Based on observation, interview, and record review, the facility failed to ensure a comfortable and homelike environment for one resident (Resident #52), whose room contained multiple areas of wall, door, and ceiling damage. A sample of 21 residents was reviewed. The facility census was 111. Review of a facility policy entitled Repair Requisition (TELs (electronic application) Work Order System), dated 07/06/15, showed the following: -Purpose was to assist in the prompt repair of equipment, or facility plant features, that may be broken or have failed; -TELs Work Order Requests are used as a communication tool and are not intended to be a permanent record of equipment service; -Requests for repairs to equipment, or the building, should be communicated via the TELs Work Order System to the maintenance department, using the TELs app on each computer. The Maintenance supervisor should check Work Order requests each day and plan to work accordingly; -Once repairs are complete, the Maintenance Supervisor should record the repair on the TELs Work Order System as appropriate. 1. Review of Resident #52's face sheet (gives basic profile information at a glance) showed the following: -admission date of 03/28/24; -Diagnoses included acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD - breathing disorder with acute exacerbation), emphysema (lung disease), insomnia, obstructive sleep apnea, dependence on supplemental oxygen, and anxiety disorder. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/13/25, showed mild cognitive impairment. Review of the resident's care plan, last reviewed 12/27/24, showed the staff to address complaints and concerns timely and encourage/allow to voice feelings and concerns. Observation and interview on 03/24/25, at 12:32 P.M., showed the following: -The resident pointed at the room door, closet doors, walls, and ceiling and said, The walls and doors look like crap, and the ceiling has water damage. He/she also pointed out the large loops of television cable on the floor next to the bed and chest of drawers; -The room door was scraped from the hinge edge to the doorknob. The scarpe was 1 to 2 inches in width; -Approximately 6 inches from the lower edge of the closet door was a jagged 2 to 3 inch hole punched through the exterior surface, with several cracks extending outward from the hole; -The closet doors showed three circular pieces of plastic of two sizes attached to the exterior; -Two areas of apparent water damage to the corner of the ceiling over the resident's bed; -Five small holes in the ceiling over the resident's bed; -Six holes/anchors in the wall between the tv/nightstand and the corner of the wall; -Four holes/anchors in the wall between the overbed light and the corner of the wall. During an interview on 03/31/25, at 11:54 A.M., the Maintenance Assistant said the facility used the electronic TELs application system. Any staff can send a repair/work order request to maintenance, and the system alerts them with new messages. Sometimes the staff just tells them directly of repairs needed. The Maintenance Assistant said they usually wait until a room is empty/vacated to do wall repairs, due to the smell/fumes. He was not aware of the wall, door, or ceiling damage or excess coiled cable in the resident's room. During an interview on 03/31/25, at 12:08 P.M., Certified Medication Technician (CMT) D said staff can either tell maintenance directly or put in a repair request on the electronic system regarding wall or door damage. During an interview on 03/31/25, at 12:14 P.M., Licensed Practical Nurse (LPN) C said any staff can put in a work order for the maintenance department through the electronic system or can just tell them directly. The LPN was not aware of a request for repairs in the resident's room. During an interview on 03/31/25, at 12:24 P.M., the Maintenance Director said staff should put in a work order on the electronic system to request repairs. He said the facility did have a pipe issue with resulting ceiling damage on 07/29/24. He was not aware of ceiling water damage or wall/door damage in the resident's room. He had not received a work request for those items. During an interview on 03/13/25, beginning at 4:06 P.M., the Administrator, Director of Nursing (DON), and the Regional Nurse Consultant said any staff can request repairs by entering a work order into the electronic system. Maintenance staff check the requests daily and the system alerts them to new requests.

Based on observation, record review, and interview, the facility failed to provide respiratory care per standards of practice when staff failed to obtain and document physician orders for the use of supplemental oxygen for one resident (Resident #53) of four sampled residents. The facility census was 111. Review of the facility's policy titled Advanced Care Procedures: Oxygen Administration, dated 12/08/05, showed the following: -Oxygen should be administered under the orders of the attending physician, except in the case of an emergency. In an emergency, oxygen may be administered without physician's order; however, the order should be obtained immediately after the crisis is under control; -Obtain physician's orders for the rate of flow and route of administration of oxygen (i.e., by tank, concentrator, nasal cannula, mask, etc.). 1. Review of Resident #53's face sheet showed the following information: -admission date of 02/10/25; -Diagnoses included acute and chronic respiratory failure with excess carbon dioxide (CO2) in the bloodstream, chronic obstructive pulmonary disease (COPD - breathing disorder), sleep apnea (disrupted breathing cycle during sleep), chronic atrial fibrillation (irregular heart function), and bronchitis. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 03/03/25, showed the following information: -Cognition intact; -On oxygen therapy, continuous on admission; -Received oxygen therapy while a resident. Review of the resident's care plan, dated 03/26/25, showed the following: -Diagnoses included COPD and respiratory failure; -Resident required staff assistance to complete daily activities of care safely related to diagnosis of respiratory failure and COPD; -Resident received oxygen therapy. Administer oxygen therapy as ordered, change tubing per protocol, ensure that supply is available at all times, observe for changes in symptoms that may indicate worsening respiratory status, notify provider of change, and provide with humidification. Review of the resident's Physician Order Sheet (POS), current as of 03/31/25, showed an order, dated 02/16/25, to change resident's oxygen tubing every week on Sunday. Staff did not document orders for oxygen use that specified the flow rate or route. Observation on 03/25/25, at 12:15 P.M., showed resident rested in bed with oxygen in use at 3 liters per minute (lpm) via nasal cannula. Observation and interview on 03/28/25, at 9:52 A.M., showed the resident rested in bed with oxygen in use at 3 lpm via nasal cannula. The resident confirmed the liter flow should be set to 3 lpm. The resident said he/she used the oxygen continuously due to COPD and recent bronchitis. During an interview on 03/31/25, at 12:08 P.M., Certified Medication Tech (CMT) D said only the nurses can adjust oxygen settings. Certified nurse aides (CNAs) are not supposed to adjust the oxygen liter flow, but they can assist the residents with the nasal cannula placement. During an interview on 03/31/25, at 12:12 P.M., Licensed Practical Nurse (LPN) B said the nurse should obtain an order for a resident's supplemental oxygen use and enter the order into the electronic medical record (EMR). The nurse should set the liter flow on the oxygen concentrator and/or portable tank. CNAs are not supposed to adjust oxygen settings. During an interview on 03/31/25, at 12:14 P.M., LPN C said the nurse should put an oxygen order in the EMR. The facility usually puts in a standing order for as needed oxygen to maintain the oxygen saturation above the percentage given by the physician. The nurses start oxygen at 2 to 3 lpm and assess the effectiveness. During an interview on 03/31/25, at 4:40 P.M., the Director of Nursing (DON), the Regional Nurse Consultant (RNC), and the Administrator said staff should obtain a physician's order for a resident's use of supplemental oxygen. The order should include the liter flow and route (nasal cannula, mask).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #41's face sheet showed the following information: -admission date of 07/11/24; -Diagnoses included paraplegia (condition characterized by partial or complete paralysis of the lower half of the body), anxiety disorder, depression, and vascular dementia with psychotic disturbance (involves cognitive decline and psychotic symptoms like delusions (belief that is persistently held despite evidence to the contrary) and hallucinations (sensory experiences that occur with an external stimuli)). Review of the resident's Physical Restraint Record of Informed Consent, dated 07/12/24, showed the resident and a witness signed on 07/10/24 agreeing to restraint use as ordered by the physician. The record did not specify the restraint agreed to and did not address side rail use. Review of the resident's care plan, dated 07/12/24, showed the following information: -Resident required side rail use as enabler related to promoting self mobility/positioning. -Bed in lowest position with wheels locked; -Encourage resident movement while in bed; -Observe for and report immediately if in need of repair; -Observe for appropriate lateral/vertical space of rails; -Observe for proper functioning; -Observe mattress for appropriate size for bed; -Observe resident's freedom of movement; -Side rail use will be reviewed on admission and quarterly by restorative nurse. -Care plan reviewed on 03/26/25 with no new approaches or changes. Review of the resident's face sheet showed the resident readmitted to the facility on [DATE]. Review of the resident's POS, dated 03/28/25, showed an order, dated 02/06/25, for siderails to promote independence with bed mobility. Review of the resident's 5 day MDS, dated [DATE], showed the following information: -Moderately impaired cognition; -Total dependence on staff for bed mobility, chair to bed transfers, and toileting hygiene; -The resident did not have any physical restraints. Review of the resident's bed entrapment grid, undated, showed staff documented measurements for Zone 3 (entrapment in horizontal space between rail and mattress), Zone 6 (entrapment between rail and edge of head/foot board), and Zone 7 (entrapment between head or foot board and mattress). Observation on 03/26/25, at 9:45 A.M., showed the resident in bed with small grab bars (near the resident's head and shoulders) on both sides of the bed in the up position. Observation and interview on 03/28/25, at 2:04 P.M., showed the resident in bed with small grab bars on both sides of the bed in the raised position. The resident said the bed came with the grab bars. Sometimes the resident will use them to pull up in bed. During an interview on 03/28/25, at 12:48 P.M. , the Corporate Nurse said the resident did not have a side rail assessment prior to 03/26/25 because he/she was newer. During an interview on 03/31/25, at 10:09 A.M., Restorative Nursing Assistant (RNA) M said the resident used his/her grab bars during care. The resident can turn by self and grabs the bar. During an interview on 03/31/25, at 11:36 A.M., the Care Plan Coordinator said the resident had paraplegia and used the grab bars for bed mobility. The resident's grab bars were added to his/her careplan with the start date of 07/12/24. She reviewed the care plan on 03/26/25. Typically, she reviewed care plans when she completed the MDS assessment. During an interview 03/31/25, at 3:59 P.M., the Director of Nursing (DON) said the resident had been in and out of the facility several times. They did not have a siderail assessment or informed consent for his/her side rails. The gap measurements do not have a date on the form, but they should have a date. Staff completed the gap measurements on 03/24/25. 5. Review of Resident #28's face sheet showed the following information: -admission date of 11/05/23; -Diagnoses included osteoporosis (condition in which bones become weak and brittle) and depression. Review of the the resident's Physical Restraint Record of Informed Consent, dated 11/02/23, showed the resident and a witness signed on 11/02/23 agreeing to restraint use as ordered by the physician. The record did not specify the restraint agreed to and did not address side rail use. Review of the resident's care plan, dated 01/24/24, showed the following information: -Required side rail use as enabler related to promoting self mobility/positioning; -Bed in lowest position with wheels locked; -Encourage resident movement while in bed; -Observe for and report immediately if in need of repair; -Observe for appropriate lateral/vertical space of rails; -Observe for proper functioning; -Observe mattress for appropriate size for bed; -Observe resident's freedom of movement; -Side rail use will be reviewed on admission and quarterly by restorative nurse. -Care plan reviewed on 02/05/25 with no new approaches or changes. Review of the resident's side rail evaluation, dated 02/08/24, showed the following information: -Resident needs side rails due to weakness; -Side rails will assist the resident with security, safety, bed mobility, transfers; -Bilateral side rails are recommended; -Benefit to side rails are to serve as enabler to promote independence and to serve as assistive device for bed mobility to increase ADL participation; -Provide assistance as required and/or needed with bed mobility; -Provide assistance as required and/or as needed with transfers and toileting; -Side rail use risks and benefits discussed/education listed on form; -Form completed by nursing; -The form did not show any signature or consent for the side rails. Review of the resident's quarterly MDS, dated [DATE], showed the following information: -Moderately impaired cognition; -Total dependence on staff for toilet hygiene, transfer for bed to chair; -Maximum assistance for bed mobility; -No physical restraint used. Review of the resident's bed entrapment grid, undated, showed staff documented measurements for Zone 3 (entrapment in horizontal space between rail and mattress), Zone 6 (entrapment between rail and edge of head/foot board), and Zone 7 (entrapment between head or foot board and mattress). Observation on 03/24/25, at 4:25 P.M., showed the resident in bed with grab bars on both sides of the bed in the raised position. Review of the resident's POS, dated 03/28/25, showed an order, dated 03/26/25, for side rails to promote independence with bed mobility. Review of the resident's Enabler/Assistive Device Review, undated on signed hard copy, dated 03/26/25 in the electronic medical record, showed the following information: -Resident required assist of one staff with bed mobility; -Interdisciplinary team recommended enabler/assistive device; -Type of device was grab bar; -Reason for recommendation was to assist with bed mobility; -Other alternatives tried included bed in low position; -Therapy has assessed the use of assistive device; -It had been determined that the clinical benefits of the device outweighed the clinical risk of the deice. The resident and/or, if applicable, resident representative had been informed and agreed with the use of this device; -Resident signed the bottom of the form; -Plan of care updated accordingly. Observation and interview on 03/28/25, at 2:07 P.M., showed the resident in bed with grab bars (rails) on both sides of the bed in the raised position. The resident said he/she had the rails when he/she got the bed. No one asked him/her if the resident wanted rails. The resident does use the rails to roll over. During an interview on 03/28/25, at 2:07 P.M., the resident's family member said the bed had the grab bars when the resident got the bed. During an interview on 03/31/25, at 9:26 A.M., Certified Nurse Aide (CNA) N said the resident used the grab bars when he/she rolled in bed. During an interview on 03/31/25, at 10:09 A.M., RNA M said the resident used his/her grab bars. He/she could use the grab bars and pull his/herself up in the bed. During an interview on 03/31/25, at 11:36 A.M., the Care Plan Coordinator said the resident had grab bars and used them. He/she typically didn't get out of bed. The resident wanted to stay in bed. The resident used them to move around in bed. The resident's siderails were added to the care plan on 01/24/24. During an interview on 03/31/25, at 3:59 P.M., the DON said the resident should have an earlier physician order for the side rails. The care plan and side rail evaluation provided was probably the earliest they have. The Assistive Device Review had a date of 03/26/25 in the computer. The facility printed off and retained a hard paper copy for the consent signature. 6. Review of the resident's face sheet showed the following information: -admission date of 07/31/23; -Diagnoses included major depressive disorder and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). Review of the the resident's Physical Restraint Record of Informed Consent, dated 05/12/21, showed the resident and a witness signed on 05/12/21 agreeing to restraint use as ordered by the physician. The record did not specify the restraint agreed to and did not address side rail use. Review of the resident's side rail evaluation, dated 09/17/23, showed the following information: -Side rail use assessment-functional status; -Reason resident needed side rails was ambulation with assistance; -Side rails will assist resident with transfers and mobility; -Recommended for both sides of the bed; -Benefit to side rails for resident was to serve as enabler to promote independence; -Additional interventions for side rail use was to provide assistance as required and/or needed with bed mobility; -Side rail use risks and benefits discussed/education listed on form; -Form completed by nursing; -The form did not show any signature or consent for the side rails. Review of the resident's care plan, dated 09/18/23, showed the following information: -Required side rail use as enabler related to promoting self mobility/positioning; -Bed in lowest position with wheels locked; -Encourage resident movement while in bed; -Observe for and report immediately if in need of repair; -Observe for appropriate lateral/vertical space of rails; -Observe for proper functioning; -Observe mattress for appropriate size for bed; -Observe resident's freedom of movement; -Side rail use will be reviewed on admission and quarterly by restorative nurse. -Care plan reviewed on 02/10/25 with no new approaches or changes. Review of the resident's progress note dated 09/20/23, at 12:43 P.M., showed staff educated the responsible party on risks versus benefits of enabler use, including potential for harm/death and increased mobility/independence, and verbalized informed consent. Review of the resident's physician order sheet, dated 03/28/25, showed an order, dated 10/25/23, for siderails to promote independence with bed mobility. Review of the resident's Side Rail Evaluation, dated 02/15/24, showed the following information: -Reason resident needed side rails was due to weakness; -Side rails would assist resident with bed mobility, transfers, safety, and security; -Benefit to side rails for resident was to serve as an enabler to promote independence, the resident and/or resident representative had expressed desire for side rails while in bed, and to serve as assistive device for bed mobility to increase ADL participation; -Additional interventions for side rail use included encourage and/or assist resident to keep bed in lowest position while in bed, provide assistance as required and/or needed with bed mobility, and provide assistance as required and/or as needed with transfers and toileting; -Side rail use risk and benefits discussed/education listed on form; -Form completed by nursing. -The form did not show any signature or consent for the side rails. Review of the resident's bed entrapment grid, undated, showed staff documented measurements for Zone 3 (entrapment in horizontal space between rail and mattress), Zone 6 (entrapment between rail and edge of head/foot board), and Zone 7 (entrapment between head or foot board and mattress). Observation and interview on 03/25/25, at 10:46 A.M., showed the resident in bed with small grab bars on both sides of the bed, in the up position. The resident said he/she used them to move in bed. He/she liked and wanted to keep them. Review of the resident's Enabler/Assistive Device Review, undated on signed hard copy, dated 03/26/25 in the electronic medical record, showed the following information: -Resident's mobility status, included bed mobility as independent with one staff assist; -Type of device/enable recommended was grab bars; -Reason for recommendation was to assist with bed mobility and assist with transfers in /out of bed; -Other alternatives that had been attempted included bed in low position; -Therapy had assessed the resident for the use of assistive device; -It had been determined that the clinical benefits of the device outweighed the clinical risk of the device. The resident and/or, if applicable, resident representative have been informed and agreed with the use of this device. -The resident signed the form; -Staff documented the plan of care had been updated accordingly. Observation and interview on 03/28/25, at 2:34 PM., showed the resident in bed with grab bars on both sides of the bed in the raised position. The resident said the rails were on the bed when he/she first got the bed. The resident said he/she did use them to move in bed. During an interview on 03/31/25, at 9:26 AM., CNA N said the resident used the grab bars when he/she rolled in bed. The grab bars stayed in the up position. During an interview on 03/31/25, at 10:09 A.M., RNA M said the resident turned on the call light if he/she needed assistance. He/she did not know for sure if the resident used the grab bars or not. During an interview on 03/31/25, at 11:36 A.M., the Care Plan Coordinator said the resident's side rails were added to his/her care plan on 09/18/23. The resident had the grab bars and used them. He/she liked to stay in bed, but could self position. During an interview on 03/31/25, at 3:59 P.M., the DON said the assessments provided for the resident were all they had. They would realize they didn't have certain pieces, such as the order, care plan, or the evaluation/assessment. She completed the resident's enabler/assessment on 03/26/25. Gap measurements should have a date on the form for when they are completed. 7. During interviews on 03/27/25, at 1:30 P.M., and on 03/31/25, at 10:09 A.M., RNA M said he/she did not do anything with side rails. He/she did not do any measurements or monitoring of any kind. The new beds come with the side rails (grab bars). He/she was not involved in the assessment for them or gap measurements. During an interview on 03/28/25, at 1:45 P.M., LPN B said all the beds on 100 hall have side rails on them all the time. They never take them off as far as he/she knew. He/she did not do any kind of bed side rail assessment form and thought the admission nurse or management took care of bed side rail information, orders, and consents for bed side rails. During an interview on 03/28/25, at 1:55 P.M., LPN E said that if a resident needed help with ambulation, bed mobility, was incontinent, or have had recent falls that nurses do an enabler assessment form for the bed side rails. The nurse will put in a physician order and obtain consent from either the resident or the guardian. Staff measured from the headboard to the mattress and from the mattress to the rails. The previous Director of Nursing (DON) was responsible for making sure the bed side rails measurements were done. Now, LPN E and the DON were responsible for making sure it got done. LPN E would notify maintenance if the rails were loose and/or needed them placed. During an interview on 03/31/25, at 10:40 A.M., Registered Nurse (RN) O said the beds already have the grab bars on them at admission. The admitting nurse should be completing the enabler assessment. If not the admitting nurse, the unit manager or medical records should be doing the assessment. It should be completed within 24 hours of admission. Therapy does an evaluation to see if grab bars are needed or not. Whoever completed the enabler assessment should also get consent. They should be completed within 24 hours of admission. That same staff should explain the risks/benefits of the grab bars. The nurse completed the assessment, unit manager, or medical records can get the gap measurements. Anyone can get the measurements. The same person who does the assessment should be getting the gap measurements. When they do the evaluation, the grab bars can be removed. Other things they would try before the grab bars was low bed or elevate head of the bed. Many residents come in the facility and want the grab bars. The grab bars should be added to the care plan. It should be added typically once the evaluation is completed and the grab bars are determined as appropriate. Gap measurements should be done by policy. He/she thought that was quarterly. During an interview on 03/28/25, at 1:25 P.M., the Rehabilitation Director said that therapy staff do an evaluation for positioning, bed mobility, and transfers for bed side rail usage and notify the nurse if they require a bed side rail. Therapy staff do not complete a side rail evaluation form, did not put in the orders, did not get consent and did not complete any gap measurements. The Rehabilitation Director said nurses do all of that. During an interview on 03/31/25, at 11:36 A.M., the Care Plan Coordinator said she added to the care plan who they give her as names that have side rails or grab bars. She was not involved in the assessment of the grab bars/side rails, consents, or the gap measurements. If on 100 hall, all beds have grab bars on them at admission. On other halls, it depended. Typically, they admit a resident straight to 100 hall. Then, they move them from 100 to another hall. It is a different bed. It just depended on the bed whether it had side rails already. She did not know the time period from when they have the grab bars to when she was told about them. Typically, she reviewed care plans when she completed the MDS assessment. They used to have a restorative nurse who did the gap measurements, consents, and assessments. She assumed the previous DON took over those responsibilities. During an interview on 03/31/25, at 3:59 P.M., the DON said most of the residents who came in to 100 hall, came in with grab bars. Therapy would evaluate and say if okay to have the grab bars. Therapy didn't give them a piece of paper that said they were needed to promote bed mobility/transfers. Observation would be done, and orders entered/care plan updated. They had been discussing risks/benefits on the enabler form, but when they changed computer systems, it got dropped. Assessment and informed consent was on that form. Gap measurements were a separate form. CNA P was responsible for the gap measurements. LPN E kept track of the measurements after CNA P got them. When a grab bar was put on, staff should have the order in place prior to putting on the grab bars. Physical therapy should evaluate the grab bars before they come on. Gap measurements should be completed when grab bars are put on. Consent form and measurement form should be done at the same time. Staff should do gap measurements any time there is a change in structure, or change in anything. Assessments should be completed on initiation of the grab bar, and then either quarterly or annually. They would realize they didn't have certain pieces, such as the order, care plan, or the evaluation/assessment. Gap measurements should have a date on the form for when it is completed. All of the enabler/assessments were completed on 03/26/25. During an interview on 03/31/25, at 4:51 P.M., the Administrator said side rail assessments should be completed on admission. They should be discussing them with the resident and family on admission. Staff should update the care plan on admission and get consent signed if they want them or declination if they don't want them. Gap measurements should be completed on admission or upon initiation of the side rails. Staff should quarterly/annually update the care plan as needed. Staff should get physician orders for side rails/grab bars. If there is no change in the bed or mattress, they should not need gap measurements again. But, maintenance staff should be doing safety checks per policy. 3. Review of Resident #53's face sheet showed the following information: -admission date of 02/10/25; -Diagnoses included acute and chronic respiratory failure with excess carbon dioxide (CO2) in the bloodstream, chronic obstructive pulmonary disease (COPD - breathing disorder), sleep apnea (disrupted breathing cycle during sleep), morbid obesity, pain, generalized anxiety disorder, and depression. Review of the resident's admission MDS, dated [DATE], showed the following information: -Cognition intact; -No functional limitation in range of motion for upper extremities; -Required partial to moderate assistance to roll left to right, sit to lying, and lying to sitting on the side of the bed. Review of the resident's POS, current as of 03/31/25, showed an order, dated 02/11/25, for siderails to promote independence. Review of the resident's care plan, dated 03/26/25, showed the following: -Required staff assistance to complete daily activities of care safely related to diagnosis of respiratory failure and COPD; -Required siderail use as enabler related to promoting self mobility/positioning; -Bed in lowest position with wheels locked; -Encourage resident movement while in bed; -Observe for and report immediately if rails in need of repair, observe for appropriate lateral/vertical space of rails, observe for proper functioning, observe mattress for appropriate size for bed, and observe resident's freedom of movement; -Siderail use will be reviewed on admission and quarterly by restorative nurse. Review of the resident's medical records showed staff did not document completion of a risk assessment or informed consent prior to the use of side rails. Observation on 03/24/25, at 12:15 P.M., showed the resident rested in bed. Grab bars were in the raised position on each side of the bed. During an interview and observation on 03/27/25, at 12:13 P.M., the resident demonstrated his/her ability to use the grab bars on either side of the bed. He/she said the side rails were already on the bed on his/her admission. Staff did not discuss with him/her any risks associated with the use of side rails. The resident said he/she did want the side rails for mobility and repositioning. Observation on 03/28/25, at 9:52 A.M., showed the resident rested in bed. Grab bars were in the raised position on each side of the bed. Based on observation, interview, and record review, the facility failed to complete a risk/benefit review. document alternatives attempted prior to bed rail use, and failed to obtain informed consent prior to the use of bed side rails for six residents (Residents #266, #26, #53, #41 #28, and #59); failed to address and/or timely address the use of bed side rails in the residents' care plans for three residents (Resident # 266, #28, and #59); failed to conduct an initial safety gap check prior to side rail use for three residents (Residents #41, #28, and #59); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 111. Review of the facility policy titled Resident Beds and Bed Safety Rails Program, dated 10/28/19, showed the following: -The scope was to maintain beds and perform bed safety rails audits; -Preventative maintenance should be conducted on all beds and bed safety rails annually; -Bed Safety Rails Audit should be performed when it is determined that the use of bed rails is an appropriate application for the resident; -Initial and annual training should be conducted on all staff that are designated to perform the bed safety rails audits and should be used during initial and annual training as a reference. Review of the facility policy titled Bedrail Use, dated 10/26/22, showed the following: -Bed rails are used to enable a resident to become more functionally independent, and when the medical condition of the resident requires the use of a bedrail; -Bed rails could be considered a form of physical restraint; therefore, the need for bedrails should be identified in the resident assessment, and the plan of care; -Bed rails may be used to help a resident position or turn. Instructions should be provided to the resident as needed; -The interdisciplinary team should determine if the benefits outweigh the risk of a bedrail; -Possible hazards and clinical benefits of the bedrail use should be explained to the resident and guardian, during the admission process and upon initial implementation; -Continued use of bedrails requires documentation of the presence of a medical symptom, which would necessitate the use of bedrails, or that the bedrails assist the resident with mobility and transfer abilities and that clinical benefits still outweigh the risks of use; -Complete an Enabler/Assistive Device/Side Rail Review and Evaluation upon admission, readmission, upon initially implementing side rail, and with significant change; -Side rails should be addressed in the care plan; -Evaluation for entrapment risk should also be completed when mattress or bed type are changed; -The resident and the resident representative should give informed consent to the use of the device, prior to its use. 1. Review of Resident #266's face sheet (brief resident profile sheet) showed the following: -admission date of 03/20/25; -Diagnoses included alcohol dependence with alcohol-induced dementia, alcohol-induced mood disorder, anxiety, and nicotine dependence. Review of the resident's current Physician Order Sheet (POS) showed an order, dated 03/20/25, for siderails to promote independence with bed mobility. Review of the resident's electronic medical record (EMR) showed staff did not document risk informed consent, signed by the resident or guardian, completed prior to the use of the bed side rails. Review of the resident's care plan, revised 03/24/25, showed the following: -Potential for falls; -Required assistance to complete daily activities of care safely. (Staff did not care plan related to the resident's side rail use.) Observations on 03/24/25, at 1:25 P.M., and on 03/25/25, at 10:05 A.M., showed quarter bedrails to each side of the resident's bed in place and in the upright position. 2. Record review of Resident # 26's face sheet showed the following information: -admission date of 02/04/25; -Diagnoses included clavicle (collarbone) fracture, presence of right artificial hip joint, and mechanical loosening of artificial hip joint. Review of the resident's admission MDS), dated [DATE], showed the following: -Cognition intact -Required substantial assistance for dressing, toilet use, and personal hygiene; -Required extensive assistance for bed mobility and transfer. Review of the resident's current POS showed an order, dated 02/04/25, for siderails to promote independence with bed mobility. Review of the resident's EMR showed staff did not document risk informed consent, signed by the resident or guardian, completed prior to the use of the bed side rails. Review of the resident's care plan, revised 02/17/25, showed the following: -The resident required side rail used as an enabler related to mobility and positioning; -Bed side rail use will be reviewed on admission and quarterly by the restorative nurse. Observation on 03/24/25, at 11:00 A.M., showed quarter bed side rails to each side of the resident's bed in place and in the upright position. The resident said that the bed side rails have been on the bed since admission and does not remember any staff reviewing the risks and benefits for use or obtaining consent to use the side rails.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of practice and in a manner to prevent possible contamination when the facility staff failed to air dry dishes before stacking; failed to wear hair restraints appropriately; failed to maintain a proper air gap to prevent possible back flow; failed to maintain the ice machine and scoop; and failed to maintain food contact surfaces and nonfood contact surfaces, including the stove/oven, in a manner that would prevent possible contamination of food. These concerns had the potential of affecting any of the residents. The facility census was 111. 1. Review of the 2022 Food Code, issued by the Food and Drug Administration (FDA), showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food; -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following: -Staff to wash, scrub, rinse, and sanitize equipment/utensils. Staff to allow items to air dry. -Remove first rack to drain board when wash and rinse cycle is complete and allow dishes to air dry; Observation on 03/24/25, beginning approximately 10:00 A.M., of the kitchen area showed the following items wet nesting (trapping water between them and preventing the ability for items to air dry): -Four small, clear plastic bowls; -Sixty-two plastic plate covers; -Ninety-four plastic bowls; -One hundred and ten plastic trays; -One hundred and thirteen white ceramic plates. Observation on 03/28/25, at approximately 10:50 A.M., showed the following items wet nesting: -Fifty-two plastic trays; -Ninety-four ceramic plates. During an interview on 03/28/25, at approximately 11:20 P.M., Dishwasher F said the following: -He/she waits as long as he/she can before stacking dishes to make sure they are dry; -He/she was trained to dry the dishes completely before putting them away; -Sometimes staff run short on time and get in a hurry. During an interview on 03/28/25, at approximately 1:35 P.M., Dietary Aide (DA) G said the following: -The dishes can never be stacked wet because it could cause bacteria to grow; -Dishes are only to be put away when they are completely dry; -He/she thinks sometimes the dishwashers get in a hurry. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said dishes need to be air dried before putting them away or it could cause growth or contamination. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -Staff should always let all the dishes air dry before putting them away; -Dishes are not to be left wet and stacked. During an interview on 03/28/25, at approximately 1:10 P.M., [NAME] J said the following: -Dishes have to be dry before being put away; -Staff should not wet-nest or use a cloth to dry dishes. During an interview on 03/28/25, at approximately 2:25 P.M., [NAME] L said dishes cannot be stacked while still wet. During an interview on 03/28/25, at approximately 2:50 P.M., the Dietary Manager (DM) said kitchen staff knows dishes cannot be put away while wet due to possible bacteria growth. During an interview on 03/28/25, at approximately 3:45 P.M., the Director of Nursing (DON) said dishes cannot be put away while still wet. Dishes have to be completely dry because of the potential of bacteria to grow. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said kitchen staff are aware that dishes are to be air dried before being put away. Staff have been trained on this and should be following the training. 2. Review of the 2022 Food Code, issued by the FDA, showed the following information: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service and single-use articles. -Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair. Review of the facility policy titled Use of Gloves and Hairnets, dated 08/15/09, showed staff to wear hair restraints (bonnets, caps, nets to cover hair) when preparing or handling food. Observation on 03/26/25, at approximately 12:00 P.M., showed the following: -The activity director walked into the kitchen, with no hairnet; -His/her hair was approximately two-three inches below the shoulders in length; -He/she grabbed a glass, walked over to the ice machine, scooped out ice, and left the kitchen. Observation on 03/27/25, at approximately 12:05 P.M., showed the following: -Cook L walked in and passed through the kitchen wearing no hairnet; -His/her hair was flowing and moving as he/she walked; -He/she went into the back of the kitchen and into a bathroom to grab a hair net; -He/she walked into the middle of the kitchen and while reading the bulletin board put on the hair net. Observation on 03/27/25, at approximately 12:10 P.M., showed hairnets located in the staff bathroom, that is in the back of the kitchen. Staff did not hairnets readily available at the kitchen entrances. During an interview on 03/28/25, at approximately 1:35 P.M., DA G said the following: -Hairnets were kept in the bathroom; -Everyone should have a hairnet on before coming into the kitchen. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -Everyone has to have on a hairnet; -Anyone coming into the kitchen should have a hairnet on; -The hairnets need to be up by the front door. During an interview on 03/28/25, at approximately 2:15 P.M., DA K said he/she will clock-in, which is in another part of the building, and then he/she comes through the kitchen, and the hairnets are kept in the bathroom, During an interview on 03/28/25, at approximately 2:25 P.M., [NAME] L said the following: -He/she said they always have a hairnet on while in the kitchen; -When asked about seeing him/her during an earlier observation, he/she said they all have to come through the kitchen to grab a hairnet; -The box of hairnets are kept in the bathroom. During an interview on 03/28/25, at approximately 2:50 P.M., the DM said the following: -Staff should have hairnets on when cooking or preparing food or just in the kitchen; -He/she expected all staff to always have on their hairnets. During an interview on 03/28/25, at approximately 3:45 P.M., the DON, said the following: -He/she has not seen where the hairnets are kept, but thinks they are somewhere in the back of the kitchen; -He/she will ask for a hairnet if needed; -No one should walk through the kitchen to get a hairnet. During an interview on 03/28/25, at approximately 3:50 P.M., the Regional Nurse Consultant said no one should go into the kitchen without a hairnet on. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said hairnets were mandatory prior to entering the kitchen. He/she expected any staff, from any department, to put on a hair net before they go into the kitchen. 3. Review of the 2022 Food Code, issued by the FDA, showed the following information: -An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch; -Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by back flow. Review of the facility policy titled Ice Chest and Ice Machines, dated 11/14/16, showed staff to install proper air gaps where the condensate lines meet the waste lines. Observation on 03/28/25, at approximately 10:50 A.M., showed the two-door refrigerator's drainpipe was laying directly on the floor drain. There was no visible air gap between the drainpipe and floor drain. During an interview on 03/28/25, at approximately 1:35 P.M., DA G said the following: -The drain hose from under the refrigerator used to be up higher and not actually on the drain, itself; -He/she was not sure what happened and why it was no longer up, off the drain. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said he/she was not aware of any air gap requirement. During an interview on 03/28/25, at approximately 2:10 P.M., [NAME] J said they knew there should be an air gap present. He/she was unsure what the size of air gap needed to be. During an interview on 03/28/25, at approximately 2:50 P.M., DM said he/she did not know about the drainpipe air gaps. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said the following: -He/she did not realize there was an issue with the air gap and would expect the air gap size to meet the requirement. 4. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following: -Wash ice scoops in the dish machine or with a detergent solution; -Rinse with clear water, followed by immersion in 100 parts per million (ppm) chlorine solution for sanitation; -If any of the components are noted to have a lime and/or calcium build-up, soak in de-lime solution until no scale is observed; -After de-liming, repeat the machine washing, or the manual wash, rinse and sanitizing steps; -Ice scoops should be kept in a closed/covered container on or next to the ice bin and should be cleaned daily. Observation on 03/24/25, beginning approximately 10:00 A.M., showed the following: -The ice machine had a thick build-up of calcium or lime substance lining the outside rim of the door, around the edges of the inside of the door, and outside ledges and rims of the ice machine; -The removable blue plastic ice scoop bin had approximately ½ inch of standing water; -There was a black, slimy substance in the water in the ice scoop bin; -There were no drain holes in the ice scoop container bin to allow the water to escape. During an interview on 03/28/25, at approximately 1:20 P.M., Dishwasher F said the following: -He/she was not sure who cleaned out the ice machine and ice scoop; -He/she will wash the scoop once in a while. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said he/she was unsure who cleaned the ice machine or the ice scoop bin. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said he/she was unsure who was to clean the ice machine or ice scoop bin. He/she has not cleaned either and did not know how often they should be cleaned. During an interview on 03/28/25, at approximately 2:50 P.M., the DM, said he/she did not realize the ice scoop bin did not have a way for the water to drain. During an interview on 03/28/25, at approximately 3:50 P.M., the Regional Nurse Consultant said he/she would expect staff to keep the ice scoop bin clean and sanitized on a regular schedule. During an interview on 03/28/25, at approximately 4:10 P.M., the |Administrator said it was an issue for water to be trapped in the ice scoop bin. The lime issue has been an ongoing issue. 5. Review of the 2022 Food Code, issued by the FDA, showed the following information: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces; -Food-contact surfaces and equipment used for time/temperature control for safety foods should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests Review of the facility policy titled, Cleaning Schedules, dated 08/10/18, showed to prevent the spread of bacteria that may cause food borne illnesses the DM should establish the frequency of equipment cleaning and the DM should supervise adherence to the cleaning schedule and inspect the kitchen weekly for cleanliness. Review of the kitchen's cleaning schedule titled, Weekly Kitchen Checklist, undated, showed the following task to be completed: -Clean all freezers and refrigerators, interior and exterior, including floors of walk-ins. -Clean walls: sanitize handles, doorknobs, etc.; -Clean ovens and grate on stove top; -Polish all stainless-steel surfaces. Review of a checklist titled Daily Kitchen Checklist, undated, showed the following: -All dishes, pots, pans and utensils are cleaned and stored properly after each meal and snack; -All work counters are cleaned and sanitized after use; -Can opener is clean and sanitized after each use; -Steam table is clean and sanitized after each use; -Sweep floors after meals and mop daily; -Oven spills are cleaned, and ovens turned off; -Food service employees wear hair restraints; -Clean ice machine exterior; -Clean mixer after each use; -Clean microwave and toaster. Observation of the kitchen, on 03/24/25, beginning at approximately 10:00 A.M., showed the following: -The standing mixer had dried food particles on the outside; -The puree machine had a greasy film on it; -Steam table sides and top prep area were covered in a grease and lint substance; -The bottom shelves of the prep table, to the left of the steam table, were covered in a grease and lint substance; -The toaster oven on counter was covered in a grease and lint substance; -The bottom shelves under counter had a layer of food crumbs and was covered in a grease and lint substance; -The prep area on the back wall was dirty with a grease film; -The can opener had dried food particles on it and was covered with a grease film; -The stand mixer had dried food on it and was covered with a grease film; -The walk-In refrigerator's ceiling, walls, and fan were covered in a growth of a white/silvery substance; -The refrigerator had a soured smell; -The walk-In freezer's ceiling, walls, and fan were covered in a growth of a white/silvery substance. During an interview on 03/28/25, at approximately 1:20 P.M., Dishwasher F, said the following: -He/she thought there was a cleaning schedule; -He/she knew to clean his/her own area; -The DM also came around and cleaned a lot. During an interview on 03/28/25, at approximately 1:35 P.M.,DA G said everyone usually cleans the area where they work. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said the following: -Everyone cleans their own areas; -He/she will clean up any messes he/she makes while cooking; -They all take turns sweeping and mopping. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -He/she believed there was a cleaning list to follow on the wall; -He/she did refer to it, sometimes; -Staff were expected to clean the areas they were working in; -All the other area's are split between staff to clean; -The deep cleaning is done by whoever has time. During an interview on 03/28/25, at approximately 2:10 P.M., [NAME] J said the following: -There was a cleaning schedule that was to be followed; -Kitchen staff were expected to take care of their own areas. During an interview on 03/28/25, at approximately 2:25 P.M., [NAME] L said the following: -Staff follow a cleaning schedule which was a check list; -Specific tasks are not assigned to anyone; -Whoever gets to it was supposed to do it; -After doing the task, staff are supposed to initial, but no one does. During an interview on 03/28/25, at approximately 2:50 P.M., the DM said the following: -He/she does have a cleaning schedule that staff are expected to follow; -Each staff were to clean their own areas and then they all have additional areas to clean; -He/she expected staff to be following the cleaning schedule. -He/she will be going over each duty with kitchen staff to ensure the cleaning duties are covered. During an interview on 03/28/25, at approximately 3:50 P.M., the Regional Nurse Consultant said the following: -The kitchen should be clean and free of debris; -There was a cleaning schedule that staff should follow; -There should not be any clutter, food, or trash anywhere; -Prep areas should be cleaned and sanitized. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator, said the following: -Staff were expected to follow a cleaning schedule; -He/she expected a cleaning schedule to be posted for all staff to follow; -He/she expected staff to be cleaning all walls, vents, windows, pipes, and all that is attached to the walls; -Everything should be cleaned on a regular schedule; -The walk-ins should be wiped down and cleaned. 6. Review of the facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following for the oven, range, and grill: -Spray with oven cleaner and let stand according to directions; -Wipe off loosened grease and dirt; -Wash and rinse; -Let air dry. Observation on 03/24/25, beginning approximately 10:40 A.M., showed the following: -The top edges of the doors on the stove were covered in a grease and lint substance; -The stoves knobs and just behind the knobs were covered in a grease and lint substance; -The stove's hood (back, top, and sides) were covered in a grease and lint substance; -The electrical components on backside of the stove, coming from the ceiling, were covered in a grease and lint substance; -The two motors, sitting on the backside of the stove, were covered in a grease and lint substance. During an interview on 03/28/25, at approximately 1:35 P.M., DA G said he/she cleaned the area as he/she was working and he/she tried to keep the stove and oven clean. During an interview on 03/28/25, at approximately 1:50 P.M., [NAME] H said he/she tried to clean up as he/she cooked. He/she was not sure who was responsible to deep clean the stove. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -The oven needed to be cleaned following every use; -He/she was unsure of how often the oven or stove top were cleaned; -He/she was not sure who is assigned to clean the oven. During an interview on 03/28/25, at approximately 2:50 P.M., the DM said the following: -He/she had a cleaning schedule that staff were expected to follow; -Each staff were to clean their own areas and then they all have additional areas to clean; -He/she expected the cooks to clean the stove, oven, and hood; -He/she expected them to be degreased, as well, on a regular basis, for a deep-clean. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said the following: -Staff were expected to follow a cleaning schedule and he/she expected one to be posted for all staff to follow; -All area, including the stove, hood, and oven, were to be cleaned on a daily schedule.

Based on observation, interview, and record review, the facility failed provide a sanitary environment in the kitchen when staff failed to ensure all areas in the kitchen were kept clean. This could have the potential to affect all of the residents. The facility had a census of 111. Review of the 2022 Food Code, issued by the FDA, showed the following information: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted; -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests Review of the facility policy titled Cleaning Schedules, dated 08/10/18, showed to prevent the spread of bacteria that may cause food borne illnesses the Dietary Manager (DM) should establish the frequency of equipment cleaning, supervise adherence to the cleaning schedule, and inspect the kitchen weekly for cleanliness. Review of the kitchen cleaning schedule titled Weekly Kitchen Checklist,: undated, showed the following task to be completed: -Clean all freezers and refrigerators, interior and exterior, including floors of walk-ins; -Clean walls: sanitize handles, doorknobs, etc. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following: -Floors: Sweep floor after each meal service; mop using disinfecting detergent solution, as needed, and at least once daily and change mop and water when becomes gray; -Ice Machines: Monthly wash machine, inside and outside, including legs and handle; -Walls and Ceilings: Walls and ceilings should be free of chipped and/or peeling paint. Wash thoroughly at least twice a year. Heavily soiled surfaces should be cleaned frequently and as required. 1. Observation on 03/24/25, beginning at approximately 10:00 A.M., of the kitchen showed the following: -Ceiling vents with grease and lint substance covering the surface; -The wall next to ice machine had a grease and lint substance covering the surface; -The wall behind the steam table had a grease and lint substance covering the surface; -Trim over the doors (entry to kitchen, office, bathroom and dry storage area) had a grease and lint substance covering the surface; -The window pane over the sink was dirty and difficult to see through; -The window sill and wall section just below was covered in a grease and lint substance; -The air conditioner unit and plastic panels holding the air conditioner in, located in the window, was covered in a grease and lint substance covering the surface; -The cabinets front & sides were covered in a grease and lint substance; -The bottom shelves under the counter had a layer of food crumbs and was covered in a grease and lint substance; -The prep area on the back wall had a grease film; -The wall switch plate cover, near dishwashing area, was covered with a grease film; -The metal slats on the 2-door refrigerator were covered with a grease film; -The top of the dishwasher was covered with a grease film. During an interview on 03/28/25, at approximately 1:20 P.M., Dishwasher F said the following: -He/she tried to clean his/her own area; -He/she did clean the walls in the dishwashing area; -The DM also came around and cleaned a lot; -He/she was unsure who was responsible to clean what areas. During an interview on 03/28/25, at approximately 1:35 P.M., DA G said the following: -Everyone usually cleaned the area where they worked; -He/she was not sure who does what, as far as cleaning. During an interview on 03/28/25, at approximately 2:00 P.M., DA I said the following: -He/she believed there is a cleaning list to follow; -Staff were to clean the area they work in and the other areas were split; -The deep cleaning was done by whoever had time. During an interview on 03/28/25, at approximately 2:10 P.M., [NAME] J said the following: -There was a cleaning schedule that was to be followed; -Kitchen staff were expected to take care of their own areas. During an interview on 03/28/25, at approximately 2:25 P.M., [NAME] L said the following: -Staff follow a cleaning schedule; -Specific tasks were not assigned to anyone; -Whoever gets to it was supposed to do it; -After doing the task, staff were supposed to initial, but no one does. During an interview on 03/28/25, at approximately 2:50 P.M., DM said the following: -He/she did have a cleaning schedule that staff were expected to follow; -Each staff were to clean their own areas and then they all had additional areas to clean. During an interview on 03/28/25, at 3:50 P.M., the Regional Nurse Consultant said the following: -The kitchen should be clean and free of debris; -There was a cleaning schedule that staff should follow; -There should not be any clutter, food, or trash anywhere and prep areas should be clean. During an interview on 03/28/25, at approximately 4:10 P.M., the Administrator said the following: -Staff were expected to follow a cleaning schedule and he/she expected one to be posted for all staff to follow; -Expected staff to clean all walls, vents, windows, pipes, and all that is attached to the walls on a regular schedule.

Based on observations, interviews, and record review, the facility failed to ensure each resident received an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) reflective of the resident's status at the time of the assessment for one resident (Resident #16) out of a total sample of 34 residents. The facility census was 115. 1. Review of the Centers for Medicare and Medicaid (CMS)'s RAI 3.0 Manual, revised October 2023, showed in the coding instructions for wandering that the frequency of the behavior during the seven day look back period should be coded. Review of the Resident's #16's admission Record, found in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 01/18/10; -Diagnoses included dementia, depression, anxiety, and schizophrenia (a chronic brain disorder - symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking and lack of motivation). Review of the resident's quarterly MDS assessment located in the MDS tab in the EMR, with an assessment reference date (ARD) of 06/05/23, showed the following: -Significantly impaired cognition; -Independent with bed mobility, transfers, walk in room and corridor, locomotion on and off unit; -Assessed to not wander, nor have physical or verbal behavioral symptoms directed toward others. Review of the resident's annual MDS assessment located in the MDS tab in the EMR, with an ARD of 08/28/23, showed the following; -Significantly impaired cognition; -Continued to be independent with activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting); -Assessed to not wander, nor have physical or verbal behavioral symptoms directed toward others. Review of the resident's Care Plan, located in the Care Plan tab of the EMR, dated 02/11/17, showed the following: -Resident has diagnosis of schizophrenia; -Resident refuses psych meds and lab monitoring; -Resident will get in to other resident belongings, turn off their oxygen concentrators, and throw their clothing through the doorway into the hall. Review of the resident's Care Plan, located in the Care Plan tab of the EMR, dated 01/06/23, showed the following: -Dementia Unit needed related to wandering in and out of resident rooms; -Resident takes other resident belongings and staff belongings. Resident will take pictures off the wall; -Resident may not be able to attend activities in the general population. It causes resident increased agitation and behaviors. During observations on 10/23/23, at 11:38 A.M., on 10/24/23, at 9:05 A.M., and on 10/25/23, at 4:05 P.M., showed the resident wandered on the secure unit. The resident observed wandering in and out of other residents' rooms and throughout the unit. Staff were observed frequently redirecting the resident. During an interview on 10/26/23, at 10:28 A.M., MDS Coordinator (MDSC) said the following: -The resident had been care planned for his/her behaviors and did not have any new ones; -The Resident Assessment Instrument (RAI) indicated to code for any new behaviors so they can be care planned, but if the resident is only observed with already existing and known behaviors, then she would not capture that information on the MDS; -Since the resident had only the long-standing behaviors, they would not be captured on more recent assessments; -The care plan for the resident was currently accurate for her behaviors. During an interview on 10/26/23, at 11:37 A.M., Nursing Assistant (NA) revealed the resident wandered on the secured unit all the time. This was the resident's normal behavior. The resident also liked to go into other residents' rooms and take clothing that he/she thinks is his/hers. During an interview on 10/26/23, at 11:42 A.M., Licensed Practical Nurse (LPN) 2 said the resident wandered all of the time, at least on a daily basis. The resident might watch television or do something for a short period of time, but still spent most of his/her time wandering the unit and into other resident rooms. During an interview on 10/26/23, at 12:00 PM, the Director of Nursing (DON) said the MDSC had not documented the resident's behaviors or wandering because they were not new behaviors for the resident. The DON said the MDSC had to reread the RAI. The resident had always been a busy pacer in the facility, but now that he/she was on the secured unit he/she wandered even more.

Based on interviews and record review, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR) was completed for one resident (Resident #15) of one sampled resident reviewed for PASARR failure to complete a Level 1 screen which prevents the completion of an in-depth evaluation (Level II PASRR) and possible identification of appropriate services. The facility census was 115. Review of the Preadmission Screening Resident Review policy, revised on 06/09, showed the following: -The process for PASRR included a Level I and/or Level II would be added to the admission checklist as one of the documents required prior to or at the time of admission; -The original documents for Level I and/or Level II determination would be placed in the medical chart behind the social services tab and a copy would also be placed in the residents financial file in the business office; -The intent of a preadmission screening was to ensure that all individuals with a diagnosis of mental illness had appropriate placement in a facility, their medical needs outweigh their mental needs, and they received appropriate services for their condition; -The nursing facility was responsible for ensuring a Level I screening was completed, submitted, and had a Level I determination on or before admission. 1. Review of Resident #15's admission Record, found in the admission Tab of the electronic medical record (EMR) showed the following: -admission date of 10/13/15; -Diagnoses included schizophrenia (a chronic brain disorder that affects less than one percent of the U.S. population), anxiety, bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), panic disorder, and depression. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment comlpeted by facility staff) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 09/01/23, showed the resident had no cognitive impairment. Review of the resident's Care Plan located in the Care Plan tab of the EMR, dated 09/11/23, showed the following: -Potential for altered mood state/psychosocial well being related to schizophrenia, anxiety, bipolar, and depression; -Resident to have no decline in mood state/psychosocial well being; -Interventions included psychological counseling at various facilities, medication management, and monitoring for mood changes. During an interview on 10/23/23, at 2:06 P.M., the reisdent said he/she had mental issues, was schizophrenic, and was on medication for that condition. The resident said she had been in and out of many different facilities, but had been at this facility several years and it was his/her home. The resident said he/she worked outside the facility several days a week. Review of the PASRR section of the resident's hard copy chart showed a PASRR was not in the chart. Review of the resident's EMR showed there was no PASRR in the record. During an interview on 10/26/23, at 9:00 A.M., Licensed Practical Nurse/Medical Records (LPN) 5 said he/she did not see a PASRR in the hard copy chart for the resident. LPN 5 said he/she was not sure what a PASRR was for. During an interview on 10/26/23, at 9:10 A.M., the Financial Specialist said after reviewing the financial records for the resident, he/she did not find a PASRR that had been completed for the resident. He/she would call the guardian and the facility that the resident had come from. A PASRR was completed for every resident to ensure the resident was at the correct level of care and the facility would be able to meet a resident's needs. The PASRR would be kept in the resident's financial records if the resident had one. Whoever did the job before him/her did not obtain the required PASSR and the resident should have a completed PASRR in the financial records. During an interview on 10/26/23, at 12:03 PM, the Director of Nursing (DON) said every resident had to have a Level I PASRR completed before being admitted to the facility. When a Level I PASRR was completed, it was sent to an outside company that determined if a resident needed a Level II. The DON said a diagnosis of schizophrenia would trigger a PASRR Level II to be completed. A Level II PASRR determined what services the resident needed from the facility, what has worked in the past, and what the resident needed now. The DON said the resident should have a PASRR completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to develop a comprehensive care plan for one resident (Resident #21) out of a total sample of 32 residents when the resident had a physician order for oxygen use and the facility failed to develop a care plan related to oxygen usage. The facility census was 115. Review of the Nursing Management Manual Policy, effective 08/15/18, under the Quality of Life section with a Person Centered Care Plan policy title, showed the following: -The purpose of a person-centered plans of care was to care approaches and goals specific to the resident's needs; -Comprehensive plan of care should be reviewed quarterly and the Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) Coordinator should ensure the care plan interventions were entered outside of routine care which would provide the Certified Nursing Assistants (CNA) with individualized information needed to meet the residents care needs; -The care plan team should develop a comprehensive care plan for each resident that included measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. 1. Review of the Resident #21's quarterly Minimum Data Set (MDS), located in the MDS tab in the electronic medical record (EMR), with an Assessment Reference Date (ARD) of 09/12/23, showed the following: -admitted on [DATE] and readmitted on [DATE]; -Cognition was intact; -Diagnoses included anxiety, asthma (a disease that affects the lungs causing repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing), and chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems); -Resident had shortness of breath on exertion and when lying flat; -Utilized oxygen therapy. Review of the resident's EMR Physician Orders showed the following, -An order, dated 09/06/23, for oxygen at two liters per nasal cannula as needed for shortness of breath. Changing all oxygen tubing every week on Fridays. Respiratory assessment for shortness of breath and albuterol sulfate (a quick relief inhaler) as needed for shortness of breath. Review of the resident's EMR Care Plan tab showed a comprehensive care plan dated 09/06/23. Staff did not care plan the resident's oxygen use. Observation on 10/24/23, at 9:32 A.M., showed the resident was sitting in a wheelchair in the dining room area. The resident was drinking coffee and had oxygen at 2L per nasal cannula. During an interview on 10/24/23, at 9:33 A.M., the resident revealed he/she had been in the hospital a few weeks ago and he/she now used oxygen as he/she needed it. During an interview on 10/26/23, at 1:01 P.M., the MDS Coordinator said if a resident was on oxygen, he/she would make a care plan reflecting the oxygen use. A problem for respiratory would be initiated and oxygen would be one of the interventions. The MDS Coordinator confirmed there was no care plan for oxygen use and there should be. He/she did not know why he/she did not establish a care plan for the oxygen use. The care plan should include interventions like oxygen saturations, changing the O2 tubing, vital signs, and physician orders for oxygen use.

Based on record review, observation, and interview, the facility failed to ensure two residents (Residents #40 and #59) out of two residents observed out of a sample of 32 residents were positioned appropriately at the dining table to ensure the residents could access their food without difficulty and at a comfortable position. This had the potential for the residents to have nutritional issues and a negative dining experience. The facility census was 115. Review showed the facility did not provide a policy related to dining and positioning. 1. Review of Resident #40's facility provided quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 09/15/23, showed the following: -admission date of 05/29/21; -Cognition was moderately impaired, made poor decisions, and supervision was required; -Resident required limited assistance with one person assist with eating. 2. Review of Resident #59's facility provided quarterly MDS, with an ARD of 07/27/23, showed the following: -admission date of 05/08/21; -Cognition severely impaired; -Required supervision for eating and required setup help only. 3. Observation on 10/24/23, at 1:03 P.M., in the dining room in the secured unit showed Resident #40 and Resident #59 were seated in their wheelchairs at the dining table. Both residents were observed where their chins were level with the top of the dining table. Both were also observed having to reach above their heads with their eating utensils in order to reach their food. Observation on 10/25/23, at 12:15 P.M. showed Resident 340 and Resident #59 were seated in their wheelchairs at the dining room table in the secured unit eating lunch. Their chins were level with the top of the table. Resident #40 had all of his/her food in bowls and was reaching up above his/her head with his/her spoon so he/she could access the food in his/her bowl in order to feed him/herself. He/She then was observed to reach up and take the bowl and put it in his/her lap so he/she could feed him/herself without having to reach above his/her head. Resident #59 was observed in his/her wheelchair at the dining table with his/her chin level to the dining table, reaching above his/her head with his/her eating utensils in order to access her food so he/she could feed herself. 4. During an interview on 10/25/23, at 12:20 P.M., with Certified Nursing Assistant (CNA) 1 and Licensed Practical Nurse (LPN) 2, both confirmed the Resident #40 and Resident #59's wheelchairs were either too low or the table was too high in order for them both to be able to feed themselves without difficulty. They confirmed both of the residents' chins were level with the table, and they had to reach up in order to be able to reach their food on their plates and in their bowls. CNA 1 confirmed Resident #40 often reaches up and gets her bowl and holds it close to him/her so he/she can feed him/herself without reaching. They both confirmed it could possibly be a potential for him/her to spill hot food on him/her when reaching up for his/her bowls. 5. During an Interview on 10/26/23, at 11:00 A.M., the Director of Nursing (DON) said she was not aware Resident #40 and Resident #59 sat so low at the dining table and had to reach up above their heads to access their food in order to feed themselves.

Based on observations, interviews, and record review, the facility failed to keep one out of six medication carts secured; failed to remove expired calibration solution from one out of the two medication rooms; and failed to removed two expired covid tests. These failures had the potential for resident medications to be tampered with, glucometers to be calibrated inaccurately, and for expired covid tests and medications which may be less effective be used. The facility census was 115. 1. Review of the Storage and Expiration of Medication, Biological, Syringes, and Needles policy, with a revision date of 10/31/16, showed the facility should ensure that all medications and biologicals are securely stored in a locked cabinet/cart or a locked medication room that is inaccessible by residents or visitors. During observations on 10/25/23, from 11:09 A.M. to 11:20 A.M., a medication cart sitting between the 100 and 200 halls by the nurses' station was unlocked and unattended. At 11:09 AM, this surveyor opened a drawer that contained medication, then closed the drawer, and continued to observe the cart. At 11:11 AM, multiple staff walked past the medication cart. At 11:16 AM, Resident # 22 ambulated with a walker past the unlocked medication cart. At 11:18 AM, the Director of Nursing (DON) walked by the unlocked cart and went into the nurses' station. At 11:20 AM, the Staff Development nurse locked the cart. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff) with an Assessment Reference Date (ARD) of 08/13/23, showed the resident indicated the resident either would not answer the mental status question or the answer was nonsensical. During an interview on 10/25/23, at 11:20 A.M., the Staff Development Nurse showed the medication cart was unlocked and she locked it. The medication cart should be kept locked to keep unauthorized people out of it. There were medications in the cart that could hurt a resident if they got a hold of it. A resident could get in the cart if it was unlocked and get something a resident should not get. 2. Review of the Storage and Expiration of Medication, Biological, Syringes, and Needles policy, with a revision date of 10/31/16, showed the facility should ensure that medications and biologicals that have an expired date should be stored separate from other medications until destroyed or returned to the pharmacy. Observation and interview on 10/25/23, at 12:41 P.M., with Licensed Practical Nurse (LPN) 1 in the medication room showed the following: -Seven boxes of recalibrate assure dose that had an expiration date of 09/20/23. LPN 1 said the recalibrate assure dose was expired and should not be in there. If an expired recalibration solution was used it could cause an inaccurate reading when calibrating the glucometer. If the glucometer had been calibrated inaccurately the residents could get inaccurate blood sugar results and may get too much insulin or too little insulin; -Two covid tests with expiration dates of 06/22/23. LPN 1 said the two covid tests kits expired on 06/22/23, however they were not using that brand any longer. The expired covid tests should be thrown away. 3. During an interview on 10/26/23, at 10:00 A.M., the Director of Nursing (DON) said her expectations were that medication should be checked for expiration dates. Med techs checked each cart each day for expired medications. Expired assure plus calibration solution could potentially give staff a false reading and be out of range. If the solution was expired staff could get a false reading and if too high could give insulin when the resident really did not need insulin.

Based on observations,interviews, and record review, the facility failed to ensure food was properly stored, prepared, distributed, and served in accordance with professional standards for food service safety as required for 115 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents. Review of the Dietary Service Manual, dated 08/10/18, showed the following: -Kitchens and dining areas should be kept clean, free from litter, and rubbish, and protected from rodents, roaches, flies, and other insects; -Utensils, counters, shelves, and equipment should be kept clean, maintained in good repair, and should be free from breaks, corrosion, open seams, cracks, and chipped areas; - Items in storage rooms should not be stored within 18 inches of sprinkler heads, and should be kept at least 6 inches from the floor; -Open food items should be covered, labeled, and dated. Opened dry goods should be kept in tightly sealed containers. 1. Observations during the tour of the kitchen on 10/23/23, at 10:05 A.M., showed the following: -In the pantry, there was a large container of oatmeal dated 10/8 to 11/8. The plastic lid was left ajar; -In the walk-in refrigerator, there was an opened and undated 10-pound box of sausage patties. The box stated to keep frozen 0 to 10 degrees Fahrenheit(F); -In the walk-in freezer, there were unopened boxes of food products placed into plastic crates on the floor. A large unopened cardboard box of beef was also noted on the floor without being raised. An opened and undated 3-gallon container of strawberry ice cream was stored on a shelf, with the lid ajar. Observations during the tour of the kitchen on 10/25/23, at 10:28 A.M., showed the following; -In the walk-in freezer, there was an opened and undated 20 lb. box of sugar cookie dough. There was an opened and undated 3-gallon container of strawberry ice cream with the lid ajar; -There were two knife storage boxes, with four knives in each. These were secured to the sides of two cupboards, near a kitchen sink and potential backsplash. The knife handles were observed with dirt and dark discoloration. The storage boxes were noted to have dried dirt and debris on all exposed sides and on the cupboard walls behind them; -There were tongs, ladles, and whisks that hung inside cupboard doors that were observed with dried debris on the handles. The cupboards were observed with dried food and dirt on the storage shelves; -Two large pitchers of tea were observed on the kitchen counters next to a kitchen sink without any lids or covers; -Pantry floors were observed with large areas of built-up dirt. Observations during the tour of the kitchen on 10/26/23, at 1:30 P.M., with the Dietary Supervisor (DS) and Registered Dietitian (RD) showed the following: -Three large pitchers of tea were observed on the kitchen counters next to a kitchen sink without any lids or covers; -The two knife storage boxes, with four knives in each, were again observed with dirt and debris; -Tongs, ladles, and whisks were observed inside cupboard doors with dried food and debris on the handles. The cupboards were observed with dirt and dried food on the shelves; -Pantry floors with visible areas of visible dirt built-up; -The 3-gallon containers of ice cream were again observed with lids ajar. During an interview on 10/26/23, at 1:44 P.M., with the DS and RD confirmed that the pitchers of tea should have been covered. The knife storage boxes and cupboard utensils should have been properly cleaned before stored. The maintenance department was supposed to clean and strip the floor wax in the pantry, but had been too busy lately. They confirmed all bins should have securely placed lids during storage, and that the ice cream should not have lids ajar. The DS and RD were unaware the box of sausages specified it should be kept frozen.

Based on interview and record review, the facility failed to check the Nurse Aide (NA) registry prior to hire to ensure new employees did not have a Federal Indicator (a registry that indicated a list of individuals who had a previous incident involving abuse, neglect, or misappropriation of property that would prevent the employee from working in a certified long-term are facility) for one (Licensed Practical Nurse (LPN) A) out of five sampled employees, The facility census was 79. 1. Record review of LPN A's personnel file showed the following: -Hired on 6/4/19; -No documentation the facility completed the NA registry check prior to or upon hire for the employee. During an interview on 3/13/20 at 11:35 A.M., Financial Specialist Assistant B said the following: -LPN A previously worked at the facility from 8/29/17 to 9/1/17. Staff checked NA Registry at that time. -He/she checked LPN A's license prior to his/her most recent hire date, but he/she did not check the NA Registry. During an interview on 3/13/20 at 1:15 P.M., the Administrator said staff should check NA registry on all new hires, even if they were rehired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all residents were free from significant medication errors when staff administered insulin (medication used to help control blood sugar levels) without priming the insulin pen, per standards of practice, prior to administration for one resident (Resident #22). The facility census was 79. Record review of the facility's policy, titled Medication Administration Procedures, Subcutaneous (just under the skin) Injection with Novolog Flexpen, dated 5/2012, showed the following: -Give the airshot before each injection: Small amounts of air may collect in the needle and insulin reservoir during normal use. To avoid injecting air and to ensure proper dosing follow the steps described below. -Hold the syringe with the needle pointing up and tap the syringe gently so any air bubbles collect in the top of the reservoir; -Dial 2 units; -Holding the syringe with the needle pointing up, tap the insulin reservoir a few times. Still with the needle pointing up, press the button as far as it will go and see if a drop of insulin appears at the needle tip. If not, repeat the process until insulin appears. 1. Record review of Resident #22's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted on [DATE]; -Diagnoses included diabetes mellitus (DM) (a chronic condition that affected how the body processed blood sugar (glucose)), chronic kidney disease, stage 3 (a stage of kidney disease where the blood pressure could be elevated, excess swelling could be seen, and lower red blood cells could be seen), and atrial fibrillation (an irregular heartbeat). Record review of the resident's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 12/31/19, showed the following: -Moderately impaired cognition; -Received insulin injections seven out seven days. Record review of the resident's care plan, last updated 2/7/20, showed staff identified the resident at risk for complications related to diabetes and intervention included administer medications as ordered for diabetes. Record review of the resident's physician order, dated 1/30/20, showed direction for staff to administer Novolog (a fast-acting insulin ) 100 Unit/milliliter (ml) Flexpen, 20 units, injected under the skin, three times day before meals. Observations on 3/12/20, at 12:15 P.M., showed Certified Medical Technician (CMT) B placed a needle on the resident's Novolog FlexPen, dialed the pen to 20 units and administered the insulin to the resident. The CMT did not prime the FlexPen prior to administration. During an interview on 3/12/20, at 12:16 P.M., CMT B said he/she never primed the FlexPens. He/she did not know he/she was supposed to. During an interview on 3/12/20 at 1:00 P.M., Registered Nurse (RN) RN C said he/she always primed the insulin pen by discharging 2 units before dialing the ordered dosage. During an interview on 3/12/20, at 1:19 P.M., the Director of Nursing (DON) said the staff received orientation upon hire. The pharmacy consultant conducted training for insulin pens and observed staff administering medications regularly. Staff should prime the insulin pens by placing a needle on the pen, dialing the pen to 2 units and discharging the 2 units. During an interview on 3/13/2020, at 1:13 P.M., the Administrator said staff should prime the insulin pen before use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff appropriately documented the results of the yearly tuberculosis (TB) (an infectious disease that generally affects the lungs, but can also affect other parts of the body) skin test for two residents (Resident #9 and #22) and failed to complete the yearly TB signs and symptoms form for one resident (Resident #58) in a selected sample of 18 residents. The facility's census was 79. General requirements for TB testing for residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit test. Each facility shall be responsible for ensuring all test results are completed and documentation is maintained for all residents; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a Mantoux PPD (tuberculin sensitivity test) two-step tuberculin test. If the initial test is negative, the second test can be given after admission and should be given one to three weeks later. -All skin test results are to be documented in millimeters (mm) of induration. -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. 1. Record review of Resident #9's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included chronic respiratory failure and stroke. Record review of the resident's physician order (PO), dated 10/20/17, showed instructions for staff to administer Tubersol 0.1 milliliters (ml) intradermal (a shallow injection), yearly, and document the lot number and expiration date in nurse notes. Record review of the resident's medication administration record (MAR) showed the following: -On 10/20/19, staff administered the TB test; -On 10/23/19, staff documented no induration or redness (Staff did not document the result of the TB test in millimeters). 2. Record review of Resident #22's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included stroke and diabetes. Record review of the resident's PO, dated 1/8/19 showed direction for staff to administer Tubersol (Tuberculin purified protein derivative (PPD) used to help diagnose tuberculosis (TB) infection) 0.1 ml intradermal yearly, and document the lot number and expiration date in nurse notes. Record review of the resident's MAR showed the following: -On 1/8/20, staff administered the TB test; -On 1/11/20, at 4:36 P.M., a nurse documented the post (TB) administration skin audit as 0. -On 1/11/20, at 8:46 P.M., medication follow-up (Tubersol 0.1 ml vial) completed. (Staff did not document the result of the TB test in millimeters). During an interview on 3/13/20 at 12:17 P.M., the Director of Nursing (DON) said the did not document the TB skin test results in mm because he/she was new employee. Facility staff educated the nurse on reading and documenting TB skin test results. 3. During an interview on 3/13/20 at 11:05 A.M., Licensed Practical Nurse (LPN) D said the following: -Staff read the results within 72 hours and documented the results in millimeters; -Staff documented negative or 0 mm if there was no redness or raised skin. During an interview on 3/13/20 at 12:17 P.M., the Director of Nursing (DON) said the following: -Staff should follow the same TB skin test policy for employees and residents; -Staff should document the results in millimeters or 0 induration. 4. Record review of Resident #58's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included anxiety, depression, high blood pressure and muscle weakness. Record review of the resident's annual signs and symptoms form, dated 8/15/19, showed the following: -Staff did not document a yes or no; -Staff did not document if the resident exhibited signs and symptoms of TB. -The resident did not sign the form. During an interview on 3/13/20 at 12:28 P.M., LPN E said he/she screened the resident and the resident had no signs or symptoms of TB, but he/she did not mark yes or no on the annual statement for tuberculin reactors. During an interview on 3/13/20 at 1:13 P.M., the DON said: -Staff should read and document the results based on facility policy. -Since the resident had a positive TB test in the past, staff had to complete an annual signs and symptoms checklist. -The resident refused to sign the form. -Staff should have completed the annual signs and symptom form.

Based on interview and record review, the facility failed to review and update the comprehensive facility assessment annually, in accordance with all applicable Federal requirements. Failure to review and update the comprehensive facility assessment annually could delay the services needed to care for the residents in day-to-day operations and in emergencies. This failure could affect all facility occupants. The facility census was 79. Record review of the facility's assessment policy, undated, showed the following: -It is the policy of this facility that it must conduct and document an individualized facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. -The facility assessment will be conducted at the facility level and may incorporate input from governing body/ownership. -The facility will review and update the facility assessment annually and as necessary whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment. -The facility assessment will address or include the following per requirements: -The facility's resident population; -Number of residents and resident capacity; -Care required by the resident population which considers: Types of diseases, conditions, physical cognitive disabilities, overall acuity and other pertinent facts that are present within the facility population. -The facility's resources; -A facility-based and community-based risk assessment, utilizing an all-hazards approach; -The Objective of the facility assessment is to evaluate the resident population and identify the resources needed to provide the necessary care and services the residents require. -The facility assessment shall enable the facility to thoroughly assess the needs of its resident population and required resources to provide the care and services the resident's need-serving as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources needed. -The facility assessment will be conducted at the facility level including the administrator, medical director, a representative of the governing body, and the director of the nursing (DON) at a minimum. The environment operations manager, other department heads, or direct care staff will be involved as needed. -Facility Assessment Update: -The facility will review and update the facility assessment annually and as necessary whenever there is, or the facility plans for, any change that would require substantial modification to any part of the assessment. -Location of the Facility Assessment: -The written facility assessment will be located in the facility administrator's office and will be accessible to appropriate parties upon request. Record review of the Facility's Assessments showed -Staff completed the 2017 facility assessment on 8/29/17. -Staff completed the 2020 Facility Assessment on 3/12/20 (during the annual survey). (There was no other documented facility assessments. During an interview on 3/13/20, at approximately 10:41 A.M., the administrator said the following: -When staff updated the 2020 facility assessment, they found the 2018 assessment in the Corporate computer which he thought was dated October 2018. This assessment was not saved and was deleted. -The facility staff could not find the 2019 Facility Assessment and they did not have a copy of the 2018 Facility Assessment. -Staff looked everywhere for the 2019 Facility Assessment and could not located it. -The last Facility Assessment, dated 8/29/17 was the only one he could find. -The previous administrator said she had completed the 2019 Facility Assessment but he could not find it. -The previous Administrator left on 1/14/20 and the current administrator started on 1/15/20.

Based on observation and interview, the facility failed to provide a switch that would activate the resident call light system in four common-use restrooms. This deficient practice had the potential to affect all residents and visitors who used the restrooms and required staff assistance. The facility had a census of 79. 1. Observation on 3/13/20, beginning at 9:00 A.M., showed two unsecured common-use restroom doors, located in the therapy hall, in which residents could access. Staff attached the restroom door key to the outside of each door. Neither restroom had a call light activation switch. 2. Observation on 3/13/20, at 11:30 A.M., showed two unsecured common-use restroom doors, located in the main lobby, in which residents could access. Staff attached the restrooms door key to the outside of each door. Neither restroom had a call light activation switch. 3. During an interview on 3/13/20, at 1:00 P.M., the maintenance supervisor said he did not know the restrooms needed a call light activation switch.