storage pantry, and failed to ensure the ice maker was maintained in a sanitary manner. The deficient practices had the potential to place 82 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include: A review of the facility's undated policy titled Labeling and Dating Inservice revealed the Importance of Labeling and Dating section included, Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that have passed their due date are discarded. The Guidelines for Labeling and Dating section included, Leftovers must be labeled and dated with the date they are prepared and the use by date. The Use By Dating Guidelines section included, Guidelines apply regardless of storage location (e.g., kitchen, pantries, etc.). During a kitchen tour on 3/29/2025 at 7:57 am with Dietary Aide (DA) DD, observations in the dry storage pantry revealed the following: Two 15-ounce (oz) packs of hot dog buns with expiration dates of 3/18/2025 and 3/26/2025 Five loaves of sandwich white bread with an expiration date of 3/26/2025 Six 23 oz. packs of hamburger buns with an expiration date of 3/26/2025 Seven 24 oz. packs of gelatin with an expiration date of 12/28/2024 Five 4.7 oz boxes of taco shells with an expiration date of 9/28/2024 Two 5-pound (lb) boxes of baking mix with an expiration date of 10/13/2024 One 5 lb. container of macaroni noodles, unlabeled and undated One 5 lb. container of egg noodles, unlabeled and undated One 5 lb. container of brownie mix, unlabeled and undated In an interview during the tour, DA DD confirmed the identified expired, unlabeled, and undated food items and stated that all dietary staff were responsible for labeling and dating food items. Observations in the walk-in refrigerator revealed: One unlabeled, undated, and unwrapped yellow block of sliced cheese sorted into two 4 quart (qt) containers One 5-gallon container of pink liquid, unlabeled and undated Three boiled eggs, unlabeled and undated One 6 lb container of bologna, unlabeled and undated Two 10 lb. containers of chicken, unlabeled and undated One 4-qt. container of apple slices, unlabeled and undated 16 sausages, unlabeled and undated Nine containers of yogurt with an expiration date of 3/25/2025 34 containers of yogurt with an expiration date of 3/11/2025 Observation of the walk-in freezer revealed: One box labeled Oxtail with an expiration date of 12/28/2024 One prepackaged bag labeled ribs with an expiration date of 3/3/2024 One 64 oz package of sausage with an expiration date of 1/1/2025 One one-gallon bag labeled raw chicken with an expiration date of 2/18/2025 36 5 oz. bread cheese curd with an expiration date of 11/31/2024. One 8-lb. unlabeled and undated frozen pink substance identified by DA DD as fish DA DD confirmed all expired, unlabeled, and undated findings in the walk-in freezer and discarded them. During the tour, observation revealed one ice machine located on the outside wall of the kitchen in the main dining room. was confirmed for kitchen use by DA DD. Observation of the ice machine revealed a brown-red substance inside, along with a white machine part touching the ice. DA DD confirmed the observation of the brown-red substance and confirmed that maintenance cleans the inside of the ice machine. DA DD provided the cleaning log, which revealed no cleaning for March 2025. In an interview on 3/30/2025 at 11:51 am, DA DD stated that if food items were not labeled, dated, expired, or stored properly, the residents could get sick. In an interview on 3/30/2025 at 11:56 am, DA BB stated she had checked the dry storage pantry the day before the survey began. She stated she had checked for dates and storage and rotated newer food items to the back and older food items to the front. DA BB stated she must have missed something during her check. DA BB stated that food items not being labeled, dated, expired, or stored properly would put the residents at risk of getting sick. In an interview on 3/30/2025 at 12:00 pm, the Certified Food Manager (CFM) stated that all food items that come in should be labeled and dated with the received date, opened date, and expiration date. The CFM stated that she would conduct in-service and add to concerns to the Quality Assurance and Performance Program (QAPI). The CFM stated that if food items were not labeled and dated or were expired, residents could get sick.

Based on record review, staff interviews, and review of facility policy titled Abuse Prevention Program and Reporting, the facility failed to ensure pre-employment screening, specifically fingerprints for three employees and background check for one employee, were obtained for four of 10 staff reviewed. Findings include: Review of the facility policy titled Abuse Prevention Program and Reporting, revised April 2023 revealed the facility prohibits the mistreatment, neglect, and abuse of resident/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family or friends. Employees are screened and trained to prevent abuse. The Procedure section line numbered 1 stated: Screen all employees prior to hire for a history of abuse, neglect, or mistreating resident/patients, exploitation and/or misappropriation of resident property during the hiring process. Screening will consist of, but not limited to criminal background checks. Review of the facility employee files revealed the following: 1. Certified Nursing Aide (CNA) AA was hired on 10/4/2023 with no fingerprint process completed. 2. CNA BB was hired on 9/21/2023 with no fingerprint process completed. 3. CNA CC was hired on 8/24/2023 with no fingerprint process completed. 4. The Director of Nursing (DON) was hired on 1/23/2023 with no background process completed. The DON had an active, unencumbered Registered Nurse license. CNA AA, CNA BB, and CNA CC had active, unencumbered CNA certifications. There were no concerns identified related to abuse or neglect within the facility. Interview on 11/29/2023 at 2:40 pm with the Human Resource Director revealed the corporate office recently changed companies used for background and fingerprint checks and the current company did not perform fingerprints. She stated new hires have not had fingerprints performed due to lack of funds to pay for them. She stated the corporate office was aware of the new hires missing fingerprints. She stated there was not a current solution to obtain the fingerprints. She further stated she was unable to locate a background check for the DON and would attempt to locate it. Interview on 11/29/2023 at 3:31 pm with the Administrator revealed the facility's corporation had recently changed companies used to obtain background checks and fingerprints. She stated the new company did not include fingerprints as part of the background check and charged an additional amount of money to perform fingerprints. She stated the corporate office was aware of the need to pay for the fingerprints and had not offered a solution for payment, therefore new hire fingerprints were not performed. She stated she was aware that some newly hired employees had not obtained fingerprints. She stated background checks were normally performed prior to hire and fingerprints were performed after hire if the background check company did not perform them when the background check was performed. Interview on 11/30/2023 at 9:05 am with the Human Resource Director revealed she was unable to provide a background check for the DON. She stated the corporate office had attempted to locate one and was unable to.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of facility document titled admission Screening- Pre-admission Screen for MR/MI the facility failed to conduct a Level II Preadmission Screening and Resident Review (PASARR) screening for one of nine sampled residents (R) (R6) following a new diagnosis of schizophrenia. Findings included: Review of facility policy admission Screening- Pre-admission Screen for MR/MI dated2/15 revealed that the appropriate state-designated agency is contracted for any resident/patient requiring a MI/MR Level II screen: Admission Annually Upon diagnosis of an MI/MR previously unknown or undetermined Record review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section A-No Level II PASARR and Section N- diagnosis revealed depression, anxiety disorder and schizophrenia. Record Review of the Electronic Medical Record (EMR) revealed that R6 was initially admitted on [DATE] and readmission date was on 2/23/2023. Record review of the EMR revealed Level 1 PASARR dated 11/5/2019 - schizophrenia or bipolar were not marked. Record review of the EMR revealed R6 diagnoses did not include dementia or Alzheimer's. An interview on 11/29/2023 at 3:50 pm with the Social Services Director (SSD) revealed that she is responsible for completing the resident Level II PASARR. SSD stated that R6 Level II PASARR was not completed. SSD further revealed that she was not aware that a Level II PASARR was required until today. SSD stated that she will apply for the R6 Level II PASARR today. SSD stated that R6 was diagnosed with schizoaffective on 12/01/2020. SSD reported that she has spoken with the physician regarding this matter. R6 was not prescribed medication for the new diagnosis of schizoaffective. An interview on 11/30/2023 at 11:55 am with the Administrator revealed the process of PASARRs. The Administrator stated that the home office gathers the documents for PASARRs and checks for approvals. The Social Services and Business Office are responsible for confirming and checking for approvals. Social Services is responsible for making sure that the PASARRs information and coding was entered correctly. Social Services should be in communication with the Director of Nursing (DON) to confirm the diagnosis. Any new diagnosis and new admissions should involve communication between DON and Social Services. All changes should be discussed in the Interdisciplinary Team Meetings (IDT) meeting. Social Services is responsible for submitting PASARRs for new diagnoses and new admissions.

Based on staff interviews, record reviews, observations, and review of the policies titled, Hand Hygiene, Glucometer Cleaning-Finger Stick Procedure, and Enteral Feeding the facility failed to provide a safe and sanitary environment for one of fifteen Residents receiving fingerstick testing; specifically R63, and one of one Residents receiving enteral feeding, R12. This deficient practice has the potential to cause adverse consequences related to infection control. The census was 69. Findings include; Review of the policy titled, Hand Hygiene Version 7.3 Reviewed 3/2022; it was revealed under Purpose, Healthcare providers must perform hand hygiene; immediately before touching a resident or the resident ' s immediate environment, before moving from work on a soiled body site to a clean body site on the same patient, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. Under the section Glove use: If your task requires gloves, perform hand hygiene prior to donning gloves, change gloves and perform hand hygiene during patient care, and perform hand hygiene immediately after removing gloves. Review of the policy titled, Glucometer Cleaning-Finger Stick Procedure, original date 8/2015 under the section Procedure; always wear gloves when performing finger sticks, wear gloves while cleaning the device thoroughly after each use and disinfecting it according to manufacturers ' recommendations with an EPA-approved disinfectant, wear gloves during finger stick glucose monitoring process, and perform hand hygiene immediately after removal of gloves and before touching other medical supplies. Review of the policy titled, Enteral Feeding, revised 5/2016 under the Procedure section; assemble equipment in the resident/patient room, wash hands and apply gloves, after the procedure is complete remove gloves and wash hands, rinse syringe thoroughly with tap water and store in a clean plastic bag labeled with date, time, and resident/patient name. 1. Record review of the Electronic Medical Record for R12 revealed under MDS/CAAs for Section C, she has a long- and short-term memory problem and altered level of consciousness; under the MDS/CAA section GG revealed the R12 is Dependent on staff for oral hygiene, toileting hygiene, bath/shower, upper body dressing, lower body dressing, chair/bed to chair Record review of the EMR revealed a diagnosis that includes Cerebral Infarction, Gastro-Esophageal Reflux Disease, Quadriplegia, Dysphagia, Constipation. 2. Record review of the EMR for R63 under MDS/CAAs Section C, it was revealed the Brief Interview for Mental Status (BIMS) score is15, cognitively intact. Record review revealed a diagnosis that included Diabetes Mellitus. During an observation of finger stick testing and administration of insulin on 11/29/2023 at 11:30 am by Licensed Practical Nurse (LPN) FF for R63 it was revealed the nurse put on gloves and cleaned the meter and put it in a cup along with a lancet and alcohol pads; all the supplies were put on a disposable tray and taken to the room; the nurse wore gloves during the finger stick testing procedure; she put the used lancet and alcohol pad in the cup. Once the procedure was completed, she took off her gloves and took the meter to the cart and cleaned it without gloves on. The Resident was given 8 units Humalog insulin by LPN FF; after she gave R63 insulin LPN FF discarded the used syringe in the hazard container on the medication cart; she took her gloves off but did not immediately sanitize her hands. She began typing on her computer and looking up medications for the Resident before going to sanitize her hands. During an observation of tube feeding on 11/29/2023 at 2:00 pm by LPN DD; it was revealed the LPN checked tube placement with her stethoscope that was hanging around her neck, she did not sanitize the stethoscope before or after use; the g tube placement was confirmed; tried to aspirate contents but nothing was obtained; the nurse proceeded to give 30 cc water, medication, and another 30cc of water. Tube feeding of Isosource one carton was given followed by 225cc of water. The Resident tolerated the procedure well. The nurse dried the inside of the syringe with tissue from the Resident's bedside table. The nurse took her gloves off and did not immediately sanitize her hands; she took the towel used in the Resident room and put it on the medication cart and began typing on the computer before sanitizing her hands. During an interview on 11/30/2023 at 10:00 am with LPN EE it was revealed this nurse provides wound care for the Residents and works in the Infection Preventionist Program; hand hygiene should be performed before and after care; after taking gloves off; if using a stethoscope will use a disposable one for Residents on isolation, with other Residents the stethoscope should be cleaned before and after Resident use. During an interview on 11/30/2023 at 10:20 am with LPN DD it was revealed the nurse stated hand hygiene should be done before entering a room and before giving medications; the Glucometer is cleaned before use and after, staff should wear gloves during the cleaning of equipment; a stethoscope should be cleaned before and after use on a Resident. During an interview with the Director of Nursing (DON) on 11/30/2023 at 10:25 am it was revealed her expectation for hand hygiene include it should be done correctly which includes before and after care or after handling soiled material, after using the restroom, after touching face, and any time after Resident care.

Based on observation, staff interview, and Quality Assessment and Performance Improvement Plan (QAPI) the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior by failing to repair peeling wall paint, ceiling light, and torn floor tiles in one of 5 halls. The Facility census was 69 residents. Observations on 11/30/2023 at 1:00 pm 1. All ceiling air vents in the dining room are rusty, and two of them are loose. 2. Hall D - two out of three ceiling lights without covers, and peeling paint on the walls. 3. The light in the middle of the D hall has only one working light tube. 4. Hall D floor linoleum is very decolorated and has torn pieces. 5. The nursing station countertop between halls D and E has chipped paint. A review of the Quality Assessment and Performance Improvement Plan (QAPI)revealed one completed task: room B-9 damaged outlet. There are no other completed tasks. Interview on 11/30/2023 at 4:50 pm with Administrator revealed maintenance data collection tool was developed to identify areas of improvement. Maintenance started repairs on 8/10/2023 on needed areas. The facility just hired a new Maintenance Director. The Administrator continued stating that facility staff constantly working on maintaining a comfortable and homelike environment for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to determine and honor waking time/shower schedule preferences for one (Resident (R) 17) of 25 Initial Pool residents reviewed for choices. This failure had the potential to lead to a decline in psychosocial well-being and unnecessary daytime sleepiness for R17. Findings include: Review of R17's undated Profile, located in the Profile tab of the electronic medical record (EMR), revealed R17 was admitted to the facility on [DATE]. Review of R17's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 07/21/22, revealed R17 had a Brief Interview for Mental Status (BIMS) score of 10 of 15, indicating moderately impaired cognition. She did not exhibit any mood or behavioral symptoms. Review of R17's 08/10/21 Care Plan, located in the Care Plan tab of the EMR, revealed, [R17] requires supervision to total assist of one to two staff for ADLs [activities of daily living]. The approaches included: Assist as needed with ADLs: supervision to total assist of one to two . Encourage them to do what they can for themselves and praise efforts. The Care Plan did not include information regarding the resident's bathing preference or schedule. In an interview with R17 on 09/26/22 at 12:08 PM, she stated her baths were scheduled for 5:00 AM three times a week. She stated, That is too early. I don't want to get up at 5:00 [AM]. R17 stated she had not been asked what time she would like her baths; it was just based on the facility schedule. R17 also stated she had never complained to the staff about her bath schedule, and added, If I did, they would probably tell me 'That's just the way it is.' R17 stated she would prefer to sleep until 8:00 AM every day. In an interview with R17 on 09/28/22 at 3:15 PM, she stated, I was up at 5:00 AM for my shower today. It was too early. I was sleepy. I don't want to get up that early. I feel sleepy all the time. In an interview on 09/29/22 at 9:44 AM with certified nurse aide (CNA) 6, she stated R17 was on the night shift schedule for bathing, and she received a bath three times a week by the 11:00 PM to 7:00 AM shift. CNA6 stated this was because all the baths could not all be done by the staff on day shift, so night shift was expected to do a certain number of baths per day. CNA6 stated R17 liked to sleep in and was not a morning person. CNA6 stated R17 had told her several times she liked to sleep in and did not like waking up early. In an interview on 09/29/22 at 9:48 AM, the Social Services Director (SSD) stated nursing had a get up list and shower schedule. She stated, I do not do an assessment of residents' preferences for times of bathing or waking . I used to at my last job, but we don't do anything like that here . Activities assesses preferences for times of activity participation. In an interview on 09/29/22 at 9:50 AM, the Director of Nursing (DON) stated shower times and days were scheduled based on room number so that no rooms were missed in the case of room changes or new admissions. The DON stated resident showers were scheduled on all three shifts to spread the workload among the staff. The DON stated per the shower schedule, based on room number, R17 was scheduled for the 11:00 PM to 7:00 AM shift three times a week. The DON provided a paper record titled, B Hall Baths dated 06/15/22 which reflected R17's showers were scheduled on the night shift. The DON stated sometimes preferences were discussed in the care plan meetings with residents or their representative. Concurrent review of the 07/29/22 Care Review form, located in the Miscellaneous tab of the EMR, showed there were no specific concerns voiced by the resident as to her bathing schedule or waking times. On 09/29/22 at approximately 11:00 AM, the DON provided a paper copy of the 08/10/21 Baseline Care Plan that documented under question 15, Preferred schedule for bathing and time of day; example days, evenings, nights. Please include frequency. However, there was only a space to check either tub bath, shower, or bed bath. Under frequency was documented, 3X [three times per] week. There were no spaces to document or checkmark preferred time of day, and this information was not included in the Baseline Care Plan or subsequent comprehensive Care Plan. The DON stated there was no policy addressing bathing preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, the facility failed to ensure one (Resident (R) 27) of 25 Initial Pool residents observed for hygiene and grooming received assistance with activities of daily living (ADLs), including personal hygiene and eating. This failure had the potential to contribute to a lack of good personal hygiene and good nutrition for R27. Findings include: Per the undated resident Profile, located in the Profile tab of the electronic medical record (EMR), R27 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment in the MDS tab of the EMR, with an assessment reference date (ARD) of 08/04/22, revealed R27 scored a zero on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. R27 did not exhibit any mood or behavioral symptoms. R27 required extensive assistance by one staff member with eating, and extensive assistance by two or more staff for personal hygiene. Review of R27's 05/12/21 Care Plan, found in the Care Plan tab of the EMR, revealed, [R27] needs ext. [extensive] to total assistance of one to two for ADLs. He sometimes eats with his hands. The goal was, [R27] will be clean and well-groomed daily thru [sic] next review. The approaches included: Assist as needed with ADLs: Requires ext. to total assist of one to two . Encourage them to do what they can for themselves and praise efforts . Observe for/report functional changes . [and] Set up his tray and assist him in keeping his hands clean as needed. In an observation on 09/26/22 at 1:26 PM, R27 was observed lying in bed in his room. His lunch tray had been removed from the room. R27 was observed with crusted orange food on his bottom lip and crusted white and orange spills on the front of his shirt going down his chest. R27 was unable to answer questions regarding eating assistance with eating and personal hygiene due to severely impaired cognition. In a subsequent observation on 09/26/22 at 3:42 PM, R27 was again observed while lying in bed with the crusted orange stains on his bottom lip and the front of his shirt with crusted orange and white spills. In an observation on 09/27/22 at 1:32 PM, R27 was sitting up in bed in his room with his meal tray in front of him on a bedside table. The resident had consumed the orange nutritional drink but only a few bites of his food. R27 was wearing a clothing protector over his shirt with an orange stain down the front. He was observed until 2:22 PM without eating, and without any staff assistance. At 2:22 PM, a certified nurse aide (CNA) entered the room and picked up R27's tray but did not remove his clothing protector or offer to clean his hands or face. R27 had not received any assistance or encouragement to eat more of his meal. Review of the 08/29/22 to 09/27/22 Personal Hygiene - Self Performance history, located in the Tasks tab of the EMR, revealed no documentation of provision of personal hygiene on 09/26/22. The record documented R27 received total assistance with personal hygiene at 2:54 PM on 09/27/22. In an interview on 09/29/22 at 11:22 AM with CNA4, she stated R27 could eat independently on rare occasions, but usually needed assistance with eating because he did not always pay attention and could make a mess. CNA4 stated some other CNAs may feel the resident should be doing as much for himself as possible, but she wanted to help him, so he ate well and did not make a mess. CNA4 stated all staff should at least clean R27's hands and face after a meal. In an interview on 09/29/22 at 11:39 AM, the Administrator stated there was no specific policy on personal hygiene assistance, but staff should always assist to clean residents' hands and faces after every meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facility policy, the facility failed to ensure one (Resident (R) 10) out of 18 sampled residents was administered requested medication (Sodium Bicarbonate-used to treat stomach upset/indigestion) by the nurse. This had the potential to increase R10's indigestion symptoms. Findings include: Review of the facility-provided policy titled Medication Administration 01/13 revealed .To administer the following according to the principals of medication administration .Medications as ordered . Review of R10's admission Record located in his electronic medical record (EMR) revealed he was initially admitted to the facility on [DATE] with multiple diagnoses to include malignant neoplasm (cancer) of larynx and gastroesophageal reflux disease (GERD). Review of R10's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/22 located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating he was cognitively intact and was fed by gastric tube. Review of R10's 'Physician's Orders in his EMR under his Orders tab revealed . Sodium Bicarbonate Tablet 650 MG [milligrams] (01/24/22) Give 650 mg via G-Tube every 6 hours as needed [PRN] for dyspepsia [indigestion] . Review of R10's Medication Administrator Record (MAR) for September 2022 located in his EMR under the Orders tab revealed Sodium Bicarbonate Tablet 650 mg Give 650 mg via G-Tube every 6 hours as needed for dyspepsia . and no entries of staff initials or check mark indicating medication was administered on 09/24/22. Review of R10's Prog Note tab revealed no Progress Note entered by the facility on 09/24/22 related to his request for medication. During an interview on 09/26/22 at 3:31 PM, R10 stated Registered Nurse (RN) 2 did not give him his sodium bicarb on 09/24/22. R10 stated RN2 told him she could not find the medication. R10 stated it was his morning dose he requested. R10 stated the medication was for his acid reflux. R10 stated the milk (tube feeding) caused him to get acid reflux bad. During an interview on 09/29/22 at 10:45 PM the Nurse Practitioner (NP) confirmed her expectation for the facility's staff was to follow the physician's orders. During an interview on 09/29/22 at 2:49 PM RN2 confirmed she did not administer R10's requested medication (Sodium Bicarbonate) on 09/24/22. RN 2 confirmed R10 requested a dose, and she could not find it on the facility's medication cart. RN2 stated she was unaware the facility had stocked supply of medication as a resource for his medication. During an interview on 09/29/22 at 3:05 PM the Director of Nursing (DON) confirmed she expected the staff to administer PRN medication to residents when it was requested. DON confirmed she was aware RN2 did not administer R10's requested medication. The DON stated RN2 should have located the medication supply room at the facility or called the pharmacy for replacement medication when it was not available on the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident (R)19) of one resident's observed catheter bag was below the level of his bladder. Six residents were residing at the facility with indwelling catheters. This had the potential to increase R19's risk of urinary tract infection (UTI). Findings include: Review of facility-provided policy titled Catheter Care 01/13 revealed To provide safe and proper care of a resident/patient with an indwelling catheter by evaluating elimination status, minimizing risk of bladder infections, and maintaining skin integrity .Position catheter drainage bag below the level of the resident/patient bladder to facilitate flow of urine . Review of R19's admission Record located in her Electronic Medical Record (EMR) revealed R19 was admitted to the facility on [DATE] with multiple diagnoses including benign prostatic hyperplasia, urinary tract infections (UTIs) and neuromuscular dysfunction of the bladder. Review of R19's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/22/22 located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating he was cognitively intact, and he had an indwelling catheter. During an observation and interview on 09/28/22 at 11:31 AM with the Assistant Director of Nursing (ADON) of R19's transport and transfer by two Certified Nurse Aide (CNA) 1 and CNA2. R19 was transported lying flat on the shower bed from the shower room on D hallway to B hallway outside his door. R19's urinary drainage bag was laying on his upper legs and peri area (not below the level of his bladder). CNA1 and CNA2 transferred R19 from the shower bed to his wheelchair using the Hoyer lift with his urinary collection bag laying on his stomach. ADON confirmed R19 was transported and transferred with his urinary collection bag not below the level of his bladder. ADON confirmed R19's urinary collection bag should be below the level of his bladder. During an interview on 09/28/22 at 1:08 PM the Director of Nursing (DON) confirmed the facility staff should ensure R19's urinary catheter collection bag remained below the level of his bladder during transport on the shower bed and during transfer to his wheelchair. DON confirmed the two CNA's failure to ensure R19's urinary collection bag was below R19's level of his bladder increased his risk for a UTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure one (Resident (R) 9) out of one resident sampled for dialysis was provided nutritional services while at dialysis appointments three days a week. This had the potential for R9's nutritional status to decline. Findings include: Review of facility-provided policy titled Nutrition 04/13 revealed Facility staff will assist in maintaining or improving the resident/patient's nutritional status by identifying risk factors affecting the nutritional status of the residents/patients on admission, and through the care management process .Facility clinicians participate as interdisciplinary team members in managing/improving the resident patient's nutritional status by monitoring, evaluating, and/or treating risk factors affecting the resident/patient's nutritional status .Develop and implement individualized interventions to prevent/reduce the risk of nutritional disorders .Liberalized diets .Supplements as indicated . Review of facility-provided document revealed .Breakfast Served at 7:30 AM Lunch Served at 11:45-12:15 PM Dinner 5:15 PM . Review of R9's admission Record located on his electronic medical record (EMR) revealed he was initially admitted to the facility on [DATE] with multiple diagnoses to include end stage renal disease (ESRD) and anemia. Review of R9's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/25/22 located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score was 10 out of 15 indicating he was moderately cognitively impaired and had dialysis treatment. Review of R9's comprehensive Care Plan located on his EMR under the Care Plan tab with initiated date of 06/29/21 revealed .at risk for altered nutrition .serve diet as ordered and offering substitutes as indicated .RD [Registered Dietitian] consult as needed .Supplements as/when ordered . Review of R9's physician's Orders in his EMR under his Orders tab revealed .Regular texture Regular fluid, thin consistency, for Nutrition large protein portions . with no scheduled meal adjustment for dialysis treatment appointments (Monday Wednesday and Friday). Review of R9's Progress Notes located in his EMR under Prog Note tab revealed 09/27/22 .Dietitian .has ESRD requiring HD [hemodialysis] x [times] 3[days]/week . with no information regarding meal adjustment schedule for the three days a week of R9's hemodialysis treatment. During an interview on 09/27/22 at 8:54 AM revealed R9 confirmed he attended dialysis three days a week and the facility provided transportation to and from the appointments. R9 stated he was in the dialysis chair for three hours. R9 stated the facility did not provide snacks or meals for him to take with him on his dialysis treatment days (three days a week). R9 stated his lunch meal was on his bedside table on his return from dialysis around 1:00 PM or 1:30 PM. R9 stated his lunch meal was cold and not reheated. R9 confirmed the facility served him breakfast around 7:30 AM before he left with transport for dialysis treatments. During an interview on 09/28/22 at 1:17 PM the Director of Nursing (DON) confirmed R9 was transported to dialysis center on Monday, Wednesday, and Friday. The DON confirmed R9's C hall was served lunch meals from 11:45 AM to 12:15 PM daily and R9 was not at the facility during those times on Monday, Wednesday, and Friday. She revealed she was unsure of the time of R9's return to the facility because she could not find the transportation log, communication documents (to and from) dialysis center, and no note was documented in R9's progress notes regarding leaving or returning to the facility. The DON verified R9's physician's orders did not include a meal adjustment schedule for him for his dialysis appointments in his EMR. During an interview on 09/29/22 at 10:15 AM the Registered Dietitian (RD) confirmed R9's physician's Orders did not include an adjustment for his lunch meal for the three days he was out of the facility for dialysis treatment. The RD stated the facility should provide snacks for him on the days he attends dialysis treatments. RD confirmed the facility served R9 breakfast meal around 7:30 AM daily. RD confirmed R9 should not wait over 4 hours to be served a meal by the facility. RD confirmed the facility did not provide R9 meals/snacks during transport or while at dialysis center for treatment. She further confirmed R9's Care Plan did not include interventions regarding meal adjustments or snacks for the three days a week when R9 was out of the facility for dialysis treatments. She confirmed R9's lunch meal should be refrigerated until R9's return to the facility and not left on his bedside table, due to increased risk of food borne illness. During an interview on 09/29/22 at 12:33 PM R9 confirmed the facility did not provide him snack/or meals to take to dialysis clinic for his ride to and from or during his treatments on 09/28/22. R9 confirmed he returned from dialysis on 09/28/22 at 2:00 PM and his lunch meal was on his bedside table and was cold. R9 confirmed he did not eat his lunch meal on 09/28/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident (R) 18) out of two sampled residents for oxygen therapy, was provided oxygen therapy at the correct flow rate and was administered by licensed nursing staff. This had the potential to increase R18's risk for respiratory complications and/or distress. Findings include: Review of facility-provided policy titled NURSING PROCEDURE MANUAL .Concentrators: Oxygen 01/13 revealed .To provide safe and proper care to a resident/patient receiving oxygen via a concentrator .Verify physician's order .Oxygen flow rate .Observe for the following at least once a shift .Oxygen flow rate as ordered . Review of R18's admission Record located in her Electronic Medical Record (EMR) revealed R18 was admitted to the facility on [DATE] with multiple diagnoses to include respiratory failure. Review of R18's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/22 located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating she was cognitively intact, and she had oxygen administered. Review of R18's physician's Orders located in her EMR under her Orders tab revealed .Oxygen at 3L [liters] via nasal cannula every shift . dated 07/19/22. Review of R18's Medication Administrator Record (MAR) in her EMR under the Orders tab for 09/22 revealed .Oxygen at 3L [liters] via nasal cannula every shift . dated 07/19/22. Review of R18's Care Plan in her EMR tab under her Care Plan tab revealed . Provide oxygen as ordered with 02 [oxygen] sat [saturation] checked each shift and prn [as needed]. LPN [Licensed Practical Nurse] RN [Registered Nurse] . 1. During an observation on 09/26/22 at 12:30 PM R18 was sitting in a rocking chair in her room. R18 oxygen was administered via nasal cannula with the nasal cannula oxygen tubing prongs in her nose connected to her oxygen concentrator. R18's oxygen concentrator flow rate was set at 2L and turned on. During an observation on 09/27/22 at 11:09 AM of R18 was lying in her bed in her room. R18's oxygen was administered via nasal cannula with the prongs in her nose and connected to her oxygen concentrator. R18's oxygen concentrator flow rate was set at 2L and turned on. During an observation and interview on 09/27/22 at 2:13 PM with Licensed Practical Nurse (LPN) 1 revealed R18 was in her room, lying on her bed. LPN1 confirmed R18's oxygen was administered via nasal cannula with a flow rate at 2L and R18's oxygen flow rate was incorrect. During an interview on 09/27/22 at 2:29 PM LPN1 verified R18's physician's Order under the Orders tab in her EMR revealed her oxygen flow rate was for 3L. LPN 1 confirmed R18's flow rate was incorrect on her oxygen concentrator and the facility did not follow R18's physician's Orders. During an interview on 09/28/22 at 1:50 PM the Director of Nursing (DON) confirmed R18's oxygen should be administered according to her physician's Order. The DON confirmed the resident's flow rate Orders should be followed to ensure R18 received adequate oxygen based on her needs. 2. During an interview and observation on 09/27/22 at 2:30 PM with LPN1 of Certified Nurse Aide (CNA)5 in R18's room revealed R18's oxygen was administered via nasal cannula. CNA5 confirmed she replaced R18's oxygen concentrator, reconnected the oxygen tubing and water bottle and turned R18's oxygen concentrator on. CNA5 confirmed she administered R18's oxygen therapy to her. CNA5 stated she was unsure of what R18's oxygen flow rate was set on her concentrator because that was the nurse's job. LPN1 confirmed R18's oxygen concentrator was set at 2L flow rate and administered to her via nasal cannula and administered by CNA5. During an interview on 09/28/22 at 1:50 PM the DON confirmed licensed nursing staff were responsible for administering resident's oxygen therapy. DON confirmed CNA staff cannot administer oxygen therapy to residents. DON confirmed she was aware CNA5 staff replaced R18's oxygen concentrator and administered oxygen therapy to R18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility document review, the facility failed to ensure one (Resident (R) 9) out of one resident sampled for dialysis, shunt was assessed and documented consistently in the Electronic Medical Record (EMR) as well as ensure he had dialysis communication forms completed. This had the potential to increase R9's risk for complications with dialysis treatment and his dialysis shunt. Findings include: During an interview on 09/29/22 at 3:59 PM the Director of Nursing (DON) stated the facility did not have a policy regarding dialysis treatment. Review of facility-provided document titled Dialysis Communication undated revealed Facility to Complete Prior to Dialysis .Facility to Complete Upon Return from Dialysis .Dialysis Center to Complete for Facility . was incomplete and had no entries for the information requested on the form. Review of R9's admission Record located in his EMR revealed he was initially admitted to the facility on [DATE] with multiple diagnoses to include end stage renal disease and anemia. Review of R9's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/25/22 located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score was 10 out of 15 indicating he was moderately cognitively impaired and had dialysis treatment. Review of R9's comprehensive Care Plan located in his EMR under the Care Plan tab dated 06/29/21 revealed no person-center interventions/information for assessing bruit or thrill of R9's dialysis shunt or communication with dialysis center. Review of R9's physician's Orders in his EMR under Orders tab revealed .DILAYIS (sic) M(Monday)-W(Wednesday)-F(Friday) 10:30 AM (name) DIALYSIS CENTER . 07/02/21 and .Assess dialysis shunt for thrill (palpated or bruit (heard) q (every) shift Document + or - if not heard or felt notify MD and dialysis . 11/12/21. Review of R9's Medication Administration Record (MAR) located in his EMR under the Orders tab for the month of September 2022 revealed .Assess dialysis shunt for thrill (palpated or bruit (heard) q shift Document + or -. If not heard or felt notify MD and dialysis. Every shift for Dialysis thrill is recognized by palpation of the site for a vibration, bruit is heard with the diaphragm of a stethoscope and sounds like a turbulent blood flow . dated 11/12/21. The following entries were noted: a. 09/09/22 (Day) was X with staff initials, 09/10/22 and 09/11/22, 09/19/22 and 0923/22 (Night) was blank and had no entry, indicating + or - was not entered. b. 09/13/22-09/18/22, 09/21/22, 09/22/22 and 09/26/22 (Day) had n entered with staff initials and check marks, indicating + or - was not entered. c. 09/13/22, 09/15/22-09/18/22, And 09/22/22 (Evening) had n with staff initials and check mars, indicating + or - was not entered. d. 09/12/13, 09/13/22, 09/16/22-09/18/22 and 09/22/22 had n entered with staff initials and check marks, indicating + or - was not entered. The Chart Codes did not have a definition for X or n entry on R9's MAR. Review of R9's Progress Notes located in his EMR under Prog Note tab revealed no information was entered regarding assessment of his dialysis shunt. Review of R9's EMR for September 2022 revealed no dialysis communication document was completed. During an interview on 09/27/22 at 8:55 AM R9 confirmed he received dialysis treatment on Monday, Wednesday and Friday at the dialysis center and was transported by the facility. During an interview on 09/28/22 at 1:17 PM the DON confirmed R9's MAR for the month of September 2022 had missing entries and n entered instead of plus or minus signed as ordered by physician. DON confirmed the facility's clinical staff did not assess R9's dialysis shunt as ordered by R9's physician. During an interview on 09/28/22 at 3:53 PM the DON confirmed she could not locate R9's dialysis communication book. She confirmed R9's last communication with dialysis was documented in R9's EMR under Misc tab was dated 08/08/22. The DON verified R9's Progress Notes for the month of September 2022 did not contain information regarding R9's dialysis communication or assessment of R9's dialysis shunt. During an interview on 09/29/22 at 3:53 PM with the Nurse Practitioner (NP) confirmed R9 was provided dialysis treatment at outpatient center Monday, Wednesday, and Friday. The NP confirmed her expectation for the facility's staff was to assess and monitors R9's dialysis shunt and document the information in R9's EMR. NP confirmed she expected the facility staff to report any of R9's dialysis shunt abnormalities to her. NP confirmed the facility should have dialysis communication record for R9 and was important. NP confirmed R9's MAR had missing entries and incorrect entries such as n and X for the assessment of his dialysis shunt with no explanation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and the facility policy review, the facility failed to ensure all nursing staff had the competencies and skill set necessary to provide care of a chest tube for one of one (Resident (R) 18) reviewed for chest tubes. This had the potential for the resident to have a decline in health status. Findings include: Review of the facility provided policy titled Facility Assessment 10/17 revealed The Administrator will coordinate the facility conducting and documenting a facility-wide assessment to determine what resources are necessary to care for its resident competently during both day-to day operation and emergencies .The facility assessment will include .care required by the resident population .overall acuity and other pertinent facts staff competencies that are necessary to provide the level and types of care needed for the resident population .facility assessment will be reviewed and updated whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment or at a minimum annually . Review of facility provided Facility Assessment reviewed date 02/28/22 revealed .We accept residents with .conditions .complex medical care and management .Respiratory [no information for chest tubes] .Services and Care We offer Based on our Resident's Needs .other special needs [revealed no information regarding chest tubes] .Competencies (this is not an inclusive list): .Specialized care . no information regarding competencies for residents with chest tubes. Review of facility-provided policy titled Chest Tubes 01/13 revealed .Chest tubes are used .for pneumothorax or hemothorax to promote lung re-expansion. A chest tube is inserted, and a closed chest drainage system is attached to promote drainage of air and fluid. Trauma, disease, or surgery can interrupt the closed negative-pressure system of the lungs, casing the lung to collapse. Air of fluid may leak into the pleural cavity. Only residents with water seal chest tubes .will be considered for admission .Evaluate resident/patient respiratory status at least 4 hours .For dislodgement of chest tubes: Vaseline gauze immediately .notify MD immediately . Review of Aspira Drainage System policy undated revealed ' .The Aspira Drainage System is a tunneled, long-term catheter used to drain accumulated fluid from the pleural or peritoneal cavity to relieve symptoms associated with pleural effusion or malignant ascites .Gravity-based design with siphon assist produces a consistent pressure flow for minimized discomfort .Aspira Patient Guide .Do not drain more than 1000 mL (milliliters) from chest .The catheter movies in and out of the exit site. The cuff may break through the skin .Call .doctor immediately . Review of R18's admission Record located in her Electronic Medical Record (EMR) revealed R18 was admitted to the facility on [DATE] with multiple diagnoses to include respiratory failure. Review of R18's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/22 located in the resident's EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating she was cognitively intact, and she had oxygen administered with no information regarding her chest tube. Review of R18's Care Plan in her EMR under the Care Plan tab revealed .has chest tube placed before admit .repeated pleural effusion .oxygen dependent, history of pleural effusion/lung collapse .document output from chest tube with each drainage. Observe for any acute SOB [shortness of breath], congestion, and report to MD . with initiated date of 07/20/22. Review of R18's Physician's Orders located in her EMR under her Orders tab revealed: a.Drain chest tube as needed if symptomatic . 09/23/22, b.May have Pneumovax per facility protocol . dated 07/18/22 and c.CHANGE CHEST TUBE DRESSING Q [every] 3 DAYS AND PRN [as needed] . dated 09/26/22. Review of R18's Medication Administrator Record (MAR) in her EMR under the Orders tab for 09/22 revealed: a.DRAIN CHEST TUBE TWICE A WEEK CONTINUE TO ASSESS FOR S/S [signs and symptoms]AND CALL MD/NP TO REVIEW FOR ANY PRN DRAIN ORDERS one time a day every Tue, Fri for PLEURAL EFFUSION . with an order date of 08/26/22 and discontinue date of 09/23/22 initials of Licensed Practical Nurse (LPN) 5 was entered on 09/09/22, initials of LPN1 on 09/13/22 and 09/16/22 and initials of LPN4 was entered on 09/20/22. b.Drain chest tube as needed if symptomatic as needed . with an order date of 09/23/22 with no staff initials entered, indicating directive was not performed. Review of facility provided 2021 and 2022 Mandatory Education documents and additional staff in-service education from 09/21-09/22 revealed no education was included or in-service related to care of chest tubes. During an observation and interview on 09/26/22 at 12:29 PM R18 stated she had pneumonia. She lifted the bottom of her shirt with her hands to her upper chest area and revealed a clear tube that hung to her waist extending from her right upper chest area. R18 did not have a dressing around the chest tube insertion site. R18 stated she had fluid on her lungs. R18's chest tube was not connected to a water seal drainage system (indicating the facility admitted R18 with chest tube without water seal drainage system per policy above). During an interview on 09/27/22 at 1:55 PM LPN1 verified R18 had a chest tube and a physician's Order to drain her chest tube as needed. LPN1, stated the Registered Nurses (RNs) at the facility drained R18's chest tube. During an interview on 09/27/22 at 2:39 PM LPN1 verified she documented on R18's MAR she performed chest tube drainage for R18 on 09/13/22 and 09/16/22 and LPN4 documented performing R18's chest tube drainage on 09/20/22. During an interview on 09/28/22 at 1:50 PM the Director of Nursing (DON) confirmed R18 had a chest tube and had an Aspira drainage system (indicating not a water seal drainage system). The DON stated R18's chest tube drainage bag was connected by plug and drained by gravity. She stated the maximum amount of fluid allowed to drain from her chest tube was 1000 mL. She stated she trained the day shift nurses on how to drain R18's chest tube. The DON confirmed she did not have documentation or written material information for the chest tube education or a sign in sheet to verify the staff members she trained. She further confirmed residents with chest tubes was not an accepted diagnosis for admission to the facility on the facility's assessment. The DON verified R18's MAR for the month of September 2022 indicated LPNs performed R18's chest tube drainage and included LPN staff initials. During an interview on 09/29/22 at 9:28 AM LPN2 confirmed she was assigned to care for R18 on 09/29/22. LPN2 confirmed the facility had not provided her chest tube training for care provided for residents with chest tubes. LPN2 stated she had not had training on resident's care for chest tubes since 2016 during her nursing school training. LPN2 confirmed she was unsure what to do for R18 if her chest tube became dislodged. LPN2 confirmed she had never drained a chest tube and was unsure how to drain R18's chest tube. During an interview on 09/29/22 at 9:30 AM Physical Therapy Assistant (PTA) confirmed she provided physical therapy treatment to R18. PTA confirmed R18 was the first resident she had cared for at the facility with a chest tube. PTA confirmed the facility had not provided her training on how to care for a resident with a chest tube. PTA stated she imagined it could be life threatening for R18 if her chest tube became dislodged. PTA stated she was unsure what to do if R18's chest tube became dislodged while she was providing therapy to R18. During an interview on 09/29/22 at 9:36 AM Certified Nurse Aide (CNA) 4 confirmed the facility had not provided her training for caring for residents with chest tubes. CNA4 confirmed she had been assigned to provide care for R18 and was unaware R18 had a chest tube. CNA4 confirmed she was aware R18 had some sort of tube coming from her upper front of her body and something drained from it but was unsure what. CNA4 stated she ensured the tube was not in R18's brief when she provided care for her. During an interview on 09/29/22 at 9:46 AM MDS Coordinator (MDSC) confirmed the facility had not provided her training for care provided to residents with chest tubes. During an interview of 09/29/22 at 9:56 AM LPN3 confirmed the facility had not provided training to her for caring for resident with chest tube. LPN3 confirmed she had not provided care for residents with chest tube in two years and none at the facility. LPN3 confirmed she was unsure how or what care to provide for residents with chest tube in the event the chest tube became dislodged. During an interview on 09/29/22 at 10:45 AM the Nurse Practitioner (NP) confirmed R18 had a chest tube. NP confirmed her expectation for the facility was to provide staff with training on care of chest tubes prior to admitting R18 to the facility with a chest tube. NP confirmed dislodgement of R18's chest tube could immediately be life threatening.

Based on observations, review of facility policy; resident, resident representative, and staff interviews; and record review, the facility failed to ensure warm water temperatures were maintained in the rooms of two sample residents (Resident (R) 22 and R40) of 25 residents reviewed for water temperatures in the Initial Pool and three supplement residents (R35, R42, and R67). Additionally, the facility failed to ensure the walls were maintained in good condition for two (R17 and R27) of 25 residents in the Initial Pool. These failures had the potential to lead to an unsanitary and uncomfortable environment for these residents. Findings include: 1. In an interview via telephone with the facility's Ombudsman on 09/26/22 at 1:07 PM, she stated she had received many complaints regarding the water in resident rooms not getting warm enough. In a telephone interview on 09/26/22 at 3:58 PM with R22's family member (F22), the family member stated the water in the resident's room was too cool and she had to go to another hall to get warm water for the resident to use for washing. In an interview on 09/29/22 at 9:01 AM, the Administrator stated the facility had no director of maintenance at the moment, so she was filling in for those duties. The Administrator stated, We have had a few grievances about the temperature of the water in the shower room . That was a complaint that was cited, and we just were put back in compliance on Monday . We use 'TELS' [building management software] and check the temps weekly in random rooms and never get temps below 100 [degrees Fahrenheit (F)]. The Administrator stated, We do not have a plan of action for water temps in resident rooms because the complaint focused on the shower room. The Administrator stated that 9:00 AM was a time when residents were bathing and the kitchen was washing dishes, so the hot water would not be at its peak temperature at that time and recommended waiting an hour to test the hot water temperatures. The Administrator stated she typically tested water temperatures in the late afternoon when they would be at their warmest because the showers and dishwasher were not in such demand. The Administrator stated that there was no exact minimum temperature specified, and she looked for temperatures that felt comfortable for the residents. Review of the most recent TELS report, dated 08/12/22 and provided on paper by the Administrator, revealed water temperatures in resident rooms were documented between 99 degrees F and 114 degrees F. In observations on 09/29/22 beginning at 10:15 AM, water temperatures in resident rooms were tested by the Administrator as follows: -On the A hall, the water in an unoccupied room was measured at 62 degrees F. -On the B hall, the water in the room of R35 and R67 was measured at 71 degrees F. -On the C hall, the water in the room of R40 and R42 was measured at 61 degrees F. -The water in rooms on D and E halls was measured at or above 95 degrees F. In an interview on 09/29/22 at 11:00 AM, the Administrator stated the water temperatures measured during the above observations were very cool, and something needed to be done to address the issue. The Administrator stated she typically tested the temperatures in the evenings when baths and dishwashing were done so that the water heater was not maxed out. The Administrator stated the water heaters were fairly new, so she would reach out to the company to troubleshoot. Review of the facility's December 2009 Maintenance Service policy revealed, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: . Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. 2. During an interview and observation conducted with R17 on 09/26/22 at 12:08 PM in her room revealed a large hole in the wall with pieces of sheet rock, insulation, and tape hanging out and pieces of sheet rock crumbling to the floor was observed on the wall near the head of the bed. The hole was directly over the resident's head as she lay in bed. R17 stated the crumbling sheet rock fell on the floor and onto her bed. She stated the hole had been there for months. R17 stated she barely noticed the hole, as she was not able to turn onto her left side. During an observation of R27 on 09/26/22 at 1:26 PM in his room while he lay in a low bed, a hole in the wall with crumbling sheet rock was observed directly above his head. There was a line of spots of peeling paint on the wall all along the side of the bed. R27 was unable to verbalize any information regarding the condition of the wall due to severely impaired cognition. During an interview and concurrent observations conducted with the Administrator on 09/29/22 beginning at 11:00 AM, the Administrator verified the holes in the walls near the head of the bed in R17 and R27's rooms were a concern and should be fixed as soon as possible. She stated each nursing station had a notebook where staff could make notes of maintenance concerns in residents' rooms to be addressed by the staff. The Administrator reviewed both notebooks and sated the issues noted above had not been documented, and she was not aware of the holes in the walls. Review of the facility's December 2009 Maintenance Service policy revealed, The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: . Maintaining the building in good repair and free from hazards. Review of the facility's 04/28/22 training record on Maintenance Service Logs/Repair Issues, provided on paper by the Administrator, revealed all staff were trained on the use of the Maintenance Service Logs using the following documentation, It's very important to follow Policy & Procedure when it comes to repairs and maintenance within the facility. Every maintenance request is to be placed in the maintenance log located at each nurse's station. This will allow for a smooth process when it comes to repairing of resident equipment, rooms, furniture, fixtures, and anything that is in disrepair. We all assume the responsibility of making sure the residents have a safe environment. Notifying appropriate staff and logging items are both important parts of the process. All action items are to be written in the maintenance log [and] brought up in morning meetings so that all are aware of the issue and may offer alternative ways to solve an issue.