**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a safe, comfortable, and homelike environment for 1 of 4 hallways observed, affecting 8 of 16 rooms (RM 400, RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER]) on the 400 hallway. The findings include: During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in room [ROOM NUMBER], looking out the window, showed 4 air filters lying on a concrete pad. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in room [ROOM NUMBER], showed a visible gap to the outside at the upper right corner of the PTAC unit (a heating and cooling unit in the wall). Further observation showed the PTAC unit was loose from the wall. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in room [ROOM NUMBER], showed dried brownish colored streaks dripping down the wall beside A bed. Further observation showed the privacy curtain separating A and B bed in room [ROOM NUMBER] was dirty with dark debris and stained. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in rooms [ROOM NUMBERS], showed in the view looking out into the courtyard had 3 hospital beds with mattresses, 2 of the beds covered with linens, 2 empty yellow barrels labeled linen, a folded wheelchair against wall, a grill beside the wheelchair, and 2 empty cardboard boxes one lying at foot of bed the other on a metal patio table. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in room [ROOM NUMBER], showed the hand soap dispenser in the bathroom did not have an outer covering for the residents in the room to push to dispense soap for hand hygiene. During multiple observations on 9/25/2023, 9/26/2023, and 9/27/2023 between the hours of 7:30 AM-2:00 PM, in rooms [ROOM NUMBERS], showed the view looking out of windows an old rusty white metal shed, inside the shed showed a riding lawn [NAME] with multiple items (construction debris) and various broken items stacked up inside the shed and lying on the ground around the outside of the shed. The ground was covered with loose brown rock, trash debris, and weeds. During an interview on 9/27/2023 at 1:15 PM, the Administrator confirmed there were 4 air filters lying on the concrete pad outside the window of room [ROOM NUMBER]. The PTAC unit in room [ROOM NUMBER] had a gap visible to the outside and was loose from the wall. The wall in room [ROOM NUMBER] had dried brown streaks on the wall beside A bed and the privacy curtain in the room was dirty and stained. The hand soap dispenser in the bathroom of room [ROOM NUMBER] did not have an outer covering making it difficult for the 2 residents in the room to wash their hands. The exterior view the residents had in rooms 409, 411, 413, and 415 were not pleasant to look at and the facility failed to provide and an optimal homelike environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to ensure 2 of 8 hand sanitizing stations were in a good working order on 1 hallway (400 hall) of 4 hallways observed, failed to ensure the staff had performed appropriate hand hygiene during meal observation on 1 of 4 hallways observed for dining, and failed to properly store the emergency water supply in a sanitary manner in one storage room (laundry storage room) observed. The findings included: Review of the facility's policy titled, Handwashing/Hand Hygiene, revised date 8/2019, showed .Hand hygiene products and supplies .alcohol-based hand rub .shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene .Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .Before and after direct contact with residents .Before and after eating or handling food .Before and after assisting a resident with a meal . Review of the facility's policy titled, Infection Prevention and Control Program, revised date October 2018, showed .infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During an observation on 9/25/2023 at 11:55 AM, on the 400 hallway, showed 2 of 8 hand sanitizer stations (1 station at the dining room entrance and 1 station beside courtyard exit door) did not function appropriately and did not dispense the hand sanitizing product. During an observation on 9/25/2023 at 3:20 PM, showed the same 2 of 8 hand sanitizer stations on the 400 hallway remained in a non-working order. During an observation on 9/25/2023 at 12:05 PM, showed the Certified Nursing Assistant (CNA) #1 had been observed touching Resident #17's bed rail, overbed table, had went into another room (room [ROOM NUMBER]) to grab a metal chair, grabbed items out of the linen cart located on the 400 hallway, returned to Resident #17's room and had begun to touch items on her meal tray. Further observation showed the CNA #1 did not perform hand hygiene before preparing to feed Resident #17. During an interview on 9/25/2023 at 12:19 PM, the CNA #1 confirmed she failed to offer or provide hand hygiene to Resident #17 prior to the meal being served and she failed to perform hand hygiene before assisting Resident #17 with meal service. During an interview on 9/27/2023 at 10:15 AM, in the Director of Nursing (DON) office, the Administrator (ADM) and the DON stated it was the facility's expectation for the staff to perform hand hygiene before and after providing resident care and especially during resident meal service. The ADM and DON confirmed the facility failed to perform appropriate hand hygiene during the meal service. During an observation on 9/27/2023 at 1:15 PM, the Administrator confirmed the hand sanitizer station hanging on the wall at the courtyard exit door and the hand sanitizing station by the dining room did not function properly. During an observation on 9/27/2023 at 3:40 PM, in the laundry storage room, showed 17 cases (6 one-gallon plastic containers in each case) of distilled water had overturned on the floor and 16 additional cases had been stored and stacked directly on the floor. During an interview on 9/27/2023 at 3:57 PM, the ADM and the Maintenance Director confirmed the cases of water had not been stored in a sanitary manner and should have been stored off the floor.

Based on facility policy review, observation and interview, the facility failed to provide milk products for 2 meals, affecting 85 of 87 residents in the facility. The findings include: Review of the facility's policy titled, Receiving, revised 9/2017 showed .Safe food handling procedures for time and temperature control will be practiced in the transportation, delivery, and subsequent storage of all food items .If quality is unacceptable, the item(s) will be immediately returned for credit . During an observation with Dietary [NAME] #1 on 9/25/2023 at 10:18 AM, in the walk-in cooler, showed 40 expired individual serving chocolate milks dated 9/17/2023 and 60 expired individual serving chocolate milks dated 9/23/2023. During aniInterview with the Dietary [NAME] #1 on 9/25/2023 at 10:23 AM, in the kitchen, showed the milk was to be picked up and returned by the milk provider today (9/25/203). Continued interview showed the milk was usually provided to all the residents and the milk was not provided on the morning breakfast tray. During an interview on 9/26/2023 at 10:27 AM, the Administrator stated the residents did not receive milk for breakfast and lunch on 9/25/2023 and stated .it was her expectation for herself or the dietary manager to be contacted when food items are not available . Continued interview confirmed the facility failed to provide the milk for the residents for 2 meals on 9/25/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on product label review, facility policy review, facility vendor instruction review, observation, and interview the facility failed to maintain a safe and sanitary food procurement and storage of thickened liquids affecting 2 Residents (#3 and #71) of 2 resident reviewed for thickened liquids, during meal observation, and failed to maintain a clean and sanitary kitchen which had the potential to affect 85 of 87 residents. The findings include: Review of a product label .[name of distributor] . Thickened Orange Juice from concentrate undated, showed, .directions after opening may be kept up to 7 days under refrigeration . Review of the facility policy Warewashing, revised 9/2017 revealed .All dishware, serviceware, and untensils will be cleaned and sanitized after each use . Review of the facility vendor instructions for the 3-compartment sink, undated revealed, .submerge in sanitizer sink for one minute . Resident #3 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis following Cerebrovascular Accident, Hypertension, Dementia, and Dysphagia. Review of a Physician order dated 4/26/2023 showed Resident #3 was to have nectar thickened liquids. Resident #71 was admitted to the facility on [DATE] with diagnosis to include Sepsis, Cerebral Infarction, and Dysphagia. Review of a Physician order dated 9/16/2023, showed resident was to have nectar thickened liquids. During an observation on 9/25/2023 at 11:14 AM, in Resident #3's room, showed an opened, undated container of thickened orange juice sitting in room temperature water in a pink plastic wash basin. The container of thickened liquid was not cool to touch. During an observation on 9/25/2023 at 11:49 AM, in Resident #71's room, showed a an opened, undated container of thickened orange juice sitting in a pink plastic wash basin. The container of thickened liquid was not cool to touch. During an interview on 9/25/2023 at 12:07 PM, showed the Director of Nursing confirmed the containers of thickened orange juice in Resident #3 and #71's rooms had been opened and were undated and sitting at room temperature. During an observation on 9/26/2023 at 12:40 PM, Dietary [NAME] #1 washed and rinsed dishware to include tray line containers and then submerged the dishware into the sanitizer sink for 10 seconds and placed items to dry. During an interview on 9/26/2023 at 12:46 PM, Dietary [NAME] #1 stated she normally washes items in the 3-compartment sink and only submerges items 10 to 15 seconds in the chemical sanitizer. During an interview on 9/27/2023 at 8:05 AM, the District Dietary Manager confirmed the facility failed to follow the chemical vendor instruction by not submerging the dishware for one full minute per instruction.

Based on facility policy review, observation and interview the facility failed to ensure kitchen equipment was maintained in good repair in 1 of 1 kitchen which had the potential to affect 85 of 87 residents. The findings include: Review of the facility's policy titled, Food Storage, revised 9/2017 showed .All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of FDA Food Code .freezer temperatures will be maintained at a temperature of 0 .or below . Review of a Freezer Temperature Log for September 2023 showed the freezer temperatures ranging from 16 to 18 degrees above the freezer-maintained guidelines. During an observationon 9/25/2023 at 10:24 AM, with Dietary [NAME] #1, showed a large amount of ice accumulation around the walk-in freezer door with the freezer temperature to be at 17 degrees. During an interview on 9/25/2023 at 10:28 AM, in the kitchen, Dietary [NAME] #1 confirmed the freezer door had been a concern for some time and the freezer temperature consistently runs between 16 to 18 degrees. During an interview and review of the documentation from a refrigeration vendor with the Administrator on 9/26/2023 at 10:31 AM, showed the freezer door was initially ordered on 7/26/2022 and was measured wrong per the vendor and the correct door had not arrived. Continued interview confirmed the freezer door had been a concern for over a year and the facility failed to have the freezer door replaced to maintain the appropriate freezer parameters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview the facility failed to properly label and store medications and supplies in 1 of 1 medication rooms. The findings include: Review of the facility policy, Storage of Medication dated 9/18, revealed, .Medications and biologicals are stored properly .Refrigerated medications should be kept in closed and labeled containers .Outdated .medications are immediately removed from stock . Observation with the Director of Nursing (DON), on [DATE] at 12:00 PM, in the Medication Refrigerator located in the Medication Room, revealed 1 vial of Tuberculin Purified Protein Derivative 5 units/0.1 milliliters opened and approximately ½ empty with no opened date. Continued observation revealed discard opened product after 30 days labeled on the box. Further observation, of the top shelf of the medication cabinet, revealed 100 Niacin 50 milligram tablets expired 10/19. Interview with the DON on [DATE], at 12:00 PM, in the Medication Room, confirmed the vial of Tuberculin Purified Protein Derivative was available for resident use and did not have an opened date label affixed to the vial. Continued interview confirmed the Tuberculin Purified Protein Derivative multi-dose vial was to be dated when opened and discarded 30 days after opened date. Further interview confirmed expired Niacin tablets were available for resident use and should have been discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Trial Balance report, medical record review, and interview, the facility failed to ensure the trust fund accounts for 4 residents (#27, #42, #44, and #58) of 25 residents with trust fund accounts of 32 residents sampled did not exceed the $2000.00 Supplemental Security Income (SSI) resource limit . The findings include: Medical record review revealed Resident #27 was admitted to the facility on [DATE]. Review of the facility's Trail Balance report dated1/22/19 revealed resident #27 had a current balance of $2084.97. Medical record review revealed Resident #42 was admitted to the facility on [DATE]. Review of the facility's Trail Balance report dated1/22/19 revealed resident #42 had a current balance of $2361.63. Medical record review revealed Resident #44 was admitted to the facility on [DATE]. Review of the facility's Trail Balance report dated1/22/19 revealed resident #44 had a current balance of $2640.34. Medical record review revealed Resident #58 was admitted to the facility on [DATE]. Review of the facility's Trail Balance report dated1/22/19 revealed resident #58 had a current balance of $2217.19. Interview with the Assistant Business Office Manager (ABOM) on 1/23/19 at 2:59 PM, in the social service office, confirmed 4 residents (#27, #42, #44, and #58) had over $2000.00 in their trust fund accounts as of 1/22/19. Interview with the Social Worker on 1/23/19 at 3:02 PM, in the social service office, confirmed there were 4 residents who had greater than $2000.00 in their trust funds. Further interview confirmed the facility failed to keep resident trust fund balances under $2000.00 for residents #27, #42, #44, and #58. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure a PRN (as needed) order for a psychotropic drug (medication capable of affecting the mind, emotions, and behavior) was limited to 14 days without a Physician's documented rationale for use of the drug for 1 resident (#9) of 5 residents reviewed for unnecessary medications of 29 residents sampled. The findings include: Medical record review revealed Resident # 9 was admitted to the facility on [DATE] with diagnoses including Dementia, A-fib, Weight loss, Anxiety, and Alzheimer's with Behavioral Disturbance. Medical record review of the current Physician's order sheet revealed .Order Date .7/13/18 .LORAZEPAM [antianxiety medication] 1 MG [milligram] TABLET .EVERY 4 HOURS AS NEEDED . Medical record review of the Medication Regimen Review dated 8/27/18 revealed .This resident is currently on the anxiolytic [medication for anxiety] therapy Lorazepam 1mg q4h [every 4 hours] PRN .PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order . (46 days after the order date). Interview with the Director of Nursing (DON) on 1/24/19 at 9:47 AM, in the DON's office, confirmed the facility failed to ensure the PRN order for psychotropic medication was limited to 14 days without the Physician's documented rationale.