**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review the provider failed to ensure the proper storage of hazardous products and sharp objects to prevent resident accidents in one of one observed facility beauty shop. Findings include: 1. Observation on 2/11/25 at 9:35 a.m. in the facility beauty shop revealed: *The door was open and no facility or beauty shop personnel were present. *There was a countertop vanity sink with two cupboards and two drawers where beauty shop products and supplies were stored. *There were 12 beauty shop products with printed warning labels on the containers. *Disinfectant Sani-wipes were stored on the countertop. -The container label read Keep Out of Reach of Children. *Bed Head hairspray was stored in one of the cupboards. -The container label read Keep Out of Reach of Children and Avoid Contact With Eyes. *Fanci Full instant hair color (liquid) was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, Flammable, May Cause Eye and Skin Irritation, and For External Use Only. *Biolage shampoo was was stored in one of the cupboards. -The container label read For External Use Only, Keep Out of Reach of Children, and Avoid Contact With Eyes. *Biolage conditioner was stored in one of the cupboards. -The container label read For External Use Only, Keep Out of Reach of Children, and Avoid Contact With Eyes. *Fanci Full instant color mousse was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, Danger, Flammable, May Cause Eye and Skin Irritation, and For External Use Only. *Acetone nail polish remover was stored in one of the cupboards. -The container label read Danger, Extremely Flammable Liquid and Vapor, Causes Serious Eye Irritation, Keep Away From Heat, Sparks, Open Flames, and Hot Surfaces. *Head and Shoulders shampoo was stored in one of the cupboards. -The container label read Keep Out of Reach of Children. *Rave 24 Hour extreme hold hairspray was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, Danger, Flammable, Avoid Inhalation, and Avoid Contact With Eyes. *Vidal [NAME] mousse was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, and Avoid Contact With Eyes. *Fanci Full color mousse white mix was stored in one of the cupboards. -The container label read Keep Out of Reach of Children, Danger, Flammable, May Cause Eye and Skin Irritation, and For External Use Only. *Suave hairspray was labeled was stored in one of the cupboards. -The container label read Keep Out of Reach of Children. *An electric blow dryer stored in one of the cupboards with the labeled products. *The cupboard that contained those hazardous products was unsecured and accessible to the residents. *In one of two sink vanity drawers there were four white containers that stored beauty supplies. - One container had two pairs of cutting scissors stored on top of the opened scissor case. *That drawer was unsecured and the scissors were accessible to the residents. 2. Observation on 2/10/25 in the resident dining room between 4:50 p.m. and 5:10 p.m. revealed: *Resident 13 had locomoted herself down the hallway and stopped at the beauty shop door and looked inside. -Staff personnel re-directed resident to the dining room for the evening meal. 3. Interview on 2/12/25 at 4:12 p.m. with director of nursing (DON) B regarding the beauty shop revealed: *She explained the beauty shop door was left open because it was located where the staff could easily access the phone and use it. -The beauty shop was located across the hall from the resident dining room. -The beauty personnel brought and stored their beauty products and supplies in the beauty shop. -She was unsure of who was responsible for cleaning, maintaining, and ensuring the proper storage of the beauty shop products and supplies and stated Maybe the activities department. -The activities director was out of the facility on 2/12/25 and unavailable for an interview. 4. Review of the providers 04/2023 Storage Areas policy revealed: *The providers policy defined storage procedures for the environmental services (housekeeping and laundry) departments. -These areas are to be maintained in a clean and safe manner. -Flammable liquids, combustible gases, etc., should not be stored in these areas where intense heat or open flame devices could ignite such matter. -Cleaning supplies, etc., shall be stored in areas separate from food storage rooms and shall be stored as instructed on the labels of such products. *No policy was provided on the proper storage of hazardous products for the facility beauty shop or for any resident environment areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to establish and maintain a process to accurately identify and reconcile as well as appropriately secure and store scheduled controlled medications in two of two medication carts for eight of eight sampled residents (1, 12, 15, 39, 49, 52, 206, and 306). Findings include: 1. Observation and interview on 2/12/25 at 9:32 a.m. in one of one medication storage room with registered nurse (RN) E and RN U revealed: *The medication storage room utilized a keyless lock entry system that required a code to enter. *There were two medication carts stored inside that room. *The carts contained drawers where the residents' individualized punch-style medication cards (bubble packs) and stock medications were stored. -There were two drawers of each medication cart that stored the majority of the residents' scheduled controlled (medications with risk for abuse and addiction) and non-controlled medication punch cards. -The remaining cart drawers stored stock medications, insulins, eye drops, inhalation medications and additional medical supplies. *Each medication cart had one drawer with a lockable box (lock box) inside of it. -The lock boxes contained a supply of the residents' as needed (PRN) non-controlled Tylenol (acetaminophen) and PRN controlled medications bubble packs. *The storage room utilized a key lock entry cupboard. -The cupboard contained a supply of the residents' scheduled and PRN controlled medications and the emergency medication kit. *A reconciliation/tracking record was used to document the PRN controlled medications and scheduled controlled Fentanyl (pain medication) patches. *There were no reconciliation/tracking records for the residents' other scheduled controlled medications. *They confirmed they used reconciliation/tracking records for the residents' PRN controlled medications and scheduled controlled Fentanyl patches to document the counted amounts of those medications. -They explained those medications were counted and documented on those tracking records every shift by two nurses. *They confirmed there were no reconciliation/tracking records maintained to document the amounts of the residents' other scheduled controlled medications. 2. Interview on 2/12/25 at 4:12 p.m. with DON B regarding the accountability of residents' medications process revealed: *The PRN controlled medications were tracked/reconciled. -They did not reconcile/track the scheduled controlled medications. -Two nurses, one coming on duty and one going off duty, were to count and reconcile/track those medications each shift. -The nurses were to count the medications in the bubble packs to reconcile the amounts of the scheduled controlled medications. -The nurses were to reconcile and document the scheduled count of those medications with each medication pass. *She was asked how she would know if a medication bubble pack was tampered with or had a medication missing: -She felt the nurses would notice if a medication bubble pack was tampered with or if there was a missing medication. -The nurses were trained to report a medication discrepancy right away to the DON. *She was asked if she reconciled or destroyed the controlled medications with the pharmacist. -She explained she did not reconcile or destroy medications with the pharmacist. -A nurse on duty would reconcile the medications when they were delivered by the pharmacy. -Two nurses on duty destroy the controlled medications. 3. Interview on 2/13/25 at 9:40 a.m. with administrator A regarding the accountability and storage of medications revealed: *She was unsure of the process for the accountability and storage of medications and requested the surveyor to speak to DON B. *Administrator A provided DON B's cell phone number as she was out of the facility on 2/13/25. 4. Interview on 2/13/25 at 10:19 a.m. with consultant pharmacist X revealed: *Asked what the process was to ensure the proper storage, security and tracking of all controlled medications. *Asked about the process for the scheduled controlled punch card (bubble pack) medications stored in the medication carts among other non-controlled punch card (bubble pack) medications that had no reconciliation log/tracking record. * Asked about the distributing pharmacy and consultant pharmacist responsibilities and processes related to controlled medications. -He explained he was not employed by the dispensing pharmacy but was contracted by the facility. -He completed the monthly resident chart medication reviews, and checked for outdated supplies and medications monthly in the medication storage room, and medication carts. -He did not review the scheduled controlled medications as the facility did not have reconciliation/tracking records for those medications. -He reviewed the PRN controlled and Fentanyl patch medication reconciliation/tracking records. -The scheduled controlled medications in the medication carts were to be monitored by the nurses. -The nurses were to monitor the medication bubble packs for signs of tampering and potential drug diversion as they administered medications during their scheduled shifts. -He stated schedule II through IV controlled medications should be locked, but some could be stored with non-controlled medications if there is a good system for tracking. -Nurses were to report medication discrepancies to the nursing supervisor. -He agreed that the medication carts are to be within their view at all times if controlled medications are secured with one lock. -He agreed that some controlled medications needed to be secured with two locks and reconciled/tracked at the change of each shift. 5. Interview on 2/13/25 at 12:04 p.m. with administrator A and DON B, who joined by phone at 12:06 p.m., revealed: *A report of residents who had ordered controlled medications was requested, but they were unable to run that report in the EMR system. *The medication error reports for the past six months were requested. -No medication error reports were provided. -Administrator A stated no medication errors had been reported in the past six months. 6. Observation and Interview on 2/13/25 at 12:10 p.m. in the medication storage room with RN E, LPN T, and consultant pharmacist X revealed: *Consultant pharmacist X stated the residents' medications were filled and delivered by the distributing pharmacy according to the printed medication administration records (MARs) provided to the pharmacy by the facility. -Medication bubble packs were filled with either a two-week supply or thirty-day supply of medications. -RN E and LPN T explained that the night nurse would check the medications in and if discrepancies were noted, the pharmacy would be contacted. -The EMR system did not automatically reconcile the scheduled controlled medications. -RN E explained that the nurses reconciled by the printed number on the card. -She further explained if it was the 11th day of the month, the nurse would punch the medication bubble marked with the number 11 to release that medication from the bubble pack medication card. -RN E stated that this was how the nurses would reconcile/track the scheduled controlled medications in the carts. -LPN T confirmed that process. *RN E and LPN T explained that the process was not always followed with new employed nurses. -Some bubble pack cards would be punched starting at the bottom of the card with the number 30. -Some bubble pack cards would be punched starting at the top of the card with the number 1. *Both nurses were unaware of a report that would indicate which residents had ordered controlled medications in the EMR system. *RN E and LPN T went through every resident medication bubble pack in each cart to identify residents who received scheduled controlled medications. -RN E and LPN T confirmed that this was the process they used to identify residents with ordered scheduled controlled medications that did not have reconciliation/tracking records. -After those residents' medication bubble packs were located, LPN T stated, I think that is all. -Eight residents with controlled medication bubble packs were identified as: *Resident 1 was on a schedule IV medication Lorazepam (a sedative medication) 0.5mg tablet by mouth twice daily (BID). *Resident 12 was on a schedule IV medication Xanax (antianxiety medication) 0.25mg tablet by mouth every night at bedtime (QHS). *Resident 15 was on a schedule IV medication Xanax 0.5mg tablet by mouth twice daily (BID). *Resident 39 was on a schedule IV medication Xanax 0.25mg tablet by mouth every night at bedtime (QHS). *Resident 49 was on a schedule IV medication Tramadol 50mg tablet by mouth twice daily (BID) *Resident 52 was on a schedule II medication Hydrocodone/APAP 5/325mg tablet by mouth every night at bedtime (QHS). *Resident 206 was on a schedule IV medication Xanax 0.5mg tablet by mouth twice daily (BID). *Resident 306 was on a schedule IV medication Tramadol 50mg tablet by mouth twice daily (BID). 7. Review of the provider's 4/8/2024 Controlled Substances-System Standard Policy revealed: *I. Policy: -A. It is the policy of [NAME] to properly acquire, receive, store, administer, track, reconcile, document, and dispose of controlled substances consistent with state and federal guidelines. *II. Purposes: -B. To accurately account for and reconcile controlled substances for prompt identification of loss or potential diversion. -D. To provide a system that oversees that controlled substances are acquired, handled, administered, reconciled, stored, and disposed of properly. -E. To assure proper record-keeping for controlled substances. *III. Procedure: -B. Record keeping: -1. Log all controlled substances on Resident's Controlled Substance Record form. -C. Place controlled substance(s) received from the pharmacy in a locked storage area with limited staff access. CII meds will be maintained in a separately locked permanent affixed compartment. Schedule III, IV, V may be stored in a separate locked container or may be integrated with other medications as long as there is a system for accountable tracking (punch cards). -E. One authorized person going off duty and one authorized person coming on duty must count and reconcile the accuracy of controlled substance supply for each resident and the facility at the shift change. -F. Controlled substance records are reconciled by a physical count of the remaining controlled substance supply at the change of each shift by the incoming and outgoing licensed nurse/designee. Controlled substance keys will be reconciled at the same time. -NOTE: The controlled substance supply of medication is always secured with two locks. (With the exception of medications that are part of a single unit package system when the supply is minimal and there is ability to detect a shortage promptly). The locks on the medication cart and the narcotic drawer are always secured.

Based on observation, interview, record review, and policy review the provider failed to ensure: *Items were not stored under the food preparation sink in one of one kitchen. *Documentation was completed for the cleaning and sanitation of one of one dishwasher. *A process was in place to test and document sanitation levels in sanitation buckets for one of one kitchen. *Refrigerator and freezer temperatures were documented for two of two refrigerators and two of two freezers in one of one kitchen. *Food temperatures were measured prior to serving by one of one cook (G) and documented. *Proper food handling processes were in place for four of four observed certified nursing assistants (CNA M, N, O, and Q) and two of two dietary staff (K, and L) during two of two observed meal services. *Refrigerators had daily temperature documentation completed for seven of seven resident refrigerators(37, 31, 45, 7, 14, 45, and 51) and one of one activity department refrigerator expired food was removed. Findings include: 1. Observation on 2/10/25 at 3:53 p.m. of the kitchen revealed: *Under the sink labeled Food Preparation sink were two cabinets. *One cabinet contained the following items: -A green bucket with an unknown black liquid in it. -A silver round pie plate with rust present on the surface. -A flat square metal instrument with a blue handle. -A box of griddle polishing pads stored in corrugated cardboard. -Three plastic fly swatters. -A corrugated cardboard box with ten cc (cubic centimeter) syringes. -A silver squeegee with a black handle. *The second cabinet contained the following items: -Potato press to make fries. -Four small frying pans. -A donut dispenser. -Two large saucepans. -Three small saucepans. -Two pan lids. -A grill cleaning brick. -A square metal dish. -A metal cylinder with multiple holes on the sides and a rod in the center. -A squeegee handle. *On the counter there was a white three-ring binder with tabs labeled for each month. *Under the monthly tabs were: -The dishwasher chemical log. -The dishwasher cleaning log. -The freezer and refrigerator temperature log. -The daily temperature for food log. -The walk-in refrigerator and freezer temperature log. Interview on 2/10/25 at 4:18 p.m. with food service manager C revealed the items stored under the sink were items used in the kitchen where residents' food was prepared. 2. Observation on 2/10/25 at 3:48 p.m. of the dishwasher revealed it was a chemical dishwasher. Review of the provider's January 2025 dishwasher chemical log revealed: *The dishwasher chemical log had a column to document the PPM (parts per million) sanitizer concentration. *This log did not include a column to document dishwasher temperature. *There were 13 days without documented chemical concentrations. *There was no chemical concentration documentation from January 8th through January 14th. Review of the provider's January 2025 dishwasher cleaning log revealed: *There were 12 days of missing documentation in January. *There was no cleaning documented for January 9th through January 14th. 3. Observation on 2/10/25 at 4:00 p.m. of the three-compartment sink in the kitchen revealed: *There are multiple buckets with liquid and a cloth in them. *There was no documentation of the liquid's chemical concentration. Interview on 2/10/25 at 4:04 p.m. with cook I revealed: *Those buckets were sanitation buckets used to wipe surfaces. *The chemical concentration was tested when the liquid was changed, but there was no documentation log. *He indicated the sanitation buckets were changed every hour. Observation and interview on 2/11/25 at 11:04 a.m. of cook H revealed: *He mixed a new bucket of sanitizer. *He did not test the chemical concentration of the contents in the new bucket. *He had filled a new bucket of sanitizing solution. *He did not test the chemical concentration of that solution. *There was no place to document the testing of the chemical concentration of the solution in the buckets. *He tested the buckets once daily. Observation and interview on 2/12/25 at 3:30 p.m. with cook K revealed: *He prepared a sanitation bucket. *He did not test the solution's chemical concentration. *When asked how he would know if the solution had the adequate chemical concentration, he tested the liquid. *The chemical concentration was read to be greater than 200 ppm. *When asked what ppm he expected the solution to be he indicated that he did not know. *He stated that he did not know where to locate that information. *Food service manager C directed him to a three-ring binder to find the information. *The information was observed above the three-compartment sink on a poster labeled Quaternary Sanitizer, which indicated the concentration should have been between 200-400 ppm. *Also on this poster was a statement that directed staff to Record the solution concentration reading in the appropriate log. 4. Interview on 2/10/25 at 4:14 p.m. with cook I revealed there were lines through the documentation areas on the temperature logs that indicated the temperatures had not been documented and those lines prevented someone from documenting a temperature on a later date. *Observation and interview on 2/11/25 at 11:10 a.m. with cook G during lunch service revealed: *The display on the Convotherm oven indicated the temperature was set at 212 degrees Fahrenheit. *She removed ground meat and mashed potatoes from the Convotherm oven. *She take had not taken the temperature of the meat or mashed potatoes removed from the Convotherm oven prior to serving. *She stated that the food had been in the Convotherm oven all morning and would be an adequate temperature. Review of the provider's walk-in refrigerator and freezer temperature logs for January 2025 revealed: *The temperature log contained an area for temperature documentation for the refrigerator and the freezer in the AM and the PM. *There was a line drawn through the area to document the AM temperatures on 1/8/25, 1/10/25, 1/15/25, 1/20/25, 1/27/25. *There was a line drawn through the area to document the PM temperatures on 1/2/25, 1/3/25, 1/7/25, and 1/8/25. Review of the provider's walk-in refrigerator and freezer temperature logs for February 2025 revealed there was a line drawn through the AM and PM documentation areas on 1/9/25. Review of the provider's January 2025 Refrigerator and Freezer temperature documentation log revealed: *There was a column to document the refrigerator temperature and another to document the freezer temperature. *There was no documentation of the freezer or the refrigerator temperatures for the first seven days in January. *In addition, there was no temperature documentation for the refrigerator or freezer on 1/9/25, 1/18/25, 1/19/25, 1/24/25, and 1/31/25. Review of the provider's January 2025 food daily temperature record revealed: *There was an area to document soup, meat, alternate meat, potatoes, vegetables, alternate vegetables, puree, and other for lunch and supper. *There was no area to document breakfast foods. *There was no area to document the temperatures of refrigerated foods. *There was no temperature documentation for lunch on 1/10/25 and 1/29/25. *There was no temperature documentation for supper on 1/2/25, 1/3/25, and 1/5/25. Interview on 2/12/25 at 3:40 p.m. with food service manager C revealed: *It was his expectation that the sanitation bucket concentration be tested each time a bucket was changed. *The buckets were changed every hour. *He verified there was no log to document the chemical concentration of the sanitation buckets. *He expected food temperatures to be taken and documented every day prior to every meal being served. *He verified there was missing documentation of food temperatures and there was no area for breakfast temperatures to be documented. *It was his expectation that the temperatures for the refrigerators and freezers in the kitchen were checked and documented daily. *Residents' personal refrigerator temperatures were to be monitored by housekeeping. 5. Observation on 2/10/25 at 5:06 p.m. of CNA N serving food revealed: *She had on a pair of gloves. *With those gloved hands she: -Pushed a resident closer to the table. -Turned pages on a 3-ring binder at the serving counter. -Delivered plates of food to residents by placing her thumbs on the edge of the plates. --She did not change her gloves during the meal service. Observation on 2/10/25 at 5:11 p.m. of CNA Q revealed she wore a pair of gloves and cut up two different residents' food items without changing them. Observation on 2/10/25 at 5:13 p.m. of food service work L revealed she had on a pair of gloves, and with those gloved hands she: *Picked up a plastic container of bread that was located in the serving area next to the steam table. *Took bread out of that plastic container and placed it on plates of food to be served to the residents. Observation on 2/10/25 at 5:16 p.m. of CNA M revealed she wore a pair of gloves and with those gloved hands she: *Served two plates of food to residents, with her thumb on the edge of the plate and touching the bread on the plate. *Continued to serve residents plates of food with those same gloved hands. Observation on 2/11/25 at 11:15 a.m. in the dining room of CNA O revealed she: *Used hand sanitizer on her hands and put on a pair of gloves. *Picked up a knife and fork and tried to cut up an unidentified resident's sausage. -The knife was dull, and she was unable to cut the sausage. *Picked up the sausage with those same gloved hands and removed the skin from the sausage. *Placed the skin on a napkin and then picked up that resident 's silverware and cut up his sausage. *Picked up his juice and gave him a drink. *Wiped her gloved hands on the napkin that the sausage skin was on. *Picked up a sausage piece with the resident's fork and then used her gloved hand to slide it off. Observation on 2/11/25 at 11:35 a.m. of CNA O revealed: *She took a pair of gloves out of her shirt pocket and put them on. -She had not completed hand hygiene before putting on the gloves. *She assisted an unidentified resident with the sausage on his plate. -She picked up the sausage with her gloved hands, removed the casing from it, and cut it up with a knife. Observation on 2/11/25 at 11:47 a.m. of food service worker J revealed she passed lunch trays to residents without performing hand hygiene between delivering of each resident's meal tray. Interview on 2/13/25 at 9:49 a.m. with CNA O regarding her observed glove use in the dining room revealed: *She used gloves if she was helping a resident with a sandwich or with the sausage if they had to peel the skin off. *She did not put gloves on if she used a utensil, like a spoon, to help a resident eat. *She stated she would use hand sanitizer if she changed her gloves. Interview on 2/13/25 at 10:55 a.m. with administrator A and DON B, who joined by phone, regarding staff glove use in the dining room revealed: *Glove use was not required in the dining room. *Staff were expected to use hand sanitizer if they were not wearing gloves in any area of the building. *They agreed staff had not used gloves appropriately. 6. Observation on 2/11/25 at 9:12 a.m. of resident 37's refrigerator revealed: *Refrigerator temperature documentation was missing for 2/1/25, 2/2/25, 2/7/25, and 2/10/25. *In the refrigerator was a bag of dates that were not dated and two oranges with brown spots. Observation on 2/12/25 at 9:22 a.m. of resident 31's refrigerator revealed: *A croissant sandwich wrapped in plastic wrap dated 2/1. *Refrigerator temperature documentation was missing for 2/1/25, 2/2/25, 2/8/25, and 2/9/25. Observation on 2/13/25 from 8:35 a.m. to 9:10 a.m. of resident refrigerators revealed: *Resident 45's refrigerator was missing temperature documentation for 2/2/25, 2/3/25, and 2/9/25. *Resident 7's refrigerator was missing temperature documentation for 2/1/25, 2/2/25, 2/8/25, and 2/9/25. *Resident 14's refrigerator was missing temperature documentation for 2/1/25, 2/2/25, 2/8/25, and 2/9/25. *Resident 45's refrigerator was missing temperature documentation for 2/2/25, 2/3/25, and 2/9/25. *Resident 51's refrigerator had a form to document the refrigerator temperatures for January that indicated he had a new refrigerator on 1/24/25. *There was not a form to document February refrigerator temperatures. *There was no thermometer in the refrigerator. Interview on 2/13/25 at 9:40 a.m. with housekeeping manager D regarding resident refrigerators revealed: *Housekeeping staff checked the temperatures of the resident refrigerators Monday through Friday. *No one was responsible for checking resident refrigerator temperatures on the weekends. Observation on 2/13/25 at 12:14 p.m. of the refrigerator in the room identified on the door as the activity room revealed: *There was a piece of paper on the refrigerator door that stated, This refrigerator is for resident and activity department only. *Refrigerator temperature documentation was missing for 2/1/25, 2/2/25, 2/8/25, and 2/9/25. *Inside the refrigerator was a blue container labeled with a name that was dated 10/2/24. 7. Review of the provider's 5/24 LTC Food Safety and Sanitation policy revealed: *Gloves will be worn when handling ready to eat foods to ensure that pathogens are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Anytime a contaminated surface is touched, the gloves must be changed-washing hands after removing the gloves and before putting on a new pair. *Hands must be washed before serving/distributing meals, & or after picking up soiled plates/waste. *Staff do not need to wear gloves when distributing food or when assisting residents to dine, as long as food is not touched with the bare hand, and or proper handling of utensils, dinnerware is adhered to. *Sanitizer buckets are changed when visibly soiled or per manufacturer's direction. The sanitizer is checked for proper concentration with test tape (per manufacture's instruction). *Cloths must be soaking in sanitizer until use, changing solutions every 4 hours to maintain active concentration. (or per manufacturer's instruction). *All refrigerators and freezers have thermometers and temperature is documented at least 1x [one *time] daily. *Cooked foods must reach the temperature recommended by Food Service Code. *Hot food is held at a temperature of 140 [degrees] F [Fahrenheit] or above. *Cold foods are held at a temperature of 40 [degrees] F [Fahrenheit] or less. *Dishwasher Temperature/appropriate sanitation levels are checked & [and] recorded daily. Review of the provider's 4/23 Food Temperatures policy revealed: *The food service will follow proper procedures in storing and monitoring food temperatures to prevent the spread of food borne illness. *Temperatures must be maintained at the following (Fahrenheit) settings for the items indicated below: -Frozen food 0 [degrees] or below; -Refrigerated food 41 [degrees] or below; Review of the provider's 4/23 Recording Hot-Cold Food Temperatures policy revealed: *Record temperatures on food temperature log. *Continue taking temperatures as needed for each item on menu and recording.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention practices were performed by: *Not following provider policy for use of personal protective equipment (PPE) for one of one resident (47) on enhanced barrier precautions by one of one staff (LPN F). *Not having placed one of one resident (37) with a pressure ulcer on enhanced barrier precautions. *Not performing appropriate hand hygiene during three of five observations of two of two staff (LPN F and RN S). *Not following provider policy for nebulizer tubing changes for one of two sampled residents (50). *Not cleaning multi-use items properly during three of four observations of one of one of one of one staff (RN S). *Not maintaining the appropriate cleanliness and storage of multi-use items in one of one observed beauty shop and one of one observed tub room. *Inappropriate glove use and hand hygiene during a blood sugar check and with insulin administration by one of one observed staff (RN S). Findings include: 1. Observation on 2/10/25 at 5:00 p.m. of resident 47's room revealed: *A sign on her door indicated enhanced barrier precautions (EBP) (use of gown and gloves during high-contact resident care activities) was required. *A plastic container with drawers containing gowns and gloves was present in her room. Interview on 2/11/25 at 10:18 a.m. with CNA W regarding EBP revealed a gown and gloves were to be when direct care was provided a resident on EBP. Observation and interview on 2/11/25 at 1:57 p.m. of licensed practical nurse (LPN) F while changing resident 47's dressing on her right lower leg revealed: *Resident 47 had an ordered daily dressing change to her right lower leg, where she received a skin graft. *LPN F was seated beside resident 47 as she changed the dressing. *LPN F was not wearing a gown. *LPN F removed her gloves after she completed the dressing change. -She did not perform hand hygiene after she removed those gloves upon completion of the dressing change. Interview on 2/11/25 at 2:03 p.m. with resident 47 revealed she felt staff at times wore a gown and gloves when providing her care or changing her dressing. 2. Observation on 2/11/25 at 1:49 p.m. of resident 37's room revealed: *Resident 37 was sitting in her recliner with a Prevalon boot (pressure reduction boots) on her left foot. *She stated that she wore the boot because she had a sore on her heel. *No personal protective equipment (PPE) (gowns, gloves, and eye protection) was observed in or near her room. *There was no sign on her door that indicated EBP was required. Interview on 2/11/25 at 4:05 p.m. with resident 37 revealed staff did not wear a gown when they changed her left heel dressing, helped her with getting dressed, or assisted her with her toileting needs. Review of resident 37's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 11/18/24 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *Her left heel ulcer was identified on 9/23/24 and was documented to be 4.4 cm (centimeters) by 5 cm, brown, dry, and intact. *2/11/25 wound documentation revealed she had a left heel ulcer that was Open, drainage moderate serosanguineous. *She was being seen by wound care for her left heel ulcer. *There were dressing changes ordered for her left heel ulcer. Review of resident 37's 2/12/25 care plan revealed: *She had an unstageable left heel Pressure injury/ulcer that was added to her care plan on 11/19/24. *The care plan did not include the use of EBP. 3. Observation on 2/10/25 at 5:00 p.m. of resident 50's room revealed: *An assembled nebulizer administration set was lying on the nebulizer machine. *There was a date written on the handheld nebulizer device of 1/29. *The date of 1/31 was written on the nebulizer tubing. Interview on 2/11/25 at 8:36 a.m. with resident 50 revealed: *She was admitted to the facility after being hospitalized with a respiratory infection. *She could not recall when she last received a nebulizer treatment. Interview on 2/12/25 at 1:25 p.m. with registered nurse (RN) E regarding resident 50 revealed: *Her last nebulizer treatment was administered on 1/27/25. *Her nebulizer treatments were ordered to be administered as needed. *When nebulizer treatments were administered as needed it was RN E's practice to dispose of the nebulizer set after a treatment was given and obtain a new set for the next treatment. *RN E reported the documentation in resident 50's EMR, indicated LPN F had documented that she changed resident 50's nebulizer tubing on 2/11/25 at 11:00 a.m. *RN E confirmed that the nebulizer set in resident 50's room was dated 1/29 and 1/31. Review of resident 50's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score of 15, which indicated she was cognitively intact. *She had been hospitalized with pneumonia, bronchitis, and hypoxia (low oxygen in the blood) prior to her admission to the facility. *She had an order for a Xopenex nebulizer as needed for shortness of breath. *There was an order to change the nebulizer tubing weekly and as needed. Review of resident 50's care plan revealed nursing staff were to: *Provide NEBULIZER meds as ordered *Change filter as per facility protocol. *Change nebulizer tubing weekly. 4. Observation on 2/11/25 at 9:35 a.m. of the facility beauty shop revealed: *One of two drawers of the sink vanity contained four small, white storage containers. *Those four containers stored a variety of beauty shop items. -One contained 11 combs and was visibly soiled with a build up of hair, lint and dust fibers. -One contained two pairs of cutting scissors located on top of the opened soiled scissor case. -The container was visibly dirty with hair, lint and dust fibers. -One contained various hair picks, combs, and tweezers and was visibly soiled with hair, lint and dust fibers. *Four of four rolling hairdryers had visibly soiled vent screens that contained a white, dry substance. 5. Observation and Interview on 2/11/25 at 9:41 a.m. with CNA V in one of one north hall tub room revealed: *A storage bin with divided compartments was labeled and stored in the tub room. -It contained the residents' personal nail trimming supplies. *One small compartment bin was unlabeled and stored in the tub room. -It contained one pair of scissors, one large nail clipper, one cuticle clipper, one pair of tweezers, approximately five disposable razors and multiple alcohol pads. -The items in the small bin were multi-use items used for the residents. -CNA V stated the residents' personal clippers and multi-use items were cleaned with alcohol wipes. 6. Observation and Interview on 2/11/25 at 9:58 a.m. with RN S revealed: *RN S performed hand hygiene, removed blood sugar supplies and insulin from the medication cart parked in the dining room. -RN S walked to resident room [ROOM NUMBER] and entered. -The supplies were placed on the residents visibly soiled walker seat. -RN S applied gloves but did not perform hand hygiene. -RN S did not clean or disinfect the surface area of the walker seat or apply a barrier for the supplies. -Resident treatments were completed and the dirty items discarded appropriately. -RN S removed her gloves, she did not perform hand hygiene, and exited the resident room. *Sani wipes with purple lid (germicidal wipes) were used for cleaning the glucometer. She stated, I wrap the glucometer in [a] wipe for ten minutes. *Staff were provided infection control training upon hire and through staff meetings. 7. Interview on 2/11/25 at 10:18 a.m. with CNA W revealed resident multi-use items and equipment were to be cleaned with Sani-wipes with the purple lid after each use. 8. Observations on 2/11/25 from 1:42 p.m. to 2:02 p.m. with RN S revealed : *Observed RN S exit resident 23 room. - She placed vital signs (VS) equipment (manual blood pressure cuff, an oxygen saturation monitor and a non-contact thermometer) on top of the medication cart. -A stethoscope remained around RN S neck. -RN S removed and discarded her gloves and did not perform hand hygiene. *RN S entered resident 22 room at 1:45 p.m., she performed hand hygiene, applied gloves and administered the residents eye drops. -RN S exited the room at 1:52 p.m. and returned to the medication cart. -She discarded her gloves and performed hand hygiene. *RN S applied gloves, and removed the VS equipment from on top of the medication cart and entered resident 45 1:55 p.m. -RN S placed the VS equipment on resident 45 bedside table. -Resident 45 bedside table was not cleaned or a barrier placed before the equipment was placed. -RN S obtained resident 45 vital signs and exited the room at 2:02 p.m. -RN S placed the VS equipment back on top of the medication cart. -RN S removed her gloves, discarded them but did not perform hand hygiene. *The VS equipment was not cleaned or disinfected before or after resident use. *Multi-use equipment and environmental surfaces were not properly cleaned and disinfected to help minimize cross-contamination and the spread of infection. 9. Interview on 2/12/25 at 4:12 p.m. with Infection Preventionist/DON B revealed: *She had completed infection prevention training in the summer of 2024 and obtained a Long-Term Care Infection Prevention Certification. -Staff were trained on infection control policies and procedures upon hire and yearly. -Staff were monitored through random observations, and audits that were tracked in a binder. -Staff were provided a variety of learning avenues with monthly meetings, annual trainings and competencies. -Infection surveillance was completed and reported to NHSN and QAPI. *Staff should use Sani-wipes (purple top) per the manufacturer's instructions. -She stated, those wipes had a wet time of two minutes. *She was unaware of the unlabeled compartment bin in the tub room that contained resident multi-use items. -She expected that no multi-use items were to be used and should be removed. *She was unaware staff had been using alcohol pads to clean the multi-use items. *Residents should have their own personal items to use. -Cleaning of multi-use items with alcohol pads was not appropriate. *Enhanced barrier precautions (EBP) training/education was provided to staff. *LPN T, or a floor nurse, or she could initiate EBP precautions. -Agreed EBP should be initiated during wound care treatment for residents with pressure sores. -Agreed that EBP was missed and should have been implemented for resident 37. -Agreed the nurse should have worn a gown during wound care treatment for resident 37. *She explained that the beauty personnel brought and stored their beauty products and supplies in the facility beauty shop. -She was unsure of who was responsible for cleaning, maintaining, and ensuring the proper storage of the beauty shop products and supplies and stated maybe the activities department. -The activities director was out of the facility on 2/12/25 and unable to interview. 10. Review of the provider's 10/24 Transmission Based Precautions and Enhanced Barrier Precautions policy revealed: *Enhanced Barrier Precautions (EBP): use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. Enhanced Barrier Precautions are used during high contact resident care activities for the following residents and should be implemented as facilities are able: -Wound requiring a dressing, regardless of MDRO status. -If on EBP a gown and gloves must be used during high contact resident care activities including (but not limited to) --wound care (any wound requiring a dressing). Review of the provider's 12/17/24 Respiratory Equipment Care policy revealed: *Empty excess fluid, Rinse nebulizer with sterile (preferred) or distilled water, shake off excess moisture, and place on a clean, dry paper towel, and store in a clean, dry location in the resident's room to air dry for the next treatment. *Replace nebulizer set weekly or more frequently based on MIFU [manufacturer's instructions for use]. Review of the providers 6/13/2024 Infection Prevention Program and Authority policy revealed: *II. Purpose/Responsibilities: -A. The function and duties of the Infection Prevention Program shall be to: -b. Maintain surveillance of the healthcare facility infection potentials. -d. Develop and implement a preventative and/or corrective program to minimize infection hazards. -g. Supervise Infection Control in all phases of healthcare activities and to act upon recommendations made by the Program. This may include: -i. Standard precautions and transmission based precautions (Isolation) policies. -ii. Hand hygiene policy. -iii. Environmental Cleaning. -vii. Consultation on and approval of cleaning/disinfection products, procedures, agents, or techniques. -B. Infection Prevention Practitioner -h. The Infection Prevention Program must meet standards imposed by OSHA, CMS, and regulatory bodies. Review of the providers 11/2024 Hand Hygiene policy revealed: *I. Purpose. -I. Hand hygiene (HH) continues to be the primary means of preventing the transmission of infection. -A. To cleanse hands to prevent the spread of infection. -B. To provide a clean and healthy environment for residents, staff, and visitors. -II. Policy. -A. HH, either with soap and water or with alcohol based hand rub (ABHR). -1. immediately before touching a resident. -2. before a clean procedure or handling an invasive medical device. -3. after contact with potential for body fluid or contaminated surfaces. -4. after touching a resident or the resident's immediate environment. -5. after removing gloves. Review of the providers 10/2024 Disinfection of Non-Critical Patient Care Equipment policy revealed: *A. Purpose. -B. For the safety and comfort of patients, all reusable (non-critical) patient care items not sent to Sterile Processing Department (SPD) for reprocessing will be cleaned, disinfected, and maintained in a safe manner between patient use. -C. Reusable equipment may have specific cleaning and disinfection Instructions for Use (IFU). -I. Information. -1. Non-Critical items are those that come into contact with intact skin but not mucous membranes. Examples include crutches, blood pressure cuffs, commodes, walkers, wheelchairs, gurneys, pumps, etc. Low level disinfectants (quats) or bleach are used on this kind of equipment. -II. Policy. -A. Items taken from a patient's room for use by another patient will be disinfected before use by next patient. -E. All reusable patient care equipment removed from a patient room/procedure room is disinfected before use on another patient. -I. Disinfectant Recommendations. -1. Reusable patient care equipment. -a. Between each patient use. -b. Stethoscopes - since stethoscopes typically hang around your neck or in a pocket, disinfect the bell and diaphragm before and after use with an alcohol wipe. Tubing can also be disinfected with an alcohol wipe. This is based upon [NAME] Stethoscope Instructions for Use (IFU). -III. Procedure. -A. [NAME] appropriate personal protective equipment (PPE) as needed for the task at hand: -1. Gloves - per standard precautions. -2. Gown - per standard precautions. -3. Facial protection - per standard precautions. -C. Using friction, wipe all surfaces with hospital-approved disinfectant. Do not touch cleaned surfaces/items and allow to air dry. -2. Surfaces should remain wet per required contact time which is stated on the product label: -e. PDI Super Sani-Cloth Canister Wipes (purple top) = 2 minutes. -g. Product varies upon availability and staff are responsible for knowing required wet contact times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (54) had his insulin medication stored in an appropriate and safe manner according to the provider's policy and accepted standards of practice Findings include: 1. Observation on 10/16/23 at 5:56 p.m. in the family dining room refrigerator revealed: *There was a black plastic bag in the lower righthand drawer. *The black bag contained two boxes of Lantus insulin pens, two boxes of Novolog insulin pens, and four loose Novolog insulin pens. -The boxes of insulin were not sealed, indicating they had been opened. *The loose pens and the boxes of insulin had prescription labels, indicating it was for resident 54. *The refrigerator had a piece of paper taped to it that read This refrigerator is for resident and Activity department only . *There was a temperature log for September 2023 taped to the outside of the refrigerator door. -Only the freezer temperatures were recorded on the temperature log. -There were only five days of freezer temperatures recorded. -There was no temperature log for the refrigerator. Observation on 10/17/23 at 9:32 a.m. of the same refrigerator revealed that the insulin was no longer in the refrigerator. 2. Interview on 10/18/23 at 11:26 a.m. with director of nursing (DON) B about the above observations revealed: *She was aware that the insulin for resident 54 was in that refrigerator. *They had kept it in there due to not having enough room in the nurse's medication refrigerator. *Resident 54's daughter had brought that insulin from home for the resident to use. -She thought that the resident's daughter had just brought the insulin in on 10/16/23. *The local pharmacist gave them approval to store the resident's insulin at their store. *She confirmed that the refrigerator in the family dining room, where they had been storing the resident's insulin, was not their normal practice and was not an appropriate area to store insulin. -All staff had access to that refrigerator. -Visitors also had access to that refrigerator if they were using the family dining room. -The refrigerator was not locked. 3. A phone interview was attempted with the resident's daughter on 10/19/23 at 10:26 a.m. with no answer. A voicemail was left explaining the purpose of the call. Resident 54's daughter returned the call on 10/23/23 at 9:48 a.m. after the conclusion of the survey. She confirmed she brought the insulin to the facility on [DATE]. 4. Review of a nursing note entered on 9/11/23 at 6:12 p.m. revealed: *Resident's daughter [name redacted] had called today and stated that they have some insulin that was rec'd [received] from the VA [Veteran's Administration], wanting to know if we can use it. I did check with [DON B] and we are able to use it, will need to take it to pharmacy when daughter brings it. I did leave message with [resident 54's daughter] on her voicemail notifying her of above, and also asked her to let us know when she is coming and to keep pens chilled until she can get them here. 5. Review of the provider's 1/1/14 Medication Storage policy revealed: *Policy: All drugs are stored under proper conditions with regard to sanitation, temperature, light, moisture, ventilation, segregation, safety and security. *Under the Procedure section: -Refrigerators used for drug storage shall maintain a temperature between 35 - 46 [degrees Fahrenheit] . at all times. -All refrigerated or frozen medications shall have the dates of reconstitution and expiration, pharmacist's initials, and storage requirements on all labeling. -All products in full, unopened cases can be stored in the general warehouse area with the exception of controlled substances or those requiring refrigeration. Once a case or carton is opened the contents are to be moved to the pharmacy area. -The following will be recorded on the environmental recording form on each business day: --The temperature of refrigerators and freezers: If the temperature moves out of the acceptable ranges, immediate action will need to be taken. A repair service will be called if necessary and the drugs/solutions will be checked for damage and discarded if necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to: *Ensure one of one sampled resident's (52) nebulizer machine and one of one sampled resident's (48) continuous positive airway pressure (CPAP) machine tubing was appropriately cleaned per policy guidelines. *Develop and implement hygienic and infection control guidelines for the maintenance of one of one sampled resident's (54) perineal care (peri-care) wiping tongs (a long-handled device used to maintain independence in wiping oneself after toileting). Findings include: 1. Observation and interview on 10/17/23 at 10:25 a.m. with resident 52 revealed he: *Was sitting in his recliner in his room with the lights off. *Was noticeably short of breath (SOB). *Stated it had not been a good day with his chronic obstructive pulmonary disease (COPD). *Stated he administered his own nebulizer treatments up to four times a day. -The nebulizer machine and the nebulizer medication solution were sitting on a table next to the resident. *Stated he did not clean the nebulizer tank or the mouthpiece after each use as he feels he is getting weaker and already had multiple falls since he was admitted to the nursing home. *Stated he had not had a staff member help him clean the nebulizer tank or the mouthpiece after each use. Review of resident 52's electronic medical record revealed he: *Was admitted to the facility on [DATE]. *Had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. *Had diagnoses of COPD, pulmonary hypertension, bronchiectasis, impaired balance, history of falls, SOB, and was oxygen dependent. *Received oxygen at 4 to 6 liters per minute via nasal cannula. *Had a self-administration of medication evaluation completed on 8/16/23. *Had a physician's order to have been able to self-administer medications daily. *Had three falls since his admission. Interview on 10/18/23 at 1:37 p.m. with director of nursing (DON) B and registered nurse (RN) charge nurse E regarding the above observation and interview with resident 52 revealed they stated: *There was no cleaning policy or procedure for the certified nursing assistants (CNAs) to assist him in cleaning his nebulizer tank and the mouthpiece. -At the time the resident was admitted , he stated that he could clean his own nebulizer tank and the mouthpiece. *They were not aware that he now felt that he could not clean his nebulizer tank and the mouthpiece due to his weakness and unsteadiness. Review of resident 52's baseline care plan dated 8/9/23 and his most recent comprehensive care plan dated 10/2/23 revealed there was no documentation that the resident was responsible for cleaning his own nebulizer tank and the mouthpiece. 3. Observation on 10/17/23 at 1:17 p.m. in resident 54's room revealed there was a pair of metal kitchen tongs with wooden handles sitting on a pile of papers and clothing in a chair. Continued observation on 10/18/23 at 11:20 a.m. with resident 54 in his room revealed: *He came out of the bathroom with the pair of tongs in hand. -There was a foul smell coming from the resident's vicinity as he rolled by in his wheelchair. -There were unidentified fibers sticking to the end of the tongs. -The metallic tip of the tongs had turned black in color. Interview on 10/18/23 at 11:26 a.m. with DON B about the above observation revealed she: *Confirmed that resident 54 used those tongs to help wipe himself after using the restroom. *Explained that was what he had done prior to moving into the nursing home. *Was not positive if there was a cleaning or a maintenance schedule for those tongs. Interview on 10/18/23 at 1:51 p.m. with charge nurse E about resident 54's cleaning tongs revealed: *Resident 54 had been evaluated by occupational therapy (OT) for the use of the tongs. -OT concluded that the tongs increased his independence. *She had previously educated resident 54 about storing the tongs in the bathroom. -She further explained that the resident was not always compliant with storing the tongs in the bathroom. *She had fashioned a bedside urinal as a place where he could store his tongs, but he did not want to keep them there. *When asked how often the tongs were cleaned, she confirmed that there was no cleaning schedule for any staff to clean or sanitize the tongs. -She was aware that the wooden handles were not a cleanable surface. -She indicated that the resident would clean the tongs with body wipes, but those wipes were not sanitizing wipes. Interview on 10/19/23 at 8:53 a.m. with DON B about the resident's tongs revealed she: *Confirmed there was no set schedule to clean or sanitize the tongs. *Was not sure how often the resident would clean the tongs with the body wipes. Review of resident 54's care plan dated 8/24/23 revealed: *Under the ADL (activities of daily living) section of his care plan: -Toilet use: Provide assist of 1 with toileting upon rising, before/after meals/activities, HS [hour of sleep] and as he calls for it or as he allows. At times he is independent with toileting as he is able. He uses a tong like device to hold toilet paper and wipe his rectal area after toileting that he brought from home and other times staff will assist him as he allows. *There was no indication in his care plan about who was responsible for cleaning his tongs, or when his tongs were supposed to have been cleaned. Review of the provider's 10/6/22 Disinfection of Non-Critical Patient Care Equipment policy revealed: *I. Purpose -A. Cleaning, disinfecting and storing equipment and supplies is important in preventing the transmission of potential pathogens within the long-term care facility. *III. Policy: -B. Resident equipment will be disinfected immediately following resident use when the item has been contaminated with blood or other potentially infectious material or is visibly soiled. -H. CPAP/BIPAP --1. Daily - wipe out the mask with clean wash cloth and empty water chamber. --2. Weekly - soak mask and head gear with mild soap and water for 30 minutes, rinse and air dry. Check and clean the filter on the back of the machine - replace when gray. --3. Change mask and tubing per home medical company recommendations. --4. Water Chamber to be filled with distilled or sterile water. -I. Nebulizers --1. Rinse with tap water, empty excess water from the neb cup, open to room air, and place on a clean, dry paper towel, covered with a paper towel in the patient's room to air dry for the next treatment. --2. The paper towel will be changed after each treatment. --3. Every 24hrs, disassemble and wash with soap and water, rinse and air dry as above, or when visibly soiled. --4. If not dry between uses, rinse with sterile water before use. --5. Discard and replace with new Neb set if grossly contaminated with the patient's secretions, malfunctions, or dropped on the floor. --6. Replace nebulizer set weekly or more frequently based on manufacturer instructions for use. -J. Disinfection Recommendations- --1. Reusable resident care equipment: All applicable label instructions on [Environmental Protection Agency]-registered disinfectant products must be followed . ---a. Between each resident use and when soiled . a. Therapy equipment . -N. Monitoring of disinfection recommendations will be done by observation by management staff . 2. Observation and interview on 10/17/23 at 9:06 a.m. with resident 48 revealed he: *Was resting in bed with the television on. *Had a continuous positive airway pressure (CPAP) machine on his night stand next to his bed. *Independently cleaned the mask for his machine daily. *Had not cleaned the tubing for the CPAP machine, and could not recall staff cleaning the tubing for the machine. Review of resident 48's care lan dated 6/5/23 revealed he: *Was admitted on [DATE]. *Had a BIMS score of 15, indicating his cognition was intact. *Had diagnoses of spinal cord injury, paraplegia, type 2 diabetes mellitus, and obstructive sleep apnea. *Had a CPAP machine and needed assistance with the maintenance and cleaning of the machine. Interview on 10/18/23 at 1:30 p.m. with DON B and RN F revealed: *Resident 48 had a CPAP machine on his admission. *The CPAP tubing was to have been cleaned weekly by staff. *Staff were to document in the resident's electronic medical record each time the tubing was cleaned. *They both confirmed there was no documentation that the CPAP tubing was cleaned weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation on 8/30/22 at 1:39 p.m. of resident 38 revealed: *She was lying on the bed sleeping under a blanket. *A pull tab alarm was attached to her wheelchair at the bedside. *A thin mat was on the floor next to the bed. Review of resident 38's medical record revealed: *She was admitted on [DATE]. *Diagnoses included Alzheimer's, Parkinson's, anxiety, and dementia. *The 6/6/22 quarterly MDS assessment listed: -A Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive impact. -Walking/locomotion required 1 to 2 person assist. -A bed alarm was used daily. -A chair alarm was not used. -She had two falls without injury and one fall with injury. *The care plan had dementia with behaviors and falls listed with the following interventions: -History of enjoying walks/assist for walks with 1 person and assistive device. -Take for wheelchair rides. -If she is walking, go to her and offer assistance. -May use wheelchair pushed by another. -Handwritten on the care plan and dated 7/12/22 was pressure pad alarm in bed @ [at] all times and pull string alarm while in wheelchair or chair. *An 8/8/22 fall investigation report revealed: -The incident occurred on 8/8/22 at 3:55 p.m. -Staff were notified from the pull tab alarm sounding and staff went to investigate and found the resident on the floor in the day room laying on her right side in front of her chair sideways one foot pedal was up pushed aside. -It looked as if resident had tried to get up and walk, she is very weak and does not understand her limitations. -Injury, not major/laceration to right ear with first aid provided. -Contributing factors to fall: unexpected movement. -No call light within reach (pull tab alarm on, she was in day room). -Bed/chair alarm used and sounding at time of fall. -Assessment: Resident liked to walk independently, she is now too weak to walk safely and is cognitively unable to understand her limitations. -Time of last purposeful hourly rounding on resident was 15:30 [3:30 p.m.]. -Staffing level at or above matrix and properly trained for situation. -Family notified 8/8/22 at 16:24 [4:24 p.m.]. Interview and review of previously requested records on 9/1/22 at 10:30 a.m. with DNS B about resident 38 revealed: *The facility did not: -Complete a fall risk assessment. -Complete a bed/chair alarm assessment. -Document education with the resident's family or representative for the bed or chair alarm. -Obtain consent from the family or representative for the bed or chair alarm. -Obtain a physician order for the bed or chair alarm. *Following a nurses meeting on 8/31/22 at 7:00 p.m., the bed and chair alarm had been discontinued. Interview on 9/1/22 at 1:25 p.m. with CNA H regarding resident 38 revealed: *She started working at the facility in 2018. *She was assigned to the hallway where resident 38 resided. *The resident was full cares and I just observe her. *The resident's most recent fall was approximately one month ago. *The resident had a history of a fall resulting in a hip fracture and surgery. *Interventions in place to prevent falls were: -A bed and chair alarm had been in place for a long time, since 2018 when I came here. -A mat on the floor next to her bed. -We usually lay her down facing the wall so she does not get out of bed, if you put her in bed not facing the wall, she will get out of bed and fall. -We monitor her often every 30 minutes. -Encourage water. -Check to see if she was incontinent. If she is messy she gets restless, so we make sure she is clean. She does not sit on the toilet anymore, she is incontinent all the time now. -Sometimes she liked to go for walks but not anymore. She is not walking now, sometimes she stands up and takes maybe three steps. -These things are in place because she has had a lot of falls. Interview on 9/1/22 at 1:45 p.m. with RN I regarding resident 38 revealed: *She had worked at the facility for one and a half years. *The resident was a fall risk due to weakness and confusion. *Falls had occurred when the resident was trying to stand up from her wheelchair or bed. *Her last fall was approximately one month ago. *The resident had sustained injuries from her falls such as bruises, skin tears, and history of a fracture related to a fall. *Mobility alarms were in place to prevent falls. *The bed was in the lowest position. *Regular checks were completed every hour or more between the nurse and the CNAs. *Nursing was always assessing the resident. *She had not documented a fall risk assessment. *Staff knew what interventions or assistance the resident needed from experience, shift reports and checking the chart to see if there had been a change in condition. *Staff identified interventions were suitable for this resident just the day by day assessment and change in her status. *Her son was involved and here almost every day. *Staff were monitored to ensure they were implementing care-planned interventions by just making sure it is done and going to check the residents to make sure things are in place the way they should be and if they are not making sure they get done and follow up. Interview on 9/1/22 at 2:05 p.m. with activity assistant J regarding resident 38 revealed: *She completed restorative therapy with residents weekly on Tuesdays. *The nurse completed the restorative plan and the schedule. *The resident did not currently participate in restorative therapy. *The nurse had not implemented a restorative therapy plan for this resident since she fell approximately 6 months ago. *She assumed restorative therapy stopped because she had a fall and was in bed and then she started using the wheelchair. *Prior to six months ago, the resident would use the NuStep machine, pulleys, and did range of motion exercises. *Interventions in place to prevent falls were: -Bed in the low position. -A pull tab alarm when she was in the wheelchair or bed. *She never fell during restorative therapy. 4. Observation on 8/30/22 at 1:21 p.m. of resident 21 revealed: *She had sat up at the end of her bed, causing her bed alarm to be activated with an audible alarm. *CNA K came in and turned off the bed alarm and resettled resident 21 in bed, then left. *While the surveyor was still in the room, resident 21 moved herself to the foot end of the bed and sat up, causing the bed alarm to sound again. CNA K responded and stated, [Resident name] let's go out of here, and assisted her out of the room. Observation on 8/30/22 at 2:02 p.m. revealed resident 21: *In her wheelchair in the hallway, during which time she stated, I want to go home. *She self-propelled her wheelchair with a clip attached to the back of her shirt at the top right shoulder, to which a string was fastened leading to an alarm that was attached to her wheelchair. Observation on 8/31/22 at 3:10 p.m. revealed resident 21 in her wheelchair in the hallway by the facility's front entrance with the alarm again attached to her wheelchair and clipped to the back of her shirt. Interview on 8/31/22 at 3:13 p.m. with CNA E revealed: *Resident 21 had the alarm mostly for bed due to her unsafe transfers, but staff also transfer the alarm to her wheelchair during the day. *She demonstrated how staff documented the alarm use in the provider's electronic charting. *The electronic charting stated the pull string alarm was to be used .in bed at night. *She stated, during the morning, she's usually walking with her walker and tires by late afternoon/evening, but she will attempt to stand so we use the alarm on the chair as well. Interview on 8/31/22 at 3:38 p.m. with DNS B regarding resident 21 confirmed: *The pull string alarm was to be used when the resident was in bed at night. *When the surveyor asked if the noise from the pull string alarm may have been a bother to resident 21, she was not aware of any concern. *She revealed they had a pressure pad floor alarm that connected to the call light system and activated the bedside call light when pressure was placed on the floor pad. Interview on 9/01/22 at 1:11 p.m. with CNA D regarding resident 21 revealed: *During the daytime, the alarm would sound once or twice when the resident was in bed. *She did not recall hearing it go off when the resident was in her wheelchair. *When asked if the alarm noise seemed to bother the resident, she stated, Yeah it does, she would look around to see where the noise is coming from. *She stated the alarm was used to prevents falls. Interview on 9/01/22 at 1:30 p.m. with social worker C revealed: *Resident 21's alarm was so she doesn't get up and the alarm was used in both the wheelchair and bed. *She stated resident 21 doesn't seem to be bothered by them. Review of resident 21's medical record revealed: *She had been admitted on [DATE]. *Her diagnosis included: unspecified dementia without behavioral disturbance, history of falling, other specified anxiety disorders, and weakness. *She had a BIMS assessment score of double zero indicating severe cognitive impairment. *She required extensive assistance of staff with her bed mobility, transfers, dressing, toilet use, and personal care. *Her initial care plan developed on 12/3/21 identified she was a fall risk and had PULL STRING alarm handwritten on her care plan. *A 12/4/21 Fall Risk Assessment identified: -Three or more falls during the last 90 days. -Safety devices of a pull string alarm on her chair and bed. *A 12/13/21 nurse note at 2:13 p.m. stated, .Daughter requesting we discontinue use of pull string alarm, concerned it is restricting resident's freedom of movement, concerned it is affecting resident's mood and adjustment. Informed daughter that staff placed alarm out of abundance of caution due to recent falls at assisted living prior to coming. Daughter agreed res [resident] is a fall risk but would like to trial no alarms. Will alert all staff and encourage res to use call light, practice close supervision of resident when ambulating. *A 12/13/21 progress note at 2:42 p.m. documented the bed and chair alarm were in place and working. *Her 12/13/21 admission MDS identified no bed alarm or chair alarm was used in the previous seven days. *A 12/22/21 progress note documented the bed and chair alarm were in place and working. *Resident falls were documented on the following dates: -1/16/22 at 7:50 p.m. in the resident's room. -5/10/22 at 2:30 p.m. in the dining room. -5/27/22 at 4:40 a.m. in the resident's room. -6/9/22 at 6:41 p.m. in the resident's room. -7/28/22 at 1:30 p.m. in the resident's room. -8/12/22 at 3:42 p.m. in the resident's room. *Her 2/14/22 quarterly review MDS assessment identified no bed alarm or chair alarm used in the previous seven days. *Her 5/2/22 quarterly review MDS assessment identified no bed alarm or chair alarm used in the previous seven days. *Her 7/18/22 quarterly review MDS assessment identified a bed alarm was used daily in the previous seven days, but no chair alarm was used. *An eight page MDS summary form completed on 7/18/22 included the fall prevention interventions used in the last 90 days noted, See Care Plan. Pull string Alarm used @ NOC [night], while elder is in bed. *Her care plan dated 7/19/22 identified her problem of fall risk with a goal to prevent falls and fall related injury through the next target date identified as 10/16/22. This problem included the intervention initiated on 12/10/21 of safety equipment, Attach the pull string alarm to [resident's first name] when she is in bed at noc [night], to alert staff when she attempts to get out of bed. This intervention's status was active. *A physician order dated 8/31/22 for a pressure pad floor alarm connected to call light system at bedside. Pull string alarm when resident up in wheelchair. *A nurse note dated 8/31/22 stated, Family update re [regarding] pressure pad alarm at night and pull string alarm during the day. Interview on 9/01/22 at 9:43 a.m. with DNS B regarding resident 21's daughter's concern with the alarm and request for a trial with no alarms revealed: *She stated they had conducted a trial period with no alarms, however, there was no clear trial period identified in the resident's record. *Review with DNS B of the initial care plan, fall risk assessment, four MDS assessments, and current care plan regarding alarm use failed to reveal a timeline on when the alarm use was broadened to be used in both the bed and wheelchair and/or when the trial with no alarms was completed. *DNS B did reveal a note in resident 21's record that stated the alarm was D/C [discontinued]12/13/21 per daughter. *She confirmed that resident 21 was currently using a chair alarm and a bed alarm. Further interview with DNS B on 9/1/22 at 9:43 a.m. regarding the use of position change alarms or pull string alarms revealed: *Assessment of these alarms for individual resident use were not documented. *She had verbal discussion with staff on the need for the position change alarms. *The fall risk assessments for residents were completed only once, upon admission. Interview on 9/1/22 at 10:20 a.m. with DNS B revealed: *The provider had a Physical Restraint/Bed Rails Policy last revised on 12/2021. *The provider did not have a policy specifically addressing position change alarms by name. *There was no procedure or process in place for the use of resident position change alarms. *There were no consent forms signed by family/representative for use of alarms prior to use. *The provider had not obtained physician orders for mobility alarms prior to use. Based on observation, interview, record review, and policy review, the provider failed to implement a system of fall risk assessments and individualized interventions for: *One of three sampled residents (2) with a history of falls. *Three of three sampled residents (21, 26, and 38) with a history of falls and use of position change alarms. Findings include: 1. Observation and interview on 8/30/22 at 4:42 p.m. with resident 2 while she sat in her lounge chair in her room revealed: *A large bruise on the left side of her face. *She was not able to explain what happened and did not remember falling. Observation and interview on 9/1/22 at 1:23 p.m. resident 2's revealed answers after the surveyor asked about: *What help she needed from staff, she said, Maybe sometimes I need help. *How she got staff attention when she needed help, she reported she did not know. *The call light button clipped to her bed within reach from the lounge chair she was sitting on, she said, That's the call light. *Using the call light in the bathroom if she was on the toilet, she replied, I don't think there is a call light in the bathroom. *How she would get staff attention to help her get off the toilet, she would turn on the light and pointed to the call light clipped to her bed. Interview on 9/1/22 at 1:37 p.m. with licensed practical nurse (LPN) F regarding resident 2's fall risks revealed: *She is fairly independent. *The staff remind her to use the call light. *They keep her walker in reach. *She needs visual checks, which meant opening the door since she likes her door partly closed. *Once per hour was a good frequency for visual checks. *Before her fall, she was very trustworthy with using the call light, now she needs more frequent reminders. Interview on 9/1/22 at 1:44 p.m. with certified nursing assistant (CNA) L regarding resident 2's fall risks revealed: *She walks too fast or gets up too fast. She wants to be independent but CNA L goes into her room more to provide supervision. After asking about resident 2's use of the call light, CNA L responded, I haven't seen her use the call light. Comparative review of the 3/31/22 admission Minimum Data Set (MDS) assessment and the 6/13/22 significant change MDS revealed resident 2 was coded as: *Having severely impaired cognition during the cognitive function interviews conducted for both assessments due to: -Incorrect orientation to current year and month. -No recall of three previously repeated items. *Having improved activities of daily living (ADL) self-performance and assistance for: -Transfer, dressing, and toilet use from weight bearing with two persons to independent with no set-up or physical help. -Walking from no walking to independent with no set-up or physical help. *Not steady with balance and needing assistance to stabilize when moving from a seated to a standing position and moving on and off the toilet that improved to being able to stabilize herself. Comparative review of resident 2's care plan last reviewed: 6/13/22 that was printed by the provider from their previous electronic health record (EHR) system and the care plan in the current EHR system revealed: *She was admitted on [DATE]. *Fall risk factors included history of falls with a hip fracture (3/22/22), impaired balance, hypertension [blood pressure pill] and diuretic [water pill] medications, impaired mobility and cognition. *There were no fall prevention interventions related to: -The frequency of visual checks. -Supervision of her independent performance of ADLs. -The resident's cognitive ability to remember to use the call light. -Ensuring she was keeping her walker within reach. *The problem for ADL status was related to the same factors listed under fall risk except impaired mobility was not included. Additional factors included thirteen diagnoses. *The ADL interventions noted she was independent with most of her ADL's but did not address staff supervision or visual checks during her independent performance of ADLs related to her impaired balance or cognition. *The care plan had not been reviewed or revised following resident 2's recent fall. Review of the fall investigation report entered by registered nurse (RN) M on 8/17/22 at 7:36 a.m. revealed: *The unwitnessed fall occurred on 8/16/22 at 11:40 p.m. *Resident 2's roommate came to the nurse station to inform staff that resident is on the floor in the bathroom. *Found resident sitting on the floor in front of the toilet, blood noted on the floor and on her night gown, noted 1 cm [centimeter] laceration to the left eyebrow. *As resident explained, she voided and got up and fell, bumped her head, she was using her walker and have a gripper slippers on [sic]. *Advised resident to call for assistance to go to bathroom and pull string. *Alarm was put on resident tonight as precautionary intervention in case she will forget to call for assistance. *The documentation fields were blank for the fall review areas regarding: -Details for previous fall risk score and post fall risk score. -If the call light was sounding at the time of the fall. -The time of the last purposeful hourly rounding for resident 2. -Why the resident thought the fall occurred. -Staff involved in the Post Fall Huddle. Interview on 9/1/22 at 10:30 a.m. with director of nursing services (DNS) B after copies of fall risk assessment and position change alarm documentation had been requested revealed: *The alarm during the night of 8/16/22 after resident 2's fall was trialed and discontinued. *Fall risk assessments were completed only at admission but she did not provide one for resident 2. Review of the provider's Falls and Accidents policy last revised on 11/2021 revealed: *The policy statement was to provide a systematic approach to fall and accident prevention and monitoring, include identifying and evaluating hazards and risk, individualized approaches to reduce the risk of falls and accidents, and monitoring for effectiveness of interventions when necessary. *The definition for supervision/adequate supervision was based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. *The policy for resident assessment and intervention stated: -Upon admission/readmission, quarterly, and with status changes, staff will assess each resident's individual risk factors. -Based on assessment of fall risk .staff will implement appropriate individualized, resident-centered interventions to reduce the likelihood of falls .and communicate the risk and intervention to the staff through the plan of care. After a fall occurs, it must be investigated for cause. *Review of individualized, resident-centered interventions, including adequate supervision and assistive devices .must occur. The plan of care must be updated/modified accordingly. 2. Observation and interview on 8/30/22 at 2:55 p.m. with resident 26 revealed: *She was lying on her right side facing the wall in her bed that was positioned low to floor. *A soft cushion mat was on the floor on the left side of the bed and the same length of the bed. *Her eyes were open, and when the surveyor spoke to her, she turned her head slightly, smiled, and responded with unclear words and continued talking as the surveyor withdrew from her line of vision. *She was wiggling her feet and a pillow was positioned between her legs. *The lights in the room were not on, the curtains were closed, and the television was on with a low volume. Observation and interview on 8/30/22 at 4:35 p.m. in the hallway outside resident 26's room revealed: *CNA G had just opened the door from inside resident 26's room. *Resident 26 was seated in a reclining four wheeled chair with pillow behind head, leaning her head and upper torso slightly to the right. *CNA G stated she and another CNA had just transferred her out of bed into the chair and they try to get her hips square so she doesn't lean to the right. *She explained resident 26 had been using the reclining chair for about one week. Interview on 9/1/22 at 1:37 p.m. with LPN F regarding resident 26's fall risks revealed: *She liked to do more frequent visual checks than hourly. *Resident 26 gets squirrelly. She did not explain what that meant. Comparative review of the 12/6/21 annual MDS and the 7/25/22 quarterly MDS revealed resident 26 was coded as: *Having severely impaired cognition during the cognitive function interviews conducted for both assessments due to: -Incorrect responses to time orientation questions. -Inability to repeat and recall three items *Having continuous inattention or easily distracted and fluctuating disorganized thinking. *Needing weight bearing support with one person for ADL performance for transfer and toilet use, and having a decline in walking performance to not walking. *Having balance that was not steady and needing assistance to stabilize when moving from a seated to a standing position and moving on and off the toilet. *Having fallen one time with no injury prior to each MDS, two separate falls. *Use of two other alarms daily on 12/6/21 MDS but use of bed and chair alarms daily on the 7/25/22 MDS. Comparative review of resident 26's care plan last reviewed: 7/26/22 printed from the previous EHR and in the current EHR revealed: *She was admitted on [DATE]. *Fall risk factors included history of falls (last on 7/17/22), impaired balance with Parkinson's, hypertension medication, and impaired cognition. *There was no intervention related to frequency of visual checks related to her squirrelly behavior. *The fall prevention interventions included safety equipment of: -Call light in reach, and encourage and remind resident to use. -Walker for ambulation with one person assistance and gait belt with wheelchair following close behind as needed. -Pressure pad alarm in bed, wheelchair, or recliner to alert staff when resident is up and out of bed/chair to prevent falls/injury. -Bed in low position when she is in it and keep floor mat at bedside on her left side. -Geri chair to prevent falls and aid with positioning. -Toilet as needed in ADL Status section. *The ADL status interventions noted: -DO NOT LEAVE ALONE IN THE W/C [wheelchair] OR TOILET. SHE TRIES TO STAND UP ON HER OWN. STAY WITH [resident] UNTIL SHE IS TRANSFERRED INTO A RECLINER. BE SURE SHE HAS THE PRESSURE ALARM UNDER HER AT ALL TIMES. -Assist with toileting upon rising, before and after meals, at HS [hour of sleep] and during rounds at night as needed. Review of the fall investigation report entered by RN N on 7/17/22 at 6:43 p.m. revealed: *The unwitnessed fall occurred on 7/17/22 at 4:15 p.m. *Resident 26 was found by staff by bed lying on her right side. *When asked, resident stated that she hit her head when she fell. *Pressure alarm was on bed, but was not sounding. *The call light questions revealed the call light was not on at the time of the fall but was within reach. *The resident was unable to state why she had not attempted to use the call light. She has dementia and history of trying to get up per self. *The last time staff had contact with the resident was at 4:10 p.m. There was no explanation about what service was provided at that time. *There was no documentation under the contributing information section to indicate potential causes for the fall. *The outcomes section noted: -Pressure pad was in place, but did not sound. Checked after fall and it was working correctly. -Continue to keep bed in low positions, [head of bed] down and pad on floor. *The reviewing manager's comments section noted DNS B commented on 8/3/22 that the care plan reviewed and appropriate. Review of care activity for resident 26 on 7/17/22 revealed CNA L had documented: *At 2:34 p.m., she was incontinent of bowel a small amount and continent of bladder. *At 2:41 p.m., the bed alarm was in place and working. Interview on 9/1/22 at 10:08 a.m. with DNS B revealed: *She was unable provide copies of fall risk assessments and position change alarm documentation including an assessment of the medical symptom that warranted the use of the alarms and a physician order. *The nurses today agreed to remove the alarm from use for resident 26. *Resident 26 had recently moved from using the wheelchair to the Geri chair but occupational therapy had not been involved to help with the positioning assessment. Review of the provider's LTC [Long Term Care] - Physical Restraint/Bed Rails Policy last revised on 12/2021, provided by DNS B when the survey team requested a policy regarding alarm use, revealed: *The purpose of the policy was to standardize guidelines for the appropriate use of physical restraints, bed rails/bed mobility devices. *The Policy Statement included the philosophy to keep residents unrestrained and as independent as possible. If the results of a comprehensive, interdisciplinary assessment determine that there are no alternative to provide resident safety, or that the alternative methods have been unsuccessful, a restraint/bed rail may be recommended. *Physical restraint was defined as any manual method, physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. *The Definitions section also defined: -Freedom of movement as any change in place or position for the body or any part of the body that the person is physically able to control. -Removes easily as can be removed intentionally by the resident in the same manner as it was applied by staff. *Policy Implementation included: -The interdisciplinary team (IDT) will evaluate the resident's safety needs. -The use of restraints shall require clinical justification must not be used to limit mobility, for convenience of staff .or as a substitute for supervision. -*If a restraint is found to be necessary, appropriate health professional will complete the appropriate documentation in the electronic health record (EHR). The assessment will include medical condition requiring the need for restraint and will be documented in the intervention. -Physician notification is required for all restraints initiated and a physician's order must be obtained prior to implementation. -Resident and family will be educated on restraint use, reasons for use, assessment results, and risks and benefits associated with restraint use. -Resident or resident's family must sign a consent form for restraint use. -Interdisciplinary team and physician will evaluate restraint usage monthly at minimum and will be reviewed at quarterly care conference by care planning team, resident and resident's family. -Staff will check the resident's restraint every 30 minutes provide exercise and therapeutic interventions .provide an opportunity for motion, exercise, and elimination for not less than ten minutes during each two-hour period .