**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure advanced directives were sent with a resident during a transfer for 1 (#205) of 1 sampled residents reviewed for appropriate documentation sent to receiving provider. The administrator identified 49 residents resided in the facility. Findings: A policy Transfer or Discharge, Information for Receiving Provider, dated 2001, read in part, Should a resident be transferred to another facility or discharged to the care of another provider, the following information is communicated to the receiving facility or provider .Advance directive information. On 02/01/25, a nurses note showed Resident #205 was transferred out to a hospital due to labored breathing and coughing up thick green phlegm. On 02/06/25, a nurses note showed hospital staff called Shanoan Springs to request a copy of the medications that were in effect at the time of the transfer to the ER on [DATE]. On 02/10/25, a nurses note showed hospital staff called Shanoan Springs to request a copy of Resident #205's advance directive. On 05/30/25 at 10:07 a.m., the DON stated they normally send out face sheets, orders, and advance directives. They stated the advance directive did not get sent. On 05/30/25 at 10:11 a.m., LPN #2 stated they sent the face sheet that stated Resident #205 had an advance directive and the medication list, but did not actually send a copy of the signed advance directive. They stated the advance directive should have been sent with Resident #205.

Based on observation, record review, and interview, the facility failed to ensure proper personal protective equipment was used for 1 (#42) of 4 sampled residents reviewed for enhanced barrier precautions. The administrator identified 19 residents resided in the facility required enhanced barrier precautions. Findings: On 05/29/25 at 9:10 a.m., LPN #1 was observed to enter Resident #42's room to administer medications via enteral tube. LPN #1 did not don PPE prior to administering the medications via enteral tube. An undated policy Enhanced Barrier Precautions, read in part, Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce the transmission of multidrug-resistant organisms .Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities. A policy Administering Medications Through an Enteral Tube, revised 11/2008, read in part, The purpose of this procedure is to provide guideline for the safe administration of medications through an enteral tube .The following equipment and supplies will be necessary when performing this procedure .Personal protective equipment (e.g.,gowns, gloves, mask, etc., as needed). An Order Summary Report, dated 05/30/25, showed Resident #42 had diagnoses which included traumatic brain injury and the need for assistance with personal care. On 05/29/25 at 9:20 a.m., LPN #1 stated the sticker on the name plate outside of room was inform staff that the resident was on enhanced barrier precautions. On 05/29/25 at 9:21 a.m., LPN #1 stated they should have donned gown and gloves prior to administering Resident #42's medications. On 05/29/25 at 9:25 a.m., the administrator stated PPE was for direct resident care for those with peg tubes, wounds, and catheters.

Based on record review and interview, the facility failed to ensure an allegation of abuse was reported within two hours of the reported incident for one (#8) of three residents sampled for abuse. The administrator identified 50 residents residing in the facility. Findings: A facility policy titled Reporting Abuse to Facility Management, dated April 2012, read in part, .The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or paged and informed of such incident . Res #8 had diagnoses which included atrial fibrillation, COPD, and chronic pain. A quarterly assessment, dated 03/27/24, documented the resident was moderately impaired with cognition and required partial to moderate assistance with most ADLs. On 04/15/24 at 2:40 p.m., Res #8 stated stated yesterday a nurse said the F word at them and it hurt their feelings. The resident stated they told other staff member but did not know their names. On 04/15/24 at 2:57 p.m., the allegation was reported to the administrator. The administrator stated they had not been informed of the incident until that time. On 04/18/24 at 2:57 p.m., CMA #2 stated Res #8 told them on Sunday night around 10:00 p.m.,that the nurse was mad at them. The resident told the CMA the nurse walked to the door and said the F word. CNA #2 stated they asked the resident if they were sure and stated they then told Res #8 to talk to the nurse. The CMA stated they did not want to make it a bigger situation because the resident fed off of situations such as that. The CNA #2 stated they reported it on Monday morning to the ADON. On 04/18/24 at 3:17 p.m., the ADON stated they reported the incident to the DON and the DON from a sister home in another town. The ADON stated they personally did not do an incident report.

Based on record review and interview, the facility failed to ensure resident assessments were accurate for two (#8 and #20) of 13 sampled residents whose resident assessments were reviewed. The administrator identified 50 residents who resided in the facility. Findings: 1. Res #8 had diagnoses which included anxiety disorder, major depressive disorder, bipolar disorder, and schizophrenia. A quarterly assessment, dated 03/27/24, documented the resident was moderately impaired with cognition. The assessment documented the resident received an antipsychotic, antianxiety, and an antidepressant medication. The assessment documented a GDR had been attempted on 10/06/23. On 04/18/24 at 10:57 a.m., the MDS coordinator stated they were brand new to the MDS position as of September of 2023. The MDS coordinator stated they found the date on a psychiatric consultation progress note for September and it had been signed and dated on 10/06/23. On 04/18/24 at 11:36 a.m., the DON stated on 09/18/24 the psychiatrist came to the facility and made changes in the resident's medication. They stated the attending physician did not want those changes to be made so the date on the MDS was not correct for a medication reduction. 2. Res #20 had diagnoses which included pressure ulcer of right heel stage 3, PVD, non-pressure chronic ulcer to right thigh, lymphedema, and non-pressure chronic ulcer of the other part of left lower leg with unspecified severity. A care plan, revised 03/09/24 documented the resident had actual impairment to their right lateral thigh, bilateral buttocks, left heel, left great toe, left shin, right lateral foot, and scabs to left toes/foot/shin. A quarterly assessment, dated 03/24/24 documented the resident had two unhealed stage three pressure ulcers. The assessment did not contain documentation of the resident having other wounds. A wound progress note, dated 04/12/24, documented the resident had a non-pressure wound right posterior lateral thigh full thickness , duration was 157 days. The note documented the resident had a stage three pressure wound of the left heel full thickness, duration of 151 days. The note documented the resident had lymphedema wound to left shin full thickness, duration 88 days. The note documented a venous wound of right medial ankle was resolved on 04/12/24. On 04/16/24 at 3:28 p.m., the DON stated they would have to do a correction for the wound section of the MDS assessment as the resident did have wounds that were not pressure ulcers which were not captured on the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to refer a resident with a new mental health diagnosis to OHCA for a PASRR level II evaluation for one (#2) of one sampled residents reviewed for PASRR. Findings: A PASRR level I was provided by another facility that was transferring services to this facility, dated 06/30/10, documented Res #2 had diagnoses including multiple sclerosis, neurogenic bladder, paraplegia, sebaceous cysts, and [NAME]-[NAME] syndrome. Res #2 was admitted on [DATE] after being transferred from another facility, and had diagnoses which included multiple sclerosis, [NAME]-[NAME] syndrome, neurogenic bladder, paraplegia, sebaceous cysts, dementia in other diseases with agitation, delusional disorder, cognitive communication deficit, and dementia with behavioral disturbances. A significant change assessment dated [DATE] documented the resident was severely impaired with cognition and diagnosed with psychotic disorder. A care plan revised on 08/14/23, documented the resident had a diagnoses of psychosis with risk of hallucinations with delusional paranoia. On 04/17/24 at 3:26 p.m., the DON confirmed diagnoses of psychosis with risk of hallucinations with delusional paranoia was listed as an admission diagnoses was not documented on the PASRR level I. The DON stated they would call OHCA to check on if a PASRR level II evaluation was needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents who were unable to carry out activities of daily living received the services to maintain grooming and personal hygiene. The Long-Term Care Facility Application for Medicare and Medicaid form documented 50 residents resided in the facility. Findings: Res #102 was admitted on [DATE] and had diagnoses which included laceration without foreign body of right eyelid and periocular area, need for assistance with personal care, and intellectual disabilities. A care plan, dated 02/06/24, documented the resident required extensive assistance of one staff member with showering or bathing. A medicare five day assessment, dated 02/08/24, documented the resident required substantial to maximal assistance with bathing. The resident was discharged on 02/12/24. On 04/17/24 at 1:33 p.m., the ADON brought bathing sheets and after review confirmed that documentation verified the resident was showered twice while a resident, on 02/09/24 and 02/10/24 out of four opportunities for a shower. The DON stated the resident was scheduled to be showered on the 7 p.m. to 7 a.m. shower schedule. The ADON stated if the resident refused or the staff were unable to shower the resident they should have informed the nursing staff. The ADON stated per the documentation the resident had not received their showers as scheduled.

Based on record review and interview, the facility failed to ensure nutritional supplements were given to one (#49) of two residents reviewed for weight loss. The DON identified 50 residents residing in the facility. Findings: Resident #49 was admitted with diagnoses including diffuse traumatic brain injury and hemorrhage with loss of consciousness of unspecified duration and need for assistance with personal care. The resident was also admitted with a gastric tube. A physician's order on 03/28/24 documented enteral feed TwoCal HN four times a day via gastric tube. On 04/02/24 a dietitian recommended the resident be given TwoCal HN five times a day via gastric tube. There was no documentation of the physician being notified of this dietitian recommendation. On 04/17/24 at 11:01 a.m., the ADON stated the dietitian would examine each resident remotely and send the recommendations to their email. They also stated there are times when we miss those recommendation related to not looking at our emails. On 04/17/24 at 11:07 a.m., the DON stated they did not see the note from the dietitian. They also stated the physician was not notified of any new recommendations.

Based on observation, record review, and interview, the facility failed to follow physician's orders for oxygen tubing care maintenance for one (#33) of one resident sampled for oxygen therapy. The administrator reported 50 residents resided in the facility. Findings: Resident #33 was admitted with diagnoses of chronic obstructive pulmonary disease, respiratory failure, and dependency of supplemental oxygen. A physician's order, dated 01/22/24, documented to change the oxygen tubing on the 5th and 20th of each month on the night shift. A quarterly assessment, dated 03/25/24, documented the resident utilized oxygen. On 04/15/24 at 10:59 a.m., an observation was made with the resident wearing oxygen via nasal canula and the tubing documented a date of 03/06/24. On 04/16/24 at 8:10 a.m., an observation was made with the resident wearing oxygen via nasal canula and the tubing documented a date of 03/06/24. On 04/17/24 at 11:50 a.m., an observation was made with the resident wearing oxygen via nasal canula and the tubing documented a date of 03/06/24. The treatment administration record for the month of April of 2024 did not document any dates suggesting the oxygen tubing had been changed since 03/06/24. On 04/18/24 at 8:09 a.m., the DON stated the oxygen tubing should have been changed on the 5th of April of 2024.

Based on observation, record review, and interview, the facility failed to ensure the use of side rails was appropriate for one (#49) of one sampled residents who were reviewed for side rails. The administrator identified 21 residents residing in the facility utilized bed rails of any type. Resident #49 was admitted with diagnoses including diffuse traumatic brain injury and hemorrhage with loss of consciousness of unspecified duration and need for assistance with personal care. An admission assessment, dated 03/25/24, documented the resident was severely impaired with cognition and was totally dependent with ADLs. A physician order, dated 03/25/24 at 7:00 a.m., documented to monitor placement and function of low air loss mattress every shift for placement and function. On 04/15/24 at 10:55 a.m., an observation was made of Res #49 lying on an air mattress with bed rails on both sides of the bed. The resident's EHR did not document a physician order for bed rails. The resident's care plan did not document a care plan for the use of side rails. The resident's records contained a consent signed by the resident's representative for bed rails. On 04/16/24 at 4:00 p.m., the DON stated the resident's representative wanted the bed rails on the bed, but had not signed a consent at that time.

Based on record review and interview, the facility failed to: a. ensure a consultant pharmacist reviewed the medication of each resident in the facility monthly for two (#8 and #42) of five sampled residents reviewed for unnecessary medications. b. ensure the physician responded in the time frame documented by the facility policy to the MRR for one (#42) of five sampled residents reviewed for unnecessary medications, and c. ensure the physician responded to the MRR request for two (#8 and #42 of five sampled residents reviewed for unnecessary medications. The administrator identified 50 residents who resided in the facility. Findings: A facility policy, dated 2024, titled Drug Regimen Review, read in part .The Consultant Pharmacist reviews the medication regimen of each resident at least monthly .If the facility has not received any communication from the physician regarding the Drug Regimen Review (DRR) within 30 business days, the facility staff will call the physician .The physician provides a written response of the report to the facility within one month after the report is sent. A copy of the report is kept by the facility until the physicians' signed response is returned .The facility maintains copies of signed reports on file for at least one year . 1. Res #8 had diagnoses which included anxiety disorder, major depressive disorder, bipolar disorder, and schizophrenia. A MRR, dated 09/21/23, documented the following medications are not being used and to indicate below if any or all of the listed medications could have been safely discontinued due to non-use at that time. The listed medications were artificial tears PRN, ketotifen ophthalmic solution PRN, loperamide PRN, lubricant eye drops PRN, milk of magnesia PRN, Mylanta PRN, and ondansetron PRN. A physician response to the request was not found for the MRR. A MRR request, dated 01/26/24, documented aripiprazole 15 mg daily, diazepam 2 mg BID, divalproex 250 mg TID, duloxetine 30 mg daily, olanzapine 2.5 mg at HS, quetiapine 50 mg at HS, topiramate 50 mg BID, were being used by the resident. The request was made to attempt a reduction for the medications. There was no documentation the request was addressed by the resident's physician. A MRR for the month of February 2024 was not found for the resident. A quarterly assessment, dated 03/27/24, documented the resident received an antipsychotic, antianxiety, and an antidepressant medication. The assessment documented a GDR had been attempted on 10/06/23. On 04/18/24 at 10:33 a.m., the physician response for 09/21/23 and 01/26/24 and the MRR for February 2024 were asked for again. On 04/18/24 11:35 AM DON stated they were not able to find documentation for the September review or the January review from the physician. 2. Res #42 had diagnoses which included generalized anxiety disorder, major depressive disorder, bipolar disorder, and dementia. A MRR request, dated 11/21/23, asked a GDR for Rilutek (an ALS agent) 50 mg po bid to be assessed for possible reduction. The physician documented they disagreed with the request as the resident was stable no changes at this time. The form was dated 01/23/24. The facility did not provide a MRR for January 2024 to review. A quarterly assessment, dated 04/07/24, documented the resident had verbal behaviors one to three days during the look back period. The assessment documented the resident had received antipsychotic, antidepressant, and opioid medications. On 04/18/24 at 1:20 p.m., the DON stated the November MRR did not have a timely response from the physician. On 04/18/24 at 2:18 p.m., the ADON stated they were not able to find the MRR request for January 2024 for Res #42.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure menus were followed. The facility identified one resident who received a puree meal, one resident who received finger foods, for a total of 48 residents who received their meals from the kitchen. Findings: On 04/17/24 at 11:00 a.m., the menu was observed and documented the noon meal was to have been french onion pork chops, pork gravy, white cheddar mac and cheese, green peas, wheat dinner roll, margarine, apple [NAME], milk, and coffee. On 04/17/24 at 11:54 a.m., cook #1 was observed to have pureed the meal for the resident who required pureed meals and had not included a roll. On 04/17/24 at 12:01 p.m., during the meal service, four meals were observed to be served without rolls. On 04/17/24 at 12:15 p.m., Res # 25 was observed to have been served butter noodles, the white cheddar mac and cheese and green beans. The resident was not served a pork chop with their noon meal. DA #3 stated the resident received finger foods. On 04/17/24 at 12:16 p.m., the DM stated the resident should have received a pork chop for lunch and it would have been cut up for finger food size. On 04/17/24 at 12:36 p.m., cook #1 confirmed they had not pureed a roll for the resident's meal. On 04/18/24 at 10:00 a.m., the menu was observed for the puree and finger foods. The menu documented the puree should get a soaked wheat dinner roll and the finger food had a square on the meat area. On 04/18/24 at 10:16 a.m., the DM stated the square under finger foods was to represent the resident could have what was on the regular menu cut up to finger food size.

Based on observation and interview, the facility failed to ensure the garbage from the kitchen was disposed of properly. The facility identified 48 residents who received services from the kitchen. Findings: On 04/15/24 at 8:25 a.m., [NAME] #1 was observed to take the trash out of the garbage can in the kitchen and placed the trash sack in a shopping cart which was located outside of the kitchen by the outside storage building. On 04/15/24 at 9:03 a.m., the DM stated the staff had been taking the trash out to the shopping cart and then they would take the trash down to the trash receptacle. The DM stated they should have immediately taken the trash to the trash receptacle bin at the street and not left the trash in the shopping cart. On 04/17/24 at 11 :25 a.m., a small bag of trash was observed unattended in the shopping cart outside by the storage room.

4. Res #2 had diagnoses which included multiple sclerosis, dementia in other diseases with agitation, delusional disorder, cognitive communication deficit, and dementia with behavioral disturbances. A quarterly assessment, dated 01/28/24, documented the resident was cognitively intact and require minimal to moderate assistance with ADLS. A physician's order, dated 04/24/2024, documented the resident had a DNR. On 04/15/24 at 09:36 a.m., an observation was made of the resident's name on a green paper directly on the doorframe outside of the resident's room indicating the full code status of the resident. On 04/17/24 at 01:16 p.m., an interview with LPN #2 stated the green paper on the doorframe was documentation of the resident as a full code. On 04/17/24 at 01:17 p.m., the DON stated they had just checked every chart, residents' code status, and checked every paper on the doorframes to ensure the correct code status was posted outside of the residents' room but had missed Res #2's. Based on observation, record review, and interview, the facility failed to ensure residents were offered to formulate an advance directive, or implemented the choice to formulate an advanced directive, for three (#8, 20, and #42) and posted the correct information regarding code status for one (#2) for 24 residents reviewed for advance directives. The administrator identified 50 residents who resided in the facility. Findings: 1. Res #8 had diagnoses which included atrial fibrillation, COPD, and chronic pain. A quarterly assessment, dated 03/27/24, documented the resident was moderately impaired with cognition and required partial to moderate assistance with most ADLs. On 04/15/24 at 10:55 a.m., a green name tag, indicating full code status, was observed by the resident room. 04/16/24 at 9:00 a.m., the residents advance directive acknowledgment form was provided. The undated form documented the resident had an advance directive. The AD acknowledgment form was signed by the resident. The resident did not have an AD in the EHR or in the hard chart. On 04/16/24 at 9:20 a.m., the administrator stated Res #8 had documented they had an advanced directive but they were not able to find one in the resident's record. On 04/16/24 at 11:39 a.m., the social service director stated they filled out the admission paper work for the resident. The social service director stated they had not went over an advance directive with Res #8. The social service director stated Res #8 had a POA and they went over the information with the POA on the day of admission. The social service director stated they were not aware if the previous social service director had went over the AD with residents or not. 2. Res #20 had diagnoses which included COPD, PVD, and lymphedema. A form titled Advance Directive Acknowledgement, dated 05/26/22, the form documented the resident did not have an advance directive, but was interested in implementing one. A quarterly assessment, dated 03/24/24, documented the resident was intact with cognition and required assistance with ADLs. A care plan, last revised 01/18/24, documented the resident had an advance directive. On 04/15/24 at 10:54 a.m., a green name tag for the resident, indicating full code status, was observed by the residents room. On 04/16/24 at 1:07 p.m., the DON stated they removed the care plan regarding the resident having an advance directive. The DON stated the social service director would talk with the resident today and find out if the resident wanted an advance directive. 3. Res #42 had diagnoses which included PVD, cardiac arrhythmia, HTN, and dementia. A form titled Advanced Directive Acknowledgement, dated 10/01/22, documented the resident's POA had indicated the resident did not have an advance directive and was interested in implementing one. A quarterly assessment, dated 04/07/24, documented the resident was moderately impaired with cognition and required assistance with ADLs. On 04/15/24 at 1:40 p.m., a green name tag for the resident, indicating full code status, was observed by the resident's room. On 04/16/24 at 9:18 a.m., the administrator stated social service should have followed up on the advance directives 24 to 48 hours when a resident or representative documented they wished to formulate an advance directive.

2. Res #35 had diagnoses which included dementia with behavioral disturbance, epilepsy unspecified, and anxiety disorders. A quarterly MDS assessment, dated 08/09/23, documented the resident was cognitively impaired, required extensive assistance with all ADLs. On 10/19/23, an initial incident report documented that CNA #1 and CNA #2 were showering Res #35 with the assistance of hospitality aide. The hospitality aide reported CNA #1 placed their hand over the mouth and nose of Res #35 on three different occasions during the shower. It was also reported that CNA #1 told the resident to shut up. The incident report documented CMA #1 heard Res #35 screaming in the shower room. The incident report documented all those involved were suspended until the investigation was complete. On 10/23/23 a final incident report documented the investigation had been completed and CNA #1 was separated from employment immediately and CNA #2 was educated one-on-one related to reporting abuse immediately. On 10/24/23 an in-service and training was initiated by management to all staff members at the facility on abuse, neglect, dementia, reporting abuse, rights of residents, and bathing residents. On 10/26/23 management completed the in-service and training for all staff members at the facility. On 04/15/24 at 09:27 a.m., the DON stated the facility had immediately reported the incident to the OSDH on 10/19/23 and started an initial investigation. They stated a thorough investigation on the incident was conducted and completed the investigation on 10/23/24. The DON stated all entities of authority were contacted as well as the family members of the resident. They stated all staff members were provided policy and procedure on abuse and neglect and everything was faxed to OSDH. The DON stated the all staff members involved in the abuse were terminated after the investigation was completed. Based on observation, record review, and interview, the facility failed to ensure residents were free from abuse and neglect for two (#35 and #40) of three residents sampled for abuse. a. On 10/19/23, an initial Incident Report documented CNA #1 did place their hand over the mouth and nose of the Res #35 on 3 different occasions during a shower. It was also reported that CNA #1 told the resident to shut up. All those involved were suspended until the investigation was complete. CNA #1 was separated from employment immediately and CNA #2 was educated one-on-one related to reporting abuse immediately. On 10/24/23 an in-service and training was initiated by management to all staff members at the facility on abuse, neglect, dementia, reporting abuse, rights of residents, and bathing residents. On 10/26/23 management completed the in-service and training for all staff members at the facility. The facility was in past non compliance after completing a QAPI meeting, dated 03/20/24, which discussed the outcome of the State Reportable Incident(s) interventions. b. On 02/11/24 at 11:15 a.m., the administrator was notified by RN #3 that Res #40 had squirted Purell Surface Disinfectant cleaner into their mouth when the cleaner was not in direct control of dietary #4 aide who was to have been using the product. The dietary aide was reported to the Nontechnical Service Worker registry and suspended during the investigation. Immediate measures were instituted and the staff were in-serviced on chemical storage. Monitoring of chemical storage was conducted and documented for 30 days. A QAPI meeting, dated 03/20/24, discussed the outcome of the State Reportable Incident(s) interventions. The facility was in past non compliance after completing the final measure to correct the deficiency on 02/21/24. The administrator reported seven incidents of abuse or neglect had occurred in the previous six months. Findings: 1. Res #40 had diagnoses which included dementia, Alzheimer's disease, and unspecified symbolic dysfunction. A significant change assessment, dated 01/05/24, documented the resident was severely impaired in cognition and required supervision or touch assistance with eating and had no restrictions in range of motion of their extremities. A care plan, dated 01/07/24, documented the resident had poor impulse control and to provide interventions to mitigate their behaviors such as anticipate their possible needs for food and thirst. A nurse note, dated 02/11/2024 at 11:06 a.m., documented that another resident reported that Res #4 was spraying the Purell surface disinfectant into their mouth in the dining room. The note documented RN #3 Res #3 was in their wheelchair sitting near the kitchen cleaning cart and dietary aide #4 was removing the bottle from the resident's hands. The note documented dietary aide #4 stated that although they had not seen the resident squirting the disinfectant into their mouth, they had the bottle pointed facing them with their hands on the trigger of the spray bottle. The note documented the resident was assessed and Poison Control was contacted and interventions were put in place recommended by them. The note documented the on call provider, the DON, and Res #40's family were also contacted. A care plan update, dated 02/23/24, documented the resident was at risk for injury related to cognitive deficit. The care plan documented to monitor the residents whereabouts and to keep all chemicals or any products that have warning labels documenting ingestion could cause harm stored behind locked doors in the departments in which they were to be used. An Incident Report Form, dated 02/11/24, included documentation of an in-service for staff to keep all chemicals which could cause harm to residents behind locked doors. The in-service form documented residents were not to have access to these storage areas at any time. Monitoring forms, dated 02/11/24 through 03/12/24, to ensure no chemicals were in a place residents could access them were provided for review. A form titled Shanoan Springs Monthly QA Minutes, dated 03/20/24, documented under number 10., Reportables reviewed to ensure investigations completed immediately, intervention implemented, and reporting timely to proper agencies. On 04/15/24 at 11:48 a.m., Res #40 was observed sitting in the dining room at a table with another resident. Res #40 was unable to be interviewed. On 04/16/24 at 12:57 p.m., the DON stated the facility did audits after the incident to ensure all chemicals were not left out. The DON stated they also included this incident and the results of the monitoring at the next QA committee meeting. On 04/17/24 at 8:52 a.m., the DM reported the product Res #40 had squirted into their mouth was Purell Professional Surface Disinfectant. At that time a bottle of the product was retrieved by the DM from the kitchen area where they stated it was locked up. The DM stated the product was used to sanitize hard surfaces in the dining room tables after meal service. The DM stated on the day of the incident, the product had been left unattended on the cart in the dining room. They stated when the dishwasher looked out of the kitchen pass and into the dining room they witnessed the resident squirting the product into their mouth. The DM stated the dishwasher came out of the kitchen, removed the product from Res #40's hands, and took them to the nurse and reported what had happened. The DM stated the product is stored in a locked cabinet in the kitchen when not in use. On 04/17/24 at 9:20 a.m., the administrator was asked why this incident had been identified as neglect. The administrator stated the incident occurred due to a staff member left the sanitizer unattended in the dining room when they knew or should have known it was on the cart and there were residents in the area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure food was served at an appetizing temperature. The facility identified 48 residents who received their meals from the kitchen. Findings: 1. On 04/17/24 at 11:00 a.m., the menu was observed and documented the noon meal was to have been french onion pork chops, pork gravy, white cheddar mac and cheese, green peas, wheat dinner roll, margarine, apple [NAME], milk, and coffee. On 04/17/24 at 11:10 a.m., [NAME] #1 was observed to obtain the temperature of the pork chops when they were removed form the oven. The temperature at that time was 184 degrees F. The pork chops were place in a deep pan and then placed on the steam table. The other food items were not observed to be temped before placing on the steam table. On 04/17/24 at 12:01 p.m., the meal service started. The steam table was not temped before service started. On 04/17/24 at 12:20 p.m., the DM stated they should have temped the food on the steam table before serving the meal. The DM stated the holding temperature on the steam table was 145 degrees. The DM temped a pork chop which was on top of the other pork chops and the temperature reading was 106 degrees F. 2. On 04/15/24 at 9:37 a.m., Res #2 stated the facility served cold food. On 04/17/24 at 12:46 p.m., the kitchen cart with the hall trays left the dining area and went to the north hall. A test tray was taken to north hall at this time also. On 04/17/24 at 12:56 p.m., the test tray was obtained immediately after the last meal had been served on the hall cart and the temperatures were as follows. The pork chop was 115 degrees F and luke warm to taste. The peas were 105 degrees F and cold to taste. The mac and cheese noodles were 107 degrees F and cold to taste. The apple dessert was 81.5 F degrees cold. The test meal was not served with a roll. On 04/18/24 at 9:28 a.m., the DM stated they had not had any complaints of cold food, but agreed the food should have been served at a palatable temperature.

Based on observation, record review, and interview, the facility failed to ensure: a. wound care was provided in a sanitary manner for one (#20) of four residents observed for wound care, b. residents' catheters were not dragging on the floor for two (#8 and #26) of four sampled resident who had catheters, and c. a water management program was implemented to prevent the growth of Legionella and other opportunistic waterborne pathogens in the buildings water system. The facility identified a census of 50 residents who resided in the facility. Findings: 1. Res #8 had diagnoses which included diabetes mellitus, personal history of urinary tract infections, and neuromuscular dysfunction of the bladder. A care plan, last revised 10/18/23 documented the resident has a suprapubic catheter for neurogenic bladder. The care plan documented to keep the catheter bag below the bladder level and monitor for sign and symptoms of UTI. The care plan documented the resident was on enhanced precautions required due to Res #8 was at an increased risk for infection and MDRO related to indwelling medical device. A quarterly assessment, dated 03/27/24, documented the resident had a indwelling catheter. On 04/15/24 at 11:07 a.m., observed Res #8's catheter under the wheelchair in a bag but the catheter tubing was on the floor. On 04/15/24 at 2:39 p.m., Res #8 was observed in a chair in their room. The catheter tubing was on floor and the bag was hung on on plastic three drawer storage unit. On 04/15/24 at 2:50 p.m., Res #8 stated they had the catheter since 2012 because they could not empty their bladder. Res #8 stated they did not realize the tubing was on the floor. On 04/16/24 at 3:00 p.m., the resident was observed in the dining room with the catheter tubing dragging the floor. On 04/16/24 at 3:45 p.m., Res #8 was observed with staff member assisting them to their room and the catheter tubing was dragging on the floor. On 04/17/24 at 2:03 p.m., CNA #3 stated the catheter bag should be covered and placed under the residents wheelchair. CNA #3 stated they would make sure the catheter was not leaking and not crimped. They stated they tried to make sure the tubing was not dragging on the floor. CNA #3 stated the catheter tubing on the floor was an infection control issue. On 04/17/24 at 2:20 p.m., the IP stated the catheter tubing absolutely should not have been dragging on the floor. 2. Res #26 had diagnoses which included neuromuscular dysfunction of bladder and cystostomy status. A quarterly assessment, dated 04/01/24, documented the resident had a catheter. On 04/15/24 at 11:21 a.m., an observation was made of the resident in the dining area with the catheter tubing dragging on the floor. On 04/17/24 at 12:06 p.m., an observation was made of the resident in the dining area with catheter tubing touching the sole of the resident's tennis shoe and then dragging the floor. On 04/17/24 at 2:21 p.m., the IP stated the catheter should not have been dragging on the floor at any time. 3. A facility policy, dated April 2013, titled Dressings, dry/clean read in part, .Personal protective equipment (e.g., gowns, gloves, mask, ect,, as needed) .clean bedside stand. Establish a clean field .wash and dry hands thoroughly . Res #20 had diagnoses which included pressure ulcer of right heel stage 3, PVD, non-pressure chronic ulcer to right thigh, lymphedema, and non-pressure chronic ulcer of the other part of left lower leg with unspecified severity. A care plan, revised 03/09/24 documented the resident had actual impairment to their right lateral thigh, bilateral buttocks, left heel, left great toe, left shin, right lateral foot, and scabs to left toes/foot/shin. A quarterly assessment, dated 03/24/24, documented the resident had two unhealed stage three pressure ulcers. On 04/15/24 at 10:45 a.m., Res #20 stated they had wounds to their left shin, lipedema that developed into a sore, and a right thigh pressure ulcer. Res #20 stated it was on an old scar from road rash and the wound would come and go. Res #20 stated the facility provided daily wound care. On 04/16/24 at 01:16 p.m., wound care was observed with LPN #1. LPN #1 used hand sanitizer, gathered supplies on a sheet of wax paper, sanitized hands and put on gloves. The LPN placed the wax paper on the resident's overbed table but had not cleaned the table first. The LPN removed the resident's nonskid sock from their right foot, cleaned the right foot, wrapped it with ace wrap, and placed the sock back on the resident's foot. The LPN moved to the left foot, removed the sock, cleaned the foot and shin, applied the dressings, wrapped the area with Kerlix and ace wrap, and replaced the sock back on the resident foot. The nurse then applied Triad cream to the resident's right thigh area. LPN #1 then removed their gloves and disposed of the supplies and gloves. The LPN did not change gloves, or perform hand hygiene, during the entire wound care observation. On 04/16/24 at 1:33 p.m., LPN #1 stated they forgot something. LPN #1 stated she did not gown up before wound care was performed as the resident was on EBP. LPN #1 was asked when should they do hand hygiene during wound care. LPN #1 stated before it was started and when they finished the wound care. On 04/16/24 at 3:38 p.m., the IP stated hand hygiene should have been performed before staff entered the room, after the field was set up, and before wound care was started. The IP stated glove changes and hand hygiene should have been performed between each wound. The IP stated the overbed table should have been cleaned before setting the wax paper on it. 4. A facility policy titled Legionella Water Management Program, revised in September of 2022, read in part, .2. The water management team consists of at least the following personnel a. The infection preventionist; b. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. the director of environmental services .5. The water management program included the following elements: a. An interdisciplinary water management team (see above); b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) waste . The facility provided a book which was to document the water management program to review. The book documented the Legionella Water Management Program and documented a water sample was obtained from the facility in March of 2023 and the results. The rest of the book did not document any other aspects of the program had been instituted. On 04/18/24 at 1:33 p.m., the IP was asked about the Water Management Program. The IP stated they thought the facility was doing something about the water program but was not sure as they were not involved. The IP stated they thought it was the administrator and the maintenance man who took care of this program. On 04/18/24 at 1:59 p.m., the administrator stated all the staff members on the Legionella Water Management Program were on the team. They stated they had not had a meeting for more than a year. The administrator did not provide meeting minutes for the team meeting. The administrator stated they did not think they had obtained a diagram of the plumbing in the facility. They stated they would get with the maintenance man to have them answer questions. On 04/18/24 at 2:11 p.m., the maintenance man stated the facility had not obtained any plumbing schematics but could contact a plumber to obtain them. The maintenance man stated they remembered the meeting and it consisted of themselves, the administrator, and several corporate people. There were no other staff in the meeting to their recollection. The maintenance man stated they had only one meeting to their recollection. They stated there were aerators in all the sinks and shower heads and they cleaned them monthly but they did not have documentation of these activities. The maintenance man stated they cleaned the ice machine monthly and did check the water temperatures on a regular basis. On 04/18/24 at 2:25 p.m., the administrator stated, based on these conversations, the water management program had not been fully put in action.

Based on observation and interview, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. The facility identified 48 residents who received their meals from the kitchen. Findings: 1. On 04/15/24 at at 8:21 a.m., an initial tour of the kitchen was conducted. The following observations were made. [NAME] # 1 was observed to take the trash out of the trash can and the trash was taken outside. [NAME] #1 was observed to return to the kitchen and did not wash their hands. [NAME] #1 placed a lid on the chicken, which was on the prep counter in marinade, and then placed the container in the refrigerator. [NAME] #1 was then observed to cover a bowl of cream cheese with plastic wrap, and then placed individual containers of butter into a bowl. Hand washing was not observed during this observation. On 04/15/24 at 8:30 a.m., the following was observed in the refrigerator: Opened containers of Thick and Easy drinks were not dated with an open date An opened bottle of water, with some water missing, in the refrigerator and did not document a name or date of opening. 17 glasses of juice which did not document a label or date. 34 small cups of both pudding and fruit which were not labeled or dated. Two containers which held half sandwiches in plastic bags were not labeled or dated. On 04/15/24 at 8:36 a.m., scoops were observed in the brown sugar, flour, and granulated sugar bins. On 04/15/24 at 8:38 a.m., the outside storage was observed to have a lock on the door. In the storage room there were items stacked on the floor including a box of tomato ketchup, a bag of pure sugar, which was on top of the ketchup, and two boxes of Thick and Easy liquid drinks. The freezers in the storage room were observed to contain food which had not been labeled and/or dated. A second freezer contained an open box of chile chicken tacos and a box of frozen beef patties both of which were open to air. In the pantry, some of the items were not dated with the date they arrived in the facility. On 04/15/24 at 8:52 a.m., which was a Monday, [NAME] #1 stated the facility received food shipments on Tuesdays and Fridays. On 04/15/24 at 8:53 a.m., in the kitchen hot pads and mitts were observed on top of a plastic container, and top of the container was observed to have been covered with debris and was next to the storage shelving holding the clean pans. Two small storage containers bins were observed to hold the serving utensils and debris was observed on the top of the bins and in the floor around the bins. The inside of the microwave was observed to have had a yellow substance spillage on the glass plate. The area under the prep counter, where the large pots were stored, had dirt and debris on the shelving. The floor in the kitchen was observed to have been dirty with dirt, debris, and dead crickets along the walls, by the refrigerator, and under the steam table. On 04/15/24 at 8:59 a.m., the floor mat by the ice machine in the dining room, was observed to have circle hole shapes through it and a black substance was observed around the mat and was also observed through the holes under the mat. The DM stated housekeeping were the ones who should have cleaned under the mat. On 04/15/24 at 9:36 a.m., housekeeper #1 stated they had not seen anyone ever take the mat up in the dining room and clean it. They stated they had only cleaned around the outside of the mat. 04/15/24 at 9:03 a.m., the DM stated the items in the refrigerator, freezers, and on the shelving in the pantry/storage room should all have been dated when it arrived, or was made and placed in the refrigerator. The DM stated the items in the freezer should not have been open to air. The DM stated the scoops should not have been left in the bins. The DM stated they had never labeled or dated the snack items in the refrigerator, or the thickened drinks when they had been opened. The DM stated floors and shelving should have been cleaned daily and did not look like they have been cleaned. 2. On 04/17/24 at 11:01 a.m., a second tour of the kitchen was made and the following things were observed. On 04/17/24 at 11:16 a.m., DA #3 was observed to run a disposable wash cloth under the faucet to wet it and clean a prep counter and microwave with the cloth without using sanitizer solution. On 04/17/24 at 11:18 a.m., [NAME] #1 was observed to touch their glasses on their face, retrieve a lid for the noodles on the stove, place hot pad mitts on their hands, and move a hot pan to the dish washing area. [NAME] #1 was then observed to have put on gloves and place some of the noodles in the food processor. Hand hygiene was not observed. On 04/17/24 at 11:26 a.m., the DM was observed to come into the kitchen, did not wash their hands, obtained a glass of tea for a resident which they took to the resident in the dining room, and then returned to the kitchen to washed their hands. On 04/17/24 at 11:26 a.m., CNA #4 was observed to enter the kitchen and did not put on a hair net or wash their hands. The CNA retrieved coffee and then stood in the kitchen by the steam table waiting on other drinks to take to a resident in the dining room. On 04/17/24 at 11:40 a.m., DA #3 was observed to use another cloth and run it under tap water to clean the prep counters without using sanitizer. On 04/17/24 at 11:53 a.m., the DM stated they did not have a sanitizer bucket made up for cleaning the prep areas. On 04/17/24 at 12:00 p.m., DA #2 was observed to enter the kitchen without washing their hands, retrieved coffee for a resident and return to the dining room. Hand hygiene was not observed. On 04/17/24 at 12:03 p.m., DA #3 was observed to wear disposable gloves and was serving the noon meal. DA #3 touched the bread sack and got bread out for a resident with same gloved hand. DA #3 did not change gloves or perform hand hygiene when they went back to serving the meals. On 04/17/24/at 12:09 p.m., DA #2 was observed to enter the kitchen without washing their hands, retrieved coffee, and returned to the dining room. On 04/17/24 at 12:13 p.m., a plate, which was served to the dining room for a resident meal, came back into the kitchen through the window pass to DA #3 as they were still serving meals. DA #3 took the plate from the other staff member and placed it in the dish washing area. DA #3 then returned to serving meals without doffing the contaminated gloves, washing their hands, and donning clean gloves. 3. On 04/17/24 at 12:48 p.m., LPN # 3 was observed to not perform hand hygiene before they started passing meals on the hall. LPN #3 was observed to scratch their head, touch their glasses and move them on to the top of their head, move a resident's overbed table, and set up a meal, uncovered food and drinks. LPN #3 pushed the cart to the other hall and delivered more resident meals in the same manner. Hand hygiene was never observed during the observation of LPN #3. On 4/18/24 at 9:27 a.m., the DM stated hair nets should be worn in the kitchen all the times and hand washing should be performed when entering the kitchen and serving meals. The DM stated they should not be taking items back through the window pass from the dining room. The DM stated, when serving the meals, the kitchen staff should not be touching anything dirty, or holding the drinking glasses by the rims. The DM stated any time they stepped away from the steam table they should have taken off their gloves, got the item, washed their hands, and re-gloved to start serving meals again. 4. On 04/15/24 at 11:56 a.m., during the dining observation, DA #1 was serving the meals in the dining room with the resident's meal plate balanced against their clothing. This was observed to occur multiple times with multiple resident meal plates. DA #1 was not observed to have performed hand hygiene during this dining observation. On 04/15/24 at 12:00 p.m., the administrator was observed serving meals without performing hand hygiene between residents, after they touched their pants, and before they went back to the window pass for another resident meal. On 04/15/24 at 12:02 p.m., DA #1 took a resident's cup into the kitchen took the lid off the cup filled the cup with liquid and took the cup back to the resident. The DA was observed to not wash their hands on entry to the kitchen. On 04/15/24 at 12:08 p.m., DA #1 was observed to carry drink glasses by the rim, touched their pants while pulling them up, and entered the kitchen to get the hall cart. Hand washing was not observed when entering the kitchen. 4. On 04/15/24 at 11:52 a.m., to 11:57 a.m., an unidentified dietary aide was observed going from the kitchen pass to deliver food trays to residents in the supervised dining room and back to pass multiple times without using hand hygiene. On 04/15/24 at 11:58 to 12:01 p.m., the unidentified dietary aide was observed delivering plates of food to residents in regular dining room and was observed to hold the plates of food against their shirt for balance. On 04/17/24 at 12:07 p.m., an unidentified dietary worker was observed to enter the kitchen, obtain drinks, and exit the kitchen without washing their hands. On 04/17/24 at 12:08 p.m., a separate unidentified dietary worker was observed to enter and obtain drinks for residents, and exit the kitchen area without washing their hands. On 04/17/24 at 12:09 p.m., an unidentified dietary aide entered the kitchen area again without washing their hands, obtained a drink for a resident, exited the kitchen, and after giving the drink to the resident, went back into the kitchen and washed their hands. They were then observed to return to the dining room. On 04/18/24 at 9:39 a.m., the administer stated the nursing staff who passed the meals to the residents should be using hand sanitizer between residents and after every three passed they should have washed their hands.

Based on record review, observation, and interview, the facility failed to ensure resident care plans were reviewed and revised after falls for two (#32 and #39) of two residents reviewed for falls. The Resident Census and Conditions of Resident report documented 56 residents resided in the facility. Findings: 1. Res #32 had diagnoses which included cerebral infarction, muscle weakness, and dysarthria. A care plan, dated 12/26/22, documented Res #32 was a fall risk related to deconditioning and gait and balance problems. The care plan documented a goal that the resident's risk for falls will be decreased through nursing and therapy interventions. An annual assessment, dated 12/26/22, documented the resident was moderately cognitively impaired, did not ambulate, required extensive two-person assistance with transfer, and had one fall with no injury. An incident report, dated 01/22/23, documented the following: Res #32 was found on the floor in the bathroom. The resident stated the fall occurred while trying to get back into the wheelchair after getting off the toilet. The resident was wearing regular socks. The resident denied pain or injuries. No injuries were observed at the time of the incident. An intervention to reinforce teaching that the resident needed to wear non-skid footwear when transferring. The care plan did not document an intervention for the 01/22/23 fall. An incident report, dated 02/27/23, documented the following: Res #32 was found on the floor in the bathroom lying on his back. The resident stated the fall occurred while trying to transfer from the wheelchair to the toilet. The resident denied pain or injuries. No injuries were observed at the time of the incident. The incident report documented interventions to anticipate needs, provide frequent visual checks, keep bed in low position, and clear pathways. The care plan did not document an intervention for the 02/27/23 fall. On 03/02/23 at 1:36 p.m., Res #32 was observed outside sitting in a wheelchair while smoking with staff supervision. On 03/06/23 at 11:32 a.m., the DON stated the care plan should have been updated after the fall incident report was completed. On 03/06/23 at 12:00 p.m., the MDS coordinator stated the care plan should have been updated immediately after a fall but it was missed for Res #32. 2. Res #39 had diagnoses which included malignant neoplasm of prostrate, seizures, acute respiratory failure, and lack of coordination. A care plan, dated 08/25/22, documented Res #39 was at risk for falls related to deconditioning and gait and balance problems. The care plan documented a goal that the resident's risk for falls will be decreased through nursing and therapy interventions. A quarterly assessment, dated 01/14/23, documented the resident was cognitively intact, required limited one person assistance with ambulation and transfer, and had one fall with no injury. An incident report, dated 02/25/23, documented the following: Res #39 was found in the floor beside the bed. The resident stated having sat up on the side of the bed and slid to the floor. The resident denied pain or injuries. No injuries were observed at the time of the incident. The incident report documented interventions to continue with antibiotic for UTI, encourage fluids, anticipate needs, and to keep foods, fluids, and call light within reach. The care plan did not document an intervention for the 02/25/23 fall. On 03/02/23 at 10:36 a.m., Res #39 was observed lying in bed with call light within reach. On 03/06/23 at 11:32 a.m., the DON stated the care plan should have been updated after the fall incident report was completed. On 03/06/23 at 12:00 p.m., the MDS coordinator stated the care plan should have been updated immediately after a fall but it was missed for Res #39.

Based on observation and interview, the facility failed to post nurse staffing information, which included all the required components, in an area where it could be reviewed by all residents and visitors. The Resident Census and Conditions of Residents form documented 56 residents resided in the facility. Findings: On 03/02/23 at 11:39 a.m., the south hall nurse staffing information was not posted. On 3/03/23 at 8:03 a.m., the south hall nurse staffing information was not posted. On 03/06/23 at 8:25 a.m., the north hall nurse staffing information was not posted. On 03/06/23 at 2:00 p.m., the corporate nurse reported the nurse staffing information should have been posted daily.

Based on record review and interview, the facility failed to limit PRN orders for psychoactive medications to 14 days for one (#12) of six sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 03/02/23, documented 14 residents received antianxiety medications. Findings: Resident #12 had diagnoses which included anxiety. A current physician order, dated 12/09/21, documented lorazepam concentrate 1 mg/0.5 ml apply to wrist topically every six hours as needed. The December 2022 TAR documented the PRN lorazepam concentrate 1 mg/0.5 ml was administered on 12/18/22. On 03/06/23 at 9:53 a.m., the DON was asked what was the protocol for use of PRN psychotropic medications. She stated they were limited to 14 days. She stated after the 14 days the use of the medication was reviewed and the physician was called. She was made aware of the residents PRN lorazepam order and where it had been administered on 12/18/22. She was asked if there was documentation to continue the use of the PRN medication past the 14 days. She stated she would look into it. On 03/06/23 at 10:10 a.m., the DON stated the resident's routine order and PRN had not been separated in the EHR. She stated the medication was received past the 14 days.

Based on observation and interview, the facility failed to ensure the laundry room was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 03/02/23, documented 56 residents resided in the facility. Findings: On 03/06/23 at 12:08 p.m., a tour of the laundry room was conducted. The following observations were made: a. Light covers were missing off of the ceiling lights and ceiling lights were burned out and/or not working. b. There was an accumulation of lint on the ceiling light covers, ceiling fan, and the laundry equipment. c. There was an accumulation of bugs inside of the ceiling light covers. d. The ceiling was not finished near the entry/exit doors. The sheet rock was not sealed. e. There was an accumulation of white residue and lint on the floor. f. There were gaps and daylight was visible under the entry/exit doors. On 03/06/23 at 12:20 p.m., the laundry supervisor was asked how staff ensured the laundry room was kept clean and maintained in good repair. She stated they had a cleaning schedule. She stated they cleaned and swept the floor every day. She stated if there were any repairs needed they reported those concerns to maintenance.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean, maintained in good repair, and chemicals were properly labeled. The Resident Census and Conditions of Residents report, dated 03/02/23, documented 56 residents resided in the facility. Findings: On 03/02/23 at 9:35 a.m., a tour of the kitchen was conducted. The following observations were made: a. There was an accumulation of black residue, trash, and food on the floor. b. There was an accumulation of black and brown residue on the wall behind the dish machine. c. There was water leaking from the hot water knob on the two compartment sink. d. The ceiling lights were not covered. The light cover was missing near the steam table. e. The baseboard was missing off of the wall in the dish wash area. f. There was an accumulation of food, grease, and black residue on the dish machine, drain boards, sinks, steam table, dish racks, food preparation table, stove, and outside area of food storage containers. g. Spray bottles of a clear and yellow liquid were stored on top of the dish machine and were not labeled. h. There was an accumulation of lint on the ceiling around the light covers, i. There was an of accumulation of brown residue and standing water in the bottom of the ice scoop holder next to the ice machine. and j. There was an accumulation of pink and black residue inside of the ice machine. On 03/06/23 at 8:13 a.m., the dietary manager was asked how staff ensure food service equipment and the physical environment of the kitchen was maintained in good repair. She stated they had a cleaning schedule and they informed the maintenance supervisor of maintenance issues. She was asked how staff ensured food was safe from chemical contamination. She stated when chemicals were not in use they were to be put away and should be labeled.

Based on record review, observation, and interview, the facility failed to don gloves prior to the administration of subcutaneous insulin injections. The Resident Census and Conditions of Resident report documented 10 residents received injections in the facility. Findings: A Subcutaneous Injections policy, revised March 2011, documented to perform hand antisepsis and put on gloves prior to a subcutaneous injection. On 03/03/23 at 8:34 a.m., RN #1 was observed to have administered a subcutaneous insulin injection to Res #50. RN #1 performed hand antisepsis but did not don gloves prior to the administration of the subcutaneous injection. On 03/03/23 at 8:45 a.m., RN #1 was observed to have administered a subcutaneous insulin injection to Res #32. RN #1 performed hand antisepsis but did not don gloves prior to the administration of the subcutaneous injection. On 03/03/23 at 8:47 a.m., RN #1 was asked if gloves should be worn during the administration of a subcutaneous insulin injection. RN #1 stated she did not believe there was a need to wear gloves because the residents did not bleed after a subcutaneous injection. She stated she would only need to wear gloves during the administration of an intramuscular injection. On 03/03/23 at 8:52 a.m., the DON stated gloves should be worn during the administration of subcutaneous injections. She stated the staff will be re-educated on proper procedure.

Based on interview and record review, the facility failed to ensure a DNR consent form was dated and signed by two witnesses for one (#9) of 24 sampled residents reviewed for advanced directives. The DON identified 22 residents with advanced directives. Findings: Resident (Res) #9's undated DNR consent form did not document two witness signatures. On 10/05/21 at 11:42 a.m., the administrator was made aware of the DNR form with only one witness and no date. She said she would call the POA of the Res and let them know there needs to be a new one signed. On 10/05/21 at 1:45 p.m., the administrator provided a new DNR consent form signed by the POA, two witnesses, and dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the PASRR I had been filled out accurately according to the residents' diagnoses for two (#5 and #38) of three residents whose records were reviewed for PASRR. The DON identified 49 residents resided in the facility. Findings: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. The Level I PASRR Screen, dated 10/09/18, read in parts, .2. (with a Yes or No response): Diagnosis of a serious mental illness (for example .severe anxiety or depressive disorder .)? The question had been answered No instead of Yes. On 10/05/21 at 3:00 p.m., the DON was in agreement the PASRR had not been filled out properly according to the resident's diagnosis.2. Resident #5 admitted to the facility on [DATE] with admission diagnoses which included major depressive disorder. The Level I PASRR Screen, dated 03/16/21, read in parts, .Question 2 (with a Yes or No response) Diagnosis of a serious mental illness (for example .depressive disorder . The question was answered ''No'' instead of ''Yes.'' On 10/07/21 at 9:37 a.m., the MDS coordinator asked about how she determined what diagnoses would trigger a yes response. She stated she was told that major depression was not included in the diagnoses to trigger a Level II PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the OHCA was notified after a resident received significant mental health diagnoses for one (#5) of three residents reviewed for PASRR. The DON identified 49 residents who resided in the facility. Findings: Resident (Res) #5 admitted to the facility on [DATE] with diagnoses which included major depressive disorder and unspecified anxiety disorder. A physician ''Progress Note, dated 07/22/21, documented additional diagnoses for the Res which read in parts, .Hallucinations .Delusions .Severe anxiety . On 10/07/21 at 9:37 a.m., the MDS coordinator was asked if she notified OHCA when the Res received the new psychotic diagnoses. She stated she was informed to only send a notification if a Res was sent out of the facility for a psychological evaluation.

Based on interviews and record review, the facility failed to ensure medications were administered as ordered for one (#30) of five sampled residents reviewed for medications. The Resident Census and Conditions of Residents report, dated 10/05/21, documented 49 residents resided in the facility. Findings: Resident (Res) #30's diagnoses included hypertension, major depressive disorder with psychotic features, stage 3 chronic kidney disease, atherosclerotic heart disease if native coronary artery without angina pectoris, and peripheral artery disease. Physician orders, dated 08/21/21, documented the Res was to receive clopidogrel bisulfate tablet (an antiplatelet medication) 75 mg one time a day, lisinopril tablet (an angiotensin-converting enzyme inhibitor medication) 2.5 mg one time a day, quetiapine furmarate tablet (an atypical antipsychotic medication) 300 mg at bedtime, Toprol XL tablet (a beta-blocker medication) 12.5 mg one time a day, and Xarelto tablet (an anticoagulant medication) 2.5 mg two times a day. A physician order, dated 08/22/21, documented the Res was to receive tamsulosin hydrochloride capsule (an alpha blocker medication) 0.4 mg two capsules in the morning. The August 2021 MAR documented clopidogrel bisulfate was not administered one out of 10 opportunities, lisinopril two out of 10 opportunities, quetiapine furmarate two out of 11 opportunities, tamsulosin hydrochloride one out of nine opportunities, Toprol XL one out of 10 opportunities, and Xarelto seven out of 10 opportunities. Medication administration notes, dated 08/28/21, 08/29/21, 08/30/21, and 08/31/21, documented the medications were not administered due to waiting for delivery from the pharmacy. On 10/06/21 at 1:26 p.m., LPN #1 was asked what was the protocol for ordering and administering medications. She stated medications were supposed to be re-ordered when they got down to seven days. She stated medications were to be administered according to the MAR. She stated when a medication was not administered, there should be a note indicating the reason the medication had not been administered. She was made aware the Res had not been administered the above medications due to waiting on delivery from the pharmacy.