Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The deficient practice had the potential to affect 57 of the facility's 57 residents who consumed food from the kitchen. Observation revealed food being served to residents on 03/182025 was not within the acceptable temperature (temp) ranges for hot and cold foods. Additionally, observation of the kitchen revealed food stored open and exposed to air in a refrigerator and freezer. The findings include: 1. Review of the facility policy titled, Food: Preparation, revised 02/2023, revealed the Dining Service Director/Cooks were responsible for food preparation techniques which minimized the amount of time that food items were exposed to temperatures greater than 41 degrees Fahrenheit (°F) and/or less than 135°F, or per state regulation. Continued review revealed when hot ground food dropped into the danger zone (below 135°F), the mechanically altered food must be reheated to 165°F for 15 seconds if held for hot service. Further review revealed all foods would be held at appropriate temperatures, greater than 135°F (or as state regulations required) for hot holding, and less than 41°F for cold food holding. Observation of the kitchen on 03/18/2025 at 11:30 AM, revealed temperature (temp) checks for fruit cocktail cups located on the counter in individual servings were at 48°F, cole slaw at 50°F, and cold mixed vegetables at 49.1°F which were all above the required 41°F or below for the acceptable range. Further observation revealed the mechanical ground beef on the steam table was temped at 129°F which was below the required 135°F acceptable hot food temperature range. In interview with the District Dietary Manager on 03/18/2025 at 11:45 AM, she stated cold foods should be held at a temperature of 41°F or below and food items on the steam table should be maintained at 135°F, or higher. In interview with [NAME] 1 on 03/20/2025 at 10:30 AM, she stated she was aware food was to be held at an acceptable temperature; however, did not remember the actual acceptable temperature for cold foods. She said she guessed it was below 40°F, and steam table foods were to be held at 140°F and above. The [NAME] reported there was a list posted in the kitchen that showed the correct temperatures and said if she did not know what the correct temperatures were she asked the manager. She further stated she completed the food temperature checks and had logged them on a list. [NAME] 1 additionally said if foods were not held at safe temperatures residents could have sicknesses, including Listeria (a foodborne, bacterial infection). In interview with the Dietary Manager (DM) on 03/20/2025 at 10:45 AM, he stated he was the manager in training. He stated he was aware of the safe temperatures required for cold foods to be held at 41°F or lower and hot foods to be held on the steam table at 135°F or above. The DM further stated foods held at unsafe temperatures could grow pathogens and cause the residents to get sick, and he would throw away any foods not temped in an acceptable range. 2. Review of the facility policy titled, Food Storage: Cold foods, revised 02/2023, revealed all Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated were to be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Further review revealed all foods were to be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation of the kitchen on 03/19/2025 at 9:30 AM, revealed stored in refrigerator 2 was an opened package of cream cheese that was not covered, and a package of precooked bacon in the original container; with both food items exposed to air contaminants. Further observation revealed in freezer 2 there was a large amount of dinner rolls in the original container which was not covered exposing the rolls to air. In continued interview with [NAME] 1 on 03/20/2025 at 10:30 AM, she stated all stored food items should be wrapped or covered to prevent potential contamination. She stated unsealed food items could develop mold or become dried out. The [NAME] reported all staff were required to follow the facility's policy and procedure to prevent potential hazards from occurring. She further stated she would not want to serve residents unsafe, stale or freezer-burnt foods. In continued interview on 03/20/2025 at 10:45 AM, the DM stated all opened food items stored in the refrigerator or freezers were to be covered or wrapped to prevent contamination. He said all food items stored in refrigerator or freezers should be stored with an opened date and an expiration date to ensure they were following food safety guidelines. The DM reported all staff were responsible to check stored food items and ensure it was covered. He stated no food items stored should be expired. He stated he would throw away anything found in storage in the refrigerator or freezer that was not wrapped or covered. The DM further stated the residents were older and more susceptible and vulnerable and could have their health affected if the facility did not follow food safety guidelines. During continued interview on 03/20/2025 at 11:00 AM, the District Dietary Manager (DM) stated the cooks took temperatures of the food served to residents daily. She stated foods not held at the correct temperature range could cause sickness in the residents. The District DM reported all staff were in-serviced monthly, were responsible for food safety in the facility, and were to ensure stored food items were sealed or covered to prevent potential contamination. She said she did not want to food served to residents that was not flavorful or was unsafe for them. The District DM further stated staff were informed they were cooking in the residents' kitchen was their home and the facility was to provide the residents a quality, homelike environment. She further stated moving forward the goal would be to ensure staff were educated on food safety guidelines and to continue with the monthly in-services. In interview on 03/20/2025 at 2:50 PM, the Administrator stated her expectations were for all dietary staff to follow the facility's policies and state guidelines for food safety. She further stated the facility's policies and state guidelines included appropriate food storage and ensuring accurate temperature ranges for both hot and cold food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to follow the care plan for two (2) of fourteen (14) sampled residents, Resident #1 and #20. Residents #1 and #20 had a care plan in place for falls; however, the care plan approaches were not followed to ensure a safe environment. The findings include: Review of the facility's policy, Comprehensive Care Plans Standard of Practice, dated November 2017, revealed it was the practice of the facility to implement a comprehensive person-centered care plan to attain the highest practicable physical well-being. Observation of Resident #1, on 08/01/18 at 8:59 AM, revealed the resident standing by his/her closet with the door ajar and the resident stated he/she had been searching in the closet for a pair of pajama bottoms. When the closet door was opened further, the cord from the television that was mounted wall hung down over the closet door, and when the resident attempted to reach up and grab the cord and place it atop of the closet doorframe, the resident leaned into the wall and struck a wall clock with his/her upper right arm/shoulder. The wall clock fell and the glass face on the clock shattered into pieces on the floor. The resident attempted to lean down to pick up the glass pieces but a Certified Nursing Assistant (CNA) entered the room and stopped the resident. The facility admitted Resident #1 on 03/27/18, with current diagnoses of Non-Alzheimer's Dementia, Seizure Disorder/Epilepsy, Depression, and Psychotic Disorder. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15) and determined the resident interviewable. Review of Resident #1's Care Plan revealed the resident was at risk for injury related to falls with an intervention to ensure a safe environment. Interview with Resident #1, on 08/02/18, at 9:45 AM revealed he/she was upset over the facility owned clock being knocked off the wall yesterday by him/her. The resident stated it was usual for the television cord to hang down over the closet door and prevent the door from opening, but he/she had learned to work around it. He/she stated staff saw the cord hanging down, but he/she reckoned it had become a usual thing. The resident stated the cord could cause an accident because he/she was unsteady on his/her feet at times. Interview with Resident #20, Resident #1's roommate, on 08/02/18 at 10:00 AM, revealed the television cord hung down all the time and both he/she and Resident #1 had to put the cord back up on the doorframe in order to open the closet door. Resident #20 stated it could cause an accident. Review of Resident #20's clinical record revealed the facility admitted the resident on 03/21/18, with current diagnoses of Heart Failure, Seizure Disorder/Epilepsy, Anxiety Disorder, Depression, and Psychotic Disorder. Review of Resident #20's Quarterly MDS, dated [DATE], revealed the facility assessed the resident to be interviewable with a BIMS score of fourteen (14) out of fifteen (15). Continued review of the MDS revealed the resident had a lower extremity impairment on one side. Review of an Incident Report, dated 07/10/18, revealed Resident #20 had recently sustained a fall in the bathroom. Review of the Fall Risk Data Set, dated 07/11/18, revealed Resident #20 had a fall risk score of six (6) on 07/11/18; however it stated regardless of the score, any resident with previous falls should be considered high risk until fall free for six (6) months. Review of Resident #20's care plan revealed the resident was at risk for injury related to falls with an intervention to ensure a safe environment. Interview with the Maintenance Director, on 08/01/18 at 9:15 AM and 08/02/18 at 10:15 AM, revealed television cords were threaded along top of the closet doorframe and secured with tape, which was not a good system, as apparently the tape came down. He stated options to secure the television cords another way was limited due to the concrete walls. He revealed a fallen cord could cause an accident. Interview with Licensed Practical Nurse (LPN) #6, on 08/02/18 at 11:20 AM, revealed residents should not be lifting the television cord over the top of their closet doorframe in order to open their closet because it could cause them to fall. Interview with CNA #6, on 08/02/18 at 11:25 AM, revealed there were times the television cords hung down over closet doors, which was a fall risk. She stated certain department heads did rounds daily to check the safety of the rooms. Interview with LPN #5, on 08/02/18 at 3:43 PM, revealed loose cords could be hazardous because residents could fall if they attempted to fix the cords themselves. He stated the care plan provided staff with goals to provide care to each resident and it was important for staff to follow each resident's care plan. Interview with the Director of Nursing, on 08/02/18 at 4:39 PM, revealed care plans should reflect a safe environment. Interview with the Administrator, on 08/02/18 at 5:08 PM, revealed loose cords provided a potentially unsafe environment.

2. Observation of the B Hallway, on 08/02/18 at 11:25 AM, revealed the wood handrail base, nearest the B Hallway shower room, had exposed wood on the corners of the handrail base, which was rough to touch. The handrail base across the hallway from the shower room had a section of wood that was peeled back (separated from the wood base) and rough to touch. Interview, on 08/02/18 at 11:30 AM, with CNA #3 revealed rough exposed wood on the base that supported the handrails could cause a resident to get a splinter or a cut in his/her skin because elderly residents had fragile and dry skin. She stated with age, a resident's skin might become thinner and therefore not as durable, so staff must protect residents from any type of skin injury. Interview, on 08/02/18 at 11:55 AM, with LPN #4 revealed rough damaged areas of wood along the wood base handrail was a concern because residents with thinning or fragile skin could obtain an injury such as a skin tear, which could become infected. Interview, on 08/02/18 at 1:30 PM, with the Unit Manager revealed administrative staff was assigned areas of the building to monitor on a routine basis and they should report any areas of the building in disrepair and potentially hazardous to residents. The UM stated residents who scraped or rubbed against rough areas of wood near the handrails could obtain a cut or a splinter. She stated older residents had fragile skin and a tear to their skin could potentially become infected. Based on observation, interview, and facility policy review, it was determined the facility failed to ensure the resident environment remained as free from accidents and hazards as possible for two (2) of fourteen (14) sampled residents, Resident #1 and #20. The resident's room had a television cord that hung down in front of the closet door, which obstructed the use of their closet door. In addition, three (3) radiator heaters located in common areas contained no end covers leaving exposed sharp metal edges, and there were chipped, rough exposed areas on the wood bases that affixed handrails to the walls on the B Hallway. The findings include: Review of the facility's policy, Incident and Accident Process, dated October 2015, revealed the purpose of the Incident and Accident process was to ensure the facility environment was as free from accident hazards over which the facility had control, and each resident received adequate supervision to prevent avoidable accidents. 1. Observation of Resident #1, on 08/01/18 at 8:59 AM, revealed the resident standing by his/her closet and the resident stated he/she had been searching in the closet for a pair of pajama bottoms; the closet door was ajar approximately eight (8) inches. When the closet door was opened further, the television cord from the mounted wall television hung down over the closet door and when the resident attempted to reach up, grab the cord, and place it atop of the closet doorframe, the resident leaned into the wall and struck a wall clock with his/her upper right arm/shoulder. The wall clock fell to the floor and the glass face on the clock shattered into pieces. The resident attempted to lean down to pick up the glass pieces but a Certified Nursing Assistant (CNA) entered the room and stopped the resident. Interview with Resident #1, on 08/02/18, at 9:45 AM, revealed he/she was upset the clock was knocked off the wall yesterday and wanted to pay for it. The resident stated it was usual for the television cord to hang down over the closet door, which prevented the door from opening, but he/she had learned to work around it. He/she stated staff knew the cord hung down, but he/she reckoned it was a usual thing. The resident stated the cord could cause an accident because he/she was unsteady on his/her feet at times. Interview with Resident #20, Resident #1's roommate, on 08/02/18 at 10:00 AM, revealed the television cord hung down all the time and both he/she and Resident #1 had to lift the cord and put it on top the doorframe in order to open the closet door. Resident #20 stated it could cause an accident. Interview with the Maintenance Director, on 08/01/18 at 9:15 AM, revealed television cords were taped into an electrical outlet, threaded along the top of the closet doorframe, and then secured with tape. He stated the tape had apparently come down in Resident #1's room, as it was not a good system. Continued interview, on 08/02/18 at 10:15 AM, revealed options to secure the television cords another way was limited due to the concrete walls. He stated a fallen cord could cause an accident. Interview with Licensed Practical Nurse (LPN) #6, on 08/02/18 at 11:20 AM, revealed residents should not be lifting the television cord to put it on top of their closet doorframe because the residents could fall. Interview with CNA #6, on 08/02/18 at 11:25 AM, revealed there were times the television cords hung down over the closet doors, which was a huge fall risk. She stated certain department heads did rounds daily to check the safety of the rooms. Interview with LPN #5, on 08/02/18 at 3:43 PM, revealed loose cords could be hazardous, as residents could fall if they attempted to fix the cord. Interview with the Administrator, on 08/02/18 at 5:08 PM, revealed loose cords provided a potentially unsafe environment. 3. Observation, on 08/01/18 at 11:00 AM, revealed two (2) radiator heaters near the B Hall exit vestibule near the kitchen, had no end caps, which exposed sharp metal edges that were at shin level. In addition, observation in the dining room revealed (1) one radiator heater near the front entry door with no end caps, which exposed sharp metal edges at shin level. Interview with CNA #4, on 08/02/18, revealed she did not know if the radiator ends were supposed to be capped off or not. She stated the metal edges contained sharp edges and she was concerned if there were a fall it could cause a skin tear. Interview with CNA #5, on 08/02/18 at 3:14 PM, revealed the exposed metal edges on the side of the radiators could be sharp and cause a skin tear or a resident's clothing could catch on the metal and cause a fall. Interview with LPN #5, on 08/02/18 at 3:43 PM, revealed he believed the radiators with no caps were a safety concern because the edges were sharp and something could get caught on the sharp metal edges. Interview with the Director of Maintenance, on 08/02/18 at 4:09 PM, revealed he did not know where the original caps for the radiators were located. He stated he believed the edges were sharp. Interview, on 08/02/15 at 5:15 PM, with the Administrator revealed the Quality Assurance Committee had not identified trends in accidents or with unsafe conditions in the residents' environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, it was determined the facility failed to ensure handrails were securely fastened to the wall in one (1) of two (2) hallways, the B Hallway. The findings include: Review of the facility's policy, Maintenance Service, revised December 2009, revealed maintenance service would be provided to all areas of the building, grounds, and equipment. The Maintenance Department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Observation, on 08/01/18 at 1:30 PM, revealed the handrail in the B Hallway, between resident rooms [ROOM NUMBERS], was attached to a wooden board that had separated from the wall, about eighteen (18) inches in length, and therefore the handrail was no longer firmly attached to the wall. Observation, on 08/02/18 at 11:55 AM, revealed the handrail between resident rooms 108-110 remained loose and not secured to the wall and unstable for use. Interview, on 08/02/18 at 11:30 AM, with Certified Nursing Assistant (CNA) #3 revealed she normally worked on the B Hallway and a number of residents depended on the handrails to move through the hallway. She stated if residents depended on the handrail, especially when trying to walk down the hall while holding onto the rail, then the unstable handrail could potentially hurt the residents, as they could fall. CNA #3 stated the resident in room [ROOM NUMBER], near the loose section of the handrail, used a wheelchair and often grabbed onto the rail for use to self-propel for mobility. Interview, on 08/02/18 at 3:20 PM, with CNA #5 revealed some residents relied on the handrail for support while walking or moving about the hallway, and a loose handrail could potentially cause them to lose their balance and fall. Interview, on 08/02/18 at 11:55 AM, with Licensed Practical Nurse (LPN) #4 revealed she had not noticed the handrail was loose, but it was of concern to her because it could potentially cause a resident to become unstable on his/her feet and fall. Interview, on 08/02/18 at 1:30 PM, with the Unit Manager (UM) revealed a loose, unstable handrail was concerning because residents attempting to ambulate while holding onto a loose handrail could potentially lose their balance and fall. She stated all handrails should be in good repair to ensure residents' safety. The UM stated the facility had a monitoring process in place where administrative staff was assigned to a number of resident rooms, and they should inspect those rooms and the shower rooms for any hazards or necessary repairs. If repairs were needed, staff should notify the appropriate staff person who could assess the situation and make the necessary repair(s). She stated she would phone the Maintenance Director or the housekeeping staff and she was not aware of any other method to transmit the need for repairs or cleaning. Interview, on 08/02/18 at 4:05 PM, with the Maintenance Director revealed he was not aware of the loose handrail in the B Hallway until it was reported to him today. He stated he learned of needed building repairs in several ways. Some staff left notes for him and some staff telephoned him to report a needed repair. However, he stated he preferred staff use the computer system to report building issues and needed repairs because the system permitted logging and tracking of needed and completed repair projects. He stated if staff reported an issue via the computer system, the system would transmit a text message to his cellular phone, and he was notified quicker of issues in the building. He stated he had provided training to staff on use of the computer notification system. Interview, on 08/02/18 at 4:40 PM, with the Director of Nursing (DON) revealed if a hallway handrail was detached from the wall; it would be unsafe for residents to use for mobility assistance. She state a loose handrail could contribute to a resident's fall. Interview, on 08/02/18 at 5:15 PM, with the Administrator revealed the Quality Assurance Committee had not identified any trends associated with areas in the building that made the environment unsafe for residents. She stated she always wanted ensure a resident's mobility through the facility's hallways was safe and as risk free as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's policy, it was determined the facility failed to provide residents a safe, clean, comfortable, and homelike environment in twelve (12) of twenty-nine (29) resident rooms, room [ROOM NUMBER], 103, 105, 107, 108, 109, 111, 112, 121, 126, 128, and 132. Observations revealed scratched walls and doors, a missing toilet tank lid, loud bathroom fans, broken vanities, holes in walls, un-painted patched areas, a door that stuck upon opening, and water stains on ceilings. The findings include: Review of the facility's policy, Quality of Life - Homelike Environment, dated August 2008, revealed residents were provided with a safe, clean, comfortable, and homelike environment and staff and management would maximize, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting to include, cleanliness, inviting colors and decor, and comfortable noise levels. 1. Observation of the restroom in Resident room [ROOM NUMBER], on 08/01/18 at 4:36 PM, revealed the toilet did not have a tank cover, which exposed the inside of the water tank. The toilet made a constant running water sound. Interview with Resident #19, on 08/02/18 at 10:39 AM, revealed he/she resided in room [ROOM NUMBER] and it bothered him/her when the toilet constantly ran water because it seemed to be such a waste of water. The resident also stated the toilet tank lid had been gone for several weeks and the water in the tank looked black, and had an odor. The resident stated he/she always had a tank cover in place in his/her own home, prior to moving into the facility. Interview with Certified Nursing Assistant (CNA) #2, on 08/02/18 at 10:49 AM, revealed the toilet tank cover had been missing for the last two (2) days. She stated she had not reported the issue to the Maintenance Department because she assumed they were aware and working on it. Interview with the Maintenance Director, on 08/02/18 at 10:42 AM, revealed he was not aware of the missing toilet tank lid. He stated staff should have informed him of the issue. Interview with Licensed Practical Nurse (LPN) #5, on 08/02/18 at 3:43 PM, revealed it was not very homelike for a resident's toilet tank not to have a cover. 3. Observation of Resident room [ROOM NUMBER], on 08/01/18 at 3:15 PM, revealed the base of the vanity was missing and the hand sanitizer dispenser was lying on the counter. The curtain rod and brackets were missing from over the window, and there were two (2) un-patched holes. Observation of Resident room [ROOM NUMBER], on 08/01/18 at 3:17 PM, revealed a golf ball sized hole in the wall near the heater unit. There were scattered, white patched areas on the wall under the air conditioner, over the window, and adjacent to the paper towel dispenser. Observation, on 08/01/18 at 3:19 PM, of Resident room [ROOM NUMBER] revealed the bottom edge of the door to the room was separated and splintered, and the wall near the heater had cracked and chipped paint. Interview with CNA #1, on 08/02/18 at 11:35 AM, revealed she filled out a stop and watch form or called maintenance when she identified any maintenance issues. She stated she never noticed the hole in the wall of room [ROOM NUMBER] or the missing vanity base in room [ROOM NUMBER]. According to the CNA, all staff knew about the unpainted wall patches. She stated the facility was the residents' home and rooms should be maintained in good repair. Interview with CNA #5, on 08/02/18 at 3:19 PM, revealed she notified the nurse or called the Maintenance Director for any maintenance issues. She stated she noticed some of the resident rooms were in disrepair, including holes and caulked areas on the walls. She revealed she had not noticed any maintenance issues with the vanity cabinets. According to the CNA, residents should have a homelike environment. Interview with LPN #3, on 08/02/18 at 9:30 AM, revealed she notified the Maintenance Director in passing regarding any maintenance issues. She stated she had not noticed the hole in the wall in room [ROOM NUMBER] or the splintered door in room [ROOM NUMBER]. The LPN revealed both were potential safety issues and stated a resident could sustain a skin tear from the door. She further revealed it was important to ensure resident rooms were homelike. Interview with the Director of Maintenance, on 08/02/18 at 4:07 PM, revealed he toured resident rooms weekly, had identified needed repairs, and stated the facility had a long-range plan for painting and updating. The Maintenance Director revealed it was important to complete repairs timely to ensure a clean, comfortable, and homelike environment for the residents. 2. Observation of the B Hallway, on 08/01/18 at 2:40 PM, revealed the door entry ways for Resident Rooms 103, 105, 107, 109, 111, and 112, had scraped, scuffed doors and areas of gouged wood at the door casings. In addition, many of the doorways had peeling or missing paint that revealed the previous color (bright green), including the wall in the hallway between Resident rooms [ROOM NUMBERS] at the mid-point above the handrail. Observation, on 08/02/18 at 11:20 AM, in Resident room [ROOM NUMBER] revealed some missing vinyl baseboard between the sink and the bathroom door that exposed an area of the wall with gouged wallboard, scrapes, and missing paint. Interview, on 08/02/18 at 3:20 PM, with CNA #5 revealed she noticed some vinyl baseboard separating from the walls in resident rooms, and had noticed the chipped paint on walls and resident room doorways. She stated the appearance of the walls and doors did not provide a clean, comfortable, or homelike appearance, and if her own home were in disrepair in similar ways, she would want the repairs completed quickly. Interview, on 08/02/18 at 3:40 PM, with LPN #5 revealed damaged walls, doorways, and ceilings did not provide a clean comfortable appearance for the residents who lived at the facility. He stated the facility should seem as homelike as possible. He stated when he identified areas of living space that needed repair, he notified the Maintenance Director, and usually did so by calling the Maintenance Director. However, LPN #5 stated after making reports of needed repairs, there were times when it seemed like a long wait before the repairs were completed. Interview, on 08/02/18 at 4:05 PM, with the Maintenance Director revealed he learned of needed building repairs in several ways. Some staff left notes for him and some staff telephoned him to report a needed repair. However, he stated he preferred staff use the computer system to report building issues and needed repairs because the system permitted logging and tracking of needed and completed repair projects. He stated if staff reported an issue via the computer system, the system would transmit a text message to his cellular phone, and he was notified quicker of issues in the building. He stated he had provided training to staff on use of the computer notification system. 4. Observation, on 08/01/18 at 11:00 AM, revealed Resident room [ROOM NUMBER]'s bathroom fan contained cobwebs and when turned on, gave off a dim light and produced an audible loud [NAME]. The ceiling in the restroom had brown stains and a hand sanitizer dispenser had fallen off the wall and was sitting on the back of the toilet tank. Interview with Resident #16, on 08/02/18 at 1:17 PM, revealed he/she resided in room [ROOM NUMBER] and did not use the bathroom fan light because it was too loud, as it rumbled and rattled. Continued observation, on 08/01/18 at 11:00 AM, revealed Resident room [ROOM NUMBER] had a vanity cabinet that held the sink and was broken away from the wall and the cabinet base was broken. Further observation revealed Resident room [ROOM NUMBER]'s bathroom door opened approximately one quarter of the way and then caught on the floor, which required extra effort to open the door completely, and there were brown stains on the ceiling. Interview with Resident #27 and #43, on 08/02/18 at 10:46 AM, revealed they resided in room [ROOM NUMBER] and Resident #27 stated the bathroom door was hard to pull and when he/she pulled the door, it scraped on the floor making a loud noise. Resident #43 stated the door to the restroom dragged and he/she had to go to the shower room to use the toilet because it was too hard to get his/her wheelchair into the bathroom. The resident stated he/she had to notify staff when he/she needed to go to the bathroom in the shower room because the shower room had a code lock. Resident #43 stated he/she would rather use the bathroom in his/her room because he/she could not use the toilet in the shower room if staff was giving another resident a shower. Resident #43 revealed the door had been sticking like that since he/she began residing in that room. Interview with CNA #3, on 08/02/18 at 11:30 AM, revealed she knew Resident #43 and #27's bathroom door stuck upon opening, which made it hard for the residents to open and Resident #43 had difficulty getting his/her wheelchair into the bathroom. She further revealed room [ROOM NUMBER] had a slant to the floor related to past foundation issues and the loose vanity cabinet caused trouble with using the drawers and the drawers closing correctly. Interview with CNA #5, on 08/02/18 at 3:14 PM, revealed a broken vanity sink could affect the resident's safety and with the cabinet being broken, she would be concerned with cuts to the residents or skin tears. She stated she was familiar with the bathroom fans being loud and stated she had called and reported to maintenance the water damage on the ceilings of rooms and restrooms because it created an unsafe environment for residents. Interview with LPN #5, on 08/02/18 at 3:43 PM, revealed he did not feel like the facility created a homelike environment for the residents. He stated broken bathroom fans should be reported to the maintenance department because they were not supposed to rattle and create noise pollution, and it indicated the fan was not working properly. LPN #5 further revealed he had noticed and reported water damage on the ceilings in the past because it did not create a homelike environment. LPN #5 stated he was aware some of the resident room doors caught on the floor making them difficult to open and it was not homelike because it was difficult for a resident in a wheelchair to get through. Interview with the Director of Maintenance, on 08/02/18 at 4:09 PM, revealed if staff found issues related to building maintenance, they were supposed to input the issue into the computer system and rate the importance as either low, medium, high, or critical. He stated some staff utilized the system and some did not. He further stated the facility recently had foundation issues, which led to the vanity coming loose from the wall in Resident room [ROOM NUMBER]. He also stated the sprinkler system was set off, which led to several water spots and leaks in the ceilings. He further stated he was aware of doors getting stuck on the floor while opening but it was not something he audited frequently, he relied on staff to report issues of that nature. Interview with the Director of Nursing, on 08/02/18 at 4:39 PM, revealed she had noticed the environment had several issues that needed addressed but her primary focus had been on improving nursing care. She stated she thought the building needed to be renovated because it was outdated and if the issues were repaired, it would create a more attractive environment for residents. Interview with the Administrator, on 08/02/18 at 4:57 PM, revealed the physical environment of the facility required attention. She stated she desired to have it repaired but safety issues in the building took precedence and were being addressed at that time. She stated based on the different environmental factors that required repair, she was concerned for resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medications were securely stored in three (3) of six (6) medication carts and within the medication refrigerator in the A Hall medication room. Observations revealed medication carts were unlocked and unattended on the A and B Halls. In addition, the key to the medication refrigerator lock was stored on a hook inside the medication room. The findings include: Review of the facility's policy, Controlled Medication Storage, dated November 2017, revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. The medication nurse on duty would maintain possession of the key to controlled medication storage areas and the Director of Nursing (DON) would keep back-up keys to all medication storage areas, including those for controlled medications. The policy further revealed the access system (key, security codes) used to lock controlled medications could not be the same access system used to obtain the non-scheduled medications. In addition, controlled medications requiring refrigeration would be stored within a locked, permanently affixed box within the refrigerator. Review of the facility's policy, Storage of Medication, dated November 2017, revealed in order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) were allowed access to medication carts. Medications rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. The policy revealed medication storage conditions would be monitored on a regular basis, as a random quality assurance (QA) check, and recommendations made for corrective action as problems were identified. 1. Observation, on 07/31/18 at 9:20 AM, revealed an unlocked medication cart located outside room [ROOM NUMBER] on the B Hallway. At 9:23 AM, three (3) staff walked past the unlocked cart. Interview with Licensed Practical Nurse (LPN) #2, on 07/31/18 at 9:23 AM, revealed she forgot to lock the medication cart when she walked away to assist a resident. The LPN revealed it was important to ensure the medication cart remained locked at all times to prevent an accidental poisoning or theft of medication. Observation, on 08/02/18 at 9:19 AM, revealed an unlocked medication cart located at the A Hall nurses' station. The third drawer of the cart was slightly ajar. Observation, on 08/02/18 at 10:36 AM, revealed an unlocked medication cart across from the B Hall nurses' station with no staff members in sight. Residents were ambulating in the area near the cart with no staff supervision. At 11:27 AM, the medication care remained unlocked and Resident #21 walked past the unlocked cart. Interview with LPN #4, on 08/02/18 at 11:27 AM, revealed she forgot to lock the medication cart when she walked away to attend to a resident. The LPN revealed there was a risk a resident could access medications in the cart and potentially overdose or die. Interview with the Unit Manager (UM), on 08/02/18 at 9:50 AM, revealed medication carts should be locked at all times to prevent unauthorized access and ensure the safety of residents. The UM revealed she monitored medication carts daily when she walked the hallways and had not identified any concerns regarding unlocked carts. Interview with the DON, on 08/02/18 at 4:39 PM, revealed she had not identified any concerns related to unlocked medication carts. Interview with the Administrator, on 08/02/18 at 5:07 PM, revealed she had not identified any systemic issues related to unlocked medication carts. She revealed it was important to ensure medication carts were secure because residents could potentially access and swallow the medications. 2. Observation, on 08/01/18 at 9:04 AM, of the A Hall medication room refrigerator revealed the door to the refrigerator was locked; however, the key to the lock was hanging from a hook on the wall. There was an unlocked metal box chained to the inside the refrigerator, which contained one (1) bottle of oral Ativan 2 milligram/milliliter. Further observation of the A Hall medication refrigerator, on 08/01/18 at 2:55 PM, revealed it contained three (3) 12-count jars of glycerin suppositories, forty-seven (47) Biscodyl suppositories, eleven (11) Acephan suppositories, eight (8) vials of insulin, one (1) vial of Procrit, six (6) vials of Engerix, six (6) vials of Tuberculin, thirteen (13) vials of Pneumovax, and one (1) vial of Aplisol. In addition, there was an emergency pharmacy box sealed with a zip tag, which contained six (6) vials of insulin and two (2) Phenergan suppositories. Observation, on 08/01/18 at 4:46 PM, revealed LPN #5 entered the A Hall medication room accompanied by a male staff member. Interview with the LPN revealed she administered a Tuberculin (TB) skin test to the staff member, which was okay because the staff member was not left alone. Interview with the UM, on 08/01/18 at 3:05 PM, revealed the medication room refrigerator would not be considered secured because the key was accessible. The UM stated it was important to maintain secured storage of medications to prevent access and potential diversion. She further revealed she had not noticed the missing lock on the metal box inside the refrigerator. Further interview with the UM, on 08/02/18 at 9:50 AM, revealed it was probably not okay to administer TB skin tests in the medication room and stated she was not familiar with the facility's policy for storage of the medication room keys. Interview with the DON, on 08/02/18 at 4:39 PM, revealed she was not aware the key to the medication refrigerator was stored inside the medication room. She stated she did not know how many sets of keys there were for the medication carts/rooms and revealed there was no system in place to track keys in the facility. The DON revealed controlled medications should be double-locked and all medications should be stored in a secured area to prevent potential diversion. Interview with the Administrator, on 08/02/18 at 5:07 PM, revealed she had not identified any concerns related to unlocked medication carts or secured storage of medications. The Administrator stated there was the potential for diversion of medication if someone gained access to the refrigerator key stored in the medication room.