Based on staff interview and record review, the facility failed to accurately complete an Annual Minimum Data Set (MDS) for a resident that had a serious mental illness for one (1) of 17 MDS reviews. Resident #2 Findings Include: The facility provided a statement on letterhead dated 10/16/24, It is the practice of this facility, Proper Name, to document data for the MDS 3.0 according to the instructions per the RAI (Resident Assessment Instrument) Manual. Record review of Resident #2's Preadmission Screening and Resident Review (PASRR) Summary of Findings Report dated 3/23/23 revealed under, Mental Health: . The individual meets criteria for having a diagnosis of mental illness as defined by PASRR with the primary diagnosis of Schizophrenia. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #2 on 4/6/23 with a medical diagnosis of Schizophrenia. Record review of Resident #2's Annual MDS with an Assessment Reference Date (ARD) of 3/14/24 revealed under section A, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? No was documented. An interview with the MDS Nurse on 10/16/24 at 12:00 PM, confirmed she made an error when completing Resident #2's MDS and revealed she must have been rushing and missed it. She explained that the MDS should be accurate so that the residents get the care they need. An interview with the Director of Nursing (DON) on 10/16/24 at 12:11 PM, confirmed the MDS should be completed accurately so that the resident's individualized care needs were met.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a smoking care plan for one (1) of 17 care plans reviewed. Resident #44 Findings include: A review of a facility policy titled, Comprehensive Care Plans, reviewed 10/23 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident An observation on 10/16/24 at 10:00 AM, revealed Resident #44 smoking with the supervision of Housekeeper #1. During the observation it was revealed that Resident #44 was observed to not be wearing a smoking vest while he was smoking a lit cigarette. A review of the care plan titled, Resident #44 is at risk for injuries related to smoking, revealed, Interventions: Resident #44 will require a smoking apron due to falling asleep while smoking initiated 5/28/24. In an interview with the Minimum Data Set (MDS) Coordinator on 10/16/24 at 10:53 AM, it was revealed after review of Resident #44's smoking care plan that staff were not following the care plan to wear a smoking apron. She then revealed the purpose of the care plan is to let staff know of the specific care a resident requires. Record review of the admission Record revealed the facility admitted Resident # 44 on 12/02/22 with a diagnosis of Nicotine Dependence. Record review of Resident # 44's Section C of the Annual MDS with an Assessment Reference Date of 10/14/24 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to promote an environment as free of accident hazards as possible, when the facility failed to provide a resident a smoking protection assistive device to prevent accidents for one (1) of three (3) residents reviewed for accidents and hazards.(Resident #44) Findings include: A review of the facility policy titled, Smoking/Tobacco Use Policy, last review 2024 revealed, Procedure: 5.) Smoking aprons will be provided for residents who are evaluated to need them by the smoking safety assessment. Wearing of the apron will be assisted by staff during smoking times for those residents who require them . An observation of Resident #44 on 10/15/24 at 12:52 PM, revealed small cigarette burn holes on the blanket covering his legs. A record review of a Smoking Safety Screen for Resident #44 dated 5/28/24, revealed the resident needed adaptive equipment during smoking with a smoking apron and supervision. Notes on safety from Interdisciplinary team: Staff noted that Resident #44 fell asleep while holding a lit cigarette. Due to the risk of injury, Resident #44 will be required to wear an apron while smoking. Review of the Smoking Safety Screen for Resident #44 dated 10/14/24 revealed resident need for adaptive equipment needed was a smoking apron and supervision. Notes on safety from the Interdisciplinary team: Resident #44 has a history of dropping ashes on clothing. Resident requires supervision and an apron. Record review of the Smoking and Tobacco/Snuff list of residents revealed Resident #44 was listed but did not have two (2) asterisks next to his name to indicate he required a smoking apron. On 10/16/24 at 10:00 AM, an observation revealed Resident #44 smoking with the supervision of Housekeeper #1 and it was observed that Resident #44 was not wearing a smoking apron while he was smoking a lit cigarette. It was observed that there were two small burn holes on the blanket covering Resident #44's legs. Interview with Housekeeper #1 on 10/16/24 at 10:04 AM, revealed the Social Service Director lets him know who requires a smoking vest, and confirmed he was unaware that Resident #44 needed a smoking vest. He then revealed he was unaware of a smoking list that reflected which residents required a smoking vest. In an interview with the Social Service Director on 10/16/24 at 10:10 AM, she confirmed Resident #44 was to wear a smoking vest and stated the housekeeper was unaware that the resident required a smoking vest. She confirmed that she updated the smoking list as changes occurred. In a review of the smoking list with the Social Service Director, she confirmed the smoking list did not reflect that Resident# 44 required a smoking vest. She then revealed that by not applying the smoking apron, the staff placed Resident #44 at risk for burning himself. An interview with the Minimum Data Set (MDS) Coordinator on 10/16/24 at 10:53 AM she revealed after review of the Smoking Assessment for Resident # 44 he should have been wearing a smoking apron and stated the smoking list should have been updated by the Social Service Director. Review of the admission Record revealed the facility admitted Resident # 44 on 12/02/22 with a diagnosis of Nicotine Dependence. Record review of Resident # 44's Section C of the Annual MDS with an Assessment Reference Date of 10/14/24 revealed a Brief Interview for Mental Status (BIMS) score was 12, indicating the resident was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review the facility failed to implement an Activities of Daily Living (ADL) care plan for one (1) of 20 care plans reviewed. Resident #48 Findings include: A review of the facility policy titled, Comprehensive Care Plans, revised 2/2017, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. #4 The Comprehensive Care Plan will describe at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . An observation of Resident #48 on 8/08/23 at 1:00 PM, revealed the resident's fingernails to be approximately 1/4 inch long with an unknown dark brown substance under nail beds. A review of the care plan for Resident #48, undated, revealed Focus: The resident has an ADL self-care performance deficit r/t (related to) fall . Intervention: .Personal Hygiene Routine: The resident requires total assist with personal hygiene . An interview with the Director of Nursing (DON) on 8/09/23 at 8:55 AM, confirmed staff were not following the ADL care plan and revealed the purpose of the comprehensive care plan is to direct the resident's care. A review of the admission Record revealed that the facility admitted Resident #48 to the facility on 7/19/22 with diagnoses that included Bilateral Primary Osteoarthritis of hip and Benign Neoplasm of the Pituitary Gland. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 6/27/23, revealed that Resident #48 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated that he was severely cognitively impaired. Section G revealed Resident #48 was extensive assistance of one staff for personal hygiene.

Based on observation, staff interview, record review and facility policy review the facility failed to maintain an environment that is free from accident hazards as is possible when an office door behind the nursing desk was left open and unsecured with a gallon bottle of Hibiclens (chlorhexidine gluconate), a small bottle of Hydrogen peroxide, syringes with needles intact, two (2) boxes of butterfly needles, vacutainer's, and a bottle of covid testing solution sitting on a shelf visible from the doorway for one (1) of three (3) days of survey. Findings include: A review of the facility policy titled, Storage of Medication, revealed, Policy: Medications and biological's are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. The medication is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedures: B.) Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access . Record review of a typed document on facility letter head, undated and signed by the Administrator revealed Lexington Manor Senior Care does not have a policy for the storage of new/unused needles. During an observation of the room behind the open floor plan nursing desk that was centrally located between all three resident occupied hallways on 8/09/23 at 8:35 AM, revealed the door was open to the room. There was no staff present in the room. The State Agency (SA) observed a large metal shelf with a 1 gallon bottle of Hibiclens, 1 small bottle of hydrogen peroxide, an open storage carry case filled with different size unopened syringes with needles intact, vacutainers, 2 boxes of butterfly needles, and a bottle of covid test solution. All the named items were in view from the doorway entrance by the SA. The SA stood at the doorway entrance of the room and waited for staff to return. The SA observed several staff walk past the nursing desk, a resident and visitor sitting in the lobby on the couch, and residents sitting in the dayroom while waiting. Interview and observation with the Charge Nurse on 8/09/23 at 8:40 AM, confirmed the open room was her office. The Charge Nurse revealed the office door should have been shut and locked before leaving. She said there are confused residents in the facility and a resident or unauthorized person could possibly enter the room, accidentally ingest the Hibiclens or hydrogen peroxide, become sick, and get 1 of the needles and stick themselves with it. During an interview with the Director of Nursing (DON) on 8/09/23 at 8:55 AM, confirmed the door to the charge nurse office should not be left open because a resident could have possibly ingested the Hibiclens and could have possibly stuck themselves with a needle. On 8/09/23 at 3:00 PM, during an interview with the Staffing Nurse , revealed any room that has sharps or medicine related items stored in it should always be locked when not occupied staff. During a phone interview with the Pharmacy Consultant on 8/09/23 at 3:46 PM, he revealed that a room with medication and related items should always be locked when not occupied by authorized staff and revealed accidental ingestion of Hibiclens and hydrogen peroxide cause nausea and vomiting and gastric distress and puts residents/unauthorized people at risk for possible needle sticks or cutaneous (skin) injury related to items not being secured in the room .

Based on observations, staff interview, record review and facility policy review, the facility failed to store narcotics in the permanently affixed compartment in the refrigerator and left an office door behind the nursing desk open and unsecured with a gallon bottle of Hibiclens (chlorhexidine gluconate), a small bottle of Hydrogen peroxide and a bottle of covid testing solution sitting on a shelf one (1) of three (3) days of survey. Findings Include: A review of the facility policy titled, Storage of Medication, revealed, Policy: Medications and biologicals are stored safely, securely, and properly, following manufactures recommendations or those of the supplier. The medication is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Procedures: B.) Medication rooms, carts and medication supplies are locked when not attended by persons with authorized access. A review of the facility policy titled, Medication Storage in the Facility,revealed . The scheduled two-five medications and other medications subject to abuse or diversion are stored in a permanently affixed, (double locked) compartment separate from all other medications or per state regulation . Nursing Station Area: Observation on 08/09/23 at 8:35 AM, revealed a room with the door open that was centrally located behind the nursing desk. There were no staff present in the room. The State Agency (SA) observed a large metal shelf with 1 one gallon bottle of Hibilcens, 1 small bottle of hydrogen peroxide, and a bottle of covid test solution. All items were in view from the doorway entrance. An observation and interview with the Charge Nurse on 8/09/23 at 8:40 AM, confirmed the open room was her office. She stated the office should have been shut and locked before leaving because there are confused residents in the facility and a resident or unauthorized person could have possibly entered the room and accidentally ingested the Hibiclens or hydrogen peroxide and become sick. An interview with the Director of Nursing (DON) on 8/09/23 at 8:55 AM, confirmed the door to the charge nurse office should not be left open because a resident could have possibly ingested the Hibiclens. An interview with the Staffing Nurse on 8/09/23 at 3:00 PM, confirmed any room that medicine related items stored in it should always be locked when not occupied with staff. A phone interview with the Pharmacy Consultant on 8/09/23 at 3:46 PM, revealed that a room with medication and related items should always be locked when not occupied by authorized staff. He revealed accidental ingestion of Hibiclens and hydrogen peroxide could cause nausea, vomiting, and gastric distress. He revealed that by not having the items in a secured room could put residents and all unauthorized people at risk for injury. Medication Room East: An observation and interview on 08/09/23 at 03:35 PM, of the medication room East with Licensed Practical Nurse (LPN) #1 revealed a refrigerator with 1 vial of floor stock Lorazepam two (2) milligram (mg)/milliliter (ml) in a small plastic bag on the shelf inside the refrigerator and nine (9) vials of Lorazepam 2 mg/ml in a small plastic bag on the shelf inside the refrigerator. LPN #1 confirmed that there was a lock box in the refrigerator that was secured, attached to the inside of the refrigerator and locked, where the narcotics that require refrigeration are stored. LPN #1 confirmed the vials of Lorazepam were not in the locked and secure box. An observation and interview on 08/09/23 at 03:40 PM, with the Director of Nursing (DON) confirmed that the Lorazepam was in plastic bags inside the refrigerator, not inside the locked box that was for narcotics needing refrigeration. When the DON attempted she was unable to open the lock box with the key, she stated that the key wouldn't open the box and that something was wrong with the lock. The DON stated that the medication nurses should have notified her that the lock was not working on the locked box so that she could have it fixed, but that no one had made her aware of a problem with the lock. An interview on 08/09/23 at 03:54 PM the Pharmacy Consultant confirmed that the secured lock box inside the refrigerator was for narcotics in need of refrigeration and that the Lorazepam should have been inside the locked box and secured inside the refrigerator. The Pharmacy Consultant confirmed a visit to the facility on August 1, 2023 but did not check the Lorazepam in the refrigerator.

Based on observation, staff interview, record review and facility policy review the facility failed to provide nail care for a resident dependent on staff for Activities of Daily Living (ADL's) as evidenced by brown substance under the resident's nails for one (1) of five (5) residents reviewed for ADL's. Resident # 48 Findings include: A review of the policy titled, Care of Fingernails for the Certified Nursing Assistant, dated 5/2019, revealed Policy: It is the purpose of this procedure to provide appropriate care according to current standards of practice. Care of fingernails will be provided by the Certified Nursing Assistant . An observation of Resident #48 on 8/08/23 at 1:00 PM, revealed the resident's fingernails to be approximately 1/4 inch long with an unknown dark brown substance under the nail beds. During an observation and interview of Resident #48's nails on 8/09/23 at 8:30 AM, with Licensed Practical Nurse (LPN) #1 and Certified Nursing Assistant (CNA)#1 revealed both CNA #1 and LPN #1 confirmed Resident #48's nails were approximately 1/4 inch long and had a brown substance under the fingernails. LPN #1 confirmed the nails were dirty and needed to cleaned and trimmed. LPN #1 then revealed a possible concern from not cleaning and trimming Resident #48's nails is the resident could scratch herself and would be at risk for infections. A review of the Progress Notes related to behavior monitoring, for the last 30 days for Resident #48, revealed no documentation of refusal of ADL care. A record review and interview with the Director of Nursing (DON) on 8/09/23 at 8:55 AM, revealed a possible concern from Resident #48's nails being long and having an unknown brown substance under them could place her at risk for an infection. A continued review of the last 30 days of Progress Notes and the daily CNA Behavior Monitoring for Resident #48 with the DON confirmed there was no documented refusals of care. An interview with the Infection Control Nurse on 8/09/23 at 2:51 PM, revealed failing to perform proper nail care could lead to accidents such as tears to the skin and and possible infections especially if the resident scratches or is a digger. A review of the admission Record revealed that the facility admitted Resident #48 to the facility on 7/19/22 with diagnoses that included Bilateral Primary Osteoarthritis of Hip and Benign Neoplasm of the Pituitary Gland. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on 6/27/23, revealed that Resident #48 had a Brief Interview for Mental Status (BIMS) score of 4 which indicated that he was severely cognitively impaired. Section G revealed Resident #48 was extensive assistance of one staff for personal hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide nail care for a resident who was dependent for her Activities of Daily Living (ADLs) as evidenced by a brown substance on top of and underneath all fingernails for one (1) of eight (8) residents observed for ADL care. Resident #26 Findings include: Review of the facilities policy titled, Shower-Tub Bath Policy dated 04/2017 revealed Policy It is the policy of this facility to promote cleanliness and comfort, to relax the resident, to stimulate circulation, and to observe the condition of the resident's skin . Procedure . 8. Wash hands properly. Review of the facilities policy titled, Care of Fingernails for the Certified Nursing Assistant dated 5/2019 revealed Policy: It is the purpose of this procedure to provide appropriate care according to current standards of practice. Care of fingernails will be provided by the Certified Nursing Assistant for all no-Diabetic residents .Procedure: . 4. Place the basin of warm water on the over -bed table. 5. Ask the resident to soak their hands in the basin 3-5 minutes. 6. Leaving one hand in the water, wash and rinse the resident's other hand. Dry the hand and place it on a dry towel. 7. Clean under the nails with the orange wood stick. 8 . Repeat with the other hand and 10. Trim the resident's nails using the nail clipper. Clip nails straight across. Shape and remove any rough edges using an emery board or nail file. An observation on 11/29/21 at 11:45 AM, revealed Resident # 26's fingernails were covered in a brown substance both on top of the nails and underneath the nails. An interview on 12/1/21 at 8:27 AM, with Licensed Practical Nurse (LPN) # 3 revealed that residents get a bath or whirlpool bath every day. LPN # 3 revealed that the residents get foot and nail care along with their baths unless they are diabetic and then the nurse does the nail and foot care. An interview on 12/1/21 at 8:30 AM, with Certified Nurse Assistant (CNA) # 1 revealed that residents get a bath every day with nail care. CNA # 1 revealed that the residents get a whirlpool bath three (3) days per week and on the other days they get a bed bath. CNA # 1 revealed that nail care is also done as needed. An observation and interview on 12/1/21 at 8:32 AM, revealed Resident #26 had a thick brown substance under her fingernails. Her fingernails were long and two of the fingernails had jagged edges. Resident # 26 stated, I want them cut but not to the bone. I scratch so I need some nails. An observation and interview on 12/1/21 at 8:37 AM, with Registered Nurse (RN) # 1, the Infection Control Nurse confirmed that Resident # 26's fingernails had dirt under them and they were jagged. An interview on 12/1/21 at 8:40 AM, with the Director of Nurses (DON) revealed that nail care should be done on whirlpool days and as needed, but if they are a diabetic then the nurse must do the trimming. The DON revealed that every shift there should be cleaning up and providing nail care as needed. The DON revealed that according to documentation the resident had not refused any care since 11/18/21. The DON revealed that it is the facility policy to provide nail care as needed and on whirlpool days. An interview on 12/1/21 at 8:53 AM, with CNA # 2 revealed that Resident # 26 received a whirlpool bath on 11/18/21, 11/22/21, and 11/29/21. CNA # 2 revealed that Resident # 26 gets a whirlpool bath on Mondays and Thursday and gets a bed bath on the other days and she has no documentation of refusals of bath or nail care by Resident # 26. She reported that the CNA that completes the whirlpool bath initials beside the resident's name indicating they completed the bath and if the resident refuses, then the CNA will write refused beside the resident's name. Review of the facility bath schedule documentation titled Monday/Thursday Baths **DO BEFORE LUNCH** Nail care must be done with each bath revealed that Resident # 26 received a whirlpool bath on Mondays and Thursdays. Resident # 26's name was listed on the Monday/Thursday Bath schedule documentation with a CNA's initials beside her name. CNA # 2 had signed and dated the document that Resident # 26 had received a whirlpool bath on 11/18/21, 11/22/21 and 11/29/21. Review of the facilities in-service conducted by the DON on 9/21/21 revealed TITLED AND DETAILED CONTENT OF INSERVICE: Nail care: See policy, Care of fingernails will be provided by the CNA for all non-diabetic residents. Report to the nurse any redness, irritation, broken skin, or loose skin or swelling. Nurse will perform cut and trim nails of diabetics. Record review of the CNA care guide for Resident # 26 revealed that the resident was to receive total assistance with ADL's. Record review of Resident # 26's admission Record revealed she was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Aphasia, Essential (primary) Hypertension, Gout, Hyperlipidemia, Hypoxemia, and Unspecified Dementia without behavioral disturbances. Record review of the Minimum Data Set (MDS) for Resident #26, with an Assessment Reference Date (ARD) of 10/7/21, Section C had a Brief Interview for Mental Status (BIMS) score of 03, which indicated that the resident had severe cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #36: An observation on 11/29/21 at 11:58 AM, of Resident #36's oxygen concentrator revealed there was no date on the O2 humidifier bottle or the O2 tubing to indicate when it was last changed. There was no O2 in use sign posted on Resident #36's door. Record review, of the Electronic Health Record (EHR) revealed Resident #36 had a Physician's Order, dated 11/25/21, for O2 at 2L via NC as needed for shortness of breath. On 11/30/21 at 3:30 PM, an interview with Licensed Practical Nurse (LPN) # 2 revealed that it is the responsibility of the nurse starting the O2 on the resident for the first time to put the O2 in use sign outside the resident's door. On 12/1/21 at 8:27 AM, an interview with LPN # 3 revealed that it is the responsibility of the nurse admitting the resident on O2 or starting O2 to put the O2 in use sign on the resident's door. On 12/2/21 at 9:12 AM, an interview with the Director of Nurses (DON) revealed it is the responsibility of the nurse starting the residents O2 for the first time to put the O2 in use sign on the resident's room door. The DON revealed the O2 tubing should be dated and labeled weekly. The DON revealed that the need to change the O2 tubing is on the Treatment Administration Records (TARS) and usually triggers for night shift to complete. Review of the facility In-service Training completed on 8/25/21 by the DON revealed TITLE AND DETAILED CONTENT OF INSERVICE: .changing and date of tubing. Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure the proper labeling of oxygen tubing and humidifier bottles and failed to place signage on resident doors indicating oxygen was in use for 4 (four) of 6 (six) residents receiving oxygen therapy. Residents #2, #26, #28 and #36. Findings include: Review of the facility policy Oxygen Concentrator reviewed 2021 revealed, . Policy Explanation and Compliance Guidelines: .h. Place an oxygen warning sign on the resident's door. Review of the facility's policy titled, Nebulizer and Oxygen Tubing Storage Policy with a review date of 2021 revealed, POLICY It is the policy of this facility to decrease the risk of potential and/or direct exposure to infection diseases, air contaminants, and bacterial exposure. We will provide our residents with the proper storage and cleaning of respiratory equipment. PROCEDURE The facility will replace all respiratory tubing's weekly. These tubing's will be dated and stored in a dated plastic bag when not in use. The plastic bags will also be changed out weekly. The equipment will be cleaned at the time of tubing change out and PRN (as needed). Documentation will be placed on the resident's record weekly. Resident #2 An observation on 11/29/21 at 12:07 PM, revealed Resident #2 had no oxygen (O2) in use sign posted on the door. Record review revealed Resident #2 had a Physician's Order, dated 11/5/21, for O2 at 2 Liters (L), via Nasal Cannulas (NC), while awake. Resident #26: An observation on 11/29/21 at 12:24 PM, revealed Resident # 26 receiving O2 via NC at 2 liters with no O2 in use sign outside the resident's door. Record review of Resident # 26's Physician's Orders dated 7/29/21 revealed Change oxygen order to O2 at 2L per NC PRN (as needed) SOB (shortness of breath). Record review of Resident # 26's admission Record revealed she was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Aphasia, Essential (primary) Hypertension, Gout, Hyperlipidemia, Hypoxemia and Unspecified Dementia without behavioral disturbances. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/7/21, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 03 which indicated Resident #26 had severe cognitive impairment. Resident # 28 An observation on 11/29/21 at 11:19 AM, revealed Resident # 28 receiving O2 via nasal cannula at 3 liters with no date or label on the O2 tubing and no O2 in use sign outside the resident's door. An interview on 11/29/21 at 11:20 AM, with Resident # 28 revealed, I don't know if they put a date on the tubing or not. Record review of Resident # 28's Physicians Orders revealed .Continue admission orders . 19. O2 @ (at) 3L (liters) per NC (nasal cannula) continuous. Dx: (diagnosis) Chronic Obstructive Pulmonary Disease (COPD). Record review of Resident # 28's admission Record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hypertension, COPD with acute exacerbation, Personal history of other diseases of the Respiratory system, End Stage Renal Disease, and Obstructive Sleep Apnea. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/9/21, revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #28 was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, facility policy review, the facility failed to prevent the possible spread of infection by failure to clean and disinfect multi-use equipment between resident use for one (1) of four (4) days of survey. Findings include: Review of facility policy titled, Policy for Cleaning and Disinfection of Resident-Care Equipment, dated 3/31/21, revealed, Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC (Centers for Disease Control) recommendations in order to break the chain of infection .Policy Explanation and Guidelines, 3b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use of another resident. An observation, on 11/29/21 at 12:15 PM, revealed CNA #5, entered and exited the rooms of Resident #31, Resident #14, and Resident #48 using a [NAME] V 3 Automated Vital Sign System to check the residents' blood pressure, without cleaning and disinfecting it between resident use. An interview on 11/29/21 at 12:20 PM, with CNA #5 confirmed that she did not clean the blood pressure machine between use on the residents. She stated that this could cause the residents to catch a cold or virus. She stated that she had in-service education on cleaning equipment and that she should have cleaned it between each resident. An interview, on 12/01/21 at 12:55 PM, with the Director of Nursing, (DON), revealed that not cleaning and sanitizing the blood pressure cuff between residents, could cause a major transfer of several infections from one resident to another. Record Review revealed CNA #5 attended an in-service titled, Cleaning of Patient Equipment - Including vital sign machine, dated 9/23/21.

Based on observation, staff interviews, and facility policy review, the facility failed to prevent the potential of a food borne illness as evidenced by food open and used after the expiration date and food stored with an open lid and past the use by date on one (1) of three (3) kitchen tours. Findings include: The facility policy titled, Storage of Refrigerated Food with a revised date of 10/17 revealed POLICY: The facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. PROCEDURE: . 4. Food taken out of original containers is put in a clean sanitized container with a tight-fitting lid. No food is left uncovered. 5. All opened foods are labeled with common name of food, date stored and use-by date. An observation on 11/29/21 at 10:20 AM, of the kitchen revealed in the walk-in refrigerator a half gallon container of buttermilk that was 3/4 (three-fourths) empty. The container had an expiration date of 11/4/21 and an opened date of 11/17/21. An interview on 11/29/21 at 10:20 AM, with Dietary Staff #3 confirmed that the buttermilk had an expiration date of 11/4/21 and an opened date of 11/17/21 and was 3/4 empty. Dietary Staff #3 confirmed that the buttermilk could have been used in cooked recipes or served as a drink for all the residents. Dietary Staff #3 confirmed that serving this out-of-date buttermilk could have caused the residents to be sick. An observation on 11/29/21 at 10:40 AM, of the 4-door refrigerator revealed a metal container with a plastic lid that had one corner opened. The metal container was 1/4 (one-fourth) full of fruit cocktail that had an opened and used by date of 11/8/21. An interview on 11/29/21 at 10:42 AM, with Dietary Staff #1, Dietary Staff #2 and Dietary Staff #3 confirmed that the metal container had a plastic lid with one corner opened, it was 1/4 full of fruit cocktail and had an opened and used by date of 11/8/21. They also revealed that the fruit cocktail could have been served to all residents, including those on a pureed diet. Dietary Staff #2 and Dietary Staff #3 revealed that the facility policy was to discard anything opened in the refrigerator after seven (7) days and if it had been served to the residents after the 7 days in the refrigerator it could have made the residents sick. An interview on 12/1/21 at 11:10 AM, with the Registered Dietician (RD) revealed that if buttermilk was used after the expiration date, then it could have made the residents sick. The RD revealed it is the facility policy to discard food when expired. The RD revealed that food stored in containers in the refrigerator must be covered with no loose lids and used within 7 days. Record review of an in-service dated 1/6/2021, titled Food Handling and Storage revealed the in-service was attended by Dietary Staff #1, #2 and #3. The in-service content included, Went over food handling and storage, to date items when you open, then open date. Make sure all containers have a date on them always first in and last out .