Based on observation, interview, and record review, facility staff failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for one (Resident #12) of five sampled residents when staff failed to promote the resident's self determination through support of resident choices when staff failed to allow the resident the choice of independently going outside the facility. The facility census was 48. 1. Review of the facility's Nursing Home Residents' Rights policy, undated, showed the resident had the right to self determination including the choice of activities, the reasonable accommodation of needs and preferences, and participation in developing and implementing a person-centered plan of care incorporates personal and cultural preferences. 2. Review of Resident #12's quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 07/10/24, showed staff assessed the resident as follows: -Cognitively Intact; -Required total dependence for transfers; -Independent using a motorized wheelchair; -Diagnosis of multiple sclerosis and depression. Review of the resident's admission sheet shows the resident is his/her own legal representative. Review of the resident's care plan, dated 04/10/24, showed staff assessed the resident's preferred activity is to go across the street to the park in his/her motorized wheelchair. Review of the resident's medical record did not contain documentation the resident with safety concerns for his/her perferred activity to go across the street to the park. Review of the resident's smoking assessment, dated 07/10/24, showed staff assessed the resident as a safe smoker. During and interview on 07/10/24 at 10:59 A.M., the resident said he/she used to be able to independently go across the road to the park but recently was told they could no longer do so and this caused him/her stress. The resident said he/she is able to operate the wheelchair without problems and would use the cell phone to ask for help if needed. During an interview on 07/10/24 at 3:05 P.M., the resident's family member said he/she would like the resident to be able to go to the park because it helps him/her with depression and anxiety, and that is important for the quality of the resident's life. During an interview on 07/11/24 at 10:34 A.M., the Assistant Director of Nursing said the resident was found to be an unsafe smoker and started hitting things with their wheelchair causing the decision to made not allowing independent trips to the park. During an interview on 07/11/24 at 10:39 A.M., the MDS coordinator said staff had a care plan meeting to addressed using a smoking apron and not allowing the resident to go to the park unsupervised due to concerns it was a health risk and the resident said he/she did not want to be supervised going to the park. During an interview on 07/11/24 at 10:41 A.M., the administrator said the resident's unsupervised trips to the park were stopped due to concerns about the residents safety. During an interview on 07/11/24 at 2:00 P.M., Certified Nurse Aid (CNA) A said he/she would ask a charge nurse to see if a resident was independent and allowed to go to the park or outside on their own. He/She said they were not aware the resident could no longer go by themselves to the park. During an interview on 07/11/24 at 2:46 P.M., the Director of Nursing said a resident who is alert and orientated should be able to make their own choices but we were concerned for the resident's safety going across the road to the park alone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to change and store oxygen tubing and/or clean oxygen concentrator filters in a manner to decrease the risk of the spread of infection for four (Resident #8, #25, #36, and #42) out of four sampled residents. The facility census was 48. 1. Review of the facility's Oxygen Administration policy, dated March 2015, showed: -At regular intervals, check and clean oxygen equipment, masks, tubing, and cannulas; -Change humidifier and tubing per cleaning guidelines; -At regular intervals, check liter flow contents of oxygen cylinder, fluid level in humidifier and access resident's respiration to determine further need for oxygen therapy. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/18/24 showed staff assessed the resident as: -Severely cognitively impaired; -Used oxygen. Review of the Physician Order Sheet (POS), dated July 2024, showed an order to change the oxygen tubing and humidity bottle monthly on the first, on the evening shift and to ensure the tubing and bottle is labeled. Observation on 07/09/24 at 11:08 A.M., showed the resident wore his/her oxygen via nasal cannula. The oxygen tubing did not contain a label with a date. Observation on 07/10/24 at 8:14 A.M., showed the resident with his/her oxygen on via nasal cannula. The oxygen tubing did not contain a label with a date. 3. Review of the Resident #25's annual MDS, dated [DATE], showed facility staff assessed the resident as follows: -Cognitively intact; -Received oxygen therapy; -Diagnoses respiratory failure. Review of the resident's POS for July 2024 showed the physican ordered oxygen three to five liters per minute (lpm) per nasal cannula, change oxygen tubing monthly and change nebulizer tubing monthly. Ensure tubing is dated. Observation on 07/09/24 at 11:41 A.M., showed the resident with his/her nasal cannula on dated 03/11 and the oxygen condenser filter covered with a white residue. Observation showed the resident's nebulizer tubing dated 11/8. Observation on 07/11/24 at 09:46 A.M., showed the resident with his/her nasal cannula on dated 03/11 and the oxygen condenser filter covered with a white residue. Observation showed the resident's nebulizer tubing dated 11/8. 4. Review of the Resident #36's Quarterly MDS, dated [DATE], showed facility assessed the resident as follows: -Cognitively intact; -Received oxygen therapy; -Diagnoses lung disease, and respiratory failure. Review of the resident's POS, dated July 2024, showed physician orders for oxygen two to five lpm per nasal cannula as needed for shortness of breath and Bilevel positive airway pressure ((BiPap) a device that helps with breathing) with a forced air pressure of 15/10 every night as tolerated. Observation on 07/09/24 at 12:00 P.M., showed the resident oxygen on per lasal cannula. Observation showed the tubing not date. Observation on 07/10/24 at 10:12 A.M., showed the resident oxygen on per lasal cannula. Observation showed the tubing not date. Observation on 07/11/24 at 9:41 A.M., the resident oxygen on per lasal cannula. Observation showed the tubing not date. During an interview on 07/10/24 at 10:12 A.M., the resident said he/she uses oxygen. 5. Review of Resident #42's Significant Change of Status MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Used oxygen; -Diagnosis of heart failure and lung disease. Review of the resident's POS, dated July 2024, showed an order to change the oxygen tubing and humidity bottle monthly, first of the month, on the evening shift and to ensure the tubing and bottle is labeled. Observation on 07/09/24 at 11:42 A.M., showed the resident wore his/her oxygen via nasal cannula. The oxygen tubing did not contain a date and the humidifier bottle dated 06/01/24. Observation showed the filter on the machine was covered with a white substance. Observation on 07/10/24 at 08:13 A.M,showed the resident wore his/her oxygen via nasal cannula. The oxygen tubing did not contain a date and the humidifier bottle was dated 06/01/24. Observation showed the filter on the machine was covered with a white substance. 6. During an interview on 07/10/24 at 11:34 A.M., Licensed Practical Nurse (LPN) B said oxygen tubing should be changed monthly by nursing, and it is triggered by an order in the Treatment Administration Record (TAR). The tubing change is indicated in the TAR, and the tubing should be dated. LPN B said filters were not regularly cleaned. During a telephone interview on 07/11/24 at 2:50 P.M., the Director of Nursing (DON) said oxygen tubing should be labeled and dated when changed and should be changed monthly. He/She said nursing does not have a preventative maintenance for cleaning oxygen filters. The DON said it is his/her responsibility to ensure the tubing is being changed. During an interview on 07/11/24 at 03:24 P.M., the administrator said oxygen tubing should be changed on a regular basis, but he/she was not sure whether this is weekly or monthly. The administrator said the new tubing and new bag should be dated. If the tubing was marked with an earlier date, the tubing was not changed after that date. He/She said it was the responsibility of the charge nurse to ensure the tubing changes occurred as ordered.

Based on interview and record review, facility staff failed to transmit the required Minimum Data Sets (MDS), a federally mandated resident assessment completed by facility staff, for ten residents (Resident #2, #6, #11, #13, #18, #26, #32, #42, #44 and #53) of sixteen sampled residents. The facility census was 48. 1. Review of Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, dated October 2023, showed: -The CMS Long-Term Care Facility RAI User's Manual is the primary source of information for completing an MDS assessment; - All Medicare and/or Medicaid-certified nursing homes must transmit MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES); -Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (no later than 14 days from the resident's admission date and/or assessment reference date (ARD) plus seven days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date; -A comprehensive or quarterly assessment is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between assessments. A comprehensive assessment is due every year unless the resident is no longer in the facility. There must be no more than 366 days between comprehensive assessments. Review of the facility's MDS and Care Planning Guidelines, dated October 2015, directed staff to use the most current CMS MDS Resident Assessment Instrument (RAI) Manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS and care planning. 2. Review of Resident #2's MDS data in the Electronic Health Record (EHR), showed a quarterly MDS completion date of 06/05/24. Review showed the assessment was not transmitted as required within 14 days of completion. 3. Review of Resident #6's MDS data in the EHR, showed a quarterly MDS completion date of 06/10/24. Review showed the assessment was not transmitted as required within 14 days of completion. 4. Review of Resident #11's MDS data in the EHR, showed an annual MDS completion date of 05/17/24. Review showed the assessment was not transmitted as required within 14 days of completion. 5. Review of Resident #13's MDS data in the EHR, showed a Significant Change of Status (SCSA) comprehensive assessment completion date of 06/10/24. Review showed the assessment was not transmitted as required within 14 days of completion. 6. Review of Resident #18's MDS data in the EHR, showed an annual MDS completion date of 06/06/24. Review showed the assessment was not transmitted as required within 14 days of completion. 7. Review of Resident #26's MDS data in the EHR, showed a SCSA completion date of 06/07/24. Review showed the assessment was not transmitted as required within 14 days of completion. 8. Review of Resident #32's MDS data in the EHR, showed a SCSA completion date of 04/18/24. Review showed the assessment was not transmitted as required within 14 days of completion. 9. Review of Resident #42's MDS data in the EHR, showed a SCSA completion date of 05/29/24. Review showed the assessment was not transmitted as required within 14 days of completion. 10. Review of Resident #44's MDS data in the EHR, showed a quarterly MDS completion date of 06/20/24. Review showed the assessment was not transmitted as required within 14 days of completion. 11. Review of Resident #52's MDS data in the EHR, showed an admission MDS completion date of 05/27/24. Review showed the assessment was not transmitted as required within 14 days of completion. 12. During an interview on 07/11/24 at 2:00 P.M., the MDS Coordinator said he/she only completes the MDS. The Director of Nursing (DON) signs off and submits them. During an interview on 07/11/24 at 2:50 P.M., the DON said he/she is responsible for submitting the MDS data and does not have a back-up person. He/She said he/she submits the data every other week but took vacation twice in June and then just forgot. During an interview on 07/11/24 at 3:24 P.M., the administrator said he/she is not sure how often the MDS data should be submitted but is usually the responsibility of the DON. The administrator said they do not have a back-up person when the DON is unavailable.

Based on interview and record review, facility staff failed to connect one resident's (Resident #1) nasal cannula tubing to the residents oxygen concentrator and failed to turn the oxygen concentrator on. The facility census was 53. 1. Review of the facility's oxygen administration policy, dated March 2015, showed when administering oxygen staff are directed to attach a face mask or cannula tubing to the humidifier and set the flow meter to the rate ordered by the physician. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 11/30/23, showed staff assessed the resident as follows: -Severe Cognitive Impairment; -Dependent on staff to roll right or left in bed; -Dependent on staff to move from sitting to a lying position; -Atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and dementia (a group of thinking and social symptoms that interferes with daily function); -Received oxygen therapy. Review of the resident's plan of care, dated 11/30/23, showed the plan of care did not contain direction for staff to provide oxygen therapy. Review of resident's physician orders, dated 6/30/23, showed an order for two to five liters of oxygen per minute per nasal cannula as needed. Review of resident's nurses notes, dated 12/10/23 at 3:37 P.M., showed the resident with diminished lung sounds and oxygen saturation at 55%. Review showed the nurses note did not contain documentation staff notified the resident's physician of the change in condition. During an interview on 1/10/24 at 2:59 P.M., Certified Nurse Assistant (CNA) A said he/she worked with the resident on 12/10/23 on the day shift, he/she last worked with the resident around 1:30 P.M. that day. and as far as he/she knew the resident's nasal cannula was on and connected to the oxygen concentrator. During a telephone interview on 1/10/24 at 3:10 P.M., the resident's attending physician said he expected staff to follow physician's orders to include for oxygen therapy. During an interview on 1/10/24 at 3:16 P.M., Licensed Practical Nurse (LPN) B said he/she was assigned to the resident's hall on the day shift of 12/10/23, and CNA A worked with the resident around 1:30 P.M., but at the end of the shift the resident was found with his nasal cannula tubing not connected to the concentrator and the concentrator was not turned on. He/She said they plugged the oxygen back up and turned it on to get the residents oxygen sats back up by utilizing the concentrator and portable tank. He/She at one point the resdient could remove the oxygen but was no longer strong enough to do so. During a telephone interview on 1/10/24 at 4:05 P.M., CNA C said he/she worked evening shift with the resident on 12/10/23 and he/she had came in around 3:00 P.M. for evening shift. CNA C said soon after the start of the shift while passing ice, he/she observed the resident with his/her nasal cannula on his/her face, without the tubing connected to the concentrator, and the oxygen concentrator was not turned on. During a telephone interview on 1/11/24 at 9:47 A.M., CNA A said I'm pretty sure I did hook the tubing back and turn on the concentrator. He/She said he/she did not know whether anyone else provided care after 1:30 P.M. to the resident or not. During a telephone interview on 1/11/24 at 10:15 A.M., the Director of Nursing (DON), said on 12/10/23 he/she was at the facility and the charge nurse reported to him/her that CNA A had removed the resident's nasal cannula tubing from the resident's portable oxygen tank but forgot to attach it to the resident's oxygen concentrator while working with the resident. He/She said the next day he/she spoke to CNA C who told him/her, he/she observed the resident's nasal cannula tubing not connected to the concentrator and didn't say anything about the concentrator not being turned on. During a telephone interview 1/11/24 at 11:26 A.M., LPN B said the resident would not have been able to pull his/her nasal cannula from the concentrator independently because he/she was too lethargic and sleepy. During a telephone interview on 1/11/24 at 3:17 P.M., the administrator said she expected staff to follow the physician's order for oxygen administration. She also said she expected staff to take the time to make sure residents' nasal cannula tubing is properly connected to the concentrator and flowing properly to the resident. MO00230021

Based on observation, interview and record review facility staff failed to meet professional standards of care when nursing staff did not sign out narcotics as they were given during a medication pass, and did not count narcotics at change of shift when the medication cart changed from one staff member to another. The facility census was 61. 1. Review of the facility's policy titled, Medications, Administration Guidelines, dated March 2015, showed the person administering the drugs must chart medications immediately following the administration. Review of the facility's policy titled, Narcotic Count, dated March 2015, showed staff were directed to do the following: -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 Tech (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 change of each shift; -After the supply is counted and justified, the nurse/CMT records the date and his/her signature verifying the count is correct. 2. Observation on 09/20/23 at 11:41 A.M., showed LPN A administered the following: -Norco (Hydrocodone/Acetaminophen) (a medication used to treat pain) 7.5/325 milligrams (mg) 1 tablet to Resident #24 and did not sign the medication out of the narcotic log book at the time he/she gave the medication; -Tramadol (a medication used to treat pain) 50 mg 1 tablet to Resident #2 and did not sign the medication out of the narcotic log book at the time he/she gave the medication; -Oxycodone (a medication used to treat pain) 5 mg 1 tablet to Resident #46 and did not sign the medication out of the narcotic log book at the time he/she gave the medication. 3. Review of the facility's on-coming and off-going narcotic count sheets, dated 07/01/23 through 09/21/23 showed the following: -On 07/01/23 at 2:00 P.M., showed the north hall count was not signed off by two licensed staff; -On 07/01/23 at 10:00 P.M., showed the north hall count was not signed off by two licensed staff; -On 07/17/23 at 2:00 P.M., showed the north hall count was not signed off by two licensed staff; -On 07/19/23 at 2:00 P.M., showed the south hall count was not signed off by two licensed staff; -On 08/02/23 at 2:00 P.M., showed the south hall count was not signed off by two licensed staff; -On 08/10/23 at 6:00 A.M. showed the north hall count was not signed off by two licensed staff; -On 08/11/23 at 10:00 P.M., showed the south hall count was not signed off by two licensed staff; -On 08/12/23 at 6:00 A.M., showed the north hall count was not signed off by two licensed staff; -On 08/17/23 at 2:00 P.M., showed the south hall count was not signed off by two licensed staff; -On 09/04/23 at 2:00 P.M., showed the north hall count was not signed off by two licensed staff; -On 09/04/23 at 10:00 P.M., showed the north hall count was not signed off by two licensed staff; -On 09/05/23 at 6:00 A.M., showed the north hall count was not signed off by two licensed staff; -On 09/05/23 at 2:00 P.M., showed the north hall count was not signed off by two licensed staff; -On 09/10/23 at 6:00 A.M., showed the north hall count was not signed off by two licensed staff; -On 09/10/23 at 2:00 P.M., showed the north hall count was not signed off by two licensed staff; -On 09/11/23 at 6:00 A.M., showed the north hall count was not signed off by two licensed staff; -On 09/18/23 at 6:00 A.M., showed the north hall count was not signed off by two licensed staff. 4. During an interview on 09/21/23 at 8:58 A.M., LPN D said narcotics should be counted each shift. He/She said narcotics should be signed out as they are given during a medication pass. During an interview on 09/21/23 at 9:30 A.M., CMT B said staff are to do narcotic counts each shift. He/She said when staff give a narcotic during a medication pass staff are to sign it out as they give it. During an interview on 09/21/23 at 11:09 A.M., RN C said that narcotics should be counted each shift and he/she said if there is a hole that means someone didn't sign the book. He/She said that he/she signs narcotics as he/she gives them in the computer and then later he/she will sign them out of the book. During an interview on 09/22/23 at 8:30 A.M., LPN A said narcotic counts are to be done each shift change. He/she said if there is a hole in the log it means the nurse did not count at change of shift. He/she said that narcotics should be signed out as staff are giving them so that staff can keep track of what medication was given and the time it was given. During an interview on 09/22/23 at 09:33 A.M., the Director of Nursing (DON) and Administrator said staff are expected to count the narcotics during shift to shift transfer of keys. The DON said if there are holes in the documentation, it means the staff forgot to sign it. The DON said narcotics should be signed out when the medication is given to the resident.

**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 residents' interest during the weekend, and for six dependent residents (Resident #7, #12, #16, #19, #31, and #264) The facility census was 61. 1. Review of the facility's Activity Programming Policy, dated March 2022 showed staff are instructed to: -Plan, organize and carry out a program of activities to meet individual residents' needs; -Implement an individualized program for residents unable to participate or attend activities; -Program activities to give residents entertainment, communication, exercise, relaxation, and opportunities to express their creative talent; -All staff is to assist residents to activities of their choice. Review of the facility's Activity Attendance Calendar, dated July 2023, showed staff did not document activity attendance on July 1, July 12, July 23, or July 29. Review of the facility's Activity Attendance Calendar, dated August 2023, showed staff did not document activity attendance on August 20 and for one resident on August 27. Review of the facility's Activity Attendance Calendar, dated September 1-20, 2023, showed staff did not document activity attendance on September 9 or 10. Review of the Activity Calendar, dated September 2023, showed the following: 09/18/23: 10:00 A.M. Noodle Ball, 1:30 P.M. Line Dancers; 09/19/23: 10:00 A.M. Nails/1:1/Librarian, 1:30 Bingo; 09/20/23: 10:00 A.M. Singing, 1:30 P.M. Wine tasting 09/21/23: Trail Day - All Day Long 09/22/23: Catholic Services, 10:00 A.M. Bible Story, 1:30 P.M. Cards; 09/23/23: 10:00 A.M. Cards, 1:30 P.M. Movie; 09/24/23: 10:00 A.M. Color, 1:30 P.M. Puzzles 2. Review of Resident #7's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/16/23, showed staff assessed the resident as: -Severely cognitively impaired; -Totally dependent on staff for locomotion off the unit: -Somewhat important to listen to music; -Somewhat important to keep up with the news; -Somewhat important to do things with groups of people; -Somewhat important to do favorite activities; -Very important to participate in religious services or practices. -Diagnoses of heart failure, arthritis, dementia, anxiety, and depression. Review of the resident's care plan, showed the resident had dementia with long and short term memory loss, was Catholic and enjoyed activities related to his/her religion, and needed activities to be consistent with his/her abilities and interests; Staff were directed to: -Discuss with the resident the activities offered while visiting; -Provide in room activities as needed; -Provide one on one visits for sensory stimulation, socialization, and emotional support. -Remind the resident of upcoming activities. Review of the resident's Activity Attendance Record, dated July 2023 showed: -The resident did not participate in an activity on July 1, 4, 5, 6, 7, 8, 9, 10, 12, 14, 15, 16,18, 19, 20 23, 25, 26, 27, 29, 30, or 31; Review of the resident's Activity Attendance Record, dated August 2023 showed: -The resident did not participate in an activity on August 2, 3, 4, 6, 8, 9, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, or 31; Review of the resident's Activity Attendance Record, dated September 1-20, 2023 showed: -The resident did not participate in an activity on September 2, 4, 5, 8, 9, 10, 11, 13, 14, 15, 16, 17, 18, 19, or 20. Observation on 09/19/23 at 2:15 P.M., showed the resident in his/her bed. Observation on 09/20/23 at 9:39 A.M., showed the resident placed in bed. Observation on 09/20/23 at 2:01 P.M., showed the resident in a Broda chair (a wheelchair especially designed to provide supportive positioning through a combination of tilt, recline, adjustable leg rest angles, with wings with shoulder bolsters and height adjustable arms) at the nurses' station. Observation on 09/21/23 at 2:00 P.M., showed the resident in in a Broda chair at the nurses' station. 3. Review of Resident #12's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely Cognitively Impaired; -Totally dependent on staff for all mobility; -No activity assessment documented; -Diagnoses of non-traumatic brain dysfunction, heart failure, dementia, anxiety, depression, and bipolar disease. Review of the resident's care plan, reviewed 08/23/23, showed the resident needed activities consistent with his/her abilities and interests. The resident enjoyed various activities such as puzzles, crafts, reading the paper, and listening to the radio. Staff are directed to: -Assess resident's mental abilities, interests, and desires; -Assist to and from activities as tolerated; -Encourage out of room visits with family and friends; -If the resident does not attend group activities, he/she will receive 1:1 visits 3-5 times per week with activity staff; -Keep resident informed of activities and encourage attendance at them; -Offer music while resident in his/her room. Review of the resident's Activity Attendance Record, dated July 2023 showed: -The resident did not participate in an activity on July 1, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, or 31; Review of the resident's Activity Attendance Record, dated August 2023 showed: -The resident did not participate in an activity on August 1, 2, 3, 4, 6, 8, 9, 10, 11, 12, 13, 14, 15, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, or 31. Review of the resident's Activity Attendance Record, dated September 1-20, 2023 showed: -The resident did not participate in an activity on September 1, 2, 5, 6, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, or 20. Observation on 09/19/23 at 2:17 P.M., showed the resident in bed without music. Observation on 09/20/23 at 9:41 A.M., showed the resident placed in bed without music. Observation on 09/20.23 at 2:12 P.M., showed the resident in bed without music. 4. Review of Resident #16's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Totally dependent from two plus staff for transfers; -No activity assessment documented; -Diagnosis of non-traumatic brain dysfunction, coronary artery disease, dementia. Review of the resident's care plan, dated 08/18/23, showed staff were directed as follows: -Assess resident's mental and physical abilities, interest, and desires; -Assist to and from activities of interest; -Encourage out of room visits with family and friends; -If resident did not attend group activities, provide 1 on 1 visits 3 to 5 times a week; -Will respect residents preference in attending church services. Review of the resident's Activity Attendance Record, dated July 2023 showed: -The resident did not participate in an activity on July 1,2 3, 4,5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, or 31; Review of the resident's Activity Attendance Record, dated August 2023 showed: -The resident did not participate in an activity on August 1, 2, 3, 4, 6,7, 8, 9, 10, 11, 12, 13, 14, 15, 16,17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, or 31; Review of the resident's Activity Attendance Record, dated September 1-20, 2023 showed: -The resident did not participate in an activity on September 1,2 , 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, or 20. Observation on 09/19/23 at 9:00 A.M., showed the resident seated in a Broda chair by the nurses desk with no staff interaction. 5. Review of Resident #19's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Totally dependent on two plus staff for transfers; -Very important to participate in activities with groups of people; -Very important to do favorite activities; -Diagnosis of heart failure, renal disease, and diabetes. Review of the resident's care plan, dated 08/08/23, show staff are directed as follows: -Provide daily opportunities for social contact; -Discuss activities offered while visiting with resident; -Encourage resident to drink fluids and have a snack during activities; -Give resident an activities calendar and remind him/her of upcoming activities; -Provide one on one visits for sensory stimulating, socialization, and emotional support; -Provide in room activities/reading materials. Review of the resident's Activity Attendance Record, dated July 2023 showed: -The resident did not participate in an activity on July 1, 3, 5, 7, 11, 12, 14,16, 17, 18, 19, 20, 21, 23, 24, 25, 26, 28, 29, 30; Review of the resident's Activity Attendance Record, dated August 2023 showed: -The resident did not participate in an activity on August 1, 2, 4, 6, 8, 10, 11, 12, 13, 14, 16,17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, or 31; Review of the resident's Activity Attendance Record, dated September 1-20, 2023 showed: -The resident did not participate in an activity on September 1, 2, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, or 19. Observation on 09/20/23 at 8:10 A.M., showed the resident sat alone in a wheelchair by the nurses desk with no interaction from staff. Observation on 9/22/23 at 1:30 P.M., showed the resident seated at a dining table with no other resident's or staff interaction. 6. Review of Resident #31's Annual MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Required extensive assistance on staff for locomotion off the unit; -Very important to have books, newspapers and magazines; listen to music, keep up with the news; do favorite activities; and participate in religious services or practices; -Diagnoses of heart failure, arthritis, anxiety, and lung disease. Review of the resident's care plan, reviewed 08/01/23 showed the resident needed activities consistent with his/her abilities and interests, enjoyed reading in his/her room, exercise class, attend some socials and to attend activities of his/her choice and be provided 1:1 activities. Staff are directed to: -Assess the resident's mental and physical abilities, interests, and desires; -Assist the resident to and from activities of interest; -Discuss activity preferences and allow choices; -Encourage out of room visits with family and friends; -If the resident does not attend group activities, will receive 1:1 visits 3-5 times per week with activity staff; -Will respect preference in attending church services and other activities. Review of the resident's Activity Attendance Record, dated July 2023 showed: -The resident did not participate in an activity on July 1, 3, 4, 5, 6, 8, 12, 13, 14, 15, 16, 17, 18, 20, 21, 23, 24, 25, 27, 28, 29, 30, or 31; Review of the resident's Activity Attendance Record, dated August 2023 showed: -The resident did not participate in an activity on August 1, 2, 4, 12, 13, 15, 17, 20, 21, 23, 24, 26, 27, 29, or 31; Review of the resident's Activity Attendance Record, dated September 1-20, 2023 showed: -The resident did not participate in an activity on September 2, 3, 5, 6, 7, 9, 10, 11, 13, 14, 15, 16, 17, or 18. Observation on 09/19/23 at 02:08 P.M., showed the resident in his/her bed. Observation on 09/20/23 at 02:10 P.M., showed the resident in his/her bed. 7. Review of Resident #264's admission MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Totally dependent on staff for locomotion off the unit: -Somewhat important to have books, magazines, and magazines to read; -Somewhat important to listen to music; -Somewhat important to be around animals such as pets; -Very important to keep up with the news; -Somewhat important to do things with groups of people; -Very important to do favorite activities; -Somewhat important to go outside and get fresh air; -Very important to participate in religious services or practices. -Diagnoses of a fractured arm, dementia, and Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of the resident's care plan, reviewed 11/9/22, showed the resident enjoyed music, gardening, working on model railroads, spending time outside, and spending time with his/her family. Staff are directed to: -Discuss activities offered while visiting; -Encourage the resident to socialize during group activities; -Provide in room activities/reading material. Review of the resident's Activity Attendance Record, dated August 2023 showed: -The resident did not participate any activity in August after his admission on [DATE]. Review of the resident's Activity Attendance Record, dated September 1-20 2023 showed: -The resident did not participate in an activity on September 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 13, 14, 15, 16, 17, 18, or 19. Observation on 09/19/23 at 02:10 P.M., showed the resident sat in his/her chair in his/her room without music. Observation on 09/20/23 at 02:10 P.M., showed the resident sat in his/her chair in his/her room without music. Observation on 09/21/23 at 10:35 P.M., showed the resident sat in his/her chair in his/her room without music. Observation on 09/21/23 at 02:25 P.M., showed the resident sat in his/her chair in his/her room without music. 8. During an interview on 09/21/23 at 2:17 P.M., Certified Nurse Aid (CNA) P said weekend activity is watching a movie, or playing board games. The activity director or aid should record what activity a resident does in the activity log. During an interview on 09/21/23 at 3:00 P.M., CNA M said we help take residents to the activities, if it is physical unsafe for a resident we don't take them. During an interview on 09/21/23 at 3:15 P.M., the activity director said if an activity is not documented it did not happen. During an interview on 09/22/23 at 08:35 A.M., CNA L said on the weekends families do things while visiting, and staff has to step up and provide coloring or set up a card game. During an interview on 09/22/23 at 08:50 A.M., CNA S said during weekends when staff is scheduled to be at the facility, there are activities to do such as 1:1, exercise class or puzzles. During an interview on 09/22/23 at 09:04 A.M., Registered Nurse (RN) T said sometimes the weekend activity is a movie and popcorn for those residents who can participate. During an interview on 09/22/23 at 9:33 A.M., the Director of Nursing (DON) and the Administrator said residents should have sensory and touch activities that are specific to the resident's needs and participation level. Dependent resident activities include one on ones weekly or more often when there are guests leading the group activities that will free up the activity staff. The Administrator said weekends usually have a staff member available to offer some activities but can be a struggle but do what they can the best they can.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess two sampled residents (Resident #20 and #45) for use of a restraint, failed to provide safe mechanical lift transfers for three residents (Residents #12,#16, and #18) in a manner to prevent accidents, failed to properly propel three residents (Resident #23, #39, #40) in wheelchairs in a manner to prevent accidents and failed to maintain medication safety when staff left a medication in one resident room (Resident #1). Staff failed to supervise short-order grills when heated for cooking. The facility census was 61. 1. Review of the facility's Use of Restraints Policy, dated March 2015, showed: -Restraints shall only be used to treat the resident's medical symptoms and never for the prevention of falls; -If the resident cannot remove a device in the same manner in which the staff applied it, given the resident's physical condition, and this restricts his/her ability to change position or place, the device is considered a restraint; -Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including placing a resident in a chair that prevents the resident from rising; -Prior to placing a resident in a restraint, there shall be a pre-restraining assessment and review to determine the need for restraints. Review of the Restraint Decision Guide, undated, showed staff are: -To determine the restraining effect; -To determine the enabling effect; -To determine safety hazards; -To assess and recognize problems; -To review diagnosis and identify cause; -To care plan, review treatment and management; -To review monitoring reminders. 2. Review of #20's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/16/23, showed staff assessed the resident as: -Severely cognitively impaired; -Inattentive and had disorganized thinking; -Unsteady during seated to standing and surface to surface transfers and walking; -Required two staff physical assistance for transfers and walking; -Dependent on two staff for toileting; -Did not use restraints; -Diagnosis of Alzheimer Dementia, anxiety and depression. Review of the resident's care plan, dated 09/21/23 showed: -Required extensive assistance of 1-2 staff for ambulation; -At risk for falls and history of falls; -Intervention dated 01/19/23 of assist to the recliner to promote decrease in anxiety and increase in comfort; -Did not contain direction to recline or elevate the legs of the recliner. Review of the resident's medical record on 09/20/23, showed the record did not contain a completed pre-restraint assessment. Observation on 09/19/23 at 2:02 P.M., showed the resident sat in a recliner at the nurse station with the legs in the raised position. Observation on 09/20/23 at 10:01 A.M., showed the resident sat in a recliner at the nurse station with the legs in the raised position. Observation on 09/22/23 at 8:30 A.M., showed the resident sat in a recliner at the nurse station with the legs in the raised position. Further observation showed the resident was restless and kicked his/her legs over the side of the recliner. 3. Review of #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Inattentive and had disorganized thinking; -Unsteady during seated to standing and surface to surface transfers and walking; -Required two staff physical assistance for transfers, walking and toileting; -Had one non-injury fall and one injury (except major) fall since admission or last prior assessment; -Did not use restraints; -Diagnosis of Alzheimer Dementia, anxiety and depression. Review of the resident's care plan dated 09/16/23 showed: -He/She attempts to self-ambulate but had a very unsteady gait and poor balance, required 1-2 staff for assistance; -At risk for falls related to advanced dementia and unsteady gait; -Intervention dated 05/24/23 of assist to the recliner at the nurse station between meals; -Did not contain direction to recline or elevate the legs of the chair. Review of the resident's medical record on 09/20/23, showed the record did not contain a completed pre-restraint assessment. Observation on 09/19/23 at 11:33 A.M., showed the resident in a recliner at the nurse station with the legs in the raised position. Further review showed the resident leaned to the left onto the armrest of the recliner. Observation on 09/19/23 at 2:00 P.M., showed the resident in a recliner at the nurse station with the legs in the raised position. Further observation showed the resident was restless and attempted to rise from the chair. Observation on 09/20/23 at 10:01 A.M., showed the resident in a recliner at the nurse station with the legs in the raised position. Observation on 09/20/23 at 4:11 P.M., showed the resident leaned over the left side of the recliner with his/her hands on the floor and buttocks draped over the armrest of the recliner. Further observation showed the legs of the recliner in the raised position. Observation on 09/22/23 at 8:30 A.M., showed the resident in a recliner at the nurse station with the legs in the raised position. 4. During an interview on 09/22/23 at 8:22 A.M., Certified Nurse Aide (CNA) M said Resident #20 and #45 have a tendency to throw themselves out of the recliners. He/She said the residents would not be able to rise unassisted from the recliners in the upright position. During an interview on 09/22/23 at 9:00 A.M., Licensed Practical Nurse (LPN) E said Resident #20 and #45 used to walk around the facility but started to get up by themselves and fall. He/She said that the residents could still get up by themselves out of the recliners but would probably fall doing so. He/She said the residents are not restrained, restraints are things like seat belts or locking the chairs legs up using a trash can. During an interview on 09/22/23 at 9:33 A.M., the Director of Nursing (DON) said he/she did not feel Resident #20 and #45 were restrained because the residents were unsafe to be up unassisted. He/She said Resident #20 and #45 can maneuver off the recliner but are unsafe doing so. He/She said restraints are determined by using a Decision Tree Guide then the resident is assessed quarterly and are things like gait belts on wheelchairs. 5. Review of the facility's Hydraulic lift (Hoyer Lift) Policy, dated March 2015, showed staff were directed as follows: -Open lift to widest point and set brakes; -When resident has been lifted clear of bed, grasp bar and move to chair, balance the resident while being lowered. 6. Review of Resident #12's quarterly MDS dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for transfers; -Totally dependent on one staff for eating; -Totally dependent on two plus staff for toilet use. Review of the resident's care plan, dated 02/17/23, showed direction for staff that the resident required staff assistance for all Activities of Daily Living (ADLs). Observation on 09/20/23 at 8:03 A.M., showed CNA F and CNA H transferred the resident from bed to a wheelchair using a Hoyer Lift. CNA F operated the lift while CNA H supported the resident. CNA did not open the legs of the lift to the widest position during any part of the transfer. 7. Review of Resident #16's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus staff for transfers. Review of the resident's care plan, dated 5/18/23, showed direction for staff the resident required staff assistance for all ADLs. Observation on 09/20/23 at 3:14 P.M., showed CNA I and CNA J transferred the resident from the bed to a wheelchair. The CNAs connected the mechanical lift sling to the lift device to transfer the resident. Staff did not spread the legs of the lift device when they lifted and moved the resident away from the bed. 8. Review of Resident #18's Quarterly MD'S, dated 09/0923, showed staff assessed the resident as follows: -Severe cognitive impairment; -Totally dependent on two plus persons for transfers. Review of the resident's care plan, dated 09/09/23, showed direction for staff the resident required staff assistance for all ADLs. Observation on 09/21/23 at 8:45 A.M., showed CNA K and CNA L transferred the resident from a bed to a wheelchair. CNA K moved the resident while lifted away from the bed while CNA L supported the resident. CNA L then moved away to position the wheelchair and left the resident suspended above the floor for several seconds before returning to assist in lowering the resident down to their wheelchair. 9. During and interview on 09/21/23 at 2:25 P.M., CNA M said when doing a mechanical lift they use two staff. One drives the lift and one steadies the resident. The legs of the lift device should be spread for safety. The staff stabilizing the resident should not walk away from the resident. During an interview on 09/21/23 at 3:14 P.M., CNA I said the legs of a mechanical lift device should be spread when transferring a resident and the resident should be stabilized by the staff who is not operating the lift. During an interview on 09/22/23 at 8:47 A.M., LPN A said mechanical lift legs are to spread to the widest position when transferring a resident. During an interview on 09/22/23 at 09:33 A.M., the DON said during a mechanical lift transfer, staff should make sure the legs of the lift are in the open position and the resident should not be ever left suspended in the air without hands on the sling/resident for safety. 10. Review of the facility's Wheelchair, use of Policy, dated March 2015, showed staff were directed as follows: -Apply brakes to lock wheels of wheelchair; -Lower footrests and place resident's feet on footrests if used, Position feet and legs in good body alignment; -Assist resident to the area of the facility desired. Encourage and instruct resident in proper guidelines for safely propelling the wheelchair. 11. Observation on 09/19/23 at 12:43 P.M., showed CNA G propelled Resident #23 from the dining room to the bathroom without foot pedals on his/her wheelchair. Observation on 09/19/23 12:52 P.M., showed CNA G propelled the Resident #23 from the bathroom to the dining room. Further observation showed the resident's heels drug the floor. 12. Observation on 09/19/23 at 11:59 A.M., showed the DON propelled Resident #39 in a wheelchair without foot rests rapidly into the dining area. 13. Observation on 9/20/23 at 3:40 PM., showed CNA O propelled Resident #40 at a fast pace down the length of 100 hall to the nurse's desk without foot rest. 14. During an interview on 09/19/23 at 12:46 P.M., CNA G said residents should have pedals on the wheelchairs prior to propelling them or the resident could get hurt. During and interview on 09/21/23 at 2:25 P.M., CNA M said you should use footrests when propelling a resident in a wheelchair. During an interview on 09/21/23 at 3:14 P.M., CNA I said you have to make sure the footrests are on the wheelchair before propelling the resident otherwise it is not safe. During an interview on 09/22/23 at 8:47 A.M., LPN A said wheelchairs should have foot rest on the chair regardless of the resident's ability to ambulate. During an interview on 09/22/23 at 09:33 A.M., the DON said residents should have leg rests on wheelchairs before staff propel to ensure resident safety. 15. Review of the facility's Medications, Storage of Policy, dated March 2015, showed staff were directed to do the following: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked mediation room, or one or more locked medication carts; -All mobile medication carts must be under the visual control of the staff at all time when not stored safely and securely, carts must be either in a locked room or otherwise made immobile; -The key to the medication cabinet, medication room, and/or medication cart is the responsibility of the person authorized to hand and administer medications. Review of the facility's Medication, Administration Guidelines Policy, dated March 2015, showed self administration of drugs is permitted with the written order of the attending physician. 16. Review of Resident #1's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's Physician's Orders Sheet (POS), dated 08/21/23 through 09/21/23, showed the record did not contain an order for Triamcinolone Acetonide Cream (TAC) (a medication used to treat skin conditions) or to leave the medication at the resident's bedside. Observation on 09/20/23 at 8:13 A.M., showed a tube of TAC 0.1% with a pharmacy label for the resident and directions stating apply topically two times a day (BID) laying on his/her dresser in his/her room. Observation on 09/20/23 at 10:07 A.M., showed the tube TAC cream lay on the resident's dresser in his/her room. Observation on 09/20/23 at 1:38 P.M. showed the tube of TAC cream sat on the resident's dresser. 17. During an interview on 09/21/23 at 8:58 A.M., LPN D said medications should not be left in a resident's room without a physician's order. During an interview on 09/21/23 at 9:30 A.M., Certified Medication Technician (CMT) B said medications should not be left unattended in a resident's room. During an interview on 09/21/23 at 11:09 A.M., Registered Nurse (RN) C said medications should not be left in a resident's room without a physician's order. During an interview on 09/22/23 at 8:30 A.M., LPN A said resident should never be given a medication they don't have a physician's order for. He/She said medications should not be left in a resident's room without an order. During an interview on 09/22/23 at 9:33 A.M., the DON said medications should not be given without a physician's order. He/she said medications should never be left in a resident's room without a physician's order for safety reasons. 18. Observation on 9/19/23 at 12:00 P.M., showed the door to the serving room for the South hall dining room open and unattended. The room contained hot steam tables and a hot grill within the reach of the unsupervised residents seated in the dining room. Observation on 9/20/23 at 11:39 A.M., showed the door in the South dining area serving room was open and unattended. The room contained a bubbling hot steam table and a hot grill within reach of residents passing through to the dining area. Observation on 9/20/23 at 04:16 P.M. through 04:41 P.M., showed the door in the South dining area serving room was unsupervised and open. Further observation showed steam rise from the steam table and heat come from the griddle. Staff and resident's passed the open doorway. 19. During an interview on 09/21/23 at 3:14 P.M., CNA I said the grills in the serving stations are not to be left unsupervised and the doors are supposed to be shut. During an interview on 09/22/23 at 9:01 A.M., The Dietary Manager said serving stations should not be left unattended with residents around due to the steam tables and the grills. During an interview on 9/22/23 at 9:15 A.M., Dietary Aid N said serving stations should not be left unattended by staff when in operation because it is a safety risk. During an interview on 09/22/23 at 09:33 A.M., the Administrator said steam tables and griddles should never be left unattended with the door to the room open. He/She said if the door is open, there should be a staff member present next to the steam table and griddle and one staff member in the dining area for safety.

Based on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of two medication storage rooms, and two of two medication carts sampled. The facility census was 61. 1. Review of the facility's policy titled, Medication, Storage of, dated March 2015, showed staff were directed to do the following: -All medications for resident's must be stored at or near the nurse's station in a locked cabinet, a locked mediation room, or one or more locked medication carts; -All mobile medication carts must be under the visual control of the staff at all time when not stored safely and securely, carts must be either in a locked room or otherwise made immobile; -The key to the medication cabinet, medication room, and/or medication cart is the responsibility of the person authorized to hand and administer medications; -An unattended medication cart must remain locked at all times. In the event a nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked medication room; - No discontinued, outdated, or deteriorated drugs or biological's may be retained for use. All such drugs must be returned to the pharmacy or destroyed in accordance with established guidelines. 2. Observation on 09/19/23 at 2:30 P.M., showed the north treatment cart was unlocked and unattended at the nurse's station. Observation on 09/20/23 at 1:30 P.M., showed the north treatment cart was unlocked and unattended at the nurse's station with resident's present in the area. Observation on 09/20/23 at 2:55 P.M., showed the north medication cart was unlocked and unattended at the nurse's station with resident's present in the area. Observation on 09/21/23 at 7:40 A.M., showed the north and south medication carts were unlocked and unattended in the dining room with residents in the area. The north cart had multiple over the counter (OTC) (medications that do not require a physician's prescription) bottles of medication sat on top of the cart. Registered Nurse (RN) C walked over to the north medication cart while the OTC sat out on it and continued his/her medication pass and did not put the medications in the cart. Observation on 09/21/23 at 8:10 A.M., showed multiple OTC medications continued to sit on top of the unlocked and unattended medication cart in the dining room with residents in the area. Observation on 09/21/23 at 8:12 A.M., showed the north treatment cart sat unlocked and unattended at the nurse's station with residents present in the area. Observation on 09/21/23 at 8:20 A.M., showed RN C pushed the medication cart with multiple OTC bottles of medications on top of the cart to the north hallway. Further observation showed he/she left the medications on top of the cart unattended while he/she went into a resident's room to give medications. Observation on 09/21/23 at 8:56 A.M., showed multiple bottles of OTC medications sat on top of the unattended medication cart in the hallway. Observation on 09/21/23 at 11:25 A.M., showed the South hall medication room contained: -One bottle of Acetaminophen (to treat pain) 650 milligram (mg) with 50 capsules had an expiration date of 10/22; -One bottle of Cetrizine (antihistamine) 10 mg with 50 tablets had an expiration date of 6/23. Observation on 09/21/23 at 12:20 P.M., showed the North hall medication cart contained: -One loose large white oval tablet; -One loose small oval orange tablet; -One loose small white oval tablet. Observation on 09/21/23 at 1:33 P.M., showed Licensed Practical Nurse (LPN) D left the treatment cart unlocked and unattended in the hallway when he/she went into a resident's room. Observation on 09/22/23 at 8:42 A.M., showed RN C left the medication cart unlocked and unattended in the hallway when he/she went in a resident's room. 3. During an interview on 09/21/23 at 8:58 A.M., LPN D said he/she would expect the medication and treatment carts to be locked if staff are not around them. He/She said medications should not be left on top of the carts unattended. During an interview on 09/21/23 at 9:30 A.M., Certified Medication Technician (CMT) B said that medication and treatment carts should be locked and not left unattended. He/She said medications should not be left unattended on top of the cart. During an interview on 09/21/23 at 11:09 A.M., RN C said that medication and treatment carts should not be left unlocked or unattended. He/She said medications should not be left unattended on top of the cart. During an interview on 09/22/23 at 8:30 A.M., LPN A said the medication or treatment carts should never be left unlocked and unattended. He/She said medications should not be left unattended on top of the medication carts. During an interview on 09/22/23 at 8:45 A.M., LPN A said all loose medications should be destroyed. If it is a narcotic it will be destroyed by two nurses or sent back to the Pharmacy. Medications should be locked in the medication storage room or in medications carts. During an interview on 09/22/23 at 8:58 A.M., CMT B said loose or expired medications should be destroyed. These medications are given to the Director of Nursing for destruction. During an interview on 09/22/23 at 9:00 A.M., RN C said loose or expired medication should be destroyed. Narcotics require two licensed nurses to destroy them. During an interview on 09/22/23 at 09:33 A.M., the Director of Nursing (DON) said loose, damaged and expired medications should be turned into the DON, unless it is a non-narcotic. Non-narcotic medications should be tossed and expired medications go to the DON office for the DON, Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) nurse to destroy or return to the pharmacy depending on the medication. The DON said the medication and treatment carts should not be left unlocked and unattended. He/she said medications should never be left unattended on top of the medication cart for safety reasons.

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. The census was 61. 1. Review of the Dining Services Manager policy, dated April 2011, showed the dining services manager is delegated the administrative authority, responsibility and accountability necessary for carrying out the assigned duties which included supervision of personnel in the dietary department; planning, preparing and serving regular and modified diets to the residents; documenting in resident records for items such as care plans, progress notes, weight committee reports and minimum data set (MDS) assessments; and budget management. Review showed the minimum qualifications for the dining services manager listed as: -High school diploma or General Educational Development (GED) equivalent; -Two years of experience in a supervisory capacity of a hospital, skilled nursing care facility, or other medical facility; -Certified Dietary Manager if required by state regulations. Review of the dietary manager's (DM) personnel records, showed the DM previously employed as the DM of a skilled nursing facility from 04/08/19 to 01/26/22 and hired as the facility's DM with an effective date of 09/16/23. Review showed the records did not contain documentation of certification or other education required for the director of nutritional services position. During an interview on 09/19/23 at 10:00 A.M., the administrator said they just had a new dietary manager (DM) take over on 09/16/23. The administrator said the new DM had prior experience as a DM in a skilled nursing facility, but he/she did not have a degree or certification related to food service management and he/she had not completed or been enrolled in any other educational courses related to food safety and management. The administrator said the facility had a part-time consultant registered dietician and did not have any certified or clinically qualified nutritional staff employed full-time. During an interview on 09/19/23 at 11:25 A.M., the DM said he/she had been a DM for a different skilled nursing facility from 04/18/19 to February 2022 and became the DM for this facility on 09/16/23. The DM said he/she did not have a degree or certification related to food service management and he/she had not completed or been enrolled in any other educational courses related to food safety and management. The DM said the facility had a part-time consultant registered dietician and did not have any certified or clinically qualified nutritional staff employed full-time.

Based on observation, interview and record review, the facility staff failed to serve food in accordance with the nutritionally calculated menus and standardized recipes. Facility staff also failed to record substitutions made to the menus. 1. Review of the facility's Menus policy, dated May 2015, showed: -Menus will be dated and posted on the bulletin board in the kitchen; -Standardized recipes are available in the dietary department for foods on the menu; -A food substitute should be consistent with the usual and ordinary food item provided by the facility. All substitutes provide equal nutritional value; -When substitutions are made, changes are posted on the menu or substitution sheet. If an entire meal is substituted, for instance for a special function, the meal should be posted on the menu. If a single item is substituted because it is not available, it should be posted on the substitution sheet. 2. Review of the facility lunch menus dated 09/19/23 (Week 3, Day 17), showed the menus directed staff to provide the residents with pork loin, boiled potatoes, buttered spinach, a dinner with margarine and apple crisp. Review of the substitution log posted on the reach-in refrigerator, showed the last documented food substitution dated 02/14/23. During an interview on 09/19/23 at 10:38 A.M., the administrator said the food items for lunch would be pork loin, buttered noodles, turnip greens and coconut cream pie. The administrator said they did not have any canned potatoes to make the boiled potatoes and did not have any spinach. The administrator said the apple crisp was substituted with the coconut cream pie based on residents requests. The administrator said he/she contacted the facility's consultant registered dietician earlier that morning who approved of the substitutions and directed him/her to serve the portions of the substituted items at the same sizes listed on the menus. The administrator said substitutions should be recorded on the substitution log, but he/she did not do that. 3. Review of the resident meal tray tickets on 09/19/23 at 12:30 P.M., showed the diet types for all residents consisted of regular, Level 7 Easy to Chew (EC7) (a diet that includes normal everyday foods of soft/tender textures only that are developmentally and age appropriate), Level 6 Soft and Bite-Sized (SB6) (a diet in which food pieces are no greater than 15 millimeters in size for adults, is soft, tender and moist throughout with no separate thin liquid, can be can be mashed/broken down with pressure from fork, spoon or chopsticks and requires chewing before swallowing) and pureed. Review of the facility lunch menus dated 09/19/23 (Week 3, Day 17), showed the menus directed staff to provide the residents on regular and EC7 diets with a dinner roll and margarine. Further observation showed the menus directed the staff to provide the residents on SB6 and pureed diets with a #16 pureed dinner roll with margarine. Review of the facility's lunch meal choice papers (papers with the menu and available substitutions listed on them that are provided to the residents for them to choose what food items the want) for 09/19/23, showed the papers did not include the dinner roll with margarine or any other type of bread. Observations on 09/19/23 during the lunch meal service, showed staff did not prepare regular or pureed dinner rolls for service at the meal and staff did not offer the residents the dinner roll with margarine or any other type of bread. 4. Review of the facility lunch menus dated 09/19/23 (Week 3, Day 17), showed the menus directed staff to provide the residents on regular, EC7 and SB6 diets with one half cup of buttered spinach. During an interview on 09/19/23 at 10:38 A.M., the administrator said the residents would receive turnip greens because they did not have any spinach. The administrator said he/she contacted the facility's consultant registered dietician earlier that morning who approved of the substitution and directed him/her to serve the portion of the substituted item at the same size listed on the menus. Review of the facility's recipe for turnip greens, undated, showed the recipe directed staff to serve a #8 scoop (four ounces) portion of prepared turnip greens. Observation on 09/19/23 at 12:57 P.M., showed Dietary Aide (DA) N served the residents on regular, EC7 and SB6 diets in the north dining room with a #10 scoop (3.2 ounces) of turnip greens (less than directed by the menus and recipe). During an interview on 09/19/23 at 1:01 P.M., the DA said the turnip greens were to be served with #8 scoop, but he/she did not have the right scoop. The DA said he/she notified kitchen staff that he/she needed someone to bring him/her a #8 scoop, but no one brought on so he/she used the #10 scoop instead. The DA said if staff do not have the right scoop for service then they should go back to the kitchen and get the correct one. During an interview on 09/21/23 at 11:04 A.M., the dietary manager (DM) said staff should follow menus unless otherwise requested by the residents. The DM said substitutions should be recorded on the substitution log with the reason for substitution and all menu items should be served unless requested otherwise by the residents. The DM said when bread is on the menus, staff should offer the residents bread if it is not on the meal choice papers for them to choose and if staff don't have the right portion scoop for service they should get the right one from the kitchen before they serve. During an interview on 09/21/23 at 11:23 AM, the administrator said staff should follow the nutritionally calculated menus unless otherwise requested by residents. The administrator said the residents should receive all food items indicated by the menus in accordance with their specified diet types and if staff don't have the right scoop size for something then they should go get it from the kitchen and not use the wrong one.

Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent contamination and out-dated use. 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. The facility staff also failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility census was 61. 1. Review of the facility's Receiving and Storage of Food policy, dated May 2015, showed The Dining Services Manager is responsible for receiving and storing food and nonfood items. Review of the facility's Storage of Dry Food and Supplies policy, dated May 2015, showed the policy directed: -the dietary department to store dry food and supplies in accordance with facility guidelines and state regulations; -metal or plastic containers with tight fitting covers, labeled on the top or side, must be used for the storage of opened items and only National Sanitation Foundation (NSF) approved storage containers and food grade vinyl bags are to be used for food storage; -staff to reseal opened boxes effectively, properly label bulk food containers, and tightly close food-grade plastic bags after they are opened; -staff to date stock with the date of delivery; -that severely dented, rusted, leaking and bulging cans must be placed in a separate, labeled holding area for return to the distributor. Review of the facility's Safe Food Handling policy, dated May 2015 showed: -Dietary employees will follow safe food handling guidelines to prevent the spread of foodborne illness; -All food, including bulk items, should be tightly sealed with an identifying label and date; -Only containers approved by the National Sanitation Foundation (NSF) can be used for storage. Observations on 09/19/23 at 10:40 A.M., showed the dry goods pantry contained: -an opened and undated bag of sweetened coconut flakes; -eight undated plastic storage containers of fruit whirls, honey nut toasted oats, crisp rice, corn flakes and raisin bran cereals removed from original packages; -a 42 ounce (oz.) box of quick oats opened to the air, with stock date of 8/17, without an opened date; -an opened 35 oz. bag of sugar frosted cornflakes, with stock date of 6/15, without an opened date; -an opened 35 oz. bag of cornflakes, with stock date of 7/15, without an opened date; -an opened 35 oz. bag of honey nut toasted oats, with stock date of 9/7, without an opened date; -an opened and undated 25 pound bag of brown sugar; -an undated 25 pound box of long grain enriched parboiled rice opened to the air; -a 6.56 pound can of sliced carrots with large dent on lower left facing side stored on shelf with rest of canned food items. Observation on 09/19/23 at 11:35 A.M., showed an undated package of pork roast gravy mix opened to the air on the upper shelf of the cook's food preparation table. Observations on 09/19/23 at 11:42 A.M., showed the counter beneath food preparation sink contained: -a bulk container of food thickener, removed from original packaging, with a portion scoop buried inside the product. Further observation showed a handwritten label on the container which read exp 12-4 and the exterior of the container heavily soiled with dried food debris; -an undated bulk container of pureed bread mix removed from original container; -an opened and undated 25 pound bag of flour stored inside an undated bulk container. Further observation showed the exterior of container heavily soiled with dried food debris; -an opened and undated five pound container of peanut butter. Observations on 09/19/23 at 2:24 P.M., showed the walk-in refrigerator contained: -an opened and undated one gallon bottle of soy sauce; -an opened and undated 70 oz. bottle of picante sauce; -an opened and undated five pound carton of grated parmesan cheese; -an opened and undated five pound container of commercially prepared cucumber and onion salad; -an opened and undated five pound container of sour cream; -an opened and undated one gallon container of mayonnaise; -an opened and undated 32 oz. carton of scrambled egg mix. Observation on 09/21/23 at 7:15 A.M., showed an opened and undated 46 oz. carton of cranberry juice cocktail in the reach-in refrigerator. Observations on 09/21/23 07:18 A.M., showed the dry goods pantry contained: -a 24 oz. box of quick grits, with a stock date of 10/28, without an opened date and opened to the air; -a 42 ounce (oz.) box of quick oats opened to the air, with stock date of 8/17, without an opened date; -an opened 35 oz. bag of sugar frosted cornflakes, with stock date of 6/15, without an opened date; -an opened 35 oz. bag of cornflakes, with stock date of 7/15, without an opened date; -an opened 35 oz. bag of crisp rice cereal, with a stock date of 8/3, without an opened date; -an opened 35 oz. bag of raisin bran, with stock date of 8/17, without an opened date; -an opened and undated 25 pound bag of brown sugar; -an undated 25 pound box of long grain enriched parboiled rice opened to the air; -a 6.56 pound can of sliced carrots with large dent on lower left facing side stored on shelf with rest of canned food items. Observations on 09/21/23 at 7:24 A.M., showed the counter beneath food preparation sink contained: -a bulk container of food thickener, removed from original packaging. Further observation showed a handwritten label on the container which read exp 12-4 and the exterior of the container heavily soiled with dried food debris; -an undated bulk container of pureed bread mix removed from original container; -an opened and undated 25 pound bag of flour stored inside an undated bulk container. Further observation showed the exterior of container heavily soiled with dried food debris; -an opened and undated five pound container of peanut butter. Observation on 09/21/23 at 7:26 A.M., showed the walk-in freezer contained: -an undated case of southern style biscuit dough opened to the air; -an undated case of country fried beef fritters opened to the air; -an undated case of chocolate chip cookie dough opened to the air; -an opened and undated plastic bag of six raw hamburger patties; -an undated plastic bag of sweet potato tots opened to the air; -an opened and undated plastic bag of shredded hashbrowns. During an interview on 09/21/23 at 10:57 A.M., the dietary manager (DM) said he/she is responsible to monitor for proper food storage daily when working, but he/she had not been able to do a good food storage check since he/she became the DM on 09/16/23. The DM said staff should ensure that opened food items are labeled, dated, and sealed before they are put away. The DM said food items are dated when placed in stock, so opened food items should have two dates on them, the stock date and opened date. The DM said scoops should not be stored inside bulk containers of food, which would include the food thickener and staff should wipe down the bulk containers between cleanings which occurs when they are emptied. The DM said the handwritten label on the bulk container of food thickener would indicate that the product is expired and should not be in use by staff. The DM said dented cans should not be stored with the in-use supply of food and all dietary staff are trained on proper food storage requirements. During an interview on 09/21/23 at 11:17 A.M., the administrator said the DM is responsible to monitor for proper food storage daily when he/she is on duty and would be expected to make corrections and reeducate staff as needed. The administrator said opened food items should be sealed, dated with opened date, and labeled if not identifiable before they are put away. The administrator said scoops should not be left inside bulk containers of food and staff should clean the bulk containers when they are emptied and as needed. The administrator dented cans should be stored separately from the rest of the food supply and staff are trained on proper food storage requirements upon hire and as needed. 2. Review of the facility's Dishwashing policy, dated May 2015, showed the policy directed staff to allow washed items to thoroughly dry before they unload the racks or store the items. Observation on 09/19/23 at 11:13 A.M., showed DA Q removed the food processor from mechanical dishwasher while wet and returned it to the base in the upright position. Observation on 09/19/23 at 11:20 A.M., showed the interior of the food processor remained wet and the social services director (SSD) added five cups of prepared turnip greens to the wet food processor to prepare the pureed turnip greens for service to the residents at the lunch meal. Observation on 09/19/23 at 11:40 A.M., showed seven metal food preparation/service pans of various sizes stacked together wet on the storage shelf next to the handwashing sink. Observation on 09/19/23 at 2:12 P.M., showed showed DA Q removed four sanitized metal food preparation/service pans from the clean side of the mechanical dishwashing station while wet, stacked them together and placed them on the storage shelf by the handwashing sink. Observation on 09/19/23 at 2:56 P.M., showed DA Q stacked eight sanitized inner-lip plates on the counter in the upright position while wet. Observation on 09/21/23 at 7:13 A.M., showed six insulated plastic domed plate covers stacked together wet upside down on the rack above the clean side of the mechanical dishwashing station. Observation also showed two metal food preparation/service pans stacked together wet on the storage shelf by the handwashing sink. During an interview on 09/21/23 at 11:03 A.M., the DM said cleansed dishes should be air dried prior to stacking in storage and staff are trained on that requirement. During an interview on 09/21/23 at 11:21 A.M., the administrator said cleansed dishes should be air dried before they are put away and staff are trained on that requirement. 3. Review of the facility's Handwashing policy, dated May 2015, showed the policy directed staff to wet their hands and forearms with water, lather their hands with antiseptic soap, and wash their hands, giving particular attention to the areas between the fingers, around cuticles, and under their fingernails when they wash their hands. Review showed the policy did direct staff how long to scrub their hands with soap and when to wash their hands. Review of the facility's Dishwashing policy, dated May 2015, showed the policy directed staff to sanitize their hands properly before they pull racks of sanitized dishes from the clean side of the dishwasher. Review of the handwashing instruction sign posted above the kitchen handwashing sink, showed the sign directed staff to scrub their hands with soap for at least 30 seconds when they wash their hands. Observation on 09/19/23 at 10:35 A.M., showed the SSD washed his/her hands at the handwashing sink. Observation showed the SSD scrubbed his/her hands with soap for approximately five seconds before he/she rinsed and dried them. Observation showed the SSD then donned a pair of gloves and prepared coconut cream pies for service to the residents at the lunch meal. Observation on 09/19/23 at 12:49 P.M., showed DA Q touched his/her face multiple times and then passed food trays to residents at the lunch meal without performing hand hygiene before he/she passed the trays. Observation on 09/19/23 at 2:44 P.M., showed DA Q dropped sanitized insulated plate holders and covers on the floor, picked them up, put them in the mechanical dishwasher and, without performing hand hygiene, the DA then put away sanitized dishes from the clean side of the mechanical dishwashing station and sanitized pans from the clean side of the three-compartment sink. Observation on 09/19/23 at 2:56 P.M., showed DA Q washed soiled dishes in the mechanical dishwashing station and then, without performing hand hygiene, put away sanitized dishes from the clean side of the station. During an interview on 09/21/23 at 11:05 A.M., the DM said staff should wash their hands anytime they do something dirty, which would include after they pick up a dropped item off the floor, after they wash soiled dishes and after they touch their body. The DM said staff should scrub their hands with soap for at least 20 seconds when they wash their hands and all staff are trained on proper hand hygiene procedures. During an interview on 09/21/23 at 11:41 A.M., the administrator said staff should wash their hands anytime their hands become contaminated, which would include after they pick something up off of the floor, after they wash dirty dishes and after they touch their body. The administrator said staff should scrub their hands with soap for at least 30 seconds when they wash their hands and all staff are trained on proper hand hygiene procedures upon hire, annually and as needed.

Based on observation, interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure indoor and outdoor waste containers remained covered when not in actual use. The facility census was 61. 1. Review of 2022 United States Food and Drug Administration Food Code, subsection 5-501.113 (Covering Receptacles), showed Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment. Observation on 09/19/23 at 10:00 A.M., showed two of four lids open on the outside dumpster which contained waste. Further observation showed Laundry Aide R placed trash in the open side of the dumpster and walked away without closing the lids. Observation on 09/19/23 from 11:25 A.M. to 12:26 P.M., showed the waste container in the mechanical dishwashing station, which contained food and paper waste, uncovered and the area unattended by staff. Observation on 09/21/23 at 6:30 A.M., showed two of four lids open on the outside dumpster which contained waste. Observation on 09/21/23 at 7:09 A.M., showed the waste container in the mechanical dishwashing station, which contained waste, uncovered and the kitchen unattended by staff. Further observation showed the administrator entered the kitchen and left without covering the waste container. Observation on 09/21/23 at 7:32 A.M., showed the waste container in the mechanical dishwashing station, which contained waste, remained uncovered and the kitchen unattended by staff. During an interview on 09/21/23 at 10:55 A.M., the dietary manager (DM) said waste containers should be covered at all times and staff are trained on this requirement. The DM said the staff who use the dumpster outside should make sure the lids are closed after use. During an interview on 09/21/23 at 11:16 A.M., the administrator said the facility did not have a policy for use and maintenance of waste containers. The administrator said waste containers should be covered when not in use and staff should be trained on that requirement during orientation. The administrator said everyone is responsible to ensure the outside dumpster remains covered and whomever puts trash in the dumpster should close the lids when they are done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to treat six residents (Resident #2, #4, #9, #19, #37 and #49) with dignity and respect. Staff failed to assist one resident (Resident #2) to cover himself/herself when he/she was partially undressed in view of others and discussed the resident's situation in front of other residents and staff, failed to assist two residents (Residents # 4 and #9) to cover their catheter urine collection bags, failed to empty a urinal prior to storing it in a bathroom shared by one resident (Resident #19) and his/her roommate causing odor which led to the resident not wanting to have visitors, failed to take one resident (Resident #37) to a private area when the resident refused a medication and continued to give the resident direction in front of others, staff failed to assist one dependent resident (Resident #49) to change out of soiled clothes and to dress appropriately for the time of day. The facility census was 63. 1. Review of the facility's Resident Rights Policy, undated, showed each resident will be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/9/22, showed staff assessed the resident as: -Cognitively intact; -Diagnoses of dementia without behavioral disturbance, Need for assistance with personal care, other lack of coordination, and muscle weakness (generalized); -Required limited one staff assistance for toileting; -Required extensive one staff assistance for dressing and personal hygiene; -Always incontinent of bladder. Observation on 9/7/22 at 8:57 A.M., showed the resident in his/her doorway with their pants down to their knees. He/She asked Certified Nurses Aide (CNA) D for assistance as he/she passed by the resident's room. The CNA said they would help the resident, walked to the nurses station, stated in front of other staff and residents that Resident #2 was at his/her doorway with his/her pants down. Further observation showed the staff walked back toward the resident saying, why me, why me? During an interview on 9/12/22 at 11:47 A.M., CNA A said he/she would assist the resident if they requested assistance, especially if the resident was exposed with their pants were down. He/She said the staff member who noticed the resident with their pants down, should have assisted them, and not told other staff. He/She said it is not acceptable for a staff member to make comments in regard to the resident needing care. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said he/she expects staff to help the residents, if they are partially exposed, and not announce to others the resident's situation. LPN B said staff should not talk under their breath or make remarks about helping a resident. During an interview on 9/12/22 at 11:37 A.M., the MDS Coordinator said if a resident asked for assistance, staff should assist the resident promptly. He/She said staff should not talk negatively about a resident or tasks. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said staff are expected to assist residents who request help without announcing the resident's needs or muttering under their breath. 3. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Neuromuscular dysfunction of bladder, retention of urine, unspecified; -Required extensive one staff assistance for bed mobility, transfers, eating, dressing, toileting, and personal hygiene; -Totally dependent on one staff assistance for locomotion on and off of the unit; -Indwelling urinary catheter. Observation on 9/7/22 at 1:21 P.M., showed the resident in bed with his/her catheter bag hung on the bed frame with urine visibly seen from the hallway. Observation on 9/8/22 at 9:31 A.M. showed the resident in bed with his/her catheter bag hung on the bed frame with urine visibly seen from the hallway. 4. Review of Resident #9's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of a stroke and paraplegia; -Extensive one staff assistance for dressing and toileting; -Indwelling urinary catheter. Observation on 9/6/22 at 11:10 A.M. showed the resident in bed with his/her catheter bag hung on the bed frame with urine visibly seen from the hallway. Observation on 9/7/22 at 1:20 P.M. showed the resident in bed with his/her catheter bag hung on the bed frame with urine visibly seen from the hallway. Observation on 9/9/22 at 10:24 A.M. showed the resident in bed with his/her catheter bag hung on the bed frame with urine visibly seen from the hallway. During an interview on 9/8/22 at 2:08 P.M., the resident said he/she is unable to cover his/her catheter bag. During an interview on 9/12/22 at 11:37 A.M., the MDS Coordinator said catheter bags should be placed in dignity bags. He/She said CNAs should ensure the residents' dignity and privacy by having the catheter bags covered. During an interview on 9/12/22 at 11:47 A.M., CNA A said they are directed to ensure catheter bags are placed in privacy bags. During an interview on 9/12/22 at 11:47 A.M., LPN B said the residents should have privacy bags for their catheter drainage bag and tubing, and they should be used when they are up and about. He/She said he/she did not know if the resident's had privacy bags on their beds. He/She said the CNAs are responsible for making sure catheter drainage bags are covered. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said he/she expects CNAs to keep catheter bags covered. 5. Observation on 9/7/22 at 8:22 A.M., showed Resident #19's room smelled of urine, and strong urine odor lingered in the resident's bathroom. A plastic bag hung in the bathroom and contained a urinal, which had urine in it. During an interview on 9/7/22 at 8:22 A.M., the resident said the urine smell in his/her room makes him/her feel awful and afraid for visitors to come in. He/She said it smelled bad because his/her roommate is frequently incontinent and the bathroom smells. Observation on 9/8/22 at 8:18 A.M., showed the resident's room smelled of urine. Observation on 9/8/22 at 8:24 A.M., showed the hallway outside of the resident's room smelled of urine. During an interview on 9/15/22 at 2:00 P.M., CNA H said the resident has complained to him/her before about his/her roommate going to the bathroom and not changing their clothes. He/She said the resident always complains about every little thing. He/She said urinals and bed pans are supposed to be stored in large bags and hung over the safety rails in the bathrooms. He/She said the bags are supposed to be changed every couple of days, and the urinals and bedpans are supposed to be cleaned before they are stored in the bags. He/She said he/she would get rid of the bag and get a new one if it had urine in it. He/She said if the bag had visible urine in it it could cause the room to smell. During an interview on 9/15/22 at 2:18 P.M., LPN P said staff had not reported to him/her that the resident's room or hallway smelled of urine. He/She said urinals and bedpans should be cleaned and stored in bags in the residents' bathrooms. He/She said urine should not be in urinals when they are placed in the storage bags. He/She said if there was urine in the bag it could cause the room to smell like urine. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said staff should address offensive room odors as they are noticed. 6. 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 with bed mobility, transfers, dressing, eating, toileting, and personal hygiene; -Did not reject care. Observation on 9/6/22 at 11:11 A.M., through 11:23 A.M., showed an unidentified staff member, in a hallway with other residents around, attempted to get Resident #37 to swallow a pill, even though the resident had refused it. The staff member repeated, swallow the pill, swallow, and swallow it. Further observation, showed another staff member came over to assist and both staff members took the resident to the Spa room, so the resident could spit the pill out. During an interview on 9/12/22 at 11:47 A.M., CNA A said if a resident refused care it should be reported to the charge nurse, so they can see if someone else could encourage the resident. He/She said he/she would come back later to see if the resident had changed their mind. During an interview on 9/12/22 at 11:47 A.M., LPN B said if a resident refused a medication, they should be taken to a private area to see if they would like to spit it out. He/She said staff should not stand over the resident and repeatedly tell them to swallow their medicine. During an interview on 9/12/22 at 11:37 A.M., the MDS Coordinator said if a resident was holding medications in their mouth the resident should be encouraged to swallow them by giving them a drink or a bite to eat, and if that did not work, ask the resident to spit it out. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said if a resident refuses care such as medications, staff should encourage them to swallow the medication, offer a drink or bite of food, or encourage them to spit it out. He/She said it could be seen as undignified if staff persisted to tell the resident to swallow medications. 7. Review of Resident #49's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately Cognitively Impaired; -Totally dependent on two staff members for dressing; -Required the supervision of one staff member for eating; -Had diagnoses of stroke; -Did not reject care. Observation on 9/7/22 at 8:43 A.M., showed Resident #49 had a yellow substance on his/her nightgown and blanket. Observation on 9/7/22 at 2:44 P.M., showed the resident continued to wear the same stained nightgown. The resident's clothes had not been changed. During an interview on 9/15/22 at 2:05 P.M., CNA H said if staff see food on a resident's clothes or blankets they should wipe it off. They said if the resident still looked sloppy they should change their clothes. He/She said it's a dignity issue if it's not cleaned up. During an interview on 9/15/22 at 2:21 P.M., LPN P said he/she expects residents to be dressed in clothes other than a nightgown during the day, unless staff has been directed otherwise. LPN P said if a resident's clothes had food on them he/she would expect staff to clean them, and if they couldn't he/she would expect them to change the resident's clothes. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said residents should have their clothing changed if soiled.

Based on observation and interview, facility staff failed to ensure resident's personal information was protected when they left the Medication Administration Records (MARs) open and unattended in public hallways for eight residents (Residents #2, #4, #16, #25, #26, #28, #33, and #46). The facility census was 63. 1. Review of the facility's Resident Rights Policy, undated, showed each resident will be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. Observation on 9/7/22 at 9:23 A.M. showed Certified Medication Aide (CMT) C left the medication cart unattended with resident #4's MAR displayed. Further observation showed two staff members and one resident passed by the medication cart with Resident #4's information displayed. Observation on 9/7/22 at 9:26 A.M. showed CMT C left the medication cart unattended with resident #16's MAR displayed. Further observation showed three staff members and two residents passed the medication cart with Resident #16's information displayed. Observation on 9/8/22 at 10:18 A.M., showed the MAR open and unattended on the 300 hall hallway. The MAR displayed eight residents' (Resident #2, #4, #16, #25, #26, #28, #33, and #46) information. Further observation showed one resident sat in the area with the information displayed. Observation on 9/8/22 at 10:32 A.M., showed (Certified Nurse Aide) CNA/CMT J left the MAR open and unattended, at the north nurses' station, with resident information displayed. During an interview on 9/12/22 at 11:37 A.M., the Minimum Data Set (MDS) Nurse said when staff walk away from the medication cart, staff must maintain privacy by locking the medication cart with everything on the cart put away, and the computer screen should be put down or the walk away button should be pushed. Further, the MDS Nurse said if a medication cart was left open or the MAR open on the computer screen, he/she would correct the situation immediately and then pull aside the staff responsible for the medication cart for re-education. During an interview on 9/12/22 at 11:47 A.M., CNA A said the CNAs are directed to make sure the medication or treatment carts are locked before leaving them unattended and to lock the screens, so the residents information is not visible to others. During an interview on 9/12/22 at 11:47 A.M., Licensed Piratical Nurse (LPN) B said staff are expected to clear the top of the medication cart, lock it, and close down the screen before the cart is left unattended. He/She said he/she would lock the cart and close the screen if he/she found a cart unattended with resident information displayed. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said staff are expected to close the screen before leaving a treatment or medication cart unattended so resident information is not exposed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility staff failed to maintain a clean, comfortable and homelike environment. Facility staff failed to maintain resident rooms and restrooms free of chipped paint and holes in the walls. Facility staff failed to maintain resident restrooms free of floor discolorations and missing bolt covers and caulk. The facility census was 63. 1. Review of the policies provided by staff showed staff did not provide a Facility Maintenance Policy. 2. Observation on 9/6/22 at 10:49 A.M., showed Resident #62's room had chipped paint and a hole in the wall behind the resident's bed. Observation on 9/6/22 at 11:07 A.M., showed resident room [ROOM NUMBER] had an area of chipped paint and multiple holes in the wall. Observation on 9/6/22 at 1:37 P.M., showed resident room [ROOM NUMBER] had several areas of chipped paint and large holes in the wall. Observation on 9/7/22 at 8:18 A.M., showed resident room [ROOM NUMBER] had an area of chipped paint and multiple holes in the wall. During an interview on 9/6/22 at 1:37 P.M., the resident said the facility is aware of the issues, and his/her family had been told they would not fix the holes until he/she moved out. 3. Observation on 9/6/22 at 11:42 A.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. Observation on 9/7/22 at 9:32 A.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. Observation on 9/8/22 at 2:12 P.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. Observation on 9/9/22 at 9:44 A.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. 4. Observation on 9/6/22 at 11:45 A.M., showed the restroom for room [ROOM NUMBER] had a rust discoloration on the floor and missing caulk around the base of the toilet. Observation on 9/7/22 at 10:18 A.M., showed the restroom for room [ROOM NUMBER] had a rust discoloration on the floor and missing caulk around the base of the toilet. Observation on 9/8/22 at 2:13 P.M., showed the restroom for room [ROOM NUMBER] had a rust discoloration on the floor and missing caulk around the base of the toilet. Observation on 9/9/22 at 9:44 A.M., showed the restroom for room [ROOM NUMBER] had a rust discoloration on the floor and missing caulk around the base of the toilet. 5. Observation on 9/6/22 at 11:48 A.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. Observation on 9/7/22 at 10:37 A.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. Observation on 9/8/22 at 2:13 P.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. Observation on 9/9/22 at 9:45 A.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. 6. Observation on 9/6/22 at 11:42 A.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. Observation on 9/7/22 at 10:41 A.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. Observation on 9/8/22 at 2:13 P.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. Observation on 9/9/22 at 9:44 A.M., showed the restroom for rooms [ROOM NUMBERS] had a rust discoloration on the floor around the base of the toilet and uncovered toilet bolts. 7. During an interview on 9/12/22 at 12:11 P.M., Housekeeper F said chipped paint or gouges in the walls should be reported to the maintenance staff. Housekeeper F said he/she had tried to get the rust stains around the toilets out, but was not able. He/She said he/she had not reported this to the maintenance department. During an interview on 9/12/22 at 11:25 A.M., the Maintenance Director said if there were problems for the maintenance department to address, staff fills out a work order and leaves it at the nurses' station and maintenance staff checks for these every morning. He/She said if walls had chipped paint or gouges and it was determined the cause was a repetitive issue such as electric wheelchairs or headboards bumping the repairs were postponed until the resident no longer lived in the room. The Maintenance Director said discoloration on the floor around the toilets were the responsibility of the housekeeping department. During an interview on 9/12/22 at 11:37 A.M., the Minimum Data Set (MDS) nurse, (the nurse responsible for maintaining a federally mandated assessment tool), said staff should fill out a maintenance slip if a maintenance issue is noted, and the maintenance department is responsible for addressing the problem. The MDS nurse said if a resident has marred walls and it was determined the resident would continue to mar the same area, wall repairs are made after the resident no longer uses that room. During an interview on 9/12/22 at 11:47 A.M., Certified Nurse Aide (CNA) A said all staff are responsible for reporting issues. He/She said the aides report issues to the nurse, who fill out a maintenance slip. He/She said the maintenance department is responsible for fixing the issues. He/She said he/she did not know of any environmental issues. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said he/she has not noticed any holes in the walls, chipped paint, or rust and discoloration around the base of toilets in resident's bathrooms. He/She said they have a desk pin they put notes on for maintenance to go through daily. During an interview on 9/6/22 at 11:47 A.M., LPN B said if staff is aware of any issues in the rooms, there are maintenance slips at the nurses' station to write any concerns on. He/she said maintenance checks the slips every day. He/She was not aware of any issues or holes in the wall. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said they do not have a policy on reporting maintenance issues but staff are directed to fill out a maintenance slip located at each nursing station with issues observed such as chipped paint, holes in drywall or rusty/dirty areas in patient rooms. He/she said maintenance looks at those slips every day and corrects the problem or contracts out the issue if needed. The DON said if the chipped paint or holes in the wall are near resident beds, the facility does not fix the issues until the resident is discharged or moved out of the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for four residents (Resident #21, #41, #48, & #58) to meet their medical and nursing needs. The facility census was 63. 1. Review of the facility's care plan policy, dated March 2015, showed: -The interdisciplinary care plan team with input from the resident, family, and/or legal representative will develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the Minimum Data Set; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -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 #21's Significant Change Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 9/8/22, showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from two staff members for bed mobility; -Required total assistance from two staff members for transfers, and toileting; -Required total assistance from one staff member for dressing; -Required extensive assistance from one staff member for eating and personal hygiene; -Did not reject care. Review of the resident's care plan, dated 7/18/22, showed staff documented the resident required assistance from one to two staff members for ADLs. Further review showed it did not contain direction in regard to the resident's facial hair preferences. Observation on 9/6/22 at 12:31 P.M., showed the resident had hair on his/her upper lip. Observations on 9/12/22 at 12:46 P.M., showed the resident had hair on his/her upper lip. 3. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance from one staff member for bed mobility, transfers, dressing, toileting and personal hygiene; -Did not refuse care. Review of the care plan, dated 8/4/22, showed it did not contain direction for staff in regard to the resident's facial hair and nail preferences. Observation on 9/6/22 at 10:55 A.M., showed the resident had long nails that varied in length and hair on his/her upper lip and chin. Observation on 9/7/22 at 8:37 A.M., showed the resident had long nails that varied in length and hair on his/her upper lip and chin. Observation on 9/9/22 at 1:46 P.M., showed the resident had long that varied in length and hair above his/her upper lip and chin. Observation on 9/12/22 at 12:39 P.M., showed the resident had long that varied in length and hair on his/her upper lip and chin. During an interview on 9/6/22 at 10:55 A.M., the resident said he/she asked the staff to cut his/her nails, but was told his/her nails were short enough. 4. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from two staff members for bed mobility, transfers, and toileting; -Required total assistance from one staff member for dressing, eating and personal hygiene; -Did not refuse care. Review of the resident's care plan, dated, 8/7/22, showed it did not contain direction for staff in regard to the resident's facial hair preference. Observation on 9/6/22 at 1:36 P.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 9/7/22 at 2:12 P.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 9/8/22 at 10:48 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 9/9/22 at 8:41 A.M., showed the resident had facial hair on his/her upper lip and chin. 5. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Had diagnoses of Alzheimer's Dementia (progressive disease of the brain that causes memory and cognitive impairment), Muscle Weakness, Difficulty Walking, Lack of Coordination, and Unsteady on Feet; -Required one staff physical assistance for transfers; -Dependent on one staff for locomotion. Review of the resident's Device Assessment, dated 8/26/22, showed staff documented the resident used a geri-chair used for positioning. Review of the resident's care plan, reviewed 8/29/22, showed it did not contain direction for staff in regard to geri-chair (padded chair designed to help seniors with limited mobility) use for the resident. Observation on 9/7/22 at 8:18 A.M., showed the resident sat reclined in a geri-chair in the activity room. Observation on 9/8/22 at 8:37 A.M., showed the resident sat reclined in a geri-chair next to the nurses station. 6. During an interview on 9/12/22 at 11:37 A.M., the MDS Coordinator said care plans should be updated within one day of receipt of a new order. Care plans should address transfers, mobility, eating, diet and nutrition, code status, wounds, oxygen use, catheter presence and care, incontinence, use of psychotropic medications, bedrails, individualized chairs and splints. He/She said when their sister facility shut down and they received those residents it was a lot to take on. He/She said they could not keep on the resident's care plans. He/She said skin problems were not usually covered in the care plan unless it was a chronic issue, such as a wound. He/She said resident preferences such as facial hair were not listed on the care plan. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said he/she did not know how often the care plan and MDS are updated. He/She said he/she tells the Director of Nursing (DON), Assistant Director of Nursing (ADON), or the MDS Nurse if any changes to the care plan are needed. He/She said he/she would expect catheters, oxygen use, splints, transfers, specialized chairs, and wound care to be listed on the care plan. He/She said he/she would also expect skin treatments and care listed on the care plan. LPN B said he/she expects care plans to be updated with order changes. He/She would expect facial hair to be addressed. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said the staff communicate changes through paper communication at the desks and the care plan is left for the DON or administration to update. He/she said care plans should be updated daily with changes, and they should address splints and contracture management, use of positioning devices such as geri-chairs, catheter use, restorative therapy. He/she said facial hair and nail care were not added to the care plan since the residents often change their minds. He/she said he/she would expect the CNA's to ask the residents if they want to be shaved, and if the resident has poor cognition, he/she would expect staff to find out their preferences with the family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide professional standards of care when they failed to assess and document the clinical status of two wounds on a routine basis to monitor for improvement or decline in the areas for one resident (Resident #62). Failed to prepare insulin as directed by the manufacturer for one resident (Resident #33), and failed to ensure three residents (Residents #49, #61, and #51), who received oxygen, had their tubing and canisters labeled. Additionally facility staff failed to notify the physician for one resident (Resident #51), who had a fall and failed to provide contracture management for two residents (Resident #48 and #53). The facility census was 63. 1. During an interview, the (Director of Nursing) DON said they did not have a wound assessment policy. 2. Review of Resident #62's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 5/24/22, showed staff assessed the resident as: -Cognitively Intact; -Required limited assistance from one staff member for bed mobility; -Required extensive assistance from one staff member for transfers; -Required extensive assistance from one staff member for toilet use; -Used a walker and a wheelchair; -Occasionally incontinent of bladder; -Had diagnoses of heart failure, hypertension (high blood pressure), hyperlipidemia (high cholesterol); -At risk for pressure ulcers; -Had no unhealed pressure ulcers at Stage 1 or higher; -Had no open lesion(s) on the foot; -Did not receive pressure ulcer care; -Did not use pressure reducing device for chair or bed. Review of the resident's nurses' notes, dated July 2022 to September 2022, showed staff documented: -7/4/22 at 1:19 P.M., First assessed a quarter size soft discolored area to right heel, treatment of skin-prep (protective barrier) started, and to float heels; -7/9/22 at 1:00 P.M., Right heel soft area; -7/10/22 at 7:18 P.M., Explained treatment orders and received optifoam (foam dressing) to heel one time a day and skin-prep; -7/19/22 at 9:01 P.M. Small open area to buttock. Staff did not document they notified the NP or physician of the newly identified wound; -7/20/22 at 12:34 A.M., Treatment continues to small blackened area to Right heel; Review showed staff did not document further in regard to the right heel or buttock wounds. Review of the Nurse Practitioner's (NP) G Note, dated 7/11/22, showed: -Chief complaint: Foot ulcers; -Pressure Injury of skin of heel, unspecified injury stage, unspecified; -Right heel intact blister; -Right heel blister without evidence of surrounding infection - will skin-prep daily with goal of keeping blister intact; -Continue boots to float heels. Review of the Wound Management Detail Reports, dated July 2022 to September 2022, showed staff did not complete an initial or weekly assessment of the areas to the resident's buttock or right heel to assess improvement or decline in areas such as size, depth, drainage, and pain. Review of the resident's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Mild Cognitive Impairment; -Required limited assistance of one person physical assistance with bed mobility; -Required extensive assistance of one person physical assistance with transfers; -History of heart failure, hypertension, PVD (peripheral vascular disease, circulation illness affecting lower extremities), hyperlipidemia; -Was at risk for pressure ulcers; -No unhealed pressure ulcers; -Other open lesion(s) on the foot; -Used pressure reducing device for chair and bed, and application of dressing to feet; -Received Hospice services. Review of the resident's care plan, updated 8/25/22, showed staff were directed to: -Consider postural alignment, weight distribution, balance stability, and pressure relief when positioning in chair or wheelchair; -Skin assessment and inspection every shift with close attention to heels; -Examine skin during bathing for signs and symptoms of breakdown, report any breakdown immediately to charge nurse; -Review showed it did not address the resident's wound to his/her buttock staff identified on 7/19/22. Review of the POS, dated 09/01/22-09/06/22, showed the resident's physician directed staff to apply skin prep to the right heel discolored soft area once a day until healed. Observation on 9/06/22 at 10:49 A.M., showed the resident rested on an air mattress (pressure-relieving to provide high levels of support for the body and the head and thus relieve any pressure point stress) with bilateral heel boots on. Multiple brown spots were seen on the bed sheet around the feet, and a foul odor lingered at the end of the bed. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said skin assessments should be completed once a week and the aides are supposed to let the nurses know if a resident has a new or worsening area in between time. He/She said it is the expectation of the staff to contact the doctor and follow up with orders and treatments. He/She said the Assistant Director of Nursing (ADON) measures the residents wounds and all areas of concern. He/She did not know where the wound documentation would be located. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said he/she believed there was poor documentation regarding the resident's skin. He/she said it is the responsibility of the nursing staff to run a weekly report on all the wounds and lay eyes on everything the facility is doing for wounds. He/she said if the treatments are not appropriate or if something is deteriorating a communication form would be filled out and sent to the physician regarding changes in the wound and the staff would follow the physician's direction/orders. The DON said if the wound is not open or boggy, then the treatments are effective and staff would not need to document on them weekly and continue the treatment. He/she said if the wound opens a weekly skin assessment would be documented until the wound heals. He/She said the nurse or whomever finds the wound would initiate a skin assessment and treatment and the following business day the he/she would evaluate it, and initiate a wound order or treatment. During an interview on 9/15/22 at 2:23 P.M., LPN P said if a resident has a wound it should be reported to the nurse and the nurse should document the measurements and wound characteristics. He/She said wound documentation should be completed by the nurse who the wound is reported to. He/She said he/she did not know why wound documentation would not be done. During an interview on 9/15/22 at 2:28 P.M., the DON said the resident did not have a wound on his/her right heel. He/She said if there was discoloration he/she would have expected the nurses to obtain a treatment and document the area in the progress notes. He/She said pressure ulcer documentation should include the stage of the wound, measurements, drainage, odor, tissue type, treatment and whether or not the wound was improving. He/She said he/she would not expect a pressure ulcer assessment for the right heel wound. He/She said he/she, the Assistant Director of Nursing (ADON) and the the MDS Coordinator complete the wound assessments. 3. Review of the facility's Medication Administration Policy, dated March 2015, showed it did not contain direction for staff in regard to insulin administration. Review of Resident #33's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 8/10/22, showed staff assessed the resident as: -Severe Cognitive Impairment; -Short and long term memory problems; -Diagnoses of diabetes mellitus. Observation on 9/8/22 at 9:36 A.M., showed Certified Medication Technician (CMT) J did not prime the resident's insulin pen before he/she administered the resident's insulin. During an interview on 9/8/22 at 9:40 A.M., CMT J said he/she does not prime insulin pens before he/she administers insulin to the residents. He/She said the only time he/she primes an insulin pen is when it's new. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said he/she did not know when an insulin pen should be primed. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said nursing staff are directed to prime the insulin pens and waste the primed amount. He/She said then they should dial the correct dosage and inject the medication. 4. Review of the facility's Oxygen Administration policy, dated March 2015, showed the purpose is to administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues and directs staff to: -Label humidifier with date and time opened; -Change humidifier and tubing per cleaning guidelines; -Check and clean oxygen equipment, masks, tubing and cannulas at regular intervals. 5. Review of Resident #49's Physician Order Summary (POS), dated September 2022, showed: -1/28/22: Oxygen tubing to be changed monthly if in use as needed (PRN). Review of the resident's Treatment Administration Record (TAR) showed it did not contain documentation staff changed, labeled or dated the resident's oxygen tubing. Observation on 9/6/22 at 10:59 A.M., showed Resident #49 had oxygen on at 2.5 Liters Per Minute (LPM). The oxygen tubing was not labeled or dated. Observation on 9/6/22 at 1:40 P.M., showed Resident #49 laid in bed. He/She wore his/her oxygen at 2.5 LPM. The oxygen tubing was not labeled or dated. Observation on 9/7/22 at 8:43 A.M., showed Resident #49 sat in his/her wheelchair. He/She wore his/her oxygen at 2.5 LPM. The oxygen tubing was not labeled or dated. During an interview on 9/12/22 at 11:47 A.M., LPN B said the oxygen tubing is changed by the nurses twice a month and it should be labeled with the staff's initials and date it was changed. 6. Review of Resident #61's 5-day MDS, dated [DATE], showed staff assessed the residents as: -Cognitively impaired; -Had diagnoses of Respiratory failure (lungs fail to get enough oxygen to the blood), Hypertension (high blood pressure), Osteomyelitis (infection or inflammation to the bone or bone marrow), and Congestive Heart Failure (CHF) (condition that affects the hearts ability to pump blood); -Had shortness of breath with exertion; -Received oxygen therapy; Review of the resident's POS, dated 8/19/22, showed an order for oxygen at 2 LPM to be delivered via nasal cannula (NC) continuously. Further review of the orders showed it did not contain direction for staff in regard to when to change the oxygen tubing or humidifier. Observation on 9/6/22 at 1:42 P.M., showed the resident in bed with oxygen in place via nasal cannula at 2 LPM. The oxygen tubing and humidifier were not labeled or dated. Observation on 9/7/22 at 8:10 A.M., showed the resident in his/her wheelchair with oxygen in place via NC at 2 LPM. The oxygen tubing and humidifier were not labeled or dated. Observation on 9/8/22 at 8:32 A.M., showed the resident in his/her wheelchair with oxygen in place via nasal cannula at 2 LPM. The oxygen tubing and humidifier were not labeled or dated. During an interview on 9/12/22 at 12:53 P.M., the DON said oxygen tubing should be changed monthly on the evening shift by nursing staff. He/she said he/she did not know when the tubing or humidifiers were last changed for resident #51 or #61. He/she did not know there was not an order to change the tubing for resident #61. The DON said anyone that is trained to use oxygen can direct residents on the use of oxygen and adjust the flow. 7. Review of Resident #51's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required extensive assistance from one staff member for bed mobility, and dressing; -Required total assistance from two staff members for transfers and toileting; -Required limited assistance from one staff member for eating; -Required total assistance from one staff member for personal hygiene; -Did not use oxygen; -Did not refuse care. Review of the resident's care plan, dated 8/10/22, showed staff assessed the resident was at risk for falls due to significant debility and very poor weight bearing, with a fall documented on 8/10/22. Further review, showed staff are directed to report all falls to the physician. Review of the progress notes, dated 8/10/22 through 8/11/22, showed they did not contain documentation that staff notified the physician of the resident's fall. Review of the POS, dated 1/31/22, showed an order for oxygen at 2-5 LPM per NC PRN for shortness of breath. Observation on 9/6/22 at 1:43 P.M., showed the resident wore oxygen. Further observation, showed the oxygen tubing and the humidifier bottle were not labeled or dated. Observation on 9/07/22 at 2:11 P.M., showed the resident's oxygen tubing and humidifier were not labeled or dated. Observation on 9/9/22 at 2:09 P.M., showed the resident's oxygen tubing and humidifier were not labeled or dated. 8. During an interview on 9/12/22 at 11:47 A.M., LPN B said oxygen should be included on the physician's orders, as well as when to change the tubing. He/She said oxygen tubing should be changed two times per month, as well as labeled with the staff's initials of whoever changed it out, and the date. He/She said the nurses are responsible for changing the tubing. He/She said humidifiers should be checked every shift by the aides and they're responsible for changing the humidifiers. He/She said it is the nurses responsibility to make sure both items are changed. He/She said it is the nurses responsibility to make sure residents are wearing their oxygen as they should. If a resident refuses or continually takes their oxygen off, he/she would try different approaches and contact the doctor. During an interview on 9/22/22 at 12:53 P.M., the DON said he/she expects staff to notify the physician if a resident falls. He/she said he/she did not know if the physician was notified when resident #51 fell. They said nursing should change the oxygen tubing, and it should be changed monthly on the evening shift. He/she did not know when the tubing or humidifiers were last changed. 9. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the residents as: -Severe cognitive impairment; -Required total assistance from two staff members for bed mobility, transfers, and toileting; -Required total assistance from one staff member for dressing, eating and personal hygiene; -Did not receive restorative care or therapy services during the look back period; -Did not refuse care. Review of the resident's care plan, dated 8/7/22, showed staff documented the resident had osteoarthritic contractures in both upper and lower extremities. Review of the POS, undated, showed it did not contain an order for therapy or restorative care services. Observation on 9/6/22 at 1:36 P.M., showed the resident hands were contracted. Observation on 9/7/22 at 8:23 A.M., showed the resident hands were contracted. Observation on 9/8/22 at 10:48 A.M.,showed the resident hands were contracted. Observation on 9/9/22 at 8:41 A.M., showed the resident hands were contracted. During an interview on 9/9/22 at 9:13 A.M., Registered Nurse (RN) H said there is no restorative care orders for the resident's contracted hands, but he/she was going to contact the nurse practitioner to address the hands. He/She said the resident was admitted to the facility with his/her hands being contracted. 10. Review of Resident #53's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -Had diagnoses of Cerebral Palsy (disorder affecting movement, muscle tone and balance) and Seizures (sudden, uncontrolled disturbance in the brain causing changes in behavior, movements, feelings and consciousness); -Required one staff physical assistance for dressing; -Had not received restorative services in the look-back period. Review of the resident's POS, dated 8/8/22 through 9/8/22 showed it did not contain an order for a right hand splint. Review of the resident's care plan, reviewed 8/17/22, showed it did not contain direction for staff in regard to a right hand splint for the resident. Observation on 9/7/22 at 8:15 A.M., showed the resident wore a splint to their right hand. Observation on 9/8/22 at 8:16 A.M., showed the resident wore a splint to their right hand. 11. During an interview on 9/9/22 at 12:59 A.M., the Director of Rehabilitation (DOR) said the restorative program stopped due to Covid-19. He/She said they are restarting the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure five residents (Residents #11, #21, #41, #48 and #62), that were unable to complete their own activities of daily living (ADL), received the necessary care and services to maintain good personal hygiene. The facility census was 63. 1. Review of the facility's Shaving the Resident Policy, dated March 2015, showed the purpose is to remove facial hair and improve the resident's appearance and morale. Review of the facility's Nails, Care of (Finger and Toes) Policy, dated March 2015, showed: -The purpose is to provide cleanliness, comfort, and prevent the spread of infection; -The nursing assistants may perform nail care on the residents who are not at risk for complications of infection. The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease. 2. Review of Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 7/3/22, showed staff assessed the resident as: -Severe cognitive impairment; -Required assistance from one staff member for personal hygiene and bathing; -Did not refuse care. Observation on 9/6/22 at 11:00 A.M., showed the resident had long hairs on his/her chin. Observation on 9/8/22 at 10:37 P.M., showed the resident had long hairs on his/her chin. 3. Review of Resident #21's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from two staff members for toileting; -Required total assistance from one staff member for dressing; -Required extensive assistance from one staff member for personal hygiene; -Did not reject care. Observation on 9/06/22 at 12:31 P.M., showed the resident had hair on his/her upper lip. Observation on 9/12/22 at 12:46 P.M., showed the resident had hair on his/her upper lip. 4. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance from one staff member for dressing, toileting and personal hygiene; -Did not refuse care. Observation on 9/6/22 at 10:55 A.M., showed the resident had long nails with varied lengths and hair on his/her upper lip and chin. Observation on 9/7/22 at 8:37 A.M., showed the resident had long nails with varied lengths and hair on his/her upper lip and chin. Observation on 9/9/22 at 1:46 P.M., showed the resident had long nails with varied lengths and hair on his/her upper lip and chin. Observation on 9/12/22 at 12:39 P.M., showed the resident had long nails with various lengths and hair on his/her upper lip and chin. During an interview on 9/6/22 at 10:55 A.M., the resident said he/she asked the staff to cut his/her nails, but was told his/her nails were short enough. 5. Review of Resident #48's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Required total assistance from two staff members for bed mobility, transfers, and toileting; -Required total assistance from one staff member for dressing, eating and personal hygiene; -Did not refuse care. Review of the care plan, dated, 8/7/22, showed staff documented the resident had osteoarthritic contractures in both upper and lower extremities. Observation on 9/6/22 at 1:36 P.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 9/7/22 at 2:12 P.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 9/8/22 at 10:48 A.M., showed the resident had facial hair on his/her upper lip and chin. Observation on 9/9/22 at 8:41 A.M., showed the resident had facial hair on his/her upper lip and chin. 6. Review of Resident #62's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Mild cognitive impairment; -Required extensive assistance from one staff member for toileting and personal hygiene; -Did not refuse care. Observation on 9/6/22 at 10:49 A.M. showed resident had long hairs on his/her upper lip, chin, and neck. 7. During an interview on 9/12/22 at 11:47 A.M., Certified Nurse Aide (CNA) A said the aides are responsible for nail care and shaving, unless the resident is a diabetic. He/She said the residents nails and facial hair should be addressed during showers. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said all staff should check for long facial hair and nails. He/She said the nurses are responsible for trimming the nails of the diabetic residents and aides are responsible for trimming all the other resident's nails. He/She said residents should be shaved on shower days and as needed by the aides. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said the CNAs are responsible to ensure shaving and nail care is completed during showers unless the resident is diabetic. He/She said if the resident is a diabetic, nail care is completed by the nurses.

**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 staff failed to properly store environmental hazards, failed to properly propel three residents (Resident #6, #28, and #59) in wheelchairs in a manner to prevent accidents, and failed to use the Hoyer lift (an assistive device used to help transfer residents between a bed and chair) in a manner to prevent accidents for one resident (Resident #1). The facility census was 63. 1. Review of the facility policy and procedure manual showed they did not have a policy for hazardous chemical storage, or sharps storage for razors, toenail clippers, scissors, or sewing pins. 2. Observation on 9/6/22 at 11:19 A.M., showed the 300 hall Spa unlocked and unattended with a plugged in hairdryer draped over a paper towel holder. The hairdryer cord hung in the sink, under the faucet. In addition, observation showed an unlocked and unattended cabinet that contained: -An open bottle of Complete TB (cleaning solution) labeled, Call poison control if ingested; -An open bottle of [NAME] Triple (Disinfectant) labeled, Harmful if inhaled; and -One unprotected disposable razor. Observation on 9/7/22 at 8:55 A.M., showed the 300 hall Spa unlocked and unattended with a plugged in hairdryer draped over a paper towel holder. The hairdryer cord hung in the sink, under the faucet. In addition, observation showed an unlocked and unattended cabinet that contained: -An open bottle of Complete TB labeled, Call poison control if ingested; -An open bottle of [NAME] Triple labeled, Harmful if inhaled; and -One unprotected disposable razor. Observation on 9/7/22 at 10:15 A.M., showed a hair dryer in the bowl of a sink in the spa located near the Physical Documentation Room. Further observation showed the hair dryer plugged into a ground fault circuit interrupter (GFI/GFCI, a type of outlet which precisely monitors the balance of electrical current moving through a circuit. If the power goes where it shouldn't, like in a short, the GFCI immediately cuts off the electricity) and water dripped from the faucet onto the hair dryer. During an interview on 9/7/22 at 10:16 A.M., the maintenance director said the hair dryer should not be stored in the sink due to the potential for electrical shock. He said staff should not count on the GFCI outlet to protect them from shock, because you cannot always count on a GFCI to work. The maintenance director said the spa is not locked, and residents have access to the room. He did not know if staff have received training on sources of electrical shock, but staff and residents should know better than to leave a hair dry in the sink. 3. Observation on 9/6/22 at 11:29 A.M., showed the Beauty shop door open, unlocked, and unattended. A sign hung on the door that said Do not lock salon door. Additional observation showed a bottle of Pure Hard Surface (A disinfectant) on the counter labeled Contact poison control if ingested. 4. Observation on 9/6/22 at 12:07 P.M., showed the north clean linen closet unlocked and unattended. Additional observation showed: -A disposable razor -45 denture cleansing tablets labeled, Contact poison control immediately if ingested. Observation on 9/7/22 at 9:00 A.M., showed the north Clean Linen Closet unlocked and unattended. Additional observation showed: -A disposable razor -45 denture cleansing tablets labeled, Contact poison control immediately if ingested. Observation on 9/8/22 at 8:46 A.M., showed the north Clean Linen Closet unlocked and unattended. Additional observation showed: -A can of Airwick Fresh Everyday Fresh Scent 24/7 Pet Odor Neutralization labeled, Contact poison control if ingested. -42 denture cleansing tablets labeled, Contact poison control immediately if ingested. 5. Observation on 9/7/22 at 2:46 P.M., showed the 100 hall north Spa unlocked and unattended with a loose hand rail on the left side of the toilet. Additional observation, showed an unlocked and unattended cabinet that contained: -8 disposable razors; -An open bottle of [NAME] Triple labeled, Harmful if inhaled. Observation on 9/8/22 at 8:30 A.M., showed the 100 Hall North Spa unlocked and unattended that contained a loose hand rail on the left side of the toilet and an unlocked and unattended cabinet. 6. Observation on 9/6/22 at 1:36 P.M., showed the South Hall Spa in the hallway unlocked and unattended with a cabinet with a sign on it stating These Cabinets Must Remain Locked which was unlocked and unattended. Items inside the cabinet included: -2 hand held hair dryers; -1 curling iron; -A box of sharps with 2 unprotected razors on top of the lid; -A jar of Petroleum Jelly labeled, Keep out of reach of children, do not get in eyes; -A tube of Antifungal Cream labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control; -A tube of Smooth and Cool Protectant labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control. -A zippered container sitting on a chair which contained Toning Glow labeled Keep of reach of children, disposable gloves recommended, wash thoroughly after use. -A jug of Soothe and Cool Cleanse with a pump labeled For external use only, avoid contact with eyes. Observation on 9/7/22 at 10:22 A.M., showed the South Hall Spa in the hallway unlocked and unattended with a cabinet unlocked and unattended. Items inside the cabinet included: -2 hand held hair dryers; -A curling iron; -A box of sharps with 2 unprotected razors on top of the lid; -A jar of Petroleum Jelly labeled, Keep out of reach of children, do not get in eyes; -A tube of Antifungal Cream labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control; -A tube of Smooth and Cool Protectant labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control'; -A jug of Soothe and Cool Cleanse with a pump labeled For external use only, avoid contact with eyes. Observation on 9/8/22 at 12:12 P.M., showed the South Hall Spa in the hallway unlocked and unattended with a cabinet unlocked and unattended. Items inside the cabinet included: -2 hand held hair dryers; -A curling iron; -A box of sharps with 2 unprotected razors on top of the lid; -A jar of Petroleum Jelly labeled, Keep out of reach of children, do not get in eyes; -A tube of Antifungal Cream labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control; -A tube of Smooth and Cool Protectant labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control'; -A jug of Soothe and Cool Cleanse with a pump labeled For external use only, avoid contact with eyes. 7. Observation on 9/6/22 at 1:48 P.M., showed the South Hall Spa near the nurses' station unlocked and unattended with a cabinet unlocked and unattended. Items inside the cabinet included: -A tube of Antifungal Cream labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control; -A tube of Smooth and Cool Protectant labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control'; Observation on 9/7/22 at 10:23 A.M., showed the South Hall Spa near the nurses' station unlocked and unattended with a cabinet unlocked and unattended. Items inside the cabinet included: -A tube of Antifungal Cream labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control; -A tube of Smooth and Cool Protectant labeled, Keep out of reach of children, if swallowed contact medical help or contact poison control. 8. Observation on 9/6/22 at 2:00 P.M., showed the South Clean Linen Closet unlocked and unattended with the shelves and floor with the following supplies: -A box of toe nail clippers; -A box of Denture Clean Tablets labeled, Do not put in mouth. Keep out of reach of children, if swallowed contact professional help or contact poison control'; -6 boxes of 50 razors; -4 bottles of Mouthwash labeled, Keep out of reach of children, if swallowed contact medical help or contact poison center; -6 bottles of Sooth and Cool Cleanser, labeled For external use only, avoid contact with eyes; -A box on the floor containing multiple items including items mentioned above. Observation on 9/7/22 at 10:24 A.M., the South Clean Linen Closet unlocked and unattended with the shelves and floor with the following supplies: -A box of toe nail clippers; -A box of Denture Clean Tablets labeled, Do not put in mouth. Keep out of reach of children, if swallowed contact professional help or contact poison control'; -6 boxes of 50 razors; -4 bottles of Mouthwash labeled, Keep out of reach of children, if swallowed contact medical help or contact poison center; -6 bottles of Sooth and Cool Cleanser, labeled For external use only, avoid contact with eyes; -A box on the floor containing multiple items including items mentioned above. Observation on 9/9/22 at 2:12 P.M., showed the South Clean Linen Closet unlocked and unattended with the shelves and floor with the following supplies: -A box of Denture Clean Tablets labeled, Do not put in mouth. Keep out of reach of children, if swallowed contact professional help or contact poison control'; -5 bottles of Mouthwash labeled, Keep out of reach of children, if swallowed contact medical help or contact poison center; -6 bottles of Sooth and Cool Cleanser, labeled For external use only, avoid contact with eyes; -A box on the floor containing multiple items including items mentioned above. 9. Observation an unattended treatment cart located at the North Nurses Station, on 9/6/22 at 12:04 P.M., showed two closed Nystatin (treats fungal or yeast infections of the skin) 100,000 units/gram powders, and one opened Nystatin 100,000 units/gram powder lay on top of the cart. 10. Observation on 9/8/22 at 10:18 A.M., showed Salonpas Lidocaine patches (for pain relief) on top of an unattended medication cart in 300 hallway. During an interview on 9/12/22 at 11:37 A.M., the Minimum Data Set (MDS) nurse, (the nurse responsible for maintaining a federally mandated assessment tool), said CNAs should check shower rooms for safety throughout their shift, and charge nurses are encouraged to inspect the shower rooms at the beginning of their shifts. If items are found in the spa rooms that are not supposed to be out, staff should immediately put those items away. He/She said razors should be kept in a locked cabinet and a sharps container should be in the cabinet as well. The MDS Nurse said any poison or toxic chemicals should be out of reach of the residents. The Clean Linen closet should not have hazardous items in the closet. During an interview on 9/12/22 at 11:47 A.M., Certified Nurse Aide (CNA) A said razors are locked in a cabinet. He/She said all staff are responsible for checking the shower room when in there. He/She said if staff notice razors or other dangerous items laid out, then they would properly dispose of the items. He/She said there is no lock on the shower room doors. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said he/she does not know how often the shower rooms are inspected and said the CNAs are to check the spa rooms every shift. Said he/she would put sharps and chemicals back in the locked cabinet. He/She said the spa rooms are not locked but the cabinets should be locked. He/She said the clean linen supply stays unlocked and chemicals are not stored in linen closet. He/She said chemicals are supposed to be locked up and out of reach of residents. During an interview on 9/12/22 at 12:52 P.M., the Director of Nursing (DON) stated hazardous chemicals should be out of reach and in a locked cabinet. During an interview on 9/12/22 at 12:53 P.M., the DON said the CNA's should check the shower rooms daily throughout their shift for hazards including razors and chemicals and encouraged the charge nurses to check them at the top of their shift but he/she said they do not do it. He/she expects if sharps or other hazards are found the staff are to secure them in a locked area including the cabinet in the shower room. He/she was not aware the cabinet in he shower room was left unlocked. 11. Review of Resident #29's Five Day Scheduled Assessment MDS, a federally mandated assessment tool, dated 8/3/22, showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance from two staff members for bed mobility and transfers. Review of Resident #10 Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Resident #10 shared a room with Resident #29. Observation on 9/6/22 at 11:32 A.M., showed sewing pins and a pair of large scissors lay unattended on the table in the residents' room. Observation on 9/6/22 at 1:30 P.M., showed Resident #29 used sewing pins and a pair of large scissors lay on the table in his/her room. Observations on 9/7/22 at 8:25 A.M., showed sewing pins and a pair of large scissors lay unattended on the table in the resident's room. Observation on 9/8/22 at 2:52 P.M., showed sewing pins and a pair of large scissors lay unattended on the table in the resident's room. Observation on 9/9/22 at 8:43 A.M., showed sewing pins and a pair of large scissors lay on the table in the resident's room. During an interview on 9/12/22 at 11:47 A.M., Certified Nurse Aide (CNA) A said he/she did not know the resident had stick pins and scissors out in the room, and was not sure if the items should be put away or not. He/She was not sure how the other residents are kept safe if they wandered into the resident's room. During an interview on 9/12/22 at 11:47 A.M., LPN B said residents with sharp objects in their rooms should be educated on storage of those objects when not in use. He/She said there are not measures in place which he/she knows of to ensure other residents do not take items. During an interview on 9/12/22 at 12:53 P.M., the DON said residents may have items such as scissors and or stick pens in their room depending on the orientation of the resident. 12. 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 directed staff to: -Lower footrests and place resident's feet on footrests if used; -Position feet and legs in good body alignment; -Elevate leg(s) as ordered. 13. Review of Resident #6's Annual MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact; - Independent for locomotion on and off of the unit; - Wheelchair used as an assistive device. Observation on 9/6/22 at 10:07 A.M. showed Certified Nurses Aide (CNA) H propelled Resident #6 from the entrance, past the nurses station, and down 300 hall without foot pedals. 14. Review of Resident #28's Annual MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact; - Diagnoses of osteoarthritis, unspecified site, urinary tract infection (UTI), and open wound to right foot; - Independent without staff assistance for locomotion on the unit; - Required extensive assistance from one staff for locomotion off the unit; - Wheelchair used as an assistive device. Observation on 9/8/22 at 8:20 A.M. showed an unidentified staff propelled the resident from the dining room to 300 hall without a foot pedal on the left side of the resident's wheelchair. The resident's foot skimmed the ground a few times and he/she could not elevate his/her foot well. 15. Observation on 9/08/22 at 11:40 P.M., showed CNA wheeled Resident #59 in his/her wheelchair from the nurses' station to the dining room. The wheelchair did not have foot pedals. During an interview on 9/9/22 at 11:54 A.M., CNA M said staff are instructed to make sure residents' feet are up on pedals before propelling them in a wheelchair. During an interview on 9/9/22 at 12:12 P.M., CNA N said staff should make sure foot pedals are on wheelchairs before propelling a resident. During an interview on 9/9/22 at 12:26 P.M., RN O said staff should only propel residents in wheelchairs when the pedals are on and the residents' feet are on them. During an interview on 9/12/22 at 12:53 P.M., CMT L said wheelchairs should all have foot pedals on before staff are to propel them. During an interview on 9/12/22 at 11:37 A.M., the MDS Nurse said staff should ensure residents are using the foot pedals on their wheelchairs before being propelled. If the resident refuses foot pedals, they should be encouraged to self-propel with their feet. When residents refuse foot pedals and need staff to propel the chair, the last resort could be pulling them backwards, or the CNA would go extremely slow and residents would be asked to hold up their feet. During an interview on 9/12/22 at 11:47 A.M., CNA A said staff are directed to use foot pedals when propelling residents in wheelchairs. He/she said staff was instructed about two months ago regarding propelling without pedals. During an interview on 9/12/22 at 11:47 A.M. LPN B said he/she said staff are to make sure foot pedals are on and positioned correctly if a resident is propelled in their wheelchair. He/She said he/she has been in-serviced on foot pedals and wheelchair use about three months ago. He/She said if resident refused to use foot pedals and still wanted staff to propel them, he/she would reeducate the resident and get with DON or whomever is in charge. During an interview on 9/12/22 at 12:53 P.M., the DON said staff are expected to make sure the foot pedals are on the wheelchair and the residents feet are elevated on them when propelling residents. 16. Review of the facility's Hydraulic lift (Hoyer Lift) Policy, undated, showed: -Purpose: To enable one individual to lift and move a resident safely; -Open lift to widest point and set brakes; -Position resident comfortably. Review of the Invacare Reliant 450 RPL450-2 (Hoyer Lift) Owner's Manual, dated 2018, showed the Hoyer lift legs must be in the maximum opened/locked position for optimum stability and safety. Observation on 9/8/22 at 10:08 A.M., showed Certified Nurse's Aide (CNA) H and Licensed Practical Nurse (LPN) I transferred Resident #1 with a Hoyer lift. Additional observation, showed staff did not open the legs of the lift when they transferred the resident. During an interview on 9/15/22 at 2:14 P.M., LPN P said he/ she would expect staff to extend the legs of the Hoyer for all transfers. During an interview on 9/15/22 at 2:28 P.M., the DON said he/ she would expect the legs of the Hoyer to be spread for safety during movement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to assess six residents (Resident #2, #14, #26, #29, #41, and #61) for the use of bed rails. Additionally staff failed to complete ongoing entrapment assessments, and/or obtain consent for the use of bedrails. The facility census was 63. 1. The facility staff did not provide a bedrail safety policy. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/9/22, showed staff assessed the resident as: -Cognitively intact; -Diagnoses of dementia without behavioral disturbance, Need for assistance with personal care, other lack of coordination, and muscle weakness (generalized); -Required extensive one staff assistance for bed mobility and transfers; -Did not use bed rails. Review of the resident's medical record showed it did not contain on-going bed rail assessments or entrapment assessments. Observation on 9/6/22 at 11:13 A.M., showed the resident in bed with grab bars raised on both sides. Observation on 9/7/22 at 9:32 A.M., showed the resident in bed with grab bars raised on both sides. Observation on 9/8/22 at 3:36 P.M., showed the resident in bed with grab bars raised on both sides. 3. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Dependent for transfers; -Required extensive two staff assistance for bed mobility and toileting; -Required extensive one staff assistance for bathing, personal hygiene and wheelchair mobility; -Required the use of a wheelchair. Review of the resident's medical showed staff documented a Quarterly Side Rail Assessment, dated 6/30/22. The assessment did not contain an updated entrapment assessment. Observation on 9/6/22 at 11:44 A.M., showed the resident's bed had a bedrail raised on the right side. Observation on 9/6/22 showed the resident in bed with a bedrail raised on the right side. Observation on 9/7/22 at 9:05 A.M., showed the resident in bed with a bedrail raised on the right side. Observation on 9/8/22 at 9:17 A.M., showed the resident in bed with a bedrail raised on the right side. During an interview on 9/8/22 at 9:17 A.M., the resident they had used the bedrail for a long time to assist with stability during care. 4. Review of Resident #26's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of malignant neoplasm of right main bronchus, depression, spondylosis (wear and tear on spinal discs) without myelopathy (nerve damage) or radiculopathy (form of pinched nerve), lumbar region, Age-related osteoporosis (a condition in which the bones become weak and brittle); -Independent without staff assistance for bed mobility and transfers; -Did not use bed rails. Review of the resident medical record showed it did not contain a bedrail assessment, consent, or an entrapment assessment. Additionally, staff did not address the use of bedrails on the resident's care plan. Observation on 9/6/22 at 11:31 A.M., showed the resident's bed had bedrails raised both sides. Observation on 9/6/22 at 1:38 P.M., showed the resident's bed had bedrails raised on both sides. Observation on 9/7/22 at 9:38 A.M., showed the resident's bed had bedrails raised on both sides. Observation on 9/8/22 at 10:22 A.M., showed the resident's bed had bedrails raised on both sides. During an interview on 9/7/22 at 9:38 A.M., the resident said they used the bedrails for transfers and bed mobility. 5. Review of Resident #29's 5-Day Assessment MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance from two staff members for bed mobility and transfers. -Did not use bed rails. Review of the resident's medical record showed it did not contain ongoing bedrail assessments. Review of the Physician Order Summary (POS), undated, showed an order for a grab bar for positioning and assistance with dressing. Review of the care plan revised 6/27/22, showed the resident used a mobility bar to assist with turning, repositioning and standing. Observation on 9/6/22 at 1:30 P.M., showed a mobility bar raised on one side of the resident's bed. Observations on 9/7/22 at 8:25 A.M., showed a mobility bar raised on one side of the resident's bed. Observation on 9/8/22 at 2:52 P.M., showed a mobility bar raised on one side of the resident's bed. Observation on 9/9/22 at 8:43 A.M., showed a mobility bar raised on one side of the resident's bed. 6. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident: -Moderate cognitive impairment; -Required extensive assistance from one staff member for bed mobility and transfers; -Did not use bed rails. Review of the resident's medical record showed it did not contain ongoing mobility bar assessments. Review of the POS, undated, showed an order for a grab bar. Review of the care plan, dated 8/4/22, showed the resident used a grab bar to assist with repositioning and transfers in and out of bed. Observation on 9/6/22 at 10:55 A.M., showed a grab bar raised on one side of the resident's bed. Observation on 9/7/22 at 8:36 A.M., showed a grab bar raised on one side of the resident's bed. Observation on 9/8/22 at 10:16 A.M., showed a grab bar raised on one side of the resident's bed. Observation on 9/9/22 01:47 PM., showed a grab bar raised on one side of the resident's bed. Observation on 9/12/22 at 12:39 P.M., showed a grab bar raised on one side of the resident's bed. 7. Review of Resident #61's 5-day MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Had diagnoses of Respiratory failure (lungs fail to get enough oxygen to the blood), Hypertension (high blood pressure), Osteomyelitis (infection or inflammation to the bone or bone marrow), and Congestive Heart Failure (CHF) (condition that affects the hearts ability to pump blood); -Required physical assistance of two staff for transfers; -Required physical assistance of one staff for bed mobility; -Did not have behaviors or reject care; -Did not use of bedrails. Review of the resident's POS, dated 3/30/22, showed a mobility bar may be used to assist in self positioning in bed and with transfers. Review of the resident's device assessment, dated 3/9/22 and signed on 3/29/22, showed mobility bars may be used for mobility. Review of the resident's medical record showed it did not contain an ongoing device assessment for June 2022. Observation on 9/6/22 at 1:42 P.M., showed the resident in bed with a grab bar raised on one side. 8. During an interview on 9/8/22 at 2:59 P.M., the Administrator said staff do not routinely document or inspect bedrails/grab bars. He/She said he/she expects staff to verbally inform the maintenance staff if there is an issue with the side rails/grab bars. He/She said the maintenance staff installs the bed rails. He/She said staff do not document entrapment assessments. During an interview on 9/12/22 at 11:25 A.M., the Maintenance Director said he/she installs the rails on the bed when asked to do so. He/She said nursing assesses the residents and rails for safety, and if there is an issue they are to inform the maintenance staff. During an interview on 9/12/22 at 11:37 A.M., the MDS Coordinator said nursing assesses the residents for bedrails safety and check for informed consent on a quarterly basis with MDS assessments. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said therapy staff orders the bedrails and performs the assessments. He/she did not know how often therapy completed the bedrail assessment and did not know who completed the entrapment assessments. During an interview on 9/12/22 at 11:47 A.M., Certified Nurse Aide (CNA) A said maintenance staff is responsible for completing the bedrail entrapment assessments, but he/she did not know how often they were completed. He/She did not know who was responsible for bed rail assessments and obtaining consent. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said the facility did not have a mobility bar policy but he/she expects the care plans to address them if the resident uses them. He/she said the use of mobility bars should be determined by an Interdisciplinary Team (IDT) before they are used, and If it is determined they are appropriate, maintenance applies the device and completes the measurements for entrapment. He/She said the nursing staff should complete a bedrail screening and ensure a consent form has been signed. The bedrail assessments should initially be completed by the nurse managers, and then quarterly assessments should be completed with the MDS assessments. He/She said mobility bars should have a physician's order.

Based on observation, interview and record review, the facility staff failed to serve meals in accordance with the nutritionally calculated menus for two residents (Residents #50 and #57) who received Level 7 Easy to Chew (a diet in which food pieces are smaller or greater than 15 millimeters in size for adults and does not include hard, tough, chewy, fibrous, stringy, crunchy, or crumbly bits, pips, seeds, fibrous parts of fruit, husks or bones) and three residents (Residents #1, #4 and #16) who received Level 6 Soft and Bite-Sized (SB)(a diet in which food pieces are no greater than 15 millimeters in size for adults, is soft, tender and moist throughout with no separate thin liquid, can be can be mashed/broken down with pressure from fork, spoon or chopsticks and requires chewing before swallowing) diets. The facility staff also failed to document and maintain a record of substitutions made to the menus. The facility census was 63. 1. Review of the facility's Menus policy, dated May 2015, showed: -Menus shall meet the nutritional needs of the resident in accordance with the attending physician's orders and the recommended dietary allowances; -The original set of menus should be kept in the Dietary Services Manager's office with copies made for the staff to use; -Menus will be dated and posted on the bulletin board in the kitchen; -A food substitute should be consistent with the usual and ordinary food item provided by the facility; -When substitutions are made, changes are posted on the menu or substitution sheet. If a single item is substituted because because it is not available, it should be posted on the substitution sheet. Dated records of substitutions are retained for 30 days. 2. Review of Resident #50's physician orders dated September 2022, showed the resident's physician directed staff to provide the resident with a Level 7 Easy to Chew diet. Review of Resident #57's physician orders dated September 2022, showed the resident's physician directed staff to provide the resident with a Level 7 Easy to Chew diet. Review of the facility lunch menus dated 09/08/22 (Week 2, Day 12), showed the menus directed staff to serve residents on Level 7 Easy to Chew diets with: -a #8 (four ounce) scoop of SB minced and moist (MM) pork rib patty; -a #8 scoop of pureed potato salad. During an interview on 09/08/22 at 10:00 A.M., the Dietary Manager (DM) said they substituted the pork rib patties with pork patties because they did not have the pork rib patties. The DM also said he/she does not maintain a record of substitutions made to the menus and he/she did not know he/she needed one. The DM said he/she chooses substitutions from the dietician approved list posted on refrigerator. The DM said the substituted items should be served the same as what is on the menu. Observation on 09/08/22 of the lunch meal service in the south dining room which began at 12:00 P.M., showed staff served Residents #50 and #57 a three ounce portion whole pork patty and #8 scoop of regular potato salad. During an interview on 09/08/22 at 12:08 P.M., the DM said he/she did not look at the menus prior to service and did not know the Level 7 Easy Chew diets were supposed to receive SBMM pork and pureed potato salad. 3. Review of Resident #1's physician orders dated September 2022, showed the resident's physician directed staff to provide the resident with a Level 6 SB diet. Review of Resident #4's physician orders dated September 2022, showed the resident's physician directed staff to provide the resident with a Level 6 SB diet. Review of Resident #16's physician orders dated September 2022, showed the resident's physician directed staff to provide the resident with a Level 6 SB diet. Review of the facility lunch menus dated 09/08/22 (Week 2, Day 12), showed the menus directed staff to serve residents on Level 6 SB diets with: - a #8 scoop of pureed potato salad; -a #10 (3.2 ounce) scoop of pureed mock pecan pie. During an interview on 09/08/22 at 10:00 A.M., the DM said they substituted the mock pecan pie with apple dump cake. The DM said there was no reason they could not have made the mock pecan pie as directed by the menus and they just decided to change it. The DM said he/she was told they could use a variety of desserts as long as they had a recipe and the dietician signed off on it. The DM said he/she did not have a recipe for the apple dump cake. The DM also said he/she does not maintain a record of substitutions made to the menus and he/she did not know he/she needed one. The DM said the substituted items should be served the same as what is on the menu. Observation on 09/08/22 of the lunch meal service in the south dining room which began at 12:00 P.M., showed staff served Residents #1, #4 and #16 a #8 scoop of regular potato salad and a #10 scoop of regular apple dump cake. During an interview on 09/08/22 at 12:08 P.M., the DM said he/she did not look at the menus prior to service and did not know the Level 6 SB diets were supposed to receive pureed potato salad and pureed cake. 4. During an interview on 09/09/22 at 9:04 A.M., the administrator said staff should prepare and serve foods in accordance with the planned menus. The administrator said it is acceptable for staff to make substitutions to the menu when food items are not available, but they should not make substitutions just because they feel like. The administrator said staff are expected to document substitutions made to the menus and he/she did not know the staff were not writing them down. The administrator also said staff should have recipes for substituted items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to use hand hygiene and provide perineal care in a manner to reduce the risk of infection for one resident (Resident #63), failed to provide wound care in a manner to reduce the risk of infection for one resident (Resident #28), and indwelling catheter (tubing placed into the bladder to drain urine into a bag) care in a manner to reduce the risk of infection for one resident (Resident #50). Additionally, facility staff failed to decrease the risk of infection for four residents (Resident #4, #19, #34, and #61) with indwelling catheters by keeping the tubing off the floor, the facility failed to handle medications in a manner to reduce the risk for infection, and failed to cleanse a Hoyer lift (mechanical device used to lift and transfer a resident) between residents. The facility census was 63. Review of the facility's Handwashing policy, dated March 2015, showed the purpose is to reduce transmission of organisms from resident to resident, nursing staff to resident and resident to nursing staff. Further review showed it did not contain direction on when staff are to wash their hands or perform hand hygiene. Review of the facility's Perineal Care policy, dated March 2015, showed the purpose is to clean the perineum and prevent infection and odor and directed the staff to: -Position the resident, wash the resident with warm wet washcloth, rinse and pat dry resident, roll resident to side and wash resident bottom with warm wet washcloth, rinse and dry resident, reposition resident to back, remove gloves and wash hands. 1. Observation on 9/07/22 at 2:19 P.M., showed Certified Nurse Aide (CNA) D put on gloves before entering Resident #63's room, but did not perform hand hygiene. Observation showed there was no hand sanitizer on the supply cart. CNA D wiped the resident's buttocks, put a new incontinence pad under the resident wearing the same soiled gloves. CNA D removed his/her gloves, but did not perform hand hygiene before he/she covered the resident with a blanket, and gave the resident his/her call light. CNA D did not perform hand hygiene before leaving the room. During an interview on 9/7/22 at 2:30 P.M., CNA D said staff are directed to use hand hygiene before and after providing care and before leaving the room. He/She did know to use hand hygiene before entering the room and putting on gloves. He/She should have performed hand hygiene before touching the clean incontinence pad, touching the resident's blanket, and before leaving the room. He/She said there was no hand sanitizer on the cart where the gloves and other perineal care supplies were located, so he/she did not perform hand hygiene before putting on the gloves. During an interview on 9/12/22 at 11:47 A.M., CNA A said staff are directed to clean hands before putting on gloves and starting a procedure. Gloves should be changed and hand hygiene performed after cleaning the resident with a soapy cloth and before rinsing the perineal area with a new washcloth. He/She said staff should remove gloves and perform hand hygiene after providing care and before moving onto another task. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said staff should perform hand hygiene before and after providing direct care to a resident, if hands become soiled, and when going from dirty to clean. During an interview on 9/12/22 at 12:53 P.M., the Director of Nursing (DON) said nursing staff is expected to wash hands when they enter and leave a room and when taking off gloves. Staff should wash or use gel between dirty and clean tasks. The DON said staff should not touch clean linens after completing dirty tasks without hand washing. 2. Review of the facility's Dressing Change (Clean) policy, undated, showed staff are instructed: -Put on second pair of disposable gloves; -Spray wound cleanser onto gauze to be used for cleaning, if required; -Cleanse wound; -Wash hands, sanitize and change gloves. Review of Resident # 28's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 7/25/22, showed staff assessed the resident as: - Cognitively intact; - Diagnoses of osteoarthritis, urinary tract infection (UTI), and open wound to right foot; - Two facility acquired, stage II (a shallow open ulcer with a red or pink wound bed) pressure ulcers. Observation on 9/7/22 at 1:22 P.M., showed Certified Medication Technician (CMT) C did not perform hand hygiene before he/she applied gloves and initiated wound care. The CMT wiped the wound on the resident's right big toe multiple times with the same gauze. CMT C changed gloves and did not perform hand hygiene. Further observation showed the CMT wiped the wound on the resident's right heel multiple times with the same gauze. During an interview on 9/12/22 at 11:47 A.M., LPN B said staff are to start in the center of the wounds and wipe in a circular motion outward. Staff should not wipe the area multiple times with the same gauze. During an interview on 9/12/22 at 11:37 A.M., the MDS Nurse said staff are expected to perform hand hygiene before entering the resident's room and to apply gloves before touching the resident for wound care. Hand hygiene and glove changes should occur every time staff touches a dirty area and before a cleaner area is touched. While cleansing a wound, gauze should be changed between cleansing one area and then another. After wound care staff should perform hand hygiene as they exit the room. During an interview on 9/12/22 at 12:53 P.M., the DON said hand hygiene should be performed before and after care and after dirty tasks and before clean care tasks. He/she would expect nursing staff to cleanse a wound starting at the center of the wound and work outward in a circular manner. The DON said the same gauze should not drag across the wound more than one time. 3. Review of the facility's Catheter Care (Indwelling) policy, dated March 2015, showed: -The purpose is to prevent infection and reduce irritation; -Staff should wash hands, apply gloves, use a washcloth to cleanse the the skin around the catheter insertion site and change position of the washcloth after each stroke or downward motion, rinse with a clean washcloth, use a clean warm soapy washcloth to cleanse and rinse the catheter from insertion site to approximately four inches outward, check tubing and drainage bag to insure proper drainage, and wash and dry hands. -The policy did not contain direction to keep the drainage bag or tubing off the floor. 4. Review of Resident #50's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of heart failure, high blood pressure, neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem), stroke, dementia, depression, and lung disease; -Had an indwelling catheter. Review of the resident's physician orders showed: -On 3/11/22 the physician ordered staff to complete catheter care every shift; -On 3/15/22 the physician ordered staff to change the indwelling foley catheter and may irrigate foley as needed with a diagnosis of neurogenic bladder. Observation on 9/7/22 at 8:51 A.M., showed CNA I washed his/her hands and applied gloves, cleansed the resident's groin area between the resident's legs with a washcloth, and then use a new washcloth to cleanse the catheter insertion site. CNA I did not sanitize his/her hands or change gloves prior to cleansing the catheter insertion site. During an interview on 9/12/22 at 11:37 A.M., the MDS Nurse said staff are expected to perform hand hygiene before entering the resident's room and to don (apply) gloves before touching the resident. Hand hygiene and glove changes should occur every time staff touches a dirty area and then before a cleaner area is touched, and perform hand hygiene as staff exits the room. During an interview on 9/12/22 at 11:47 A.M., CNA A staff should use hand hygiene and put on new gloves before providing care. Gloves should be removed and hand hygiene used before moving from one area to another. During an interview on 9/12/22 at 12:53 P.M., the DON said nursing staff should perform hand hygiene when entering and leaving the room and before and after cleansing the catheter. 5. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of Neuromuscular dysfunction of bladder, presence of urogenital implants, retention of urine, unspecified; -Required extensive assistance from one staff for bed mobility, transfers, eating, dressing, toileting, and personal hygiene. Review of the resident's Physicians Order Sheet (POS), dated September 2022, showed an order for an indwelling urinary catheter for a diagnosis of Neurogenic bladder. Observation on 9/6/22 at 11:19 A.M., showed the resident's catheter tubing touched the ground under his/her wheelchair. Observation on 9/6/22 at 11:29 A.M., showed CNA J propel the resident from his/her room to the dining room. The resident's catheter tubing touched the floor. Observation on 9/6/22 at 12:14 P.M., showed the resident sat in the dining room, his/her catheter tubing touched the floor. Observation on 9/6/22 at 3:31 P.M., showed the resident sat in his/her room, his/her catheter tubing touched the ground under his/her wheelchair. Observation on 9/7/22 at 1:21 P.M., showed the resident in bed, his/her catheter bag touched the floor. Observation 9/8/22 at 9:31 A.M., showed the resident in bed, his/her catheter bag touched the floor. 6. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Did not refuse care; -Required extensive assistance from one staff member for personal hygiene; -Had an indwelling catheter. Observation on 9/6/22 at 1:48 P.M., showed Resident #19's catheter tubing rested on the floor under his/her wheelchair. Observation on 9/7/22 at 8:17 P.M., showed the resident's catheter tubing rested on the floor under his/her wheelchair. Observation on 9/7/22 at 1:21 P.M., showed the resident's catheter tubing rested on the floor under his/her wheelchair. Observation on 9/8/22 at 8:14 A.M., showed the resident's catheter tubing rested on the floor under his/her wheelchair. 7. Review of Resident #34's quarterly MDS, dated [DATE], showed staff assessed the resident as: - Cognitively intact; - Had diagnoses of high blood pressure, neurogenic bladder, quadriplegia, depression, pulmonary disease, and traumatic brain injury; - Had an indwelling catheter; - Was totally dependent on staff for toileting. Review of the resident's physician order, dated 2/10/22, showed catheter care every shift. Observation on 9/7/22 at 8:45 A.M., showed the resident sat in his/her wheelchair in his/her room with the catheter bag hooked to the side of the wheelchair. Further observation showed the catheter tubing touched the floor. 8. Review of Resident #61's 5-day MDS, dated [DATE], showed staff assessed the residents as: -Cognitively impaired; -Had diagnosis of Respiratory failure (lungs fail to get enough oxygen to the blood), Hypertension (high blood pressure), and Osteomyelitis (infection or inflammation to the bone or bone marrow); -Did not have a diagnosis of benign prostatic hyperplagia (BPH), an enlargement of the prostate gland that can cause urinary difficulty or diagnosis of urinary retention (difficulty with urination); -Had an indwelling catheter; -Required physical assistance of one staff for toileting. Review of the resident's physician order, dated 8/18/22, showed an the physician ordered an indwelling catheter for BPH with retention for the resident. Observation on 9/7/22 at 8:10 A.M., showed the resident sat in his/her wheelchair in his/her room with the catheter bag hooked to the side of the wheelchair. Further observation showed the bottom of the catheter bag touched the floor. 9. During an interview on 9/12/22 at 11:47 A.M., CNA A said the catheter tubing should be placed around the leg to prevent it from touching the floor. He/She said if the tubing did touch the floor, then it should be replaced by the nurse. During an interview on 9/12/22 at 11:47 A.M., Licensed Practical Nurse (LPN) B said he/she would expect staff to change or replace catheter tubing that had touched the floor. During an interview on 9/12/22 at 11:47 A.M., LPN B said he/she would expect catheter tubing to be underneath a resident's wheelchair and not touching the ground. He/She said if the catheter touches the floor it is to be replaced by the nurse. During an interview on 9/12/22 at 12:53 P.M., the DON said catheter bags and tubing should not rest on the floor and he/she would expect staff to correct it by maneuvering it so it did not rest on the floor. 10. Review of the facility's Medication Administration policy, dated March 2015, showed it did not contain direction for staff on how to prepare or dispense medication from a multiple dose bottle. Observation on 9/7/22 at 9:21 A.M., showed CMT C entered room [ROOM NUMBER], administered medications to the resident, exited the room, and did not sanitize his/her hands. Further observation showed the CMT touched and opened the medication cart, opened an unidentified medication and dispensed pills into his/her hand, placed one pill in a cup, and placed the remaining pills back in to the medication bottle. The CMT shut the medication cart, touched and opened the second drawer, opened an unidentified medication and dispensed pills in to his/her hand, placed one pill in a cup, and placed the remaining pills back in to the medication bottle. Observation on 9/7/22 at 9:26 A.M. showed CMT C did not sanitize his/her hands, touched and opened the medication cart, opened an unidentified medication and dispensed pills in to his/her hand, placed one pill in a cup, and placed the remaining pills back in to the medication bottle. During an interview on 9/12/22 at 11:37 A.M., the MDS Nurse said when medications are from a stock bottle, the medication should not be touched, but instead poured directly into the medication cup or into the cap of the medication bottle and then dumped into the medication cup. He/She said staff are not to touch medication with their bare hands. During an interview on 9/12/22 at 11:47 A.M., LPN B said staff are supposed to pour stock meds on to a pill counter or in the lid of the bottle, obtain the quantity, and pour them back into the bottle. Staff should not touch medication with their bare hands due to cross contamination. During an interview on 9/12/22 at 12:53 P.M., the DON said he/she expects staff to either pour medications from a bottle directly into the medication cup or into the lid of the bottle. He/she said staff should never touch medication with bare hands. 11. Review of the facility's Environmental policy, undated, showed semi-critical items that consist of items that may come in contact with mucous membranes or non-intact skin should be free from all microorganisms and should be cleansed and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Review of the facility's Implement Environmental Infection Control - Cleaning and Disinfection policy, undated, showed between each use, nondisposable medical equipment should be cleansed and disinfected. Review of the facility's Hydraulic Lift (Hoyer Lift) policy, undated, showed it did not contain direction for staff in regard to cleansing the lift after use. Observation 9/8/22 at 10:08 A.M., showed CNA H and LPN I entered Resident #1's room with a Hoyer lift, staff did not clean the lift, and staff transferred the resident from his/her bed to his/her wheelchair. LPN I pushed the lift back to the hallway, and did not disinfect the lift. Observation on 9/8/22 from 10:12 A.M. to 10:21 A.M., showed the lift remained in the hallway, and had not been cleansed or disinfected. During an interview on 9/8/22 at 10:12 A.M., CNA H said the Hoyer lift should be sanitized after each use. He/she said whoever removed the lift from the room should have sanitized it. He/she would sanitize it. During an interview on 9/15/22 at 2:14 P.M., LPN P said staff are expected to to clean the lift after every use. The lift should be cleaned before it is placed in the hallway to ensure it's not used before it's cleaned. He/She said the lift should not be left in the hallway dirty. During an interview on 9/15/22 at 2:28 P.M., the DON said he/she would expect any area of the lift that was touched by the resident to be cleaned with a disinfecting wipe. He/She said it should be cleaned after each use.

Based on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage to prevent the growth of food-borne pathogens. Facility staff also failed to store food in a manner to prevent cross-contamination and out-dated use. The facility census was 63. 1. Review of the facility's Dishwashing policy, dated May 2015, showed the policy directed staff to allow items to thoroughly dry before unloading racks or storing items. Observation on 09/06/22 at 10:28 A.M., showed multiple metal food preparation and service pans of various sizes stacked together wet on the storage shelf. Observation on 09/08/22 at 9:35 A.M., showed DA R removed coffee cups from the clean side of the mechanical dishwashing station and dried the cups with cloth towel before he/she put them away on the storage rack. Observation on 09/08/22 at 9:41 A.M., showed seven metal food preparation and service pans stacked together wet on the storage shelves. Observation on 09/08/22 at 9:47 A.M., showed three two quart plastic storage containers stacked together wet in the cabinets below the microwave. During an interview on 09/08/22 at 12:46 P.M., the Dietary Manager (DM) said staff should ensure dishes are dry before they are put away and they can dry the dishes with a towel. The DM said he/she had never been told dishes had to be air dried. During an interview on 09/09/22 at 8:58 A.M., the administrator said staff should allow dishes to air dry before they are put away. The administrator said that should be a part of their training. The administrator said it is never appropriate for staff to dry dishes with a towel. 2. Review of the facility's Storage of Dry Food and Supplies policy, dated May 2015, showed Open boxes are to be effectively re-sealed. Observation on 09/06/22 during the initial kitchen tour which began at 10:28 A.M., showed: -the walk-in refrigerator contained: *an opened and undated two liter bottle of lemon-lime soda; *an opened and undated 32 ounces (oz.) container of pineapple juice; *an opened and undated container of liquid eggs; -the walk-in freezer contained an undated and unlabeled bag of a shredded off-white food substance opened to the air and an opened and undated bag of ravioli; -the reach-in refrigerator contained three unlabeled and undated pitchers which contained yellow, brown and red liquids. Observation on 09/08/22 at 10:21 A.M., showed the dry goods pantry contained: -an opened and undated 16 oz. bag of tiny twists pretzels; -two undated plastic containers of cornflakes; -two undated plastic containers of raisin bran; -two undated plastic containers of crisp rice cereal; -two undated plastic containers of cheerios; -two undated plastic containers of fruit whirls cereal Observation on 09/08/22 at 10:29 A.M., showed the reach-in refrigerator contained: -an opened and undated two pound carton of strawberry yogurt; -an opened and undated 46 oz. carton of cranberry cocktail juice; -an opened and undated 46 oz. carton of tomato juice. Observation on 09/08/22 at 10:33 A.M., showed the cook's station contained an opened and undated 25 pound bag of flour and a four pound box of salt dated 10-28 opened to the air. During an interview, the DM said the date on the box of salt is the receipt date and staff should have dated it when they opened it. The DM also said he/she would not know how staff would cover the hole in the box. Further observation of the cook's station showed: -an undated large plastic bin with an opened and undated bag of pureed bread mix inside; -an undated large plastic bin with an opened and undated bag of fish breading inside. During an interview on 09/08/22 at 12:46 P.M., the DM said staff should date and label any opened food items and ensure containers are resealed. During an interview on 09/09/22 at 9:03 A.M., the administrator said staff should date opened food items and stored them in a closed container or resealed in a bag.