Based on observation, interview, and record review, facility staff failed to maintain professional standards of care, when they failed to check placement of a Gastrostomy Tube ((G-Tube) a tube placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) prior to administration of G-tube feeding, and failed to follow the physician's orders regarding water flushes for one (Resident #4) of one sampled resident with a G-tube. The facility census was 47. 1. Review of the facility's policy for Medication, Administration by Naso-Gastric or Gastrostomy Tube, undated, showed staff are directed: -Wash hands; -Verify the recipient with physician orders and medication administration record; -Check for tube placement; -Give medications only by gravity. Never force with plunger; -At completion of medication administration, flush tube with water as ordered; -If resident is bolus fed, clamp tube and follow physician orders (to include but not limited to amount of formula, amount of water, and time the tube feeding can be off each day). Review of the facility's policy on Physician Orders, undated, showed staff are directed as follows regarding Tube Feeding: -Specify the type of feeding, amount, frequency of feeding, frequency for tube change, and rationale if as needed; -Should always be followed by water. 2. Review of Resident #4's annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/02/24, showed staff assessed the resident with a feeding tube, received 51 percent (%) or more total calories via tube feeding, and received 501 cc (cubic centimeter) or more average daily fluid intake via tube feeding. Review of the resident's plan of care, last updated 05/07/24, showed staff assessed the resident to be dependent on staff for all fluids and nutrition, and directed staff as follows: -Nothing by mouth related to dysphagia (difficulty swallowing); -Has a G-tube and received all nutrition and fluids per tube. Is dependent on a licensed nurse for this; -Received all medications per G-tube; -Ensure patency and placement of G-tube before flushes/feeding by auscultation (using a stethoscope to listen to sounds of the body) or aspiration (withdrawing fluid/substance); -Ensure head is elevated at least 30 degrees before feedings. Review of the resident's Progress Notes, dated 07/18/24, showed the Registered Dietician documented: -Nothing by mouth, received tube feeding for sole nutrition; -Lactose-reduced food with fiber 1.5 bolus six times daily; -Flushes increased per recommendation to 100 mililters (ml) before and after bolus feedings. Review of the resident's Physician's Order Sheet (POS), dated 07/01/24 - 08/01/24, showed a gastrostomy status (presence of a G-tube) and Dysphagia. Review showed nothing by mouth and with tube feedings. Review showed the physician ordered may crush or alter medications unless otherwise indicated. May mix medication and give with feedings. Review showed staff are directed to administer: -Isosource 1.5 Calorie liquid one carton/240 ml via feeding tube every four hours, at 2 A.M., 6 A.M., 10 A.M., 2 P.M., 6 P.M., and 10 P.M.; -Flush tube with 100 ml of water before and after bolus feeding. Every four Hours at 2 A.M., 6 A.M., 10 A.M., 2 P.M., 6 P.M., and 10 P.M. Observation on 07/29/2024 at 2:24 P.M., showed the Director of Nursing (DON) entered the resident's room with the prepared medications, poured a carton of Isosource 250 ml into a graduated container (used to measure liquids), and filled a separate graduated container with 50 ml of tap water. Observation showed the DON attached a syringe to the resident's G-tube, administered the medications and the bolus feeding of Isosource, flushed with the 50 ml of water, and closed the tube. Staff did not check placement of the resident's G-tube and did not flush the G-tube as ordered by the physician. Observation on 07/30/24 at 10:02 A.M., showed Licensed Practical Nurse (LPN) B entered the resident's room with the prepared medications, poured a carton of Isosource 250 ml into a graduated container, and filled a separate graduated container with 300 ml of tap water. Observation showed the LPN attached a syringe to the resident's G-tube, administered the medications, flushed with approximately 50 ml of water, administered the bolus feeding of Isosource, flushed with approximately 50 ml of water, discarded the remaining 200 ml of water in the sink, washed his/her hands and left the room. Staff did not check placement of the resident's G-tube and did not flush the G-tube as ordered by the physician. During an interview on 07/30/24 at 10:02 A.M., LPN B said the resident's Medication Administration Record (MAR) directs staff on how much water to administer, and he/she believed the directions are to give 100 ml. The LPN said he/she had 300 ml of water in the container, but he/she only administered approximately 100 -110 ml of water total (100 ml with the feeding and 10 ml with the medications) and discarded the remainder. Observation on 07/31/24 at 10:50 A.M., showed LPN A entered the resident's room with the prepared medications, retrieved and poured a carton of Isosource 250 ml into a graduated container, filled another graduated container with tap water. Observation showed the LPN checked tube placement by auscultation, administered the medications, flushed with an unknown amount of water, administered the bolus feeding, then flushed with more water, and closed the tube. Staff did not flush the resident's G-tube as ordered by the physician. During an interview on 07/31/24 at 10:50 A.M., LPN A said he/she flushed the resident's G-tube with approximately 250 ml water. During an interview on 08/01/24 12:22 P.M., LPN A said he/she should follow physician's orders all the time. The LPN said staff should check for tube placement by auscultation with about 10 ml of air, to ensure the tube is in the stomach before administering any medications or feeding. The LPN said he/she mis-read the physician's order for the water flushes the day prior, and thought it was 120 ml, but he/she realized after he/she administered the feeding, that the order was for 100 ml before and after the bolus feeding. During an interview on 08/01/24 at 1:23 P.M., the DON said staff does not need to check for placement prior to administering medications or feeding via G-tube. The DON said he/she never checked for placement before feeding via G-tube unless he/she met resistance. However, if he/she met resistance during medication administration or feeding, he/she would stop, close the G-tube, and check for bowel sounds, or use a syringe to aspirate from the tube for gastric contents. The DON said he/she expects staff to follow physician's orders every time they administer medications or tube feedings to residents. The DON said he/she only flushed the resident's G-tube with 50 ml at the time, by default, because he/she did not remember the exact amount, but he/she later confirmed the physician's order is to flush with 100 ml before and after bolus feeding. During an interview on 08/01/24 at 1:45 P.M., the administrator said he/she expects staff to always follow physician's orders. He/She said staff should always follow physician's orders to give medications and feedings via tube to the resident, and if the order is written to flush with 100 ml of water, he/she expects staff to flush the tube with 100 ml of water.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, facility staff failed to update care plans in regards to smoking for three (Resident #1, #11, and #13) out of six sampled residents. The facility census was 70. 1. Review of the facility's Care Plan Comprehensive Policy, undated, showed assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition. Review staff were directed to: -Apply current standards of practice in the care plan process; -Update care plans when a significant change in condition has occurred, at least quarterly, and when changes occur that impact the resident's care. 2. Review of the Resident #1's Quarterly Minimum Data Sheet (MDS), a federally mandated assessment tool, dated 05/17/24, showed staff assessed the resident as follows: -Cognitively intact; -Tobacco use, not assessed. Review of the resident's care plan, dated 05/09/24, showed the resident will have supervised smoking in designated areas and will smoke safely throughout the next review. Cigarettes and lighters are kept at nursing station. Observation on 07/30/24 at 3:45 P.M., showed the resident outside without staff smoking a cigarette. Observation on 07/31/24 at 8:00 A.M., showed the resident outside without staff smoking a cigarette. Observation on 07/31/24 at 9:50 A.M., showed the resident in his/her wheelchair in the hallway with a pack of cigarettes and a lighter in the pocket of his/her shirt. Observation on 07/31/24 at 10:23 A.M., showed the resident outside without staff smoking a cigarette. Observation on 07/31/24 at 10:28 A.M., showed the resident wheeled into the facility with his/her cigarettes and lighter in their pocket and went to the dinning room for lunch. Observation on 08/01/24 at 8:15 A.M., showed the resident outside without staff smoking a cigarette. 3. Review of Resident #11's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent with care and transfers; -Independent with manual wheelchair; -Current Tobacco user. Review of the resident's care plan, dated 06/28/24, showed resident will: -Have supervised smoking in designated areas; -Smoke in designated smoking area at designated times, staff assigned to assist with residents that smoke. Observation on 07/29/24 at 3:15 P.M., showed the resident outside without staff smoking a cigarette. Observation on 07/30/24 at 12:30 P.M., showed the resident outside without staff smoking a cigarette. Observation on 07/30/24 at 3:45 P.M., showed the resident outside without staff smoking a cigarette. Observation on 07/31/24 at 10:26 A.M., showed the resident outside without staff smoking a cigarette. Observation on 08/01/24 at 8:15 A.M., showed the resident outside without staff smoking a cigarette. 4. Review of Resident #13's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent with manual wheelchair; -Tobacco use; not assessed. Review of the resident's care plan, dated 05/16/24, showed resident will: -Have supervised smoking in designated areas; -Smoke in designated smoking area at designated times, staff assigned to assist the resident; -Cigarettes and lighters are kept at nursing station. Observation on 07/30/24 at 12:30 P.M., showed the resident outside without staff smoking a cigarette. Observation on 08/01/24 at 8:20 A.M., showed the resident outside without staff smoking a cigarette. Observation on 07/29/24 at 10:41 A.M., showed resident in his/her room with cigarettes and lighter in vest pocket. Observation on 07/30/24 at 3:30 P.M., showed resident in his/her room with cigarettes and lighter in vest pocket. 5. During an interview on 08/01/24 at 12:30 P.M., the Care Plan Coordinator said resident care plans are updated quarterly, annually, with significate changes, and regularly when something needs to be added. He/She said Resident #1, #11, and #13 keep their cigarettes and light on themselves. He/She said the residents do not need to be supervised when smoking. He/She said he/she was not aware that their care plan said supervised smoking and cigarettes and lighters are kept at nurses station. He/She said he/she expects the care plans to be updated. He/She said it is his/her responsibility to update care plans. He/She said the policy was just updated about three weeks ago and it just didnt get changed in care plan. During an interview on 08/01/24 at 1:08 P.M., the Director of Nursing (DON) said care plans should be updated weekly because things change so quickly. He/She said care plans should be updated. He/She said he/she does not think the residents are allowed to keep their lighter on themselves. He/She said the residents do not need to be supervised while smoking. He/She said he/she was unaware the care plans said residents have to be supervised while smoking. He/She it is the care plan coordinators responsibly to update care plans. He/she said he/she believes it is his/her job to monitor care plans are being updated. During an interview on 08/01/24 at 1:47 P.M., the administrator said care plans are updated quarterly, significant change in condition, or an event happens. He/She said that residents do not need to be supervised when smoking and they can keep cigarettes and lighters on them. He/She said he/she expects the care plans to be updated. He/She said it is the care plan coordinator responsibly to update care plans. He/She said it is the director of nursing and administrator job to monitor to ensure they are being updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to store medications in a safe and effective manner when staff failed to date and label insulin pens (to treat high blood sugar). The facility census was 47. 1. Review of the facility's Labeling Drugs and Medication policy, undated, shows facility staff were directed as follows: -All drugs and biologicals must be properly labeled and legible at all times; -Labels must be permanently affixed to each container; -Medications in container having no labels must be destroyed in accordance with the facility procedures governing the destruction of medications; -Labels for individual drug containers must contain: Resident's full name and room number, expiration date (when applicable), and other appropriate information; -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. Review of Lantus Insulin Pen Instruction insert, dated 06/2023, shows Lantus Insulin pens can only be used up to 28 days after it's first used and throw away the Lantus pen after 28 days, even if it still has insulin left in it. Review of Novolog Insulin Pen Instruction insert, dated 10/2023, shows Novolog insulin pens should be thrown away after 28 days of opening, even if it still has insulin left in it. 2. Observation on [DATE] at 7:56 A.M., showed the 100 hall medication cart contained: -Five opened and undated Lantus Insulin Pens; -One opened and undated Novalog Insulin Pen; -One opened and undated Tresiba Insulin Pen. During an interview on [DATE] at 8:10 A.M., Certified Medication Tech (CMT) E said when he/she opens a medication he/she labels with open date. He/She said if medication is not dated then you will not know when medication is no longer good. He/She said if medication is not dated it's a risk for the medication to not be effective if it's expired. 3. Observation on [DATE] at 1:32 P.M., showed the Memory Care unit medication cart contained: -Two Fiasp insulin pens without an open date; -One Humalog insulin pen without a patient identifier or an open date; -One Lantus Solostar insulin pen without a patient identifier or an open date. 4. Observation on [DATE] at 1:55 P.M., showed a sign in memory care unit medication room directed staff all insulin bottles need to be dated when opened and all insulin expire 28 days after opening, regardless of expiration date on bottle and goes by date opened. 5. Observation on [DATE] at 10:45 A.M., showed a sign in the main medication room refrigerator directs staff: -Date all insulin when it is opened; -Good for 28 days, then it must be destroyed; -Insulin expire after it is open and you can not give it after 28 days open. 6. During an interview on [DATE] at 1:32 P.M., CMT C said insulin pens expire 30-45 days after they are opened, and any staff who administers insulin to a resident is expected to, and should always check the expiration/discard date prior to administering insulin to a resident. The CMT said any staff who removes the insulin from the refrigerator and opens it, should label the pen with the resident's name, date of birth , open date, and expiration/discard date, there should be someone that does audits, and there should be a system to double check for those things. During an interview on [DATE] at 12:20 P.M., CMT D said when opening a new insulin pen, you put the open date on pen. He/She said the insulin pen is usually labeled with resident's name already on pen or if the pens come in a box the label is on the box, a sharpie is used to write the residents name on the insulin pen. He/She said whoever opens the pen is responsible for dating and labeling the pen. He/She said a pharmacy comes in once a month to check for expired medication and make sure medication are labeled. He/She said insulin pens are only good for 28 days after opening. He/She said if insulin is given after 28 days the insulin is expired and the insulin would not be effective. He/She said if he/she found an insulin pen opened and not dated, he/she would discard the pen and get a new on and label and date it. During an interview on [DATE] at 12:25 P.M., License Practical Nurse (LPN) A said when opening a new insulin pen it needs to have open date and expiration date. He/She said the insulin pens should have the resident's name on the pen and the pen cap. He/She said whoever opens the pen is responsible for labeling and dating the pen. He/She said insulin is only good for 28 days after opening. He/She said after the 28 days the insulin may not be effective and not at its full potential. He/She said if insulin pen found with no date or label, he/she would notify the Director of Nursing and the insulin pen would have to be wasted because he/she would be unsure of how long the insulin had been opened. During an interview on [DATE] at 1:12 P.M., the Director of Nursing (DON) said when opening an insulin pen the date that it was opened should be written on the insulin pen along with resident name. He/She said he/she expects that if insulin pens are taken out of original box that it is labeled with resident's name. He/She said it is the CMT's responsibility to make sure insulin pens are dated and labeled. He/She said he/she is unsure of how long insulin pens are good for after opening. He/She said if past expiration date, the insulin would lose its potential and not be effective. During an interview on [DATE] at 1:51 P.M., the administrator said insulin pens should be dated when opened and have Resident's name. He/She said its pharmacy's responsibility to label the Insulin pens and the Nurses and CMT's responsibility to ensure open dates are on insulin pens. He/She said after expiration the insulin weakens its effect. He/She said if staff can not verify when insulin pen was opened, not to given insulin and get a new insulin pen. He/She said a pharmacist comes in monthly and checks medication to check expiration dates. He/She said the DON should be monitoring the insulin pens to ensuring dating and labeling of insulin pens are being done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to change gloves and wash/sanitize hands during wound care for one resident (Resident #14), during medication administration for one resident (Resident #4) and failed to implement the enhanced barrier precautions (EBP) (an infection control intervention) policy developed and educate staff who required EBP and place appropriate personal protective equipment (PPE) in close proximity for two out of four sampled residents, one resident (Resident #14) with a wound and one of one resident (Resident #4) with an indwelling gastrostomy tube ((g-tube) surgically placed tube that enters the stomach to deliver fluids and nutrition, that required EBP). The facility census was 47. 1. Review of the facility's policy on Handwashing, undated, showed the purpose of handwashing is to reduce transmission of organisms from resident to resident, nursing staff to resident, and resident to nursing staff. Review of the facility's policy on Hand Cleanser (Antiseptic), undated, showed the purpose is to cleanse the hands between resident contacts during care and to prevent the spread of infection. Review of the facility's policy on Perineal Care, undated, showed the purpose is to cleanse the perineum (area between genitals and anus), to prevent infection and odor, and directed staff: -Wash hands; -Provide male/female perineal care; -Remove gloves and wash hands; -Position resident comfortably. Review of the facility's EBP to infection Control Guidance policy, dated March 2024 showed: -To prevent broader transmission or multidrug-resistance organisms (MDRO), bacteria resistant to antibiotics and/or antifungals, and to help protect residents with chronic wounds and indwelling devices. EBP should be implemented for the period of their stay or until wounds have been resolved or indwelling medical devices have been removed; -Residents who require EBP are those with an indwelling medical device including a feeding tube (g-tube) regardless of their MDRO status and residents with a wound, regardless of their MDRO status; -Staff should use EBP when providing high contact resident care activities such as: bathing/showering, transferring residents from one position to another, providing hygiene, changing briefs or toileting, caring for or using an indwelling medical device, and performing wound care; -EBP includes the use of gloves and a gown; -Residents who are placed on EBP should have personal protective equipment (PPE) in close proximity outside the door and a trash can in the resident's room for disposal prior to leaving the room. Review of the Centers for Disease Control (CDC) website https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html article, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021, showed: -Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities; -Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room). 2. Review of Resident #4's Annual Minimum Data Set (MDS), a federally mandated assessment, dated 05/02/24 showed staff assessed the resident as follows: -Severely cognitively impaired; -Use of a feeding tube. Observation on 07/29/2024 at 2:24 P.M., showed the Director of Nursing (DON) entered the resident's room with prepared medications, did not wash his/her hands, put on a gown and applied gloves, administered the medications/feeding via G-tube, and wiped up spilled liquid from the bedside table with paper towels. The DON continued to wear the same soiled gloves and administered a medication under the resident's tongue. The DON removed his/her gloves, gown, and bagged the dirty supplies. The DON did not wash his/her hands before he/she left the resident's room. Observation on 07/30/24 at 9:26 A.M., showed the resident's room did not have PPE in close proximity outside the door as directed per the facility EBP policy. Observation on 07/30/24 at 10:02 A.M., LPN B entered the resident's room and administered medication, feeding, and fluids to the resident via G-tube with a gown on. Observation on 07/31/24 at 9:41 A.M., showed the resident's room did not have PPE in close proximity outside the door as directed per the facility EBP policy. Observation on 08/01/24 at 9:27 A.M., showed the resident's room did not have PPE in close proximity outside the door as directed per the facility EBP policy. During an interview on 08/01/24 at 1:23 P.M., the DON said he/she should have changed gloves and washed/sanitized hands between the tube feeding and administration of the sublingual medication. 3. Review of Resident #14's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively impaired; -Open Lesion; -Application of non surgical dressing. Observation on 07/29/24 at 1:50 P.M., showed the DON entered the resident's room to provide wound care. Observation showed the DON washed his/her hands, placed a gown on and gloves. The DON cleansed the wound on the residents right side face. With the same soiled gloves the DON, cleansed a wound on the residents left side of face, used a clean cotton-tipped applicator to apply vaseline to both wounds and covered both wounds with a dressing. The DON did not wash his/her hands before he/she left the resident's room. Observation on 07/30/24 at 9:26 A.M., showed the resident's room did not have PPE in close proximity outside the door as directed per the facility EBP policy. Observation on 07/31/24 at 9:37 A.M., showed the resident's room did not have PPE in close proximity outside the door as directed per the facility EBP policy. Observation on 08/01/24 at 12:20 P.M., showed the resident's room did not have PPE in close proximity outside the door as directed per the facility EBP policy. During an interview on 08/01/24 at 1:23 P.M., the DON said he/she did not realize he/she did not change gloves during wound care and he/she knew better. 5. During an interview on 08/01/24 at 12:19 P.M., Certified Medication Technician (CMT) G said he/she did not know what resident's required EBP. The name plates don't have yellow dots. If they do, it might mean the resident is a fall risk. He/She said, it is just a smiley sticker. During an interview on 08/01/24 at 12:25 P.M., CNA F said the name plates don't have yellow dots. He/She said no one has told him/her about it or what it means. He/She did not know which resident's required gloves and gowns. During an interview on 08/01/24 at 1:14 P.M., the DON said anyone with an open area, wounds, residents with tube feedings, and anyone with a catheter should be on EBP. Staff should wear gowns and gloves and there should be a stop sign on the door so staff know. The sign at the nurses desk and in the dayroom with only two residents names is incorrect. The sign in the dayroom should not be out in the open. The DON said staff should wear gloves anytime they perform perineal care, wound care, and tube feeding to residents. The DON said staff should change gloves in between dirty and clean tasks, wash hands, dry and apply clean gloves. During an interview on 08/01/24 at 1:45 P.M., the administrator said he/she expects staff to wear gloves when doing cares and treatment to residents, change gloves between dirty & clean tasks, and when switching residents. The administrator said staff should wash hands after they remove gloves, and when hands are visibly soiled.

Based on observation, interview, and record review, facility staff failed to maintain proper documentation, assessment, and monitoring for the use of a physical restraint for one resident(Resident #43), who had been placed in chairs that prevented the resident from rising and ambulating. The facility census was 47. 1. Review of the facility's Use of Restraints Policy, dated March of 2012, showed: -Physical restraints are defined as any manual method or physical or mechanical device, material equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body; -If the resident cannot remove a device in the same manner as staff applied it, given the resident's physical condition and this restricts his/her typical ability to change position or place, the device is considered a restraint; -Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints are not permitted, including placing a resident in a chair that prevents the resident from rising, or placing a resident who uses a wheelchair so close to a wall, that the wall prevents the resident from rising; -Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints; -Restraints shall only be used upon the written order of a physician and after informing the resident and or legal representative; -Care Plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms, but the underlying problems that may be causing the symptoms; 2. Review of Resident #43's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 11/30/22, showed staff assessed the resident as: -Moderate Cognitive Impairment; -Required extensive assistance from two staff members for bed mobility; -Totally dependent on two staff members for transfers; -Did not walk in room or corridor; -Required extensive assistance from one staff member for locomotion; -Used a wheelchair; -Had diagnoses of Anemia, Dementia, chronic pain, and repeated falls. Review of the resident's Care Plan, revised 1/31/23, showed staff documented to ensure the recline function is not engaged on the recliner, as the resident is unable to disengage it himself/herself. Review of the resident's Physician Order Sheet (POS), dated March of 2023, showed it did not contain an order for restraints. Review of the resident's medical record, showed it did contain a restraint consent, or notification of the resident's responsible party in regard to restraint use. Observation on 3/6/23 at 10:34 A.M., showed the resident sat in a recliner with the foot rest up. The resident tried to get out of the recliner multiples times and Certified Nurse Aide (CNA) K told the resident to sit down, or he/she would fall. Further observation showed the resident scooted forward in the recliner and sat directly on the foot rest. Observation on 3/6/23 at 11:19 A.M., showed the resident sat in a recliner with the foot rest up. The resident tried to get out of the recliner with no staff present and another resident yelled at the resident to sit back. Certified Medication Technician (CMT) E entered the common area and asked the resident to sit back. Observation on 3/6/23 at 11:27 A.M., showed the resident sat in a recliner with the foot rest up, and tried to get out of it. The resident scooted himself/herself forward onto the foot rest of the recliner and the recliner tipped forward. CMT E ran and caught the resident, before the chair fully tipped over on top of the resident. Observation on 3/7/23 at 11:46 A.M., showed CNA I propelled the resident from his/her room to the dining room in a wheelchair. The CNA sat the resident in his/her wheelchair up against the table and locked the wheels of the wheelchair. The resident stood up multiple times, but could not leave the table. CNA I and CMT H repeatedly asked the resident to sit back down. During an interview on 3/7/23 at 1:40 P.M., CNA I said he/she propelled the resident up to the table and locked the wheels of the wheelchair, because the resident is a fall risk and he/she stands up all the time. The CNA said if the wheels are not locked, the wheelchair will roll back when the resident stands up and he/she will fall. During an interview on 3/9/23 at 9:05 A.M., CMT E said he/she had seen the resident trying to get out of the recliner and he/she almost did the previous day. The CMT said if a resident is trying to get up, and something is stopping them it is considered a restraint. The CMT said the foot rest on the recliner is a restraint because the resident can't put it down himself/herself. The CMT said staff lock the wheels of the wheelchair at the dining room table to keep the resident from rolling his/her chair backward and falling down. The CMT said locking the wheelchair wheels at the table restricts the resident's movement and is a restraint. During an interview on 3/9/23 at 11:45 A.M., Registered Nurse (RN) G said some days the resident tries to climb out of the recliner and staff put the resident in a wheelchair, because he/she can't put the footrest of the recliner down by himself/herself. The RN said staff should get the resident up, if he/she is trying to get out of the recliner, because if not, it is considered a restraint. The RN said the resident does not have a consent for restraint use. The RN said staff lock the wheels of the resident's wheelchair at the table because staff don't want the resident rolling backward and falling. The RN said if the resident is unable to step around the wheelchair he/she is restrained. The RN said the resident is active and wants to get up on his/her own and walk, but he/she falls. During an interview on 03/9/23 at 1:42 P.M., the Social Service Director (SSD) the facility does not use restraints. The SSD said locking a resident's wheelchair is not allowed unless they can unlock it themselves or the resident is being transferred. He/She said staff should not prevent the resident from getting up and out of a recliner. The SSD said he/she is responsible for obtaining restraint consents for the residents. The SSD said if staff prevent the movement of a resident, that is a restraint and that is not allowed. During an interview on 3/9/23 at 5:06 P.M., the Director of Nursing (DON) said a restraint is anything that restricts a residents' movement. The DON said staff are not supposed to lock wheelchairs unless the resident is being transferred, or the resident can unlock it. He/She said if a resident is unable to get themselves out of a chair they are restrained. The DON said if the resident is moving around frequently, staff should find the resident a different chair, and not tell them to sit back down.

Based on observation, interview, and record review, facility staff failed to obtain physician orders for the use of Continuous positive airway pressure (CPAP), a non-invasive ventilation machine that involves the administration of air usually through the nose by an external device at a predetermined level of pressure, for one resident (Resident #9). Additionally, staff failed to develop and implement a person centered comprehensive care plan for the resident's use of CPAP. The facility census was 47. 1. Review of the facility's CPAP Administration policy, dated March 2015, showed: -Contact Quality Assurance Nurse prior to placement for clarification of orders and support; -Check physician orders for pressure setting and method of administration; -Assist resident as needed with applying and adjusting CPAP mask and head strap. Review of the facility's Physician Order policy, dated March 2015, showed: -Current lists of orders must be maintained in the clinical record of each resident to avoid confusion and errors; -Oxygen orders: specify the rate of flow, route and rationale; -Treatment orders: specify what is to be done, location and frequency, and duration of treatment. 2. Review of Resident #9's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/25/23, showed staff assessed the resident as: -Severely cognitively impaired; -Used oxygen; -Did not use CPAP; -Diagnoses of eye cancer, heart failure, chronic obstructive pulmonary disease (COPD), a tightening of airways making it difficult or uncomfortable to breathe, and high blood pressure. Review of resident's admission Inventory sheet, dated 1/18/23, showed the resident was admitted to the facility with his/her CPAP. Review of the resident's Baseline Care Plan, dated 1/18/23, showed staff documented the resident uses oxygen. Further review showed it did not contain direction for staff in regard to CPAP use. Review of the resident's Medical Record, showed it did not contain a comprehensive care plan. Review of the Physician Order Sheet (POS), dated March 2023, showed it did not have orders for CPAP use or settings. Review of the resident's progress notes, dated 2/16/2023 at 11:55 P.M., showed staff documented the resident rested quietly in bed, eyes closed, respirations even and non-labored, wearing CPAP. Observation on 3/06/23 at 10:50 A.M., showed a CPAP on the resident's bedside table with three liters (L) of oxygen connected via a concentrator. Observation on 3/07/23 at 11:32 A.M., showed a CPAP on the resident's bedside table with three L of oxygen connected via a concentrator. Observation on 3/08/23 at 1:41 P.M., showed a CPAP on the bedside table with three L of oxygen connected via a concentrator. Observation on 3/09/23 at 8:24 A.M., showed a CPAP on the bedside table with three L of oxygen connected via a concentrator. During an interview on 3/9/23 at 10:35 A.M., Registered Nurse (RN) A said there should be a physician's order for the resident's CPAP, and the order should include when the CPAP should be worn, settings, and if oxygen is used with it. The RN said staff would not know how to appropriately use the CPAP if there were no orders. The RN said he/she doesn't know why there is not an order for CPAP use and settings. He/She said he/she didn't know the resident used a CPAP. During an interview 3/09/23 at 5:23 P.M., the Director of Nursing (DON) said he/she expects staff to obtain orders for CPAP use and the orders should be on the POS. The DON said the order should address the use of CPAP, cleaning, and parameters for use including the settings. He/she said if the resident brought the CPAP machine from home and the settings are not known, then he/she would expect staff to contact the provider to clarify the settings. He/She said if staff could not clarify the settings a new sleep study should be completed. The DON did not know the resident used CPAP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, staff failed to ensure two residents (Resident #2 and Resident #43) had an appropriate indication for the use of antipsychotic medications (used to treat psychosis). The facility census was 47. 1. Review of the facility's Antipsychotic Medication Use Policy, dated March 2015, showed: -Residents will only receive antipsychotic medications when necessary to treat a specific conditions for which they are indicated and effective; -Antipsychotic medications shall only be used for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions); -Schizo-affective disorder; -Mood Disorders; -Depression with psychotic features, and treatment refractory major depression; -Psychosis, Not otherwise specified (NOS); -Brief psychotic disorder; -Schizophrenia; -Delusional disorder; -Schizophreniform disorder; -Atypical psychosis; -Dementing illnesses with associated behavioral symptoms; -Medical illnesses or delirium with manic or psychotic symptoms and/or treatment-related psychosis or mania. -Antipsychotic medications will not be used if the only symptoms are one or more of the following: -Restlessness; -Impaired memory; -Inattention or indifference to surroundings; -Fidgeting; -Nervousness; -Uncooperativeness; -Verbal expressions or behavior that are not due to conditions listed above and do not represent a danger to the resident or others. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/10/23, showed staff assessed the resident as: -Severe Cognitive Impairment; -Had physical behaviors directed towards others; -Had verbal behaviors directed towards others; -Did not reject care; -Wandered; -Did not receive antipsychotic medication; -Diagnoses of unspecified dementia, (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) unspecified severity with behavioral disturbance, anxiety, depression, pain, idiopathic progressive neuropathy (nerve damage of unknown source), repeated falls, discitis (infection of the discs between the vertebra of the spine), and chronic pain. Review of the resident's care plan, revised 2/23/23, showed staff documented: -Diagnosis of dementia, able to make some needs known; -Impaired vision; -Receives psychotropic medication due to dementia with behavioral diagnosis; -Yells out frequently and repeats things over and over related to being hard of hearing. Will yell out Whoopie or Yoo Hoo a lot. If yelling out offer toileting, repositioning, or one on one; -2/23/23 resident heard yelling, found sitting on the floor. Review of the resident's Progress notes, dated 2/24/23, showed Registered Nurse (RN) G documented the resident was seen by the physician. No complaints voiced. Resident continuously yelling whoopie. Medications and labs reviewed. See physician order sheet (POS) for new orders. Review of the resident's Physician Order Sheet (POS) dated, March 2023, showed an order dated 2/24/23 for Seroquel (antipsychotic medication) 25 milligrams (mg) two times a day (BID) for unspecified dementia with behavioral disturbance. Observation on 3/6/23 at 10:55 A.M., showed an unidentified staff member read the resident's mail to him/her while he/she lay in bed. Observation on 3/6/23 at 11:48 A.M., showed the resident sat in a recliner in the day room. Further observation, showed the resident waved his/her arms and yelled because he/she wanted his/her socks removed. An unidentified staff member removed the resident's socks and the resident stopped yelling. Observation on 3/6/23 at 1:27 P.M., showed the resident sat in the day room and ate a granola bar and ice cream. Observation on 3/7/23 at 9:01 A.M., showed the resident lay in bed. Further observation showed the resident kicked at his/her blankets, and yelled get me up. During an interview on 3/7/23 at 9:31 A.M., RN G said the resident yells and sleeps a lot. During an interview on 3/7/23 at 11:50 A.M., Certified Medication Technician (CMT) H said the resident has good and bad days. The CMT said the resident was deaf and has a lot of anxiety because of it. Observation on 3/9/23 at 9:03 A.M., showed the resident in the day room with his/her eyes closed, and the lights dimmed. During an interview on 3/9/23 at 12:13 P.M., RN G said the resident's physician was in the facility a few weeks ago, and the resident wouldn't stop screaming. The RN said the physician ordered Seroquel to see if it helped the resident's screaming, and to see if the screaming was a behavior. The RN said the minute staff walks away from the resident he/she starts screaming again. The RN said the resident's screaming bothers the other residents. During an interview on 3/9/23 at 5:53 P.M., the Director of Nursing (DON) said the physician started the resident on Seroquel to see if it helped calm him/her, and because he/she screams a lot. The DON said the resident yells for attention, and if he/she is yelling it means he/she needs something. He/She said dementia with behaviors is not an appropriate diagnosis for the use of Seroquel. 3. Review of Resident #43's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate Cognitive Impairment; -Did not exhibit behaviors directed at self, or others; -Received antipsychotic medication seven out of seven days in the look back period (time used to complete the assessment); -Had diagnoses of Anemia, Dementia, chronic pain, and repeated falls. Review of the resident's POS, dated March 2023, showed an order dated 1/26/23 for Zyprexa (Antipsychotic) 2.5 mg daily for Unspecified Dementia. Review of the resident's Care Plan, revised 1/31/23, showed staff documented the resident uses Psychotropic medications due to Dementia and behaviors. During an interview on 3/09/23 at 9:05 A.M., CMT E said the resident receives an antipsychotic medication. The CMT said it is appropriate to start a resident with Dementia on an antipsychotic for their mood swings and behaviors. During an interview on 3/09/23 at 11:45 A.M., RN G said the resident receives Zyprexa which is an antipsychotic medication. The RN said he/she doesn't know why the resident receives the medication, but the order shows it is for unspecified Dementia. The RN said Dementia is an appropriate diagnosis for the use of antipsychotic medications, depending on the resident's behaviors. During an interview on 3/09/23 at 5:06 P.M., the DON said Dementia is not appropriate diagnosis for antipsychotic medication use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair. The facility census was 47. Review of the policies provided by the facility showed they did not contain a policy for environmental concerns. 1. Observations from 3/6/23 at 10:00 A.M. through 3/9/23 at 8:49 A.M., showed the 100 hall floor with black marks, dirty and with cracked flooring. Further observation showed the walls with black and brown marks. 2. Observation on 3/6/23 at 10:49 A.M., showed Resident #51's room had a dirty, scratched, cracked and stained floor. Further observation showed the walls with black marks, chipped paint and gouges. Observation on 3/7/23 at 9:52 A.M., showed the room had a dirty, scratched, cracked and stained floor. Further observation showed the walls with black marks, chipped paint and gouges. Observation on 3/9/23 at 8:50 A.M., showed the room had a dirty, scratched, cracked and stained floor. Further observation showed the walls with black marks, chipped paint and gouges. During an interview on 3/7/23 at 9:52 A.M., the resident said the condition of the room bothered him/her and he/she said it isn't homelike. 3. Observation from 3/6/23 at 10:31 A.M., showed room [ROOM NUMBER] had a dirty, scratched and stained floor. Further observation showed the walls with black marks and gouges and brown stains in the toilet. Observation on 3/7/23 at 9:01 A.M., showed the room had a dirty, scratched and stained floor. Further observation showed the walls with black marks and gouges and brown stains in the toilet. Observation on 3/8/23 at 9:08 A.M., showed the room had a dirty, scratched and stained floor. Further observation, showed the walls with black marks and gouges and brown stains in the toilet. 4. Observation on 3/6/23 at 10:38 A.M., showed Resident #44's room with stains on the sheet, and the toilet with a black substance in the bowl and a brown substance around the base. Further observation showed the walls with black marks, chipped paint and gouges and the bathroom door with scratch marks. Additional observation, showed the floors had stains and were dirty. Observation on 3/7/23 at 9:07 A.M., showed the toilet with a black substance in the bowl and a brown substance around the base. Further observation, showed the walls with black marks, chipped paint and gouges and the bathroom door with scratch marks. Additional observation, showed the floors had stains and were dirty. During an interview on 3/8/23 at 9:01 A.M., the resident he/she noticed the floor and walls. He/She said the room is not homelike. 5. Observation on 3/6/23 at 10:44 A.M., showed room [ROOM NUMBER] with a rusted and loose piece of dry wall edging at the entrance to the bathroom, gouges in the the wall, and the painted door frame of the bathroom with scratches. 6. Observation on 3/6/23 at 10:37 A.M., showed room [ROOM NUMBER] had sticky, black spots over the entire floor, with shoe prints and wheel tracks on the floor. Further observation showed gouges in the dry wall edges by the bathroom, multiple reddish brown stains on the floor, and the bathroom with a palm-sized dry wall patch. Additional observation showed the toilet with brownish red build-up in the bowl and a brown build-up around the base. During an interview on 3/9/23 at 10:13 A.M., Certified Nurse Aide (CNA) R said he/she has not noticed any environmental concerns, but if he/she did he/she would report them. After visiting a room on the 100 hall the CNA said the room is not homelike. 7. Observation on 3/6/23 at 10:50 A.M., showed room [ROOM NUMBER] with black arc shaped scratches on the floor from the door. 8. Observation on 3/7/23 at 11:21 A.M., showed the Special Care Unit (SCU) hallway had 118 cracked floor tiles. Further observation showed the SCU assisted dining room had 24 cracked floor tiles. During an interview on 3/09/23 at 9:05 A.M., Certified Medication Technician (CMT) E said the floors on the unit are in bad shape. During an interview on 3/9/23 at 11:45 A.M., Registered Nurse (RN) G said knows the tiles are cracked, but he/she doesn't know if it has been reported to the maintenance department. During an interview on 3/9/23 at 4:34 P.M., the Maintenance Director said he/she didn't know about the cracked tiles on the SCU. He/She said staff has not reported it in the maintenance log. If tile is cracked he/she is supposed to replace or repair it. 9. During an interview on 3/9/23 at 10:35 A.M., Registered Nurse (RN) A said he/she has noticed the environmental concerns and has reported the issues to maintenance. He/She said staff are directed to complete the maintenance form if there are concerns. He/She said the new maintenance supervisor is trying to fix the necessary repairs, but he/she just recently started his/her new position. During an interview on 3/9/23 at 4:34 P.M., the Maintenance Supervisor said staff are directed to put environmental concerns in the maintenance log book. He/She said he/she is aware of the repairs that are needed in the facility. He/She is attempting to complete all the repairs, but he/she just started at the facility two weeks ago. He/She said he/she believed the facility is homelike, but knows the resident rooms require maintenance. During an interview on 3/9/23 at 5:06 P.M., the Director of Nursing (DON) said the building is a work in progress and the maintenance supervisor is attempting to work on the environmental concerns. He/She said the maintenance supervisor is making a list and attempting to get things repaired. He/She said staff are directed to document environmental concerns in the maintenance logs. He/She said he/she has noticed the condition of the resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility staff failed to ensure a comprehensive plan of care was developed and implemented for four residents (Resident #3, #9, #34, and #44). The facility census was 47. 1. Review of the facility's Care Plan Comprehensive policy, dated March 2015, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff; -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; -The resident's comprehensive care plan is developed within seven days of the completion of the resident's comprehensive assessments (MDS) and Care Area Assessment (CAA); -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred; at least quarterly; and when changes occur that impact the resident's care (i.e. change in diet, discontinuation of therapy, changes in care areas that do not require a significant change assessment). 2. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident with Range of Motion (joint movement) impairments to both upper extremities. Review of the resident's care plan, dated 10/27/22, showed it did not contain the impairments or direction for staff in regard to the impairments. Observation on 3/6/23 at 10:17 A.M., showed the resident had contracted hands. Observation on 3/6/23 at 12:07 P.M. showed the resident had contracted hands. Observation on 3/8/23 at 9:18 A.M., showed the resident had contracted hands. Observation on 3/8/23 at 5:05 P.M., showed the resident had contracted hands. During an interview on 3/9/23 at 11:45 A.M., Registered Nurse (RN) G care plans are kept off of the Special Care Unit (SCU) up front on the chart racks. He/She said staff who work the unit do not have access to the care plans. The RN said he/she hasn't looked at the care plans and doesn't know if they are up to date. The RN said he/she knows the resident's hand are contracted, but he/she doesn't know why it's not care planned. He/She said the contractures should be listed on the care plan. During an interview on 3/09/23 at 4:54 P.M., the MDS Coordinator said there should definitely be interventions for the resident's hand contractures of the care plan. He/She said staff are updated on care plan changes by word of mouth. He/She said the SCU staff are expected to know what's on the residents' care plans. During an interview on 3/09/23 at 5:06 P.M., the Director of Nursing (DON) said he/she expects ROM issues to be on a resident's care plan, with interventions like passive range of motion (PROM). The DON said he/she doesn't know how staff are notified when the care plans are updated. 3. Review of Resident #9's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/25/23, showed staff assessed the resident as: -Severe Cognitive Impairment; -Required assistance from one staff member for dressing; -Uses oxygen; -Did not use a Continuous Positive Airway Pressure (CPAP), a machine that uses mild air pressure to keep breathing airways open while you sleep; -Received anticoagulants; -Diagnoses of heart failure, chronic obstructive pulmonary disease (COPD- a tightening of airways making it difficult or uncomfortable to breathe), high blood pressure, arthritis, and depression. Review of the resident's medical record showed it did not contain a person centered comprehensive care plan. Further review showed staff documented the resident fell on 2/6/23, 2/23/23, and 2/25/23. Observation on 3/6/23 at 10:50 A.M., showed a CPAP on the resident's bedside table with 3 liters (L) of oxygen attached via a concentrator. Observation on 3/7/23 at 11:32 A.M., showed a CPAP on the resident's bedside table with 3 L of oxygen attached via a concentrator. Observation on 3/8/23 at 1:41 P.M., showed a CPAP on the resident's bedside table with 3 L of oxygen attached via a concentrator. Observation on 3/9/23 at 8:24 A.M., showed a CPAP on the resident's bedside table with 3 L of oxygen attached via a concentrator. During an interview on 3/9/23 at 2:20 P.M., the MDS Coordinator said the resident's baseline care plan is complete, but the comprehensive care plan was started today. 4. Review of Resident #34's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -admitted to the facility on [DATE]; -Moderate Cognitive Impairment; -Required supervision from one staff member for eating; -Required extensive assistance from one staff member for dressing; -Required extensive assistance from two staff members for bed mobility; -Totally dependent on one staff member for locomotion on the unit; -Totally dependent on two staff members for transfers, toileting, personal hygiene and bathing; -Used a wheelchair; -Always incontinent of bowel and bladder; -Received an antipsychotic, antianxiety, and antidepressant medication seven out of seven days in the look back period; -Received oxygen; -Had diagnoses of Hypertension, Dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory), Parkinson's Disease (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), anxiety, and depression. Review of the resident's medical record showed it did not contain a comprehensive person centered care plan. Observation on 3/6/23 at 10:28 A.M., showed the resident lay in bed. Observation on 3/6/23 at 12:30 P.M. showed an unidentified staff member fed the resident lunch. Observation on 3/7/23 at 11:34 A.M., showed the resident in a broda chair (reclined wheelchair). Observation on 3/8/23 at 9:19 A.M., showed the resident in a broda chair with his/her eyes closed. During an interview on 3/8/23 at 9:20 A.M., CNA J said staff provided all care for the resident because he/she is unable to. He/She said the resident got sick a few months ago and went downhill quickly. During an interview on 3/9/23 at 12:15 P.M., Registered Nurse (RN) G said the MDS Coordinator should complete the residents' care plans, and he/she didn't know why the resident would not have one. During an interview on 3/9/23 at 2:20 P.M., the MDS Coordinator said the resident has no baseline or comprehensive care plan. He/She didn't know why it was not completed. 5. Review of Resident #44's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required limited assistance from one staff member for bed mobility, transfers, dressing, toileting and personal hygiene. -Required supervision assistance from one staff member for eating; -Received pain medication in the past five days; -Received an antidepressant and diuretic medication seven out of seven days in the look back period; -Received an anticoagulant medication four out of seven days in the look back period; -Received an antibiotic medication three out of seven days in the look back period; -Received an opioid pain medication six out of seven days in the look back period; -Used a wheelchair; -Received oxygen therapy; -Continuous Positive Airway Pressure (CPAP) machine; -Had a diagnosis of Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), Hypertension, Gastroesophageal Reflux Disease (GERD) Hyponatremia (a condition that occurs when the level of sodium in the blood is too low), Depression, and Respiratory Failure. Review of the resident's medical record showed staff did not complete the resident's comprehensive person centered care plan until 3/9/23. Observation on 3/6/23 at 10:35 A.M., showed the resident wore oxygen. Further observation showed a CPAP machine next to the bed. Observation on 3/6/23 at 1:13 P.M., showed the resident wore oxygen. Further observation showed a CPAP machine next to the bed. Observation on 3/7/23 at 10:36 A.M., showed the resident wore oxygen. Further observation showed a CPAP machine next to the bed. During an interview on 3/7/23 at 10:36 A.M., the resident said he/she didn't remember participating in a care plan meeting. During an interview on 3/9/23 at 2:24 P.M., the MDS Coordinator said he/she just created a comprehensive care plan for the resident after the surveyors asked for a copy and he/she noticed there wasn't one. The MDS Coordinator said he/she started this position about six months ago and is trying to get caught up. 6. During an interview on 3/9/23 at 10:35 A.M., RN A said care plans are updated by the Interdisciplinary Team (IDT) team, which includes activities, dietary, social services and the MDS Coordinator, but not the aides or nurses. He/She said the care plan should include any changes, including falls, hospice, diets, weight, and medical devices. He/She said if there is no care plan, the staff should relay the information to each other. During an interview on 3/9/23 at 2:20 P.M., the MDS Coordinator said the comprehensive care plan should be completed within 14 days of the residents' admission date, and should be updated with every significant change, quarterly and annual assessment. He/She said the care plan should include anything triggered from the CAA, falls, hospice, cognition, discharge goals, pertinent diagnoses, Activities of Daily Living (ADLS), special diets, psychotropic medications, facial hair preferences and pain. The baseline care plan should be completed upon admission along with a clinical assessment. He/She said the facility did not have an MDS Coordinator for eight to nine months before he/she started and he/she is trying to get the care plans caught up. He/She said if there is no comprehensive care plan, or if the care plan is not updated, staff would rely on word of mouth from other staff members to know what type of care the resident requires. During an interview on 3/09/23 at 5:23 P.M., the Director of Nursing (DON) said care plans should be updated with any changes and should include care areas such as falls, psychotropic medication use, anticoagulants, hospice and continuous positive airway pressure (CPAP) machine usage. He/she said the Minimum Data Set (MDS) coordinator is responsible for updating care plans at least quarterly, but any staff can update the care plan. He/She said care plans fell through the cracks, but he/she expects every resident to have a comprehensive person centered care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed ensure three dependent residents (Resident #12, #14, and #51) received the necessary care and services to maintain good grooming and personal hygiene when staff failed to maintain the residents' facial hair and nails, and failed to ensure residents wore clean clothes. The facility census was 47. 1. Review of the facility's Activities of Daily Living (ADL) policy, dated March 2015, showed: -The purpose is to assist the resident in achieving maximum function; Review showed it did not contain direction for staff in regard to shaving, nail care and ensuring residents wear clean clothing. 2. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/6/23, showed staff assessed the resident as: -Severe Cognitive impairment; -Required extensive assistance from one staff member for personal hygiene. Review of the care plan, revised 3/1/22, showed staff documented the resident required maximum assistance with ADLs. Further review showed the resident required assistance keeping his/her hair washed and neat. Review showed it did not contain direction for staff in regard to facial hair or nail care preferences. Observation on 3/6/23 at 10:24 A.M., showed the resident had long hairs on his/her chin and disheveled hair. Observation on 3/8/23 at 4:08 P.M., showed the resident had long hairs on his/her chin, disheveled hair, and uneven yellow nails. Observation on 3/9/23 at 8:45 A.M., showed the resident had long hairs on his/her chin, disheveled hair, and uneven yellow nails. 3. Review of Resident #14's Annual MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited assistance from one staff member for dressing and personal hygiene. Review of the care plan, revised 2/28/22, showed staff documented the resident requires staff assistance with ADLs. Staff are directed to notify the charge nurse if the resident needs his/her fingernails or toenails trimmed. Review showed it did not contain direction for staff in regard to facial hair preferences. Observation on 3/6/23 at 10:30 A.M., showed the resident wore a dirty shirt and had unkempt facial hair and long fingernails. Observation on 3/7/23 at 9:02 A.M., showed the resident wore the same dirty shirt and had unkempt facial hair and long fingernails. Observation on 3/8/23 at 12:33 P.M., showed the resident with a white substance on the front of his/her shirt and long fingernails. Observation on 3/9/23 at 10:02 A.M., showed the resident wore the same dirty shirt and had long fingernails. During an interview on 3/6/23 3:04 P.M., the resident said he/she has unwanted facial hair and long nails and he/she preferred to be clean shaven and for his/her nails to be kept short. He/She said sometimes staff don't offer to shave him/her or trim his/her nails. He/She said he/she has asked staff to shave him/her and trim his/her fingernail, but he/she has been ignored. 4. Review of Resident #51's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance from one staff member for personal hygiene. Review of the baseline care plan, dated 3/6/23, showed staff are directed to assist with ADL care as needed to promote health, hygiene and safety and provide assistance from one staff member for bathing. Review showed it did not contain direction for staff in regard to facial hair or nail care preferences. Observation on 3/6/23 at 10:49 A.M., showed the resident had facial hair on his/her chair and uneven nails. Observation on 3/7/23 at 9:53 A.M., showed the resident had facial hair on his/her chair and uneven nails. Observation on 3/8/23 at 1:54 P.M., showed the resident had facial hair on his/her chair and uneven nails. During an interview on 3/7/23 at 11:59 A.M., the resident said he/she has vision issues and didn't know he/she had facial hair. He/She said it would him/her if he/she has facial hair. He/She said staff has not offered to shave him/her or trim his/her nails. He/She said he/she is bothered by his/her nails being different lengths. The resident said he/she has had a shower since he/she was admitted , but he/she has not been shaved and his/her nails have not been trimmed. During an interview on 3/9/23 at 10:13 A.M., Certified Nurse Aide (CNA) R said residents receive shaves and nail care during their showers. He/She said showers are provided every two to three days and the aides are responsible for completing the showers. The CNA said he/she has seen some residents with long nails and facial hair. He/She said he/she tries to provide care when he/she can, even if it's not the residents shower day. The CNA said the residents' should be changed daily or if it's dirty. He/She said he/she has not noticed resident #14 in the same dirty clothes. He/She said he/she doesn't feel it is dignified for the residents to wear the same dirty clothes, and have unkempt facial hair and long nails. During an interview on 3/9/23 at 10:35 A.M., Registered Nurse (RN) A said residents should receive shaves and nail care during their showers twice a week. The RN said the resident's clothing should be changed in the morning and when dirty. He/She said he/she has noticed Resident #12's facial hair, but he/she has not noticed Resident #14 wearing the same dirty shirt or his/her long finger nails. The RN said he/she clipped the resident 14's fingernails a couple of weeks ago. He/She said staff should notify the nurse if they see residents with long nails, but staff has not notified him/her. The RN said it is disgusting and he/she is ashamed a resident wore the same dirty clothes, and has unkempt facial hair and long nails. During an interview on 3/9/23 at 5:06 P.M., the Director of Nurse (DON) said staff are expected to provide shaves and nail care during the residents' showers twice a week and as needed. The DON said he/she has seen some residents with unkempt facial hair and long nails. The DON said he/she expects staff to offer nail trims or shaves anytime the resident needs it. He/She said the residents' clothes should be change daily and if soiled, and if the resident refuses care it should be documented. He/She said another staff member should attempt to provide the care at another time, or try another approach. He/She said it is not dignified for residents to wear soiled clothing, have unwanted facial hair, and long nails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility staff failed to provide an ongoing program of activities designed to meet the residents' interest during the weekends. Additionally, staff failed to invite dependent residents to activities. The facility census was 47. 1. Review of the facility's Role of the Activity Director, dated March 2012, showed: -The activity director provides a key role in enhancing the quality of a resident's daily life. The activity director plans and promotes meaningful activities based on the resident's interest and desires to provide a more homelike atmosphere in the facility; -Make morning visits to all residents; -Schedule activities that will involve as many residents as possible. Review showed it did not contain direction in regard to weekend activities. 2. Observation from 3/6/23 at 10:00 A.M. through 3/9/23 at 5:00 P.M., showed the March activity calendar with Bingo led by resident as the Saturday activity and Family Day for the Sunday activity. During an interview on 3/8/23 at 2:04 P.M., Resident #19 said when there are weekend activities they are held by resident volunteers. The resident said he/she would participate in weekend activities. During an interview on 3/8/23 at 2:12 P.M., Resident #10 and #15 said they didn't know if the facility offered weekend activities, but if they did, they would participate. During an interview on 3/9/23 at 10:13 A.M., Certified Nurse Aide (CNA) R said the facility offers the residents two activities a day. The CNA said he/she didn't know if activities were offered on the weekends. The CNA said he/she has noticed staff offer to take some of the residents to activities, but not all of the residents. During an interview on 3/9/23 at 10:35 A.M., Registered Nurse (RN) A said the weekend activities include bingo on Saturday and family day on Sunday. The RN said he/she doesn't consider family day an activity, and the facility does not have activity staff on the weekends. He/She said he/she doesn't know if activity staff provides one on one activities. During an interview on 3/9/23 at 1:56 P.M., the Activity Director (AD) said the facility does not have activity staff on the weekends. He/She said the Saturday activities are held by the residents, or staff turns on the television. During an interview on 3/9/23 at 5:06 P.M., the Director of Nursing (DON) said staff doesn't provide activities on the weekends. He/She said activities should be provided on the weekends. 3. Observation on 3/6/23 at 11:17 A.M., showed the AD held an activity with six residents in a dining room on the Special Care Unit (SCU). Further observations, showed all six residents left the activity independently when it was finished. Additional observation showed dependent residents did not attend the activity. Observation on 3/7/23 at 10:02 A.M., showed the AD entered the SCU with an activity cart, and took it to a dining room. Three independent residents joined the activity. Further observation showed the AD went to three other independent resident's rooms and invited them to the dining room for the activity. Additional observations showed the AD didn't invite dependent residents to the activity. During an interview on 3/09/23 at 9:05 A.M., Certified Medication Technician (CMT) E who worked on the SCU said They get the bad end of the stick back here or the shaft, with activities. During an interview on 3/09/23 at 11:45 A.M., RN G said the dependent residents are never invited activities on the unit or on the main halls. He/She said the dependent residents never get to do anything. The RN said it's always the same residents who get to go to activities every day and he/she didn't know why the dependent residents aren't invited. During an interview on 3/9/23 at 1:56 P.M., the AD said he/she attempts to spend one on one time with all the dependent residents in the SCU one to two times a day. 4. Review of Resident #12's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/6/23, showed staff assessed the resident as: -Severe Cognitive impairment; -Required extensive assistance from one staff member for bed mobility; -Required limited assistance from one staff member for transfers. Review of the resident's care plan, revised 3/1/23, showed: -Needs a reminder and assistance to attend activities of his/her choice; -Will attend at least one activity a week; -Needs reminders of the activities that are going on that day; -Needs assistance to attend activities that he/she chooses. Observation on 3/8/23 at 9:30 A.M., showed the resident lay in bed. Further observation, showed the AD asked other residents on the hall if they wanted to join the activity, but did not ask the resident. Observation on 3/8/23 at 12:44 P.M., showed the resident lay in bed. Further observation showed the facility held church services in the day room. Observation on 3/8/23 at 1:15 P.M., showed the resident lay in bed. Further observation showed the AD asked other residents on the hall if they wanted to join the bingo activity, but did not ask Resident #12. Observation on 3/9/23 at 9:39 A.M., showed the resident lay in bed. Further observation showed the facility held an activity in the dining room. 5. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from two staff members for bed mobility and transfers. Review of the resident's care plan, revised 3/1/23, showed: -Needs reminders and assistance to activities of his/her choice; -Will attend at least one activity a week; -Loves singing/church activities; -The AD will provide a one on one activity twice a week. Observation on 3/7/23 at 1:03 P.M., showed the resident lay in bed. Further observation showed the facility held live music in the common area. Observation on 3/8/23 at 1:15 P.M., showed the resident lay in bed. Further observation showed the AD asked other residents on the hall if they wanted to join the bingo activity, but did not ask Resident #21. Observation on 3/9/23 at 9:43 A.M., showed the resident lay in bed. Further observation showed the facility held an activity in the dining room. 6. Review of Resident #32's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required supervision for bed mobility and transfers. Review of the resident's care plan, revised 10/20/22, showed: -Needs to be invited and assistance to attend activities; -Will attend at least one activity each week; -Needs a reminder and assistance to activities of his/her choice; -Loves church activities; -Occasionally likes to go to bingo. Observation on 3/8/23 at 9:30 A.M., showed the resident lay in bed. Further observation showed the AD asked other residents on the hall if they wanted to join an activity, but did not ask Resident #32. Observation on 3/8/23 at 12:44 P.M., showed the resident lay in bed. Further observation, showed the facility held church in the day room. Observation on 3/8/23 at 1:15 P.M., showed the AD asked other residents on the hall if they wanted to join the bingo activity, but did not ask Resident #32. Observation on 3/9/23 at 9:42 A.M., showed the resident sat in the common area while the facility held an activity in the dining room. During an interview on 3/9/23 at 10:35 A.M., RN A said he/she has not seen Resident #12. #21 or #32 attend activities. He/She didn't know if the AD asked the residents if they wanted to participate in activities. During an interview on 3/9/23 at 1:56 P.M., the AD said he/she didn't invite residents to activities if they were asleep. The AD said he/she didn't invite Resident #12, #21 and #32 to the activities because they were asleep. During an interview on 3/9/23 at 5:06 P.M., the DON said staff are expected to assist all dependent residents to activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when they failed to properly propel three residents (Resident's #14, #37, #53) in wheelchairs and failed to use a gait belt and the required number of staff when transferring two residents (Resident #21 and #43). The facility census was 47. 1. Review of the facility's Wheelchair Use Of policy, dated March 2015, showed: -The purpose is to provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living; -Lower footrests and place resident's feet on footrests if used; -Encourage and instruct resident in proper guidelines for safely propelling the wheelchair. 2. Review of Resident #14's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/17/22, showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited assistance from one staff member for locomotion on and off unit; -Used a wheelchair. Observation on 3/8/23 at 11:05 A.M., showed Certified Medication Technician (CMT) Q propelled the resident down the hallway and into the dining room without the use of foot pedals. The resident lifted their feet to keep them off the floor. 3. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from one staff member for locomotion on and off the unit; -Used a wheelchair. Observation on 3/8/23 at 9:20 A.M., showed Certified Nurse Aide (CNA) M propelled the resident down the hallway with one foot pedal on the wheelchair. Further observation showed the resident had both feet on the foot pedal. Additional observation showed one of the resident's feet fell off the pedal, and bounced on the floor. The CNA propelled the resident as he/she held his/her foot up. 4. Review of Resident #53's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required supervision and setup help for locomotion on the unit; -Required extensive assistance from one staff member for locomotion off the unit; -Used a wheelchair. Observation on 3/6/23 at 2:58 P.M., showed an unidentified staff member propelled the resident down the hallway without foot pedals on the wheelchair. During an interview on 3/9/23 at 10:13 A.M., CNA R said staff should use foot pedals when propelling residents in their wheelchairs. He/She said if staff didn't use foot pedals the resident could fall, or be injured. During an interview on 3/9/23 at 10:35 A.M., Registered Nurse (RN) A said staff should use foot pedals when propelling residents in their wheelchairs. The RN said he/she has noticed the staff propelling residents without foot pedals and he/she has reminded the staff to use foot pedals. The RN said if staff don't use the foot pedals the resident could fall out of the wheelchair and get injured. During an interview on 3/9/23 at 5:06 P.M., the Director of Nursing (DON) said staff are expected to use foot pedals when propelling residents. He/She the staff had an in-service a couple of weeks about on safely propelling a resident in a wheelchair. He/She said if staff don't use foot pedals the resident could fall or be injured. 5. Review of the facility's Transfer Activities Policy, dated March 2015, showed: -Purpose: To transfer the resident safely; -Obtain assistance from another individual if necessary for safe transfer; -Put on gait belt and shoes; -Grasp resident around the waist, supporting the back and head, and rise to a standing position; -Support may be provided by the use of a waist belt; -Do not allow the resident to fall into the chair; -Lower the footrests, placing the resident's feet on them. 6. Review of Resident #21's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from two staff members for bed mobility and transfers. Review of the resident's care plan, revised 7/19/22, showed the resident required maximum assistance from one to two staff members for transfers and bed mobility. Further review, showed staff are directed to use a gait belt during transfers. Observation on 3/7/23 at 10:47 A.M., showed CNA M entered the resident's room to provide care and transferred the resident from his/her wheelchair to the bed without the use of a gait belt. During an interview on 3/7/23 at 11:02 A.M., CNA M said he/she didn't always use a gait belt to transfer the resident. He/She said he/she wasn't told to use a gait belt. The CNA said the resident is a one to two person assistance depending on the resident's mood. He/She said he/she didn't know what the resident's care plan said in regard to transferring the resident. During an interview on 3/9/23 at 4:55 P.M., RN A said staff should use a gait belt to transfer the resident. The RN said the resident requires assistance from one to two staff members depending on the resident's mood. He/She said he/she didn't know staff were not using a gait belt when transferring the resident. The RN said the resident could be injured if the gait belt is not used during transfers. 7. Review of Resident #43's Quarterly MDS,a federally mandated assessment tool, dated 11/30/22, showed staff assessed the resident as: -Moderate Cognitive Impairment; -Required extensive assistance from two staff members for bed mobility; -Totally dependent on two staff members for transfers; -Did not walk in room or corridor; -Required extensive assistance from one staff member for locomotion; -Used a wheelchair; -Had diagnoses of Anemia, Dementia, chronic pain, and repeated falls. Review of the resident's care plan, dated 1/31/23, showed staff documented: -Resident requires assistance from two staff members for transfers; -Resident uses a wheelchair propelled by staff. Observation on 3/7/23 at 11:43 A.M., showed CNA I entered the resident's room, provided care, sat the resident on the edge of the bed, did not apply a gait belt, held the resident's hands and assisted the resident to stand with white cotton socks on. Further observation showed the resident yelled out as the CNA leaned back, pulled the resident's arms, and sat him/her in a wheelchair as his/her knees buckled. Additional observation showed the CNA propelled the resident from his/her room to the dining room without foot pedals, and the resident's feet slid on the floor. During an interview on 3/7/23 at 11:43 A.M., CNA I said he/she transfers the resident by himself/herself because the resident can stand up and walk. The CNA said the resident's socks were not non-skid socks, and he/she didn't know if the resident had any. He/She said the transfer was not safe, and he/she didn't have a gait belt so he/she didn't use one. The CNA said he/she would do things correctly if he/she had more time. During an interview on 3/9/23 at 4:55 P.M., RN A said staff should use a gait belt when transferring a resident to prevent injury to the resident and/or the staff member. He/She said it is not safe to transfer a resident without a gait belt. During an interview on 3/9/23 at 5:06 P.M., the DON said staff are expected to follow the resident's care plan and use the number of staff directed when transferring a resident. He/She said staff know they should use a gait belt when transferring resident #21.

Based on observation, interview, and record review, facility staff failed to maintain a correct count of controlled medications stored in the facility. The facility census was 47. 1. Review of the facility's Narcotic Count Policy, date March 2012, showed: -Staff are 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 narcotics supply for each individual resident at the change of each shift; -Narcotic records are reconciled by a physical count of remaining narcotic supply at each shift change by the incoming and outgoing licensed nurse, and the record retained for at least one year; -One prescription for a controlled substance is entered on one individual narcotic sheet; -If the count is not accurate, the nurse going off duty is to remain on duty until the count is reconciled and the Director of Nursing (DON) must be notified for further instruction. 2. Review of Resident #201's Controlled Drug Record, dated 2/17/23, showed the facility received 30 milliliters (mL) of Dilaudid (a narcotic pain medication) on 2/17/23, and administered a dose of 0.5 mL on 2/19/23. Review showed staff documented the resident had 29.5 mL left in the bottle. Further review showed staff did not document the controlled medication had been counted since 2/19/23. Observation on 3/6/23 at 2:20 P.M., showed the medication room had a double locked cabinet that contained controlled medications to be destroyed. Further observation showed 25 mL of Dilaudid in the resident's medication bottle. Review of the facility's Controlled Drug Log, showed it did not contain a Controlled Drug Record for six controlled medications, stored in the facility's medication destruction cabinet. 3. Observation on 3/6/23 at 2:20 P.M., showed the following controlled medications stored in the destruction cabinet: -40 1 milligram (mg) tablets of Ativan (controlled anxiety medication); -Seven 12 microgram (mcg) Fentanyl (controlled narcotic pain medication) patches; -167 0.5 mg tablets of Clonazepam (controlled anxiety medication); -25 mL of Dilaudid; -26 5 mg tablets of Methadone (controlled medication similar to morphine). During an interview on 3/6/23 at 2:30 P.M., CMT S said staff count the amount of cards and bottles in the destruction cabinet at all shift changes. He/She said staff do not make sure the amount of pills and liquid is correct. The CMT said staff are supposed to count the amount of medication that remains including the pills. The CMT said there was 22 or 23 mL of Dilaudid left in the resident's bottle. The CMT said that is a major discrepancy with the controlled log, and he/she needed to go get the Director of Nursing (DON). During an interview on 3/06/23 at 3:13 P.M., The DON said there is 24 to 25 mL of Dilaudid in the resident's bottle. The DON said he/she will investigate, but said it appears someone forgot to sign the medication out when it was administered. The DON said staff are expected to count the controlled medications at every shift change and when they give the keys to another staff member. He/She said staff don't typically count the overstock medications or the medications set aside to be destroyed. The DON said staff always just count the medication cards, to make sure the right number remain. He/She said the process for counting the controlled medications due for destruction needs to change. During an interview on 3/09/23 11:45 AM, RN G said staff should count controlled medications due to be destroyed. The RN said staff are supposed to count the quantity of pills, or liquid with controlled medications.

Based on observation, interview and record review, the facility staff failed to change gloves and perform hand hygiene as often as necessary to prevent cross-contamination. Facility staff also failed to clean and sanitize soiled utensils between uses to prevent cross-contamination. The facility census was 47. 1. Review of the facility's Glove Use policy, dated May 2015, showed the policy directed staff to remove their gloves and wash their hands when they change or walk away from a specific task. Review also showed the policy directed staff to wash their hands after they dispose of trash or food, after handling dirty dishes, after they pick up anything from the floor, when they change tasks, and any other time deemed necessary. Observation on 03/09/23 from 7:00 A.M. to 7:26 A.M., showed Registered Nurse (RN) A prepared plates of food for residents in the main dining room with gloved hands. Observation showed while he/she wore the same gloves, the RN: -picked up a pizza cutter from the countertop, used the pizza cutter to cut up multiple food items on a resident's plate while he/she held the food down on the plate with his/her gloved hands and returned the pizza cutter to the countertop; -obtained packets of jelly and butter from containers on the countertop; -picked up a knife from the countertop, used the knife to spread the jelly and/or butter on toast, waffles, pancakes and biscuits while holding them with his/her gloved hands and set the knife back onto the countertop; -picked up the bottle of pancake syrup and poured syrup onto waffles and pancakes; -served the plates of food to residents. Observation showed the RN repeated this process while he/she wore the same gloves for multiple plates of food served to residents during this time. Observation showed the RN's gloves visibly soiled with grease and food debris. During an interview on 03/09/23 at 7:26 A.M., the RN said he/she had been trained on when and how to wash his/her hands. The RN said gloves should be changed and hand hygiene preformed when gloves become contaminated. The RN said he/she did not change his/her gloves because he/she just touched the same things over and over. The RN said he/she had prepared plates for residents the same way for 18 years and no one had ever gotten sick because of it. Observation on 03/09/23 at 7:30 A.M. showed Dietary Aide (DA) B lifted the trash can lid in the mechanical dishwashing station with his/her bare hands to dispose of trash and, without performing hand hygiene, obtained a container of juice from the refrigerator, poured the juice in a glass and then handed the glass to staff to serve to a resident. Observation showed the DA continued to prepare drinks for service to the residents without performing hand hygiene. Observation on 03/09/23 at 10:02 A.M., showed DA B washed dirty dishes at the mechanical dishwashing station. Observation showed, without performing hand hygiene, the DA put away sanitized dishes from the clean side of the dishwashing station. During an interview on 03/09/23 at 9:52 A.M., the Dietary Manager (DM) said staff should wash their hands anytime they touch anything soiled and between tasks which would include when they go from the dirty side of the dishwashing station to the clean side. The DM said a trash can lid would be considered dirty and staff should wash their hands after they touch the trash can lid. The DM said if staff member dropped an ice scoop on the floor and picked it up, he/she would expect staff to wash their hands after they picked up the ice scoop. The DM also said if gloves become soiled, staff should remove the gloves and wash their hands. The DM said all staff are trained on handwashing procedures. During an interview on 03/09/23 at 10:18 A.M., the administrator said staff should perform hand hygiene between contact with different residents, between tasks and when they become soiled. The administrator said items dropped on the floor and a trash can lid would be considered something soiled and staff should perform hand hygiene if they touch them. The administrator also said staff should not wear the same gloves for multiple tasks and they should perform hand hygiene after they remove their gloves. 2. Review of the facility's Handling Ice Scoop policy, dated May 2015, showed the policy directed staff to sanitize the ice scoop and tray/container through the dishwashing machine a minimum of once daily and the ice scoop is to be stored according to state regulations. Observation on 03/07/23 at 11:35 A.M., showed CNA I obtained the ice scoop from the container on the counter in the secured memory care dining room and dropped the ice scoop on the floor. Observation showed the CNA picked the ice scoop up from the floor, set it on the counter, opened cabinets and drawers, looked around and then, without cleaning and sanitizing the ice scoop, used the scoop that he/she dropped on the floor to scoop ice from the cooler into a glass, poured a can of soda into the glass and served the glass to Resident #16. Observation showed the CNA then placed the soiled ice scoop back into the container. Observation on 03/07/23 at 12:00 P.M., showed CMT H removed the soiled ice scoop from the container and used it to portion ice from the cooler into glasses of tea and water for service to all the residents of the secured memory care unit at the lunch meal. During an interview on 03/07/23 at 12:00 P.M., CMT H said he/she got the ice scoop from the container on the counter and did not wash the ice scoop before he/she used it to put ice in the resident drink glasses. The CMT said he/she probably should have washed the ice scoop before use because so many of the residents on the unit wander and touch things. During an interview on 3/07/23 at 1:40 P.M., CNA I said he/she would of normally gotten another scoop and he/she did not wash the ice scoop, because he/she was not thinking straight. During an interview on 03/09/23 at 9:20 A.M., the DM said if staff drop an ice scoop on the floor, the ice scoop should be washed before it is used again. During an interview on 03/09/23 at 10:13 A.M., the administrator said if staff drop a utensil on the floor, the utensil should be washed before it is used again. 3. Review of the facility's Sanitizing The Three-Compartment Sink policy, dated May 2015, showed the policy directed staff to submerge dishes in the sanitizing solution for one to two minutes after they washed and rinsed. Observation on 03/09/23 at 6:33 A.M., showed a quaternary ammonium (QUAT) sanitizer connected to the dispenser at the three-compartment sink and the third compartment of the sink filled with a sanitizing solution. Observation also showed DA C washed dishes in the three-compartment sink and after he/she washed and rinsed the dishes, he/she placed the dishes in the sanitizing solution, immediately removed them and placed them on the drain counter. Observation on 03/09/23 at 9:18 A.M., showed DA C washed dishes in the three-compartment sink. Observation showed after the DA washed and rinsed the dishes, he/she placed the dishes in the sanitizing solution, immediately removed them and placed them on the drain counter. Review of QUAT sanitizer's product label showed instruction to completely immerse food contact surfaces in a 200 to 400 parts per million active QUAT solution for at least 60 seconds before the items are removed to drain and dry. During an interview on 03/09/23 at 9:20 A.M., the DM said manually washed dishes should be placed in the sanitizing solution for two minutes before they are removed to dry. The DM said the DA had worked at the facility since October 2021 and had been trained to let the dishes stay in the sanitizer. During an interview on 03/09/23 10:13 AM, the administrator said staff should leave manually washed dishes in the sanitizer for one minute and staff should be trained on that requirement. 4. Review of the 2017 United States Food and Drug Administration Food Code, showed: -3-302.11 (A) Food shall be protected from cross contamination by: (3) Cleaning equipment and Utensils as specified under paragraph 4-602.11(A) and sanitizing as specified under subsection 4-703.11; -4-602.11(A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. -4-703.11 After being cleaned, equipment food-contact surfaces and utensils shall be sanitized in: (A) Hot water manual operations by immersion for at least 30 seconds and as specified under subsection 4-501.111; (B) Hot water mechanical operations by being cycled through equipment that is set up as specified under subsections 4-501.15, 4-501.112, and 4-501.113 and achieving a utensil surface temperature of 71 degrees Celsius (160 degrees Fahrenheit) as measured by an irreversible registering temperature indicator; or (C) Chemical manual or mechanical operations, including the application of sanitizing chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under subsection 4-501.114. Observation on 03/09/23 from 7:00 A.M. to 7:26 A.M., showed Registered Nurse (RN) A prepared plates of food for residents in the main dining room. Observation showed the RN picked up a pizza cutter from the countertop, used the pizza cutter to cut up multiple food items on a resident's plate, which included undercooked eggs, and then returned the pizza cutter to the countertop. Observation showed the pizza cutter covered with undercooked egg yolk. Observation also showed the RN picked up a knife by the pizza cutter on the countertop, used the knife to spread jelly and/or butter on toast, waffles, pancakes and biscuits and then set the knife back onto the countertop by the pizza cutter before he/she served the plates of food to residents. Observation showed the RN repeated this process using the same soiled pizza cutter and knife to prepare multiple plates of food served to residents during this time. During an interview on 03/09/23 at 9:20 A.M., the DM said he/she could not locate a policy for when staff should change or wash food preparation utensils. The DM said staff should use a separate utensil for each different food item instead of the same utensil if they need to cut up foods and he/she thought staff knew that. During an interview on 03/09/23 at 10:13 A.M., the administrator said staff should use a different utensil for different food items to prevent cross-contamination and staff should be trained on that requirement.