**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview on 11/15/24 at 4:39 p.m. with social service designee F revealed she was unable to find documentation to support bed hold information had been provided to resident 5 or his representative for the hospital transfers on 4/23/24 and 7/6/24. Review of the provider's undated Bed Reserve Policy Notification revealed: *This Bed Reserve Policy will be given to you at the time of admission and a copy will be given to you each time you are transferred from the facility. *Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room. Under certain conditions, we can reserve your existing bed for you at your request, so when you return to the facility, you will have the same bed and room as before. Review of the provider's April 2021 Bed-Hold and Return Agreement revealed the resident, or their representative would be given the opportunity to request a bed-hold and pay a basic per-diem (daily) rate when absent from the facility. Based on interview, record review, and policy review, the provider failed to provide bed-hold notice to the resident and/or their representative regarding the transfer to a hospital for one of one sampled resident (5) for two of three occasions. Findings include: 1. Review of resident 5's electronic medical record (EMR) revealed: *He was transferred to the hospital on [DATE], 4/23/24, and on 7/6/24. *His representative was notified of resident 5's 12/27/23 transfer and the bed hold policy. *There was no documentation that the bed hold information was given to the resident or his representative for the 4/23/24 and 7/6/24 hospital transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review the provider failed to ensure the timely review and revision of one of one (424) sampled resident's care plan. Findings include: 1. Observation on 11/12/24 at 4:22 p.m. of resident 424 revealed: *There was personal protective equipment (equipment worn to minimize exposure to a hazard, such as gowns, gloves, face shield and/or masks) (PPE) sign on her door. *There was PPE hanging in a supply caddy on her door. *She had a sign that indicated to check in with the nurse before entering the color of the sign was pink indicating enhanced barrier precautions *She was sitting in her recliner, feet elevated, with Prevlon pressure reduction boots on both of her feet. *A pressure reduction cushion was in her wheelchair. Interview on 11/13/24 at 10:03 a.m. with resident 424 revealed that she: *She was admitted to the facility about three weeks ago. *Her husband also lived in the facility. *She had sores on her feet that she said resulted from her falling and laying on a garage floor for about two to three days before she was found. Review of resident 424's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses include: rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood) and acute kidney failure. *Her nurse progress notes indicated: -She had barricaded herself in her husband's room on 10/26/24 and 10/28/24. -Her family had been called in to help calm her behaviors on 10/26/24 and 10/27/24. Interview on 11/13/24 at 11:46 a.m. with nurse supervisor, registered nurse (RN) S revealed: *She was unable to identify which transmission-based precaution was to be followed when attending to resident 424 by looking at the sign on the door. *She identified that she would look in resident 424's care plan to identify which precautions were to use. Interview on 11/13/24 at 11:58 a.m. with licensed practical nurse (LPN) Y revealed: *She identified that resident 424 was on EBP by the color of the sign on her door. *She stated that resident 424 was on EBP due to her wounds. Review of resident 424's 11/13/24 care plan revealed: *Upon admit she was placed on EBP related to multiple wounds. *She had a focus area of impaired skin integrity. -Prevalon boots were not listed as an intervention related to her wounds. *She was diagnosed with MRSA on 11/6/24. -Her care plan indicated the antibiotic therapy related to wound infection with MRSA. -Contact precautions were not added to her care plan with the addition of the MRSA diagnosis. -EBP remained on her care plan related to multiple wounds. *Her admitting diagnosis was Rhabdomyolysis. -There were no focus areas, goals, or interventions that addressed possible complications related to this diagnosis. *There was a focus area that identified barricades self in husbands room. -There were no interventions for that focus area. -Her care plan did not address the use of family as an intervention for her behaviors. Interview on 11/14/24 at 1:38 p.m. with clinical care coordinator, RN C and director of nursing (DON) B regarding resident 424 revealed: *She was on EBP due to her wounds. -She was recently diagnosed as being positive for Methicillin-resistant Staphylococcus aureus (MRSA) (a bacteria that is resistant to multiple antibiotics) in one of her wounds. --That was an indication to advance her precautions from EBP to contact precautions. -Her care plan was not changed from EBP to contact precautions. *She had a history of behaviors that involved barricading herself in her husband's room. -RN C agreed there was no intervention addressed on the care plan related to this. -Her family had been called multiple times as an intervention to her behaviors. -RN C agreed the use of family as an intervention for her behaviors was not addressed in her care plan. Review of the provider's September 2019 Care Plans policy revealed: * Individualized, resident- centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay. * The personal history, habits, likes and dislikes, life patterns and routines, and personality facets must be addressed in addition to medical/diagnosis-based care considerations. * Interventions act as the means to meet the individual's needs. * Care Plans should be updated between care conferences to reflect current care needs of the individual resident as changes occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure adequate pain management for one of one sampled resident (375) who expressed she had pain. Findings include: 1. Interview on 11/13/24 at 10:08 a.m. with resident 375 revealed she: *She had asked for medication for pain relief that morning during medication administration time for her pain. *Reported she had pain to the whole left side of her body. *Was told by licensed practical nurse (LPN) L there was no pain medication available. 2. Review of resident 375's current care plan on 11/8/24 revealed: *She was at risk for pain, she had: -Recently had a right-hand surgery and an incision. -Back pain due to a fall. -Diagnoses of peripheral vascular disease, congestive heart failure, and type 2 diabetes. *A focus area indicated that she was at risk for pain. *The goal for this focus, states that level of pain is through next review. *The interventions included: * Evaluate efficacy of pain management. * Notify MD if inadequate pain relief. * Provide analgesic as ordered. *Utilize non-pharmacological intervention (cold/warm wash cloth, massage, distractive activities, reposition, etc.) or ordered analgesic medications. If interventions not effective, then notify MD. 3. Review of resident 375's Electronic Medical Record (EMR) revealed: *She was admitted to the facility on [DATE]. *Her Brief Interview of Mental Status assessment (BIMS) score was a 9, which indicated she was moderately cognitively impaired. *Her diagnoses included: dorsalgia (pain in the back), gout, postural kyphosis (spinal deformity), peripheral vascular disease, type 2 diabetes mellitus without complications, rhabdomyolysis (muscle tissue break down), pain in left shoulder, pain in left hip, pain in left knee. *A progress note (PN) on 11/13/24 at 2:39 a.m. indicated Resident 375 complained of pain and requested pain medication. -There was an active order for Tramadol on the medication administration record (MAR). -She was agreeable to changing positions by moving from her bed to her recliner. -There was no Tramadol in the medication cart. *She had a physician order for Tramadol (pain medication) 50mg give 1 tablet by mouth every 8 hours as needed (PRN) for severe pain. *There was no documentation that the Tramadol had been administered. *A PN on 11/13/24 at 1:29 p.m. by LPN L indicated The resident calling out in pain to the bottom while sitting upright in reclining chair. Resident has an PRN order for Tramadol without medication available to issue. LPN L, had called the clinic and awaiting signature from the doctor to have the prescription sent to pharmacy for the medication. *No current order for additional available pain medications indicated in her EMR. 4. Interview on 11/14/24 at 1:39 p.m. with director of nursing (DON) B and clinical care coordinator (CCC) C revealed: *The pharmacy had not received a written prescription from the physician for the Tramadol. *The pharmacy is not able to fill the order until the written prescription is received. *CCC, C confirmed the provider should have followed up with the physician regarding the Tramadol. *Standing orders for additional pain control were not always put in a resident's EMR when they were admitted . 5. Interview on 11/14/24 at 1:00 p.m. LPN L, regarding resident 375's pain revealed: *She had assessed resident 375's pain level and location of her pain on 11/13/24. -She confirmed resident 375 had complained of pain in her bottom. *She checked resident 375's MAR to see what pain medication the physician had ordered. *She confirmed resident 375 had an order for Tramadol and there was no Tramadol available on the medication cart for administration to resident 375. *She called the clinic and requested the written Tramadol prescription be sent to the pharmacy. *It had been 7 days since the physician had ordered the Tramadol. 6. Observation on 11/14/24 at 3:05 p.m. with LPN L, verified the Tramadol was now available on the medication cart for resident 375. Review of the provider's 3/23/23 Pain Management Policy revealed: *The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. *'Pain Management' is defined as the process that includes the following: a. Assessing the potential for pain. b. Effectively recognizing the presence of pain. c. Identifying the characteristics of pain. d. Addressing the underlying causes of pain. e. Developing and implementing approaches to pain management. f. Identifying and using specific strategies for different levels and sources of pain. g. Monitoring for effectiveness of interventions; and h. Modifying approaches as necessary. *Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: -Peripheral vascular disease *Pain management interventions shall be consistent with the resident's goals for treatment. Such goals will be specifically defined and documented. *Pain management interventions shall reflect the sources, type and severity of pain. *Strategies that may be employed when establishing the medication regimen include: -Combining long-acting medications with PRNs [as needed] for breakthrough pain. *Implement the medication regimen as ordered, carefully documenting the results of the interventions. *Report the following information to the physician or practitioner: -Significant changes in the level of the resident's pain.

Based on interview, record review and policy review the provider failed to ensure one of one sampled resident (67) who required dialysis treatment was monitored for abnormalities upon returning from his dialysis treatment. Findings include: 1. Interview on 11/13/24 at 8:40 a.m. with resident 67 revealed: *He received dialysis on Mondays, Wednesdays, and Fridays. *There was a dialysis port located in his chest. -He stated that port went directly to his heart. Review of resident 67's electronic medical record (EMR) revealed: *His admission date was 3/22/24. *His diagnoses included: end stage renal disease, dependence on renal dialysis, heart disease, Parkinson's disease, and cognitive communication deficit. *His physician orders included: -Dialysis Monday Wednesday Friday. -REMINDER NURSES: Open and complete 1st section of dialysis UDA [user defined assessment] prior to leaving dialysis and then complete 2nd 2 sections of UDA after dialysis upon return two times a day every Mon, Wed, Fri. *His care plan included Report significant changes in pulse, respirations and BP [blood pressure] immediately. Review of resident 67's vitals recorded in his dialysis UDA section three Post-Dialysis Evaluation vitals recorded revealed: *His 11/1/24 blood pressure (BP), temperature, pulse, and respirations vitals were documented as his post-dialysis vitals on 11/4/24; and his 10/30/24 oxygen saturations (O2) were documented as his post-dialysis vitals on 11/4/24. *His 10/30/24 O2 was documented as his post-dialysis vitals on 11/6/24. *His 11/6/24 BP, temperature, pulse, and respirations were documented as his post-dialysis vitals on 11/8/24; and his 10/30/24 O2 was documented as his post-dialysis vitals on 11/8/24. *His 11/6/24 his BP, temperature, pulse, and respirations were documented as his post-dialysis vitals 11/11/24; and his 10/30/24 oxygen saturations were documented as his post-dialysis vitals on 11/11/24. *On 11/13/24 there were no vital signs documented. Interview on 11/14/24 at 2:14 p.m. with registered nurse BB regarding dialysis assessments revealed: *She was aware resident 67 required dialysis. *She had completed the post-dialysis UDA section three that included resident 67's vital signs taken upon his return from dialysis. -Section three vitals should be the vitals when the resident returns from dialysis. *Ideally would be done each time. -They try to get the CNAs to get the vitals and then the nurse would document. *Confirmed this does not always happen. Interview and record review on 11/14/24 at 4:29 p.m. with director of nursing (DON) B regarding their process for when a resident returned from dialysis was to: *Complete the dialysis UDA, which included: -The amount of fluid removed from the resident during dialysis. -Medications administered during the dialysis treatment. -Obtain the resident's vital signs. --A certified nursing assistant or a nurse could obtain the resident's vital signs. *The nurse was responsible for documenting the vital signs on the post-dialysis UDA. *DON B confirmed resident 67's vital signs documented in his post dialysis UDAs were not always taken the day the assessment was completed. -Her expectation was for the vitals to be obtained and documented each time a resident would return from their dialysis treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review the provider failed to ensure: *Fourteen of twenty-nine residents (10, 23, 46, 49, 53, 55, 64, 65, 67, 70, 224, 274, 375 and 424) had received a summary of their baseline care plan. *One of one sampled resident (424) had a baseline care plan completed within forty-eight hours of admission. Findings include: 1. Record review of resident 64's electronic medical record (EMR) revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 2. Record review of resident 65's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 3. Record review of resident 53's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR a baseline care plan summary had been reviewed with the resident or resident's representative. 4. Record review of resident 67's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 5. Record review of resident 55's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 6. Record review of resident 23's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 7. Record review of resident 10's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 8. Record review of resident 46's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 9. Review of resident 49's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 10. Review of resident 70's EMR revealed: *He had been admitted on [DATE]. *There was no documentation in his EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 11. Review of resident 274's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 12. Review of resident 224's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 13. Review of resident 375's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. 14. Review of resident 424's EMR revealed: *She had been admitted on [DATE]. *There was no documentation in her EMR that a baseline care plan summary had been reviewed with the resident or resident's representative. *Her baseline care plan was not signed as completed until 10/29/24. 15. Interview on 11/13/24 at 4:30 p.m. with social services designee F regarding residents' baseline care plans revealed: *She would have completed the baseline care plan upon admission. *She would not have reviewed the baseline care plan with the resident or the resident's representative. *She had not provided a summary of the baseline care plan to the resident or the resident's representative. *She had been in her position since June 2024 and felt she had not received very much training for her position. 16. Interview on 11/14/24 at 1:38 p.m. with clinical care coordinator registered nurse (RN) C regarding residents' baseline care plans revealed: *She would have reviewed the baseline care plan with the resident or the resident's representative. *She had not been documenting in the resident's EMR that the baseline care plan had been reviewed with the resident or representative or that a summary of that care plan had been offered. 17. Review of the provider's September 2019 Care Plans policy revealed: *A Baseline Care plan is started by nursing staff on the first day of admission to provide guidance to direct care givers as soon as possible after admission and completed no later the 48 hours after admission.

1. Observation on 11/12/24 at 3:30 p.m. of the kitchen revealed: *The walk-in freezer revealed: -There was a form (form 403) on the door of the walk-in refrigerator/freezer titled Walkin Frig Freezer where daily temperatures for November were documented. --It indicated Code for adequate temperature: Freezer: Not greater than 0 degrees F [Fahrenheit] or food maintained solid. --Daily documented freezer temperatures of the walk-in freezer were recorded chronologically in November were as follows: 12, 15,12, 28, 12, 23, 29, 30, 2, 0, 5, 0 degrees F. --There was no documented actions taken for temperatures that were outside the adequate temperature range. -There was ice build up around the door to the walk-in freezer. -The metal lining of the walk-in freezer door was separated and had exposed cracked foam. -There was frost on the cooling unit in the walk-in freezer and ice build-up on the pipes on the back of the unit. *The 3 Door Fridge Unit had: -Two temperature gauges were being documented daily on the provider's form 403. -The temperature gauges were identified as GUAGE A and GUAGE2. -Between November 1st through the 12th GUAGE A was documented as reading 36-41 degrees Fahrenheit. -During the same time frame GUAGE2 was documented as 38-45 degrees F. -There were four days with greater than the 2-degree variance from 40 degrees. --There was no documentation of actions taken for temperatures that were outside the adequate temperature range. -A container of diced ham in the three-door refrigerator dated 10/24. -There was uncooked corn beef hash stored above the potatoes and wine. *Another stand-up freeezer had: -Two baked pies with pieces removed that were dated 9/22 and 8/18. --The pies were covered loosely with plastic wrap. *The plastic liners in the flour and sugar containers were ripped. 2. Observation on 11/14/24 at 9:22 a.m. of the kitchen revealed: *The office freezer had: -Chicken nuggets that were not dated. -One thermometer that had a solid red line that extended to 34 degrees Fahrenheit with a broken red line extending from 34 degrees to 52 degrees Fahrenheit. *The walk-in refrigerator had dust on the front of the cooling unit and on the walls and ceiling. *The walk-in freezer had: -There were no documented actions taken for the temperatures that were outside the adequate temperature range. -Dates on the bags of cut up chicken ranged from 1/8 to 11/3. -There were multiple bags of undated cut-up chicken. -One bag of undated chicken pieces appeared freezer burned, and the bottom of the bag contained a frozen bloody liquid. -There was ¾ inch of frost build-up on the side of the walk-in cooler cooling unit that extended to 1/3 of the front portion of the unit. -The back of the walk-in cooler cooling unit had one to three inches of ice build-up on the back of the unit that extended onto the tubing behind the unit. *In the three-door refrigerator there was a container of frozen meat that extended above the sides of the container and was stored above wine and a box of pastries. 3. Interview on 11/14/24 at 9:22 a.m. with dietary manager T revealed: *She indicated that all freezer and refrigerator temperatures were documented daily and there needed to be two thermometers in the refrigerator and one in the freezer. *She indicated that if the two thermometers in the refrigerators did not match, she would check the temperature with another thermometer and discard the thermometer that did not read accurately. -She stated that this action was not documented anywhere. *When asked how she determined when food was discarded according to the dates on the packages, she stated she did not know the answer. *She stated she had discarded all the food that was thawed out in the walk-in freezer when the temperatures were out of range. *She stated she was told the walk-in freezer door was being replaced. *She indicated that on Friday (11/8/24) the cooling unit in the walk-in freezer was not working. -Maintenance director I removed the ice from the cooling unit and the cooling unit then began working. -Maintenance director I installed longer screws on the wall side exterior latch of the walk-in freezer so the door would latch. *She stated that the ice currently present on the cooling unit of the walk-in freezer was better than it was previously. *She agreed that the metal liner on the door of the walk-in freezer was separated with exposed cracked foam and light was visible around the door. *When shown the undated bag of chicken pieces that appeared freezer burned with frozen bloody liquid on the bottom of the bag, she indicated that this bag appeared to have thawed and refrozen. -She did not throw out any of the turkey or chicken on that Friday because she felt they had not thawed. -She said she would dispose of that bag of chicken. -The bags of chicken should be dated. *She stated that maintenance oversaw the cleaning of the cooling unit in the walk-in refrigerator. *She indicated that when she defrosted meat in the cooler, and raw meat needed to be stored on the bottom shelf in a container. *If meat was precooked, she did not put it on the bottom of the refrigerator. *If meat needed to be defrosted more rapidly than able to in the refrigerator she would run it under cool water. 4. Review of the provider's temperature logs revealed: *On 10/9/24 dietary manager T documented on the Walkin Frig and Freezer titled temperature log margin Got rid of the stuff out of [the] freezer. -Below the above documentation was written Freezer door wouldn't shut but got fixed on the 8th. *Daily documented freezer temperatures for Walkin Frig and Freezer reported in degrees Fahrenheit between October 1st and 11th, 2024 were 22, 20, 18, 20, 20, 20, 18, 20, 20, 22, 23. -There was a note in the margin that stated, walk in door not shutting properly Got rid of all the food *Logs of freezer defrosting was requested but not provided 5. Interview on 11/14/24 at 9:40 a.m. with dietary aide P revealed that she was unfamiliar with the process of checking temperatures in the coolers because the cooks performed this task. 6. Interview on 11/14/24 at 9:45 a.m. with dietary aide V revealed: *If the two thermometers in the refrigerator did not match, she would double-check the gauge that was reading out of range. *If she determined that gauge was reading inaccurately, she would notify her supervisor to replace the inaccurate gauge. 7. Interview on 11/14/24 at 4:39 p.m. with administrator A regarding the kitchen revealed: *She was aware the walk-in refrigerator door had ice build-up around the door. *They had thrown out food numerous times after identifying the food had partially thawed out. -She was not aware the chicken and turkey had not been thrown away after having been partially thawed out. 8. Review of the provider's 8/31/18 Freezer policy revealed: *Freezer defrosting was to be completed monthly. *Freezers should remain frost free. 9. Review of the provider's 10/15/18 Freezer Storage Chart revealed: *Unopened frozen chicken nuggets were to be disposed of after 1-3 month *Unopened whole or cut up chicken was to be disposed of after 10 months. *Baked pies were to be stored unopened and be disposed of after 8 months. *Opened baked pies recommended storage was not applicable. 10. Review of the provider's 3/9/20 Food Storage policy revealed: *Products were to be examined for signs of defrosting. *The refreezing of defrosted food is not recommended because of increase in growth of-food bacteria and the deterioration in food quality. *Thaw meat preferably by placing in deep pan and setting on the lowest shelf in refrigerator. *Thawing food under cold running water is no longer recommended due to strict guidelines set forth by the 2013 Food Code. *Alcoholic beverages must be stored in a separate locked area. 11. Review of the provider's 8/8/19 Record of Refrigeration Temperatures policy revealed: *A daily temperature record is to be kept of refrigerated items. *The freezer must be clean and food must be frozen solid with no indications of thawing and must be frost free. *The refrigerator must be 41 degrees Fahrenheit or less (1-2-degree variance) *Note on temp forms the plan of action when temps are not acceptable. 12. Review of the provider's 12/28/20 Refrigerated Storage Chart policy revealed that opened ham should be discarded after one week. Based on observation, interview, record review, and policy review, the provider failed to maintain clean and sanitary conditions in one of one observed kitchen where residents' food was stored and prepared. Findings include:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Based on observation, interview, and policy review, the provider failed to ensure infection control and prevention practices were maintained by one of one licensed practical nurse (LPN) Q during medication administration for one of one sampled resident (44). Findings include: 1.Observation on 11/13/24 at 9:35 a.m. of LPN Q during resident 44's medication administration revealed: *Resident 44 was on precautions for COVID-19. *With personal protective equipment (PPE) (gown, gloves, shield, and N95 mask) on: -She picked up a medication cup off of the medication cart that contained resident 44's prepared medications. -She knocked on resident 44's door and went into her room. -She sat the cup of medications and a nasal spray, down on a bedside table. -She assisted the resident into a more upright position in bed. -She administered the nasal spray into the left nostril, recapped the nasal spray, and set it back down on the bedside table. -Once she finished administering the rest of the medications, she removed the full trash bag in the bathroom and replaced it with a new one. -She removed her shield, gown, and gloves and washed her hands with soap and water. -She picked up the nasal spray and trash bag and then left the room. *Outside of the room by the PPE cart she: -Placed the trash bag into another trash can. -Placed the nasal spray on the PPE cart, discarded her mask into the trash can, and used hand sanitizer to disinfect her hands. -Picked up the nasal spray, opened the medication cart, and put the nasal spray back into the nasal spray manufacturer's original box. 2. Interview on 11/13/24 at 4:26 p.m. with LPN Q revealed: *She knew she did not wipe off the nasal applicator after administering the nasal spray to resident 44. *She did not think she was allowed to wipe down something that went into a nasal cavity. 3. Interview on 11/14/24 at 10:30 a.m. with registered nurse (RN) infection preventionist E revealed: *Nurses were to wipe off the nasal spray applicator in precaution rooms with an alcohol wipe. *Nurses were to clean the bottle outside of the room and then put it back in the medication cart. 4. Interview on 11/14/24 at 11:25 a.m. with staff development coordinator D revealed: *She educated staff on PPE, handwashing, different isolation precautions, infection control, and types of transmission every year. *She stated for nasal sprays, staff were supposed to wipe the tip off after every application with an alcohol wipe. *She did not believe there was any education regarding wiping off nasal spray bottles once out of precaution rooms. 5. Interview on 11/14/24 at 11:35 a.m. with director of nursing DON B revealed: *Staff had not received education recently regarding infection control practices. *They had not provided staff education for administering nasal spray in precaution rooms. *Her expectation was for staff to place a barrier down for nasal sprays and wipe the nasal applicator after each use. The provider's Nasal Spray Administration policy dated 11/21/18 and Infection Prevention Program policy revised 2/20/24 did not address infection control practices following nasal spray administration in precaution rooms. B. Based on observation, record review, interview, and policy review the provider failed to ensure two of two sampled residents (274 and 424) had been placed on contact precautions due to having been diagnosed with a multi-drug resistant organism (MDRO) infection. Findings include: 1. Observation on 11/14/24 at 2:30 p.m. of resident 274's door revealed: *She had a sign that indicated to check in with the nurse before entering the color of the sign was pink indicating enhanced barrier precautions. *PPE (personal protective equipment worn to minimize exposure to a hazard, such as gowns, gloves, face shield and masks) was on the outside of the door. Review of resident 274's electronic medical record (EMR) revealed: *She had been admitted [DATE] with a diagnosis of Methicillin-resistant Staphylococcus aureus (MRSA) to her left ankle. *She had been receiving intravenous (IV) antibiotics through her peripherally inserted central catheter (PICC) and had been using a wound vacuum. *Resident 274's care plan indicated she had been on enhanced barrier precautions due to her wound and PICC line. Interview on 11/14/24 at 2:45 p.m. with clinical care coordinator registered (RN) C regarding resident 274's enhanced barrier precautions revealed: *She had known that resident 274 had a diagnosis of MRSA upon admission. *Agreed that resident 274 had not been on contact precautions for her MRSA infection in her wound. 2. Observation on 11/12/24 at 4:22 p.m. of resident 424 revealed: *There was PPE hanging in a supply caddy on her door. *She had a sign that indicated to check in with the nurse before entering the color of the sign was pink indicating enhanced barrier precautions Observation on 11/13/24 at 8:37 a.m. of resident 424 revealed: *She was being propelled in her wheelchair by an unknown staff member out of the dining room. *The same unknown staff member stopped in the hallway and assisted her to stand and ambulated with assistance of one staff and a front wheeled walker in the hallway. Interview on 11/13/24 at 10:03 a.m. with resident 424 revealed that she: *She was admitted to the facility about three weeks ago. *She had sores on her feet that she said resulted from her falling and laying on a garage floor for about two to three days before she was found. Review of resident 424's electronic medical record (EMR) revealed: *She was admitted on [DATE]. * On 10/6/24 she was diagnosed with a positive Methicillin-resistant Staphylococcus aureus (MRSA) (a bacteria that is resistant to multiple antibiotics) in her right ankle wound. *She was taking Linezolid for the MRSA infection. Interview on 11/13/24 at 11:58 a.m. with licensed practical nurse (LPN) Y revealed: *She identified that resident 424 was on EBP by the color of the sign on her door. *She stated that resident 424 was on EBP due to her wounds. Interview on 11/14/24 at 1:38 p.m. with clinical care coordinator, RN C and director of nursing (DON) B regarding resident 424 revealed: *She was on EBP due to her wounds. -She was recently diagnosed as being positive for MRSA in one of her wounds. --That was an indication to advance her precautions from EBP to contact precautions. *RN C agreed that resident 424 was not advanced from EBP to contact precautions. 3. Review of the provider's 2/20/24 MRSA policy revealed: * Risk of transmission increases in the following situations and therefore, contact precautions and/or droplet precautions should be considered: Any site with active MRSA infection. * Consideration could be to use Enhanced Barrier Precautions [EBP] when the resident no longer meets the definition for contact precautions. * Resident may not leave the room while in precautions except for medically necessary reasons. When the resident leaves the room, precautions should be maintained to minimize the risk of transmission of pathogen to others and containment of environmental surfaces or equipment. A. Based on observation, interview, record review, policy review, and manufacturer's recommendations, the provider failed to ensure one of two observed ice machines were maintained in a clean and sanitary manner. Findings include: 1. Observation on 11/14/24 at 9:22 a.m. of an ice machine located in the therapy room revealed: *The water/ice spout had pink slime (a bacteria colony that can grow in ice machines) in it. *The water tray had metal bars over the top of it that were rusted. *There was a white, flaky, residue, that covered the underside of the machine where the spout extended from. Interview on 11/14/24 at 9:22 a.m. with certified medication aide (CMA) U regarding the ice machine located in the therapy room revealed that the ice machine was used three times daily for resident water passes. Interview on 11/14/24 at 1:42 p.m. with housekeeper K regarding the ice machine located in the therapy room revealed: *Each housekeeper is assigned a different area to keep clean. *He has cleaned the ice machine, by having wiped down the outside areas of it. *He said the housekeepers do not clean the internal parts of the ice machine. *He said supervisor would know more about the ice machine. Interview on 11/14/24 at 1:46 p.m. with housekeeper supervisor R regarding the ice machine located in the therapy room revealed: *Housekeepers wiped down the outsides of the ice machine. *She said housekeepers had tried to keep the ice machine clean. *She confirmed the bars on the tray were rusted, and did not know if they could be replaced. *She confirmed there was pink slime on spout of the machine. *She said the maintenance staff takes apart and does the internal cleaning of the ice machine. Interview on 11/14/24 at 1:49 p.m. with maintenance director I regarding the ice machine located in the therapy room revealed: *Confirmed there was pink slime on the spout of the ice machine. *Used a brush to clean it every six months. *A chlorine spay product was used. *The product observed was CDS liquid chlorinator pool water disinfection. -He said he would pour that into a spray bottle and would add a little water to it. -He said he does not measure the amounts of the product or the water he would add to the spray bottle. Review of the provider's Ice Machine Log Semi-Annual Inspection revealed: *The 4/13/24 documentation included cleaned/checked. *The 7/27/24 documentation included checked cleaned as needed cleaned air filters. *The 10/22/24 documentation included Cleaned all Ice machine/cleaned Ran through cleaning cycles/filters. Review of the provider's June 2019 Sanitization policy revealed: *Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. *Damaged or broken equipment that cannot be repaired shall be discarded. Review of the manufacturer's instructions for installation, operation, and maintenance of the Manitowoc ice machine that was located in the therapy room revealed: *Manitowoc Ice Machine Cleaner and Sanitizer are available in convenient 16 oz (473 ml) and 1 gal (3.78l) bottles. These are the only cleaner and sanitizer approved for use with Manitowoc products. *Preventative Maintenance Cleaning Procedure Perform this procedure as required for your water conditions. Recommended monthly. -Allows cleaning the ice machine without removing all of the ice from the bin -Removes mineral deposits from areas or surfaces that are in direct contact with water during the freeze cycle (reservoir, evaporator, auger, drain lines). *Cleaning/Sanitizing Procedure This procedure must be performed a minimum of once every six months. -All ice must be removed from the bin -The ice machine and bin must be disassembled cleaned and sanitized -The ice machine produces ice with the cleaner and sanitizer solutions -All ice produced during the cleaning and sanitizing procedures must be discarded. *Ice machine sanitizer is used to remove algae or slime. *Refer to the chart and add the correct amount of sanitizer and cool water for your model ice machine. *Remove the top cover from the ice chute and pour the sanitizer/water solution into the evaporator. Add the entire amount of premixed solution. Interview on 11/14/24 at 4:39 p.m. with administrator A regarding the ice machine located in the therapy room revealed: *She was not aware the appropriate chemicals for cleaning and sanitizing the machine were not being used. *Her expectation was for the manufacturer's recommendations for cleaning and sanitizing to be followed.

Based on observation, interview, record review, and policy review the provider failed to ensure the range hood vents, ice machine, and ceiling tiles were maintained in a clean condition in one of one kitchen. Findings include: 1. Observation on 6/18/24 at 2:20 p.m. during the initial tour of the main kitchen revealed: *The range hood vents were covered with a greasy film and lint. *The sides of the ice machine had a layer of hard water scale build up on them. *The back of the ice machine had hard water scale deposits embedded between the fins of the cooling fan. *Ceiling tiles above the refrigerator by the dietary manager's office had several dark water stains on them. 2. Interview and observation on 6/18/24 at 2:30 p.m. with dietary aide C regarding the range hood revealed: *The range hood was cleaned by a contracted service. *She was not sure the last time they had cleaned the range hood. *The range hood and vents were not part of the weekly kitchen cleaning schedule. *A sticker on the side of the range hood had documented the contractor had cleaned the range hood in March of 2024. 3. Interview on 6/18/24 at 4:47 p.m. with dietary manager A regarding the range hood, ice machine, and ceiling tiles revealed: *She did not have the range hood on the kitchen cleaning schedule. *Maintenance was responsible for removing the vents in the range hood and cleaning them. *She was not sure the last time the vents were cleaned. *The ice machine was moved into the kitchen from another area of the building. *Staff had tried to clean the sides and back of the ice machine in the past. *Maintenance replaced some of the ceiling tiles in the kitchen when the new lights were installed. *She thought the stains on the ceiling tiles were due to condensation from the air conditioning duct. *She agreed the range hood, ice machine, and ceiling tiles were not clean. 4. Interview on 6/19/24 at 10:40 a.m. with maintenance director B regarding the range hood, ice maker, and ceiling tiles revealed: *He used a computer program to track and document maintenance tasks. *Maintenance was responsible for cleaning the range hood and vents monthly. *The vents had not been cleaned yet in June. *They do have a contractor that cleans the range hood and vents semi-annually. *He cleaned the ice maker when they replaced the kitchen floor in May. *The ice maker had been in the facility for several years and was due to be replaced. *He did not have a replacement date. *He felt the condensation from the air conditioning duct work had created the moisture spots in the ceiling tile. *He agreed the ceiling tile above the refrigerator by the dietary manager's office needed to be replaced. 5. Review of the 2024 kitchen exhaust fan log monthly inspection revealed the hood and filters were to be cleaned monthly: *Those tasks were marked as completed in January, February, March, April, and May of 2024. 6. Review of the provider's 2018 Cleaning Schedules policy revealed: *The Food and Nutrition Services staff shall maintain the sanitation of the Food and Nutrition Services Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition or other clinically qualified nutrition professionals. *Maintenance director B did not have a specific policy regarding the cleaning of kitchen equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, interview, and policy review the provider failed to ensure the family was notified of a change in condition for one of one sampled resident (1). Findings include: 1. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *Her diagnoses included: unspecified psychosis not due to a substance or known physiological condition, hypertension, mild cognitive impairment, rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement, protein-calorie malnutrition, contracture of muscle, and personal history of COVID-19. *She had become ill with nausea, vomiting, and diarrhea on 2/2/23. *She continued to have symptoms on 2/3/23 and 2/4/23. *Her physician had been called on 2/2/23 and 2/4/23 with new orders for an antiemetic drug (a medication that eases nausea or vomiting) with each physician's call. *On 2/4/23 she had an emesis of dark brown grainy texture. *She was taken via ambulance to the emergency room on 2/4/23. *There had been no documentation her family had been notified of the change in her condition on 2/2/23 or 2/3/23. *On 2/4/23 the facility attempted to contact the family by phone before transferring her to the emergency room but was unsuccessful. *Resident 1 was pronounced dead at the emergency room on 2/4/23. Interview on 2/20/23 at 1:00 p.m. with administrator A and director of nursing B regarding resident 1's notification of change in condition revealed: *Family had not been contacted on 2/2/23 or 2/3/23 when resident 1 had become ill. *When a resident had a change of condition the family or responsible party should have been notified by the nurse. Review of the provider's December 2019 Notification of Change of Condition policy revealed: *The facility will provide care to residents and provide notification of resident change in status. *The facility should have informed the resident's representative when there was a change in condition.