**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and keep three resident's (Residents #1, #29, and #40) equipment in good, working order. The facility also failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 39. Review of the facility's policy titled, Safe Environment, dated 01/30/25, showed: - The resident has a right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely; - Housekeeping and maintenance services necessary to maintain a sanitary, including but not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored, orderly, and comfortable interior; - Environment refers to any environment in the facility that is frequented by residents, including but not limited to the residents' rooms, bathroom, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. 1. Observations on 05/13/25 at 12:41 P.M., 12:44 P.M., and 12:47 P.M., of the facility's linen carts showed: - The protective covering tattered and torn with rips on the 100 Hall; - The protective covering with a large rip toward the front top-side area, tattered and torn on the 200 Hall; - The protective covering tattered and torn with rips on the 300 Hall. 2. Observations on 05/13/25 at 10:00 A.M., 05/14/25 at 8:06 A.M., and 2:20 P.M., 05/15/25 at 7:30 A.M., and 05/16/25 at 6:50 A.M., and 10:30 A.M., of the 100 Hall showed: - A strong urine odor; - Large visible areas of a dark, brown-like stain on the carpet in front of Rooms 102, 103, 104, and 105. 3. Observations on 05/13/25 at 11:15 A.M., 05/15/25 at 10:20 A.M., and 05/16/25 at 12:18 P.M., of room [ROOM NUMBER] showed: - A four inch (in.) by six in. area of exposed and broken dry wall behind the resident door. 4. Observations on 05/13/25 at 12:12 P.M., and 05/14/25 at 12:02 P.M., of Resident #40's wheelchair showed: - A two in. by three in. opened ripped area with exposed foam on the right-side armrest; - The resident lay his/her right arm on the right-side armrest. 5. Observations on 05/13/25 at 12:34 P.M., 05/14/25 at 12:05 P.M., and 05/15/25 at 11:52 A.M., of Resident #29's wheelchair showed: - A one in. by three in. opened ripped area with exposed foam on the right-side armrest; - The resident lay his/her right arm on the right-side armrest. 6. Observations on 05/13/25 at 12:37 P.M., 05/14/25 at 12:07 P.M., and 05/15/25 at 11:54 A.M., of Resident #1's wheelchair showed: - A seven in. opened area of exposed foam on the left-side armrest; - The resident lay his/her left arm on the left-side armrest. 7. Observation on 05/15/25 at 9:07 A.M., of the 100 Hall showed: - A three in. by five in. cracked piece of corner molding near the floor adjacent to the spa. 8. Observations on 05/15/25 at 2:31 P.M., and 05/16/25 at 12:09 P.M., of the dining room floor showed; - A large visible oblong water-like stained area on the carpet connected to the vinyl flooring near the nurses' station; - A visible three foot (ft.) straight line dark stained area on the carpet near the employee time clock; - A large visible area of a dark, brown-like stain on the carpet in front of the wall vent near the nurses' station leading past the piano toward the 300 Hall. 9. Observations on 05/15/25 at 2:34 P.M., and 05/16/25 at 12:13 P.M., of the 300 Hall showed: - Large visible areas of a dark, brown-like stain on the carpet in front of Rooms 301, 302, 303, 305, and 306; - A five in. by two in. exposed sheetrock area on the ceiling located over the television in room [ROOM NUMBER]. 10. Observation on 05/16/25 at 7:00 A.M., of the 100 Hall showed: - A missing piece of molding on the right side of the door frame in room [ROOM NUMBER]; - A missing piece of molding on both sides of the door frame in room [ROOM NUMBER]; - A missing piece of molding on the left side of the door frame in room [ROOM NUMBER]; - A missing piece of molding on the left side of the door frame in room [ROOM NUMBER]. Review of the Maintenance Repair Log, dated 12/24/25 - 05/08/25, showed: - No documentation of areas of concerns addressed. During an interview on 05/14/25 at 7:11 A.M., Licensed Practical Nurse (LPN) D said the carpets had always been this dirty. Family members and visitors had asked about the odors and the carpet being so dirty. Housekeeping cleaned, however the odors were still there. During an interview on 05/15/25 at 2:57 P.M., the Maintenance Supervisor (MS) said the facility had a special type of floor machine specifically used for the upkeep of the facility's carpet, but it was no longer used. He/She used a residential type carpet shampoo machine recently to clean some areas of the the carpet in the dining room. By the time he/she shampooed a three ft. x three ft. section of the carpeted floor, the water had to be dumped. The water turned black within five minutes of using the facility's carpet shampoo machine. The facility needed a machine that could clean larger areas of the carpet throughout the facility. During an interview on 05/16/25 at 9:27 A.M., Certified Nurse Aide (CNA) G said there was a clipboard at the nurses' station and anyone could add areas that needed to be fixed to the clipboard. The maintenance staff checked it daily. During an interview on 05/16/25 at 9:29 A.M., LPN D said there was a clipboard laying on the nurses' desk ledge and staff could add to it for things to be fixed and the maintenance staff reviewed it. During an interview on 05/16/25 at 9:46 A.M., the MS said he/she had only been in this role for about two weeks, however, staff did put items that needed repaired on the clipboard at the nurses' station. He/She checked it daily and sometimes in the evening before leaving the facility. During an interview on 05/16/25 at 12:15 P.M., the Administrator said the facility had went awhile without any maintenance staff, other than the administration staff assisting. There was not any maintenance staff from September 2024 until about two weeks ago. The repair log clipboard was kept at the nurses' station and staff could write down repairs and also tell the maintenance staff of any concerns related to the facility environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) for four residents (Residents #18, #27, #29 and #33) out of 12 sampled residents. The facility census was 39. Review of the facility's policy titled, Resident Assessment Instrument (RAI/MDS) Process, last reviewed, January 2025, showed: - One of the functions in the RAI/MDS process is to gather data to develop comprehensive and individualized care plans that meet the medical, nursing, mental and psychosocial needs of each resident. Each care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; - Ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment by staff qualified to assess relevant core areas and are knowledgeable about the resident's status, needs, strengths and areas of decline. 1. Review of Resident 18's medical record showed: - admitted on [DATE]; - Diagnoses of hemiplegia (paralysis of one side of the body) right dominant side, cerebral infarction (stroke) and cerebral vascular disease (a condition that affects blood flow to the brain). Review of the resident's May 2025 Physician's Order Sheet (POS) showed: - An order for aspirin (an antiplatelet medication that prevents platelets (small cell fragments in the blood that form clots) from sticking together and forming a blood clot) 81 milligram (mg) chewable tablet by mouth one time a day related to cerebral infarction, dated 12/18/24; - No order for an anticoagulant (a medication used to slow the formation, prevent, or treat blood clots and also known as a blood thinner) medication. Review of the resident's annual MDS, dated [DATE], showed: - Received an anticoagulant; - Did not receive an antiplatelet. Review of the resident's Care Plan, dated 10/16/24, showed: - History of cardiovascular accident (heart attack) and transient ischemic attacks (TIA - mini-strokes); - Resident at risk related to antiplatelet therapy due to a history of stroke episodes. During an interview on 05/15/25 at 10:00 A.M., the resident said he/she did not take a blood thinner. 2. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnoses of type 2 diabetes mellitus (DM - high blood sugar), chronic obstructive pulmonary disorder (COPD - a lung disease that causes breathing difficulties), congestive heart failure (where the heart can't pump effectively), peripheral vascular disease (narrowing of the blood vessels outside the heart and brain), and bilateral (both sides) above the knee amputation. Review of the resident's May 2025 POS showed: - An order for Xarelto (an anticoagulant medication) 15 mg tablet by mouth one time a day, dated 02/15/25. Review of the resident's annual MDS, dated [DATE], showed: - Resident did not receive an anticoagulant medication. Review of the resident's Care Plan, dated 03/05/25, showed: - Resident on anticoagulant therapy (Xarelto) and was at risk for bleeding and bruising. 3. Review of Resident #29's medical record showed: - admitted on [DATE]; - Diagnoses of hemiplegia and stroke. Review of the resident's May 2025 POS showed: - An order for Eliquis (an anticoagulant medication) 5 mg by mouth two times a day related to cerebral infarction, dated 11/18/24; - No order for an antidepressant. Review of the resident's annual MDS, dated [DATE], showed: - Received an antidepressant; - Did not receive an anticoagulant. Review of the resident's care plan dated, 05/07/25, showed: - Received anticoagulant medication daily; - The use of an antidepressant medication not addressed. 4. Review of Resident #33's medical record, showed: - admitted on [DATE]; - Diagnoses of dementia (a disease that affects thinking, memory, and behavior), psychosis (mental health condition that causes a loss of contact of reality), depression (mood disorder characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities), and anxiety (a feeling of uneasiness or worry about something that is going to happen or could happen). Review of the resident's May 2025 POS showed: - An order for Eliquis 5 mg by mouth two times daily, dated 12/02/24; - No order for insulin; - No order for an an antiplatelet medication. Review of the resident's annual MDS, dated [DATE], showed: - The resident received insulin injections daily; - The resident received an antiplatelet medication; - The resident did not receive an anticoagulant medication. Review of the resident's Care Plan, dated 03/04/25, showed: - Insulin, anticoagulant, and antiplatelet medications not addressed. During an interview on 5/16/25 at 10:20 A.M. the MDS Coordinator said he/she was fairly new to this position and got the information from the POS and spoke with staff before completing the residents' MDS. He/She said aspirin was an anti-platelet medication and not an anticoagulant medication, and should not be documented as such. During an interview on 05/16/25 at 12:25 P.M., the Director of Nursing (DON) said aspirin was not an anticoagulant and should not be documented as one on the MDS. She did not believe Eliquis was an anticoagulant either. She said the MDS should be completed and should reflect the medications the residents were receiving. During an interview on 05/16/25 at 12:09 P.M., the Administrator said if the residents were taking the medications, then the MDS should be completed correctly for what the residents were taking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff utilized safe transfer techniques for three residents (Residents #29, #32, and #37) when staff failed to transfer the resident with the assist of a gait belt (a device used to aid in the safe movement of a person from one place to another) out of four sampled residents. The facility census was 39. Review of the facility's policy titled, Gait Belt Use, undated, showed: - The purpose of a gait belt is to provide better control and balance while assisting a resident with ambulation or transfer; - Assist the resident to a sitting position; - Apply the belt to the resident's waist; tighten to fit snugly with the buckle at the side; - Bring the resident to a standing position while straightening your knees; - After the resident is standing, the belt provides assistance stabilizing the turning of the resident. 1. Review of Resident #29's medical record showed: - An admission date of 10/21/21; - Diagnoses of hemiplegia (paralysis of one side of the body), cerebral infarction (stroke), muscle weakness, and a history of falls. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) , dated 02/04/25, showed: - Severe cognitive impairment; - Substantial/Maximal assistance with lying to sit, bed to chair transfers, and activities of daily living (ADLs). Review of the resident's Care Plan, dated 05/07/25, showed: - Dependent on staff for all ADLS; - Did not address how to transfer the resident. Observation on 05/15/25 at 10:37 A.M., of the resident's transfer from the bed to the wheelchair showed: - Certified Nursing Assistant (CNA) F and CNA G did not put a gait belt around the resident's waist; - CNA F locked the wheelchair wheels and lifted the resident to the side of the bed; - CNA F and CNA G placed their hands under the resident's armpits; - CNA F and CNA G pulled up on the resident to assist him/her to a semi-standing position, pivoted the resident, and positioned him/her in the wheelchair. 2. Review of Resident #32's medical record showed: - An admission date of 05/14/24; - Diagnoses of hemiplegia, spastic quadriplegic cerebral palsy (a permanent and severe neuromuscular disorder that affects all four limbs and the trunk), vascular dementia (impaired blood supply to the brain), and chronic pain. Review of the resident's quarterly MDS, dated [DATE], showed: - Mild cognitive impairment; - Maximal assistance with lying to sit, bed to chair transfers, and ADLs; Review of the resident's Care Plan, dated 03/03/25, showed: - Dependent on staff for all ADLs; - Did not address how to transfer the resident. Observation on 05/15/25 at 10:05 A.M., of the resident's transfer from the bed to the wheelchair showed: - CNA F and CNA J did not put a gait belt around the resident's waist; - CNA J assisted the resident to the side of the bed; - CNA J pulled up resident from around the waist, pivoted the resident, and CNA F pulled on the resident's pants waistband to position the resident in the wheelchair. Observation on 05/15/25 at 10:14 A.M., of the resident's transfer from the wheelchair to the toilet showed: - CNA F and CNA J did not put a gait belt around the resident's waist; - CNA J lifted the resident from around the waist to position the resident on the toilet; - CNA F lifted the resident from the side to reposition the resident on the toilet; - CNA J lifted the resident from around the waist from the toilet while CNA F placed a brief under the resident; - CNA J pivoted the resident from a standing position to the wheelchair. 3. Review of Resident #37's medical record showed: - An admission date of 01/13/25; - Diagnoses of dementia (decline in cognitive functioning that affects memory, language, problem-solving) cerebrovascular disease (affects blood vessels and supply to the brain), neuropathy (nerve damage), and tremors (involuntary movements). Review of the resident's quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Substantial/Maximal assistance with lying to sit, bed to chair transfers, and ADLs. Review of the resident's Care Plan, dated 05/1/25, showed: - Dependent on staff for all ADLS; - Did not address how to transfer the resident. Observation on 05/15/25 at 10:31 A.M., of the resident's transfer from the bed to the wheelchair showed: - CNA G and CNA J did not put a gait belt around the resident's waist; - CNA J assisted the resident to the side of the bed; - CNA J pulled up the resident from around the waist and pivoted the resident to the wheelchair During an interview on 05/15/25 at 3:25 P.M., Licensed Practical Nurse (LPN) D said staff should use a gait on the residents during transfers. Staff were reminded this morning. During an interview on 05/15/25 at 3:26 P.M., Registered Nurse (RN) I said Resident #29 was a two person gait belt transfer. Gait belts should always be used on everyone that required assistance. RN I said whether the resident was a one or two person transfer, a gait belt should be used. During an interview on 05/16/25 at 9:30 A.M., CNA G said Resident #29 was a two person gait belt transfer and a gait belt should always be used. Staff should always use a gait belt when transferring any of the residents for safety. During an interview on 05/16/25 at 12:20 P.M., the Director of Nursing (DON) said any resident that was not independent with transfers should have a gait belt applied to them for a safety transfer unless they were transferred with a mechanical lift. During an interview on 05/16/25 at 12:25 P.M., the Administrator said she would expect a gait belt to be used on residents that required assistance with transfers.

Based on interview and record review, the facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medications to ensure nursing staff signed at the beginning and the end of each shift for one medication cart out of two sampled medication carts. The facility's census was 39. Review of the facility's policy titled, Narcotic Count, revised, March 2015, showed: - The purpose of this policy is to complete a physical inventory of narcotics at each shift change to identify discrepancies; - One Registered Nurse (RN), Licensed Practical Nurse (LPN) or Certified Medication Technician (CMT) going off duty and one RN, LPN, or CMT coming on duty must count and justify accuracy of the narcotics supply for each individual resident at the change of each shift; - Narcotic records are reconciled by a physical count of the remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse. - After the supply is counted and justified, the nurse/CMT records the date and his/her signature, verifying the count is correct. 1. Review of the CMT Narcotic Count Records, dated 01/01/25 - 01/31/25, showed: - No signature and/or initials by the charge nurse or CMT on the shift verification of controlled substance count sheet for 124 missed opportunities out of 248 opportunities. Review of the CMT Narcotic Count Records, dated 02/01/25 - 02/28/25, showed: - No signature and/or initials by the charge nurse or CMT on the shift verification of controlled substance count sheet for 112 missed opportunities out of 224 opportunities. Review of the CMT Narcotic Count Records, dated 03/01/25 - 03/31/25, showed: - No signature and/or initials by the charge nurse or CMT on the shift verification of controlled substance count sheet for 124 missed opportunities out of 248 opportunities. Review of the CMT narcotic count records, dated 04/01/25 - 04/30/25, showed: - No signature and/or initials by the charge nurse or CMT on the shift verification of controlled substance count sheet for 120 missed opportunities out of 240 opportunities. 5. Review of the CMT narcotic count records, dated 05/01/25 - 05/13/25, showed: - No signature and/or initials by the charge nurse or oncoming CMT on the shift verification of controlled substance count sheet for 60 missed opportunities out of 104 opportunities. During an interview on 05/13/25 at 10:17 A.M., CMT K said that he/she did count with the charge nurse at the beginning and the end of his/her shift but there wasn't space on the form for the nurse to sign or initial. During an interview on 05/16/25 at 12:48 P.M., the Director of Nursing (DON) said she expects oncoming and offgoing staff to count and reconcile the narcotics in the medication cart every shift. During an interview on 05/16/25 at 1:03 P.M., the Administrator said staff were to be counting the narcotics on the medication cart every shift. Two staff, the oncoming and offgoing staff, were to count together to ensure no discrepancies had occurred on the prior shift.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%). There were 30 opportunities with four errors made, resulting in an error rate of 13.33% for three residents (Residents #8, #10 and #30) out of six sampled residents. The facility's census was 39. Review of the facility's policy titled, Insulin Administration, last revised May 2012, showed: - The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the Humalog/lispro (a rapid insulin that helps lower mealtime blood sugar spikes) Kwik Pen (insulin in a pen-type device) instructions, revised July 2023, showed: - Prime the pen by turning the dose knob to two units; - Hold the pen with the needle pointing up; - Tap the cartridge holder gently to collect air bubbles at the top; - Push the dose knob in until it stops, and zero is seen in the dose window, count to five slowly, insulin will be visible at the tip of the needle; - Select the dose; - Give the injection after selecting the area and cleaning the site with an alcohol swab. Review of the Fiasp/Novolog/insulin aspart (fast-acting insulin that helps lower mealtime blood sugar spikes) Flex Pen administration instructions, dated September 2021, showed: - Prime the pen by turning the dose selector to two units; - Keep the needle upwards and press the push-button until the dose selector reads zero; - Turn the dose selector to select the number of prescribed units; - Push the needle into the skin, then press the dose button until dose selector indicates zero; - Keep the push-button fully pushed in after injection; - Leave the needle under the skin for six seconds and then remove it. 1. Review of Resident #8's Physician Order Sheet (POS), dated May 2025, showed: - An order for insulin aspart Pen per sliding scale for blood sugar of 0-200 = 0 units, 201-300 = 5 units, 301-400 = 7 units, 401 - 500 = 9 units, if over 500 call physician, subcutaneously (injection under the skin) before meals and at bedtime, dated 04/02/25; Observation on 05/14/25 at 11:20 A.M., of Resident #8's medication administration showed: - Licensed Practical Nurse (LPN) E administered 5 units of Novolog subcutaneously for a blood sugar of 217; - LPN E failed to prime the Novolog FlexPen per the manufacturer's instructions prior to the insulin administration. 2. Review of Resident #10's POS, dated May 2025, showed: - An order for Novolog FlexPen per sliding scale for blood sugar of 0-200 = 0 units, 201-300 = 4 units, 301-400 = 8 units, 401-500 = 12 units subcutaneously before meals, dated 02/05/25. Observation on 05/14/25 at 11:47 A.M., of Resident #10's medication administration showed: - LPN E administered 4 units of Novolog subcutaneously for a blood sugar of 257; - LPN E failed to prime the Novolog Flex Pen per the manufacturer's instructions prior to the insulin administration. 3. Review of Resident #30's POS, dated May 2025, showed: - An order for insulin lispro Pen per sliding scale for blood sugar of 0-150 = 0 units, 151-200 = 5 units, 201-250 = 7 units, 251-300 = 9 units, 301-350 = 11 units, 351-400 = 13 units, 401+ = 15 units, if greater than 400 give 15 units and if greater than 500 call the physician subcutaneously before meals and at bedtime, dated 04/01/25; - An order for insulin lispro 3 units subcutaneously before meals, dated 04/20/25. Observation of at 05/14/25 at 11:30 A.M., of Resident #30's medication administration showed: - LPN E administered 11 units of Humalog subcutaneously for a blood sugar of 322; - LPN E failed to prime the Humalog Kwik Pen per the manufacturer's instructions prior to the insulin administration; - LPN E administered the 3 units of Humalog subcutaneously as ordered; - LPN E failed to prime the Humalog Kwik Pen per the manufacturer's instructions prior to the insulin administration. During an interview on 05/14/25 at 11:45 A.M., LPN E said he/she was unaware of the need to waste 2 units of insulin to prime the pen needle before administering insulin to residents. During an interview on 05/16/25 at 11:33 A.M., LPN D said he/she dialed up 2 units of insulin to waste in order to prime the needle before giving the insulin to the resident. During an interview on 05/16/25 at 12:07 P.M., the Administrator said she expects staff to waste 2 units of insulin in order to prime the pen needle before administering insulin to the resident. During an interview on 05/16/25 at 12:29 P.M., the Director of Nursing (DON) said she expects nursing staff to prime the pen needle of the insulin pen by wasting 2 units of insulin before administration of insulin.

Based on interview and record review, the facility failed to document likes and dislikes on the meal card and failed to follow the preferences for one resident (Resident #35) out of 12 sampled residents. The facility census was 39. Review of the facility's policy titled, Resident's Food Likes and Dislikes, last reviewed January 2025, showed: - A dietary assessment will determine the resident's food likes and dislikes; - On admission, or within 24 hours after the resident's admission, the Dietary Manager (DM) will interview the resident to determine the resident's food likes and dislikes; - A written record will be maintained of the resident's likes and dislikes; - Residents will be consulted periodically to determine if any changes need to be made in order to meet the resident's needs. 1. Review of Resident #35's medical record showed: - An admission date of 05/03/24; - Diagnosis of heart failure (a heart condition when the heart does not pump like it should). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/20/25, showed: - Cognition intact; - Independent with eating. Review of the resident's undated meal card showed: - Dislikes included beans, broccoli, powdered eggs, and oatmeal. Observation on 05/13/25 at 12:26 P.M., of the noon meal plate served to the resident showed: - A pork chop, steamed broccoli, a baked potato, a lemon bar, and tea to drink. During an interview on 05/13/24 at 10:36 A.M., the resident said staff served him/her broccoli again. He/She didn't like broccoli and had told the kitchen staff that. The kitchen staff serve broccoli on his/her plate every time it was on the menu. During an interview 05/14/25 at 10:05 A.M., the DM said he/she had not been in this role for very long. If a resident had on their dietary card a dislike, the resident should not be served that item and an alternate should be offered. During an interview on 05/15/25 at 11:33 A.M., the Director of Nursing (DON) said the dietary department was responsible for the resident's meal card documentation and the assessment should be done right away upon admission. The dietary department needed to be talking to the residents about their likes and dislikes. During an interview on 05/16/25 at 12:20 P.M., the Administrator said the dietary department should be speaking with the residents upon admission, documenting their likes and dislikes on the dietary card, and serving the residents their preferences. The dietary cards should be updated as the resident's choices change.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These deficient practices had the potential to affect all residents. The facility census was 39. Review of the facility's policy titled, Storage of Food and Refrigeration, dated 01/30/24, showed: - Ensure food needing refrigeration is properly stored to prevent food-borne illness; - All containers must be labeled with the contents and date the food item was placed in storage. Review of the facility's policy titled, Dish Washing, dated 01/30/25, showed: - Ensure dishes are properly sanitized after each use; - Facilities must have appropriate and adequate testing equipment, such as test strips and thermometers, to ensure adequate washing and sufficient concentration of sanitization solution is present to effectively clean and sanitize dishware and kitchen equipment. Review of the facility's policy titled, Cleaning, revised 01/30/25, showed: - Ensure a clean and sanitary environment; - All equipment, food contact surfaces, and utensils shall be cleaned; - The floor of the kitchen must be cleaned daily and after each spill or contamination. Review of the facility's policy titled, Employee Hygiene and Hair Restraints, undated, showed: - Ensure proper hygiene and work habits in the workplace; - Employees must keep hair from contacting exposed food, clean equipment, utensils, and linens; - Hair restraints shall be worn by all Dining Services staff when in food production areas, dishwashing areas, or when serving food. 1. Observation on 05/13/25 at 10:24 A.M., of the Traulsen stand up refrigerator near the Dietary Manager's (DM) office showed: - An opened bag of chocolate chip cookies undated, not labeled, and unsealed; - An opened bag of french fries undated, not labeled, and unsealed; - An opened bag of tortellini undated, not labeled, and unsealed. 2. Observation on 05/13/25 at 10:26 A.M., of the white Whirlpool refrigerator located near the deep freeze in the dry goods area showed: - Two clear lid covered aluminum containers with cooked chicken wings and vegetables undated and not labeled. 3. Observations on 05/13/25 at 10:29 A.M., 05/14/25 at 8:47 A.M., and 05/15/25 at 10:47 A.M., of the canned goods area showed: - A large dented 105 ounce (oz.) can of sliced pears on the top right-side shelf. 4. Observation on 05/13/25 at 10:32 A.M., of the dish machine showed: - A buildup of a white substance on the top, sides, and front panels; - A plastic storage box contained a dirty scour pad and a dirty scrub brush with scattered debris sat on top; - Two boxes of spoons, one box of knives, one box of forks, a squeegee, a green scrubbing brush, and a 38 oz. bottle of dishwashing liquid sat on top. 5. Observation on 05/13/25 at 10:34 A.M., of the Victory three-door standup refrigerator next to the kitchen sink showed: - Four plastic wrapped deli sandwiches undated and not labeled; - An opened zip lock bag of block cheese and individual cheese slices undated and unsealed; - An opened plastic container of mini blueberry muffins undated and unsealed; - A note located on the front-side of the third door, Make sure everything has a label, item name, date opened and use-by date. 6. Observation on 05/13/25 at 10:36 A.M., of the kitchen floors showed: - Dirt, debris, and a plastic cup under the three door Victory standup refrigerator; - Two biscuits, aluminum foil pieces, dirt, and debris under the Vulcan stove; - Dirt and debris under the Vulcan double fryer; - Dirt and debris under the five pan well electric steam table. 7. Observation on 05/13/25 at 10:41 A.M., of the ice machine showed, - A dirty apron, a dirty glove, and a door stopper sat on top. 8. Observation on 05/13/25 at 10:45 A.M., of the kitchen showed: - A ceiling light fixture with two non-working bulbs located over the can opener table in front of the Vulcan stove. 9. Observations of Kitchen Employee A showed: - On 05/13/25 at 10:48 A.M., Kitchen Employee A with facial hair on sides and front of his/her face and did not wear a beard guard ; - On 05/13/25 at 10:52 A.M., Kitchen Employee A did not wear a beard guard, opened the ice machine, and scooped out ice cubes into glassware; - On 05/13/25 at 12:14 P.M., Kitchen Employee A did not wear a beard guard and served resident food trays during the noon meal service; - Kitchen Employee A did not wear a beard guard while performing food preparation and/or delivering food services to staff and residents. 10. Observation on 05/14/25 at 8:32 A.M., of the five pan well electric steam table showed: - A buildup of a dark hardened substance and grease on the bottom of each steam compartment under the electric coils. Review of the May 2025 Kitchen Daily, Weekly, and Monthly Cleaning Schedule Sheets showed: - No dates of cleaning completed by kitchen staff. Review of the May 2025 Kitchen Dish Machine Sanitation Testing Log showed: - No documentation of testing. During an interview on 05/13/25 at 10:18 A.M., the DM said he/she was not doing sanitation strip checks for the dish machine. He/She wasn't in-serviced on testing the dish machine with the testing strips. During an interview on 05/15/25 at 10:39 A.M., Kitchen Employee B said the kitchen floors and equipment should be cleaned daily. Any opened food placed back into the refrigerator should be sealed, labeled, and dated. Dented canned goods should not be used and taken off the shelf. A beard guard should be worn if a kitchen employee had a beard or visible facial hair to prevent hair from getting on the food or drinks. During an interview on 05/15/25 at 10:43 A.M., the DM said he/she was aware the kitchen cleaning schedule sheets were not being completed and dated by staff. During an interview on 05/16/25 at 7:29 A.M., Kitchen Employee C said the kitchen floors and equipment should be cleaned daily. Any opened food placed back into the refrigerator should be sealed, labeled, and dated. Dented canned goods should not be used and taken off the shelf. A beard guard should be worn if a kitchen employee had a beard or visible facial hair to prevent hair from getting on the food or drinks. During an interview on 05/16/25 at 7:56 A.M., the DM said the kitchen floors and equipment should be cleaned daily. All foods opened should be sealed, dated, and labeled before placing back into the refrigerator. Dented canned goods should be removed from the inventory and not be used for resident consumption. A beard guard should be worn if a kitchen employee had a beard or visible facial hair to prevent hair from getting on the food and drinks. During an interview on 05/16/25 at 11:04 A.M., the Administrator said the kitchen floors and equipment should be cleaned daily. All foods opened should be sealed, dated, and labeled before placing back into the refrigerator. Dented canned goods should be removed from the inventory and not be used for resident consumption. Kitchen employees with facial hair should wear a beard guard to prevent hair from falling onto food and drinks during meal preparation and meal delivery.

Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) during tracheostomy (trach - a surgical opening in the neck through the wind pipe to allow air into the lungs) care (sterile suctioning and dressing change) for one resident (Resident #7) out of one sampled resident. The facility failed to implement enhanced barrier precautions EBP and proper infection control practices when staff administered medications through a peripherally inserted central catheter (PICC- a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) for one resident (Resident #27) out of one sampled resident. The facility also failed to maintain proper glove use during peri care for one resident (Resident #37) out of six sampled residents and one resident (Resident #32) outside the sample. The facility census was 39. The facility did not provide a policy addressing tracheostomy care. The facility did not provide a policy addressing infection control practices while connecting and disconnecting intravenous (IV) tubing during medication administration. Review of the facility's policy titled, Wound Care and Management of Indwelling Medical Devices, last reviewed April 2024, showed: - EBP will be used in conjunction with standard precautions and the use of personal protective equipment (PPE) to putting on of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing; - Indwelling medical devices, including, but not limited to central venous catheters (PICC), urinary catheters, peg tubes, and tracheostomy tubes, will be managed according to established protocols and best practices; - Ensure proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious material; - Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment will occur; - Wear a gown that is appropriate to the task to protect skin and prevent soiling of clothing during procedures and activities that could cause contact with blood, body fluids, secretions, or excretions; - Use protective eyewear and a mask, or a face shield, to protect the mucous membranes of the eyes, nose, and mouth during procedures and activities that could generate splashes or sprays of blood, body fluids, secretions, and excretions. Select mask, goggles, face shields, and combinations of each according to the need anticipated by the task performed. Review of the facility's policy titled, Hand Hygiene, last reviewed January 2024, showed: - Hands should be washed for at least 20 seconds using soap and water under the following conditions: when coming on duty; whenever hands are visibly dirty; before having contact with a resident; after having direct contact with a resident (e.g., taking a pulse or BP, lifting, etc.); before performing invasive procedures; after contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin; after handling items potentially contaminated with blood, body fluids, excretions, or secretions; before putting on gloves; after removing gloves; or whenever in doubt; - Hand sanitizers containing at least 60% alcohol may be used when soap and water is not readily available. Hand sanitizer should not be used when hands are visibly dirty or contaminated with blood; - Hands washed prior to providing resident care; - Hands washed between each resident; - Change gloves between dirty and clean; - Do not wear gloves in the hallway. Review of the facility's policy titled, Glove Use, undated, showed: - Gloves should be removed when changing or walking away from specific tasks and hands should be then washed per the guidelines. 1. Review of Resident #7's May 2025 Physician Order Sheet (POS) showed: - Diagnoses of hemiplegia (paralysis of one side of the body) following a cerebral infarction (stroke) affecting the right side, tracheostomy, and gastrostomy (G-tube - a tube inserted in the stomach to provide nutrition and medications); - An order for trach care, dated 02/25/25; - An order for cefdinir (an antibiotic medication) 300 milligram (mg) per G-tube two times daily for respiratory infection for seven days, dated 05/12/25. Observation on 05/15/25 at 8:50 A.M., of the resident's trach care showed: - No signage of EBP; - A three drawer cart of PPE sat outside the resident's door; - Licensed Practical Nurse (LPN) D performed hand hygiene and did not put on a gown or a face shield prior to entering the residents room; - LPN D performed the trach care; - LPN D failed to put on the appropriate PPE before performing the trach care. During an interview on 05/16/25 at 9:35 A.M., Certified Nurse Aide (CNA) G said staff should wear gloves, a gown, and a face shield when providing care for a resident with a trach. Staff should wear PPE when a resident was on EBP, isolation, or airborne precautions. During an interview on 05/16/25 at 11:47 A.M., LPN D said he/she forgot to put an isolation gown on before entering the Resident #7's room and should have put a face shield on before providing care. 2. Review of Resident #27's May 2025 POS showed: - An order for ertapenem sodium (an antibiotic medication) solution 1 gram (gm) intravenously (IV-administered into the vein) every 24 hours for infection, dated 05/15/2025; - An order for sodium chloride solution (salt water) 0.9 %, 10 milliliters (ml) IV flush every 24 hours for six days before administering IV medication and use 10 ml IV flush one time a day for five days after IV medication administration, dated 05/14/25. Observation on 05/15/25 at 9:45 A.M., of the resident's IV medication administration showed: - No signage of EBP; - A three drawer cart of PPE sat outside the resident's door; - LPN D performed hand hygiene, put on gloves, and did not put on an isolation gown; - LPN D disconnected the IV medication tubing and the PICC line connector lay against the resident's upper arm; - LPN D did not disinfect the PICC line connector prior to connecting the 10 ml sodium chloride solution flush syringe; - LPN D flushed the PICC line with 10 ml of sodium chloride solution; - LPN D clamped the PICC line; - LPN D did not apply a disinfectant lock cap to the connector and the PICC line connector lay on the resident's upper arm; - Resident #27 asked LPN D if he/she was going to put a cap on the end of the PICC line; - LPN D said no because there wasn't a cap on it when he/she started the antibiotic medication administration. - LPN D removed gloves and performed hand hygiene. Observation on 05/16/25 at 9:40 A.M., of the resident's IV medication administration showed: - No signage of EBP; - A three drawer cart of PPE sat outside the resident's door; - LPN D performed hand hygiene, put on gloves, and did not put on an isolation gown; - LPN D lay gloves and supplies on the resident's bed without a barrier; - LPN D used an alcohol swab to clean the PICC line connector prior to attaching the 10 ml sodium chloride solution flush syringe; - LPN D disconnected the 10 ml sodium chloride solution flush syringe and the PICC line connector rested on the resident's arm; - LPN D did not disinfect the PICC line connector prior to attaching the IV medication tubing; - LPN D removed gloves and performed hand hygiene. 3. Observation on 05/15/25 at 10:15 A.M., of Resident #37's peri care showed: - CNA G and CNA J entered the resident's room, did not perform hand hygiene, and put on gloves; - CNA G and CNA J removed the resident's soiled brief; - CNA G and CNA J did not remove gloves and did not perform hand hygiene; - CNA J cleaned the resident's front peri area; - CNA G rolled resident to the right side while CNA J cleaned the residents' back peri area; - CNA G and CNA J did not change gloves and did not perform hand hygiene; - CNA G and CNA J put a clean brief and pants on the resident; - CNA J moved the resident to the edge of the bed; - CNA J lifted the resident from around the waist to pivot the resident into a wheelchair; - CNA G did not remove gloves, did not perform hand hygiene, exited the resident's room, and pushed the resident in a wheelchair to the dining room; - CNA J exited the resident's room, did not remove gloves, did not perform hand hygiene, entered Resident #32's room, did not change gloves, and did not perform hand hygiene. 4. Observation on 05/15/25 at 10:25 A.M., of Resident #32's peri care showed: - CNA J entered the resident's room and did not change gloves and did not perform hand hygiene after providing care to Resident #37; - CNA F and CNA J performed peri care, did not change gloves, did not perform hand hygiene, and transferred the resident to a wheelchair; - CNA J removed gloves, did not perform hand hygiene, and exited the resident's room; - CNA F removed gloves, did not perform hand hygiene, exited the resident's room, and pushed the resident to the dining room in a wheelchair. During an interview on 05/15/25 at 10:45 A.M., CNA J said hand hygiene should be done before entering or leaving a resident's room. Gloves should be changed whenever they were dirty. During an interview on 05/15/25 at 10:45 A.M., CNA F said hand hygiene was done before going into a resident room or before leaving the room. When doing peri care, gloves and hand hygiene needed to be done when going from dirty to clean care. During an interview on 05/16/25 at 11:45 A.M., LPN D said he/she wasn't sure if PPE needed to be worn while administering IV medications through a PICC line. Sometimes information didn't get communicated to staff like it should. EBP should be in place for any resident with wounds, G-tube, trach, colostomy, and catheters. Gowns and gloves should be worn when providing care to residents with anything requiring EBP. When accessing a PICC line, nurses didn't have to do anything to the PICC line connector before or after connecting a flush or tubing. The only thing would be to put a disinfectant cap on the end. Staff should always remove gloves and wash hands before leaving a resident room, especially after peri care. During an interview on 05/16/25 at 11:50 A.M., the Administrator said nurses should be wearing PPE when providing care to residents with EBP. Nurses should scrub the hub of the PICC line with an alcohol swab before and after connecting anything to the PICC, such as a flush or IV tubing. Nurses should also be utilizing the disinfectant cap when the PICC was not being used to prevent any kind of infection. She expects staff to always wash their hands before and after resident care. Staff were to remove their gloves before leaving a resident room. During an interview on 05/16/25 at 12:15 P.M., the Director of Nursing (DON) said EBP was in place for residents with wounds, tracheostomies, ostomies, catheters or PICC lines. Staff should be putting on at a minimum of gloves and gowns when providing care to these residents. When nurses were administering IV medications, they should disinfect the PICC line connector with an alcohol swab before and after flushing or connecting medication lines. A disinfectant cap should be applied to the PICC line connector after use. Staff should always remove their gloves and perform hand hygiene before exiting a resident room.

Based on interview and record review, the facility failed to provide and document that residents received or declined the influenza (a viral infection of the respiratory system) immunizations and failed to provide and document pertinent education to residents or resident representatives regarding benefits, side effects, or warnings of the influenza immunization for two residents (Residents #37 and #40) out of five sampled residents. The facility's census was 39. Review of the facility's policy titled, Immunizations of Residents, last reviewed January 2024, showed: - The purpose of this policy is to ensure all residents are afforded the opportunity to receive vaccinations for preventable diseases; - Administering essential immunizations/vaccinations is key to the health and well-being of long-term care residents. Establishing an immunization program facilitates achievement to this objective; - Vaccinating persons at high risk for complications and their contacts each year before seasonal increases in influenza virus circulation is the most effective means of reducing the effects of influenza. When vaccine and epidemic strains are well-matched, achieving increased vaccination rates among persons living in closed settings (e.g., nursing homes) and among staff can reduce the risk for outbreaks by inducing herd immunity. 1. Review of Resident #37's medical record showed: - admission date of 01/13/25; - No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this influenza season; - No documentation of the consent or refusal for the influenza vaccination for this influenza season; - No documentation the influenza vaccination was administered or declined for this influenza season. 2. Review of Resident #40's medical record showed: - admission date of 04/30/25; - An order for an annual influenza vaccination, dated 04/30/25; - No documentation the facility provided information and education for the influenza vaccination to the resident and/or the resident representative for this influenza season; - No documentation of the consent or refusal for the influenza vaccination for this influenza season; - No documentation the influenza vaccination was administered or declined for this influenza season. During an interview on 05/16/25 at 10:23 A.M., the Director of Nursing (DON) said the admitting nurse was responsible for administering and following up on immunizations. During an interview on 05/16/25 at 10:45 A.M., the Administrator said the admitting nurse obtained consent during the admission. The admitting nurse was responsible for administering any immunizations, but the Infection Preventionist and DON should be conducting audits of the new admissions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for one resident (Resident #27) out of two sampled residents. The facility's census was 39. Review of the facility's policy titled, Bed and Bed Rail Maintenance to Reduce/Prevent Entrapment, last reviewed January 2024, showed: - This facility will assess the bed and bed rails for each resident and document such assessment prior to the use of bed rails for every resident. If the resident uses a different bed or when bed rails are added, the assessment and subsequent documentation must be repeated. Review of the facility's policy titled, Bed Rails, last reviewed January 2025, showed; - This facility will attempt to use appropriate alternatives prior to installing a side or bed rail; - If a bed or side rail is used, this facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements: a.) assess the resident for risk of entrapment from bed rails prior to installation, b.) review the risks and benefits of bed rails with the resident or resident representative and obtained consent prior to installation, c.) ensure the bed's dimensions are appropriate for the resident's size and weight, d.) follow the manufacturers' recommendations and specifications for installing and maintaining bed rails, e.) the facility will assess the resident's need for bed rails and all factors involved, including alternatives. Alternatives to bed rails will always be attempted before consideration of bed rail application. Documentation in the resident's record will reflect this assessment and related information, including how the alternatives failed to meet the resident's assessed needs; - Before bed rails are installed, the facility should: a.) check with the manufacturer(s) to make sure the bed rails, mattress, and bed frame are compatible since most bed rails and mattresses are purchased separately from the bed frame; - When installing and using bed rails, the facility should: a.) ensure the bed's dimensions are appropriate for the resident, b.) confirm the bed rails to be installed are appropriate for the size and weight of the resident using the bed, c.) install bed rails using the manufacturers' instructions to ensure proper fit, d.) inspect and regularly check the mattress and bed rails for areas of possible entrapment, e.) regardless of mattress width, length, and/or depth, the bed frame, bed rail, and mattress should leave no gap wide enough to entrap a resident's head or body, f.) check bed rails regularly to make sure they are still installed correctly as rails may shift or loosen over time. Ongoing precautions may include following manufacturer equipment alerts and recalls and increasing resident supervision; - The facility must also conduct routine preventative maintenance of beds and bed rails to ensure they meet current safety standards and are not in need of repair. 1. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnoses of type 2 diabetes mellitus (DM - high blood sugar), chronic obstructive pulmonary disorder (COPD - a lung disease that causes breathing difficulties), congestive heart failure (where the heart can't pump effectively), peripheral vascular disease (narrowing of the blood vessels outside the heart and brain), and bilateral (both sides) above the knee amputation; - No documentation of the maintenance inspection for the side rails. Observations on 05/13/25 at 10:25 A.M., and 2:45 P.M., 05/14/25 at 8:17 A.M., 05/15/25 at 9:48 A.M., and 05/16/25 at 11:11 A.M., and 1:15 P.M., of the resident's bed showed: - The resident's bed with bilateral quarter side rails in the upright position, loosened, and moved with minimal effort. During an interview on 05/13/25 at 10:25 A.M., the resident said the side rails didn't fit his/her bed. Both side rails moved whenever he/she used them for transfers and bed mobility and that was a concern. Staff were aware that the side rails were loose, but no one has done anything about it. During an interview on 05/16/25 at 9:20 A.M., the Maintenance Supervisor (MS) said he/she had not done any inspections/assessments for side rails and/or grab bars. He/She had only been in this position for two weeks. During an interview on 05/16/25 9:30 A.M., the Administrator said the facility had been without a MS since September 2024. The current MS started at the beginning of May. She and the Director of Nursing (DON) had been conducting visual inspections of the bed rails daily. Monthly inspections of the side rails to assess for proper fit had been completed monthly, but she didn't have any documentation to provide. During an interview on 05/16/25 9:33 A.M., the DON said that visual daily inspections of the resident side rails had been completed. She was not sure about about monthly inspections. A side rail consent, physicians order, and bed dimensions should be obtained prior to side rails being placed on a resident's bed. Weekly visual checks, an initial assessment, and then quarterly assessments should be done and side rails should be added to the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility census was 38. Review of the facility's policy titled, Safe Environment, undated, showed: - A safe, clean, comfortable and homelike environment environment, allowing the resident to use his or her personal belongings to the extent possible; - This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Observations made on 06/18/24 at 12:22 P.M. and 06/20/24 at 8:52 A.M., of the 100 hall and unit, showed: - Several areas of exposed sheetrock and peeled paint on the right side wall by bed 1 in resident room [ROOM NUMBER]; - Several areas of exposed sheetrock, peeled paint and scuff marks on the left side wall by the air conditioner/heating unit near bed 2 in resident room [ROOM NUMBER]; - A 3-1/2 foot (ft.) x 5 inches (in.) of missing flooring at the entrance of resident room [ROOM NUMBER]; - A missing hand rail between resident room [ROOM NUMBER] and resident room [ROOM NUMBER]; - An 18 in. x 12 in. area of the ceiling with exposed sheetrock over bed 2 in resident room [ROOM NUMBER]; - Several areas of exposed sheetrock and peeled paint between the two windows in the unit dining room; - Several areas of exposed sheetrock, peeled paint and scuff marks on the wall with the large butterfly canvas picture in the unit dining room; - Three light fixtures with no protective covering in the unit hallway. Review of the maintenance log, dated 05/02/24 to 06/01/24, showed no documentation of the areas of concern addressed. During an interview on 06/20/24 at 9:27 A.M., Housekeeper C said any environmental concerns are reported to maintenance or written down on the maintenance log located at the nurse's station. During an interview on 06/20/24 at 9:44 A.M., Housekeeper D said he/she writes any environmental concern on a piece of paper and is given to maintenance to repair or fix. He/She has not seen anything recently to report to maintenance as an environmental concern. During an interview on 06/20/24 at 10:32 A.M., the Maintenance Supervisor (MS) said staff should be writing down any environmental concerns on the maintenance repair log. MS said it is hard to remember what needs to be fixed when he/she is told in passing. MS said daily rounds are done and in the process of fixing the things he/she has been made aware of on the maintenance log. MS has been in the maintenance supervisory position since April. During an interview on 06/20/24 at 10:37 A.M., the Administrator said she would expect staff to write down any environmental concern that needed to be addressed in a timely manner on the maintenance repair log located at the nurse's station.

Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments, a federally mandated assessment tool to be completed by the facility staff, for one resident (Resident #8) out of 12 sampled residents. The facility census was 38. Review of the facility's policy titled, Resident Assessment, undated, showed: - This facility conducts initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity; - The comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, uses the resident assessment instrument (RAI - a means of ensuring that residents receive the highest quality of care and can maintain the highest quality of life) specified by the Centers for Medicare and Medicare (CMS, the federal agency that runs the Medicare, Medicaid, and Children's Health Insurance Programs, and the federally facilitated Marketplace); - Within 14 days after this facility completes a resident's assessment, this facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System including an annual assessment. 1. Review of Resident #8's medical record showed: - The brief interview for mental status (BIMS) (a test used to get a quick snapshot of how well the resident is functioning cognitively), score of 15, indicated the resident to be cognitively intact; - No documentation of a urinary tract infection (UTI, an infection that occurs when bacteria enters and grows in the urinary tract). Review of the resident's annual MDS assessment, dated 04/07/24, showed section I2300 marked for urinary tract infection in the last 30 days. Review of the facility's CMS 802 Matrix (a tool used to identify pertinent care categories), dated 06/17/24, showed resident marked for a UTI. During an interview on 06/19/24 at 10:02 A.M., the resident said he/she has not had a UTI since last year in 2023 and it was treated with medication. During an interview on 06/19/24 at 10:50 A.M., the MDS Coordinator (MDSC) said he/she has only been in the position for three weeks and works at another facility. He/She is currently reviewing resident soft charts and has found discrepancies. If a resident does not have a urinary tract infection and is not being treated with an antibiotic, it should not be marked on the resident assessment. During an interview on 06/19/24 at 10:58 A.M., the Director of Nursing (DON) said the resident had a UTI and a physician order for Cefdnir (an antibiotic for bacterial infections) which was completed back in July 2023. The resident assessment should not have been marked for a UTI in the last 30 days on the annual MDS or indicated on the CMS 802 Matrix. This will be addressed with the MDSC.

Based on observation, interview and record review, the facility failed to develop a care plan with specific interventions to meet individual needs of two residents (Residents #1 and #35) out of 12 sampled residents. The facility census was 38. Review of the facility's policy titled, Comprehensive Care Plans, not dated, showed: - The purpose of this policy is each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals and address the resident's medical, physical, mental, and psychosocial needs. - Measurable objectives and timeframes to meet the resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment utilizing the Resident Assessment Instrument (RAI) process; - The comprehensive care plan will be reviewed and revised, based on changing goals, preferences and needs of the resident and in response to current interventions, by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. 1. Review of Resident #1's medical record showed: - admission date of 05/16/24; - Diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning) and paranoid schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly, out of touch with reality, disorganized speech or behavior). Review of the resident's care plan, revised 06/07/24, showed - The resident smoked; - No individualized interventions for smoking. Observations showed: - On 06/17/24 at 10:20 A.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision; - On 06/18/24 at 3:30 P.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision. 2. Review of Resident # 35's medical record showed: - admission date of 05/14/24; - Diagnosis of cerebral palsy ( a group of neurological disorders that affect the brain and nervous system, causing lifelong impairments in movement and coordination) and anxiety (a feeling of worry, nervousness or unease about an imminent event or something with an uncertain outcome). Review of the resident's care plan, revised 06/10/24 , showed - The resident smoked; - No individualized interventions for smoking. Observations showed: - On 06/17/24 at 10:40 A.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision; - On 06/18/24 at 10:36 A.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision; - On 06/19/24 at 10:25 A.M., the resident sat outside in a designated smoking area, wearing a protective apron, with staff supervision. During an interview on 06/18/24 at 1:01 P.M., the resident said he/she wears the apron when he/she smokes. During an interview on 06/20/24 at 11:37 A.M., the Director of Nursing (DON) said any resident that smokes and has an apron/protector should be included on the care plan. The DON said the resident has worn the protector since he/she has been in this facility. During an interview on 06/20/24 at 12:20 P.M., the Clinical Liaison said if a resident smokes then it should be on the care plan with interventions in place.

Based on observation, interview and record review, the facility failed to appropriately assess the use of bed rails, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to using bed rails and appropriately plan care for one resident (Resident #34) out of 12 sampled residents. The facility census was 38. Review of the facility's policy titled, Restraints-Physical-Side Rails, not dated, showed: - Assess resident's need for restraint use; - Obtain physician's order for restraint; - Develop or review resident care plan for type of restraint, reason for use, alternate methods to be used and method application; - Determine the type of side rails to be used; - Determine the medical symptoms to be treated with the side rails; - Involve the resident and the resident's representative in planning for side rail use. Many residents request to have side rails up when in bed to improve bed mobility and provide a feeling of safety; 1. Review of Resident #34's medical record showed: - An admission date of 03/26/23; - Diagnoses of chronic obstructive pulmonary disease (COPD- A group of lung diseases that block airflow and make it difficult to breathe), falls, severe protein calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function); - No documentation of any attempts made with alternative methods prior to bed rail use; - No documentation of an informed consent signed explaining the risks and benefits for the bed rail use; - No documentation of a bed rail assessment completed. Review of the resident's quarterly Minimal Data Set (MDS-a federally mandated assessment completed by the facility), dated 03/24/24, showed: - Requires substantial assistance with bed mobility; - No bed rail use. Review of the resident's care plan, dated 06/03/24, showed the use of bed rails not addressed. Observation of the resident on 06/17/24 at 10:22 A.M. and 06/18/24 at 12:17 P.M., showed quarter bed rails on right and left side of bed with left side of bed up against the wall closest to the door. During an interview on 06/17/24 at 10:22 A.M., the resident said he/she uses the bed rails to get in and out of bed. During an interview on 06/19/24 at 4:12 P.M., LPN J said the resident uses the bed rails for bed mobility and to get in and out of bed. He/she said the resident's bed was from hospice and it came with the bed rails. The charge nurse should have completed an assessment for the use of the side rails. During an interview on 06/20/24 at 11:30 A.M., the Director of Nursing (DON) said side rail assessments should be completed upon admission and quarterly. She said the charge nurse is responsible for completing the assessment. During an interview on 06/20/24 at 12:00 P.M., the Administrator said the charge nurse starts the bed rail assessment, should notify DON and update MDS (Minimal Data Set) Coordinator. She said bed rail assessments should be completed upon admission, when the need arises and quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide food of the resident's preferences, and failed to document likes and dislikes on the meal cards for three residents (Residents #18, #34, and #38) out of 12 sampled residents and one resident (Resident #37) outside the sample. The facility census was 38. Review of the facility's policy, titled, Resident's Food Likes and Dislikes, not dated showed: - A dietary assessment will determine the resident's food likes and dislikes; - On admission, or within 24 hours after the resident's admission, the Dietary Manager will interview the resident to determine the resident's food likes and dislikes; - A written record will be maintained of the resident's likes and dislikes. - Residents will be consulted periodically to determine if any changes need to be made in order to meet the resident's needs. 1. Review of Resident #18's medical record showed: - Diagnoses of anemia (a condition when blood produces a lower-than-normal amount of healthy red blood cells), hypertension (HTN) (high blood pressure), diabetes (a disease that occurs when the body has too much blood sugar), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and depression (a common and serious mental health condition that can affect how people think, feel, and act). During an interview on 06/18/24 at 12:30 P.M., the resident said he/she did not like spaghetti and had asked for chicken strips and fries for lunch. He/She said, I just tell them what I want. Review of the resident's meal card showed no dislikes documented. 2. Review of Resident #34's medical record showed: - Diagnoses of anemia and chronic obstructive pulmonary disease (COPD) (a chronic lung disease that makes it difficult to breathe). Review of the resident's quarterly MDS, dated [DATE] showed: - A BIMS score of 15 out of 15, indicated the resident to be cognitively intact; - Independent for eating, hygiene, dressing and transfers. During an interview on 06/17/24 at 10:22 A.M., the resident said he/she does not like white gravy and the kitchen staff continue to put it on his/her plate. The resident said he/she has asked the staff several times for it not to be served to him/her. He/she said that card means nothing, just this morning they served it on the plate again. Review of the resident's meal card showed white gravy documented under the dislikes. 3. Review of Resident #38's medical record showed: - An admission date of 05/03/24; - Diagnoses of heart failure (a heart condition when the heart does not pump like it should). Review of the resident's admission MDS, dated [DATE] showed: - A BIMS score to be 14 out of 15, indicated the resident to be cognitively intact; - Independent for eating. Observation on 06/17/24 at 12:26 P.M. noon meal plate served to the resident showed sliced ham, steamed broccoli, stuffing, roll, pears with cool whip and tea to drink. During an interview on 05/17/24 at 12:45 P.M., the resident said he/she takes medications and cannot have green vegetables. The resident said, they served me broccoli again today and I have told the kitchen staff before about it. He/she said his/her dislikes are coffee and fruit punch. Review of the resident's meal card showed no dislikes or the resident cannot have green vegetables documented. 4. Review of Resident #37's medical record showed: - Diagnoses of diabetes and cardiorespiratory conditions (serious disorders that affect the heart and lungs). Review of the resident's quarterly MDS, dated [DATE] showed: - A BIMS score to be 13 out of 15, indicated the resident to be cognitively intact; - Independent with all Activities of Daily Living (ADL's). During an interview on 05/19/24 at 12:35 P.M., the resident said he/she does not like eggs of any kind. He/She said staff has been told numerous times no eggs for him/her. Review of the resident's meal card showed no dislikes documented. During an interview 06/20/24 11:05 A.M., the dietary manager (DM) said she is responsible for assessing residents upon admission for their likes and dislikes. She said she would document the resident's likes and dislikes on their individualized dietary cards. The DM said if she is notified of a change, then the dietary card is updated at that time, and the residents are assessed periodically for changes. During an interview on 06/20/24 at 11:33 A.M., the Director of Nursing (DON) said the dietary department is responsible for the resident's meal card documentation and the assessment should be done right away upon admission. He/She said the dietary department needs to be talking to the resident's about their likes and dislikes. During an interview on 06/20/24 at 12:20 P.M., the Administrator said the dietary department should be speaking with the resident's upon admission and documenting their likes and dislikes on the dietary card and serving the resident's their preferences. She also said the card should be updated as the resident's choices change.

Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected two Certified Nurse Assistants (CNA) A and CNA B out of two sampled CNA's. The facility's census was 38. Review of the facility's policy titled, Nurse Aide Regular In-Service Training,, dated 01/30/24 showed: - The facility's in-service training must be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. 1. Review of the in-service record for CNA A showed: - A hire date of 01/24/23; - A total of eight hours and 25 minutes of annual in-service training for January 2023 through January 2024; - Less than twelve hours of in-service education for January 2023 through January 2024. 2. Review of the in-service record for CNA B showed: - A hire date of 05/13/23; - A total of 7 hours and 45 minutes of annual in-service training for May 2023 through May 2024; - Less than twelve hours of in-service education for May 2023 through May 2024. During an interview on 6/19/24 at 8:00 A.M., the Clinical Liaison said the facility does the in-services face to face and cannot get the employees to attend the in-services at times. She said the CNA's should have at least 12 hours of annual in-service training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment. The deficient practice had the potential to affect all residents in the facility. The facility's census was 29. Review of the facility's policy, Housekeeping, undated, showed: - Establish standards of cleanliness and consistency in the way in which resident rooms and common areas are cleaned and maintained; - The facility will be cleaned on a regular basis according to a specified cleaning schedule and according to federal/state guidelines; - The floors, walls, ceiling, and vents are to be kept clean; - Resident's room floors are to be clear of spills, stains, and debris; - If nursing personnel notice any of these sanitary violations occurring in the resident's room, housekeeping and/or maintenance should be notified promptly; - The hallway floors are to be clean and dry. Observations on 04/25/23 at 12:15 P.M., of Hallway 100 showed: - Two 3 foot (ft.) sections of metal flooring transition strips were missing; - Two 6 ft. sections of baseboard were missing; - Carpet near the kitchen counter with a 2 ft. diameter (dia.) brown substance; - Carpet near the dining table with a 3 ft. dia. brown substance. Observations on 04/26/23 at 8:40 P.M., of room [ROOM NUMBER] showed: - A plastic frame broken and separated from the packaged terminal air conditioner (PTAC); - Bathroom with two 1 inch (in.) dia. holes near water lines under the sink and a 2 ft. dia. wall section unpainted above the sink. During an interview on 04/26/23 at 8:46 P.M., the resident in room [ROOM NUMBER] said the air conditioner trim didn't look right and needed to be fixed. Observations on 04/28/23 at 8:35 P.M., of Hallway 200 shower room showed: - A shower stall with brown grime build-up on the ceramic tiles covering the back wall near the floor transition; - A white substance covered several ceramic tiles inside the shower stall back wall; - A 20 in. x 5 in. section on the right side of the shower stall near the tub with missing ceramic tile and with sharp metal trim exposed; - A section of two 6 in. dia. areas with paint peeled away from the shower ceiling. Observations on 04/28/23 at 8:35 P.M., of Hallway 100 shower room showed: - The bath tub floor with a red substance near the drain; - The shower floor with a brown substance near the drain; - A white substance covered several ceramic tiles inside the shower stall back wall. Observations on 04/25/23 at 12:15 P.M., of Hallway 200 showed: - The flooring section near the north side of the nursing station with a 2 in. dia. corner missing and two flooring pieces with cracked edges. During an interview on 4/28/23 at 8:54 A.M., Registered Nurse (RN) A said that both showers were used but the 100 Hallway shower room wasn't used very often. The 200 Hallway shower room was the favorite and there were no problems with the shower room. During an interview on 04/28/23 at 10:37 A.M., Housekeeper G said he/she worked only part-time. The shower rooms were cleaned after each resident was showered and the expectations were to complete a deep clean when necessary. The damage to the shower room was reported to the housekeeping supervisor. During an interview on 04/28/23 at 10:39 A.M., Housekeeper H said he/she mostly worked in laundry, but any damage to the facility was reported to the housekeeping supervisor. During an interview on 04/28/23 at 10:40 A.M., RN A said that the expectations were for staff to notify the Administrator or the Maintenance Director if there was an emergency repair needed. There were work orders to fill out if there was non-emergency repairs that need to be made. During an interview on 04/28/23 at 10:47 A.M., the Maintenance Director said there were plans to change the floors and most staff members come straight to him if there were problems noticed in the building. There were also work order forms available. He said he was expected to check for repairs or issues with walls and floors. During an interview 04/28/23 at 11:38 P.M., the Administrator said she expects the facility to be kept clean and repairs should be made once staff or residents notices concerns. The Maintenance Director was now using an electronic building management account. She was not aware that showers had grime build up and were missing tiles but it should be repaired. She said that the flooring was an issue and there were plans to make replacements.

Based on interview and record review, the facility failed to provide a Preadmission Screening and Resident Review (PASRR) (a federally mandated preliminary assessment to determine whether a resident may have a mental illness or an intellectual disorder to determine the level of care needed) for one resident (Resident #7) out of two sampled residents. The facility census was 29. Review of the facility's policy titled, Preadmission Screening for Individuals with a Mental Disorder/Intellectual Disability, undated, showed: - The purpose is to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission; - The screening helps to ensure individuals are not inappropriately placed in nursing homes for long term care; - All applicants to a Medicaid certified nursing facility be evaluated for a serious MD and/or ID; - The initial screening is referred to as a Level I identification of individuals with MD or ID and is completed prior to admission to the facility; - A negative Level I screen permits admission to proceed and ends the prescreening process, unless possible serious MD or ID arises later; - A positive Level I screen necessitates an in-depth evaluation of the individual, by state designated authority, known as a PASRR, which must be conducted prior to admission to the facility; - The PASRR will be a guide in developing an assessment that will assist in the continuity of care and services in the best interest of the resident. 1. Review of Resident #7's medical record showed: - An admission date of 09/08/22; - Diagnoses of depression (loss of pleasure or interest in life), bipolar disorder (a mental disorder causing extreme mood swings, including emotional highs and lows); - No level I PASRR. During an interview on 04/28/23 at 1:30 P.M., the Business Office Manager said she was unable to find the PASRR for Resident #7, she did find an old email which showed the paperwork had been sent in without a physician's signature. Central Office Medical Review Unit (COMRU) found it was deleted due to the physician's signature never was sent. This all happened back before she was employed at the facility. During an interview on 04/28/23 at 1:35 P.M., the Administrator said she would expect there to be a Level I PASRR for all residents.

Based on observation, interview, and record review, the facility failed to follow physician's orders pertaining to the flush amount with the tube feeding for one resident (Resident #24) out of two sampled residents. The facility also failed to obtain a physician's order for oxygen (O2) therapy for one resident (Resident #27) out of six sampled residents. The facility's census was 29. Review of the facility's policy titled, Receiving and Recording Medication Orders, undated, showed: - A current list of orders will be maintained in the medical record of each resident; - Orders will be written/signed and placed in chronological order in the medical record; - When recording orders for routine medications, specify the type, route, dosage, frequency, and strength of the medication ordered; - When recording oxygen orders, specify the rate of flow, route, and rational; - When recording orders for tube feedings, specify the route, type of feeding, amount, frequency of feeding and rationale if as needed (PRN). The order should always specify the amount of water to give following the feeding; - Telephone orders may be accepted by a licensed nurse only. Telephone or verbal orders must be recorded on the Physicians' Order Sheet when received and must be recorded by the nurse receiving the order. Telephone or verbal orders for drugs must include: the name and strength of the drug; the quantity or specific duration of the drug; the dosage and frequency of administration; the route of administration; the date and time received; the corresponding diagnosis/reason for the drug; the telephone or verbal orders must be countersigned by the physician within 48 hours of receiving the order; - Standing orders must be recorded in the same manner as a telephone order. Record the order on the Physician's Order Sheet. Review of the facility's policy titled, Enteral Nutritional Therapy, (Tube Feeding), undated, showed: - Follow the feeding with the prescribed amount of water and administer in the same manner. 1. Review of Resident #24's Physician's order sheet (POS), dated 04/25/23, showed: - Diagnoses of dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or throat), encounter for attention to the gastrostomy (artificial opening to the stomach), hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the left non-dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis characterized by one sided weakness, but without complete paralysis); - An order for Osmolite 1.5 (a tube feeding formula) 360 milliliters (ml) per gastrostomy tube (g-tube) four times a day and flush the g-tube with 50 ml of water before and after the feeding, dated 04/13/23. Observation on 04/26/23 at 11:37 A.M., showed: - Registered Nurse (RN) A and Certified Nursing Assistant (CNA) J repositioned Resident #24 with the head of the bed elevated; - RN A checked for placement of the g-tube, checked the residual (the amount of liquid drained from a stomach following administration of enteral feed), administered 360 ml of Osmolite 1.5 via the g-tube, and flushed the g-tube with 125 ml of water before and after the g-tube feeding. During an interview on 04/27/23 at 3:04 P.M., Licensed Practical Nurse (LPN) F said he/she would expect 50 ml water flush to be given if that was what the order was. During an interview on 04/27/23 at 3:04 P.M., LPN E said he/she would expect 50 ml of water to be given with a tube feeding if that was the physician's order. If the nurse believed that was not adequate or if the resident had signs of dehydration, they would talk to the doctor with the concern. During an interview on 04/27/23 at 3:37 P.M., RN A said he/she would expect 50 ml of water to be given and for the physician's order to be followed. During an interview on 04/27/23 at 3:38 P.M., the Director of Nursing (DON) said she would expect the nurse to flush a residents g-tube with 50 ml of water before and after the feeding if that was the physician's order. 2. Review of Resident #27's (POS), dated 04/25/23, showed: - Diagnoses of chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), acute respiratory distress (a serious lung condition that causes low blood oxygen); - No documentation of a physician's order for oxygen therapy. Observations showed: - On 04/25/23 at 10:15 A.M., the resident sat in a wheelchair in his/her room with O2 via nasal cannula (a medical device to provide supplemental oxygen therapy) at 4 liters per minute (L/min); - On 04/26/23 at 8:49 A.M., the resident lay in bed with the head of the bed elevated and O2 via nasal cannula at 4 L/min; - On 04/26/23 at 11:17 A.M., the resident sat in a wheelchair in his/her room with O2 via nasal cannula at 4 L/min; - On 04/27/23 at 10:15 A.M., the resident sat in a wheelchair in his/her room with O2 via nasal cannula at 4 L/min. During an interview on 04/27/23 at 10:21 A.M., CNA K said the staff did not remove the resident's oxygen during transfers. The resident was short of breath without the O2. During an interview on 04/27/23 at 3:57 P.M., the DON said she would expect there to be a physician's order for oxygen. The last time she looked at the resident's chart, the resident was to be on 4 L/min of oxygen. During an interview on 04/27/23 at 4:01 P.M., RN A said he/she would expect there to be a physician's order for oxygen. During an interview on 04/27/23 at 4:03 P.M., CNA/Certified Medication Technician (CMT) I said the resident was on 4 L/min of O2.

Based on observation, interview, and record review, the facility failed to store medications in a safe and effective manner five out of 13 times when staff left the unattended medication cart unlocked. This had the potential to affect all residents. The facility census was 29. Review of the facility's Medication Administration policy, not dated, showed: - Keep the medication cart in view at all times; - Lock the cart when not standing next to it or working from it; - Keep the key to the medication cart with you at all times, never leave key in lock on the cart. Observations on 04/27/23 of medication pass showed: - At 11:21 A.M., Certified Medication Technician (CMT) B entered Resident #6's room to administer the resident's medications and left the keys in the lock of the unlocked medication cart. The medical cart remained unlocked and unattended in the hall outside of the resident's room until CMT B returned to the medication cart at 11:25 A.M.; - At 1:58 P.M., Registered Nurse (RN) A entered Resident #18's room to administer the resident's medications and left the keys in the lock of the unlocked medication cart. Other facility staff walked past the unlocked, unattended medication cart in the hall outside of the resident's room while RN A was in the resident's room. RN A returned to the medication cart at 1:59 P.M.; - At 2:02 P.M., RN A entered Resident #19's room and left the keys in the lock of the unlocked medication cart. The medication cart remained unlocked and unattended in the hall outside of the resident's room until RN A returned to the medication cart at 2:04 P.M.; - At 2:05 P.M., RN A placed the unlocked medication cart into the dining room. The unattended and unlocked medication cart remained in the dining room where multiple residents were playing Bingo with the Activities Director. RN A returned to the dining room and locked the medication cart at 2:10 P.M. Observation on 04/28/23 at 8:20 A.M., of the medication pass showed: - At 8:22 A.M., CMT B entered Resident #82's room to administer the resident's medications and left the keys in the lock of the unlocked medication cart. The medical cart remained unlocked and unattended in the hall outside of the resident's room until CMT B returned to the medication cart at 8:24 A.M. During an interview on 04/28/23 at 9:30 A.M., CMT B said the medication cart should be locked anytime it was not being used and was stepped away from. The medication cart keys should remain on the person of who was responsible for the cart. During an interview on 04/28/23 at 9:35 A.M., RN A said it was bad practice to walk away from an unlocked medication cart. The medication cart should remain locked unless being used and should never be left unattended while unlocked. The medication cart keys should remain on the person of who was responsible for the cart. During an interview on 04/28/23 at 1:30 P.M., the Director of Nursing (DON) said the medication cart should never be left unlocked. If the person was not preparing medication, then it should be locked. The keys should never be left on the cart and should be on the person responsible for the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide and document residents received or declined appropriate immunizations and failed to provide and document pertinent education to residents or a resident's representative regarding the benefits, side effects, or warnings of those immunizations for five residents (Residents #2, #6, #24, #26, and #27) out of five sampled residents. The facility census was 29. Review of the facility's policy titled, Influenza and Pneumococcal Immunizations - Residents, undated, showed: - Upon admission to the facility, permission must be obtained from the resident or representative to administer pneumococcal vaccine and influenza vaccine annually (in the fall), unless contraindicated; - All residents will be assessed for pneumococcal vaccine status upon admission; - Residents without proof of previous pneumococcal vaccination should be offered the pneumococcal vaccine(s) unless contraindicated; - Influenza immunizations must be offered annually from October 1st to March 31st (with doctor's order). Through this time of facility-wide immunizations (until March 31), all new admissions should be assessed for previous immunization that season and immunized, if appropriate; - Each resident or the resident's representative has the opportunity to refuse the immunization; - The resident's medical record will include documentation that the resident or the resident's representative was provided education regarding the benefits and potential side effects and the resident either received the immunization, did not receive the immunization due to medical contraindications or refused the immunization. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - Over [AGE] years of age; - No record of an annual flu vaccination; - No record of the pneumococcal (infection caused by bacteria that can range from ear and sinus infections to pneumonia and bloodstream infections) vaccination; - No documentation of refusal or education of the immunizations. Review of Resident #6's medical record showed: - admitted on [DATE]; - Over [AGE] years of age; - No record of an annual flu vaccination; - No record of the pneumococcal vaccination; - No documentation of refusal or education of the immunizations. Review of Resident #24's medical record showed: - admitted on [DATE]; - Over [AGE] years of age; - No record of an annual flu vaccination; - No record of the pneumococcal vaccination; - No documentation of refusal or education of the immunizations. Review of Resident #26's medical record showed: - admitted on [DATE]; - Over [AGE] years of age; - No record of annual flu vaccination; - No record of the pneumococcal vaccination; - No documentation of refusal or education of the immunizations. Review of Resident #37's medical record showed: - admitted on [DATE]; - Over [AGE] years of age; - Immunization: Consent Or Refusal sheet, signed on 03/27/23, with a refusal of the Influenza vaccination, Pneumococcal PPSV23 (pneumonia vaccine that protects against 23 Pneumococcal bacteria) vaccination, and PCV13 (pneumonia vaccine that protects against 13 Pneumococcal bacteria) vaccination; - No documentation of education of the vaccinations. During an interview on 04/28/23 at 1:23 P.M., the Director of Nursing (DON) said vaccinations should be documented and recorded. The consent or refusal forms were mailed out to a responsible party last of September/first of October 2022, before the flu vaccination was done, if the resident was able to sign their own, they did that. The resident and/or the family member should be asked about the pneumococcal vaccination when admitted , and the doctor called by whoever was doing the assessment for the admitting paperwork. Then the information should be entered into the preventative tab on the computer. The risk and benefit page with side effects should be given to the resident to sign and a copy put it back in our folder/file and in their chart. She didn't do the vaccinations this year. Licensed Practical Nurse (LPN) F and LPN D were the ones that did the vaccinations this year. The vaccine records should be updated on the residents' chart yearly and as the residents get vaccinations, they should be documented. During an interview on 04/28/23 at 1:23 P.M., the Administrator said there should be a list showing which residents were due and when in a binder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, the facility failed to ensure COVID-19 (a respiratory disease caused by SARS-CoV-2) vaccination education and declinations were documented in the medical record for five residents (Resident #2, #6, #24, #26, and #27) out of five sampled residents reviewed for immunization documentation. The facility census was 29. Record review of the facility's policy titled, COVID-19 Vaccination-Residents, undated, showed: - Licensed nursing staff and/or physicians/physician extenders will provide residents and/or resident representatives with information necessary to make an informed consent including corresponding vaccine Fact Sheets; - Informed Consent forms will be reviewed with each resident and/or resident representative. Each resident and/or resident representative will be provided with the opportunity to ask questions and/or consult with their physician(s) regarding the vaccine. Consent or declination will be provided on the appropriated Informed Consent form and retained in the resident's medical record; - Administration of the vaccine will be recorded including the specific name of the vaccine, date(s) of the dosage administration, the lot number and the expiration date as well as the specific arm in which the vaccine was injected. The facility provided an undated, hand written list of residents' names with vaccinated and booster status out to the side. 1. Review of Resident #2's medical record showed: - admitted on [DATE]; - No record of Covid-19 vaccine; - No documentation of refusal or education of Covid-19 vaccination. Review of Resident #6's medical record showed: - admitted on [DATE]; - No record of the Covid-19 vaccination; - No documentation of refusal or education of Covid-19 vaccination. Review of Resident #24's medical record showed: - admitted on [DATE]; - No record of the Covid-19 vaccination; - No documentation of refusal or education of Covid-19 vaccination. Review of Resident #26's medical record showed: - admitted on [DATE]; - No record of the Covid-19 vaccination; - No documentation of refusal or education of Covid-19 vaccination. Review of Resident #27's medical record showed: - admitted on [DATE]; - No record of the Covid-19 vaccination; - No documentation of refusal or education of Covid-19 vaccination. During an interview on 4/28/23 at 1:23 P.M., the Director of Nursing (DON) said vaccinations should be documented and recorded. The information should be entered into the preventative tab on the computer. The risk and benefit page with side effects should be given to the resident to sign and a copy put it back in their chart. Vaccine records should be updated on residents' charts yearly, and as they get the vaccinations, they should be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year. This affected two out of two sampled Certified Nurse Assistants (CNA). The facility's census was 29. Review of the facility's policy titled, Nurse Aide Regular In-Service Training, undated, showed: - In-service training must be no less than 12 hours per year; - Dementia care and resident abuse prevention training must be included. 1. Review of the in-service record for CNA B showed: - A hire date of 09/01/21; - A total of zero hours of annual in-service training for September 2021 through September 2022; - Less than twelve hours of in-service education for September 2021 through September 2022. 2. Review of the in-service record for CNA C showed: - A hire date of 12/20/21; - A total of zero hours of annual in-service training for December 2021 through [DATE]; - Less than twelve hours of in-service education for December 2021 through [DATE]. During an interview on 04/28/23 at 1:23 P.M., the Director of Nursing (DON) said she was responsible for the in-services of CNA's and they should have had at least 12 hours, including dementia care and abuse and neglect. The facility did have a list of what was required. In-service sheets were put out to be read and signed, but when she went back to get them, they were gone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This has the potential to affect all residents. The facility census was 29. Review of the facility's policy titled, Storage of Food in Refrigeration, showed: - Ensure food needing refrigeration is properly stored to prevent food-borne illness; - Fresh fruits, vegetables, eggs, cheeses, and other perishable items will be stored in refrigeration of at 41 degrees Fahrenheit (F) or below; - Store raw meats on the bottom shelves to prevent contamination of other perishable items; - Food being returned to storage after cooking or preparation must be covered; - All containers must be labeled with the contents and date food item was placed in storage; - Previously cooked foods can be held in refrigeration of 41 degrees F or lower for up to three days and then must be discarded; - Food items that remain sealed from the supplier may be held until the expiration date if unopened. Review of the facility's policy titled, Food Safety, showed: - Ensure the facility follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness; - Ensure the facility follows safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes; - The facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety; - The facility's refrigerators and/or freezers must be in good working condition to keep foods at or below 41 degrees F and the freezer must keep frozen foods frozen solid. 1. Observations of the dry food storage room on 04/25/23 at 9:29 A.M., showed: - One white chest style freezer without a thermometer with black grime on the exterior, the interior coated with 1 inch (in.) thick frost build-up on all sides, the interior of lid with broken plastic; - One gray residential style reach-in refrigerator with black grime build-up around a built-in ice dispenser and the lower section of the door, the interior with a brown grime build-up on the lower freezer shelf; - One white residential style reach-in refrigerator with a one gallon clear plastic container filled with tuna salad, dated 04/21/23, and one small clear plastic container with pureed bread, dated 04/22/23. 2. Observations of the kitchen on 04/25/23 at 9:35 A.M., showed: - One heating, ventilation, and air conditioning (HVAC) unit with a brown grime build-up on the front exterior surfaces and between the ventilation louvers; - One black oscillating fan with black grime on the blades and the housing; - The commercial style can opener with a chipped cutting edge, black grime build-up, and base edges with black grime build-up. 3. Observations of the south hall dining area on 04/25/23 at 12:01 P.M., showed: - Three partially covered plastic containers with oranges, apples and pears, undated, in the refrigerator. 4. Observations of the main dining area on 04/25/23 at 12:22 P.M., showed: - Resident #8 eating the tuna salad. 5. Observations of the dry food storage room on 04/26/23 at 9:18 A.M., showed: - One white residential style reach-in refrigerator with a one gallon clear plastic container filled with tuna salad, dated 04/21/23, and one small clear plastic container with pureed bread, dated 04/22/23; - Floor with a sticky film; - The area between the chest type freezer and reach in refrigerator with dust and a black grime build up. 6. Observations of the kitchen on 04/26/23 at 9:25 A.M., showed: - Six 16 in. x 24 in. x 1 in. and two 16 in. x 12 in. x 1 in. deep baking pans with black grime build-up in the inside the corners, on the cooking surface and outer surfaces; - The range hood with a brown grime build up on the interior and peeled paint; - The range hood with dust build and brown grime build up on the exterior; - The commercial dishwasher with a white build-up on the exterior surfaces. 7. Observations of the kitchen on 04/28/23 at 11:28 A.M., showed: - Eight round ceiling diffusers (one of the few visible parts of an air conditioning system) with brown grime build-up on the front exterior surfaces and between the ventilation louvers; - The ceiling paint peeled away from an area above a light fixture over a food prep counter; - A commercial style reach-in freezer near the office with black grime build-up along the door gasket; - A white reach in refrigerator near the office with a musty odor inside; - One metal exit door with a brown substance near the floor and a one inch gap; - One metal storage rack near the office with 10 plastic containers of dish detergent, five containers of disinfecting cleaner, four gallon bottles of oven cleaner, 13 one gallon bottles of de-[NAME], and disposable food service ware. During an interview on 04/25/23 at 9:46 A.M., the Dietary Manager said the ceiling areas should be clean and intact above any food service areas. The light fixture had been hanging loose for a while. All cookware should look clean and not have a dark build up. All leftover foods should be in sealed containers with dates. Any leftover food should be thrown out after three days, but if something smells bad, it may be thrown out sooner. The floors and appliances should be clean. The can opener should be washed daily and the grime on the base should be removed. The chipped can opener blade should be replaced. There had been an odor in the reach-in refrigerator near the office. During an interview on 04/25/23 at 12:22 P.M., Resident #8 said eating half of a tuna salad sandwich was enough and the other meals were never pleasing. During an interview on 04/27/23 at 8:56 A.M., the Maintenance Director said that staff should follow the facility's kitchen policy. The kitchen appliances and the HVAC unit should be clean and work properly. The can opener blade had never been replaced but one would be ordered. A thermometer will be placed in the chest style deep freezer. The floors, walls and ceiling should be clean and intact. During an interview on 04/28/23 at 10:58 A. M., Dietary Aide D said expectations were to follow the policy and keep the kitchen clean. Normally food was thrown out after three days. During an interview on 04/28/23 at 11:38 A.M., the Administrator said the freezer and refrigerators should be clean and not have black grime build up on the door gaskets. There should be no odor in the refrigerator. Food should never be served that had been stored over three days after being made. The back door to the kitchen should not have an air gap near the floor due to pests. The ceiling vents should be clean and not have dust or grime build up. She said that no cleaning supplies or chemicals should be stored in the kitchen area around any food items or serving ware. The HVAC unit should be clean with no grime build up on the unit and no dust build up on the intake vent or ceiling vents. The chest type freezer should not have grime on the outside of the machine and there should be no frost build up inside. All appliances should be clean. The ceiling should be intact above the food prep areas and lights should be installed properly.

Based on observation and interview, the facility failed to ensure the dumpster was maintained to keep pests out and/or to keep the garbage contained in the dumpster. This failure had the potential to affect all residents. The facility census was 29. Review of the facility's policy titled, Trash Pickup and Recycling, undated, showed: - Provide a clean, safe, and sanitary environment; - Trash will be collected from each resident room daily. Review of the facility's policy titled, Housekeeping, undated, showed: - Garbage and trash are to be stored in designated areas; - Trash bags are to be secured tightly when removed from trash container to prevent spills or contamination; - Gloves should be worn when removing and handling trash; - Receptacles are to be kept clean and covered with no trash placed on top; - Garbage and trash should be collected according to the facility schedule; - The dumpster area is to be kept clean at all times, free of debris, rodents and standing water. 1. Observation of the dumpster area on 04/25/23 at 9:24 A.M., 11:46 A.M., and 2:05 P.M., showed: - One 8 yard (yd.) blue dumpster partially filled with one plastic lid completely opened. 2. Observation of the dumpster area on 04/27/23 at 8:44 A.M., 10:25 A.M., 1:59 P.M., and 3:52 P.M., showed: - One 8 yd. blue dumpster partially filled with one plastic lid completely opened. 3. Observation of the dumpster area on 04/28/23 at 10:11 A.M., showed: - One 8 yd. blue dumpster partially filled with one plastic lid completely opened; - Thirty purple and clear disposable gloves lay on the ground near the dumpster with other debris. During an interview on 4/28/23 at 10:47 A.M., the Maintenance Director said the trash dumpster should be closed when it was unattended. During an interview on 04/28/23 at 10:58 A.M., Dietary Aide D said part of the job was to take trash from the kitchen to the dumpster and the dumpster lid should be closed when it was left unattended. During an interview on 04/28/23 at 11:00 A.M., the Dietary Manager said facility staff were expected to place tied trash bags in the dumpster, close the lid when finished and ensure the area around the dumpster was clean. During an interview on 04/28/23 at 11:38 A.M., the Administrator said the dumpster area should be kept in order and the lid should be closed when it was not being filled.