Based on observation, interview, review of the facility policy and manufacturer labeling, the facility failed to ensure that medications were safely stored in 1 of 3 medication carts. Findings include: Review of the facility policy titled, General Guidelines for Medication Storage dated 6/21/2017 states Medications and biological's are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. On 9/18/24 at approximately 4:01 PM, inspection of the facility's treatment cart revealed one opened 100 ml (milliliter) bottle of Sterile 0.9% (percent) Normal Saline, USP (United States Pharmacopoeia) by Medline which was had been dated by the facility as opened on 9/18/24 and was approximately 90% full. During an interview on 9/18/24 at approximately 4:05 PM, Licensed Practical Nurse (LPN)2 read the manufacturer's label which states Contents sterile unless container is opened or damaged and the facility dating of the opened container and acknowledged that the contents were no longer sterile, since it had been opened and returned to the treatment cart.

Based on review of the facility policies, observations and interviews, the facility failed to follow proper infection control guidelines related to handling soiled clothes, and linens for transport in 3 of 3 soiled linen rooms. The facility further failed to ensure the proper handling of clean wet and dry linens, and the folding of clean linen in 1 of 1 main laundry room. Findings include: Review of the facility policy titled, Indications for Glove Use, states, The facility recognizes and implements Standard Precautions. The use of enhanced and transmission-based precautions is implemented as clinically indicated and recommended by health authorities. Procedures: Gloves are worn when: 3. Touching or having the potential to touch urine, stool or vomitus while providing care, treatment or services. 4. Handling items or environmental surfaces that are likely soiled with blood or body fluids, except sweat. 6. When staff has non-intact skin on the hands or wrist. Review of the facility policy titled, Hand Hygiene/Handwashing, revealed Hand Hygiene/Hand Washing is the most important component for preventing the spread of infection. Maintaining clean hands is important for patients/residents/visitors as well as staff. Procedures: A. After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as mucous membranes, non-intact skin, body fluids, blood or wounds. Review of the facility policy titled, Laundry, states, Laundry services will comply with appropriate guidelines to assure that measures are implemented to provide pro effective laundry service. The procedures for personnel are, 5. Personnel in the laundry services are properly garbed at all times. When handling soiled linens, gowns, and gloves, at a minimum will be donned. These are removed as soon as possible after completing of duties involving soiled linens. Handwashing, Hands are washed after handling soiled linens even if gloves have been worn. At all times laundry service personnel are in compliance with the Facility Handwashing Policy. All Linens, 1, Linens are to be handled in a safe manner to prevent contamination of the linen, the personnel and the environment. Clean linen is never held up against personnel's body. An observation on 09/19/2024 at 08:20 AM, revealed the laundry worker (LW) picking up soiled laundry from 3 shower rooms throughout the facility. The laundry worker went into the areas and took the lid off of bins and reached in with her bare hands and removed soiled clothes and soiled linens and placed them into a bin that she had brought into the soiled area. Some of the soiled clothes and linens were in bags and some were not. The LW continued the same practice in all three soiled areas. She brought the bin back to the laundry room and washed her hands and put on gloves and a gown and removed the lid from the bin of soiled linens and clothes and started to sort them into individual bins. The LW then removed the gown and gloves and opened the clothes dryer to remove dry linens to be folded. When she opened the dryer door, a washcloth fell to the floor and she picked it up and put it into a basket with other clean clothes to be folded. The LW then went to the washer and opened it, the clothes were ready for the dryer. Another washcloth fell to the floor, and as she was holding most of the clean wet clothes up against her uniform, she stepped on it, then picked it up and placed it with the clean wet clothes, she was putting in the dryer. The LW then turned on the dryer. She then put on a gown and gloves and pushed the bin of soiled clothes to the washer and placed them in the washer and turned it on. She then removed the gown and the gloves, washed her hands and started folding the clean basket of clothes. The sheets and bedspreads were observed touching the floor and the clothes she was wearing, while she was attempting to fold them. During an interview on 09/19/2024 at 08:45 AM with the LW, this surveyor informed the laundry worker of the following concerns. 1. Using bare hands to pull soiled clothes and linens from a bin in the 3 shower rooms. She had also failed to wash her hands after placing them in the bin. The LW confirmed that she had picked up the soiled clothes and linens without wearing gloves and a gown and did not wash her hands until she returned to the laundry room. 2. The laundry worker confirmed that she had picked up the clean washcloth from the floor and placed it with the clean linens to be folded and used for residents. 3. She also confirmed that the wet washcloth she had stepped on, she had picked it up and then placed in the clothes dryer with clean wet linens. She stated, I thought the dryer would get hot enough to kill any germs on it. 4. Lastly, the LW confirmed that the sheets and bedspreads had touched her uniform and had touched the floor during the folding process.

Based on observations, record review, interviews, and policy review, the facility failed to protect and value residents' private space by failing to knock on doors and/or request permission and/or pause prior to entering resident (R) rooms for 3 (R46, R205, and R51) of 4 residents sampled for dignity. Findings include: A review of the facility policy Resident Rights, revised 11/01/17, revealed The facility staff will provide the patient/resident with his/her right to privacy and security. The procedures of the policy included 2. Staff: A. Knocks on doors for permission to enter. (a) During an observation of medication administration on the 200 Hall on 08/24/22 at 8:55 AM, Licensed Practical Nurse (LPN)1 walked into R46's room to administer medication without knocking and waiting to enter. Review of R46's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/22, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderately impaired cognition. Per the MDS, the resident also had unclear speech. Review of R46's care plan revealed an intervention with an approach start date of 08/09/22. The intervention directed staff to provide privacy during care to maintain dignity. Another intervention with an approach start date of 08/09/22 directed staff to avoid overstimulating the resident. However, there were no interventions directing staff not to knock on the resident's door prior to entering (to avoid startling and/or agitating the resident, for example). (b) During an observation of medication administration on the 200 Hall on 08/24/22 at 9:03 AM, LPN1 walked into R205's room to detach R205's G-tube for transport without knocking and waiting to enter. Review of R205's MDS with an ARD of 07/04/22, revealed the resident had a BIMS score of 8, indicating moderately impaired cognition. Per the MDS, the resident also had unclear speech. Review of R205's care plan revealed an intervention with an approach start date of 07/07/22. The intervention directed staff to talk with the resident during care and allow the resident time to respond. However, there were no interventions directing staff not to knock on the resident's door prior to entering (to avoid startling and/or agitating the resident, for example). (c) During an observation of medication administration on the 200 Hall on 08/24/22 at 9:06 AM, LPN1 walked into R51's room to perform a blood sugar finger stick without knocking and waiting to enter and, again, at 9:09 AM without knocking and waiting to enter to administer medications. Review of R51's admission MDS with an ARD of 07/13/22, revealed the resident had BIMS score of 13, which indicated the resident was cognitively intact. During an interview with R51 on 08/24/22 at 9:22 AM, the resident stated staff sometimes knocked prior to entering his/her room and sometimes did not, noting he/she expected staff to knock on the door before coming into the room. During an interview on 08/24/22 at 9:11 AM, LPN1 stated she knew she was supposed to knock on residents' doors and wait to be told to come in before entering their rooms. LPN1 also stated she did not know why she did not do it and thought she knocked on one door. An interview with Certified Nursing Assistant (CNA)1 was conducted on 08/24/22 at 2:32 PM. The CNA stated he worked at the facility for three years and knew to knock on residents' doors and wait to be invited to enter. An interview with CNA2 was conducted on 08/24/22 at 2:49 PM. CNA2 stated she had worked at the facility for six years. CNA2 stated the facility was the residents' home and she always knocked and waited to hear a resident tell her to enter. Per CNA2, if a resident was nonverbal, then she waited a few seconds after knocking prior to entering the room. During an interview with the Assistant Director of Nursing (ADON) on 08/25/22 at 12:27 PM, the ADON stated staff were expected to knock on open or closed doors and wait until someone granted permission to enter or, if a resident could not speak or was hard of hearing, staff should knock, wait, and then enter. The ADON noted if a resident did not want someone to knock on his/her door, then it would be care planned. During an interview with the Administrator on 08/25/22 at 11:54 AM, the Administrator stated she expected staff to knock and wait for permission to enter all resident rooms. She stated the facility was the residents' home and privacy was expected. Per the Administrator, staff should knock and wait.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review the facility failed to provide to make proper and timely accommodations for Resident #6 for one of one residents reviewed for environment. Resident (R) #6 was admitted to the facility on [DATE] with the diagnosis including but not limited to Encounter for orthopedic aftercare following surgical amputation, Abnormal posture, Contact with and (suspected) exposure to other viral communicable diseases, Diarrhea, Cough, Acute Osteomyelitis of the left ankle and foot, Unspecified open wound to the left foot, Major Depressive Disorder, Cellulitis, Cataract extraction to the Right Eye, Diarrhea, Non-pressure chronic ulcer of other parts of left foot with necrosis of muscle, Peripheral Vascular Disease, Diarrhea, Partial Traumatic Amputation at level between knee and ankle, right lower leg, Muscle weakness (generalized), Unsteadiness on feet, lack of coordination, Hyperlipidemia, Essential (primary) hypertension, Gastro-esophageal reflux disease without esophagitis, Pain, Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity, Type 2 diabetes mellitus with diabetic neuropathy, unspecified. R #6 has the Brief Interview Mental Status (BIMS) of 15. An Observation and Interview on 6/8/2021 at 10:33 AM revealed that R #6's restroom had been out of order for almost a year. R #6 stated that they had to use the restroom across the hall or use one of the other public restrooms in the facility because the one in their room is locked. Upon observation of the restroom door was an OUT OF ORDER sign and was locked. An Interview with the Maintenance Director on 6/10/2021 at approximately 10:00 AM revealed that R #6's restroom was not out of order, but was locked because R #6 had gotten stuck last year because they used their electric wheelchair which does not fit. R #6 stated that they have enough sense to not do that anymore and would love to be able to use their own restroom instead of having to go across the hall but believed the restroom was not working.

Based on Record Review, including the Dialysis Services Agreement, and staff interview the facility failed to assess and monitor the Resident's health condition before and after dialysis treatments for one of one sampled resident reviewed for dialysis services. Findings: The facility admitted Resident (R) #33 on 1/27/2021 with diagnoses including, but not limited to, Chronic Kidney Disease, Acute Respiratory Disease, Dependence on Renal Dialysis, Hypertension, Type 2 Diabetes, Heart Failure, and Chronic Obstructive Pulmonary Disease. The physician's order reviewed on 6/9/2021 at 11:12 AM indicates that R #33 to receive Dialysis services on Mondays, Wednesdays, and Fridays. A review of the dialysis communication record, for May and June, on 6/10/2021 at 11:02 AM revealed no record of assessment and/or monitoring of the Resident's health condition before and after dialysis for the following dates: 5/19/2021, 5/21/2021, 5/24/2021, and 6/9/2021. Review of the dialysis services agreement on 6/10/2021 at approximately 11:30 AM states under A. Obligations of nursing facility and/or Owner. 1. ESRD Residents information. The nursing facility shall ensure that all appropriate medical and administrative information accompanies all ESRD Residents at the time of referral to ESRD Dialysis Unit. This information, shall include, but not limited to, where appropriate, the following: D. Appropriate medical records, including the history of the ESRD Resident's illness, laboratory and x-ray findings; In an interview with the Director of Nursing (DON) s/he acknowledged that required documentation to indicate the R #33 has been properly assessed and monitored pre and post dialysis was not in the Residents' clinical record or the facility records.

Based on observation, record review, and interviews the facility failed to ensure that changes made to the menu were done by a qualified professional. In addition, the facility failed to inform the residents in advance and provide them with the opportunity to participate in this activity. The Certified Dietary Manager (CDM) removed and added food items from and to the menu without consulting the Physician, Dietitian, and Residents. During the initial walk through of the kitchen on 6/08/21 at 10:29 AM the CDM stated that [s/he] had made changes to the menu because [s/he] knows that the Residents won't eat certain foods, such as Brussels Sprout, Oatmeal, and Mushrooms. In an Interview with R #33 on 6/8/2021 at approximately 11:15 AM [s/he] stated that [s/he] prefers Bacon and Sausage with Breakfast and that [s/he] was getting it until a couple of weeks ago. R #33 said that [s/he] has requested these items back multiple times to no avail. On 6/8/21 at approximately 2:30 PM the CMD stated that R #33 cannot have bacon and sausages because [s/he] is on a Renal Diet. When asked if [s/he] has a food preference list/card for R #33 the CMD was unable to locate it and [s/he] could not record R #33 ' s food preference. Review of the menu provided by the CDM found breakfast does not have grits or oatmeal and has either boiled, scrambled or cheddar scrambled eggs daily. For the lunch menu mushroom was scratched off and yellow rice handwrote below. Seasoned Brussel sprout was also scratched off and cauliflower handwrote below. Resident choice meal, scampi, rice, cauliflower/broccoli blend, and garlic toast were handwritten on the menu. The Dietary Manager (DM) was not able to provide evidence to indicate that this meal was chosen by the residents. Review of the facility's position description. Job Title: Dietary Manager. Summary Description: The dietary the manager is responsible for planning, organizing, developing, and directing the overall operation of the Dietary Services Department in accordance with the current applicable federal, state, and local standards, guidelines, and regulation, established facility policies and procedures and as may be directed by the administrator, to ensure that the quality of food services and nutritional care is provided at all times. Review of the facility's policy titled Nutrition Policies and Procedures Subject: Menus under Procedures: The Facility Dietitian approves and signs all menus, diet modifications, and menu changes. In a phone interview with the Registered Dietitian on 6/10/2021 at approximately 11:35 AM [s/he] stated that [s/he] has not made changes to the facility ' s menu since 2020. The Dietitian concurred that the CDM does not have the credential to make changes to the menu without consulting a dietitian, physician, and resident.