Based on record review and interview, the facility failed to complete a new PASARR Level I assessment when a new serious mental illness diagnosis was received for one (#6) of three sampled residents reviewed for PASARR assessments. The DON identified 111 residents who resided in the facility. Findings: A Level I PASARR, dated 05/26/17, documented Res #6 did not have a serious mental illness. On 05/05/20, Res #6 had a new documented diagnosis of psychosis not due to a substance or known physiological condition. There was no documentation the OHCA had been contacted to see if a Level II PASARR was required. On 05/14/24 at 11:25 a.m., the DON was asked to provide documentation the OHCA was notified when Res #6 had new diagnosis of psychosis to see if a Level II PASARR was required. On 05/14/24 at 1:05 p.m., the DON stated there was no documentation indicating the OHCA had been notified.

Based on observation, interview, and record review, the facility failed to ensure nail care was performed for two (#26 and #94) of two residents reviewed for nail care. The DON reported 111 residents resided in the facility. Findings: 1. Res #26 was admitted to the facility with diagnoses of anxiety, depression, psychotic disorder, and dementia. On 05/13/24 at 10:37 a.m., resident #26 was observed up in his wheelchair. The resident's fingernails were observed to be long and discolored. On 05/14/24 at 1:01 p.m., the resident was asked when the last time staff cut his fingernails. He reported he couldn't remember. The resident was asked if he usually has them that long, he reported no. On 05/14/24 at 11:35 a.m., the resident reported the nurse cut his nails last night. On 05/16/24 at 11:11 a.m., the DON reported if resident is diabetic podiatry comes monthly and performs nail care. Reports if they are not diabetic then CNA or any staff are responsible for nail care. 2. Res # 94 admitted to the facility with diagnoses of hypertension, stroke, and diabetes. An admission assessment, dated 02/29/24, documented impairment on one side of the upper and lower extremities. On 05/13/24 at 8:38 a.m., resident #94 was observed eating breakfast and the resident's fingernails were observed to be long. On 05/14/24 at 12:56 p.m., the resident was asked when the last time his nail care was done. He reported the last time his nails were trimmed was by his daughter in law. On 05/15/24 at 11:25 a.m., the resident was observed in the dining room. The resident reported a nurse cut his nails yesterday. On 05/16/24 at 11:11 a.m., the DON reported if resident is diabetic podiatry comes monthly and performs nail care. Reports if they are not diabetic then CNA or any staff are responsible for nail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician was notified timely of a final culture and sensitivity from a urinalysis for one (101) of two sampled residents reviewed for antibiotic use. The DON reported 111 residents resided in the facility. Findings: Resident #101 was admitted to the facility on [DATE] with diagnosis to include respiratory failure with hypoxia. A skilled nursing assessment, dated 04/30/24, read in part, .urine was light urine and very cloudy, c/o burning with urination. Order received for UA . A nurse's progress note, dated 05/01/24 at 5:36 p.m., read in part, .abnormal UA, awaiting cultures . A physicians's order, dated 05/02/24, documented the Resdient was to receive one tablet of Augmentin 875-125 MG (Amoxicillin & Pot Clavulanate) twice a day for five days for a urinary tract infection. A final laboratory services report with culture and sensitivity. dated 05/03/24, documented the resident was resistant to amoxicllian. There was no documentation in the nurses progress notes or in the electronic clinical record the physician was notified of the final report until 05/06/24. A handwritten note on the final laboratory report, documented the physician was notified of the results on 05/06/24 and an order was given to Linezolid 600 mg. A physician's order, dated 05/06/24, documented the order for the antibiotic switched to one tablet of Linezolid 600 MG (Linezolid) by mouth two times a day for a urinary tract infection. The hand written note was written by LPN #1. The May 2024 Medication Administration record documented Resident #101 continued to receive Augmentin after the final laboratory report was received on 05/03/24 for six doses. On 05/15/24 at 9:05 a.m., LPN #1 stated Resident #101 was diagnosed with a UTI and the facility was waiting on the culture and sensitivity to come back and notify the physician of the final results. LPN #1 stated when the initial report came back Resident #101 was started on Augmentin when the nurse practitioner was notified of the preliminary results came back positive for a UTI. LPN #1 stated the final results were dated 05/03/24 and when they came to work on 05/06/24 they noticed the physician had not been notified yet. The LPN then stated they notified the nurse practitioner and noted in on the final lab results. LPN #1 then stated the resident was resistant to Augmentin so the antibiotic was changed by the nurse practitioner. On 05/16/24 at 11:38 a.m., the DON stated the physician was notified in the afternoon on 05/06/24 and he did not make any changes to the medications ordered. The DON then stated staff had notified the nurse practitioner on 05/06/24 prior to the doctor coming in for rounds. On 05/16/24 at 12:23 p.m., the regional nurse stated the facility did not notify the physician until three days after culture and sensitivity came back. The regional nurse then stated it was not a timely notification of the results.

Based on record review, observation, and interview, the facility failed to ensure a resident's O2 concentrator was set according to physician's orders for one (#43) of one sampled resident reviewed for oxygen. The Resident Census and Conditions of Residents report, dated 04/03/23, documented 28 residents received respiratory treatments. Findings: Res #43 had diagnosis which included dependence on supplemental O2. A physician order, dated 03/01/22, documented 02 at 3 lpm via NC to keep saturation greater than 90 percent. A quarterly resident assessment, dated 03/09/23, documented the resident's cognition was intact. On 04/03/23 at 10:18 a.m., Res #43 was observed with O2 in place via NC at 2 lpm. They stated their O2 was supposed to be set at 3 lpm. On 04/03/23 at 10:46 a.m., RN #3 was asked about Res #43's O2. She stated their O2 could be 2 to 4 lpm. She was asked to review the physician's order for the resident's O2. She stated the order was 3 lpm. She was made aware the resident's O2 was observed at 2 lpm.

Based on record review, observation, and interview, the facility failed to ensure medications were administered in accordance with physician orders for one (#83) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents report, dated 04/03/23, documented 115 residents resided in the facility. Findings: Res #83 had diagnoses which included secondary hypertension. A physician order, dated 07/22/22, documented to administer losartan potassium 25 mg one time per day for secondary hypertension. The order documented to hold the medication if blood pressure was below 120/80. A MAR for July 22 2022 through July 31 2022, documented the resident received the losartan when blood pressure was below parameters four out of 10 opportunities. A MAR for August 2022 documented the resident received the losartan when blood pressure was below parameters four out of 31 opportunities. A MAR for September 2022 documented the resident received the losartan when blood pressure was below parameters 10 out of 30 opportunities. A MAR for October 2022 documented the resident received the losartan when blood pressure was below parameters four out of 31 opportunities. A MAR for November 2022 documented the resident received the losartan when blood pressure was below parameters nine out of 30 opportunities. A MAR for December 2022 documented the resident received the losartan when blood pressure was below parameters ten out of 31 opportunities. A MAR for January 2023 documented the resident received the losartan when blood pressure was below parameters four out of 31 opportunities. A MAR for February 2023 documented the resident received the losartan when blood pressure was below parameters two out of 28 opportunities. A MAR for March 2023 documented the resident received the losartan when blood pressure was below parameters 15 out of 31 opportunities. A MAR for April 1 2023 through April 5 2023 documented the resident received the losartan when blood pressure was below parameters two out of five opportunities. On 04/05/23 at 3:36 p.m., the DON stated someone should have clarified the order before administering the medication outside of blood pressure parameters. She stated the medication should not have been administered if the blood pressure was below the physician ordered parameters.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The Resident Census and Conditions of Residents report, dated 04/03/23, documented 115 residents. Two residents received nutrition and hydration solely through a feeding tube. Findings: On 04/03/23 08:50 a.m., a tour of the kitchen was conducted. The following observations were made: a. there was an accumulation of black and brown residue on the floor and the walls in the dish wash area, b. there was a large hole in the wall in the dish wash area, c. there was an accumulation of white, brown, and black residue inside of the ice machine, d. there was an accumulation of grease and food on the floor in the cook area, e. there was an accumulation of pink and black residue, and ice buildup on the wall in the walk in cooler, f. paint was peeling off of the floor, and there was an accumulation of food and black residue on the floor in the walk in cooler, g. there was an accumulation of lint and black residue on the racks in the walk in cooler, and h. the material on the floor was separating, there were gaps and the floor was not easy to clean. On 04/03/23 at 1:11 p.m., the CDM was asked how staff ensure the kitchen was kept clean and maintained in good repair. She stated they had a cleaning schedule. She stated they cleaned daily and as needed. She stated they reported maintenance concerns to the maintenance supervisor for repairs. She was made aware of the above observations.

Based on observation and interview, the facility failed to store distilled water for use in CPAP machine and/or oxygen concentrator in a sanitary manner up off of the floor for two (#57 and #75) of three residents reviewed for oxygen. The DON identified eight residents who used oxygen concentrators and three residents who used CPAP machines. Findings: 1. Resident (Res) #57 had diagnoses which included obstructive sleep apnea. A physician order, dated 03/27/19, documented for the resident to use a CPAP machine when sleeping at bedtime related to obstructive sleep apnea. An opened partial plastic gallon jug of distilled water was observed stored on the floor between the resident's bed and bedside table on 11/03/21, 11/04/21, and 11/09/21. 2. Res #75 had diagnoses which included chronic obstructive pulmonary disease and chronic sleep apnea. A physician order, dated 10/08/21, documented to change the oxygen water canister every 72 hours. A physician's order, dated 10/12/21, documented to increase oxygen to 3L from 7:00 p.m. to 7:00 a.m. and then decrease down to 2L during the day. On 11/03/21 at 9:12 a.m., a plastic container of distilled water was observed on the floor next to her oxygen concentrator with humidifier. A physician order, dated 11/05/21, documented the resident was to receive oxygen at 3L via nasal cannula at bedtime. On 11/09/21 at 1:53 p.m., the DON stated she was not aware distilled water was being stored on the residents' floor. The DON stated the water should be stored on a table top.

Based on interviews and record review the facility failed to provide a sufficient number of staff on a 24 hour bases to meet the needs of the residents. The ''Census and Conditions of Residents'' report documented 95 residents resided in the facility. Findings: A ''Resident Listing Report,'' dated 11/03/21, documented the following: a. Sixteen residents resided on Hall 100, b. Seventeen residents resided on Hall 200, c. Thirty residents resided on Hall 300, and d. Thirty-two residents resided on Hall 400. A ''Daily Schedule, dated 11/02/21 and 11/03/21, for the 11 p.m. to 7 a.m. shift documented the following: a. One CNA for Hall 100, b. One CNA for Hall 200, c. One CNA for Hall 300, and d. One CNA for Hall 400. On 11/03/21 at 5:47 a.m., LPN #1 stated on night shift there were four CNAs, each assigned to one of four halls. The LPN stated there also were two nurses. She stated we used to have more CNAs for night shift. The LPN stated it was difficult to get it all done. On 11/03/21 at 5:58 a.m., LPN #2 stated he was working as a CNA that night. On 11/03/21 at 10:00 a.m., Resident (Res) #3 was asked if he received the help and care he needed without having to wait a long time. He stated it took over 30 minutes for his call light to be answered. He stated the facility was short staffed. On 11/04/21 at 9:36 a.m., Res #57 stated last night when she woke up and needed to be repositioned from back to side, it took an hour and ten minutes for her light to be answered. She stated her light went on around 3:00 a.m. She stated she had back problems. On 11/04/21 at 3:00 p.m., during the resident group meeting, the residents were asked if they received the help and care needed without waiting a long time. The residents stated on 400 Hall it took from 20 minutes to an hour for their call lights to get answered. They stated it depended on the time of day. They said it was hard to get help during meal times and while showers were being given. The residents stated on 300 Hall on evening shift the wait was 20 to 30 minutes and weekends were not good. The residents stated night shift was short staffed on 300 and 400 Halls. They said you had to wait 45 minutes to an hour to get help. The residents stated they did not get the help they needed for toileting which resulted in incontinence. Eight of ten residents in the meeting voiced problems with call lights being answered timely. The residents stated they had to wait at least an hour three to four times a week. On 11/10/21 at 9:03 a.m., the staffing coordinator stated it was the facility's goal to have five to six aides on night shift, but had not been able to do that recently. She said the facility was in the process of hiring more nurses and CNAs.

Based on interviews the facility had routinely been working the DON as charge nurse. The ''Census and Conditions of Residents'' report documented 95 residents resided in the facility. Findings: On 11/03/21 at 6:47 a.m., during entrance conference with the administrator and DON, they were asked about the full time DON coverage. The DON stated she worked at least 40 hours a week. She stated one day a week or every other week she worked the floor as a charge nurse. On 11/10/21 at 9:03 a.m., the staffing coordinator was asked how often the DON worked as charge nurse. She stated the DON worked one to three times a week as charge nurse. She stated the facility was trying to hire nurses to fill the needed positions. On 11/10/21 at 9:27 a.m., the administrator stated the DON had been working as charge nurse. The administrator stated the DON was the first one to come off the schedule if they had someone to work as charge nurse. She stated the facility was trying to hire more nurses and CNAs.

Based on record review and interview, the facility failed to guarantee the person designated to serve as the DM was certified no later than one year after hire. The DON identified 91 residents received services from the kitchen. Findings: An employee handbook signature page documented the DM started employment at the facility on 08/05/19. There was no documentation the DM was certified as a dietary manager. On 11/03/21 at 5:50 a.m., the DM was asked how long he had been in his current position. He stated about two years. He was asked if he was certified as a DM. He stated he was not. He stated he had taken all of the courses for the class, but needed to test again.

Based on observation and interview, the facility failed to follow proper food service sanitation. The DON identified 91 residents who received services from the kitchen. Findings: On 11/03/21 at 5:40 a.m., a tour of the main dining room was conducted. The following observations were made: a. [NAME] residue and/or trash in the cabinets and/or the floor below the drink station, b. An uncovered bowl of brown sugar on a shelf in the serving area, and c. two boxes of foam to go containers stored on the floor in the serving area. At 5:50 a.m., a tour of the kitchen was conducted. The following observations were made: a. An accumulation of lint on the ceiling vents and/or ceiling area around the vents, b. Bowls, plates, and silverware were stored with the food contact surface facing upward on dish storage racks in the dish wash area, c. Ceiling lights were burned out, d. An accumulation of black residue was inside the ice machine, e. An accumulation of brown residue was in the bottom of the ice scoop container used for the ice machine. f. An accumulation of white residue was on the floor under the ice machine, g. Tips of four knives were missing and/or bent located on the knife magnet holder on the wall, h. A plastic bag of unpackaged bologna was dated 10/21/21 in the four door reach in cooler, i. Plastic bags of ham, bologna, sliced cheese, and a container of red onions were not sealed/covered during storage in the four door reach in cooler, j. A buildup of black residue was on four metal grates used to drain grease off of foods, k. Black duct tape was used to cover up cracks on a food processor container stored on a rack next to the four door reach in cooler, l. An accumulation of black residue was on on the base of the table mounted can opener, m. An oven hood light was burned out, n. Fiberglass reinforced panels/wall areas in bad repair on the electrical panel wall. The wall was not secure and was pushed in, o. The cook area had food buildup and grease on the floor, wall, fryer, stove, oven and tilt skillet. p. The three compartment sink area had food splatters on the wall and black residue on the floor, q. The three compartment sink area had a wall in bad repair, holes in the sheet rock, and metal was not secured to the wall, r. An accumulation of brown residue was on the plastic dish storage containers in the walk in cold hold unit hallway, s. Three boxes of foam to go containers were stored on the floor in the dry storage room, t. A white bulk bin lined with a black plastic bag had a white dry substance which was not tabled. u. A metal scoop stored on top of the container had a dried white substance, v. The ceiling was not finished in the walk in cold hold unit hallway. Material was peeling and the sheet rock was not sealed, w. The chemical rack in the mop sink room was rusted, x. Lights were not shielded or shatterproof in the dry food storage room, y. A 25 pound bag of table salt on a shelf in the dry storage room was open and not sealed, z. The walk-in cooler had an accumulation of ice buildup and black residue on a wall, gaps between the ceiling and walls, holes in the walls, material peeling off of the floor, and accumulation of black residue on the racks. At 7:10 a.m., a tour of the bistro was conducted. The following observations were made: a. No paper towels stored at the hand sink, and b. The barista was preparing food without proper hair restraints. At 7:15 a.m., a tour of the serving area on hall 200 was conducted. There was glass cleaner, oven cleaner, carpet spotter, and ant/roach spray stored next to clean plastic food storage containers in a cabinet below the counter. On 11/04/21 at 2:50 p.m., the DM was asked what was the protocol for maintaining food service equipment and food service areas in good repair and kept clean. He stated he had cleaning schedules. He stated they cleaned upon opening and closing and as needed. He stated any maintenance issues were to be reported to the maintenance department for repairs. He was asked how dishes, utensils, single service items, and food was to be stored. He stated up off of the floor, food contact surface down, containers closed and date marked. He stated food should be discarded within 24 hours after it was opened. The DM was asked what staff were required to wear to protect food and equipment from contamination. He stated hair restraints. He was asked what was required to be stored at the hand sink. He stated paper towels. He was asked where chemicals were to be stored. He stated separate from dishes and food. The DM was made aware of the above observations.