Based on record reviews, observation, and interviews, the facility failed to ensure a resident's continuous enteral feeding (intake of food through a tube placed into the stomach) was not stopped and restarted by a certified nursing assistant (CNA) for 1 (Resident #228) of 2 (Resident #10 and Resident #228) sampled residents investigated for enteral feeding. Findings: Review of Resident #228's record revealed, in part, an admission date of 06/25/2024 and diagnoses including mild protein-calorie malnutrition and failure to thrive. Review of Resident #228's Minimum Data Set with an Assessment Reference Date of 07/02/2024 revealed, in part, Resident #228 required enteral feeding through a gastrostomy tube (an artificial hole in the stomach to deliver enteral feedings). Review of Resident #228's July 2024 Physician's Orders revealed, in part, an order for Isosource 1.5 calories (a type of enteral feeding formula) at 40 milliliters an hour continuously via a feeding pump. Further review revealed an order to check the placement of Resident #228's gastrostomy tube prior to the administration of feedings. Review of Resident #228's care plan revealed, in part, Resident #228 was care planned to be at risk for malnutrition related to poor appetite and enteral feedings with an intervention to administer enteral feedings as ordered by the physician. Observation on 07/08/2024 at 10:35 a.m. revealed Resident #228 was being assisted with care by S7CNA. Further observation revealed Resident #228's enteral feeding pump was on hold and alarming. Observation then revealed S7CNA restarted Resident #228's enteral feeding pump. In an interview on 07/10/2024 at 10:39 a.m., S8Licensed Practical Nurse (LPN) indicated CNAs were not supposed to manipulate a resident's enteral feeding pump at all during care of the resident. S8LPN indicated the CNAs were supposed to have the nurse stop, pause, or restart the enteral feeding pump. In an interview on 07/11/2024 at 1:02 p.m., S7CNA indicated during care of a resident who was being administered enteral feedings, S7CNA paused the enteral feeding pump in order to lower the head of the bed. S7CNA stated once the resident's care was completed, S7CNA would elevate the HOB and restart the enteral feeding pump. In an interview on 07/11/2024 at 1:40 p.m., S7CNA confirmed she paused and restarted Resident #228's tube feeding pump while providing care on 07/08/2024. S7CNA stated she should have asked the nurse to turn off the enteral feeding pump and then restart it. In an interview 07/11/2024 1:55 p.m., S9Corporate Registered Nurse confirmed a CNA should not manipulate a resident's enteral feeding pump. In an interview on 07/11/2024 at 1:59 p.m., S2Director of Nursing (DON) indicated only a nurse should pause and restart a resident's enteral feeding pump. S2DON confirmed a CNA should not operate a resident's tube feeding pump.

Based upon observations, record reviews, and interviews, the facility failed to assess a resident's respiratory status and provide oxygen (O2) accordingly for 1 (Resident #12) of 1 (Resident #12) sampled residents reviewed for respiratory care. Findings: Observation on 07/08/2024 at 12:03 p.m. revealed Resident #12 was wearing a nasal cannula (NC) connected to an oxygen concentrator at 2.5 liters per minute (lpm). Observation on 07/09/2024 at 10:10 a.m. revealed Resident #12 was wearing a nasal cannula (NC) connected to an oxygen concentrator at 2.5 liters per minute (lpm). Observation on 07/10/2024 at 11:31 a.m. revealed Resident #12 was wearing a nasal cannula (NC) connected to an oxygen concentrator at 2.5 liters per minute (lpm). Review of Resident #12's electronic medical record (EMR) revealed an order dated 04/23/2024 for oxygen at 2 lpm via NC as needed (PRN) for saturations less than 93 Further review revealed instructions to check and record oxygen saturation levels. Review of Resident #12's electronic medication administration record (EMAR) for May, June, and July 2024 revealed the oxygen saturation was only documented for the PRN O2 order once; on 05/24/2024 at 7:07 p.m., the measurement was 93%. In an interview on 07/10/2024 at 12:19 p.m., S3Licensed Practical Nurse (LPN) indicated Resident #12 was always on O2 when she entered the room. S3LPN indicated she believed Resident #12 was supposed to be on continuous O2. In an interview on 07/10/2024 at 12:25 p.m., S8LPN indicated Resident #12 had an order for PRN oxygen at this time. In order to administer O2 as PRN in computer, the special requirement for oxygen saturation measurement must be met and recorded; but Resident #12 was wearing O2 continuously, so the last recorded saturation was on 05/24/2024. S8LPN indicated the Resident #12's oxygen saturation should have been taken and recorded before administering oxygen. In an interview on 7/11/2024 at 10:55 a.m., S2DON indicated Resident #12's oxygen order was unclear, and the nurses should have been measuring the O2 saturations and documenting them. S2DON further indicated the O2 should have only been given to the resident if saturations were less than 93%, and Resident #12 had been wearing the O2 continuously and should not have been.

Based on observation, and interviews, the facility failed to ensure staff removed gloves and perform hand hygiene prior to exiting a resident's room for 1 (S6Housekeeper) of 1 (S6Housekeeper) housekeepers observed for infection control. Findings: Observation on 07/10/2024 at 1:05 p.m. revealed S6Housekeeper exited the elevator on the first floor by the dining room with her gloves on. Observation further revealed she was the only person on the elevator. In an interview on 07/10/2024 at 1:10 p.m., S6Housekeeper indicated she forgot to take her gloves off after cleaning a resident's room on the second floor. In an interview on 07/10/2024 at 1:15 p.m., S5Housekeeping Supervisor indicated staff should take off gloves and perform hand hygiene when exiting resident rooms. In an interview on 07/10/2024 at 2:27 p.m., S4Assistant Director of Nursing/Infection Preventionist indicated gloves should be removed and hand hygiene performed when exiting resident rooms. In an interview on 07/10/2024 at 3:50 p.m., S2Director of Nursing confirmed gloves should be removed prior to leaving a resident room.

Based on observation and interviews the facility failed to ensure expired medications were not available for use for 1 (Medication Room a) of 1 (Medication Room a) medication rooms observed during medication storage observations. Findings: Observation on 07/09/2024 at 2:17 p.m. of Medication Room a revealed the following, in part, a bottle of Aspirin 325 milligrams (mg) with an expiration date of 04/2024. Further observation revealed four boxes of Influenza Fluad Quadrivalent (injectable medication use to prevent the flu) with an expiration date of 06/30/2024. In an interview on 07/09/2024 at 2:20 p.m., S3Licensed Practical Nurse (LPN) indicated the above mentioned medications should not have been available for resident use. In an interview on 07/09/2024 at 2:55 p.m., S2Director of Nursing (DON) indicated the above mentioned medications should not have been available for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure a resident's nurse documented and communicated a resident's fall for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents reviewed for accidents. Findings: Review of the facility's Accident/Incident Reports policy and procedure revealed, in part, all accidents and/or incidents including residents will be reported to the Charge Nurse and to the appropriate department head immediately upon knowledge of occurrence, so that it may be evaluated. Further review revealed an accident and/or injury was defined as an unexpected happening which may or may not have caused loss or injury. Review also revealed following an incident, an incident report will be completed on any accident and/or incident that occurred within the facility and information regarding accidents and/or incidents that involve a resident will be recorded in the resident's medical record in the nurses' notes. Review of the facility's Fall policy and procedure revealed, in part, when a resident sustained a fall or was found on the ground without a witness to the fall, the following should be completed: note position of resident; record vital signs; evaluate the resident for injuries, perform range of motion on all extremities; and, observe for the cause of the fall. Further review revealed if the fall involved head injury or was unwitnessed, neurological checks should be initiated. Review also revealed documentation of fall information should be completed in the resident's medical record. Review of Resident #3's record revealed, in part, Resident #3 was admitted on [DATE] following surgical intervention of a left femur fracture sustained from a fall at home. Further review revealed Resident #3 was discharged from the facility on 10/21/2023. Review of Resident #3's Minimum Data Set (MDS) with an Assessment Reference Date of 10/11/2023 revealed, in part, Resident #3 had one fall with no injury and one fall with injury that was not major since admission to the facility. Review of Resident #3's Nurse Data Collection and Screening completed on 10/04/2023 revealed Resident #3 was assessed as a high risk for falls. In an interview on 12/20/2023 at 10:56 a.m., S3Licensed Practical Nurse (LPN) stated that Resident #3 was moved to a room closer to the nurse's station, because Resident #3 had two falls back to back shortly after he was admitted . In an interview on 12/20/2023 at 2:28 p.m., Resident #3's wife stated the facility had informed her that Resident #3 had 2 falls while Resident #3 was admitted to the facility. Resident #3's wife further stated Resident #3's falls were on two separate days around 11:00 p.m. Review of Resident #3's Nurse's Note from 10/07/2023 at 6:34 p.m. revealed, in part, S4LPN documented Resident #3 denied pain or discomfort from his fall. Review of Resident #3's Nurse's Notes from admission to discharge did not reveal any documentation Resident #3 had a fall prior to S4LPN's nurse's note on 10/07/2023 at 6:34 p.m. Review of Resident #3's Neurological Observations Head Injury flowsheet revealed neurological assessments were initiated on 10/06/2023 at 11:00 p.m. In an interview on 12/21/2023 at 11:17 a.m., S4LPN stated when she arrived to work on the morning of 10/07/2023, S4LPN received in report that Resident #3 had fallen on the night of 10/06/2023. S4LPN further stated Resident #3 had fallen again the following night on 10/07/2023. Review of Resident #3's Nurse's Notes from 10/08/2023 at 12:43 a.m. revealed, in part, S6LPN documented Resident #3 had an unwitnessed fall on 10/07/2023 at 11:15 p.m. Review of Resident #3's Nurse Practitioner's Progress Note from 10/09/2023 revealed, in part, Resident #3 had two unwitnessed falls over the weekend while attempting to ambulate. In an interview on 12/21/2023 at 12:11 p.m., S5MDS Nurse confirmed Resident #3's 10/11/2023 MDS revealed Resident #3 had a fall with no injury and a fall with an injury that was not major since admission. S5MDS Nurse stated she used S4LPN's nurse's note from 10/07/2023 at 6:34 p.m. and S6LPN's nurse's note from 10/08/2023 at 12:43 a.m. to obtain Resident #3's fall data. In an interview on 12/21/2023 at 12:23 p.m., S2Assistant Director of Nursing (ADON) stated the only documented evidence she had of Resident #3's 10/06/2023 fall was the neurological checks initiated on 10/06/2023 at 11:00 p.m. by S7LPN. S2ADON stated the facility's nursing administration was not made aware of Resident #3's fall on 10/06/2023. In an interview on 12/21/2023 at 2:38 p.m., S1Director of Nursing (DON) stated when a nurse noted a resident's fall, an incident report and communication to the facility's administration should be completed. S1DON confirmed that discussion of the details of a resident's fall could prevent future falls from occurring. In an interview on 12/21/2023 at 2:41 p.m., S2ADON stated Resident #3's nurse should have communicated Resident #3's fall on 10/06/2023 at 11:00 p.m. in order for interventions to be placed to prevent future falls. S2ADON confirmed there was no documented evidence that the nurse documented the details of Resident #3's fall on 10/06/2023. In an interview on 12/21/2023 at 2:45 p.m., S8Quality Improvement Nurse confirmed there was no documented evidence Resident #3's nurse communicated Resident #3's 10/06/2023 fall to administrator or documented any specifics regarding Resident #3's 10/06/2023 fall. S8Quality Improvement Nurse further confirmed Resident #3's 10/06/2023 fall details were important to discuss with the facility administration in order to place appropriate interventions to prevent future falls.

Based on record review and interview, the facility failed to ensure a thorough investigation was conducted when an injury of unknown origin was discovered for 2 (Resident # 7 and Resident #34) of 2 (Resident # 7 and Resident #34) sampled residents reviewed for injuries of unknown origin. Findings: Review of the facility's Incident Investigation and Reporting Policy revealed the facility's investigation should include signed statements from all staff involved. Further review revealed, if only oral information can be obtained for a statement, the facility must have at least two persons present to receive information and the reporter must have the statement read back to him or her. The reporter, the recorder, and the witness must also sign. Resident #7 Review of Resident #7's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 06/23/2023 revealed, in part, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 1 indicating severe cognitive impairment and Alzheimer's disease. Review of Resident #7's departmental note dated 08/28/2023 revealed, in part, Resident #7's was screaming in pain. Resident #7's left ankle and foot was assessed and found to be turned inward. Further review revealed Resident #7 was sent to the hospital for evaluation. Review of the facility's Health Standard Incident Report dated 08/28/2023 revealed, in part, Resident #7 had an injury of unknown origin discovered by the nurse on 08/28/2023. Further review revealed, in part, the facility's administrative staff was alerted to a possible fracture to Resident #7's left lower leg and Resident #1 was sent to the hospital for evaluation. Further review of the incident report revealed an investigation was conducted and statements were obtained from 5 staff members (S8Certified Nursing Assistant (CNA), S11CNA, S22MDS Nurse, S25Licensed Practical Nurse (LPN), and S26LPN). Further review revealed 5 residents were interviewed for abuse, and camera footage was reviewed. Additional review of the incident report revealed the facility did not find the injury suspicious of abuse. Review of the facility's camera footage on 08/28/2023 from 5:00 a.m. until 9:15 a.m. revealed, in part, various staff members from multiple departments completing tasks on the hallway with Resident #7 present. Further review revealed, S11CNA and S20CNA entered and then exited Resident #7's room twice between 8:28 a.m. and 8:35 a.m. Additional review revealed S9Human Resources entered and then exited Resident #7's room at approximately 8:51 a.m. In an interview on 09/13/2023 at 1:15 p.m., S20CNA stated she was present in Resident #7's room on the morning of 08/28/2023 to assist S11CNA with Resident #7's a.m. care. S20CNA stated she observed S11CNA complete a manual transfer on Resident #7 and then they both left the room to get supplies to change Resident #7. S20CNA further stated she and S11CNA entered Resident #7's room again a few minutes later to provide incontinence care and that was when they noticed her left foot looked strange and twisted and they then notified the S25LPN. In an interview on 09/14/2023 at 10:18 a.m., S2Director of Nursing (DON) stated she had no documented evidence S20CNA was questioned or a written statement was obtained from S20CNA regarding care provided and/or what she observed on the morning of 08/28/2023 related to Resident #7's injury of unknown origin. S2DON confirmed statements were obtained from only 5 staff members (S8CNA, S11CNA, S22MDS Nurse, S25LPN, and S26LPN) the morning of 08/28/2023. S2DON confirmed there were multiple staff members present the morning of 08/28/2023 before the injury was discovered that were not questioned or asked to provide a statement. In an interview on 09/14/2023 at 1:31 p.m., S20CNA stated the facility staff never questioned her or asked her to provide a statement regarding what she observed while providing care to Resident #7 or when she became aware of Resident #7's injury on the morning of 08/28/2023. In an interview on 09/14/2023 at 1:45 p.m., S1Administrator stated not all staff observed on the hallway and observed entering Resident #7s room during the camera footage on 08/28/2023 were interviewed and/or asked to provide a statement regarding any knowledge of Resident #7's injury of unknown origin. S1Administrator stated S20CNA was not asked to provide a statement of care provided and/or observed on 08/28/2023. Record review revealed no documented evidence and the facility did not present any documented evidence S20CNA was questioned about care provided and/or observed for Resident #7 on 08/28/2023. Resident #34 Review of Resident #34's record revealed, in part, Resident #34 had a diagnosis of unspecified dementia. Review of the facility's Statewide Incident Management System (SIMS) report revealed an incident was discovered at 1:15 p.m. on July 27, 2023 for Resident #34. Further review revealed, S23Licensed Practical Nurse noticed a bruise and small laceration located on the lower left forearm of Resident #34 and Resident #34 could not state what happened due to severe cognitive impairment. Review revealed Resident #34 was in a private room and did not have a roommate. Further review revealed, five staff members were interviewed in regards to the incident with Resident #34. Review of the facility's investigation revealed no documented evidence of statement completed by the above stated staff members. In an interview on 09/14/2023 at 12:30 p.m., S1Administrator stated he had no documented evidence that written statements were gathered from staff in regards to Resident #34. In an interview on 09/14/2023 at 12:40 p.m., S24RegionalSupervisor stated the facility had no documented evidence of written staff's statements. There was no documented evidence and the facility did not present any documented evidence that staff interviews were completed and a thorough investigation was completed upon the discovery of a bruise and laceration to Resident #34's lower left forearm.

Based on interview and record review, the facility failed to ensure a resident with an identified mental health diagnosis was referred for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #48) of 1 (Resident #48) sampled residents reviewed for PASARR. Findings: Review of Resident #48's clinical record revealed, in part, an admit date of 01/31/2019. Review of Resident #48's Level 1 PASARR screening dated 01/31/2019 revealed, in part, Resident #48 was not diagnosed with a mental illness; therefore, no psychiatric diagnoses were selected to review. Review of Resident #48's diagnosis list revealed, in part, an active diagnosis of schizophrenia (a serious mental illness that can cause distorted reality, delusions, and paranoia) with an onset date of 01/27/2021. Review of Resident #48's last documented comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/20/2023 revealed, in part, Resident #48 was assessed to have active diagnoses of schizophrenia and did not have a diagnosis of dementia. Further review revealed Resident #48 was not evaluated for a Level II PASARR. Review of Resident #48's Quarterly MDS with an ARD of 08/02/2023 revealed, in part, Resident #48 was assessed to have active diagnoses of schizophrenia and did not have a diagnosis of dementia. Additional record review revealed Resident #48 received antipsychotic medications daily. Review of Resident #48's September 2023 physician orders revealed, in part, Resident #48 received Risperdal 0.5 milligrams twice daily (a medication used to treat schizophrenia) with a target behavior of paranoia. Review of Resident #48's care plan revealed, in part, Resident #48 had potential for behaviors secondary to a diagnosis of schizophrenia with interventions to monitor for behaviors and to approach resident in a calm manner. Review of Residents #48's clinical record revealed no documented evidence and the facility did not present any documented evidence a Level II PASARR was completed on Resident #48. In an interview on 09/14/2023 at 10:25 a.m. S18Social Worker stated she was responsible to submit a Level II PASARR when a resident was newly diagnosed with a mental illness. S18Social Worker further stated Resident #48 was diagnosed with schizophrenia after his admission and she did not ensure Resident #48 received the required Level II PASARR screening.

Based on observation, interview, and record review the facility failed develop a care plan for dental issues for 1 (Resident #33) of 21 residents (Resident #48, Resident #7, Resident #79, Resident #40, Resident #21, Resident #24, Resident #3, Resident #38, Resident #34, Resident #36, Resident #29, Resident #33, Resident #11, Resident #46, Resident #16, Resident #60, Resident #49, Resident #43, Resident #2, Resident #51, and Resident #68) reviewed. Findings: Review of Resident #33's Yearly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/16/2023 revealed, in part, Section L - Oral/Dental Status no issues indicated. Review of Resident #33's dental evaluation forms dated 12/06/2022 and 06/06/2023 revealed, in part, obvious or likely cavity, broken natural teeth, and loose natural teeth. Review of Resident #33's care plan revealed, in part, Resident #33 was not care planned for dental issues. An observation on 09/12/2023 at 09:18 a.m. of Resident #33's mouth revealed one tooth noted to left lower side, gray in color, not positioned correctly and multiple areas on upper and lower gums of black to dark brown areas where teeth should have been. In an interview on 09/12/2023 at 9:18 a.m., Resident #33 stated he would like to see a dentist and have a set of dentures. In an interview on 09/13/2023 at 10:17 a.m., S18MDS/Licensed Practical Nurse (LPN) stated Resident #33 had no documentation, and she could not present documentation, of a plan of care being developed for Resident #33's dental issues. S18MDS/LPN stated Resident #33 should have had a care plan developed for Resident #33's dental issues. In an interview on 09/14/2023 at 1:35 p.m., S1Administrator stated there was no documentation, and he could not present documentation, Resident #33 had a care plan developed for oral/dental issues. S1Administrator further stated Resident #33 should have had a care plan developed for oral/dental issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's weight bearing restriction order was implemented for 1 (Resident #7) of 3 (Resident #3, Resident #7, and Resident #29) residents reviewed for accidents. Findings: Review of Resident #7's Quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 06/23/2023 revealed an admit date of 10/26/2018. Further review revealed, in part, Resident #7 had a Brief Interview of Mental Status (BIMS) score of 1 indicating severe cognitive impairment. Further review revealed Resident #7 had a diagnosis of schizophrenia (a mental disorder) and Alzheimer's disease (a brain disorder that causes memory loss). Review of Resident #7's departmental note dated 08/28/2023 revealed, in part, Resident #7 was screaming in pain and upon assessment her left ankle and foot was found to be turned inward. Further review revealed Resident #7 was sent to a hospital for evaluation. Review of Resident #7's hospital Discharge summary dated [DATE] revealed, in part, Resident #7 had a closed fracture of the left tibia and fibula (bones located in the lower leg) and advanced osteoporosis (a condition in which the bone strength weakens and becomes susceptible to a fracture). Resident #7 underwent surgical repair on 08/29/2023 with intramedullary nailing (a metal rod is placed inside the cavity of a bone). Further review revealed, in part, discharge instructions for Resident #7 was to be non-weight bearing to left leg and follow-up with outpatient orthopedic in two weeks. Review of Resident #7's physician orders for August 2023 and September 2023 revealed no documented evidence of an order for Resident #7 to be non-weight bearing to left leg. Review of Resident #7's resident care details revealed, in part, no care instructions for Resident #7 to be non-weight bearing to left leg. Review of Resident #7's care plan revealed, in part, no revision made to Resident #7's plan of care to include non-weight bearing to left leg. There was no documented evidence and the facility did not present any documented evidence to show that Resident #7 was to be non-weight bearing on her left leg upon her hospital return on 08/30/2023. In an interview on 09/13/2023 at 3:58 p.m., S11Certified Nursing Assistant stated she had no knowledge of Resident #7's non-weight bearing restrictions to her left leg. In an interview on 09/14/2023 at 12:30 p.m., S30Medical Records Nurse stated the floor nurse who readmitted Resident #7 from the hospital on [DATE] was responsible for reviewing hospital documentation and putting in any new orders. S30Medical Records Nurse further stated she was responsible to review Resident #7's physician orders after Resident #7 returned from the hospital and put in any orders the floor nurse may have missed. S30Medical Records Nurse confirmed a non-weight bearing order was not put in Resident #7's physician orders when Resident #7 returned from the hospital on [DATE] and should have been. In an interview on 09/14/2023 at 1:45 p.m., S1Administrator confirmed a non-weight bearing order should have been implemented for Resident #7 on 08/30/2023 per the hospital discharge instructions.

Based on observation and interview, the facility failed to post nurse staffing data as required. Findings: Observation on 09/11/2023 at 9:45 a.m. revealed nurse staffing data was not posted and readily accessible to residents and visitors in the building. Observation on 09/11/2023 at 2:20 p.m. revealed nurse staffing data was not posted and readily accessible to residents and visitors in the building. Observation on 09/12/2023 at 9:10 a.m. revealed nurse staffing data was not posted and readily accessible to residents and visitors in the building. Observation on 09/13/2023 at 9:02 a.m. revealed nurse staffing data was not posted and readily accessible to residents and visitors in the building. There was no documented evidence and the facility did not present any documented evidence that nurse staffing data was posted and readily accessible to residents and visitors. In an interview on 09/13/2023 at 9:10 a.m. S9Human Resources stated Nurse Staffing information should be posted daily and is posted at the front desk by the welcome sign. S9Human Resources walked with surveyor over to the front desk and stated the Nurse Staffing information was not posted and should have been posted.

Based on interviews and record reviews, the facility failed to ensure assessments of a dialysis access site were documented upon the resident's return from dialysis for 1 (Resident #46) of 1 sampled residents investigated for dialysis. Findings: Review of Resident #46's physician's order dated 03/23/2023 revealed, in part, orders for hemodialysis on Monday, Wednesday, and Friday. Review of Resident #46's Nursing Facility/Dialysis Clinic Communication sheet for July, August, and September 2023 revealed, in part, the dialysis access site assessment was not documented as being conducted upon Resident #46's return from dialysis on 07/05/2023, 07/28/2023, 08/21/2023, and 08/25/2023. Review of Resident #46's Nurse's notes did not reveal documentation that Resident #46's dialysis access site was assessed upon Resident #46's return from dialysis on 07/05/2023, 07/28/2023, 08/21/2023, and 08/25/2023. There was no documented evidence, and the facility did not present any documented evidence of documenting Resident #46's dialysis access assessments for the above mentioned dates. In an interview on 09/13/2023 at 3:42 p.m., S13Licensed Practical Nurse (LPN) stated an assessment of Resident #46's dialysis access site should be documented on the facility's dialysis communication sheet upon Resident #46's return from dialysis. In an interview on 09/14/2023 at 9:40 a.m., S12LPN stated an assessment of Resident #46's dialysis access site should be documented on the facility's dialysis communication sheet or in a nurse's notes upon Resident #46's return from dialysis. In an interview on 09/14/2023 at 1:00 p.m., S2Director of Nursing (DON) stated an assessment of Resident #46's dialysis access site should be documented on the facility's dialysis communication sheet or in a nurse's notes upon Resident #46's return from dialysis. S2DON confirmed the assessment of Resident #46's dialysis access site was not documented on 07/05/2023, 07/28/2023, 08/21/2023, and 08/25/2023 and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide in-service training for nurse aides to ensure the continuing competence of nurse aides and no less than 12 hours per year for 2 (S4Certified Nursing Assistant and S5Certified Nursing Assistant) of 5 (S4Certified Nursing Assistant, S5Certified Nursing Assistant, S8Certified Nursing Assistant, S10Certified Nursing Assistant, and S11Certified Nursing Assistant) CNAs training records reviewed for in-service training. Findings: Review of S4CNA's In-service Educational Attendance Record revealed, in part, a hire date of 12/29/2020. Further review of S4CNA's In-service Educational Attendance Record revealed the following: 02/02/2023: 1 hour - Documenting Activities of Daily Living (ADL); 03/23/2023: 0.5 hour - room [ROOM NUMBER] Staff educate; 04/24/2023: 2 hours - Duties, Handling, Hearing, Speaking; 06/18/2023: 1 hour - Call lights, round every 2 hours, company concerns, meal times; 07/14/2023: 15 minutes - Documenting work; 07/16/2023: 10 minutes - Call ins; 07/17/2023: 30 minutes - Float Aide room [ROOM NUMBER] B; and 07/18/2023: 20 minutes - Duties. Review of S5CNA In-service Educational Attendance Record revealed, in part, a hire date of 05/13/2019. Further review of S5CNA's In-service Educational Attendance Record revealed the following: 02/5/2023: 1 hour - Restorative Dining; 03/06/2023: 30 minutes - CNA charting; 03/10/2023: 1 hour - Dignity and respect; 03/28/2023: 30 minutes - Health screen; 04/24/2023: 1 hour - Duties, Handling, Hearing, Speaking; 04/28/2023: 30 minutes - Incidents; 05/09/2023: 30 minutes - Gloves; and 05/11/2023: 30 minutes - Making rounds. There was no documented evidence and the facility did not present any documented evidence of completion of 12 hours of in-service education for S4CNA and S5CNA as required. In an interview on 09/14/2023 at 2:55 p.m., S1Administrator stated he and his staff were not able to provide any further in-service hours for S4CNA and S5CNA since being asked for the documentation on 09/12/2023.

Based on observation, interview and record review, the facility failed to: 1.) Ensure a resident's suprapubic catheter (a tube that is passed through the lower abdominal wall directly into the bladder to drain urine) was secure to prevent pulling for 1 (Resident #36) of 1 (Resident #36) sampled residents investigated for catheter care; and, 2.) Ensure a resident's suprapubic catheter (a tube that is passed through the lower abdominal wall directly into the bladder to drain urine) drainage bag was positioned below the level of the bladder for 1 (Resident #36) of 1 (Resident #36) sampled residents investigated for catheter care. Findings: Review of the facility's urinary catheter policy revealed, in part, the drainage bag should be positioned lower than the bladder by attaching to a fixed part of the bed frame. Further review revealed the drainage bag should not be attached to the side rails. Review of Resident #36's medical record revealed, in part, Resident #36 had the following diagnosis: Functional Quadriplegia, Neuromuscular Dysfunction of the Bladder, Presence of Urogenital Implants, and Retention of Urine. Review of Resident #36's Minimum Data Set with an Assessment Reference Date of 07/19/2023 revealed, in part, Resident #36 required extensive assistance from staff for toileting. Review of Resident #36's Comprehensive Care Plan revealed, in part, Resident #36 had a suprapubic catheter and required assistance with toileting. Further review revealed, Resident #36's urine catheter bag should be positioned below the bladder and Resident #36's catheter should be secured to prevent pulling. Observation on 09/11/2023 at 11:06 a.m. revealed, Resident #36's suprapubic catheter bag hanging on the upper left side rail of her bed. Observation on 09/12/2023 at 8:55 a.m. revealed, Resident #36's suprapubic catheter bag hanging on the upper left side rail of her bed. Observation on 09/13/2023 at 9:37 a.m. revealed, S17Certified Nursing Assistant (CNA) entered Resident #36's room to provide incontinence care. Observation revealed, Resident #36's suprapubic catheter bag hanging on the upper left side rail of her bed. Observation further revealed, S17CNA proceeded to perform incontinence care on Resident #36, turned Resident #36 on her right side, which caused Resident #36's catheter to be pulled tight. Observation also revealed no secure device in place. In an interview on 09/13/2023 at 10:45 a.m., S17CNA stated she did not have a secure device in place and she did not secure Resident #36's catheter during incontinence care. S17CNA further stated she should have ensured Resident #36's catheter was secured. Observation on 09/13/2023 at 2:20 p.m. revealed, Resident #36's suprapubic catheter bag hanging on the upper left side rail of her bed. In an interview on 09/13/2023 at 2:22 p.m., S2Director of Nursing (DON) confirmed Resident #36's suprapubic catheter bag was placed at the head of her bed and it should not have been. S2DON further stated Resident #36 did not have a securement device in place to ensure her catheter tubing was not pulling and she should have. In an interview 09/13/2023 at 2:30 p.m., S7Quality Improvement Nurse stated Resident #36's catheter bag should have been secured and placed lower than the level of Resident #36's bladder.

Based on observations, interviews, and record review, the facility failed to: 1. Ensure food that was cooled improperly was not served to facility residents; 2. Implement a system where a refrigerator and freezer temperature was monitored and documented; 3. Ensure food held at an improper temperature on the facility's steam table was not served to the facility's residents; and 4. Ensure the concentration level of the sanitizing solution in the facility's 3 compartment sink was correct. This deficient practice was identified for 74 residents who consume food from the facility as documented on the facility's Census and Conditions of Resident CMS Form-672. Findings: 1. Review of the facility's Storage of Cooked Foods policy revealed, in part, cooked foods must be cooled to 70 degrees Fahrenheit within two hours and then to 41 degrees Fahrenheit or lower in an additional four hours for a total cooling time of six hours. If food is not cooled to 70 degrees F in two hours, then it must be cooled to 41 degrees F within four hours. Observation on 09/12/2023 at 9:15 a.m. revealed S28Dietary Staff placed a metal container of oatmeal into the facility's walk- in refrigerator that was hot to the touch. A temperature check of the above mentioned oatmeal with S27Dietary Manager on 09/12/2023 at 11:25 a.m. revealed the temperature of the oatmeal was 75 degrees Fahrenheit. A temperature check of the above mentioned oatmeal with S27Dietary Manager on 09/12/2023 at 3:35 p.m. revealed the temperature of the oatmeal was 42 degree Fahrenheit. In an interview on 09/12/2023 at 5:23 p.m., S27Dietary Manager stated the oatmeal in the facility's walk in refrigerator was not cooled down properly and was not safe to serve. In an interview on 09/13/2023 at 9:08 a.m., S28Dietary Staff confirmed the above mentioned oatmeal was served to the facility's resident's for breakfast on 09/13/2023. In an interview on 09/13/2023 at 9:08 a.m., S27Dietary Manager stated that the above mentioned oatmeal should not have been served to the residents, as it had been improperly cooled the day before. In an interview on 09/13/2023 at 9:38 a.m., S24Regional Supervisor stated if S27Dietary Manager knew the above mentioned oatmeal was cooled improperly, then it should not have been served to the facility's residents. 2. Review of the facility's Storage of Refrigerated Food policy revealed, in part, temperatures were to be monitored regularly and was to be documented on the approved temperature monitoring log. Review of the facility's Storage of Frozen Food policy revealed, in part, temperatures were to be monitored regularly and was to be documented on the approved temperature monitoring log. Review of the United States Drug and Food Administration (FDA) Food Code 2022 revealed, in part, cold holding equipment used for temperature control for food safety shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the devices temperature display. Observation on 09/12/2023 at 9:25 a.m. of the facility's activity room freezer revealed, it contained two gallon containers of ice cream (one full and one half full), one closed bag of assorted two stick freezer pops, and two closed packages of assorted popsicles. Further observation revealed no thermometer was present in freezer. Observation on 09/12/2023 at 9:25 a.m. of the facility's activity room refrigerator revealed, two closed bottles of orange juice, a closed bottle of sparkling apple cider, and two cartoons of eggs. Further observation revealed, no log of the facility's activity room refrigerator temperature present. Observation on 09/13/2023 at 9:10 a.m. of the facility's activity room freezer revealed, it contained two gallon containers of ice cream (one full and one half full), one closed bag of assorted two stick freezer pops, and two closed packages of assorted popsicles. Further observation revealed no thermometer was present in freezer. Observation on 09/13/2023 at 12:00 p.m. of the facility's activity room refrigerator revealed, two closed bottles of orange juice, a closed bottle of sparkling apple cider, and a tray of assorted cheeses. Further observation revealed, no log of the facility's activity room refrigerator temperature present. Observation on 09/14/2023 at 9:00 a.m. of the facility's activity room freezer revealed, it contained two gallon containers of ice cream (one full and one half full), one open bag of assorted two stick freezer pops, two packages of assorted popsicles (one open and one sealed). Further observation revealed no thermometer was present in the freezer. Observation 0on 09/14/2023 at 9:55 a.m. of the facility's activity room refrigerator revealed, two bottles of orange juice (one opened and one closed), and a closed bottle of sparkling cider, and a tray of assorted cheeses. Further observation revealed, no log of the facility's activity room refrigerator temperature present. In an interview on 09/14/2023 at 9:55 a.m., S29Activities stated food was kept for resident use in the facility's activity room refrigerator and freezer. S29Activites also stated that there was not a thermometer present in the facility's activity room freezer. S29Activites further stated she was not aware that a log had to be kept of the facility's activity room refrigerator and freezer. In an interview on 09/14/2023 at 10:00 a.m., S1Administrator stated the facility's activity room freezer should have had a thermometer in place, if the freezer contained food available for a resident's consumption. S1Administrator further stated a temperature log should have been kept of the facility's activity room refrigerator and freezer. The facility was unable to produce a temperature log for the facility's activity room refrigerator and freezer. 3. Review of the facility's Monitoring Temperatures of Cooked Food policy revealed, in part, potentially hazardous cooked foods, after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum 135 degrees Fahrenheit or higher. Further review revealed, when food is placed in the hot holding equipment, if the temperature is below 135 degrees Fahrenheit, the food should be reheated to 165 degrees Fahrenheit for fifteen seconds. A temperature check of the foods on the facility's steam table on 09/12/2023 at 11:01 a.m., revealed the pureed carrots' temperature was 121 degrees Fahrenheit. The pureed carrots on the facility's steam table were observed on 09/12/2023 between 11:01 a.m. to 11:29 a.m. Observation revealed the pureed carrots being held of the facility's steam table were not reheated, and the temperature of the pureed carrots was not rechecked. Observation on 09/12/2023 at 11:29 a.m. until the end of lunch service revealed, S28Dietary Staff served 3 plates of food for different residents containing the above mentioned pureed carrots without reheating them as required. A temperature check of the foods on the facility's steam table on 09/12/2023 at 4:02 p.m., revealed, the chopped meatballs' temperature was 100 degrees Fahrenheit, the baked chicken's temperature was 120 degrees Fahrenheit, the mechanical soft ground chicken patties' temperature was 110 degrees Fahrenheit, the pureed jambalaya's temperature was 125 degrees Fahrenheit, the pureed green beans' temperature was 125 degrees Fahrenheit, and the gravy's temperature was 120 degrees Fahrenheit. Observation on 09/12/2023 of the above mentioned foods was conducted from 4:02 p.m. until it was served on the second floor at 4:51 p.m. which revealed, at no point were any of the above mentioned foods reheated or had their temperatures checked. Observation on 09/12/2023 starting at 4:51 p.m. revealed Resident #45 was served a plate with chopped meatballs and gravy, Resident #40 was served a plate with chopped meatballs and gravy, Resident #5 was served a plate with chopped meatballs and gravy, Resident #4 was served a plate with chopped mechanical soft chicken patties and gravy, and Resident #19 was served a plate with chopped meatballs and gravy from the above mentioned steam table Review of steam table temperature logs for June, July, August, and September 2023 revealed no record that temperatures of the food held of the steam table temperatures were checked before each meal. There was no documented evidence and the facility did not present any documented evidence of steam table food temperature were monitored for the months of June, July, August, and September 2023. In an interview on 09/12/2023 at 5:23 p.m., S27Dietary Manager stated that the temperature of food held for service on the facility's steam table should be 145 degrees Fahrenheit or higher. S27Dietary Manger further stated that the pureed carrots, the chopped meat balls, the baked chicken, the mechanical soft ground chicken patties, the pureed jambalaya, the pureed green beans, and the gravy were not at a safe temperature to serve, and should not have been served to the facility's residents without being reheated. In an interview on 09/13/2023 at 9:38 a.m., S24Regional Supervisor stated that the above mentioned foods that were held at a subpar temperature on the steam table should not have been served to the facility's residents. S24Regional Supervisor further stated logs of the temperatures of food held on the steam table should have been kept. 4. Review of the facility's Manual Warewashing policy revealed, in part, items should be immersed in the third sink in hot water or chemical sanitizing solution. Further review revealed, if chemical sanitizing is used, the sanitizer must be mixed to the proper concentration and the concentration of the sanitizing solution should be checked with a test kit. A test of the facility's 3 compartment sink was conducted on 09/12/2023 at 11:10 a.m. with S27Dietary Manager and revealed, the test strip placed in the sanitizing sink was bright blue, which was not one of the colors that indicated a part per million (ppm) measurement of the sanitization solution labeled on the side of the test strip bottle. In an interview on 09/12/2023 at 11:10 a.m., S27Dietary Manager stated she was unsure of the ppm measurement of the sanitization solution in the sanitizing sink, because the color of the test strip was not one indicated on the side of the test strip bottle for a ppm range. In an interview on 09/12/2023 at 5:23 p.m., S27Dietary Manager stated because she could not tell what the ppm of the sanitization solution was in the sanitizing sink, she did not know if the kitchen ware was properly sanitized or not. In an interview on 09/13/2023 at 9:08 a.m., S27Dietary Manager stated that she still could not get the test strips used to check the ppm of the sanitization solution in the sanitizing sink to indicate a color that would indicate the ppm on the sanitization solution in the sanitizing sink. S27Dietary Manger confirmed that the dietary staff continued to sanitize the kitchen ware in the sanitizing sink and used this kitchen ware to cook the resident's breakfast despite not knowing the ppm level of the sanitization solution in the sanitizing sink. S27Dietary Manger again stated that did not know if the facility's kitchen ware was properly sanitized because she could not tell what the ppm of the sanitization solution was in the sanitizing sink. In an interview on 09/13/2023 at 9:38 a.m., S24Regional Supervisor stated S27Dietary Manger should have found a way to sanitize the facility's kitchen ware differently, or had someone come to inspect the sanitizing sink and did not.

Based on observations, interviews, and record review the facility failed to ensure: 1. Staff performed hand hygiene during wound care for 2 (Resident #46 and Resident #71) of 2 (Resident #46, Resident #71) sampled residents observed for wound care and; 2. Staff performed hand hygiene during incontinence care for 2 (Resident #36 and Resident #46) of 2 (Resident #36 and Resident #46) sampled residents observed for incontinence care, Findings: Review of the facility's Dressing Change Policy and Procedure revealed, in part, steps in the procedure include: wash hands thoroughly before beginning the procedure, put on disposable gloves, remove dressing and pull gloves over dressing and discard, perform hand hygiene, cleanse the area as ordered, dry the skin, perform hand hygiene, apply disposable gloves, dress the area as prescribed, remove gloves and discard, and wash hands. Review of the facility's Hand Hygiene policy revealed, in part, indications for hand hygiene include: hand hygiene should be performed when entering or exiting a resident's room, before and after procedures, before and after applying gloves, and when hands are visibly soiled. Resident #36 Observation on 09/13/2023 at 9:37 a.m. revealed S17Certified Nursing Assistant (CNA) entered Resident #36's room to provide incontinence care. Observation further revealed S17CNA put on clean gloves, opened Resident #36's soiled brief, and cleaned the top of Resident #36's genital area and down Resident #36's left and right groin area. Observation further revealed S17CNA placed an adult brief on Resident #36, and covered Resident #36 with her gown without changing gloves and performing hand hygiene. In an interview on 09/13/2023 at 10:45 a.m., S17CNA stated she should have removed her gloves and completed hand hygiene after she provided incontinence care to Resident #36 and before she touched Resident #36's adult brief and gown. In an interview on 09/13/2023 at 2:22 p.m., S2Director of Nursing (DON) stated S17CNA should have removed her gloves and completed hand hygiene after she provided incontinence care to Resident #36 and before she touched Resident #36's adult brief and gown. Resident #46 Observation on 09/12/2023 at 12:50 p.m., revealed S3Treatment Nurse (TN) cleaned Resident #46's left ischial (forms the lower and back region of the hip bone) wound with wound cleanser and applied calcium alginate (a dressing used to absorb wound drainage) and Medihoney (antibacterial honey used for wound healing) to Resident #46's left ischial wound bed without changing her gloves or performing hand hygiene between steps. Observation on 09/12/2023 at 12:55 p.m., revealed S16CNA performed incontinence care of a loose bowel movement for Resident #46. Further observation revealed that once S16CNA completed Resident #46 incontinence care, S16CNA removed her soiled gloves, did not perform hand hygiene, and reached into her pocket and pulled out new gloves to put on. Further observation revealed S16CNA then placed on new gloves and touched both Resident #46 and Resident #46's bedrail while assisting S3TN with wound care. Observation on 09/12/2023 at 12:57 p.m., revealed S3TN cleaned Resident #46's right buttocks wound with wound cleanser and applied calcium alginate and Medihoney to Resident #46's right buttocks wound bed without changing her gloves or performing hand hygiene between steps. Observation on 09/13/2023 at 9:36 a.m., revealed S6CNA removed gloves from her pocket and applied gloves without performing hand hygiene and performed incontinence care of a loose bowel movement for Resident #46. S6CNA removed dirty gloves, obtained gloves from her pocket, and applied gloves without performing hand hygiene. Observation on 09/13/2023 at 9:42 a.m., revealed S3TN cleansed Resident #46's right buttock with wound cleanser and gauze, applied Medihoney on the calcium alginate dressing, applied it to the wound bed then secured with bordered gauze without changing her gloves or performing hand hygiene between steps. Further observation revealed S3TN cleaned Resident #46's left ischial wound with wound cleanser, applied applied Medihoney on the calcium alginate dressing, applied it to the wound bed then secured with bordered gauze without changing her gloves or performing hand hygiene between steps. Further observation revealed S3TN cleaned Resident #46's sacral wound with dakin's solution without performing hand hygiene and applying clean gloves. In an interview on 09/13/2023 at 10:00 a.m., S3Treatment Nurse stated she should have removed gloves after cleaning Resident #46's right ischium wound, performed hand hygiene, applied clean gloves, and then applied dressing to Resident #46's right buttock wound. S3Treatment Nurse also stated she should have followed the same process with Resident #46's left ischial wound and sacral wound. S3TN further stated she did not remove her gloves, perform hand hygiene after cleansing the right ischial, and applying the dressing to Resident #46's right ischium wound. S3TN further stated she cleaned Resident #46's left ischium wound, applied the dressing to Resident #46's left ischial wound, and then cleaned Resident #46's sacral wound with dakin's solution with the same gloves. S3Treatment Nurse also stated she should have performed hand hygiene after returning to Resident #46's room prior to applying clean gloves. In an interview on 09/13/2023 at 11:47 a.m., S3TN stated that gloves are supposed to be changed and hand hygiene performed between cleansing wounds and placing a clean wound dressing on, and she should have changed her gloves between those steps when performing wound care to Resident #46's right buttocks and left ischial wounds on 09/12/2023. In an interview on 09/13/2023 at 10:27 a.m., S7Quality Improvement (QI) Nurse stated hand hygiene should be performed prior to starting wound care, gloves should be applied, dressing should be removed and disposed of per standards, gloves should be removed, and hygiene should be performed prior to moving to cleansing the wound. S7QI Nurse further stated clean gloves should be applied after performing hand hygiene, the wound should be cleansed, and then gloves should be removed, hand hygiene should be performed and clean gloves should be applied to apply the clean dressing to the wound. S7QI Nurse confirmed S3TN should have removed gloves and performed hand hygiene after cleansing a wound, prior to applying a dressing. S7QI Nurse further stated S3TN should have performed hand hygiene after returning to Resident #46's room with additional supplies. S7QI Nurse stated hand hygiene should be performed before applying gloves and after removing gloves. S7QI Nurse confirmed S6CNA should have performed hand hygiene after removing gloves. In an interview on 09/13/2023 at 11:00 a.m., S6CNA stated she should have performed hand hygiene before applying gloves to perform personal care and after removing gloves. S6CNA also stated she stored gloves in her pocket and should not store gloves in her pocket. S6CNA confirmed she did not perform hand hygiene after removing gloves before she obtained gloves from her pocket during Resident #46's incontinence care. In an interview on 09/13/2023 at 4:23 p.m., S16CNA stated she should not have had gloves in her pocket. S16CNA further stated, after performing incontinence care on Resident #46, she should have performed hand hygiene after removing her gloves before placing new gloves on. Resident #71 Observation on 09/12/2023 at 10:40 a.m. revealed S3TN was observed disposing items in the red biohazard bag, and with the same soiled gloves, removed the red biohazard bag from the garbage can and exited Resident #71's room wearing soiled gloves. In an interview on 09/13/2023 at 10:27 a.m., S2DON stated gloves should be removed and hand hygiene should be performed prior to exiting a resident's room. S2DON confirmed S3Treatment Nurse should have removed gloves and performed hand hygiene prior to exiting Resident #71's room on 09/12/2023. In an interview on 09/13/2023 at 1:30 p.m., S3Treatment Nurse acknowledged she did not remove her gloves and perform hand hygiene prior to exiting Resident #71's room on 09/12/2023 after completing wound care.

Based on observation, interview, and record review the facility failed to ensure a functional call light was available for 2 (Resident #46 and Resident # 48) of 2 (Resident #46 and Resident # 48) sampled residents investigated for call lights. 26 initial pool residents were observed for call bell use. Findings: Resident #46 Review of Resident #46's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/2023 revealed, in part, resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact, and that Resident #46 required extensive assistance with bed mobility and transfers. Review of Resident #46's care plan revealed, in part, an intervention to place the call light within Resident #46's reach and to educate Resident #46 on calling for assistance. A test of Resident #46's call light was conducted on 09/11/2023 at 10:06 a.m., which revealed the call light was not functioning and notifying staff at the nursing station. Further observation revealed the indicator light did not stay illuminated on the wall of Resident #46's room or illuminate outside of Resident #46's room above the door. Observation on 09/13/2023 at 10:00 a.m., revealed Resident #46's lying in bed. Further observation revealed, Resident #46's call light was tested again for functioning, which revealed, the call light was not functioning and notifying staff at the nursing station. Further observation revealed the indicator light did not stay illuminated on the wall of Resident #46's room or illuminate outside of Resident #46's room above the door. Observation on 09/14/2023 at 9:30 a.m., revealed Resident #46's lying in bed. Further observation revealed, Resident #46's call light was tested again for functioning, which revealed, the call light was not functioning and notifying staff at the nursing station. Further observation revealed the indicator light did not stay illuminated on the wall of Resident #46's room or illuminate outside of Resident #46's room above the door. In an interview on 09/14/2023 at 9:35 a.m., S16Certified Nursing Assistant (CNA) stated Resident #46's call light should be placed within her reach to call if assistance is needed. S16CNA further stated Resident #46 can use the call light, but sometimes hollers for assistance instead of using call light. In an interview on 09/14/2023 at 9:40 a.m., S12Licensed Practical Nursing (LPN) stated to prevent falls, Resident #46's call light should be placed within her reach to call for assistance. S12LPN further stated Resident #46 can use the call light, but often screamed for assistance instead of using the call light. A test of Resident #46's call light was performed by S12LPN on 09/14/2023 at 9:45 a.m., and S12LPN confirmed that Resident #46's call light was not working. In an interview on 08/14/2023 at 9:50 a.m., S19Maintenance Supervisor confirmed Resident #46's call light was not working. S19Maintenance Supervisor further stated Resident #46's call light should be working. In an interview on 09/14/2023 at 10:00 a.m., S1Administrator stated Resident #46's call light should have been functioning and was not. Resident #48 Review of Resident #48's MDS with an ARD of 08/02/2023 revealed, in part, Resident #48 received hospice services and required staff assistance with bed mobility, transfers, dressing, eating, toileting, and hygiene Review of Resident #48's care plan revealed, in part, staff should assist Resident #48 with activities of daily living (ADL) and place the call light within reach. Observation on 09/12/2023 at 9:15 a.m. revealed Resident #48 was lying in bed and the call light cord was positioned between the mattress and the side rail and the call light button was hanging down close to the floor. Resident #48 was asked if he could locate his call light. Further observation revealed Resident #48 was unable to reach the call light. Observation on 09/12/2023 at 1:01 p.m. revealed Resident #48 was sitting up in his bed and the call light cord was positioned between the mattress and the side rail and the call light button was hanging down close to the floor. Further observation revealed Resident #48 was unable to reach the call light. Observation on 09/13/2023 at 10:18 a.m. Resident #48 was lying in bed and the call light cord was positioned between the mattress and the side rail and the call light button was hanging down close to the floor. Resident #48 was asked if he could find his call light. Resident #48 felt on the right side of his bed and was unable to locate the call light. In an interview on 09/13/2023 at 10:18 a.m., Resident #48 was asked how he gets assistance from staff if he cannot find the call light. Resident #48 stated he has to wait for staff to come into his room and he gets tired of waiting. In an interview on 09/14/2023 at 10:09 a.m., S16CNA stated Resident #48 required total assistance with ADL's and was able to use the call light when he needed staff assistance. Observation on 09/14/2023 at 10:10 a.m. Resident #48 was lying in bed and the call light cord was positioned between the mattress and the side rail and the call light button was hanging down close to the floor. Further observation revealed Resident #48 was unable to reach the call light. In an interview on 09/14/2023 at 10:10 a.m., Resident #48 stated he did not know where his call light was. In an interview on 09/14/2023 at 10:18 a.m., S2Director of Nursing confirmed Resident #48's call light should have been in reach to allow him to call staff for assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to perform assessment of left foot injury and educate a resident on the risk factors of refusal of care in accordance of professional standards of practice for 1 (Resident #4) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents. Findings: Review of Resident #4's incident report dated 02/24/2023 revealed, in part, resident reported left ankle pain and did not remember injuring it. Further review revealed Resident #4's Nurse Practitioner (NP) was notified, and ordered an x-ray which revealed a fracture to the left ankle. Resident #4's NP ordered to wrap Resident #4's left foot with kerlix gauze and wear a soft boot until seen by an orthopedic physician. Review of Resident #4's current care plan with goal date of 05/25/2023 revealed, in part, Resident #4 was at risk for skin breakdown with documented approaches to include daily skin checks with routine care and weekly body audits by the nurse. Review of Resident #4's weekly body audit dated 02/03/2023, 02/11/2023, 02/18/2023, 02/25/2023, 03/04/2023, 03/11/2023, and 03/18/2023 revealed, in part, no new skin conditions noted. Review of Resident #4's hospital record dated 03/20/2023 revealed, in part, Resident #4 presented to emergency department from an orthopedic clinic for concern of necrotic infected foot. Further review revealed Resident #4 reportedly sustained a hit to his left foot a month or so ago after which x-ray revealed ankle fracture and had an appointment to see orthopedic physician on the day of presentation however upon examination of the foot there was concern that it appeared necrotic and infected. Review of Resident #4's hospital Discharge summary dated [DATE] revealed, in part, diagnoses at discharge: lymphedema and thickened plaque like malodorous skin over the left foot with cellulitis and tenosynovitis resulting in sepsis and left lower extremity peripheral arterial disease with associated pain. Review of Resident #4's nurse's notes dated January 2023, February 2023, and March 2023 revealed, in part, entry on 01/11/2023 and 01/22/2023 revealed Resident #4 refused to get out of bed. Further review revealed entry on 03/27/2023 Resident #4 refused body audit. In an interview on 03/28/2023 at 1:03 p.m., Resident #4 stated he refused to remove his sock to the left foot because of pain to the left foot. Resident #4 further stated he was only asked once to remove the sock from the left foot and never asked again. Resident #4 also stated he was not educated on the risk of developing further injury due to refusal of assessment and following doctor's orders. In a telephone interview on 03/28/2023 at 1:24 p.m., S3LPN stated she completed Resident #4's weekly body audits and unable to recall if there was a sock or dressing to the left foot which was not removed for assessment. S3LPN also stated she did document no new skin issues on the weekly body audits she completed and did not document bilateral feet were not assessed. S3LPN stated Resident #4 was known to refuse care but did not refuse care at any time during her shifts. In an interview on 03/28/2023 at 2:42 p.m., S1Director of Nurses (DON) stated Resident #4's left foot was wrapped with kerlix per the physician order received on 02/24/2023 but did not document care provided. S1DON further stated Resident #4 often refused baths and was unsure if documentation is available. S1DON also stated she was not notified by any of her nurses that Resident #4 refused care or weekly body audits. S1DON stated the nurses should have educated Resident #4 on the risk of refusing assessments.

Based on interview and record review the facility failed to: failed to ensure the staff vaccination rate was 100%. This deficient practice had the potential to affect all 77 residents listed on the facility's census. Findings: Review of the facility's policy Mandatory COVID-19 Vaccination Policy and Procedure revealed, in part: All staff, covered by this policy, and were required to be fully vaccinated as a term and condition of employment at this facility. A list of employees to include their vaccination status and exemption status shall be tracked and securely maintained by the Infection Preventionist. Review of the facility's COVID-19 Staff Vaccination log report revealed, in part, 3 staff members partially vaccinated, and 1 staff member not vaccinated without exemption /delay. The facility staff vaccination record also revealed, 8Certified Nurse Assistant (CNA), S9Housekeeping (HK) and S10HK were marked as partially vaccinated with the COVID-19 vaccination. Further review revealed S8CNA and S9HK were out of the recommended time frame required for the second dose of a two dose series and S10HK received only one dose of a two dose series and S11Dietary was not vaccinated, without exemption/delay. Calculation of the facility's Staff matrix formula revealed 96.4 percent staff vaccination, not the required 100 percent for staff vaccination per CDC guidelines. In an interview and record review on 08/09/2022 at 3:45pm, S2DON stated S8CNA had the first dose of a two doses series of the Pfizer Covid-19 vaccination on 05/5/2022 and was due the second dose on 6/5/2022. S2DON further stated S9HK received the first dose of Moderna COVID-19 vaccination on 6/24/2022 and the second dose was due on 07/24/2022. S2DON stated there was no documentation of an exemption or temporary delay for S8CNA and S9HK. Review of Nursing Staff schedules dated June 2022 through July 2022, revealed S3CNA worked at the facility on 06/06/2022, 06/08/2022, 06/13/2022, 06/14/2022, 06/15/2022, 06/17/2022, 06/21/2022, 06/22/2022, 06/23/2022, 06/28/2022, 06/29/2022, 07/18/2022, 07/19/2022, 07/20/2022, 07/21/2022, 07/23/2022, 07/24/2022, 07/25/2022, 07/26/2022, 07/27/2022, 7/30/2022, and 07/31/2022. Review of Housekeeping Staff schedules dated August 2022 with S2DON confirmed S9HK worked 08/03/2022, 08/04/2022, 08/05/2022, and 08/09/2022. In interview on 08/10/2022 at2:40pm, S2DON confirmed S8CNA and S9HK had worked on the days identified above without the second dose of the required COVID-19 vaccination. In an interview on 08/09/2022 at 2:45pm, S2DON stated the facility was not aware S8CNA and S9HK did not complete the required two dose series of the Pfizer and Moderna COVID-19 vaccination or had an approved exemption. S2DON/IP further stated S8CNA and S9HK continued working at the facility without receiving the required two dose series of the Pfizer and Moderna vaccinations. In an interview on 08/09/2022 at 3:45pm, S2DON acknowledged S8CNA and S9HK were partially vaccinated and had only received the first dose of a two dose COVID-19 vaccination series. S2DON and IP acknowledged S8CNA and S9HK should not have worked in the facility without being fully vaccinated for COVID-19 or having a documented exemption. S2DON and IP acknowledged S8CNA and S9HK should have completed the second dose of the two series Moderna and Pfizer vaccinations as required or obtained an exemption. S2DON and IP acknowledged the facility did not follow up on S8CNA and S9HK COVID-19 vaccination status and was not aware the recommended interval between the first and second doses of the Pfizer and Moderna vaccinations had passed.

Based on interview, the facility failed to ensure quarterly Quality Assurance (QA) meetings were conducted. This deficient practice had the potential to affect any of the 77 residents residing in the facility as documented on the facility's Resident Census and Conditions of Residents, form CMS-672. Findings: There was no documented evidence and the facility was unable to provide any documented evidence that quality assurance meetings were held on a quarterly basis as required. In an interview on 08/12/2022 at 3:21pm, S1Administrator indicated the facility did not have any formal meetings for the first of second quarter for the year 2022. S1Administrator further stated he forgot to host the meetings, and QA meetings were not completed as required. In an interview on 08/12/2022 at 4:02pm, S7Corporate Nurse stated there was no documented first or second quarter Quality Assurance meeting.

Based on observation, interview, and record review the facility failed to maintain a sanitary environment in the kitchen to prevent the possibility of the contamination of food. This deficient practice had the potential to affect any of the 74 of the 77 residents who consumed meals prepared in the facility kitchen as documented on the facility's physician's orders list of dietary orders. Findings: Observation on 08/09/22 at 10:19am during the initial tour of the kitchen revealed an approximately 3 foot long by 6 inches high hole observed at bottom of the wall near the dietary manager office with wet blankets lying on the floor surrounding the hole. Further observation revealed small gray/black circles in an irregular pattern of an unknown substance near the ceiling above the hole. Further observation revealed small gray/black circles in an irregular pattern of an unknown substance around the door frame of S3Dietary Manager's office and the kitchen's exit door frame near S3Dietary Manager's office. Observation further revealed an approximately 3 foot fan with 15 inch blades circulating air near the oven and stove while food was being prepared on the stove. [NAME] circles in an irregular pattern of an unknown substance and gray/black circles in an irregular pattern of an unknown substance were observed on the ceiling tiles near the pantry and cooler. In an interview on 08/09/2022 at 10:19am S3Dietary Manager stated the hole had been reported to S4Maintenance and S1Administrator. S3Dietary Manager further stated the hole in the wall was due to a water leak from the rain. Observation on 08/11/2022 at 2:45pm revealed dark gray/black unknown substance along the walls of the kitchen near the S3Dietary Manager's office and along the wall where beverages were stored. Observation further revealed a vent by the cooler that appeared rusted with dark gray/black circles in an irregular pattern of an unknown substance expanding out on the ceiling surrounding the vent. Further observation revealed a warped, peeling, and moist spot on the bottom of the wall near the chemical room. Observation further revealed S3Dietary Manager's office had gray/black circles in an irregular pattern of an unknown substance near and around the electrical outlet and also behind S3Dietary Manager's desk. Observation also revealed the fire outlet by the dietary manager office to have a dark reddish brown circles in an irregular pattern of an unknown substance around a fire sprinkler with an unknown dark gray/black spotty substance on the ceiling tiles above. The above observation also revealed a sticker from a kitchen ventilation service company which read the exhaust system was cleaned on 05/02/2022 and had expired on 08/02/2022 on the oven/stove hood vent. Observation on 08/11/2022 at 4:20pm revealed S4Maintenance took measurements of how far the unknown substance extended. From the sink to the wall by S3Dietary Manager's office measure 22 feet. The outer front wall of S3Dietary Manager's office measured 8 feet 4 inches. S3Dietary Manger's office was 10 feet by 8 feet. From S3Dietary Manager's office to the back wall measure 16 feet. The back wall to the freezer doors measured 11 feet 8 inches. The freezer doors to the sink measured 10 feet. Observation on 8/11/2022 at 4:25pm revealed black fuzzy particles of an unknown substance located on the oven/stove hood vent, and staff was informed of the above observations. S4Maintenance then began cleaning the above mentioned oven/stove hood vent and the black, fuzzy particles of the unknown substance was observed falling on S4Maintenance's white shirt. Observation on 08/11/2022 at 5:19pm revealed uncovered food was directly under a ceiling vent with an unknown gray, furry substance observed on the vent and ceiling tiles surrounding the vent. Observation further revealed uncovered plates used to put food for residents on were also located under the vent which had an unknown, gray furry substance. Observation also revealed the floors of the kitchen were slick with moisture and an approximately 3 foot fan with 15 inch blades was noted to be blowing toward the oven during food preparation. Observation further revealed a fan noted on the floor blowing towards the oven during food preparation. The observation also revealed a second fan to be circulating air, pointed towards the stove during food preparation. Additionally, the kitchen observation revealed S12Dietary's hair at the nape of the neck was not fully restrained in a hair net while she was preparing food. Observation on 08/11/2022 at 5:30pm revealed kitchen staff utilized the 3 compartment sink to wash food preparation pans, which was located directly under an area of ceiling tile covered with the unknown gray/black spotty substance. Observation further revealed an area of an unknown grayish/black substance was protruding from the ceiling tile onto the wall. Observation on 08/12/2022 at 6:36am revealed dietary staff placing food on the steam tables while an approximately 3 foot fan with 15 inch blades was circulating air on the floor by the steam tables in the kitchen. Observation on 08/12/2022 at 6:42am revealed a dark gray fuzzy unknown substance in and around the ceiling vent above the stove, oven, and microwave. Observation on 08/12/2022 at 7:05am revealed the food on the steam table was uncovered and located directly under a ceiling vent and surrounding ceiling tiles which were covered with an unknown dark gray/black substance which extended over the uncovered food on the steam table. Further observation revealed multiple holes in the wall with a spotty dark gray/black unknown substance behind the steam tables which had uncovered food on them. Observation on 08/12/2022 at 7:08am revealed 50 steam table trays were stored approximately 5 feet from the above mentioned wall. Further observation revealed 27 out of the 50 steam table trays had visible water dripping between the trays. Observation on 08/12/2022 at 7:15am revealed small gray/black circles in an irregular pattern of an unknown substance near the ceiling above the hole by S3Dietary Manager's office. The door to exit the kitchen by the dietary office had a dark gray/black spotted area of an unknown substance around the frame. Observation on 08/12/2022 at 8:10am revealed S1Administrator on a ladder wiping walls around the hole by the S3Dietary Manager's office with virex (a cleaning agent used to kill virus fungi, bacteria, mold, and mildew). Observation on 08/12/2022 at 11:10am revealed holes to the left of the ice maker with an unknown dark gray/black spotty substance around them. Further observation revealed 8 vents on the ceiling in the kitchen had the unknown dark gray/black spotty substance on the vents and extending from the vents onto the ceiling. Record review of the facility's root cause analysis related to moisture in the kitchen wall dated 05/02/2022 revealed a kitchen leak was identified on 05/01/2022. Further review revealed the following root causes: negative pressure caused by change in cooling system, hot and cold air combination between 1st and 2nd floor, and the air combination leads to excess moisture. There was no documented evidence and the facility was unable to provide any documented evidence which ensured the kitchen was being monitored and maintained in a sanitary condition. In an interview on 08/12/2022 at 7:10am, S3Dietary Manager indicated the steam table trays should not be stored wet. In an interview on 08/12/2022 at 7:44am S1Administrator observed and verified the above mentioned observations with the unknown substances on the walls, ceiling, vents, and hood. S1Administrator further confirmed the kitchen should have been kept clean and fans should not be used in the kitchen. In an interview on 08/12/2022 at 1:54pm S2Director of Nursing stated if she saw an unknown dark gray/black spotted substance along the walls, ceilings, vents, and hood in the kitchen she would believe it to not be safe to eat from the kitchen. In an interview on 08/12/2022 at 2:18pm S6Dietary stated she noticed the unknown dark gray/black substance along the walls, ceilings, and vents about 2 months ago. S6Dietary further stated she could not recall anyone coming to clean the walls. In an interview on 08/12/2022 at 3:32pm S5Clinical Dietician stated she saw the above mentioned areas on the walls when she came to the facility last month. S5Clinical Dietician further indicated maintenance staff were responsible for cleaning the walls and ceiling. In an interview on 08/12/2022 at 3:40pm, S5Clinical Dietician acknowledged that unknown biological particles that fall on food should not be eaten. S5Clinical Dietician further stated many things such as contaminants are not visible but if particles are visible in the air, such particles could contaminate food. S5Clinical Dietician last visited the facility on 07/26/2022. S5Clinical Dietician further stated she observed the hole in the wall near S3Dietary Manger's office. S5Clinical Dietician further stated she recommended the dietary manager clean the kitchen equipment and walls to remove the unknown gray/black substance. S5Clinical Dietician further stated the maintenance department was responsible for cleaning the air conditioner vents and the hood over the oven and stove. In an interview on 08/12/2022 at 3:55pm S5Clinical Dietician stated she reported the wall in the kitchen needed to be repaired to S1Administrator. S5Clinical Dietician further stated if fans are circulating air in the kitchen, unidentified particles had the potential to contaminate uncovered food.