**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain a clean, sanitary environment related to dusty vent covers in four rooms on one hall, (rooms 112, 113, 114, and 115) with the potential to affect eight residents in these four rooms. Findings included: A policy for environmental services and cleaning was requested, but one was not provided. Observations during the initial tour and screening of residents on 5/2/2023, and subsequent observations on 5/3/2023 and 5/4/2023, revealed a build-up of dust on the ceiling vent covers in the bathroom of Room (Rm) 112, RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER] as follows: Observation in room [ROOM NUMBER] on 5/2/2023 at 10:27 a.m. and 5/3/2023 at 9:10 a.m. revealed a dusty vent in the bathroom. Observation in room [ROOM NUMBER] on 5/2/2023 at 10:37 a.m. and 5/3/2023 at 1:00 p.m. revealed a dusty vent in the bathroom. Observation in room [ROOM NUMBER] on 5/2/2023 at 10:42 a.m. and 5/3/2023 at 8:20 a.m. revealed a dusty vent in the bathroom. Observation in room [ROOM NUMBER] on 5/2/2023 at 10:48 a.m. and 5/3/2023 at 9:20 a.m. revealed a dusty vent in the bathroom. During a walk-through on 5/4/2023 starting at 11:00 a.m. with the Maintenance Director (MD) and the housekeeping supervisor, dusty vent covers in the bathroom of RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER] was confirmed as follows: Observation at 11:01 a.m. dusty vent in bathroom [ROOM NUMBER]. Observation at 11:02 a.m. dusty vent in bathroom [ROOM NUMBER]. Observation at 11:03 a.m. dusty vent in bathroom [ROOM NUMBER]. Observation at 11:04 a.m. dusty vent in bathroom [ROOM NUMBER]. Interview on 5/4/23 at 11:05 a.m. with MD confirmed that the vents were dusty and needed cleaning. He revealed that housekeeping was responsible for dusting the outside of the ceiling vents, and maintenance was responsible for deep cleaning up the inside of the vent. He revealed that the vents are checked monthly, and cleaned as needed, and revealed there was a constant exhaust fan and that is why it was dirty. His expectation was that the vent covers should be clean and should not have a build-up of dust on them. The Maintenance Director provided a work history report for the past year showing that the exhaust fans were checked monthly, and documented, as clean if necessary.

2. Record review of the physician orders for R#176 revealed an order dated 11/17/2022 for oxygen via NC (nasal canula) at two LPM (liters per minute) continuous. Record review of the comprehensive care plan did not reveal a care plan for oxygen use. Observation on 5/2/2023 at 9:17 a.m. and 2:25 p.m. R#176 was observed lying in bed with oxygen (O2) via nasal cannula in use at three liters per minute from a concentrator located at the bedside. Observation on 5/3/2023 at 11:37 a.m. and 12:55 p.m. R#176 was observed lying in bed with O2 via nasal cannula in use at four liters per minute from a concentrator located at the bedside. Interview on 5/4/2023 at 3:25 p.m. with LPN AA revealed that the charge nurses are responsible for developing comprehensive care plans and confirmed oxygen administration was not care planned for R#176 and should have been included. Interview on 5/4/2023 at 12:58 p.m. with Director of Nursing (DON) revealed her expectations of staff is to develop and implement a person-centered care plan based on the resident care needs. The DON reported that care plans are revised to reflect new medications and treatments and she was unsure why R#176 oxygen therapy was not care planned. She reported she was aware of her oxygen orders and confirmed oxygen administration should have been care planned because it's a medication. Cross refer F695. Based on observation, staff interviews, record review, and review of the facility's policy titled, Care Planning-Interdisciplinary Team, the facility failed to follow/develop the comprehensive care plan for two of eleven residents (R) (#18, #176) reviewed for oxygen therapy. Findings include: Review of the undated policy provided by the facility titled, Care Planning-Interdisciplinary Team, policy interpretation and implementation revealed comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 3. The IDT includes but is not limited to a. attending physician; b. registered nurse; c. nursing assistant; d. food and nutrition services staff; e. resident or resident's representative; f. other staff as appropriate. 1. Record review of the most recent quarterly Minimum Data Set (MDS) for R#18 dated 3/14/2023 revealed in section J-health conditions included shortness of breath (SOB), section O-special treatment, procedures, and programs included oxygen. Record review of the care plan R#18 revealed a goal and interventions that included oxygen via n/c as needed (prn) for shortness of breath/respiratory distress, diagnosis (Dx) Hypoxia. Interventions included administering oxygen as ordered. Observation on 5/2/2023 at 11:09 a.m. R#18 was lying in bed, and appeared to be asleep, oxygen (O2) was coming from a concentrator at the bedside, with a flow rate of five liters per minute (5/LPM) via nasal cannula (n/c). The n/c was in the resident's nose, a water bottle dated 4/29/2023. Observation on 5/3/2023 at 8:30 a.m. R#18 was sitting up in bed, had just finished eating breakfast, n/c in the nose, O2 concentrator at the bedside with a flow rate at 5/LPM via n/c. Interview on 5/4/2023 at 9:55 a.m. with the Administrator revealed that R#18 was evaluated for hospice, and the order for oxygen may have been changed. The Administrator further stated that the oxygen settings should be set as ordered by the physician, and care plans followed.

2. Record review of the physician order for R#18 revealed oxygen (O2) two liters per minute (LPM) via nasal cannula (n/c) continuously for shortness of breath (SOB) to keep O2 saturations (Sats) greater than 90%-order dated 10/22/2023; oxygen therapy three liters via mask at hours of sleep (hs) for hypoxia-order dated 3/31/2023, clean oxygen concentrator and change O2 tubing every (q) week every Friday. Observation on 5/3/2023 at 11:11 a.m. R#18 was lying in bed sleeping, n/c in the nose, and the O2 concentrator at the bedside with a flow rate at five LPM. Observation and interview on 5/3/2023 at 11:30 a.m. in the room of R#18 with Licensed Practical LPN she confirmed the oxygen concentrator was running at five LPM via n/c and was in R#18's nose. LPN AA revealed she worked here as needed (prn) and was not at the facility often. LPN AA was not sure what the oxygen setting should be set at but would check the order for the correct setting. LPN AA checked the order and confirmed the oxygen setting should be set at two LPM, and she did not know who or why they would have turned it up to five LPM. Interview on 5/4/2023 at 9:55 a.m. with the Administrator revealed her expectation was that orders from the physician should be followed, and oxygen setting should be set as ordered by the physician. Based on observations, staff interviews, and record review the facility failed to follow the physician's order for one of eleven residents (R) (#18, #176) reviewed for receiving oxygen therapy. Findings include: Observations on 05/02/2023 at 01:22 p.m., 05/03/2023 at 01:44 p.m., and 05/04/2023 at 11:21 a.m. revealed R#176's nasal cannula was operating at the rate of 3LPM while no orders for oxygen were found in the medical record. Observation and interview 5/4/2023 at 2:27 p.m. with Licensed Practical Nurse (LPN) AA confirmed the care plan did not reveal information involving respiratory care utilizing oxygen via nasal cannula at 3LPM. Record review of the most recent MAR & TAR for R#176 dated 5/4/2023 at 12:55 p.m. revealed no instructions for the administration of oxygen. LPN AA confirmed that R#176's oxygen was being delivered to R#176 at three LPM and did not have a physician's order for this medication. LPN AA reported that she had not checked her O2 settings. Interview on 5/4/2023 at 12:58 p.m. with Director of Nursing (DON) revealed her expectation of nurses was to ensure oxygen was administered per physicians' orders. She will investigate this matter and find out exactly why this happened. Interview on 5/4/2023 at 1:06 p.m. with Nursing home Administrator (NA) revealed the expectations of nurses were to ensure oxygen was administered per physicians' orders. She will investigate this matter and find out exactly why this happened. She will further make sure that all parties involved receive education on the proper steps to administer any medication including obtaining the necessary orders before doing so.

Based on observation, policy review and staff interviews, the facility failed to ensure frozen food items in the walk-in freezer were properly labeled, dated, and discarded. In addition, the facility failed to maintain the cleanliness of the main ice machine located in the kitchen. This deficient practice had the potential to effect 107 residents receiving an oral diet. Findings include: 1. During the initial tour observation and interview on 10/26/21 at 9:00 a.m. with the Dietary Director (DD) revealed the following items were located in the freezer without proper labeling to include a date indicating when the item was received, when the item was opened, the expiration date, and/or the use-by date: One large, clear, plastic bag of Beef Ravioli with a hand-written date of 2/23/21 and no indication of what this date represents. One large, clear, plastic bag of Minit Chocolate Puree Dessert with a hand-written date of 3/2/21 and no indication of what this date represents. One medium, clear, plastic bag of Salmon with a hand-written date of 4/6/21 and no indication of what the date represents. One medium, clear, plastic bag of Salisbury Steak with a hand-written date of 9/18/21 and no indication of what this date represents. One medium, clear, plastic bag of hot dogs with a hand-written date of 10/20/21 and no indication of what this date represents. DD verified the frozen food items were improperly labeled and missing dates indicating when the item was received, when the item was opened, the expiration date, and/or use-by date. DD continued to state she could not confirm if the dates written on the clear, plastic, Ziploc bags was the date the package was opened or the date the package was received. Additional items in the freezer: One frozen package of pork, unlabeled Three 3-pound (lb.) bags of Medium Cheese Ravioli, unlabeled Four 2 lb. boxes of Fried [NAME] Tomatoes, unlabeled One 1 lb. box of Assortment Mini Quiches, unlabeled One 12.7-ounce (oz.) box of Wrapped Cocktail Franks, unlabeled DD verified the listed items do not have a label to include a date indicating when the item was received, when the item expires, and/or the use-by date. Review of the undated facility policy titled Food Storage revealed sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Further review revealed frozen foods should be covered, labeled, and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 2. On 10/26/21 at 10:30 a.m., during an observation of the kitchen with Assistant Maintenance Director (AMD) revealed the ice machine was dirty with a dark, grease-like substance located on the back wall of the ice machine. Continued observation revealed dark grease-like substance located underneath the ridge of the ice machine door opening. An interview with AMD on 10/26/21 at 10:30 a.m. confirmed the dirty, dark, grease-like substance located on the back wall of the ice machine and the dark grease-like substance located underneath the ridge of the ice machine door opening. An interview with Maintenance Director (MD) and the AMD on 10/27/21 at 10:30 a.m. revealed it is the responsibility of the maintenance staff to maintain the cleanliness in the kitchen as well as the ice machines in the building. AMD stated the policy used for maintaining the cleanliness of the ice machines is entitled Ice Machines. Review of undated facility policy entitled Ice Machine revealed check water filters, clean coils, sanitize interior, sanitize interior of ice machine per manufacturer's instructions and clean out and sanitize the ice bin, and clean exterior. Review of the maintenance log for cleaning ice machines dated 6/30/21 through 9/30/21 revealed electronic documentation states due date, Category (ice machines/ice bins), Task Description (Ice Machines: check filters clean coils, sanitize interior, delime as necessary), and Task Completion (marked done on time by). Continued review of maintenance log for the ice machines revealed no indication which ice machine was cleaned.