**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure one resident (Resident #3) out of 18 sampled residents who required continuous oxygen received continuous oxygen as ordered by the physician. Facility staff failed to store oxygen tubing and nebulizer masks in a manner to prevent respiratory infection for two residents (Resident #3 and #52) out of 18 sampled residents. The facility census was 52. 1. Review of the facility's Oxygen Therapy Policy, undated, showed all oxygen and nasal cannula tubing should be stored in a plastic bag, that is attached to oxygen concentrator, or E-tank (portable oxygen tank), when not in use. Review of the facility's Nebulizer Treatment policy, undated, showed staff should store nebulizer cannula and tubing in a plastic bag at bedside, with the resident's name and date the equipment was changed. 2. Review of Resident #'3 Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/17/24, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required moderate assist from staff for bathing, dressing, personal hygiene, bed mobility, transfers and ambulation in wheelchair; -Did not use oxygen; -Diagnosis of Dementia, asthma and respiratory failure. Review of the resident's Physician Order Sheet (POS), dated June 2024, showed physician orders: -Oxygen at two Liters Per Minute (LPM) per nasal cannula continuously, keep oxygen saturation above 92%, every shift for shortness of breath; -Budesonide Inhalation Suspension 0.5 milligrams (mg)/2 milliliters (ml), one vial inhale orally via nebulizer every 12 hours for 14 days. Review of the resident's care plan, dated 06/17/24, showed the care plan did not address the resident oxygen use and nebulizer use. Review of the resident's nurse's note, dated 5/23/24, showed Registered Nurse (RN) I documented the resident with diminished and coarse lung sounds. X-ray results state pneumonia and bronchitis. Review of the resident's face sheet, undated, showed staff documented the resident had a new diagnosis of pneumonia on 05/26/2024. Observation on 06/17/24 at 2:32 P.M., showed the resident in his/her room. The resident wore oxygen via nasal cannula from an oxyen concentrator. Observation showed an oxygen tank sat on the back of the resident's wheelchair with an unbaggged and uncovered nasal cannula wrapped around the tank. Observation 06/18/24 at 8:06 A.M., showed the resident not in his/her room. The resident's oxygen concentrator is on and the oxygen tubing and cannula laid directly on the resident's bed pad and sheets. The tubing is not bagged or covered. Observation on 06/18/24 at 8:52 A.M., showed the resident in his/her wheelchair, in his/her room. The resident wore oxygen from the tank on the back of his/her wheelchair. Certified Nurse Aide (CNA) B entered the resident's room to assist the resident to bed. The CNA assisted the resident from the wheelchair to the bed. The resident continued to wear oxygen tubing from the tank on the back of the wheelchair. The CNA picked up the oxygen tubing and nasal cannula from the resident's bed and placed the nasal cannula and oxygen tubing on the bedside table. The CNA then took the oxygen tubing from the tank off of the resident and placed it over the handle of the wheelchair. The CNA moved the wheelchair across room, placed the call light over the resident's lap and left the room. The CNA did not bag or cover the oxygen tubing or nasal cannula over the wheelchair handle or the tubing on the bedside table. The CNA did not place the nasal cannula from the concentrator on the resident before he/she left the room. Observation on 06/19/24 at 9:23 A.M., showed the resident in his/her bed with the nasal cannula from the concentrator in his/her nose, with wheelchair out of reach. The oxygen tank on the back of the wheelchair, has the oxygen tubing and nasal cannula hung over the handle, the tubing and nasal cannula are not bagged or covered. The nasal cannula hung an inch from the floor. Licensed Practical Nurse (LPN) N entered the resident's room and checked the resident's oxygen saturation. The resident has a nebulizer mask on his/her nightstand out of reach, it is not bagged or covered. No bags observed in the resident's room for oxygen tubing or nebulizer mask. The LPN left the resident's room and did not place the resident's oxygen tubing or nebulizer mask in a bag. Observation on 06/19/24 at 11:07 A.M., showed CNA K assisted the resident out of bed and into a wheelchair. The CNA placed the resident's oxygen tubing and nasal cannula on the sheet of the resident's bed. The resident asked to use the restroom. The CNA assisted the resident to the restroom without his/her oxygen. The CNA placed the resident in a new wheelchair without an oxygen tank, and propelled the resident out of his/her room. The CNA left the oxygen tubing from concentrator on the resident's bed, not bagged or covered and the oxygen tank tubing over the other wheelchair not bagged or covered. The CNA propelled the resident passed the nurse's station where LPN N sat and into the dining room with activities and left the resident without his/her oxygen. The resident repeatedly opened his/her mouth, yawned and took multiple deep breaths. During an interview on 06/19/24 at 11:26 A.M., the resident said he/she feels short of breath, but he/she is not able to run down to his/her room to get his/her oxygen. Observation on 06/19/24 at 11:32 A.M., showed the resident propelled himself/herself in his/her wheelchair to another dinning room table. The resident took deep breaths, opened his/her mouth wide and gasped for air multiple times. Observation on 06/19/24 at 11:37 A.M., showed LPN N entered the dining room and asked the resident where is his/her oxygen. The LPN said to the resident, he/she is supposed to be on continuous oxygen and the resident's hands are really cold. The LPN left the dining room, returned with an oxygen tank and placed the resident on oxygen. During an interview on 06/19/24 11:42 A.M., CNA K said he/she did not know the resident received continous oxygen. The CNA said he/she thought oxygen was only given in the resident's room. The CNA said information doesn't get passed down to the aides very well. Observation on 06/20/24 at 7:41 A.M., showed CNA K propelled the resident down the 300 hall with the oxygen tank on the back of the resident's wheelchair. Oxygen tubing and nasal cannula hung over the oxygen tank. The resident did not have oxygen in place. Observation on 06/20/24 at 10:05 A.M., showed the resident in bed, with nasal cannula from concentrator in his/her nostrils. Over 10 feet of oxygen tubing laid directly on the floor, with debris around the tubing. A nebulizer mask laid on the nightstand not bagged or covered. Observation on 06/20/24 at 10:09 A.M., showed Restorative Aide (RA) E switched the oxygen tank on the resident's old wheelchair to the resident's new wheelchair in the hallway, outside of the resident's room. The RA then took the wheelchair with the oxygen tank, back into the resident's room and the left the resident's room. The wheelchair is out of reach of the resident. The oxygen tubing is not bagged or covered. During an interview on 06/20/24 at 1:05 P.M., the RA said there should be plastic bags on the concentrators or tanks and staff are supposed to put the oxygen tubing in the plastic bag. The RA said he/she wasn't thinking, because there wasn't a plastic bag on the tank. The RA said he/she didn't think to get a plastic bag, normally he/she would go get a bag and label it, then put the tubing in it. The RA said not putting the nasal cannula in a bag creates the risk of infection. The RA said the resident has had a respiratory infection, but he/she doesn't know any details. The RA said nebulizer masks should have a plastic bag, not sure why it wasn't bagged, but he/she didn't notice it. The RA said excess oxygen tubing is not supposed to be on the floor, it needs to be picked up. The RA said he/she did notice all of the resident's excess tubing on the floor, and he/she probably should have picked it up. Observation on 06/20/24 at 11:32 A.M., showed the resident in bed with his/her call light on. The resident had oxygen on via concentrator and nasal cannula is in the resident's nostrils. CNA K entered the resident's room and took the nasal cannula out of the resident's nose and placed the nasal cannula directly on the sheet of the resident's bed. The back of the resident's pants are wet. The sheet the CNA placed the nasal cannula on had pieces of debris and had wet spots. The CNA propelled the resident out of room and left the resident's nasal cannula on the dirty sheets and the nebulizer mask on the end table not bagged or covered. During an interview on 06/20/24 at 11:49 A.M., CNA K said he/she doesn't even know what he/she is supposed to do with oxygen tubing. The CNA said he/she also doesn't know what to do with nebulizer masks either. The CNA said he/she just tries to keep it off the floor. The CNA said he/she doesn't bag or cover oxygen tubing or nebulizer masks at all, there isn't even a bag in the resident's room. During an interview on 06/20/24 at 1:00 P.M., the Director of Nursing (DON) said the resident used to have a bag in his/her room for oxygen tubing. The DON said he/she doesn't know what happened to it. 3. Review of Resident #52's Significant MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent on staff for dressing, bed mobility, transfers and ambulation in wheelchair; -Required maximal assist from staff for bathing and personal hygiene; -Frequent incontinence of bowel and bladder; -Did not use oxygen. Review of the resident's POS, dated June of 2024, showed physician orders: -Oxygen at two LPM via nasal cannula every 24 hours as needed for shortness of breath; -Ipratroplum-Albuterol Inhalation Solution 0.5-2.5 MG/3 ML, 3 ML inhale orally four times a day for Pneumonia for five days. Review of the resident's nurse's notes, dated 06/19/24, showed staff documented the resident received antibiotics for pneumonia. Review of the resident's care plan, dated 06/18/24, showed staff documented the resident has oxygen therapy due to ineffective gas exchange. Observation 06/18/24 at 8:20 A.M., showed the resident in a reclined wheelchair in the dining room. Observation showed the resident's oxygen tubing and nasal cannula from the concentrator are on the resident's bed, not bagged or covered. Observation on 06/18/24 at 9:54 A.M., showed the resident's Broda chair with an oxygen tank on the back of the chair. The oxygen tubing and nasal cannula to the tank hung over the tank and not bagged or covered. Observation on 06/19/24 at 9:34 A.M., showed the resident's reclined wheelchair in the residents room with an oxygen tank on the back of the wheelchair. Observation showed the oxygen tubing and nasal cannula hung over the oxygen tank not bagged, or covered. The resident's nebulizer mask is out of the resident's reach on the bedside table and is not bagged, or covered. The nebulizer is not on and it had liquid in the container. Observation on 06/19/24 at 11:53 A.M., showed the residents the oxygen tubing and nasal cannula from concentrator hung over the bed by the headboard and the cannula touched the frame of the bed. Observation showd the tubing and nasal cannula not bagged or covered. CNA K entered the room and removed the nebulizer mask from the resident and placed the nebulizer mask and machine back on the nightstand. The CNA did not bag or cover the nebulizer mask, or oxygen tubing on the resident's bed. 4. During an interview on 06/20/24 at 1:11 P.M., LPN N said oxygen tubing should be rolled up and placed on a higher table so its not on the floor. The LPN said he/she thinks the nebulizer mask should be put up on the machine. The LPN said excess oxygen tubing should not be on floor and if it touches the floor staff should get a new one. The LPN said if oxygen tubing on the tanks is not in use, it should be off the floor and wrapped around the tank. The LPN said putting oxygen cannulas on a resident's sheet could contaminate it. There would be a risk of infection if it gets dirty and the resident breaths it in. The LPN said he/she did know if oxygen tubing should be stored in a bag when not in use. The LPN said he/she knew nebulizer masks should be bagged. The LPN said he/she does not know why the residents did not have bags for their oxygen and nebulizer tubing and masks. The LPN said he/she did see Resident #3's oxygen tubing on the floor yesterday, he/she picked it up and placed on the table. The LPN said he/she didn't think to replace the oxygen tubing, he/she was busy. During an interview on 06/20/24 at 2:46 P.M., the DON said oxygen tubing should be kept off the floor and maintained in bags for coverage. The DON said he/she wants staff to curl up the oxygen tubing and ensure it is not on the floor, if a bag is not available. The DON said the staff can put the oxygen tubing on the bedside table and go get a bag. The DON said he/she expects staff to do the same thing for nebulizer masks and oxygen tubing for oxygen tanks. The DON said if oxygen tubing is on floor, staff need to roll it up and place on the bedside table, or bed, staff don't have to get new tubing unless its the nasal cannula touching the floor. The DON said he/she does not know why there is not bags in the resident rooms for oxygen tubing and nebulizer masks. The DON said there is a problem with keeping the bags in the resident rooms. The DON said he/she would have to look up Resident #3's order for oxygen. The DON said if a resident is on continuous oxygen, staff would have to remove the nasal cannula for changing clothes or transfers, but for the majority of the time the resident should be on oxygen. The DON said he/she expects the use of oxygen to be on a resident's care plan.

Based on observation, interview, and record review, facility staff failed to store medications in a safe manner when staff failed to ensure expired medications and supplies were not stored with current resident medications, and failed to ensure all medications and treatments were labeled in two out of four medication carts. Additionally, staff failed to ensure medications were not lose in one medication cart. The facility census was 52. 1. Review of the facility's Storage of Medications, dated April of 2007, showed drugs and biologicals shall be stored in packaging, containers or other dispensing systems in which they are received. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner. Drug containers that have missing, incomplete, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Drugs shall be stored in an orderly manner in carts. Each resident's medications shall be assigned to a cubicle, drawer or holding area to prevent the possibility mixing medications of several residents. 2. Observation on 06/18/24 at 3:13 P.M., showed the 200 hall medication cart contained: -One bag of 24 adhesive tape remover pads with an expiration date of of 11/2022; -Three tubes of Diclofenac Sodium 1% topical gel (used to relieve pain from arthritis) with the label removed; -One red rubber urethral catheter with an expiration date of 4/25/24; -One Eucerin topical cream with an expiration date of 10/20/22; -One Urea 20 intensive hydrating cream (lotion) unable to read label script or expiration date and one tube with an expiration date of 04/2024; -Three laxative 10 milligram (MG) suppository without a label script; -14 Acetaminophen 650 mg suppositories laying in drawer not in original container; -Three Albuterol sulfate/ Ipratropium Bromide (helps control symptoms of lung diseases, such as asthma, chronic bronchitis and emphysema) .0.5mg-3mg per 3 milliliters (ml) tubes without a label; -One bottle of vitamin C 250 MG, with an expiration date of 1/2024; -One bottle of Alcohol-free liquid skin prep with an expiration date of 01/19/2024; -Two vials of Haldol (antipychotic medication) 5 mg per ml, with an expiration date of 05/24 and without a label; -Two tubes of Diclofenac Sodium 1% topical Gel stored in a bag with two different resident's names; -Two boxes of omnifix (tape ideal for dressing retention on joints) with an expiration date of03/2024; -Roll of omnifix without a box without an expiration date; During an interview on 06/19/24 at 10:27 A.M., RN I said he/she doesn't check the medication cart often enough for expired medications, the facility needs to institute a policy for that. The RN said if a medication is missing a label or is unreadable staff should call the pharmacy for a new label. The RN said there should be dividers between residents medications and residents creams are in separate bags. The RN said he/she was not aware that two different resident's creams were stored in the same bag, they should not be. The RN said he/she never puts open dates on inhalers, he/she doesn't think it changes the expiration date. The RN said medications should stay in the original box, until used, he/she does not know why they medications are out of their box in the medication cart. The RN said to his/her knowledge you don't have to put an open date on eye drops. 3. Observation on 06/18/24 at 4:23 P.M., of 100/300 medication cart contained: -One Fluticasone Propionate/Salmeterol Diskus inhalation powder (prescription medication used to treat asthma and chronic obstructive pulmonary disease) 250-50 Micrograms (MCG) open, opened and without an open date; -One Trelegy (prescription medication used to treat asthma and chronic obstructive pulmonary disease) 100 MCG/62.5 MCG/25 MCG opened and without an open date; -One Fluticasone/Salmeterol AER 250/50 opened and without an open date; -One Trelegy 100 MCG/62.5 MCG/25 MCG opened and without an open date; -One Breo Ellipta inhaler (combination medication inhaler for the treatment of chronic obstructive pulmonary disease) 100-25 opened and without an open date; -One Anoro Ellipta AER (combination medication inhaler for the treatment of chronic obstructive pulmonary disease) 62.5-25 opened and without an open date; -One Latanoprost Solution .005 % (treats high pressure inside the eye and helps treat glaucoma) opened and without an open date; -27 unidentified loose pills in the bottom of the medication care drawers. During an interview on 06/19/24 at 4:39 P.M., CMT Q said there is not a schedule to clean out expired medications in the carts. The CMT said staff are supposed to put open dates on eye drops and inhalers, he/she tells all new staff and they don't listen to him/her. The CMT said he/she has gone to management and they do not do anything about it. The CMT said staff should destroy medications that the script has been torn off, or fell off of. The CMT said prescription creams should have dividers to keep them from touching each other. The CMT said Albuterol should remain in the original box with the script until used, or staff wouldn't know whose they are. The suppositories should remain in the original box until used. The CMT said resident medication cards are packed in the drawer and pills will fall out when staff push them in the drawer.

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 53. Review of the facility provided policies, showed the records did not contain a policy related to the qualifications for Director of Food and Nutrition Services. Review of the dietary manager's (DM) personnel records showed a hire date for the DM position listed as 01/04/24. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 06/19/24 at 8:05 A.M., the DM said he/she had been the DM for about a year, and he/she did not have prior experience as a dietary manager in a nursing facility and he/she did not have a degree or certification related to food service management. The DM said he/she started certification classes through the facility's consultant registered dietician (RD) in December 2023, but only had two or three classes before the RD had to stop the classes for unknown reasons. The DM said the RD only works part-time and the facility did not have any certified or clinically qualified nutritional staff employed full-time. During an interview on 06/19/24 at 9:03 A.M., the administrator said, although the DM had been the interim DM since the previous DM left last year, he/she did not officially appointed the DM as the manager until 01/04/24. The administrator said the DM began certification classes with the facility's part-time consultant RD, but the RD had to postpone the classes due to his/her own staffing issues. The administrator said he/she placed ads to find a qualified DM upon the advisement of the RD, but they had not been able to hire a qualified DM to date. The administrator said he/she knew that the DM did not have the qualifications required for the position and the facility did not have any certified or clinically qualified nutritional staff employed full-time.

**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 and clean. The facility census was 52. 1. Review of the policies provided by the facility showed they did not contain a policy for environmental concerns. Observation on 4/4/23 at 11:35 A.M. showed room [ROOM NUMBER] with an unpainted dry wall patch approximately two feet in length behind the bed. Observation on 4/4/23 at 3:09 P.M., showed Resident #50's room with gouges on the wall behind the bed. Further observation showed gouge marks and black marks on the wall at the foot of the bed. Observation on 4/5/23 at 10:01 A.M., showed Resident #1's room with food and debris on floor, and gouges on the wall behind the bed. Further observation showed the resident's bedside table, and refrigerator with a thick layer of dust. During an interview on 4/5/23 at 10:01 A.M., Resident #1 said staff don't clean his/her room enough. The resident said hasn't cleaned his/her room in at least three days. Observation on 4/6/23 at 9:05 A.M., showed Resident #33's bed rested against the wall in his/her room. Further observation showed an unsanded dry wall patch approximately four feet in length behind the bed. Observation on 4/5/23 at 10:22 AM., showed room [ROOM NUMBER] with a dirty floor and brown marks on the shower floor and shower chair. Further observation showed black marks on the walls and the door trim. Observation on 4/7/23 at 10:47 A.M., showed the room with a dirty floor and brown marks on the shower floor and shower chair. Further observation showed black marks on the walls and the door trim. Observation on 4/6/23 at 8:28 A.M., showed room [ROOM NUMBER] with debris on the floor and bedside table, and a white substance on the seat and arm of the resident's chair. Further observation showed the walls with gouges, chipped paint and black marks. Observation on 4/7/23 at 10:47 A.M., showed the room with debris on the floor and bedside table, and a white substance on the seat and arm of the resident's chair. Further observation showed the walls with gouges, chipped paint and black marks. During an interview on 4/7/23 at 9:28 A.M., the Maintenance Director said staff should document environmental concerns on the form hanging on the wall. He/She said he/she conducts monthly room audits, and is currently working on repairing the rooms on the 200 hall. The Maintenance Director said he/she completed repairs on the 300 hall about two months. He/She said staff has not reported any issues in room [ROOM NUMBER] or 304. During an interview on 4/7/23 at 10:07 A.M., Certified Nurse Aide (CNA) N and CNA O said staff should report environmental and housekeeping concerns to the charge nurse. They said they had not noticed the any rooms with holes or gouges in the walls. During an interview on 4/07/23 at 10:26 A.M., the Housekeeping Supervisor said the resident's rooms are cleaned daily. He/She said the housekeepers have a cleaning list they fill out daily and turn in to him/her, and she checks the rooms before he/she leaves for the day. He/She said the rooms including the bathrooms should be dusted, wiped down and sanitized, swept, and mopped daily. The Housekeeping Supervisor said staff should report any needed room repairs by filling out the maintenance for on the clipboard. During an interview on 4/7/23 at 10:13 A.M., Registered Nurse (RN) H said staff should report environmental issues to the Maintenance Director or document the information on the clipboard. He/She said staff should notify housekeeping or clean up messes if they see them. During an interview on 4/7/23 at 10:47 A.M., the Housekeeping Supervisor said he/she doesn't know who is responsible to clean the chair in room [ROOM NUMBER]. He/She said she/he just cleaned the floor yesterday, and noticed the debris around the chair and the bedside table. He/She said he/she has not cleaned room [ROOM NUMBER] in a couple of days. He/She said he/she knows the floor is disgusting and the shower needs to be cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure the resident's environment remained free of accident hazards when they failed to properly propel seven residents (Resident #10, #20, #22, #25, #33, #40, and #58) in wheelchairs in a manner to prevent accidents. The facility census was 52. Review of the facility's Wheelchair, Use of policy, undated, showed: -The purpose is to provide mobility for the non-ambulatory residents with safety and comfort; -Encourage and instruct resident in proper guidelines for safely propelling the wheelchair; -Place foot pedals in position and ensure feet are resting on the foot pedals when staff are propelling resident distances. 1. Review of Resident #10's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/10/23, showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/4/23 at 12:41 P.M., showed an unidentified staff member propelled the resident in a wheelchair from the dining room to the restroom without the use of foot pedals. Observation on 4/4/23 at 1:00 P.M., showed an unidentified staff member propelled the resident in a wheelchair from the hallway to the dining room. Further observation showed the resident's feet touched the floor. Observation on 4/5/23 at 8:51 A.M., showed the Activity Director (AD) propelled the resident in a wheelchair down the hallway without the use of foot pedals. Further observation showed the resident's feet slid on the floor. 2. Review of Resident #20's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Moderate Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/4/23 at 11:26 A.M., showed Certified Nurse Aide (CNA) I propelled the resident in a wheelchair without foot pedals. 3. Review of Resident #22's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/5/23 at 8:44 A.M., showed CNA G propelled the resident in a wheelchair from the dining room to the nurses' station without the use of foot pedals. Observation on 4/5/23 at 8:48 A.M., showed the AD propelled the resident in a wheelchair without the use of foot pedals. 4. Review of Resident #25's admission MDS, dated [DATE] showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/4/23 at 12:33 P.M., showed CNA I propelled the resident in wheelchair without foot pedals. Observation on 4/5/23 at 8:54 A.M., showed CNA D propelled the resident from the nurses' station to his/her room without the use of foot pedals. Further observation showed the resident's right foot slid on the floor. Observation on 4/6/23 at 8:49 A.M., showed License Practical Nurse (LPN) J propelled the resident in a wheelchair without foot pedals. Further observation showed the resident wore non-skid socks and his/her feet touched the floor. 5. Review of Resident #33's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/4/23 at 1:19 P.M., showed CNA F propelled the resident quickly from the dining room to his/her room without the use of foot pedals. Further observation showed the resident's feet touched the floor and bent backwards. Observation on 4/6/23 at 8:42 A.M., showed CNA E propelled the resident from the dining room to his/her room, back into the hall, and then back to his/her room, without the use of foot pedals. Further observation showed the resident's feet slid on the floor. 6. Review of Resident #40's Annual MDS, dated [DATE] showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/5/23 at 8:55 A.M., showed CNA D propelled the resident in a wheelchair without the use of foot pedals. Further observation showed the resident's foot slid on the floor. Observation on 4/6/23 at 8:53 A.M., showed LPN J propelled the resident in a wheelchair without the use of foot pedals. Further observation showed the resident wore non-skid socks and his/her feet touched the floor. Observation on 4/6/23 at 8:57 A.M., showed LPN J propelled the resident in a wheelchair without the use of foot pedals. Further observation showed the resident's feet touched the floor. 7. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Used a wheelchair for mobility. Observation on 4/7/23 at 8:54 A.M., showed CNA D propelled the resident in a wheelchair from the nurses' station to his/her room without the use of foot pedals. Further observation showed the resident's right foot slid on the floor. During an interview on 4/6/23 at 8:47 A.M., the Director of Nursing (DON) said staff should monitor the position of the residents' feet when being propelled in wheelchairs. He/She said staff do not always have to use foot pedals when propelling residents. The DON said foot pedals are not required if the resident is able to propel themselves. The DON said he/she believed cognitively impaired residents are able to hold their feet up when propelled in wheelchairs. He/She said if staff do not use foot pedals the resident could be injured or fall if their feet touch the floor. During an interview on 4/6/23 at 11:18 A.M., the DON said staff should use foot pedals if the residents' feet touched the floor. He/She said the standard is if a resident can hold their legs up, the staff member can propel the resident without foot pedals. During an interview on 4/7/23 at 10:09 A.M., CNA O said staff should use foot pedals when propelling a resident in a wheelchair. During an interview on 4/7/23 at 10:13 A.M., Registered Nurse (RN) H said staff are expected to use foot pedals when propelling a resident in a wheelchair. He/She said the resident could be injured if foot pedals are not used, because the resident's foot could get in the wheels. During an interview on 4/6/23 at 8:52 A.M., the Administrator said staff are expected to use foot pedals when propelling residents if the resident is unable to hold their feet up. He/She said the resident's cognition and physical abilities dictate whether or not staff use foot pedals. He/She said if a resident has a cognitive impairment it is up to the staff member to determine whether or not foot pedals should be used. He/She said if a staff member is propelling a resident and their foot touches the floor the resident could be thrown forward, or their feet could get tangled in the wheels of the wheelchair. The Administrator said staff has not been educated on wheelchair safety in the past 10 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #33) had an appropriate indication for the use of anti-psychotic medications. Additionally staff failed to provide a 14-day stop date for as needed (PRN) antianxiety medication, for six residents (Residents #5, #33, #34, #37, #50 and #52). The facility census was 52. 1. Review of the facility's Psychotropic Medication Use Policy, dated September 2022, showed: -Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective; -Antipsychotic medications shall generally be used only for the following conditions/diagnosis as documented in the record, consistent with the definition in the Diagnostic and Statistical Manual of Mental Disorder; -The timeframe for PRN psychotropic medications, which are not Antipsychotic medications will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner; -The timeframe for PRN psychotropic medications which are Antipsychotic medications will be limited to 14 days. A new order will not be entered without the physician or prescriber first evaluating the resident. 1. Review of Resident #33's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool dated 3/14/23, showed staff assessed the resident as: -Severe cognitive impairment; -No behaviors; -Received Antipsychotic medication seven out of seven days in look back period; -Diagnoses of Stroke, Dementia, Anxiety Disorder, and Depression. Review of the resident's Physician Order Sheet (POS), dated April 2023, showed an order dated 1/27/23 for Zyprexa (Antipsychotic) 5 milligram (mg) tablet, two times a day for Dementia. Review of the resident's medical record showed it did not contain an appropriate diagnosis for the use of an Antipsychotic medication. During an interview on 4/07/23 and 11:29 A.M., Registered Nurse (RN) P said, he/she does not know if Dementia is an appropriate diagnosis for Antipsychotic medications, he/she can not diagnose or prescribe medications. During an interview on 4/07/23 at 11:34 A.M., Director of Nursing (DON) said Dementia on it's own is not an appropriate diagnosis for Antipsychotic, but if there is certain behavioral symptoms, it is. During an interview on 4/07/23 and 11:28 A.M., the administrator said dementia is not an appropriate diagnosis to receive an Antipsychotic medication. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed staff assessed the resident as: - Severely cognitively impaired; - No behaviors; - Received antianxiety medication seven days of the seven day look back period (period of time used to complete the assessment); - Diagnoses of heart failure, end stage renal disease (ESRD - permanent kidney failure that requires a regular course of dialysis or a kidney transplant), respiratory failure, dementia, anxiety and depression. Review of the resident's Physician Order Sheet (POS), dated April 2023, showed an order dated 3/26/23 for Lorazepam (to treat anxiety) 0.25 milliliters (ml) administered every two hours as needed (PRN). Further review showed it did not contain documentation of a stop date. 3. Review of Resident #33's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Did not have behaviors; -Received Antianxiety medication seven days of the seven day look back period; -Diagnoses of Stroke, Dementia, Anxiety Disorder, Depression. Review of the resident's POS, dated April 2023, showed an order to administer Lorazepam Oral Concentrate 2 MG/ML (Lorazepam), Give 0.25 ml by mouth every 2 hours as needed for anxiety related to Generalized Anxiety Disorder. Further review, showed a start date of the medication as 3/26/23 and the POS did not contain a stop date for the medication. 4. Review of Resident #34's significant change MDS, dated [DATE], showed staff assessed the resident as: - Severely cognitively impaired; - No behaviors; - Received Antipsychotic and antidepressant medications seven days of the seven day look back period; - Diagnoses of ESRD, stroke, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and depression. Review of the resident's POS, dated April 2023, showed an order dated 3/26/23 for Lorazepam 0.25 ml administered every two hours PRN for anxiety. Further review showed it did not contain documentation of a stop date. 5. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Behaviors daily; -Received Antianxiety medication seven out of seven days in look back period; -Received Antidepressant medication seven out of seven days in look back period; -Diagnoses of Anxiety Disorder, and Depression. Review of the resident's POS, dated April 2023, showed an order to administer Lorazepam Oral Concentrate 2 MG/ML, Give 0.25 ml by mouth every 2 hours as needed for anxiety related to Generalized Anxiety Disorder. Further review, showed a start date of the medication as 4/3/23 and the POS did not contain a stop date for the medication. 6. Review of Resident #50's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Verbal behaviors directed towards others four to six days in seven day look back period; -Received Antipsychotic medication seven out of seven days in look back period; -Received Antidepressant medication seven out of seven days in look back period; -Diagnoses of Anxiety Disorder, Dementia and Schizophrenia. Review of the resident's POS, dated April 2023, showed an order to administer Lorazepam Oral Concentrate 2 MG/ML, Give 0.25 ml by mouth every 2 hours as needed for anxiety related to Generalized Anxiety Disorder. Further review, showed a start date of the medication as 4/3/23 and the POS did not contain a stop date for the medication. 7. Review of Resident #52's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No behaviors or psychosis; -Did not reject care; -Did not receive an anti-anxiety medication during the seven day look back period. Review of the resident's POS, dated 2/14/23, showed an order for Lorazepam 0.25 ml administered every three hours PRN. Further review showed it did not contain documentation of a stop date. Review of the resident's care plan, dated 3/13/23, showed it did not contain direction for staff in regard to the resident receiving an anti-anxiety medication. 8. During an interview on 4/07/23 and 11:29 A.M., RN P said PRN orders for antianxiety medication is for seven days and then the medications get reevaluated. The RN said the medications have a seven day stop date. The RN said the residents on hospice do not have a stop date, because the residents are on hospice. The RN said he/she did not know hospice residents had to have a 14 day stop date, he/she thought it is different for residents on hospice. During an interview on 4/07/23 at 11:34 A.M., DON said PRN antianxiety medications should be limited to 14 days. The DON said hospice does not have stop dates, because staff reviewed with practitioner and they chose not stop them. The DON said he/she had addressed not having stop dates for hospice residents with the physician and hospice. During an interview on 4/7/23 and 11:28 A.M., the administrator said psychotropic medications administered PRN, should only be administered for 14 days and have a stop date. He/She said the physician should be contacted if the medication is needed for more than 14 days to obtain an extension. He/She said the DON is responsible to ensure medication administered on PRN basis are required to have a stop date. He/She said he/she conducted an in-service a few months ago educating staff on the requirement to get a stop date on PRN medication. He/She said he/she did not know residents were prescribed psychotropic medication without a stop date.

Based on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens and cross-contamination. Facility staff also failed to serve drinks to residents at meals in a sanitary manner and perform hand hygiene as often as necessary to prevent cross-contamination. The facility census was 52. 1. Review of the facility's Dish and Utensil Handling policy, undated, showed the policy directed staff to air dry dishes, cups and glasses prior to storage. Observations on 04/04/23 at 11:07 A.M., showed Dietary Aide (DA) C removed sanitized insulated plate holders and dome covers from the clean side of mechanical dishwashing station while wet, stacked them together and stored them on a service cart. Observation also showed six insulated plate holders and 12 domes covers stacked together wet on the cart. During an interview on 04/04/23 at 12:24 P.M., the Dietary Manager (DM) said staff should allow dishes to dry before they are stacked and put away. Observations on 04/04/23 during the lunch meal service, which began at 12:37 P.M., showed staff used the wet stacked plate holders and dome covers to serve plates of food to residents who ate in their rooms. Observation on 04/06/23 at 10:23 A.M., showed three plastic service trays stacked together wet on a storage shelf on the clean side of the mechanical dishwashing station. During an interview on 04/06/23 at 10:34 A.M., the administrator said staff should allow clean dishes to air dry before they are put away and they staff are trained on that requirement. The administrator said the cook and DM are responsible to monitor the washing and storage of dishes daily. 2. Review of the facility's Handwashing and Glove Usage policy, undated, showed the policy directed staff to wash their hands upon entering the kitchen, between tasks, before and after they handle foods, and after they touch any part of their uniform, face or hair, and before and after they work with an individual resident. Review also showed the policy directed staff to use gloves whenever direct food contact is required. Observations on 04/04/23 from 12:22 P.M. to 12:35 P.M., showed an unidentified staff member placed his/her bare hands on the dining table, picked up a cup by the rim with his/her bare hand and delivered the cup to a resident. Observation showed the staff member then picked up a resident's eye glasses and placed them on the resident's face. Observation showed the staff member went back to the drink cart, picked up a cup by the rim with his/her bare hand, delivered it to a resident and then repeated the process for another resident. Observation showed the staff member did not wear gloves when he/she handled the cups by the rims or perform hand hygiene in between tasks. Observations on 04/06/23 from 7:15 A.M. to 7:25 A.M., showed the DM served drinks to residents in the dining room. Observation showed the DM picked up the glasses of drinks with his/hands over the tops of the drinks and his/her fingers touched the rims of the glasses. Observation also showed the DM put his/her hands in his/her pockets to obtain an item, entered the kitchen, filled up a pitcher with ice water and returned to the dining room to serve drinks to residents without performing hand hygiene. Observation on 04/06/23 from 11:58 A.M. to 12:08 P.M., showed DA C poured milk into a cup, touched the top of the cup with his/her bare hand and delivered the cup to a resident. Observation showed the DA returned to the drink cart, touched items on the drink cart, lifted a cup by the rim with his/her bare hand to prepare a drink and then delivered the drink to a resident. Observation showed the DA again returned to the drink cart, picked up another cup by the rim with his/her bare hand, put his/her hand into the ice pitcher and used a plastic cup to retrieve ice, placed the ice in the cup and then gave the cup to a resident. Observation showed the DA did not wear gloves when he/she handled the cups by the rims or perform hand hygiene in between tasks. Observation on 04/06/23 at 12:00 P.M., showed an unidentified staff member picked up a cup from the drink cart by the rim with his/her bare hand, put a beverage in the cup and then delivered the drink to a resident. Observation showed the staff member returned to the drink cart, picked up a cup by the rim with his/her bare hand and delivered it to a resident. Observation showed the staff member again returned to the drink cart, touched items on the cart, scooped up ice with a plastic cup while his/her fingers touched the side of the ice pitcher, filled two cups with the ice and a beverage and then delivered the drinks to the residents. Observation showed the staff member did not wear gloves when he/she handled the cups by the rims or perform hand hygiene in between tasks. During an interview on 04/06/23 at 7:25 A.M., the DM said staff should grab glasses by the sides and not the tops when they serve drinks to residents. The DM said he/she was half awake and did not realize he/she served the residents drinks with his/her hand over the tops of the glasses. The DM also said staff should wash their hands between dirty and clean tasks and after they touch anything dirty. During an interview on 04/06/23 at 10:35 A.M., the administrator said staff should wash their hands before food preparation and any time they make their hands dirty, which would include putting their hands in their pockets or touching their bodies. The administrator said staff should hold the bottom of glass to give residents their drinks; not with their hands over the tops or rims of the glass. The administrator said the staff are trained on this requirement and the DM and nursing staff are responsible to monitor food service and hand hygiene during food served.

Based on interview and record review, the facility staff failed to screen three new employees out of ten employee files reviewed, prior to employment to determine if any had a Federal indicator with the Nurse Aide Registry which would prohibit employment at the facility. The facility census was 41. 1. Review of the facility's Abuse, Prevention and Prohibition Policy, dated 11/2018 showed facility staff are directed as follows: The facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties. A person at a supervisory level will interview potential employees. All employees will have criminal background checks, state and federal required checks, employment reference checks (previous and current), and license/certification confirmation. The facility will make reasonable efforts to uncover information about any past criminal prosecutions. The facility will report any knowledge it has of actions by a court of law against an employee, which would indicate that they are unfit for service as a nurse aide or other facility staff, to the nurse aide registry, licensing authorities or other mandated state agencies. The facility will prescreen potential residents for behaviors, needs and personal histories, which might lead to conflict, neglect, or abuse. 2. Review of Receptionist D's employee file showed a hire date of 11/09/18. Further review showed the file did not contain a pre-employment Nurse Aide registry check. 3. Review of Housekeeper E's employee file showed a hire date of 12/17/20. Further review showed the file did not contain a pre-employment Nurse Aide Registry check. 4. Review of Registered Nurse (RN) F's employee file showed a hire date of 10/20/20. Further review showed the file did not contain a pre-employment Nurse Aide Registry check. 5. During an interview on 03/24/21 at 10:21 A.M., the business office manager (BOM) said he/she is responsible for checking staff's pre-employment records but did not know what the nurses aide registry is or that it needed to be checked for every employee, not just Certified Nurse Assistants (CNA)s. 6. During an interview on 03/24/21 at 10:35 A.M., the Director of Nursing (DON) said she was not aware all employees must have the nurse aide registry check before employment. 7. During an interview on 03/24/21 at 10:35 A.M., the administrator said she was unaware all employees must have the nurse aide registry checked before employment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to notify the resident and/or resident representative in writing of a facility initiated transfer to a hospital, including the reasons for the transfer, for three sampled residents (Resident #20, #43, and #45). The facility census was 40. 1. Review of Resident #20's Discharge Return Anticipated Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 1/12/21, showed the resident was discharged to the hospital. Review of the resident's medical record showed the resident was discharged due to injuries sustained in a fall. Further review showed record did not contain documentation the resident or resident representative were notified of the transfer or the reason for the move in writing. 2. Review of Resident #43's Discharge Return Not Anticipated MDS, dated [DATE], showed the resident was discharged to the hospital. Review of the resident's medical record showed the resident was discharged due to elevated potassium levels. Further review showed the record did not contain documentation the resident or resident representative were notified of the of the transfer or the reason for the move in writing. 3. Review of Resident #45's Discharge Return Anticipated (MDS), dated [DATE], showed the resident was discharged to the hospital. Review of the resident's medical record showed the resident was discharged due severe pain in the hip and leg. Further review showed the record did not contain documentation the resident or resident representative were notified of the of the transfer or the reason for the move in writing. During an interview on 3/25/21 at 10:00 A.M., the social service designee said the facility does not send a written notice of discharge and he/she was not aware the facility needed to do so. Documents related to transfers or discharge are the social workers responsibility. During an interview on 3/25/21 at 10:15 A.M., the Director of Nursing (DON) said they were not aware the facility was required to provide a written notice of discharge to residents or their representative. During an interview on 3/25/21 at 10:20 A,M., the administrator said the facility does not provide a written notice of transfer to residents or their representatives.