Based on interview, record review, and facility policy review, the facility failed to implement their grievance procedure as evidenced by the failure of the staff to record the nature and specifics of a grievance filed by 1 (Resident (R)29) of 18 sampled residents. Findings included: A facility policy titled Concern/Grievance Procedure dated 11/23, revealed b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. An admission Record revealed the facility admitted R29 on 07/13/23. According to the admission Record, the resident had a medical history that included diagnoses of acute upper respiratory infection and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/17/24, revealed R29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. During an interview on 12/02/24 10:29 AM, R29 stated the Environmental Services Director (ESD) spoke ill to them and accused them of stealing a resident's clothes. During an interview on 12/04/24 at 9:11AM, the Wound Care Nurse (WCN) stated she received a complaint/grievance from R29 on 12/02/24 that the ESD yelled at them and stated they stole a resident's clothes. The WCN stated she spoke with the ESD about the resident's concerns, the ESD apologized and stated she did not feel she raised her voice at the resident, but she had not documented R29's grievance on a grievance form yet. During an interview on 12/04/24 at 9:24 AM, the Director of Nursing (DON) stated a resident's grievance/concern should be documented on the grievance form. The DON stated she was not aware of R29's grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, record review, observations, and interviews, the facility failed to assist residents with Activities of Daily Living (ADL) care for 1 of 1 Resident (R)40, reviewed for ADLs. Findings include: Review of the undated facility policy titled Facial Hair, Removal read, Facial hair will be removed as needed per resident preference. Review of the undated facility policy titled, Nail Care read, Resident's will receive proper nail care .To clean the nail bed, to keep nails trimmed, and to prevent infections and injury . Review of the undated facility policy titled Oral care read, This facility will provide necessary service to maintain good oral hygiene . Review of R40's Face Sheet, provided by the facility, revealed R40 was admitted to the facility on [DATE] with diagnoses which included stroke, kidney failure, and heart failure. Review of R40's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/28/22, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R40 was cognitively intact. The MDS revealed R40 required limited physical assistance of one person for her personal hygiene needs. Review of R40's Care Plan, provided by the facility, last updated 10/01/22 read, Resident requires assistance with bed mobility, transfers, walking, toilet use, personal hygiene . One of the interventions included in the care plan was, Assist with bathing, dressing, and grooming needs every shift. Review of R40's Behavior and Mood report, provided by the facility, dated 12/2022 did not document refusal of care by R40. During an observation and interview on 12/11/22 at 10:58 AM, R40 was lying in bed. Her fingernails had a black build up under the nails and a black substance at the base, along the cuticle line. R40 had long chin hair. Her teeth had a buildup of white substance along the upper gumline. R40 stated she has been sick and unable to care for herself as much as she used too. R40 felt on her chin and said Oh my, I'm so sorry. I didn't realize they were that long. R40 stated her teeth have not been brushed in a while. She said no one had offered to help her and she was unable to brush them herself. During an observation and interview on 12/12/22 at 9:06 AM, R40 had long chin hairs. She had a black buildup under her fingernails and along the cuticle line. Her teeth continued to have a white build up along the gum line. R40 said she would be leaving for dialysis soon and did not think she would be able to get her teeth brushed or shaved before she left. During an interview on 12/12/22 at 2:29 PM, Certified Nurse Aide (CNA)1 stated R40 was at dialysis. She stated she did not brush R40's teeth or shave her before R40 left for dialysis. CNA1 stated CNAs did not do nail care. CNA1 stated, Activities usually does that. During an observation on 12/13/22 at 10:15 AM, R40 was lying in bed asleep. R40 had long chin hairs, a buildup of black substance under her fingernails and a white substance along her gum line. During an observation and interview on 12/13/22 at 11:24 AM, R40 was clean shaven. She continued to have a black substance under her nails and a white buildup along her gum line. R40 stated no one brushed her teeth yesterday and no one had offered to help her brush her teeth today. During an interview on 12/13/22 at 11:53 AM, the Activity Director stated she provided nail care as an activity weekly, but nursing was responsible for routine nail care. During an interview on 12/13/22 at 12:33 PM, the Director of Nursing (DON) stated her expectation was that females should not have chin hairs. The DON stated she expected residents' teeth to be brushed at least daily. She stated CNAs were responsible to ensure residents' fingernails were cleaned. The DON stated she expected nail care to be completed daily and as needed if hands were soiled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, record review, interview, and observations, the facility failed to ensure each resident received oxygen therapy in accordance with professional standards of care for 1 Resident (R)40 of 2 residents reviewed for respiratory care. R40 received oxygen via an oxygen concentrator. The oxygen concentrator required a filter that was not present. The opening where the filter was supposed to be had an accumulation of dirt and lint covering the outer edges and inner surfaces. This failure could place residents receiving oxygen at risk for infection. Findings include: Review of the undated facility policy titled, Oxygen Therapy, read, If using an oxygen concentrator, check and clean filter on outside of concentrator weekly as indicated by washing the foam filter with soap and water to prevent dust from entering concentrator. Review of the undated user manual for the oxygen concentrator read, .NOTE: There is one cabinet filter located on the back of the cabinet .CAUTION DO NOT operate the concentrator without the filter installed . Review of the undated Face Sheet provided by the facility, revealed R40 was admitted on [DATE] with diagnoses which included respiratory failure. Review of R40's Care Plan, last revised on 10/01/22, provided by the facility, revealed R40 had a potential for respiratory distress and infection. The care plan indicated R40 was to receive oxygen therapy. The care plan did not address ensuring the oxygen concentrator filter was in place. Review of R40's Physician Orders dated 12/2022, provided by the facility, revealed R40 was to receive oxygen at three liters a minute as needed. The orders also indicated, since 08/26/22, the oxygen filter was to be cleaned once a week if it has a filter. Review of R40's Treatment Administration Record (TAR) dated 12/2022, provided by the facility, revealed the filter on R40's oxygen concentrator was to be changed weekly on Fridays. The TAR was signed as completed every Friday in December. During an observation on 12/11/22 at 10:58 AM, R40 was lying in bed. She was receiving oxygen at 3 liters per minute (LPM) via an oxygen concentrator. The area on the back of the concentrator meant to contain a filter was empty. The empty space had an accumulation of dust and lint around the edges and inner surface. During an observation on 12/12/22 at 09:06 AM, R40 was lying in bed. She was receiving oxygen at 3 LPM via an oxygen concentrator. The area on the back of the concentrator meant to contain a filter was empty. The empty space had an accumulation of dust and lint around the edges and inner surface. During an interview on 12/13/22 at 12:03 PM, Registered Nurse (RN)2 stated the night nurses were responsible to clean oxygen concentrator filters and ensuring they were in place. She stated when orders read if it has a filter it meant if the concentrator required a filter. She said nurses knew if the concentrator required a filter because there was a space on the back of the concentrator for the filter. During an observation on 12/13/22 at 12:10 PM, RN2 verified the filter on R40's oxygen concentrator was missing. During an interview on 12/02/22 at 1:52 PM, the Director of Nursing (DON) stated R40's oxygen concentrator required a filter. The DON stated the facility did not have a process for ensuring the oxygen concentrator filter was in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and interviews, the facility failed to ensure expired medications were removed from 1 of 2 medication storage rooms. Furthermore, the facility failed to ensure all medications were securely stored in their original packing to prevent the medications from falling into the bottom of 1 of 4 medication carts. Failure to provide accurate labeling of medications nullifies the ability to facilitate consideration of precautions and safe administration of medication, to ensure they work as they should, as well as minimizing loss or diversion. Findings include: Review of the undated facility policy titled, Storage of Drugs, states, All drugs shall be stored appropriately. 1. Drugs shall be stored in an orderly manner in a locked area. 4. Drugs shall not be kept on hand after the expiration date on the label. Review of the facility's policy titled, Destruction of Controlled Substances, dated 08/2018 states: All discontinued, contaminated, or expired controlled substances shall be disposed of in accordance with state laws and regulations. 1. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. An observation on 12/12/22 at 3:23 PM in medication storage room [ROOM NUMBER] revealed three boxes of Assure Dose Control Solution with an expiration date of 10/05/22. Additionally, a four-week pill box of medications, not labeled or in their original packaging was also discovered. The expired medication was verified by Licensed Practical Nurse (LPN)4. An observation on 12/12/22 at 3:44 PM of medication cart 1 revealed two loose pills, one discovered in drawer 2, a large white oval pill, identified by LPN2 as a Sucralfate 1MG tab. Two half size small white oval pills, not identifiable, were found in drawer 3 of the medication cart. The loose medications were confirmed by LPN2, and the Unit Manager, Registered Nurse (RN)1. An interview on 12/13/22 at 2:01 PM with the Unit Manager, RN1, disclosed that expired medications should go back to the pharmacy and loose medicine should be put in the drug buster. RN1 included that staff should be aware of the policy and they all attend yearly training on their medication policy. She also explained the staff should be cleaning the carts and rooms and checking for expired medications and loose or damaged items nightly. An interview on 12/13/22 at 2:03 PM with the Pharmacist revealed medications come in on totes and are put in the carts by the nurses, they are stored and locked in the carts and dispensed from there. The Pharmacist further expressed narcotics are double locked and refrigerated items are kept in the refrigerator, non-controlled substances are sent back to the pharmacy and controlled substances are destroyed with her and the Director of Nursing (DON), in the drug buster, a form is completed, and then the loose medications are put in the drug buster. Medication carts and rooms are checked weekly by the nursing staff, and she comes in and does a monthly check. The Pharmacist inserted staff should be checking carts daily, but she will plan to come by weekly and ensure they are complying, educate staff with an in-service and keep following up with weekly visits. An interview on 12/13/22 at 2:33 PM with the DON revealed she was unsure of why the pill box, containing medication was in medication storage room [ROOM NUMBER]. She explained it was a possibility that it was bought in by a resident's family and they had not come back to retrieve them. She stated they were locked in the cabinet in the room so that no one else would have access to them.

Based on review of facility policy, observation, and interview, the facility failed to ensure: 1) Accurate labeling and dating of foods, 2) Removal of expired foods from refrigeration and storage. This failure had the potential to affect all residents Findings include: Review of the 2020 facility policy and procedure titled, Food Storage (Dry, Refrigerated, and Frozen) states: Guideline: Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Procedure: 1. General storage guidelines to be followed: A.) All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. B.) Discard Food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. C.) Leftover contents of cans and prepared food will be stored in covered, labeled, and dated containers in refrigerators and/or freezers. 4. Dry storage guidelines to be followed: F.) Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure. During the initial kitchen tour on 12/11/22 at 11:00 AM, an observation revealed in Cooler 1 contained, an open tube of ground beef with no label or date. One carton container Molly's Kitchen, no open or expiration date. A plastic Ziploc bag with approximately 22 boiled eggs with the use by date of 12/10/22. Approximately five shrivel red peppers that were soft to touch. A clear container of chopped mushrooms with a use by date of 12/10/22. A clear container of cream corn with the use by date of 12/10/22. A metal bowl of salad not labeled, no expiration date. Two tomato soup cups, no label. Small container with red chopped onions, no label or expiration date. During the initial kitchen tour on 12/11/22, an observation revealed in Freezer ONE contained one container of barbeque pork. The container was cracked and had visible freezer burn. During the initial kitchen tour on 12/11/22, an observation revealed in the dry storage area contained Devils food cake mix, opened, with no expiration date. A ten-pound bag of chocolate chips opened, no expiration date. A carton of orange gelatin mix, opened with no open or expiration date. A four-tier rack with damaged can goods in the entry of the dry room storage area, no label. On 12/12/22 at 09:40 AM, an interview with the Certified Dietary Manager (CDM)/ Food Service Director revealed she encourages staff to do spot checks twice a week to make sure there is no expired foods in the freezer or coolers. The CDM stated that the kitchen supervisor doesn't work on weekends, but she is supposed to throw out all foods that are going to expire on the weekend. She further stated all staff is responsible to check temperatures daily. Additionally, the CDM stated that when the company sends dented or damaged cans, the kitchen staff is responsible for taking pictures and sending the pictures via email to the company in order to receive their food credit. She then stated that once they receive credit for the damaged cans, then they can discard them in the dumpster.