**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and review of the facility policy titled, Bed Hold, the facility failed to provide the resident or representative with written information that included the duration of the bed hold policy and the reserve payment amount at the time of transfer to an acute care hospital for one of three residents (R) (R30) reviewed. This failure had the potential to place R30 at risk of denial of re-admission and loss of their room following hospitalization. Findings include: Review of the facility policy titled, Bed Hold, dated 12/1/2014, revealed the Policy section included, All residents are given the option of reserving their bed when leaving the facility with the intent to return. A Bed Hold Authorization Form should be completed and signed by the resident/responsible party each time a resident leaves the facility. The Procedure section included, . 2. Bed Hold Policy and Bed Hold Authorization Form: All residents/responsible parties are given a copy of the State Specific Bed Hold Policy and Bed Hold Authorization Form upon admission. In the case of emergency transfer the resident or responsible party is provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. Review of R30's admission Record revealed diagnoses including, but not limited to, cerebral infarction, severe protein calorie malnutrition, aphasia, hemiplegia and hemiparesis, dysphagia, aphasia, dysarthria, chronic obstructive pulmonary disease (COPD), congestive heart failure, anemia, generalized muscle weakness, and gastro-esophageal reflux disease. Review of R30's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Pattern) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Review of R30's electronic medical record (EMR) revealed no documentation that the facility provided the resident with a bed hold agreement for hospital transfers dated 7/6/2024, 7/20/2024, 9/5/2024, and 1/28/2025. In an interview on 4/4/2025 at 10:04 am, R30 revealed that he had several hospital stays since being admitted to the facility. R30 stated that he has had a lot of medical issues. He further stated he did not recall receiving or signing a bed hold agreement at the time of transfers to the hospital. In an interview on 4/5/2025 at 3:17 pm, Licensed Practical Nurse (LPN)AA revealed when residents were transferred to the hospital, after receiving the order from the physician, there was a packet that was sent with them that contained the residents face sheet, physicians' orders, code status, and the bed hold policy. She further stated the original bed hold was sent with the resident, and a copy of the bed hold was given to the Business Office Manager to be placed in the resident's file. In an interview on 4/5/2025 at 3:26 pm, the Revenue Cycle Manager (RCM) revealed that when a resident was sent to the hospital, the bed hold policy was sent with the resident, and a copy was put in the resident's financial file. During the interview, the RCM was unable to locate the bed hold policies for R30 for the hospital transfer dates of 7/6/2024, 7/20/2024, 9/5/2024, and 1/28/2025. The RCM confirmed that R30 did not receive a bed hold agreement during any of the hospital transfers that occurred. In an interview on 4/5/2025 at 3:40 pm, the Administrator revealed that when a resident was transferred to the hospital, the bed hold policy was expected to accompany the resident at the time of the transfer. Further interview revealed that there was also a copy of the bed hold policy that was placed in the residents' financial file, which was kept in the Business Office.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Oxygen, Administration-Nasal Canula, the facility failed to follow a physician order for oxygen (O2) therapy for one of 11 residents (R) (R1) receiving O2 therapy. The deficient practice had the potential to place R1 at risk of medical complications and unmet needs. Findings include: Review of the facility policy titled, Oxygen, Administration-Nasal Canula, dated October 2023, revealed the Procedure section included, 1. Check the resident's clinical record for the physician's order. 5. Turn the flow meter to the ordered flow rate. Review of R1's electronic medical record (EMR) revealed diagnoses including, but not limited to, acute and chronic respiratory failure, unspecified asthma, other specified chronic obstructive pulmonary disease (COPD), and pneumonia. Review of R1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section O (Special Treatments, Therapies, and Programs) documented R1 received O2. Review of R1's Physician's Orders revealed an order dated 4/1/2025 for O2 at 3 liters per minute (LPM) via nasal cannula (NC) as needed for O2 for oxygen therapy Observations on 4/4/2025 at 8:14 am, and 4/5/2025 at 9:15 am and 1:40 pm revealed R1 was receiving O2 via a NC at 4 LPM via an O2 concentrator. During an interview on 4/5/2025 at 1:49 pm, Licensed Practical Nurse (LPN) AA confirmed that R1's O2 was set at 4 LPM. She confirmed the physician's order was for R1's O2 to be set at 3 LPM. During an interview on 4/5/2025 at 3:15 pm, the Unit Manager revealed that she expected staff to follow the physician's orders for O2 and ensure the flow meters were set to deliver the ordered amount of O2.

Based on observations, staff and resident interviews, and record reviews, the facility failed to ensure respiratory equipment was maintained in a sanitary manner for one of 11 residents (R) (R25) receiving oxygen (O2) therapy. This deficient practice had the potential to place R25 at risk of respiratory complications and a diminished quality of life. Findings include: Review of R25's electronic health record (EHR) revealed diagnoses including, but not limited to, respiratory failure, unspecified with hypoxia, chronic obstructive pulmonary disease (COPD), emphysema, systolic (congestive) and diastolic (congestive) heart failure, obstructive sleep apnea, acute respiratory failure, and acute and chronic respiratory failure with hypoxia Review of R25's Annual Minimum Data Set (MDS) assessment, dated 1/9/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview of Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented R25 was dependent on staff for mobility. Section J (Health Conditions) documented R25 had shortness of breath or trouble breathing when lying flat. Section O (Special Treatments, Procedures, and Programs) documented R25 received O2 therapy and non-invasive mechanical ventilation while a resident. Review of R25's Physician Orders revealed orders dated: 1/30/2025 for O2 at 3 liters per minute (LPM) via nasal cannula (NC) two times a day, 10/25/2024 to apply CPAP (continuous positive airway pressure) at bedtime for O2 therapy and remove CPAP in the morning one time a day for O2 therapy, and 10/21/2024 for ipratropium-albuterol solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter) one vial inhale orally via nebulizer every 8 hours related to COPD and albuterol sulfate HFA [high-flow aerosol] inhalation aerosol solution 108 (90 Base) MCG (microgram)/ACT (actuator) one inhale orally every 4 hours as needed for dyspnea (trouble breathing). Observation on 4/4/2025 at 8:00 am revealed R25 receiving O2 at 3 LPM via a NC. Observation revealed the O2 concentrator was covered with debris, and the nebulizer mask and CPAP mask were lying on the nightstand, uncovered and exposed to the environment. In an interview, R25 revealed that she was unable to turn and reposition herself in bed independently or reach the nightstand. She revealed that the nurses placed and removed the respiratory masks for her. Observation on 4/4/2025 at 12:18 pm revealed R25 receiving O2 at 3LPM via NC. The oxygen concentrator was covered with debris, and the nebulizer mask and CPAP mask were lying on the nightstand, uncovered and exposed to the environment. Observation on 4/5/2025 at 8:58 am revealed R25 receiving O2 at 3LPM via NC. The oxygen concentrator remained covered with debris. In a concurrent observation and interview on 4/5/2025 at 2:10 pm, Licensed Practical Nurse (LPN) AA confirmed R25 was receiving O2 at 3LPM via NC. LPN AA confirmed the O2 concentrator was covered with debris. Observation revealed the respiratory masks were in a protective bag, however, LPN AA confirmed they were not in a protective bag and were uncovered and exposed to air on 4/4/2025. LPN AA verified that R25 was unable to reach her nightstand and that the nurses would have placed the nebulizer and CPAP masks on the nightstand uncovered. LPN AA stated she thought Environmental Services was responsible for cleaning O2 concentrators and that the night nurses were responsible for changing and bagging nebulizer and CPAP masks. During an interview on 4/15/2025 at 3:15 pm, the Unit Manager (UM) confirmed the findings of the O2 concentrator with debris and the respiratory masks being unbagged and exposed to the environment after viewing pictures of the findings. The UM revealed her expectations of staff were that they ensure the O2 concentrator was clean and that respiratory masks were placed in protective bags when not in use. A policy related to oxygen equipment maintenance and storage was requested and not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the Centers for Disease Control and Prevention (CDC) website and Clinical Laboratory Improvement Amendments of 1988(CLIA) regulations, the facility failed to ensure a current Centers for Medicare & Medicaid Services (CMS) CLIA Certificate of Waiver. The facility census was 56. Findings include: Review of the CDC CLIA website revealed The CLIA of 1988 regulations apply to all United States (US) facilities or sites that test human specimens for health or disease assessment. Review of the CLIA of 1988 regulations revealed .Certification of Laboratories . (b) Certificate Requirement: No person may solicit or accept materials derived from the human body for laboratory for laboratory examination or other procedure unless there is effect for the laboratory a certificate issued by the Secretary under this section applicable to the category of examinations or procedures which includes such examinations or procedure. Review of the facility-provided CLIA waiver revealed an expiration date of [DATE]. Record review revealed the facility conducts blood glucose checks for 15 residents per day and urinalysis testing for residents as ordered by the physicians. In an interview on [DATE] at 10:00 am, the Building Manager confirmed that the facility's CLIA certificate was expired. The Building Manager stated there had been a request for renewal that had been denied. Further interview revealed that because the facility was in transition from one company to the next, the CLIA certificate had expired and not been renewed.

Based on staff interviews and facility document review, the facility failed to employ a qualified dietitian. This deficient practice had the potential to place the 56 residents residing in the facility at risk of unmet nutritional needs and a diminished quality of life. Findings include: A job description for the Registered Dietitian was requested and was not provided. Review of the facility-provided document titled Dietary Manager included, Job Summary: The primary purpose of the Dietary Manager position is to assist the Dietitian in planning, organizing, developing, and directing the overall operation of the Dietary Department. An interview on 4/4/2025 at 8:30 am with the Dietary Manager (DM) revealed the facility did not have a Registered Dietitian (RD). She stated that the facility has been without an RD for the past two months. She stated that she communicated with the Minimum Data Set (MDS) nurse about residents' diets. In an interview on 4/4/2025 at 8:52 am, the Administrator revealed the former RD was offering support until an RD was hired. In an interview on 4/5/2025 at 12:43 pm, the former RD stated that her last day of service to the facility was 1/26/2025, she was no longer affiliated with the facility, and was not offering support to the facility. In an interview on 4/5/2025 at 2:23 pm, the MDS Coordinator stated that the facility does not currently have an RD. She stated that she did not communicate with the DM about the residents' diets. In an interview on 4/5/2025 at 1:28 pm, the Administrator revealed she was unaware that there was no RD for the facility. She stated someone would be covering until a new RD was available, and was unable to provide confirmation of the coverage. In an interview on 4/5/2025 at 1:45 pm, the Building Manager stated the facility was in the process of a change in company ownership. He stated he was unaware that the RD's contract had ended.

Based on staff interviews and record review, the facility failed to employ a qualified Social Service Worker on a full-time basis to provide services for the residents in the facility. The facility was licensed for 126 beds. Findings include: Review of the facility's licensure revealed that the facility was licensed for 126 beds. Review of the facility personnel files revealed there was no Social Services Worker employed by the facility to provide consultation or oversight of the facility's resident population. In an interview on 4/5/2025 at 9:28 am, the Human Resources Director revealed that the last day the previous Social Services Director worked at the facility was on February 28, 2025, and there had not been any person working in the capacity of the Social Worker in the facility since that day. In an interview on 4/5/2025 at 1:28 pm, the Administrator revealed that she was aware the facility had not employed a qualified Social Service Worker since February 28, 2025. In an interview on 4/5/2025 at 1:45 pm, the Building Manager revealed that he was unaware that the facility did not have a qualified Social Services Worker working in the facility.

Based on staff interviews and review of the facility-provided document titled CNA/STNA (Certified Nursing Assistant/State Tested Nursing Assistant), the facility failed to provide the required in-service training for the CNAs employed by the facility. This deficient practice had the potential to adversely affect the 56 residents residing in the facility. Findings include: Review of the facility-provided document titled, CNA/STNA, dated 11/2023, revealed the Specific Educational/Vocational Requirements section included, Must attend a minimum of 12 continuing education programs provided by the center in order to maintain certification. During an interview on 4/4/2025 at 2:30 pm, the Human Resource Director (HRD) revealed that the Director of Nursing (DON) was responsible for submitting CNA in-service hours to the State Agency to determine compliance. She further stated the DON had not submitted the 2024 in-service hours. During an interview on 4/5/2025 at 10:15 am, the HRD stated she had contacted the State Agency, and the 2024 CNA training hours had not been received by the agency. During an interview on 4/5/2025 at 4:03 pm, the Administrator stated the DON was responsible for providing education, and the HRD was responsible for submitting the CNA in-service hours to the State Agency. The Administrator confirmed that the education records for CNAs for 2024 could not be found and was unable to provide evidence of the required in-service training for the facility's CNAs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility documents titled Resident Fund Management Service and Burial Account, the facility failed to ensure that one of seven sampled residents (R) (R2's) burial account funds were not used to pay the care cost balance. This deficient practice had the potential to affect all residents who had a trust funds account with the facility. Findings include: A review of the Resident Fund Management Service document, dated [DATE], revealed that the Resident Fund Account was a transferring account (automatic transfer of care cost payments due the facility) with a $70.00 monthly allowance amount. A review of the Burial Account document revealed that it was a deposit-only account for money to be used for burial expenses only and was revocable (it may be closed prior to death). A review of the Resident Statement Landscape revealed that R2 had a trust fund account for care costs and a burial account. Further review revealed on [DATE], R2's trust fund account balance was $4185.83. On [DATE], $4115.00 was transferred from the trust fund account to the burial account, leaving a balance of $70.00 in the trust fund account. A review of the Close Transaction Report, dated [DATE] (to close R2's trust account), revealed that $70.83 was due to R2 to close the trust fund account. A check numbered 003614, dated [DATE], from the Resident Fund Management Service (RFMS) Petty Cash Account revealed the check was made payable to R2 and had the facility's address. A review of the Close Transaction Report dated [DATE] (to close R2's burial account) revealed a balance of $4115.00. There were two checks for the burial disbursement dated [DATE], check numbered 003613 for $1998.52 with R2 as the payee and check numbered 003615 for $2116.48 with the facility as the payee. A review of the Trial Balance dated [DATE] revealed R2's burial account was closed on [DATE], with a zero balance. A review of the facility's Petty Cash bank account statement dated [DATE], through [DATE], revealed that check numbers 003613 and 003614 were cleared as paid on [DATE], and check 003615 was cleared as paid on [DATE] from the facility's petty cash account. There was no evidence that the Responsible Party authorized the facility to transfer money from the burial account to pay an outstanding balance of care cost. A review of medical records revealed that R2 expired on [DATE]. In an interview on [DATE] at 12:57 pm, the Business Office Manager (BOM) revealed that the only authorization she had was to transfer money from R2's trust account to his burial account and that she was not aware that the burial account funds could not be used to pay the care cost balance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure vital signs were obtained as ordered for two of seven sampled residents (R) (R1 and R3). This deficient practice had the potential to negatively affect R1 and R3's physical health and well-being. Findings include: 1. A review of R1's medical records revealed admission to the facility on 2/11/2016, with a readmission date of 9/5/2021. Diagnoses included but were not limited to hypertension and type 2 diabetes mellitus. A review of the Order Summary for R1 revealed an order dated 5/4/2023 with a start date of 5/8/2024 for vital signs to be obtained every Monday, every day shift. A review of the Weight and Vitals Summary revealed no vital signs were documented on any dates in May 2024. Two entries of vital signs were recorded for June 2024, dated 6/1/2024 and 6/3/2025. There was no evidence of vital signs recorded for 6/10/2024 and 6/17/2024. 2. A review of R3's medical records revealed admission to the facility on [DATE] with a readmission date of 4/11/2024. Diagnoses included but were not limited to hypertension and major depressive disorder. A review of the Order Summary for R3 revealed an order dated 1/14/2024 with a start date of 1/15/2024 to obtain vital signs every day shift every Monday for monitoring. A review of the Weights and Vitals Summary dated 1/1/2024 through 7/1/2024 revealed no evidence that vital signs were obtained on any dates in May 2024. In an interview on 7/11/2024 at 2:12 pm, the Director of Nursing (DON) revealed that staff should document vital signs during the shift and that missing documentation should be entered within 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and review of the facility policy titled Clinical Documentation, the facility failed to ensure clinical records contained complete and accurate documentation for one of seven sampled residents (R) (R1). Findings include: A review of the facility's policy titled Clinical Documentation, dated [DATE], revealed the section titled Clinical Documentation Overview stated, Facility nursing staff documents the provision of nursing care according to nursing standards and regulatory requirement. Documentation tools are designed to demonstrate the clinical care provided to the resident and to ensure the appropriate information is available to all interdisciplinary team members regarding treatment interventions and responses. Frequency of nursing documentation is based on resident clinical status, clinical need and regulatory requirements. Components of the nursing documentation proves include but are not limited to documentation in progress notes that reflect the ongoing clinical condition of the resident. A review of R1's Progress Notes dated [DATE] through [DATE] revealed an entry dated [DATE] that Licensed Practical Nurse (LPN BB) was alerted by staff to the resident's room in response to the resident being unresponsive. Upon entry to the room, the resident had no pulse noted and his eyes were closed with no respiration noted. The Director of Nursing (DON) was notified of resident status. A late entry dated [DATE] revealed Registered Nurse (RN) AA pronounced R1 deceased at 1:05 am. A review of R1's medical records revealed that there was no evidence of documentation of vital signs or documentation of the events prior to R1's death. The last documented vital signs were dated [DATE]. In an interview on [DATE] at 7:49 pm, Certified Nursing Assistant (CNA) DD revealed on [DATE] around 8:30 pm, R1 asked for assistance. She stated she assisted him to the nurse's station, and two nurses assessed him, including checking his pulse, oxygenation, vital signs, and administering oxygen. She stated R1 exhibited sweating, shaking and holding his chest. She further stated the two nurses took R1 to his room and placed him in his bed. In an interview on [DATE] at 2:12 pm, the Director of Nursing revealed that staff should document during the shift and enter missing documentation within 24 hours.

Based on observation, staff interviews, and review of the facility document titled CNA/STNA (Certified Nursing Assistant/State Tested Nursing Assistant), the facility failed to ensure that one resident (R) (R11) of 16 sampled residents was provided perineal care. This failure placed R11 at risk for unmet needs and a diminished quality of life. Findings include: A review of the facility document titled CNA/STNA, dated November 2023, revealed the Responsibilities section stated, Provide resident care in a manner conducive to safety and comfort. Resident care includes but is not limited to assist resident with or performs Activities of Daily Living (ADL). A review of the Significant Change Minimum Data Set (MDS) Assessment, dated 2/6/2024, revealed section GG (Functional Abilities and Goals) documented that R11 required partial/moderate assistance with toileting and was dependent for personal hygiene, section H (Bladder and Bowel) documented R11 was always incontinent of bladder and bowel, section I (Active Diagnoses) included Alzheimer's disease, dementia, and anxiety, section O (Special Treatments and Programs) documented R11 received Hospice care. A review of the care plan, dated 3/27/2024, revealed that R11 has episodes of incontinence of the bladder and bladder. The interventions included performing incontinent care as needed. During an observation on 4/24/2024 at 9:56 am, R11 was observed lying in bed, and her bed sheets were soaked with urine. Her incontinent brief was heavily soiled with brownish substance with a stagnant urine odor. The bed pad was heavily saturated with urine, and the back of her sweatshirt was wet from the lower back to the upper back with urine. At 10:14 am, CNA KK provided perineal care to R11. A review of an in-service on perineal care dated 4/1/2024 revealed no evidence that CNA KK attended the in-service. In an interview on 4/24/2024 at 10:14 am, CNA KK stated that this was the first time she had entered R11's room on this date. She further stated she arrived at work at 6:40 am. She continued to state that the resident had a bath scheduled for that morning by the hospice CNA. She explained that the hospice CNA would have changed R11 during the bath. In an interview on 4/24/2024 at 11:39 am, Hospice CNA LL revealed that incontinent care provided to the resident depended on the person assigned to the hospice residents and that mostly the night shift on the weekend, specifically on Monday, was the worst about not providing incontinent care. She further stated that R11 was always soaked when she arrived to provide care. In an interview on 4/24/2024 at 6:17 am, the Regional [NAME] President of Operations revealed that the CNAs are to check and make rounds every two hours to check for dryness and reposition the resident.

Based on staff interviews, record review, and review of the facility policy titled Clinical Staffing Standard, the facility failed to ensure that a Registered Nurse (RN) other than the Director of Nursing (DON) was assigned to direct nursing care of the residents for 27 of the 28 days reviewed. The facility census was 77 residents. This failure had the potential to negatively impact all residents residing at the facility. Findings include: A review of the facility policy titled Clinical Staffing Standard, dated October 2023, revealed the Procedure section documented 4. Staffing will include a Registered Nurse 8 hours a day. A review of the Facility Two Week Staffing Grid dated 3/19/2024 through 4/1/2024 and 4/2/2024 through 4/15/2024 revealed that an RN was assigned to direct nursing care for eight or more hours each day. Twenty-four of the 28 days documented an RN for eight hours per day, three days documented an RN for eight and one-half hours per day, and one day documented an RN for 23 hours per day. However, the facility was unable to provide timesheets for an RN who provided direct nursing care for the 28 days from 3/19/2024 through 4/15/2024. The RN time documented on the two-week staffing grids was the former DON's hours. There was no evidence that an RN, who was not the DON, worked as a direct care nurse on the dates from 3/19/2024 through 4/15/2024. In an interview on 4/24/2024 at 6:17 pm, the Regional [NAME] President of Operations revealed the eight hours per day of RN hours listed on the two-week staffing grids for the dates from 3/19/2024 through 4/15/2024 were the former DON's hours. The Regional [NAME] President of Operations offered an explanation that other facilities also list the DON as the RN on the two-week staffing grids.

Based on observations, staff interviews, and review of the facility policies titled Cleaning and Sanitizing Dietary Areas and Equipment, and Deep Fryer Cleaning, the facility failed to ensure that the kitchen equipment was kept clean and sanitary and failed to ensure pureed food was prepared in a manner to prevent foodborne illness. These deficient practices had the potential to place 11 of 11 residents who received a pureed diet, and all residents who received an oral diet at risk of contracting a foodborne illness. The census was 81 residents. Findings include: A review of the undated facility policy titled Cleaning and Sanitizing Dietary Areas and Equipment, revealed a Policy statement: All kitchen areas and equipment shall be maintained in a sanitary manner and be free of buildup food, grease, or other soil. The facility will provide sanitary food service that meets state and federal regulations. A review of the undated facility policy titled Deep Fryer Cleaning, revealed a Policy statement: Deep fryer will be cleaned on a regular basis as recommended by the manufacturer. The Procedure section lines numbered 2 stated: Wipe down the exterior at the end of the day. 3: Clean the fry baskets at the end of the day. During the initial kitchen walk-through on 2/20/2024 at 9:00 am with the Dietary Manager, observation revealed the two ovens had burned food stains, the deep fryer had debris, and the deep fryer oil was dark in color. Observation revealed the back of the oven, and the deep fryer had a build-up of a brown substance. A follow-up walk-through on 2/21/2024 at 8:30 am in the main kitchen revealed all previous observations including the food stains in the oven and debris and dark-colored oil in the deep fryer remained unchanged. All observations were confirmed with the Dietary Manager during the walk-through. During observation of puree preparation on 2/21/2024 at 10:30 am, [NAME] DD used a spatula to stir the puree on the robot coupe and then placed the spatula on the counter of the food prep metal table, she then picked the spatula up, stirred the puree and placed it on the rags she had used to wipe down the counter and other areas in the kitchen. She then used the spatula to empty the puree into a food pan. In an interview on 2/21/2024 at 10:45 am, [NAME] DD acknowledged that she placed the spatula on the counter and the dirty rags and then used it to stir the puree and when empting the puree into a food pan. She stated that she was supposed to wash the spatula before using it to stir the pureed food. In an interview on 2/21/2024 at 2:30 pm, the Dietary Manager stated her expectation was that the cook should have washed the spatula after placing it on the counter and after placing it on the dirty rag she had used to wipe down surfaces before she used it to stir the puree. She stated that she expects dietary staff to follow the guidelines and rules for cleaning and washing utensils and for dietary staff to clean them after use. She further stated that the dietary staff is responsible for cleaning the back of the oven and the deep fryer. She stated that she has a cleaning schedule that should be followed for each task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and a staff interview, the facility failed to provide a safe, clean, and comfortable environment that was free from damaged walls, damaged floors, damaged bathroom light fixtures, missing baseboards, missing or damaged built-in closet drawers, a broken curtain rod and a stained ceiling tile. Specifically, the facility failed to ensure resident rooms were in good repair in twelve of fifty-one resident rooms (rooms 101, 203, 205, 208, 210, 403, 503, 505, 506, 508, 509, 511), one activity room and one hallway. This failure has the potential to diminish the resident's quality of life. Findings include: During environmental rounds on 12/19/2022 from 3:50 p.m. to 4:30 p.m. with the Administrator, the following concerns were identified: Observation in room [ROOM NUMBER] revealed a scuffed baseboard behind the resident's bed. Observation in room [ROOM NUMBER] revealed that the flooring at the foot of both A and B beds was worn and gouged. The finish on the footboards for both A and B beds was peeling and flaking. Further observation revealed that the exhaust fan in the bathroom was not flush against the ceiling. Observation in room [ROOM NUMBER] revealed flaking paint on the wall around the sink. Observation in room [ROOM NUMBER] revealed that the wall behind both A and B beds was scuffed, the curtain rod over the window was broken in half, and there was a missing baseboard behind the sink in the room. The feeding pump pole for bed B was rusty and had dried enteral feeding at the base of the bar. Further, observation revealed dried enteral feeding on the floor under the bed. The exhaust fan/light cover was missing in the bathroom, and the toilet tissue holder was broken. Observation in room [ROOM NUMBER] revealed that the wall behind the bed was scuffed. The corner of the wall at the sink in the room was scuffed and gouged. Further observation revealed that the built-in cabinet drawers were missing pull knobs and could not be opened. Observation in the hallway near the dining room revealed a brown stained ceiling tile. Observation in room [ROOM NUMBER] revealed scraped/smeared paint on the wall above the commode in the bathroom. Observation in room [ROOM NUMBER] revealed that the built-in closet drawers were off the track. Observation in room [ROOM NUMBER] revealed peeling and flaking paint on the baseboard near the entrance door. The built-in closet doors were broken and off the track. Observation in room [ROOM NUMBER] revealed peeling and flaking paint on the wall next to the window and the closet. Observation in room [ROOM NUMBER] revealed that the drywall repair at the foot of A bed needed to be sanded or painted. Further observation revealed that one of the six built-in drawers was missing. Observation in room [ROOM NUMBER] revealed a brown dried substance along the wall and window blinds next to bed C. Observation in room [ROOM NUMBER] revealed a stained and dirty fall mat next to bed A. Further observation revealed that the wall behind bed A was scuffed. Observation in the activity room on the 500 Hall revealed that one wall had large cracks, and a portion of the drywall was peeling away from the wall. Interview on 12/19/2022 at 4:30 p.m. with the Administrator, she revealed that during the 11/15/2022 Quality Assurance and Performance Improvement (QAPI) meeting on 11/15/2022, the staff had identified areas of the building that needed painting and baseboards needed repair or replacement but would have to be approved by corporate.

Based on observation, staff interview, record review, and review of facility policy titled, Menus, the facility failed to ensure the correct portion size of food was served according to the planned facility menu for ten foods requiring pureed diets during the lunch meal service. The deficient practice had the potential to affect the caloric intake value of all residents receiving a puree diet. Findings include: Record review of an undated policy titled Menus revealed that menus must be followed as written with the following exceptions: when ethnic, cultural, geographic, or religious habits of the resident population require a substitution. Record review of the Fall/Winter 2022 Diet Spreadsheet for Week 4, Day twenty-six, documented that 4-5 ounces of pureed herbed pork were planned for residents on a pureed diet. Observation on 12/15/2022 at 12:35 p.m. of the lunch meal service revealed that dietary staff were serving 3 ounces of the pureed pork loin. Interview on 12/15/2022 at 3:00 p.m. with the Dietary Manager, she confirmed that the dietary staff should have served 4-5 ounces of the pureed pork loin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy, titled, Customer Satisfaction, the facility failed to ensure grievance documentation included the steps taken to investigate grievances and the outcome of the investigations for one (Resident [R] #59) of three residents reviewed for grievances. Findings include: A review of an undated facility policy, titled, Customer Satisfaction, indicated, The facility Administrator is responsible for the direction of the Grievance process. The follow up is conducted by the Director of Social Services/designee or Administrator. The resident/family has the right to request a written resolution to all grievances. Review of the admission Record for Resident (R) #59 revealed the resident had diagnoses which included chronic obstructive pulmonary disease and hemiplegia (paralysis on one side of the body) affecting the left non-dominant side. A review of the quarterly Minimum Data Set, dated [DATE], revealed R#59 scored 13 on a brief interview for mental status, which indicated the resident was cognitively intact. The MDS indicated the resident required supervision and set-up assistance with dressing and bathing. A review of the care plan, dated as reviewed on 02/16/2022, revealed the facility admitted R#59 following a cerebrovascular accident (stroke) with left hemiplegia affecting the left non-dominant side. The care plan indicated the resident was involved with activities of daily living (ADLs). The interventions included assisting the resident with all ADLs. A review of a Complaint Form, dated 03/16/2022 revealed a grievance was verbally submitted by R#59, who stated they would like help picking out their clothing and to go to the shower once per week. The form indicated staff were educated on the importance of resident care and assisting residents. The form did not indicate the steps the facility took to investigate the grievance and a summary of the findings or conclusions. There were areas at the bottom of the form where staff were to document whether or not the grievance was resolved; who informed the resident/complainant of the findings and the date this was done; and any response from the resident/complainant. All of these areas were blank. During an interview on 04/05/2022 at 1:21 PM, R#59 stated they verbally informed Social Worker EE of their concerns. During an interview on 04/05/2022 at 2:10 PM, Social Worker EE revealed the resident had voiced the concerns to her, and the Director of Nursing (DON) would have been responsible for following up and speaking to the resident after the grievance was filed. An interview was conducted on 04/05/2022 at 2:25 PM with the Administrator, who stated the previous DON, who was employed at the time of the resident's grievance, no longer worked for the facility. The Administrator reviewed the grievance form at this time and confirmed that it did not indicate the resident was notified of the results. During an interview on 04/07/2022 at 5:31 PM, R#59 revealed Social Worker EE had followed up and verbally informed the resident of the investigation and findings. The resident revealed they were receiving more assistance with dressing and receiving the number of showers requested. During an interview on 04/06/2022 at 4:00 PM, Social Worker (SW) EE indicated that when a grievance was filed, she gave it to the affected department to investigate, and they were responsible for getting back with the complainant and documenting the resolution. SW EE further indicated that the complainant was given a verbal resolution. SW EE indicated that she also followed up with the residents to make sure the grievance was no longer a concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a resident with a newly diagnosed, serious mental illness was referred for a level II Preadmission Screening and Resident Review (PASRR) for one (Resident [R] #3) of two residents reviewed for PASRR. Findings include: The facility did not have a policy for their PASRR referral process. A review of the admission Record revealed the facility admitted R#3 on 02/11/2016 with no mental illness diagnoses. The admission Record indicated new diagnoses of major depressive disorder, psychotic disorder with delusions, and schizophrenia were added on 09/09/2019. A review of R#3's quarterly Minimum Data Set (MDS), dated [DATE], revealed R#3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of the plan of care, dated 03/28/2022, revealed R#3 was at risk for adverse reactions from daily use of medications for depression, insomnia and schizophrenia. A review of the April 2022 Medication Administration Record (MAR) revealed R#3 received medications to treat the schizophrenia diagnosis, including a Haldol (antipsychotic) 100 milligram (mg) injection monthly, Depakote tablets 875 mg twice daily, and a Seroquel 400 mg tablet twice daily. The MAR also indicated the resident received a Lexapro 10 mg tablet every night at bedtime for the major depressive disorder diagnosis. A review of R#3's PASRR documentation revealed the PASRR Level I Assessment form was dated 10/15/2010, and had depressive disorder checked as a mental illness (MI). There was no documentation to indicate the resident had a PASRR screening completed since the new diagnoses of schizophrenia and psychotic disorder were added. A review of psychiatric visit notes revealed R#3 was followed by psychiatry monthly. During an interview on 04/08/2022 at 3:23 PM, Licensed Practical Nurse (LPN) OO indicated that it was the responsibility of the nurse to make the social worker (SW) aware when a resident received a new mental illness (MI) diagnosis. LPN OO further indicated it was the responsibility of the SW to update the resident's PASRR level I assessment when the resident received a new MI diagnosis. During an interview on 04/08/2022 at 5:05 PM, the Administrator revealed that it was her expectation that nursing would notify the SW to have another PASRR screening completed with any new MI diagnosis. During an interview on 04/08/2022 at 5:37 PM, the Director of Nursing revealed that it was her expectation when a resident had a new MI diagnosis that it would go through the interdisciplinary team and go through proper protocols for the resident PASRR to be reassessed. The SW was on vacation and not available for interview during the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility policy, titled, Skin Management Standards, the facility failed ensure a pressure relieving device was used consistently for one resident (R) (R#38) and failed to ensure treatments were provided as ordered for one resident (R#45) of four residents reviewed for pressure ulcers. Findings include: A review of the policy, dated August 2021, titled, Skin Management Standards, page 15, Routine Preventative Care, indicated, 2. All residents will be assessed for risk of skin breakdown using the skin assessment tool in [electronic health record software program] at the following intervals: Admission, Readmission, Quarterly, Change of Condition. Residents with a score of 8-12 or greater will be considered at high risk for skin breakdown and preventive interventions will be implemented. The policy indicated routine preventive interventions included, but were not limited to, Turning and repositioning as clinical condition dictates. Proper body alignment shall be maintained, and positioning devices utilized. Additionally, the policy indicated, 4. All interventions and outcomes should be documented in the resident's medical record. 1. Review of the admission Record revealed R#38 had diagnoses which included peripheral vascular disease and cerebral palsy. A review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated R#38 had long-term and short-term memory problems and was severely impaired in cognitive skills for daily decision-making per a staff assessment for mental status. The MDS did not indicate the resident refused care. The MDS revealed R#38 was totally dependent on one-person for bed mobility, transferring, personal hygiene and bathing. The MDS revealed the resident had two unstageable pressure ulcers which were present upon admission/entry or reentry. The MDS also indicated the resident had a pressure-reducing device for the bed, was not on a turning and repositioning program, and did not receive pressure ulcer/injury care. Review of a Skin Only Evaluation, dated 03/31/2022 at 10:50 AM, revealed the left thigh wound measured 2.0 cm in length by 1.5 cm in width by 0.1 cm in depth. The wound to the right lateral lower leg measured 1.5 cm in length by 1.5 cm in width by 0.1 cm in depth. There was no odor, no tunneling, and no undermining to either wound. During an interview on 04/05/2022 at 12:00 PM, Licensed Practical Nurse (LPN) AA revealed the resident's pressure wounds were acquired in-house. The nurse stated the resident was very rigid from having cerebral palsy (CP) and the legs were contracted and crossed, and pressure areas developed. She indicated this probably occurred because someone did not use a pillow between the resident's legs, but that the wounds were healing nicely now. During an interview on 04/06/2022 at 1:42 PM, LPN JJ revealed the resident had a diagnosis of CP and had contractures when admitted . She stated pillows were being used for positioning, and that the resident had a low-loss air mattress. On 04/06/2022 at 5:07 PM, the resident was observed to be asleep in bed. LPN JJ informed the resident she was there to change the dressings on their legs. LPN JJ asked the resident if she could change the dressings. The resident agreed, as long as it did not take long. The resident then became verbally abusive, and LPN JJ calmed the resident by singing, and the resident sang along. LPN NN then removed the soiled dressing from the left thigh, just above the knee, while LPN JJ held up the resident's right leg, which was crossed over the left thigh due to contractures. The LPNs maintained clean technique, donning and doffing gloves and performing handwashing appropriately throughout this dressing change. LPN JJ then continued by removing the soiled dressing to the right outer leg. The wound to the left anterior thigh was red in color, the wound edges were intact, there was no odor, no undermining and no tunneling. There was minimal drainage. The wound to the right lower leg appeared red in color. The wound edges were intact, there was no odor, no undermining and no tunneling. There was minimal drainage of a thin, serosanguinous fluid. The LPN performed the dressing change to this wound with no break in clean technique. The treatments were performed per the physician's orders. The LPNs then repositioned the resident and placed a pillow between the resident's legs. During an observation on 04/07/2022 at 10:10 AM, the resident was lying supine (on their back) in a low bed with a fall mat in place on the left side of the bed. The resident had a pillow lying on top of the comforter. During an observation in R#38's room on 04/07/2022 at 10:17 AM, Certified Nursing Assistant (CNA) II assisted the surveyor to observe the resident's positioning in bed. The resident was sleeping in a low bed with a fall mat on the left side of the bed on the floor. A pillow was on top of the blanket. CNA II lifted the blanket, revealing R#38 had a bunny boot on the right foot. The resident's right leg was crossed over to just above the left knee, with the weight of the right leg resting on the left leg. There was no pillow between the resident's legs. The CNA put the blanket back over the resident's legs, leaving the pillow on top of the blanket, and exited the room. When asked about the pillow, CNA II revealed she thought the pillow should be between the resident's legs, but she thought it was the resident's bath day and she was not assigned to this resident today. She stated the resident could not move on their own. She revealed she usually watched other CNA staff to find out what needed to be done. She thought maybe there was a care guide in the resident's closet, but upon checking, there was not. She stated she believed there was an activities of daily living (ADL) book at the nurses' desk. Interview with CNA KK on 04/07/2022 at 10:21 AM revealed there was not a care guide or care guide cards in the closets of residents. She stated the nurse would inform her of any new orders and how to care for the residents. An observation in R#38's room on 04/07/2022 at 10:57 AM revealed the resident had been turned slightly to the right side. The pillow for the resident's legs remained on top of the comforter. During an interview on 04/07/2022 at 11:07 AM, CNA LL revealed there was an ADL notebook at the nursing station that informed the aides of how to care for a resident. She stated R#38 was bedfast and needed to be fed, and because of the resident's leg contractures, it was hard to reposition the resident. She stated sometimes a pillow helped to keep the pressure off. On 04/07/2022 at 12:06 PM, LPN OO confirmed in an interview that there was a CNA ADL book at the nursing station, and the CNAs were to use this to see the type of care a resident required. A review of the MDS [NAME] Report, from the ADL book located at the nursing station, indicated an assessment reference date of 07/17/2021. No revision dates were included on the report. There was no reference to R#38 having pressure ulcers and no instructions for the CNAs to turn and reposition R#38 or to apply any type of pressure relief device. On 04/07/2022 at 12:07 PM, an observation in the resident's room revealed the resident lying on the right side, having slid down in the bed. The pillow was lying on top of the comforter. On 04/07/2022 at 1:44 PM, observation in the resident's room revealed the resident lying on their back, with the pillow still positioned on top of the comforter. On 04/07/2022 at 2:51 PM, the surveyor observed R#38 with CNA LL. The resident was in bed. CNA LL raised the blankets from the resident's lower legs to reveal a bunny boot on the resident's right foot and a pillow between the legs. CNA LL indicated R#38 did not move on their own. During an interview on 04/08/2022 at 8:29 AM, CNA GG revealed she was an agency nursing assistant. She stated that when she arrived on the floor, the CNAs did rounds, and that was how she knew what her residents needed. She did not think there was any type of care guide in use. During an interview on 04/08/2022 at 10:26 AM, the interim DON revealed she was not working in the facility at the time R#38's pressure ulcers were identified; however, as a nurse, she would expect interventions to be in place to prevent pressure on body parts. She further stated there was not a policy related to interventions when treating pressure ulcers. During an interview on 04/08/2022 at 10:28 AM, the Administrator revealed she would hope that proper positioning would be put into place and interventions should have been in place. Care plans should have interventions listed. On 04/08/2022 at 11:12 AM, the surveyor conducted a telephone interview with the resident's physician, who revealed the resident had been gradually declining, from walking last year to using a wheelchair, and that the resident's contractures had worsened. He indicated a pillow could have been used between the legs to prevent pressure, but the resident quite possibly could have developed a lesser wound even with a pillow in use. The pressure ulcer developed because of the pressure of the legs being in contact with each other, but the resident had multiple comorbidities that could have played a part. 2. A review of R#45's admission Record revealed the facility admitted the resident on 12/09/2021 and readmitted the resident on 02/03/2022, with diagnoses including cerebrovascular disease, type two diabetes, vitamin D deficiency, chronic obstructive pulmonary disease, atherosclerotic heart disease of coronary artery without angina pectoris, acute and chronic respiratory failure with hypoxia, anxiety disorder, hyperlipidemia, and muscle weakness. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS did not indicate the resident refused care. The MDS revealed the resident was totally dependent on two-person physical assistance with ADLs and was always incontinent of bladder and bowel. The MDS revealed the resident was independent with eating with set-up help only. The MDS revealed the resident had two stage 4 pressure ulcers present upon admission and received skin and ulcer treatments that included a pressure-reducing device for the bed, pressure ulcer/injury care, and applications of ointments/medications. Review of an admission Summary, dated 01/14/2022 at 4:50 PM, revealed the resident returned to the facility from the hospital. The summary indicated the resident was positive for COVID-19 and had wounds on the sacrum, left heel and abdomen. A review of the Braden Scale for Predicting Pressure Ulcer Risk, dated 01/14/2022 revealed the resident's pressure ulcer risk score was 10, which indicated the resident was at high risk for pressure ulcer development. Review of a physician's order, dated 01/16/2022, revealed the treatment order for the left heel wound was to clean with normal saline and apply wet to dry dressing daily on day shift; however, this order was not transcribed to the January 2022 TAR. A review of the Body Audit, dated 01/19/2022, revealed the sacral ulcer measured 13.4 cm by 1.8 cm by 5 cm and the heel wound measured 3 cm by 2.5 cm by undetermined depth. A review of the Skin Only Evaluation, dated 01/22/2022, revealed the sacral ulcer measured 13 cm by 1.5 cm by 5 cm. The wound bed had granulation tissue present and there was heavy dressing saturation with serosanguineous drainage. The left heel wound measured 3 cm by 2.5 cm and depth undetermined. The wound bed had slough tissue present and there was moderate dressing saturation with serosanguineous drainage. The peri-wound condition indicated there was maceration. A review of the January 2022 TAR revealed a treatment order for the sacral wound, with a start date of 01/16/2022 and a stop date of 02/03/2022. The directions were to clean with normal saline and apply a wet-to-dry dressing daily on day shift. The treatment due on 01/30/2022 was not initialed by a nurse as completed. A review of the Skin Only Evaluation, dated 02/04/2022, revealed the resident's sacral pressure ulcer measured 8 cm long, by 5 cm wide, by 1 cm deep. The resident's left heel wound measured 5 cm long, by 4 cm wide, by 1 cm deep. Both wounds had granulation tissue and serosanguineous drainage present. A review of the February 2022 TAR revealed the following treatment orders: A treatment order for the left heel wound, with a start date of 01/16/2022 and a stop date of 02/03/2022, indicated the directions were to clean with normal saline and apply a wet-to-dry dressing daily. The treatments scheduled for 02/01/2022 and 02/03/2022 were not initialed by a nurse as completed. A treatment order for the sacral pressure ulcer, with a start date of 01/16/2022 and stop date of 02/03/2022, indicated the directions were to clean with normal saline and apply a wet-to-dry dressing daily. The treatments scheduled for 02/01/2022 and 02/03/2022 were not initialed by a nurse as completed. A treatment order for the left heel pressure ulcer, with a start date of 02/09/2022 and stop date of 03/18/2022, indicated the directions were to cleanse the area with normal saline, pat dry, apply Dakin's 0.25% soaked gauze and cover with a dry dressing. The dressing was to be changed daily and as needed for a soiled, loosened, or dislodged dressing. The treatments scheduled for 02/21/2022, 02/24/2022, 02/26/2022, and 02/28/2022 were not initialed by a nurse as completed. A treatment order for the sacral pressure ulcer, with a start date of 02/08/2022 and no stop date, indicated the directions were to cleanse the area with normal saline, pat dry, apply Dakin's 0.25 % soaked gauze, and cover with dry dressing. The treatment was to be provided daily and as needed for a soiled, loosened, or dislodged dressing. The treatments scheduled for 02/08/2022, 02/12/2022, 02/21/2022, 02/24/2022, 02/25/2022, 02/26/2022, and 02/28/2022 were not initialed by a nurse as completed. A review of the March 2022 TAR revealed a treatment order for the left heel, with a start date of 02/09/2022. The directions were to cleanse the area with normal saline, pat dry, apply Dakin's 0.25% soaked gauze, and cover with a dry dressing. The treatment was to be provided daily and as needed for a soiled, loosened, or dislodged dressing. The treatments scheduled for 03/05/2022 and 03/12/2022 were not initialed by a nurse as completed; however, the treatment was discontinued on 03/18/2022, as the left heel pressure ulcer healed on 03/17/2022. Further review of the March 2022 TAR revealed a treatment order for the sacral pressure ulcer, with a start date of 02/08/2022 and no stop date. The directions were to cleanse the area with normal saline, pat dry, apply Dakin's 0.25 % soaked gauze, and cover with a dry dressing. The treatment was to be provided daily and as needed for a soiled, loosened, or dislodged dressing. The treatments scheduled on 03/05/2022, 03/12/2022, and 03/27/2022 were not initialed by a nurse as completed. A review of the April 2022 TAR revealed all skin treatments were initialed by nurses as completed. During an interview and observation on 04/05/2022 at 12:32 PM, R#45 revealed he/she was getting stronger and could turn and reposition independently. The resident further revealed there was a problem with pressure ulcer treatments not being done on the weekends in the past, but that had been resolved and they were now being done as ordered. The resident stated the pressure ulcer to the sacrum was getting smaller and had almost healed. R#45 was observed lying in a bariatric bed on a pressure-relieving mattress. During an interview on 04/06/2022 at 1:39 PM, LPN NN revealed she worked at the facility part-time for over a year and was now full-time. LPN NN revealed R#45's pressure ulcer to the sacrum had gotten smaller and had almost healed. During an observation of the dressing change on 04/06/2022 at 3:37 PM, LPN NN washed her hands and prepared a clean tray with all supplies, including hand sanitizer, gloves, and pre-poured treatment medications including gauze, Dakin's solution, normal saline, and a bag in which to place the soiled bandage and supplies. R#45 was informed by LPN NN of the skin treatment. The resident raised the bed with the bed control. LPN NN, after removing the soiled dressing to the sacral area, placed the soiled dressing in a trash bag. LPN NN removed her gloves, washed her hands with soap and water and re-gloved. The resident was observed with skin folds that covered the sacral pressure ulcer. The skin folds were pulled apart and LPN NN cleaned the sacral area with normal saline. The pressure ulcer was observed with no drainage or odor. LPN NN removed her gloves, washed her hands, and re-gloved. LPN NN was observed packing the wound with Dakin's solution-soaked gauze. LPN NN covered the area with a dated and initialed bandage and removed her gloves and washed her hands with soap and water after the procedure. During an interview on 04/08/2022 at 10:28 AM, the Administrator revealed the treatments were being done; however, Treatment Administration Records were not being signed off on the weekends by the agency nursing staff. She also stated it was expected that the Treatment Administration Records would be signed off when the treatment was done. During an interview on 04/08/2022 at 2:48 PM, LPN NN revealed that when she came in on Mondays after the weekend, treatments had not been done, and even on the weekdays after following other nurses, the treatments had not been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility policy, titled, Medication Administration Guidelines, the facility failed to ensure medication carts were locked when unattended for two (Hall 400 and Hall 500 carts) of four carts observed. Findings include: A review of the facility policy titled, Medication Administration Guidelines, dated August 2021, indicated, Medication carts are to be kept locked at all times when not under visual supervision. An observation on 04/05/2022 at 9:13 AM revealed the medication cart located at the 500 Hall nursing station was positioned outside the nursing station, unlocked. The nurse was not in view of the medication cart. One resident was sitting to the left of the cart, in the hall. Multiple staff, including maintenance, housekeeping, and therapy staff, were in the hallway working. Licensed Practical Nurse (LPN) AA was observed to return to the medication cart at 9:19 AM. LPN AA was interviewed at this time, and she revealed she had unlocked the medication cart earlier and then stepped away. She stated the medication cart should have been locked. An observation on 04/05/2022 at 9:37 AM revealed LPN CC was in a resident room on Hall 400, assisting with removing clothes from the closet. The medication cart was located outside the resident room, unlocked and out of LPN CC's line of sight. LPN CC returned to the medication cart and prepared medications for a resident in room [ROOM NUMBER], then left the cart unlocked again as she walked away from the cart and into a resident's room. At 9:48 AM, LPN CC was interviewed and stated she assumed the cart should have been locked. During an interview on 04/05/2022 at 12:01 PM, the Interim Director of Nursing (DON) stated the medication carts should be locked when the nurse was not standing at the cart. During an interview on 04/05/2022 at 12:06 PM, Regional Nurse Consultant (RNC) BB revealed the medication carts were to be locked when the nurses stepped away from the cart and the cart was not in view. On 04/05/2022 at 3:49 PM, the Administrator stated in an interview that her expectation was that the medication carts were to be locked when not in view of the nurse. An observation on 04/06/2022 at 11:57 AM revealed the medication cart on Hall 400 was unlocked, located in front of the nursing station. There was no nurse in view. Maintenance workers were observed working in the hallway. During an interview on 04/06/2022 at 11:59 AM, LPN DD revealed the nurse who was assigned to the cart on Hall 400 had gone to lunch. LPN DD then came to the cart and locked it. In a follow-up interview with the Administrator on 04/06/2022 at 12:03 PM, the Administrator again stated the medication carts were to be locked when the staff stepped away from the cart.