**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Insomnia, Adjustment Disorder with Depressed Mood, Dementia with Psychotic Disturbance, and Schizophrenia. Review of a PASRR Level 2 Outcome (completed prior to admission) dated 11/4/2023, revealed Resident #19 had a PASRR level 2 Outcome related to severe mental illness. Review of an admission MDS assessment dated [DATE], revealed Resident #19 was not coded for a PASRR Level 2 Outcome. Further review of the admission MDS assessment revealed Resident #19 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Bipolar, Anxiety, Seizures, Restless Leg Syndrome, and Nicotine Dependence. Review of a PASRR Level 2 Outcome dated 3/27/2025, revealed Resident #35 had a PASRR Level 2 Outcome related to severe mental illness. Review of an admission MDS assessment dated [DATE], revealed the resident was not coded for a PASRR Level 2 Outcome. Further review of the admission MDS assessment revealed the resident scored a 15 on the BIMS assessment which indicated Resident #35 was cognitively intact. During an interview on 5/6/2025 at 12:13 PM, RN (Registered Nurse) MDS K stated a fall with minor injury should be coded if the resident experienced bruising and swelling as a result from the fall. During further interview RN MDS K stated Resident #69's fall occurred on 1/16/2025 and the resident developed bruising on 1/17/2025 as a result from the fall. RN MDS K confirmed the discharge MDS assessment for Resident #69 was not coded accurately. During a record review and interview on 5/6/2025 at 12:47 PM, RN MDS K reviewed the annual MDS assessment for Residents #41, the admission MDS assessments for Residents #19 and #35. RN MDS K confirmed the MDS assessments for Residents #41, #19, and #35 were not coded accurately. During an interview on 5/6/2025 at 1:25 PM, the Director of Nursing (DON) stated it was her expectation for MDS assessments to be coded accurately. The DON confirmed the facility failed to ensure the accuracy of the MDS assessments for Residents #41, #19, and #35. Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual Version 1.19.1 review, medical record review, and interview, the facility failed to ensure MDS assessments were accurate for 4 residents (Resident #19, #35, #41, and #69) of 18 residents reviewed for MDS assessments. The findings include: Review of the MDS 3.0 RAI Manual, dated 10/2024, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness .Falls Since Admission/Entry or Reentry or Prior Assessment .whichever is more recent .Code .one [yes] .if the resident had one injurious fall . [superficial bruises] since admission/entry or reentry or prior assessment . Review of the medical record revealed Resident #41 admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar Disorder, and Anxiety. Review of a Preadmission Evaluation Screening Resident Review (PASRR) dated 1/17/2024, revealed Resident #41 had a PASRR Level 2 Outcome related to a serious mental illness. Review of an annual MDS assessment dated [DATE], revealed Resident #41 was not coded for a PASRR Level 2 Outcome. Further review of the annual MDS assessment revealed Resident #41 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Review of the medical record revealed Resident #69 admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Lack of Coordination, and Dementia. Review of the facility's communication tool titled SBAR [Situation, Background, Assessment, and Recommendation], dated 1/16/2025, revealed Resident #69 had an unobserved fall from the bed. Further review of the SBAR revealed Resident #69 had no bruising or other injuries. Review of a Weekly Summary Note dated 1/17/2025, revealed .Face- Bruising .Red Purple Black .Residents [Resident #69] left eyes swelling has decreased but the eye lid is discolored with bruising . Review of a Nurse Practitioner Progress Note dated 1/17/2025, revealed .[Resident #69] . seen for follow up on fall yesterday .Patient's left eye bruised this am . Review of a Nurse Progress Note dated 1/19/2025, revealed .[Resident #69] Continues to have purple colored bruising to left eye due to fall . Review of a discharge MDS assessment dated [DATE], revealed Resident #69 was severely impaired for cognitive skills for daily decision making. Further review of the discharge MDS assessment revealed Resident #69 was not coded for the 1/16/2025 fall with minor injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Insomnia, Adjustment Disorder with Depressed Mood, Dementia with Psychotic Disturbance, and Schizophrenia. Review of a PASRR Level 2 Outcome (completed prior to admission) dated 11/4/2023, revealed Resident #19 had a PASRR level 2 Outcome related to severe mental illness. Review of an admission MDS assessment revealed Resident #19 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. Review of a comprehensive care plan revised 4/2/2025, revealed Resident #19's PASRR Level 2 Outcome recommendations were not addressed on the care plan. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, Anxiety, Depression, Bipolar Disorder, Insomnia, and Tobacco use. Review of a quarterly MDS assessment dated [DATE], revealed Resident #32 scored a 7 on the BIMS assessment which indicated severe cognitive impairment. Review of a PASRR Level 2 Outcome dated 12/28/2024, revealed Resident #32 had a PASRR Level 2 Outcome related to severe mental illness. Review of a comprehensive care plan revised 5/5/2025, revealed Resident #32's PASRR Level 2 Outcome recommendations were not addressed on the care plan. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Bipolar, Anxiety, Seizures, Restless Leg Syndrome, and Nicotine Dependence. Review of a PASRR dated 3/27/2025, revealed Resident #35 had a PASRR Level 2 Outcome related to severe mental illness. Review of an admission MDS assessment dated [DATE], revealed Resident #35 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a comprehensive care plan revised 4/23/2025, revealed Resident #35's PASRR Level 2 Outcome recommendations were not addressed on the care plan. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Cirrhosis, Atrial Fibrillation, and Difficulty Walking. Review of a quarterly MDS assessment dated [DATE], revealed Resident #25 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Physician's Order dated 4/28/2025, revealed Resident #25 was on droplet transmission-based precautions related to a COVID-19 infection with an end date of 5/9/2025. Review of a comprehensive care plan revised 5/5/2025, revealed Resident #25 was on droplet transmission-based precautions related to a COVID-19 infection. The care plan was not revised until 7 days after the positive result. During a record review and interview on 5/6/2025 at 12:47 PM, Registered Nurse (RN) MDS K reviewed the PASRR Level 2 outcomes and the comprehensive care plans for Residents #41, #19, #32, and #35 and confirmed the comprehensive care plans were not revised to include PASRR Level 2 Outcomes and specialized services provided by the facility. RN MDS K reviewed the COVID-19 positive result and the comprehensive care plan for Resident #25 and confirmed the comprehensive care plan was not revised timely for Resident #25. During an interview on 5/6/2025 at 1:25 PM, the Director of Nursing (DON) stated it was her expectation for care plans to be updated with PASRR level 2 outcomes, updated with specialized services which were provided by the facility, and also stated she expected care plans to be revised timely. During further interview the DON confirmed the facility failed to revise the comprehensive care plans for Residents #41, #19, #32 and #35. The DON also confirmed the facility failed to revise the comprehensive care plan for Resident #25 timely. Based on facility policy review, medical record review, and interview, the facility failed to revise the comprehensive care plans for 4 residents (Residents #41, #19, #32, and #35), the facility also failed to revise a comprehensive care plan timely for 1 resident (Resident #25) of 18 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revised 3/2022, revealed .A comprehensive, person-centered care plan .meet the resident's physical, psychosocial, and functional needs .describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being, including .any specialized services to be provided as a result of PASARR [Preadmission Assessment and Resident Review] recommendations and .which professional services are responsible for each element of care .and .reflects currently recognized standards of practice .care plans are revised as information about the residents and the residents' condition change . Review of the medical record revealed Resident #41 admitted to the facility on [DATE] with diagnoses including Dementia, Bipolar Disorder, and Anxiety. Review of a PASRR dated 1/17/2024, revealed Resident #41 had a PASRR Level 2 Outcome related to serious mental illness. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 scored an 8 on the Brief Interview for Mental Status (BIMS) which indicated moderate cognitive impairment. Review of the comprehensive care plan revised 3/10/2025, revealed Resident #41's Level 2 PASRR and recommended specialized services were not addressed on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 resident (Resident #4) of 2 residents reviewed for hospice services. The findings include: Review of the facility policy titled, Hospice Program, dated 2001, revealed .Director of Nursing or Designee will coordinate care provided to the resident by our facility staff and the hospice staff .responsible for the following .obtaining the following information from the hospice .most recent hospice plan of care specific to each resident . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Anxiety Disorder, and Encounter for Palliative Care. Review of the Physician's Order for Resident #4 dated 12/17/2024, revealed .admit to [Hospice Name] hospice continuous . Review of the facility document titled, Hospice IDG Comprehensive Assessment and Plan of Care Update Report, for Resident #4 dated 1/7/2025, revealed, .Benefit Period Dates .1/6/2025 to 4/5/2025 . Continued review revealed no further documentation of a new recertification period for hospice services or a revised care plan after 4/5/2025. Review of a comprehensive care plan dated 1/30/2025, revealed Resident #4 .End of Life .Resident requires HOSPICE SERVICES R/T [related to] ALZHEIMERS DISEASE .notify hospice of change of condition . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Further review revealed the resident received hospice services. During an interview on 5/6/2025 at 9:20 AM, the Social Services Director (SSD) stated she was the hospice coordinator for the facility. The SSD stated there were hospice plan of care binders located at each nurse station for each resident that received hospice services. The SSD confirmed Resident #4 remained on hospice services and the hospice plan of care had not been updated for Resident #4. During an interview on 5/6/2025 at 10:35 AM, the Director of Nursing (DON) confirmed that Resident #4 remained on hospice services and the hospice plan of care had not been updated for Resident #4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations and interview the facility failed to offer hand hygiene assistance prior to meals for 5 residents (Residents #9, #33, #56, #58, and #5) of 18 residents observed on 1 of 3 hallways, the facility failed to wear adequate Personal Protective Equipment (PPE) when delivering meal trays to 3 residents (Residents #25, #35, and #64), and the facility failed to perform appropriate hand hygiene during medication administration for 1 resident (Resident #283) of 18 residents observed for infection control. The facility also failed to ensure staff wore adequate PPE when sorting soiled linens. The findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 2001, revealed .personnel are trained .in serviced .importance of hand hygiene .preventing the transmission of healthcare-associated infections .residents .are encouraged to practice hand hygiene . 1. The facility failed to offer or assist with hand hygiene prior to a meal for Residents @9, #33, #56, #58, and #5. 1a. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Heart Failure, and Dementia. Review of the comprehensive care plan for Resident #9 revised 3/7/2025, revealed .ADL [activities of daily living]/Mobility .resident is at risk for ADL/mobility decline and requires assistance related to H/O [history of] CVA [Cerebrovascular Accident] [stroke] with right hemiplegia . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. Further review revealed the resident was dependent upon staff for assistance with personal hygiene. During an observation on 5/4/2025 at 12:25 PM, on the 600 hall, revealed Certified Nursing Assistant (CNA) B placed the meal tray in front of Resident #9, setup the meal tray for the resident to eat, and failed to offer or assist the resident with hand hygiene before the meal tray was delivered or before the resident began eating the meal. 1b. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Chronic Kidney Disease, Heart Failure, and Diabetes. Review of the comprehensive care plan for Resident #33 revised 1/7/2025, revealed .ADL/mobility decline and requires assistance related to H/O CVA with right hemiplegia . Review of an annual MDS assessment dated [DATE], revealed Resident #33 scored a 10 on the BIMS assessment which indicated moderate cognitive impairment. Further review revealed the resident was dependent upon staff assistance for personal hygiene. During an observation on 5/4/2025 at 12:27 PM, revealed CNA C placed the lunch meal tray in front of Resident #33, setup the meal tray for the resident to eat, and failed to offer or assist Resident #33 with hand hygiene before the meal tray was delivered or before the resident began eating the meal. 1c. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Diabetes, and Chronic Pain. Review of the comprehensive care plan for Resident #56 revised 1/17/2025, revealed .ADL/Mobility .requires assistance related to non-ambulatory . Review of a quarterly MDS assessment dated [DATE], revealed Resident #56 scored a 12 on the BIMS assessment which indicated moderate cognitive impairment. Further review revealed the resident required substantial/maximal assistance by staff with personal hygiene. During an observation on 5/4/2025 at 12:30 PM, CNA C placed the lunch meal tray in front of Resident #56, setup the meal tray for the resident to eat, and failed to offer or assist Resident #56 with hand hygiene before the meal tray was delivered or before the resident began eating the meal. 1d. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Dementia, and Chronic Pain. Review of the comprehensive care plan for Resident #58 revised 1/16/2025, revealed .ADL/Mobility .self-care deficit R/T [related to] .dressing .hygiene . Review of a quarterly MDS assessment dated [DATE], revealed Resident #58 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Further review revealed the resident was dependent upon staff assistance for personal hygiene. During an observation on 5/4/2025 at 12:35 PM, CNA B placed the lunch meal tray in front of Resident #58, setup the meal tray for the resident to eat, and failed to offer or assist Resident #58 with hand hygiene before the meal tray was delivered or before the resident began eating the meal. 1e. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis, Chronic Kidney Disease, and Diabetes. Review of an admission MDS assessment dated [DATE], revealed Resident #5 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident required substantial/maximal assistance with personal hygiene. Review of the comprehensive care plan for Resident #5 revised 5/6/2025, revealed .ADL/mobility .requires assistance related to CVA . During an observation on 5/4/2025 at 12:37 PM, CNA C placed the lunch meal tray in front of Resident #5, setup the meal tray for the resident to eat, and failed to offer or assist Resident #5 with hand hygiene before the meal tray was delivered or before the resident began eating the meal. During an interview on 5/4/2025 at 12:40 PM, CNA B confirmed hand hygiene was not offered or provided to Resident #9 and Resident #58 before the lunch meal was served or before the residents began eating their meal. During an interview on 5/4/2025 at 12:45 PM, CNA C confirmed hand hygiene was not offered or provided to Resident #33, Resident #56, and Resident #5 before the lunch meal was served or before the residents began eating their meal. During an interview on 5/6/2025 at 10:35 AM, the Director of Nursing (DON) confirmed it was the facility's expectation for the staff to offer hand hygiene assistance to all residents prior to meal service. 2. The facility failed to wear adequate PPE while delivering meal trays to Residents #25, #35, and #64. Review of the facility's policy titled, Infection Prevention and Control Program, dated 2001, revealed An infection Prevention and Control Program (IPCP) 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 .The program is based on accepted national infection prevention and control standards .management is a process that consists of .managing the affected residents .preventing the spread to other residents .educating the staff .Prevention of infection .implementing appropriate .transmission-based precautions . Review of the facility's policy titled, Personal Protective Equipment, dated 2001, revealed .Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) .includes but is not necessarily limited to .Gowns/aprons/lab coats .eye wear (goggles and/or face shields) .PPE required for transmission-based precautions is maintained outside .the resident's room . 2a Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Cirrhosis, Atrial Fibrillation, and Difficulty Walking. Review of a quarterly MDS assessment dated [DATE], revealed Resident #25 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Physician's Order dated 4/28/2025, revealed Resident #25 was on droplet transmission-based precautions related to a COVID-19 infection with an end date of 5/9/2025. Review of a comprehensive care plan revised 5/5/2025, revealed Resident #25 was on droplet transmission-based precautions related to a COVID-19 infection. During an observation on 5/4/2025 at 11:30 AM, revealed Resident #25's door was closed with an 8.5 x 11 inch laminated sign attached to the door which read .STOP .DROPLET PRECAUTIONS .EVERYONE MUST .make sure their eyes .are fully covered before room entry . The sign also displayed an image of a face shield and eye goggles. Further observation revealed a yellow cloth isolation supply bin hanging from the door. The isolation bin contained multiple isolation gowns, multiple boxes of various sized gloves, and a disposable stethoscope. The isolation storage bin did not contain goggles or face shields. During an observation and interview on 5/4/2025 at 12:22 PM, Licensed Practical Nurse (LPN) S was observed removing PPE from Resident #25's isolation bin, donned (put on) gloves, and an isolation gown. Further observation revealed LPN S entered Resident #25's room and set up the meal tray without wearing a face shield or eye goggles. LPN S stated an isolation gown and gloves were applied because Resident #25 had an active COVID-19 infection and confirmed a face shield or eye goggles were not donned. 2b Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, and History of Blood Clots. Review of an admission MDS assessment dated [DATE], revealed Resident #35 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Physician's Order dated 4/28/2025, revealed Resident #35 was on droplet transmission-based precautions related to a COVID-19 infection with an end date of 5/9/2025. Review of a comprehensive care plan revised 4/29/2025, revealed Resident #35 was on droplet transmission-based precautions related to a COVID-19 infection. During an observation on 5/4/2025 at 11:35 AM, Resident #35's door was closed with an 8.5 x 11 inch laminated sign attached to the door which read .STOP .DROPLET PRECAUTIONS .EVERYONE MUST .make sure their eyes .are fully covered before room entry . The sign also displayed an image of a face shield and eye goggles. Further observation revealed a yellow cloth isolation supply bin hanging from the door. The isolation bin contained multiple isolation gowns, multiple boxes of various sized gloves, and a disposable stethoscope. The isolation storage bin did not contain goggles and contained 1 face shield which had a broken elastic strap. During an observation and interview on 5/4/2025 at 12:28 PM, LPN U was observed removing PPE from Resident #35's isolation bin, donned gloves, and an isolation gown. Further observation revealed LPN U entered Resident #35's room without a face shield or eye goggles. LPN U stated an isolation gown and gloves were applied because Resident #35 had an active COVID-19 infection and confirmed a face shield and goggles were not donned. 2c Review of the medical record revealed Resident #64 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Obesity, Lack of Coordination, Cough, and Wheezing. Review of an admission MDS assessment dated [DATE], revealed Resident #64 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of a Physician's Order dated 4/30/2025, revealed Resident #64 was on droplet transmission-based precautions related to a COVID-19 infection with an end date of 5/11/2025. Review of a comprehensive care plan revised 5/1/2025, revealed Resident #64 had an active COVID-19 infection. During an observation on 5/4/2025 at 11:25 AM, Resident #64's door was closed with an 8.5 x 11 inch laminated sign attached to the door which read .STOP .DROPLET PRECAUTIONS .EVERYONE MUST .make sure their eyes .are fully covered before room entry . The sign also displayed an image of a face shield and eye goggles. Further observation revealed a yellow cloth isolation supply bin hanging from the door. The isolation bin contained multiple isolation gowns, multiple boxes of various sized gloves, and a disposable stethoscope. The isolation storage bin did not contain eye goggles or face shields. During an observation and interview on 5/4/2025 at 12:14 PM, CNA V was observed removing PPE from Resident #64's isolation bin, donned gloves, and an isolation gown. Further observation revealed CNA V entered Resident #64's room without a face shield or eye goggles. CNA V stated an isolation gown and gloves were applied because Resident #64 had an active COVID-19 infection and confirmed a face shield or goggles were not donned. During an interview on 5/5/2025 at 3:00 PM, the Infection Preventionist stated there was additional PPE available in the central supply area, and also stated the staff members were expected to don eye goggles or a face shield prior to entering rooms with droplet precautions signage. The Infection Preventionist confirmed the facility failed to wear the appropriate PPE of goggles or a face shield when entering the isolation rooms for Residents #25, #35, and #64. During an interview on 5/6/2025 at 1:25 PM, the Director of Nursing (DON) stated staff members were expected to wear eye goggles or a face shield prior to entering rooms with droplet precautions for all resident tasks. The DON also stated the facility failed to have adequate PPE of face shields or goggles available outside the resident rooms in the PPE bins. During further interview the DON confirmed the facility failed to wear the appropriate PPE for Residents #25, #35, and #64. 3. The facility staff failed to perform hand hygiene during medication administration for Resident #283. 3a Review of the medical record revealed Resident #283 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Urinary Tract Infection, Sepsis, Alerted Mental Status, and Respiratory Failure. During an observation on 5/6/2025 at 7:55 AM, revealed LPN T prepared multiple and various oral tablet medications for Resident #283 into a clear 30 milliliter (mL) medication cup which was placed on the medication cart. LPN T dropped a Calcium-Vitamin D pill bottle onto the floor, picked the bottle up out of the floor, and then placed the pill bottle back into the medication cart. Continued observation revealed LPN T did not disinfect or clean the medication bottle after the bottle touched the floor and did not clean the hands after retrieving the bottle from the floor. Further observation revealed LPN T retrieved the prepared medications and administered the medications to Resident #283. During an interview on 5/5/2025 at 8:00 AM, LPN T confirmed hand hygiene was not performed after picking up a soiled item from the floor, the soiled medication bottle was not cleaned after touching the floor, was placed back into the clean medication cart, and the medications were administered to Resident #283 with soiled hands. During further interview LPN T confirmed infection control guidelines were not followed during the medication administration. During an interview on 5/5/2025 at 3:00 PM, the Infection Preventionist stated staff were expected to wash their hands or use hand sanitizer after picking up soiled items from the floor and prior to medication administration. During further interview the Infection Preventionist confirmed the facility failed to ensure infection control guidelines were followed during medication administration for Resident #283. During an interview on 5/6/2025 at 1:25 PM, the DON confirmed the facility failed to ensure infection control guidelines were followed during medication administration for Resident #283. 4. The facility staff failed to ensure staff wore appropriate PPE when sorting soiled linens. During an observation on 5/5/2025 at 4:00 PM, revealed the facility had 2 washers in use which contained facility linen, and multiple empty soiled linen containers of various sizes. Further observation of the soiled linen room revealed no gowns or aprons available for staff use. During an interview on 5/5/2025 at 4:02 PM, Laundry Aide W stated 2 loads of laundry were recently sorted and actively washing. During further interview the Laundry Aide stated she wore gloves when handling soiled linens and stated she has never worn a gown or apron when handling or sorting soiled linens. During an interview on 5/5/2025 at 4:05 PM, Laundry Aide X stated she wore gloves when handling soiled linens and stated she has never worn a gown or apron when handling or sorting soiled linens. During an interview on 5/5/2025 at 4:07 PM, the Housekeeping Laundry Supervisor stated gowns were available for staff use in the soiled linen room and stated the gowns were stored next to the washers. The Housekeeping Laundry Supervisor stated Laundry Aides were expected to wear a gown or apron when handling or sorting soiled linens. During an observation and interview on 5/5/2025 at 4:08 PM, the Housekeeping Laundry Supervisor observed the soiled linen room and washer area which revealed no gowns or aprons available for use. The Housekeeping Laundry Supervisor confirmed gowns and aprons were not available for use and also confirmed the facility failed to follow infection control guidelines when handling soiled linens. During an interview on 5/5/2025 at 4:10 PM, the Infection Preventionist confirmed the facility failed to follow infection control guidelines when handling soiled linens. During an interview on 5/6/2025 at 1:25 PM, the DON stated she expected the Laundry Aides to wear a gown or apron when handling soiled linens related to potential exposure to infectious organisms. During further interview the DON confirmed the facility failed to follow infection control guidelines when handling soiled linens.

Based on facility policy review, observations, and interviews, the facility failed to ensure kitchen equipment of 1 gas cook top oven and 1 deep fryer was maintained in good working condition. The findings include: Review of the facility's Nutritional Services policy titled, Cleaning & Sanitization, dated 9/2/2020, revealed .The Director of Food and Nutrition Services will develop, implement, and monitor schedules for cleaning, sanitizing and maintenance . Review of facility documentation titled, Instructions .Facility Inspection: Inspect kitchen small appliances, undated, revealed .Conduct safety and operation inspections .Visually inspect all appliances for damage .Test functionality of appliances and proper operation of all controls .Inspect all tethered gas fed appliances . During an observation and interview of the kitchen during the initial tour on 5/4/2025 at 10:45 AM, with the Certified Dietary Manager (CDM) and [NAME] revealed on inspection of the cook top stove, the debris pan located under the gas burners was extremely hot to the touch as well as the handle of the stove. All of the stove burners had been off for hours according to the Cook. All control knobs for the cook top stove and oven were in the OFF position, yet the debris pan, and stove handle remained extremely hot. The deep fryer was located next to the cook top stove, and the cook stated the deep fryer's pilot light and stove top burners pilot lights will not stay lit at times and were not functioning properly. During an interview on 5/4/2025 at 11:53 AM, the CDM confirmed the cook top oven and deep fryer were in need of professional repair. The CDM acknowledged the temperatures of the debris pan and oven door handle had the potential to burn users hands while the burners and stove were not in operation. During an interview on 5/6/2025 at 12:22 PM, the Administrator stated he was made aware of the observations of the gas cook top stove and the deep fryer after the initial tour of the kitchen on 5/4/2025. The Administrator confirmed both pieces of equipment were in need of repair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, Incident Reporting System document review, medical record review and Interview, the facility failed to ensure 1 (Resident #6) of 7 residents reviewed were free from sexual abuse. Resident #12 (Perpetrator) was observed with his hand in the shirt of Resident #6. The findings include: Review of the facility policy titled, Abuse Prohibition Plan, dated 4/1/2018, revised 10/24/2022, revealed, .The facility has a zero-tolerance policy for abuse .sexual abuse is prohibited .The facility shall attempt to identify and shall investigate any reported violation or allegation of abuse .The abuse applies to anyone involved with residents of this facility .'Abuse Coordinator' of this facility is the Administrator .'Abuse' means the willful infliction of injury .It includes .sexual abuse .is non-consensual sexual contact of any type with a resident. It includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault .All staff shall monitor residents and shall be educated regarding how to identify signs and symptoms of abuse. This includes staff to resident abuse and certain resident to resident altercations. Resident, staff, or family report of abuse .The alleged offender shall immediately be removed, and the Resident protected .the staff member shall immediately remove the perpetrator from the situation and another staff member shall stay with the alleged offender and wait for further instruction from Administration .Employees must always report any allegations of abuse or suspicion of abuse immediately to their supervisor .any staff member or person affiliated with this facility who has witnessed or who believes that a resident has been a victim of .abuse .shall immediately report, or cause a report to be made of, the mistreatment or offense . Review of the Incident Reporting Systems document revealed, .[Named Dietary Staff M] stated .I was watching from the other door and saw [Resident #12] put his hand down [Named Resident #6's] shirt. I opened the door and coughed to get him to stop then shut the door and watched again. [Named Housekeeping Staff VV] came in to mop dining room floor and after he left [Resident #12] put his hand down .underneath [Named Resident #6]'s shirt again and she tried to stop and shoo [fanning arms around to redirect] him away. [Resident #6] seemed upset and kept trying to get [Resident #12] to leave her alone . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Insomnia, History of Benign Neoplasm of the Brain and Mild Intellectual Disability. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE], for Resident #6, revealed a BIMS (Brief Interview for Mental Status) score of 13 ,which indicated no cognitive impairment. Continued review revealed Resident #6 required the use of a wheelchair. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Systolic and Diastolic Heart Failure, Hemiplegia (paralysis on one side of the body), and Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS assessment dated [DATE], for Resident #12, revealed a BIMS score of 12, which indicated moderate cognitive impairment. Continued review revealed Resident #12 required the use of a wheelchair. Review of the Nurse's Event Note dated 3/31/2024 at 10:30 AM, revealed LPN O documented, (Dietary Staff M) reported to multiple nursing staff that Resident #12 had his hand down Resident #6's shirt. LPN O asked Resident #6 if she felt violated or uncomfortable in any way? Resident #6 told LPN O that she was uncomfortable, and she waved her hand to get Resident #12 to go away. LPN O went to speak with the Administrator and when she returned Resident #12 was wheeling towards Resident #6. Resident #12 then turned round and headed back toward the nurses' station. Resident #12 did not receive direct supervision by staff following the incident. During an interview on 5/15/2024 at 3:36 PM, the Dietary Staff N said she looked out of the kitchen door and saw Resident #12 sitting really close to Resident #6. Resident #12 had his hand on the top part of Resident #6's leg. During an interview on 5/15/2024 at 4:07 PM, revealed LPN O said she was made aware of the touching incident between Resident #6 and Resident #12. LPN O stated she pulled Resident #6 out of the dining room. LPN O said when Resident #6 was asked about the incident with Resident #12, Resident #6 stated she felt uncomfortable. During an interview on 5/20/2024 at 4:00 PM, the Director of Nursing (DON) stated expectations were for the staff to intervene when there has been suspected abuse. The DON stated staff would have also been expected to remove the resident from the harmful situation, immediately take the resident to the nurse, and report the incident to the Abuse Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, personnel file review, and interview, the facility failed to protect a resident's right to be free from misappropriation and/or exploitation for 1 (Resident #7) of 7 sampled residents reviewed when Certified Nursing Assistant (CNA) BB transferred money from Resident #7's bank card to her (CNA BB) personal account. The findings include: Review of facility policy titled, Abuse Prohibition Plan, effective date 11/2/2023, revealed, .The facility has a zero-tolerance policy for abuse .The resident shall not be subjected to mistreatment, neglect, exploitation, or misappropriation of property .The Abuse Policy applies to anyone involved with the residents of this facility, including, but not limited to, all facility staff .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent .The facility shall report to the State Nurse Aide Registry or State Licensing Authority any knowledge it has of actions by a court of law against and employee, which would indicate unfitness for service as a nurse aide or other facility staff .The facility must take steps to ensure that the resident is protected from abuse . Review of facility policy titled, Resident Rights and Resident Responsibilities, effective date 11/20/2023, revealed, .The resident has the right to a dignified existence, self-determination .The resident has the right to exercise his or her rights as a resident and as a citizen or resident of the United States .The resident has a right to be treated with respect and dignity . Review of the police department's Incident/Investigation Report, dated 9/5/2023 at 12:18 PM, revealed the (Named Police Department) responded to a crime incident of Financial Exploitation of Elderly or Vulnerable Person. The victim, Resident #7, alleged money in the amount of $350.00 had been stolen from her bank card. The suspect listed was CNA BB. Review of the facility Investigation Summary, dated 9/8/2023, revealed, .Verified approx. [approximately] 400.00 missing from Pt's [patient's] [Resident #7] bank card. Ongoing police investigation. Received email from Family Member CC with copy of transaction for September . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease, Osteomyelitis of Vertebra, Chronic Respiratory Failure with Hypoxia, Chronic Diastolic (Congestive) Heart Failure, Depression, and Anxiety Disorder. Review of the admission Minimum Data Set (MDS) assessment for Resident #7 dated 8/19/2023, revealed a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated moderate cognitive impairment. Review of Resident 7's bank statement dated September 2023, revealed a transaction dated 9/1/2023, showing CNA BB withdrew $350.00 from Resident #7's account. Review of the Nurse's Event Note, for Resident #7, dated 9/5/2023, revealed, .type of Occurrence .Misappropriation of Resident Property/Exploitation .Pt. [patient] reported that someone named [First Name of Certified Nursing Assistant (CNA) BB] took 400.00 off her bank card and the bank is the one that told her the name of the person was [Named CNA BB]. Pt. reported that she had given [Named CNA BB] her card to get her a couple of cokes out of the machine . Review of the personnel file for CNA BB revealed the facility terminated CNA BB for .Policy/Conduct Violation . on 9/6/2024. Review of a (Named County) Criminal Court document dated 4/16/2024, revealed CNA BB was charged with 1 count Financial Exploitation Elderly/Vulnerable Person on 10/02/2023. During an interview on 5/15/2024 at 4:10 PM, Resident #7 stated that CNA BB had stolen $350.00 from her bank card. Resident #7 stated, I had to get the police involved . Review of the document titled, Misappropriation Decision Tree, dated 5/16/2024, revealed accused individual CNA BB was an employee of the facility. The accused CNA BB wrongfully used Resident #7's money. The accused CNA BB's act was deliberate, and Resident #7 did not consent. The Decision Tree ended with notice of intent to place CNA BB on Abuse Registry. During a telephone interview on 5/16/2024 at 4:45 PM, Family Member (FM) CC stated a CNA took $350.00 out of Resident #7's bank card. FM CC confirmed that she provided the facility with the September 2023 bank statement showing the transaction on 9/1/2023. During an interview in the conference room on 5/16/2024 at 5:15 PM, the Administrator stated Resident #7 had given CNA BB her bank card to use to get Resident #7 two drinks out of the drink machine. The Administrator stated Resident #7 reported the bank had notified her that CNA BB had taken $350.00 out of her bank account and sent it to a Cash Application. The police came and started an investigation. The Administrator stated, I spoke with [Named Police Detective] two to three months ago. I was told there was enough evidence to proceed, and charges are being filed. During an interview in the conference room on 5/17/2024 at 9:05 AM, the Housekeeping Supervisor confirmed she had reported an allegation of misappropriation to the Administrator that was brought to her attention by Housekeeper DD (noted in a written statement dated 9/5/2023). The Housekeeping Supervisor stated Resident #7 had reported CNA BB had taken money from her account to Housekeeper DD, who then reported it to her (Housekeeping Supervisor). During an interview in the conference room on 5/17/2024 at 9:37 AM, Housekeeper DD confirmed that Resident #7 had told her CNA BB took $400.00 from her bank account and her bank told her it was CNA BB (as noted in a written statement dated 9/5/2024). Housekeeper DD stated, I reported it to my supervisor [Named Housekeeper Supervisor]. During an interview in the conference room on 5/17/2024 at 10:30 AM, the former Director of Nursing (DON) stated the facility substantiated the allegation of misappropriation when FM CC sent the facility a copy of the transaction on 9/1/2023, which verified money had been transferred to CNA BB's Cash Application. The former DON stated, .When the police phoned [Named CNA BB] from the facility, she denied the allegation. I found it odd she offered to refund the resident the money . When asked if the facility reported CNA BB to the Abuse Registry, the former DON stated, No. During an interview in the conference room on 5/17/2024 at 11:50 AM, the Social Worker confirmed during an interview Resident #7 stated she had given her card to CNA BB to purchase a drink from the vending machine for her. The Social Worker stated Resident #7 told her the bank had confirmed CNA BB had transferred almost $400.00 from her (Resident #7) account to an online account belonging to CNA BB (as noted in a written statement dated 9/5/2023). During a phone interview on 5/17/2024 at 1:34 PM, the Police Detective stated Resident #7's missing funds had been investigated and CNA BB was arrested 12/1/2023 and charged with 1 count of Financial Exploitation Elderly/Vulnerable Person. The Police Detective stated the court case had been continued a few times and CNA BB is due back in court on 5/28/2024 at 9:00 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review, observation and interview, the facility failed to provide effective housekeeping and maintenance services to maintain a clean, safe, and homelike environment as evidenced by dirty walls with black vertical marks, vertical scrapes that resulted in damaged sheet rock and holes in the walls in 15 resident rooms (Rooms 204, 205, 208, 506, 508, 509, 511, 600, 601,604, 605, 606,607,608, and 609) of 48 observed rooms throughout the facility. In addition, 1 hole was observed in the drywall in 1 nutrition room (400 Hall nutrition room) of 2 nutrition rooms observed in the facility. The findings include: Review of facility policy titled, Resident Rights and Resident Responsibilities, effective date 11/20/2023, revealed, .The resident has a right to a safe, clean, comfortable and Homelike environment . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which included Paraplegia, Pressure Ulcer of Right Buttock, Stage 4, Pressure Ulcer of Sacral Region, Stage 4, Essential (Primary) Hypertension, Lack of Coordination, Unspecified Cirrhosis, and Other Specified Interstitial Pulmonary Diseases. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 revealed, a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. Observation and interview in Resident #8's room on 5/14/2024 at 5:25 PM observed the wall behind the headboard Resident 8's bed with a golf ball sized hole through the sheet rock, black vertical marks, and vertical scrapes into the wall that resulted in sheet rock damage with sheet rock dust noted on headboard. Resident #8 was lying in the bed on his back. Resident #8 was asked about the wall behind the headboard. Resident #8 stated the wall was like that on admission. Resident #8 stated if a wall at his home had a hole in it Resident #8 would repair it. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Atherosclerotic Heart Disease, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Presence of Urogenital Implants, Sepsis, and altered Mental Status. Review of the Quarterly MDS assessment dated [DATE] for Resident #10 revealed, a BIMS score of 14 which indicated cognitively intact. Observation and interview in Resident #10's room on 5/14/2024 at 5:35 PM, observed vertical scrapes into the wall that resulted in damaged sheet rock behind Resident #10's headboard. Resident #10 was asked about the wall behind the head of his bed. Resident #10 stated it should be fixed. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Metabolic Encephalopathy, Parkinson's Disease without Dyskinesia, Transient Cerebral Ischemia, and Hypotension. Review of the Quarterly MDS assessment dated [DATE] for Resident #22 revealed, a BIMS score of 11 which indicated moderate cognitive impairment. Observation and interview in Resident #22's room (606 A) on 5/15/2024 at 5:50 PM, observed black vertical marks and deep vertical scrapes into the wall with damaged sheet rock behind Resident #22's headboard. Resident #22 was asked about the wall behind the head of his bed. Resident #22 stated It was on there when I moved in. It needs to be repaired. I would expect them to repair it. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease, Chronic Obstructive Pulmonary, Morbid (Severe) Obesity, Personal History of Traumatic Brain Injury, and Type 2 Diabetes Mellitus. Review of the Quarterly MDS assessment dated [DATE] for Resident #23 revealed, a BIMS score of 12 which indicated moderate cognitive impairment. Observation and interview in Resident #23's room on 5/15/2024 at 5:55 PM, observed black vertical marks and vertical scrapes into the wall that resulted in sheet rock damage behind the Resident #23's headboard. Resident #23 was asked about the wall behind the headboard. Resident #23 stated, It makes me feel awful. It needs to be fixed. It would never get that way at my house. I would repair it, paint it, and get the wall back to normal or better. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks and scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks and scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed B there were black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in the 400 Hall Nutrition Room on 5/15/2024 beginning at 10:00 AM, observed a hole in the wall behind the door through the sheet rock the size of the door handle noted. During an interview in the 400 Hall Nutrition Room on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the hole in the wall behind the door through the sheet rock the size of the door handle. The Administrator stated the wall needed to be repaired. During an interview in the 400 Hall Nutrition Room on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed the hole in the wall behind the door through the sheet rock the size of the door handle. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks on the wall with scrapes and dents into the wall that resulted in damaged sheet rock behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes and dents into the wall that resulted in damaged sheet rock behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were black vertical marks on the wall with scrapes and dents into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were black vertical marks on the wall with scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed deep vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed the deep vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed B there were deep vertical scrapes into the wall that resulted in damaged sheet rock. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed on the wall to the right of the window peeling paint noted in an area approximately one-and-a-half-inch square, vertical scrapes into the wall that resulted in sheet rock damage behind the headboard of bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed small area of peeling paint to the right of the window, vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. The Administrator stated the walls needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed B there were vertical scrapes into the wall that resulted in damaged sheet rock, and a small area of peeling paint to right of the window. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage behind the headboards of bed A and bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage behind the headboards of bed A and bed B. The Administrator stated the walls needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboards of bed A and bed B there were vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, holes approximately the size of screws noted in the wall at the foot of bed A near the wardrobe and on the wall next to bed A's TV. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed holes in the wall at the foot of bed A near the wardrobe and on the wall next to bed A's TV. The Administrator stated the holes needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed there were holes in the wall at the foot of bed A near the wardrobe and on the wall next to bed A's TV. The Maintenance Director stated the holes needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed black vertical marks and vertical scrapes into the wall that resulted in sheet rock damage behind the headboards of bed A and bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical black marks and vertical scrapes into the wall that resulted in sheet rock damage behind the headboards of bed A and bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboards of bed A & bed B there were vertical black marks and vertical scrapes into the wall that resulted in sheet rock damage. The Maintenance Director stated the wall needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed black vertical marks on the wall behind the headboard of bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical black marks on the wall behind the headboard of bed A. The Administrator stated the wall needed to be painted. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were vertical black marks. The Maintenance Director stated the wall needed to be painted. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed black vertical marks and deep vertical scrapes into the wall that resulted in sheet rock damage to the wall behind the headboard of Bed A. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage behind the headboard of bed A. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A there were vertical black marks and deep vertical scrapes into the wall that resulted in sheet rock damage. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed vertical scrapes into the wall that resulted in sheet rock damage behind the headboard of bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed B there were vertical scrapes into the wall that resulted in sheet rock damage. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed the wall behind the headboard of bed A with a golf ball size hole through the sheet rock, black vertical marks, and vertical scrapes into the wall that resulted in sheet rock damage. Sheet rock dust noted on the headboard of bed A. Observed the wall behind the headboard of bed B with vertical scrapes into the wall that resulted in damaged sheet rock. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed a golf ball size hole through the sheet rock, with black vertical marks, and vertical scrapes into the wall that resulted in sheet rock damage behind the headboard of bed A. Sheet rock dust noted on headboard of bed A. Vertical scrapes into the wall that resulted in damaged sheet rock behind bed B. The Administrator stated the wall needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed behind the headboard of bed A golf ball size hole through the sheet rock, black vertical marks, and vertical scrapes into the wall that resulted in sheet rock damage. Sheet rock dust noted on headboard of bed A. Vertical scrapes into the wall that resulted in damaged sheet rock behind the headboard of bed B. The Maintenance Director stated the walls needed to be repaired. Observation in room [ROOM NUMBER] on 5/15/2024 beginning at 10:00 AM, observed holes approximately the size of screws in the wall above the headboard of bed A near the Auxiliary Drain box. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 3:00 PM, the Administrator confirmed holes in the wall above the headboard of bed A near the Auxiliary Drain box. The Administrator stated the holes needed to be repaired. During an interview in room [ROOM NUMBER] on 5/15/2024 beginning at 5:20 PM, the Maintenance Director confirmed there were holes in the wall above the headboard of bed A near the Auxiliary Drain box The Maintenance Director stated the holes needed to be repaired. Observations were made of 48 resident rooms and 2 Nutritional Rooms with 15 resident rooms in need of wall repairs and painting. Observation of 1 nutritional room with a hole in the wall needing repaired and painted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to notify the Physician/Nurse Practitioner and family for 1 of 5 (Resident #1) residents reviewed for falls with injury. The findings include: 1. Review of the facility's policy titled, Notification of Change, dated 11/30/2017 and revised 3/28/2023 revealed, The purpose of this policy is to ensure the facility informs the resident, consistent with his or her authority, when there is a change requiring notification .The facility shall inform the resident, consult with the resident's physician, and/or notify the resident's family member .when there is a change requiring such notification .Circumstances requiring notification include: 1. Accidents a. resulting in injury . Review of the facility's policy titled, Accidents and Supervision, dated 11/1/2017 and revised 10/21/2021 revealed, .the resident environment remains as free of accident hazards as is possible: and each resident receives adequate supervision and assistive devices to prevent accidents .'Accident' refers to any unexpected or unintentional incident, which results in injury or illness to a resident . Review of the facility's policy titled, Wound Care Guidelines, dated 6/6/2022, revealed, .Accurate and timely wound assessment is important to ensure correct diagnosis and for developing a plan of care to address the resident, the wound, and the skin problems that impact healing .Skin tears are a traumatic break in the skin .Procedure: Identify and evaluate the wound and surrounding area .Initiate the weekly wound assessment form and classify as indicated .Notify physician and/or nurse practitioner to obtain treatment orders as needed .Discuss the plan of care with the resident and/or family as indicated . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial Infarction, Presence of Cardiac Pacemaker, and Non Pressure Chronic Ulcer of Right Heel and Midfoot. The resident was admitted to the facility for a five-day Hospice Respite stay. Resident #1 discharged home on 9/18/2023 with family. Review of the Nurse's Event Note for Resident #1 dated 9/18/2023, revealed on 9/16/2023 at 8:00 PM, Resident #1 received a skin tear to her left shin. The Event Note stated the resident received the skin tear in her room and no other details were documented of how the injury occurred. The Event Note stated the Nurse Practitioner was notified of the injury on 9/20/2023, five days after the injury occurred, and the Responsible Party, listed as Resident #1, was notified on 9/18/2023. 3. During an interview on 9/22/2023 at 3:00 PM, Family Member (FM) #1 stated Resident #1 had been admitted to the facility for a five-day Hospice Respite stay 9/13/2023-9/18/2023. FM #1 stated the staff banged her leg in the shower causing a wound, and the wound was never treated. During an interview on 9/2/2023 at 2:28 PM, Licensed Practical Nurse (LPN) #1 stated the resident had a skin tear on her leg that she obtained at the facility. During an interview on 9/26/2023 at 2:49 PM, Registered Nurse (RN) #1, also known as Unit Manager #1, stated when nurses are told a resident has a skin tear, the nurse should assess and measure the wound, and apply a dressing. They also fill out the paperwork required, and notify the provider and the family. During an interview on 9/26/2023 at 3:00 PM, LPN #2, also known as the Treatment Nurse, stated she did not know about Resident #1 having a skin tear until after Resident #1 was discharged home. LPN #2 stated after Resident #1's family took her home, they called back and complained to the Administrator about a wound on her shin. During an interview on 9/26/2023 at 3:30 PM, CNA #3 stated she provided care to Resident #1 on 9/15/2023, 9/16/2023, and 9/17/2023. CNA#3 stated on Saturday, 9/16/2023, she and another CNA got Resident #1 up to take a shower. CNA #3 stated when they were transferring Resident #1 to the shower chair, Resident #1 went down but did not fall to the ground. CNA #3 stated during this event, Resident #1 bumped her leg and obtained a skin tear that was bleeding. During an interview on 9/26/2023 at 4:02 PM, RN #1 stated the skin tear Resident #1 obtained in the shower, should have been reported to the physician or Nurse Practitioner (NP) and the family when it happened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to revise the care plan for 1 of 5 (Resident #1) residents reviewed. The findings include: 1. Review of the facility's policy titled, Baseline Careplan, dated 11/2016 and revised 10/21/2022, revealed, The facility shall develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial Infarction, Presence of Cardiac Pacemaker, and Non Pressure Chronic Ulcer of Right Heel and Midfoot. The resident was admitted for a five-day Hospice Respite stay. Resident #1 discharged home on 9/18/2023 with family. Review of the Nursing admission Form for Resident #1 dated 9/13/2023 revealed 1+ pitting edema (swelling) to right lower extremity, incontinence of bowel and bladder, was bed or chair bound, required extensive assistance of two people for transfers, and a vascular wound to the right posterior heel. Review of the Baseline Care Plan for Resident #1 dated 9/13/2023, revealed Problems for Bathing/Hygiene Dependent, Dressing/Grooming Extensive Assistance, Toileting Dependent, Eating Tray Preparation, Ambulation/Transfer Extensive Assistance, Assistive Devise/Aide Wheelchair, Mouth Care Dentures Upper Dentures Lower, Bladder/Bowel Incontinence, Respiratory Compromise, Terminal Care, Cardiac Diagnosis, Diabetes, Skin Integrity, At Risk for Falls, Advanced Directives, Cognitive Behavior, At Risk for Elopement, and Use of Psychotropic Medications. Appropriate goals and interventions were implemented. The Care Plan did not address a fall which resulted in a skin tear on 9/16/2023. Review of the Nurse's Event Note for Resident #1 dated 9/18/2023, revealed on 9/16/2023 at 8:00 PM, Resident #1 received a skin tear to her left shin. The Event Note stated the resident received the skin tear in her room, and no other details were documented as to how the injury occurred. During an interview on 9/27/2023 at 8:43 AM, the DON reviewed Resident #1's care plan with surveyor. The DON confirmed Resident #1's care plan had not been updated to reflect a fall resulting in a skin tear on 9/16/2023, and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to provide mouth care for 1 of 5 (Resident #1) residents reviewed. The findings include: 1. Review of the facility's policy titled, Activities of Daily Living (ADL), dated 3/9/2022 and revised 3/9/2023 revealed, .The facility shall, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .Care and services shall be provided for the following activities of daily living: 1.oral care .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial Infarction, Presence of Cardiac Pacemaker, and Non Pressure Chronic Ulcer of Right Heel and Midfoot. The resident was admitted for a five-day Hospice Respite stay. Resident #1 discharged home on 9/18/2023 with family. Resident #1 did not have an Minimum Data Set assessment completed. Review of the Nursing admission Form for Resident #1 dated 9/13/2023 revealed 1+ pitting edema (swelling) to right lower extremity, incontinence of bowel and bladder, bed or chair bound, required extensive assistance of two people for transfers, required assistance with Activities of Daily Living, and a vascular wound to the right posterior heel. Review of the Baseline Care Plan for Resident #1 dated 9/13/2023, revealed Problems for Bathing/Hygiene Dependent, Dressing/Grooming Extensive Assistance, Toileting Dependent, Eating Tray Preparation, Ambulation/Transfer Extensive Assistance, Assistive Devise/Aide Wheelchair, Mouth Care Dentures Upper Dentures Lower, Bladder/Bowel Incontinence, Respiratory Compromise, Terminal Care, Cardiac Diagnosis, Diabetes, Skin Integrity, At Risk for Falls, Advanced Directives, Cognitive Behavior, At Risk for Elopement, and Use of Psychotropic Medications. 3. During an interview on 9/22/2023 at 3:00 PM, Family Member (FM) #1 stated Resident #1 had been admitted to the facility for a five-day Hospice Respite stay, 9/13/2023-9/18/2023. FM #1 stated the staff did not remove and clean Resident #1's dentures. FM#1 stated she had to scrub the grime from her dentures when Resident #1 discharged home on 9/18/2023. During an interview on 9/26/2023 at 3:30 PM, CNA #3 stated she provided care to Resident #1 on 9/15/2023, 9/16/2023, and 9/17/2023. CNA #3 stated she did not clean Resident #1's dentures or do mouth care on 9/15/2023, 9/16/2023, or 9/17/2023. CNA#3 was asked why mouth care was not provided to Resident #1. CNA #3 stated, I guess it just slipped my mind. CNA#3 was asked if mouth care should be provided to residents who are unable to perform their own mouth care, CNA #3 replied, yes. During an interview on 9/27/2023 at 11:30 AM, the Regional Nurse Consultant stated mouth care should be provided daily and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to provide wound care and administer medications as ordered for 1 of 5 (Resident #1) residents reviewed. The findings include: 1. Review of the facility's policy titled, admission Orders, dated 11/30/2016 and revised 3/28/2023 revealed, To provide guidance on admission orders needed for the residents immediate care .At the time each resident is admitted , the facility shall have physician or other authorized individual orders for the resident's immediate care in accordance with law and regulation and professional practice acts, before care, treatment, and services are provided . Review of the facility's policy titled, Medication Reconciliation, dated 8/2018 and revised 11/23/2022, revealed, Medication Reconciliation/Drug Regimen Review is an interdisciplinary process between Nursing, Medical Staff and Pharmacy that compares the resident's most current list of home medications against the physician's orders upon admission and discharge, addresses discrepancies/issues, and thereby decreases potential Adverse Drug Events (ADEs) and omissions of medication therapy .Medication Reconciliation is the process of verifying, clarifying and reconciling the resident's most current list of medications against the physician's order on admission to the nursing home. It occurs at time of admission and discharge .Residents shall have all medications reconciled upon admission and at discharge. The nurse shall review the medication list with the resident/representative. The physician/practitioner shall review the resident's medication and any recommendation/order. The final outcome of this process is to generate the most accurate medication list and to identify potential or actual clinically significant medication issues .Procedure: admission: 1. Upon admission staff shall obtain a list of current medications from the referral source i.e. hospital, resident/representative or another source .2. Upon admission the nurse and resident/representative shall review and clarify the medication list as indicated .3. The Physician/Practitioner shall review the medication orders and recommend recommendations/orders, if indicated, which shall be completed by the next calendar day . Review of the facility's policy titled, Medication Administration, dated 11/2017 and revised 8/4/2023 revealed, .Medications shall be administered by licensed medical or nursing personnel acting within the scope of their practice and per the Physician's Signed Order . Review of the facility's policy titled, Wound Care Guidelines, dated 6/6/2022, revealed, .Accurate and timely wound assessment is important to ensure correct diagnosis and for developing a plan of care to address the resident, the wound, and the skin problems that impact healing .Skin tears are a traumatic break in the skin .Procedure: Identify and evaluate the wound and surrounding area .Initiate the weekly wound assessment form and classify as indicated .Notify physician and/or nurse practitioner to obtain treatment orders as needed .Initiate the treatment on the physician orders and/or treatment administration record .Notify therapy, dietary, and other team members as appropriate related to risk factors that may impede healing, hydration, and nutritional status .Discuss the plan of care with the resident and/or family as indicated .Complete a weekly wound assessment each week .Identify, implement, and/or revise interventions and the plan of care as needed .Monitor for decline and/or worsening .Notify MD [Medical Doctor] and RP [Responsible Party] .Treatment Guidelines/Suggestion .Option 1. Clean with normal saline, apply skin prep, and stay strips, monitor and change as needed .Option 2. Clean with normal saline, apply skin prep, apply stay strips, cover with transparent dressing, change twice a week . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Atherosclerosis Heart Disease, Old Myocardial Infarction, Presence of Cardiac Pacemaker, and Non Pressure Chronic Ulcer of Right Heel and Midfoot. The resident was admitted for a five-day Hospice Respite stay. Resident #1 discharged home on 9/18/2023 with family. Review of the Nursing admission Form for Resident #1 dated 9/13/2023 revealed 1+ pitting edema (swelling) to right lower extremity, incontinence of bowel and bladder, bed or chair bound, required extensive assistance of two people for transfers, and a vascular wound to the right posterior heel. Review of the Hospice admission Orders for Resident #1 dated 9/13/2023, revealed the following medications were ordered to be given: Polyethylene Glycol 17 grams daily and Docusate Calcium 240 mg daily. Continued review of the admission Orders revealed the following medications had been discontinued: Furosemide 40 mg ½ tablet (20 mg) daily, Furosemide 40 mg daily as needed when feet are swollen, and Lidocaine 4% topical patch daily. Review of the September 2023 Medication Administration Record (MAR) for Resident #1 revealed Resident #1 was given Furosemide 40 mg by mouth at 8:00 AM on 9/14/2023, 9/15/2023, 9/16/2023 and 9/17/2023, Lidocaine 4% topical patch applied on 9/14/2023, 9/15/2023 and 9/17/2023. Continued review revealed Docusate Calcium 240 mg and Polyethylene Glycol 17 grams was not administered. During an interview on 9/22/2023 at 3:00 PM, Family Member (FM) #1 stated Resident #1 had been admitted to the facility for a five-day Hospice Respite stay, 9/13/2023-9/18/2023. FM#1 stated the facility staff banged her leg in the shower causing a wound, and the wound was never treated. Review of the Nurse's Event Note for Resident #1 dated 9/18/2023, revealed on 9/16/2023 at 8:00 PM, Resident #1 received a skin tear to her left shin. The Event Note stated Resident #1 received the skin tear in her room, and no other details were documented as to how the injury occurred. During an interview on 9/26/2023 at 2:49 PM, Registered Nurse (RN) #1, also known as Unit Manager #1, stated when nurses are told a resident has a skin tear, the nurse should assess and measure the wound, and apply a dressing. RN #1 stated she was told about Resident #1's skin tear and asked LPN #1 if she had applied a dressing. RN #1 stated LPN #1 stated she did not apply a dressing to Resident #1's skin tear . During an interview on 9/26/2023 at 3:00 PM, LPN #2, also known as the Treatment Nurse, stated she did not know about Resident #1 having a skin tear until after she was discharged home. LPN #2 stated after Resident #1's family took her home, they called back and complained to the Administrator about a wound on her shin. During an interview on 9/26/2023 at 3:30 PM, CNA #3 stated she provided care to Resident #1 on 9/15/2023, 9/16/2023, and 9/17/2023. CNA#3 stated on Saturday, 9/16/2023, she and another CNA got Resident #1 up to take a shower. CNA #3 stated when they were transferring Resident #1 to the shower chair, Resident #1 went down but did not fall to the ground. CNA #3 stated during this event, Resident #1 bumped her leg and obtained a skin tear that was bleeding. CNA #3 stated she told another CNA that came into the shower room, to go tell the nurse. CNA #3 stated a nurse never came to the shower room. CNA #3 stated she held pressure to the skin tear and it stopped bleeding. CNA #3 stated a dressing was not applied to Resident #1's skin tear. CNA #3 stated she told LPN #1 and RN #1 about the skin tear and they replied, OK. CNA #3 stated Resident #1 didn't want to get up the following day (9/17/2023), so she gave Resident#1 a bed bath. CNA #3 stated the skin tear did not have a dressing on it. During an interview on 9/27/2023 at 9:05 AM, the Hospice Case Manager stated Resident #1 had an order in the past for Furosemide but was only given for 3 days and then discontinued. The Case Manager reviewed Resident #1's medication orders and confirmed the order for Furosemide had been discontinued on 7/9/2023. During an interview on 9/27/2023 at 9:17 AM, the Admissions Coordinator (AC) stated she transcribed Resident #1's orders upon admission on [DATE]. While reviewing the orders with surveyor, the AC confirmed the medications Furosemide and Lidocaine patch had been discontinued, but was placed on the active order list in error. The AC also confirmed the medications Polyethylene Glycol 17 grams daily and Docusate Calcium 240 mg were entered into the system in error, to be administered as needed but the medications were ordered to be given daily. The AC stated the usual process for new admissions is the first nurse enters the new orders, the orders are sent to the pharmacy and confirmed, then two other nurses are to review the orders and verify they are accurate. The AC stated each nurse is to initial at the top of the admission order form to ensure accuracy. The AC confirmed only her initials were at the top of the admissions order form. During an interview on 9/27/2023 at 10:42 AM, the Director of Nursing (DON) confirmed the admission orders for Resident #1 were incorrect. The DON stated new admission orders are to be verified by three nurses. The DON stated Resident #1's admission orders were only verified by one nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to provide a clean, safe, and sanitary environment in 2 of 4 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) observed. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 10/24/2022, revealed, .It is the policy of this facility to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines . Review of the facility's policy titled, Housekeeping-Cleaning and Disinfecting, revised 7/12/2021, revealed, .Bathroom cleaning and disinfection to include, but not limited to: a. Remove soiled linen and trash . Review of the facility's policy titled, Resident Rights and Responsibilities, .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .The resident has a right to a safe, clean, comfortable and Homelike environment, including but not limited to receiving treatment and supports for daily living safely . Observation in room [ROOM NUMBER] on 11/8/2022 at 11:20 AM, revealed the bathroom had dirty linens in the floor, feces in the commode, and black debris around the base of the commode. Observation in room [ROOM NUMBER] on 11/8/2022 at 11:44 AM, revealed a bath pan in the floor with a moderate amount of dark brown debris in it, and disposable wipes with a moderate amount of dark brown debris on it in the floor. Observation in room [ROOM NUMBER] on 11/8/2022 at 11:50 AM, revealed the bathroom had dirty linens in the floor, feces in the commode, and black debris around the base of the commode. Observation and interview in room [ROOM NUMBER]'s bathroom on 11//8/2022 at 11:58 AM, revealed the bathroom had dirty linens in the floor, feces in the commode, and black debris around the base of the commode. The Director of Nursing (DON) confirmed the dirty linens in the floor, feces in the commode and black debris around the base of the commode. She confirmed the bathroom was dirty. Observation and interview in room [ROOM NUMBER]'s bathroom on 11/8/2022 at 12:00 PM, revealed the bathroom had a bath pan in the floor with a moderate amount of dark brown debris in it, and disposable wipes with a moderate amount of dark brown debris on it in the floor. The DON confirmed the bathroom was dirty, had a bath pan in the floor with a moderate amount of dark brown debris and disposable wipes with moderate amount of dark brown debris in the floor. She stated nursing staff were responsible to dispose of dirty linens and trash in the appropriate containers and she expected the dirty linens and trash to be disposed of appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure dignity for 1 of 8 sampled residents (Resident #22) who required assistance with meals, and failed to ensure dignity for 2 of 10 sampled residents (Resident #23 and Resident #325) who required an indwelling catheter. The findings include: Review of the facility policy titled, Promoting/Maintaining Resident Dignity Policy, dated 11/30/2017, revealed, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity . Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Dementia with Lewy Bodies and Dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 required extensive assistance with one person assist with eating. Observation in Resident #22's room on 3/30/2022 at 8:12 AM, revealed Certified Nurse Aide (CNA) #1 was standing while assisting the resident with his breakfast meal. During an interview on 3/30/2022 at 8:13 AM, CNA #1 confirmed he was standing while he assisted Resident #22 with his meal. He stated, I know I am suppose to be at eye level when I assist him with his meal. If there is a chair in the room I will sit down but if there isn't a chair in the room I just stand. During an interview on 3/30/2022 at 8:43 AM, the Director of Nursing (DON) stated the staff were to sit down in a chair or a stool when they assisted residents with their meals. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses which included Fournier Gangrene, Acquired Absence of other Genital Organs and Inflammatory Disorders of Scrotum. Review of the 5-Day MDS assessment dated [DATE], revealed Resident #23 had an indwelling urinary catheter. Observation in Resident #23's room on 3/27/2022 at 3:53 PM, revealed a urinary drainage bag without a privacy cover. During an interview on 3/27/2022 at 3:53 PM, the DON confirmed Resident #23's urinary drainage bag did not have a privacy cover. Review of the medical record revealed Resident #325 was admitted to the facility on [DATE] with diagnoses which included Encephalopathy, Acute Respiratory Failure and Schizophrenia. Review of the Physician's Orders for Resident #325 revealed, .3/26/2022 Maintain indwelling catheter 2 times Daily .Catheter site care 1 time daily .Change catheter bag 2 times monthly .Change Foley catheter 1 time monthly . Observation in Resident #325's room on 3/27/2022 at 5:31 PM, revealed a urinary drainage bag without a privacy cover. During an interview on 3/27/2022 at 5:31 PM, the DON confirmed Resident #325's urinary bedside drainage bag did not have a privacy cover.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure call lights were in reach for 2 of 44 sampled Residents (Resident #64 and #326) reviewed. The findings include: Review of the facility policy titled, Call Lights: Accessibility and Response, dated 6/11/2021, revealed, .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside .to allow Residents to call for assistance .with each interaction in the Resident's room or bathroom, staff will ensure the call light is within reach of Resident and secured, as needed . Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #64 required extensive assistance of 2 staff for be mobility, toileting, and personal hygiene. Review of the Care Plan Report dated 3/15/2022-Present for Resident #64 revealed, .Place call bell/light within easy reach . Review of the medical record revealed Resident #326 was admitted to the facility on [DATE] with diagnoses which included History of Falling, Unsteadiness of Feet and Difficulty in Walking. Review of the admission MDS assessment dated [DATE], revealed Resident #326 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. Continued review revealed he required supervision of 1 staff member for transfers, extensive assistance of 1 staff member for toileting, and he was occasionally incontinent of urine. Review of the Care Plan Report dated 3/15/2022-Present for Resident #326 revealed, .At Risk For Falls R/T [Related To] S/P [Status Post] FALL AT HOME WITH RIGHT FEMUR FRACTURE .Place call bell/light within easy reach .Remind R [Resident] to call for assistance before moving from bed-to-chair and from chair-to-bed . Observation in Resident #64's room on 3/27/2022 at 3:47 PM, revealed the resident was lying in bed with his call light laying across the chair, not in reach of the resident. Observation and interview in Resident #64's room on 3/27/2022 at 3:53 PM, Licensed Practical Nurse (LPN) #2 confirmed his call light was laying across the chair not in his reach. Observation in Resident #326's room on 3/27/2022 at 5:35 PM, revealed the resident lying in bed on his left side. Continued observation revealed the call light was under the right side of the bed on the floor. Observation and interview in Resident #326's room on 3/27/2022 at 5:36 PM, the Director of Nursing confirmed the call light was under the right side of the bed on the floor and it was not within Resident #326's reach. She stated, The call light should always be within the resident's reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interview, the facility failed to implement interventions on care plan for 1 of 44 sampled residents (Resident #10). The Findings include: Review of the facility's policy titled, Comprehensive Careplan, dated 3/25/2021, revealed, .it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .comprehensive care plan will include measurable objectives .the objectives will be utilized to monitor the resident's progress .alternative intervention will be documented . Review of the medical record revealed Resident #10 was admitted on [DATE] with a diagnosis which included Hypertensive Heart Disease, Hyperlipidemia, and Dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #10 required extensive assist with Activities of Daily Living (ADLs). Review of the Care Plan dated 5/10/2021-Present revealed a plan of care developed to address falls with the intervention for the use of fall mattress overlay. Observation in Resident #10's room on 3/27/2022 at 3:37 PM, 3/28/2022 at 7:32 AM, and 3/28/2022 at 7:37 PM, revealed no mattress overlay to the bed. Observation an interview in Resident #10's room on 3/29/2022 at 11:23 AM, LPN #7 confirmed there was no fall mattress overlay on Resident #10's bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, and interview, the facility failed to perform Interdisciplinary Team (IDT) Care Plan meetings and failed to invite resident #67 to any IDT Care Plan meetings for 1 of 44 sampled residents (Resident #67). The Findings include: Review of the facility policy titled, Comprehensive Careplan, dated 3/25/2021, revealed, .it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights .our resident person-centered plan of care includes the Comprehensive care plan and the Resident care needs .Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives .comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set [MDS] assessment .other factors identified by the interdisciplinary team or in accordance with the resident's preferences and potential for discharge, will also be addressed in the plan of care .the comprehensive care plan will be prepared by an interdisciplinary team, that includes, but is not limited to .physician .Registered Nurse [RN] .nurse aide .The resident and the resident's representative .the comprehensive care plan will be revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment . Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Osteoarthritis, and Idiopathic Neuropathy. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Review of the medical record for Resident #67 revealed the last IDT Care Plan was completed on 12/10/2021. Further review of the IDT Care Plan Review note for 11/12/2021 and 12/10/2021 revealed Resident #67 was not present for her care meeting. During an interview in Resident #10's room on 3/27/2022 at 4:08 PM, Resident #10 stated, I want to work on going back home. Continued interview in Resident #10's room on 3/28/2022 at 10:30 AM, resident was asked if she was invited to her care plan meetings, she stated, What are you talking about? The care plan process was discussed with Resident #10. Resident #10 stated, It would be nice to discuss my care. I am young and would like to try and go home. During an interview with the MDS Coordinator on 3/29/2022 at 10:57 AM, she stated residents are only invited to care plan meetings if the resident is their own responsible party. The MDS Coordinator confirmed that Resident #67 had not been invited to her care plan meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation review, medical record review, observations, and interviews, the facility failed to ensure 1 of 79 sampled residents (Resident #19) had clean and groomed fingernails. The facility also failed to ensure 4 of 44 sampled residents (Resident #27, #34, #37, and #51) received their showers and baths as scheduled. The findings include: Review of facility documentation dated 5/28/2014, titled, CNA [Certified Nurse Aide] Assignment Sheet, revealed, .Routine patient care - nail care . Review of an undated facility documentation titled, Shower Days For Facility, revealed, .A [person in bed A] bed showers are scheduled/offered on Monday, Wednesday, and Friday. B [person in bed B] bed showers are scheduled/offered on Tuesday, Thursday, and Saturday . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Dementia. Observation and interview in Resident #19's room on 3/27/2022 at 3:38 PM, revealed the resident had dried brown debris under his fingernails on both hands. The resident stated he had already received his bath this date (3/27/2022). Observation and interview in Resident #19's room on 3/27/2022 at 3:40 PM, CNA #1 stated residents' fingernails are cleaned with bathing and when needed. Continued interview he stated he had already given Resident #19 his bath but did not clean his nails. Continued interview CNA #1 confirmed Resident #19 had brown dried debris under his fingernails on both hands. Observation and interview in Resident #19's room on 3/27/2022 at 3:53 PM, Licensed Practical Nurse (LPN) #2 stated residents' nails are cleaned with bathing and as needed. LPN #2 looked at Resident #19's hands and confirmed his nails had brown dried debris under his fingernails on both hands. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses which included Dysphagia, Hemiplegia, and Cerebrovascular Disease. Review of the Activities of Daily Living (ADL) Verification Worksheet revealed Resident #27 had received 4 showers from 1/3/2022-1/31/2022, 5 showers from 2/2/2022-2/27/2022, and 4 showers from 3/1/2022 -3/28/2022. Observation in Resident #27's room on 3/28/2022 at 7:58 AM, revealed the resident's hair was matted and oily. Observation and interview in Resident #27's room on 3/28/2022 at 8:42 PM, CNA #6 held the residents head up so the surveyor could visualize her hair. Continued observation revealed a crusty, scaly area to the top of the resident's head. The back of resident's hair was matted in knots, and she had hair loss to the top of her head. CNA #6 stated, I had her hair in good shape at one time. Her hair is a wreck; it is pitiful. She has scabs on her head with bald spots. The last time I was able to give her a shower, her hair came out in chunks. She further stated, I am usually on this hall by myself, [referring to 400 and 600 hall] which currently consists of 29 residents. There is no way I can give all the showers when I have both the halls. Observation and interview in Resident #27's room on 3/28/2022 at 8:42 PM, LPN #6 confirmed the resident's hair was matted and the resident had crusty and scaly areas on her head. During an interview on 3/30/2022 at 4:25 PM, the Director of Nursing (DON) stated, Residents should receive showers three times per week. The DON reviewed the ADL Verification Worksheet for Resident #27 and confirmed the resident did not receive her showers three times per week as scheduled. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, and Parkinson's Disease. Review of the ADL Verification Worksheet revealed Resident #34 had received no showers from 1/3/2022-1/31/2022, 3 showers from 2/2/2022-2/27/2022, and 3 showers from 3/1/2022 -3/28/2022. Observation in Resident #34's room on 3/27/2022 at 4:00 PM, revealed Resident #34 had a disheveled appearance and oily hair. During an interview in Resident #34's room on 3/30/2022 at 9:38 AM, Family Member #1 stated, She [Resident #34] is not receiving her showers regularly. Her hair is oily and smelly. Resident #34 stated, All the CNAs do is wash my face. During an interview on 3/31/2022 at 12:23 PM, The DON reviewed the ADL Verification Worksheet and confirmed Resident #34 did not receive her showers three times per week as scheduled. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses which included Dementia. Review of the ADL Verification Worksheet revealed Resident #37 had received 1 shower from 1/12/2022-1/31/2022, 3 showers from 2/1/2022-2/27/2022, and 1 shower from 3/1/2022 -3/27/2022. Observation in Resident #37's room on 03/27/2022 at 3:34 PM, revealed the resident's feet were exposed and his skin appeared very dry. Observation in Resident #37's room on 3/29/2022 at 11:07 AM, revealed the resident's feet were exposed and his skin still appeared very dry. During an interview on 3/28/2022 at 9:46 AM, CNA #7 stated, We have 13 to 14 residents each. Showers are scheduled for residents in A bed on Mondays, Wednesdays, and Fridays and B bed on Tuesdays, Thursdays, and Saturdays. During an interview on 3/30/2022 at 7:06 PM, the DON confirmed CNAs were to administer scheduled and by choice showers per the facility schedule and she expected the nurses to monitor that showers were completed. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure and Absence of Left Lower Limb above the knee. Review of the Quarterly Minimum Data Set assessment dated [DATE], revealed Resident #51 had a Brief Interview for Mental Status Score of 14, which indicated no cognitive impairment. Continued review revealed the resident required extensive assist of 2 staff for bathing. Review of the ADL Verification Worksheet revealed Resident #51 had received 3 showers from 2/1/2022-2/25/2022, and 1 shower from 3/1/2022-3/26/2022. Review of Resident #51's current Care Plan revealed, .bathing: bath/shower 3 x [times] week prn [as needed] as tolerated alternating days with bed baths . Observation and interview in Resident #51's room on 3/27/2022 at 4:55 PM, revealed she was wearing a hospital gown and her hair appeared oily. She stated, I haven't had a shower, and this upcoming Tuesday will be three weeks. My hair hasn't been washed either. She put her hand on her head and stated, See how greasy it is, it needs washed. She stated, If there's only one CNA on this hall, I won't get up to get a shower because they have to use a lift to get me up and that takes 2 people. During an interview on 3/28/2022 at 7:39 AM, with CNA #2 when asked about showers given to Resident #51, she stated, She's probably telling you the truth; I'm the only aide on this hall [300 Hall]. I have 23 residents and if there's 1 aide on this hall, then residents don't get showers whether it's their shower day or not. During an interview on 3/29/2022 at 12:19 PM, LPN #3 stated, When we have only 1 CNA on this hall [300 Hall], the residents don't always get their showers. There's no way 1 CNA can get them all done. During an interview on 03/30/2022 at 6:30 PM, the DON confirmed the residents in B beds got showers or patient preference on Tuesday, Thursdays, and Saturdays, unless the resident refused. During continued interview, she reviewed Resident #51's ADL Verification Worksheet and she stated, Whatever is charted on her bath sheet is what she got.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to follow physician orders for 4 of 44 sampled residents (Resident #11, #18, #27, and #61) reviewed. The findings include: Review of the facility policy titled, Physician Verbal Order Policy, dated 5/30/2021, revealed, .Physician orders may be received by telephone, by a licensed nurse or other licensed or registered healthcare specialist who are legally authorized to do so .follow through with orders by making appropriate contact or notification (e.g. lab or pharmacy) . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Multiple Sclerosis, Chronic Obstructive Pulmonary Disease (COPD), and Obstructive Sleep Apnea. Review of Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #11 received oxygen (O2) therapy. Review of the Physician's Order dated 1/2/2022, revealed Resident #11 had an order for O2 at two liters per minute (2L/min) per nasal cannula to maintain saturation above 90%. Review of the Care Plan for Resident #11 dated 1/04/2022-Present revealed, .Respiratory At Risk for shortness of breath plan of care to include administration of O2 per MD orders . Observation in Resident #11's room on 3/27/2022 at 4:27 PM and on 3/28/2022 at 6:36 PM, revealed the O2 concentrator was set to deliver 3.5 L/min of oxygen. Observation and interview in Resident #11's room on 3/28/2022 at 7:24 PM, Licensed Practical Nurse (LPN) #5 confirmed the O2 order was for 2L/min per nasal cannula, as needed (PRN). Continued interview LPN #5 confirmed the O2 concentrator was not set to 2L/min as ordered. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses that included Chronic Respiratory Failure with Hypoxia and COPD. Review of the 5-Day MDS assessment dated [DATE] revealed Resident #18 had a BIMS score of 8, which indicated moderate cognitive impairment. Continued review of the MDS revealed Resident #18 received oxygen. Review of the Physician's Orders dated 1/18/2022, revealed Resident #18 had an order for O2 at 2 L/min per nasal cannula. Review of the Care Plan for Resident #18 dated 5/21/2021-Present revealed, .At risk for shortness of breath related to [Named Resident] has diagnosis of CHF [Congestive Heart Failure .O2 dep. [dependent], HX [history] PNA [Pneumonia]; Bilateral Airspace Disease .Dyspnea, Pleural Effusion, Hypoxic Respiratory failure due to fluid overload, COPD EXAC [exacerbation] .Oxygen per MD [Medical Doctor] order . Observation in Resident #18's room on 3/28/2022 at 7:34 AM, revealed the O2 concentrator was set to deliver 4 L/min of oxygen. Observation and interview in Resident #18's room on 3/28/2022 at 7:40 AM, the Director of Nursing (DON) confirmed Resident #18's oxygen concentrator was set to deliver 4 liters of oxygen per minute and the physician's order was for 2 L/min. Review of the medical record revealed Resident #27 was admitted on [DATE] with diagnoses which included Dysphagia, Hemiplegia, and Cerebrovascular Disease. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #27 required total assist for bed mobility, dressing, toileting, personal hygiene, and bathing. Review of the Physician's Orders dated 9/28/2021, revealed Resident #27 had an order for Anti-Dandruff 0.5 percent (%) shampoo topical Tuesday, Thursday, and Saturday. Observation in Resident #27's room on 3/28/2022 at 7:58 AM, revealed the resident's hair was matted and oily. Observation and interview in Resident #27's room on 3/28/2022 at 8:42 PM, CNA #6 held residents head up so the surveyor could visualize the resident's hair. Observation revealed a crusty, scaly area to the top of her head. The back of resident's hair was matted in knots and she was bald on the top of her head. CNA #6 stated, I had her hair in good shape at one time but nursing has been out of the medicated shampoo. During an interview on 3/28/2022 at 10:21 AM, LPN #6 opened the medication cart and was unable to find anti-dandruff shampoo. Continued interview with LPN #6 confirmed she was unable to locate shampoo for Resident #27 in residents room or the medication room. During an interview on 3/28/2022 at 10:33 AM, Risk Management/Central Supply LPN confirmed she had not ordered any anti-dandruff shampoo for Resident #27. She stated, I can not remember the last time I ordered anti-dandruff shampoo for the facility. The LPN called the pharmacy to check for the last time pharmacy may have sent the shampoo. The LPN provided the pharmacy packing slip delivery sheet that revealed Resident #27 received Ketoconazole Shampoo (anti-dandruff shampoo) on 3/9/2021. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses which included Tracheostomy and Chronic Diastolic (Congestive) Heart Failure. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #61 was rarely/never understood. Continued review revealed Resident #61 received O2 therapy. Review of the Physician's Orders dated 12/10/2020, revealed Resident #61 had an order for O2 at 10 L/min via trach mask. Observation in Resident #61's room on 3/27/2022 at 3:53 PM, revealed the O2 concentrator was set to deliver O2 at 8 L/min of oxygen. Observation and interview in Resident #61's room on 3/28/2022 at 10:11 AM, the Assistant Director of Nursing (ADON) confirmed the O2 concentrator was delivering oxygen at 8 liters per minute, and the physician's order was for 10 L/min of oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent a pressure ulcer from worsening for 1 of 10 sampled residents (Resident #18) reviewed for pressure ulcers. The findings include: Review of the facility's policy titled, Pressure Injury Prevention and Non-Pressure Ulcer Management, revised 10/15/2021, revealed, .This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries .The facility shall establish and utilize a systematic approach for pressure injury prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate .Licensed nurses will conduct a full body assessment on all residents upon admission/re-admission and weekly .Weekly assessments will be signed off using the skin audit order weekly and new findings upon admission/re-admission, weekly and PRN [as needed] assessments will be documented in the EHR [Electronic Health Record] using the [Named facility] Initial Skin Injury assessment/notes .Assessments of pressure injuries will be performed by a licensed nurse and documented weekly on the Weekly [Named facility] Wound Assessment form in the EHR .Nursing assistants will report any skin concerns to the resident's nurse .The Skin and Nutrition Focus Team will meet weekly to review documentation regarding skin assessments, nutritional status, labs, management of illnesses that may impede healing, progression towards healing and the effectiveness of current preventative and treatment modalities . Review of the facility's policy titled, Documentation of Wound Treatments, revised 9/21/2021, revealed, .The facility must maintain clinical records on each resident in accordance with accepted professional standards and practice that are- 1. Complete 2. Accurate 3. Readily accessible 4. Systematically organized .Complete the weekly [Named facility] Wound Assessment which includes the type of injury/wound (pressure, partial or full thickness wounds) anatomical location, stage, measurements, and a complete description of the wound, including tunneling, undermining, odor, exudate, pain etc .Frequency of Wound Documentation: 1. Weekly, unless contraindicated 2. After each dressing change 3. PRN with any resident change in condition or change in wound status . Review of the facility's policy titled, Skin Assessment Policy, revised 9/21/2021, revealed, .It is our policy to perform a full body skin assessment as part of our systematic approach for pressure ulcer/injury prevention and for the promotion of healing of various skin conditions, including pressure ulcers/injuries .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes, Personal History of Malignant Neoplasm of Large Intestine, and Chronic Diastolic (Congestive) Heart Failure. Medical record review of the 5-Day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Continued review revealed she required extensive assistance of 2 staff members for bed mobility and she was at risk for developing pressure ulcers/injuries. Medical record review of the Pressure Sore/Clinical Condition Record dated 5/20/2021 revealed the resident was at risk to develop a pressure ulcer due to immobility. She had urinary incontinence, diabetes mellitus, chronic obstructive pulmonary disease, and end stage renal disease. The head of the bed must be elevated at all times. She had pale skin with poor turgor, and bilateral lower extremity edema. She also had iron deficiency anemia as well as a hemoglobin of 8.6. Medical record review of the wound care notes dated 11/22/2021 revealed Stage 2 ulcer partial thickness on the right buttock. There was no exudate but surrounding skin showed erythema, induration, and maceration. The wound measures 1.7 cm x 0.5 cm x 0.1 cm. Continued medical record review of wound care notes dated 12/3/2021 revealed the ulcer had resolved. Medical record review of wound care notes dated 12/20/2021 revealed a Stage 2 partial thickness ulcer on the right buttocks with small amount of bloody exudate and measuring 2.0 cm x 1.0 cm x 0.1 cm. Physician's orders revealed Cleanse area with NS (normal saline) daily and pat dry. Xeroform to wound bed and cover with border dressing. Medical record review of notes dated January and February 2022 revealed there were no notes present in the record nor were there any measurements of the ulcer. Physician's orders revealed Happy [NAME] #2 - 120 mg zinc oxide, 25 gm hydrocortisone cream1%, 15 gm nystatin compounded by Pharmacy. Apply to buttocks bilaterally twice daily for Stage 2 pressure ulcer right buttock. Medical record review of skin assessments on 1/18/2022, 1/25/2022, 2/1/2022, 2/8/2022, 2/15/2022, 2/22/2022 on the 7:00 PM - 7:00 AM shift revealed no new findings. There was also no documentation of the presence of a pressure ulcer. Medical record review of the Nurse Practitioner notes from 1/8/2022 to 2/18/2022 revealed the resident had no skin issues and skin was warm and dry. Medical record review of a note from the Wound Care Physician dated 1/20/2022 revealed Moisture Associated Dermatitis of unknown duration. To be evaluated by wound specialist in 7 days. Medical record review of the Nutritional Status dated 1/4/2022 revealed S2 pressure wound right buttock. Review of an undated note revealed admitting diagnosis: S2 ulcer of sacral region. Under protein needs S4 DTI (deep tissue injury) US (unstageable) full thickness, venous, diabetic, arterial. Resident is noted to be at risk for malnutrition for NEW us wound to sacrum. Medical record review of skin assessments on 3/1/2022, 3/8/2022, 3/15/2022, 3/22/2022, 3/29/2022 all revealed there were no skin issues with skin being warm and dry. Medical record review of physician's orders dated 3/22/2022 revealed sacrum - cleanse with NS; pat dry; apply Santyl ung (ointment) nickel thickness and cover with silicone bordered foam daily. Medical record review of a wound note dated 3/22/2022 revealed unstageable pressure ulcer was found by therapy when weighing the resident using the lift. The wound had moderate serosanguinous drainage and measures 8.0 cm x 6.8 cm x UTD (unable to determine). There were no other wound care notes or skin assessments from 1/18/2022 until this note. During an interview on 3/28/2022 at 7:39 AM, with Certified Nursing Aide (CNA) #2, who is assigned to Resident #18's hall, she stated, .There is 1 CNA for 23 residents and 6 are assisted dining .I have talked to upper management about getting help .we try to reposition every 2 hours and we answer call lights when we can .It's hard when you're the only one on the hall . During an interview on 3/28/2022 at 11:15 AM, the Wound Specialist (Corporate) stated, The wound that was discovered on 3/22/2022 was the same wound as seen on 1/18/2022, when she [Resident #18] came back from the hospital. The Wound Specialist confirmed the wound should have been assessed weekly when it was first discovered on 1/18/2022, and it was not. Review of the Wound Specialist's (Corporate) credentials revealed, PT [Physical Therapist], CWS [Certified Wound Specialist,] FACCWS [FELLOW OF THE COLLEGE OF CERTIFIED WOUND SPECIALISTS,] DAPWCA [Non-physician certified in wound care], CSWS [Certified Skin and Wound Specialist] and DWC [Diabetic Wound Certified]. During an interview on 3/28/2022 at 12:22 PM, with Certified Occupational Therapist Assistance (COTA) and Physical Therapist Assistant (PTA), they stated they saw the wound on Resident #18's sacrum on 3/21/2022 when they were obtaining her monthly weight. They stated when they rolled her over to place her on the sling to the lift scale, she was not wearing a brief and they saw the wound on her sacrum. When asked if they weighed the resident in February 2022, they stated yes. When asked if they saw a wound on her sacrum in February, they stated they did not notice one, but if she had been wearing a brief, they wound not have seen her sacrum. They stated they informed the Regional Wound Specialist (Corporate) on 3/22/2022 about the wound. During an interview on 3/28/2022 at 3:45 PM with CNA #2, she stated she has taken care of Resident #18 many times. She stated the resident was incontinent frequently, and she would change her brief when she could. She stated, Her bottom has had that place on it for about a month or more. We put a cream on it. It got worse. I told the treatment nurse, and she said just keep putting cream on it. During an interview on 3/31/2022 at 12 PM with the Corporate Wound Nurse, she stated she has done research and she believed the unstageable pressure ulcer found on Resident #18 on 3/22/2022 was not the same wound as the Stage 2 documented on 1/18/2022 and 2/2/2022. When this surveyor discussed with her the fact the charge nurse wrote an order for a treatment for a Stage 2 Pressure Ulcer to Right buttock on 2/2/2022, she stated, The charge nurses are not competent to assess and document wounds. When this surveyor asked for the qualifications of the Wound Specialist (Corporate) she stated, She is a Physical Therapist, Wound Care Specialist and Skin Care Specialist. When this surveyor told her a CNA stated she noticed the wound was getting worse and told the treatment nurse, the Corporate Wound Specialist stated, Do you have documentation of that? Do you just take someone's word through an interview? Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses of Congestive Heart Failure and Unstageable Pressure Ulcer to Sacral Region. Medical record review of the Significant Change MDS assessment dated [DATE], revealed Resident #64 had 2 unstageable pressure ulcers. Medical record review of the Physician Order Sheet dated March 2022 for Resident #64 revealed, .Clean area with Normal Saline, Apply Calcium Alginate to promote autolytic debridement, apply skin prep to periwound (around) and cover with foam .dated 3/3/2022 . Continued review revealed the resident did not have an order for Santyl to be applied to his sacral area. Observation of wound care in Resident #64's room on 3/27/2022 at 3:55 PM revealed Licensed Practical Nurse (LPN) #2 performed wound care to the resident's sacrum applying santyl to the sacral wound, then applied calcium alginate, and covered it with a bordered gauze. During an interview on 3/28/2022 at 10:36 AM, the Wound Specialist (Corporate) looked at Resident #64's physician orders and confirmed the resident did not have an order for santyl to be applied to his sacral wound. She stated, He had an order for santyl for another area, but it has been discontinued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility documentation, facility policy review, medical record review, and interview, the facility failed to prevent an accident for 1 of 14 sampled residents (Resident #34) who required a mechanical lift for transfers. The findings include: Review of the facility's documentation titled, Statement of Inservice Training for Employees, dated 8/21/2020, revealed 15 signatures of staff and the following areas of instructions were covered, 506 - A [Resident #34's room]: Staff to be mindful of positioning equipment when using lift/shower chair and transferring patients. Review of the facility's policy titled, Safe Resident Handling and Transferring, dated 8/2021, revealed, .it is the policy of this facility to provide safe handling and transferring for residents who need assistance . Review of the facility's policy titled, Accidents and Supervision, dated 10/21/2021, revealed, .resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents .refers to any unexpected or unintentional incident, which results in injury .to a resident .risk .staffing or physical environment .that influences the likelihood of an accident .specific interventions to try to reduce a resident's risks for hazards in the environment .communicating the interventions to all relevant staff . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus (DM), Muscle Weakness, and Parkinson's Disease. Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #34 required extensive assistance for bed mobility, dressing, toileting, and total assistance for bathing. Review of the Care Plan for Resident #34 dated 2/12/2022 - Present, revealed a plan of care developed to address Activities of Daily Living (ADL) with an intervention dated 3/23/2021 mechanical lift with 2 person transfer status. Review of the Nurse's Event Note dated 8/21/2020, revealed detailed description of occurrence, .CNA [Certified Nurse Aide] alerted the nurse that patient had fell backward for the shower chair in the patients room. When entering room patient was already back up in the chair. Staff stated they witness patient hit back of head on floor. Patient has a large hematoma on the back of head. Staff stated that while transferring patient with lift to shower chair that the leg to the shower chair was positioned on the leg to the lift and when they attempted to move the shower chair off of the lift the chair tipped backwards and patient landed on back in chair on floor. Continued review of the Nurse's Event Note revealed steps implemented to prevent recurrence, Staff inserviced on proper positioning and use of equipment . During an interview on 3/29/22 at 10:45 AM, Resident #34 stated, Did you know [named CNA #6] dropped me from the shower chair? During an interview on 3/30/2022 at 9:38 AM, Family Member #1 reported that Resident #34 did have a fall while getting up to shower chair. Family Member #1 stated Resident #34 fell back and hit her head which caused a knot to back of her head. During an interview on 3/30/2022 at 10:03 AM, CNA #6 stated on 8/21/2020, she was transferring Resident #34 with the mechanical lift when she fell back in the shower chair and hit her head on the floor. CNA #6 stated Resident #34 was still in the shower chair when she fell back, and two other CNAs were present in the room during the transfer. CNA #6 stated, I am not sure exactly what happened, I just know my finger was mashed up under the resident and ever since then the resident tells everyone I threw her out of the shower chair. During an interview on 3/30/2022 at 12:46 PM, Director of Nursing (DON) stated, I have been the DON since 2020, I was working here but right off, by memory, I do not recall the fall. DON was asked what the staff was inserviced on, and what interventions were implemented to prevent recurrence per Nurse's Event Note. The DON stated she had requested the information from the corporate office but had not received it at this time. During an interview on 3/30/2022 at 5:25 PM, the DON stated, We are unable to locate an investigation for this fall at the corporate building and all I have is the Nurse's Event Note and Statement of Inservice Training for Employees dated 8/21/2020. During an interview on 3/30/2022 at 5:26 PM, CNA #6 verified her signature was not on the in service training for 8/21/2020. During an interview on 3/30/2022 at 5:27 PM, the DON confirmed the shower chair was positioned on the mechanical lift during a transfer, which caused Resident #34 to have a fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure orders were complete for 2 of 2 sampled residents (Resident #35 and #55) who had a colostomy. The findings include: Review of the facility's policy titled, Ostomy Care Policy, dated 5/1/2021, revealed, .it is the policy of this facility to ensure that residents who require colostomy .receive care consistent with professional standards of practice .a licensed nurse will determine the actual type of ostomy through physical assessment, medical record review, and collaboration with the attending physician .ostomy appliance will be provided by licensed nurses under the orders of the attending physician .the products required for changing ostomy devices will be noted on the resident's eTar [electronic treatment authorization request] . Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses which included Colostomy Status. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #35 had an ostomy. Review of the Physician's Orders for Resident #35 dated 1/25/2022, revealed, .Change colostomy pouch/appliance PRN [as needed] .Change colostomy pouch/appliance every 3 days . The order did not contain the type or size flange or wafer. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with a diagnosis which included Colostomy Status. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #55 had an ostomy. Review of the Physician's Orders for Resident #55 dated 12/31/2021 revealed, .Change colostomy pouch/appliance PRN .Change colostomy pouch/appliance every 3 days . The order did not contain the type or size flange or wafer. During an interview on 3/29/2022 at 2:30 PM, the Director of Nursing (DON) confirmed Resident #35's physician order for the colostomy did not contain a wafer or flange size, and it should have. During an interview on 3/29/2022 at 2:43 PM, the DON confirmed Resident #55's physician order for the colostomy did not contain a wafer or flange size, and it should have.

Based on facility documentation review and interview the facility failed to ensure there was a Registered Nurse (RN) on duty for 8 consecutive hours a day, 7 days a week for the 18 months reviewed. 9/1/2020 through 3/27/2022. The findings include: Review of the Daily Staffing (Nursing) sheets revealed there were 5 days (10/26/2021, 12/24/2020, 11/29/2020, 11/28/2020, and 11/27/2020) there was not a Registered Nurse on duty for 8 consecutive hours as required. During an interview on 3/30/2022 at 9:10 AM, the Assistant Director of Nursing, also known as the Staffing Coordinator, confirmed the facility did not have 8 consecutive hours of Registered Nurse coverage on 10/26/2021, 12/24/2020, 11/29/2020, 11/28/2020, and 11/27/2020.

Based on facility policy review, observation, and interview, the facility failed to promote a homelike environment for 5 of 5 residents observed, in the dining room, during the breakfast meal on 3/28/2022. The findings include: Review of the facility's policy titled, Resident Rights and Resident Responsibilities, dated 1/2022, revealed, .The resident has a right to a safe, clean, comfortable and Homelike environment, including but not limited to receiving treatment and supports for daily living safely . Observation in the 100 Hall dining room on 3/28/2022 at 7:30 AM, revealed 3 residents sitting in the dining room eating breakfast. Continued observation revealed the meal plates were on meal trays. Observations in the 100 Hall dining room on 3/28/2022 at 7:56 AM and 7:59 AM, revealed Certified Nurse Aide (CNA) #3 assisted 2 residents to the dining room, set up their meal trays and left the plate on the tray. During an interview on 3/28/2022 at 7:40 AM, Registered Nurse (RN) #1 confirmed meal plates were on the meal trays for the 3 residents sitting in the dining room. During an interview on 3/28/2022 at 8:00 AM, CNA #3 confirmed she did not remove the plate from the tray when she served the breakfast meal to the two residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure orders were complete for 8 of 10 sampled residents (Resident #11, #23, #27, #35, #37, #55, #61, and #274) who had an indwelling urinary catheter. The findings include: Review of the facility's policy titled, Indwelling Urinary Catheter, dated 1/1/2016 and revised on 3/30/2022, revealed, .An indwelling urinary catheter will be utilized only when a resident's clinical condition demonstrates that catheterization was necessary .The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable) . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Neuromuscular Dysfunction of Bladder and Chronic Pain. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had an indwelling urinary catheter. Review the current Physician's Orders for Resident #11 revealed, .maintain suprapubic catheter two times daily .Change suprapubic catheter PRN [as needed] . The orders did not contain a catheter size or a bulb size. Observation in Resident #11's room on 3/27/2022 at 4:27 PM, revealed an indwelling urinary catheter drainage bag on the right side of the bed, facing the door. During an interview on 3/29/22 at 2:37 PM, the Director of Nursing (DON) confirmed Resident #11's physician order for the indwelling urinary catheter was incomplete because it did not contain a size for the catheter, or the bulb. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses which included Fournier Gangrene, Acquired Absence of other Genital Organs and Inflammatory Disorders of Scrotum. Review of the 5-Day MDS assessment dated [DATE], revealed Resident #23 had an indwelling urinary catheter. Review of the current Physician Orders for Resident #23 revealed, .Maintain Indwelling catheter . The indwelling catheter order did not contain a catheter size or a bulb size, making it an incomplete order. Observation in Resident #23's room on 3/27/2022 at 3:53 PM, revealed the resident laying in bed with the indwelling urinary catheter drainage bag clipped to the bedframe on the left side of the bed, facing the door. During an interview on 3/29/2022 at 2:25 PM, the DON confirmed Resident #23's physician order for the indwelling urinary catheter was incomplete because it did not contain a size for the catheter, or the bulb. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses which included Neurogenic Bladder. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #27 had an indwelling urinary catheter. Review of the Physician's Orders for Resident #27 dated 11/15/2018, revealed, .Maintain Indwelling Catheter .foley catheter size 14 Fr [french] .Change foley catheter PRN [as needed] . The Physician's Order did not specify the size of bulb to be used. Observation in Resident #27's room on 3/27/2022 at 4:00 PM, revealed the resident had an indwelling urinary catheter drainage bag to the right side of the bed. During an interview on 3/29/2022 at 2:39 PM, the DON confirmed Resident #27's physician orders did not reflect a complete order for the indwelling urinary catheter. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses which included Fournier Gangrene and Cutaneous Abscess of the Perineum. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #35 had an indwelling urinary catheter. Review of the Physician's Orders for Resident #35 dated 1/25/2022, revealed, .Maintain indwelling catheter 24fr Foley Catheter .Change Foley catheter one time monthly . The Physician's Order did not specify the size of bulb to be used. Observation in Resident #35's room on 3/27/2022 at 3:28 PM, revealed a foley catheter draining to a bedside drainage bag on the side of the bed. During an interview on 3/29/2022 at 2:30 PM, the Director of Nursing confirmed Resident #35's physician order for the indwelling urinary catheter did not contain a bulb size. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses which included Retention of Urine and Urinary Tract Infection (UTI). Review of Resident #37's admission MDS assessment dated [DATE], revealed Resident #37 required an indwelling urinary catheter. Review of the current physician orders for Resident #37 revealed there were no orders for an indwelling urinary catheter and no order for catheter care. Observation in Resident #37's room on 3/27/2022 at 3:34 PM, revealed a urinary catheter drainage bag hanging on the right side of the bed. During an interview on 3/29/2022 at 1:35 PM, Licensed Practical Nurse (LPN) #7 confirmed Resident #37 did not have a physician order for an indwelling catheter or for catheter care. During an interview on 3/29/2022 at 7:13 PM, the DON confirmed Resident #37 did not have an order for an indwelling urinary catheter and/or care. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with a diagnosis which included Paraplegia and Neuromuscular Dysfunction of Bladder. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #55 had an indwelling urinary catheter. Review of the Physician's Orders for Resident #55 dated 12/4/2021, revealed, .Maintain indwelling catheter .by shift .Change Foley Catheter .as needed. The order did not include the catheter size or bulb size. Observation in Resident #55's room on 3/27/2022 at 3:30 PM, revealed the resident had an indwelling urinary catheter drainage bag on the left side of the bed. During an interview on 3/29/2022 at 2:39 PM, the DON confirmed Resident #55's physician's orders did not reflect a complete order for the size of the indwelling urinary catheter. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses which included Other Specified Disorders of The Bladder. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #61 had an indwelling urinary catheter. Review of the current Physician's Orders for Resident #61 revealed, .10/6/2020 Change Foley Catheter PRN .1/28/2020 Change Foley Catheter one time monthly #18F/10 ml [milliliter] [bulb] .12/7/2020 Maintain Foley Catheter 2 times daily 16 French . Observation in Resident #61's room on 3/27/2022 at 3:53 PM, revealed the resident had an indwelling urinary catheter drainage bag to the bedside. During an interview on 3/29/2022 at 2:30 PM, the DON confirmed the orders for the indwelling urinary catheter (the order for the maintaining the catheter and the order to change the catheter once a month) contained 2 different sizes of catheters. Review of the medical record revealed Resident #274 was admitted to the facility on [DATE] with diagnoses which included Fracture Shaft Of Right Femur, Displaced Bimalleolar Fracture Left Lower Leg, Morbid Obesity, Congestive Heart Failure, and Chronic Pain Syndrome. Review of the hospital records for Resident #274 dated 12/16/2021, revealed the resident had a foley catheter in place related to pain and fractures in both lower extremities. Review of the current Physician Orders for Resident #274 revealed there was no order for a foley catheter. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #274 had an indwelling urinary catheter. Observation in Resident #274's room on 3/27/2022 at 3:58 PM, revealed the resident had an indwelling urinary catheter drainage bag to the left side of the bed. During an interview on 3/29/2022 at 2:35 PM the DON confirmed there was not a physician's order for an indwelling urinary catheter for Resident #274.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to label and date the oxygen tubing for 18 of 36 sampled residents (Resident #4, Resident #8, Resident #10, Resident #11, Resident #12, Resident #18, Resident #30, Resident #32, Resident #34, Resident #35, Resident #45, Resident #51, Resident #54, Resident #61, Resident #64, Resident #72, Resident #273 and Resident #274) reviewed with oxygen therapy and properly store 3 of 36 sampled residents (Resident #18, Resident #30, and Resident #32) with respiratory treatments, the facility also failed to have complete physician orders for 1 of 36 sampled residents (Resident #54) who received respiratory treatments. The findings include: Review of the facility policy titled, Oxygen Concentrator and Oxygen Storage, dated 12/21, revealed .TO administer oxygen for the treatment of certain diseases or conditions in a safe manner .Cannulas and mask should be changed weekly .Change tubing weekly and as needed; document in medical record .Obtain physician's orders for the rate of flow and route of administration of oxygen (mask, nasal cannula etc.) . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD). Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 received oxygen therapy. Review of the current Physician's Orders for Resident #4 revealed orders for oxygen use and tubing change every week. Observation in Resident #4's room on 3/27/2022 at 3:47 PM, revealed the nasal cannula and humidification bottle were not dated. Observation and interview in Resident #4's room on 3/27/2022 at 6:58 PM and 7:00 PM, Licensed Practical Nurse (LPN) #6 confirmed the nasal cannula and humidification bottle were not dated. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Emphysema and Dependence on Supplemental Oxygen. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #8 received oxygen therapy. Review of the current Physician Orders for Resident #8 revealed orders for oxygen and tubing change every week. Observation in Resident #8's room on 3/27/2022 at 3:34 PM, revealed oxygen in use at 5 LPM via nasal cannula and oxygen tubing was not dated. During an interview on 3/27/2022 at 6:05 PM, LPN #1 confirmed Resident #8's oxygen tubing was not dated. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #10 received oxygen therapy. Review of the current Physician's Orders for Resident #10 revealed orders for oxygen use and tubing change every week. Observation in Resident #10's room on 3/27/2022 at 3:37 PM, revealed oxygen cannula bag was dated 2/13/2022 and no date was on tubing or oxygen humidifier. During an interview on 03/27/22 at 4:22 PM, LPN #6 confirmed oxygen tubing was not dated for Resident #10 and 2/13/2022 was the date on cannula bag, I think it should be done once per week. LPN #6 ran the physician's orders and confirmed tubing should be changed weekly on the 11-7 shift. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and Chronic Diastolic Congestive Heart Failure. Review of the Annual MDS assessment dated [DATE], revealed Resident #11 received oxygen therapy. Review of the current Physician's Orders for Resident #11 revealed orders for oxygen use. Observation in Resident #11's room on 03/27/2022 at 4:36 PM, revealed oxygen tubing not dated. Observation and interview in Resident #11's room on 3/27/2022 at 4:45 PM, LPN #2 confirmed the oxygen tubing was not dated. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Pleural Effusion. Review of the admission MDS assessment dated [DATE] revealed Resident #12 received oxygen therapy. Review of the current Physician's Orders for Resident #12 revealed orders for oxygen use and tubing change every week. Observation in Resident #12's room on 3/27/2022 at 3:28 PM, revealed her lying in bed and talking with a visitor. She had oxygen in nares and the tubing was not dated. Observation in Resident #12's room on 3/27/22 at 6:59 PM, revealed oxygen via nasal cannula and tubing was not dated. During an interview on 3/27/2022 at 4:50 PM, LPN #1 confirmed Resident #12's oxygen tubing was not dated. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Acute on Chronic Diastolic Congestive Heart Failure, Chronic Respiratory Failure with Hypoxia, and Dependency on Supplemental Oxygen. Review of the 5 Day MDS assessment dated [DATE], revealed Resident #18 received oxygen therapy. Review of the current Physician's Orders for Resident #18 revealed orders for oxygen use and tubing change every week. Observation in Resident #18's room on 3/27/2022 at 4:41 PM, revealed the oxygen cannula and tubing was draped over the arm of the chair and was not dated, and the nebulizer mask was laying on the bedside table not dated. During an interview on 3/27/2022 at 5:37 PM, the Director Of Nursing (DON) confirmed Resident #18's oxygen tubing was draped across the arm of the chair and was not dated. The DON confirmed the nebulizer mask was not properly stored and not dated. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included Chronic Respiratory Failure, Chronic Diastolic Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #30 received oxygen therapy. Review of the current Physician's Orders for Resident #30 revealed orders for oxygen use and tubing change every week. Observation in Resident #30's room on 3/27/2022 at 5:04 PM, revealed oxygen tubing touching the floor and was not dated, and a nebulizer mask was laying on the bedside table not dated and not covered. Continued observation revealed the oxygen humidification bottle was not dated, and the trach mask was not dated. Observation and interview in Resident #30's room on 3/27/2022 at 5:34 PM, the DON confirmed the oxygen tubing was not dated and touching the floor, and the nebulizer mask was not dated and not properly stored. The DON confirmed the oxygen humidification bottle was not dated, and the trach mask was not dated. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Emphysema, and Chronic Respiratory Failure. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #32 received oxygen therapy. Review of the current Physician's Orders for Resident #32 revealed orders for oxygen use and tubing change every week. Observation in Resident #32's room on 3/27/2022 at 3:40 PM, revealed the oxygen humidifier bottle was not dated. Continued observation revealed the nebulizer mask and tubing was laying on the bedside table, not dated and not stored in a plastic bag. During an interview on 3/27/2022 at 5:32 PM, the DON confirmed the oxygen tubing was not dated for Resident #32. She confirmed the oxygen humidifier bottle was not dated, and the nebulizer mask was not dated or stored in a plastic bag. She confirmed the tubing should be dated when changed, the oxygen humidifier bottle should be dated, the nebulizer mask should be clean and stored in a plastic bag and should be dated. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and Dependence on Supplemental Oxygen. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #34 received oxygen therapy. Review of the current Physician's Orders for Resident #34 revealed orders for oxygen use and tubing change each week. Observation in Resident #34's room on 3/27/2022 at 4:00 PM, revealed no date on the oxygen tubing. Observation and interview in Resident #34's room on 3/27/2022 at 4:22 PM, LPN #6 confirmed oxygen tubing or humidifier bottle was not dated for Resident #34, and LPN #6 ran the physician orders which revealed it should be changed weekly on the 11-7 shift. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Chronic Diastolic Congestive Heart Failure. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #35 received oxygen therapy. Review of the current Physician's Orders for Resident #35 revealed orders for oxygen use and tubing change every week. Observation in Resident #35's room on 3/27/2022 at 3:28 PM, revealed oxygen tubing was not dated. Observation and interview in Resident #35's room on 3/27/2022 at 5:31 PM the DON confirmed the oxygen tubing was not dated. Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses which included Emphysema. Review of the Significant Change In Status (SCIS) MDS assessment dated [DATE], revealed Resident #45 received oxygen therapy. Review of the current Physician's Orders for Resident #45 revealed orders for oxygen use and tubing change every week. Observations in Resident #45's room on 3/27/2022 at 3:30 PM and 7:00 PM, revealed oxygen in the resident's nares and tubing was not dated. Observation and interview in Resident #45's room on 3/27/2022 at 4:51 PM, LPN #1 confirmed oxygen tubing was not dated. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and Chronic Systolic Congestive Heart Failure. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #51 received oxygen therapy. Review of the current Physician's Orders for Resident #51 revealed orders for oxygen use. Observations in Resident #51's room on 3/27/2022 at 4:55 PM and 6:40 PM, revealed resident in bed and her oxygen tubing was not dated or labeled. Observation and interview in Resident #51's room on 3/27/2022 at 6:45 PM, LPN #2 confirmed the oxygen tubing was not labeled or dated. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #54 received oxygen therapy. Observation in Resident #54's room on 3/27/2022 at 3:55 PM, revealed the resident had oxygen in use at 2 LPM via nasal cannula. Continued observation revealed the oxygen tubing was not dated. Observation and interview in Resident #54's room on 3/27/2022 at 6:01 PM, LPN #1 confirmed oxygen tubing was not dated. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses which included Tracheostomy, Acute on Chronic Respiratory Failure and Chronic Diastolic Congestive Heart Failure. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #61 received oxygen therapy. Review of the current Physician's Order dated 12/10/2020 for Resident #61 revealed .Oxygen at 10 liters via trach mask . Observation in Resident #61's room on 3/27/2022 at 3:53 PM, revealed the oxygen tubing and the oxygen humidification bottle was not dated, and the oxygen concentrator was delivering oxygen at 8 liters per minute. Observation and interview in Resident #61's room on 3/27/2022 at 3:53 PM, LPN #3 confirmed the oxygen tubing was not dated or initialed. She stated, We are supposed to date them. Observation and interview in Resident #61's room on 3/27/2022 at 5:27 PM, the DON confirmed the oxygen tubing and the oxygen humidification bottle were not dated. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses which included Unspecified Systolic Congestive Heart Failure, Primary Pulmonary Hypertension, and Cardiomyopathy. Review of the SCIS MDS assessment dated [DATE], revealed Resident #64 received oxygen therapy. Review of the current Physician's Orders for Resident #64 revealed orders for oxygen use. Observation in Resident #64's room on 3/27/2022 on 3:47 PM, revealed oxygen tubing was not dated or on the resident. Observation and interview in Resident #64's room on 3/27/2022 at 3:50 PM, LPN #3 confirmed oxygen tubing was on the chair and not dated. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #72 received oxygen therapy. Review of the current Physician's Orders for Resident #72 revealed orders for oxygen use. Observation in Resident #72's room on 3/27/2022 at 3:55 PM, revealed the oxygen tubing was not dated. Continued observation revealed the oxygen humidification bottle was not dated. Observation and interview in Resident #72's room on 3/27/2022 at 5:36 PM, the DON confirmed the oxygen tubing was not dated and the oxygen humidification bottle was not dated. She confirmed the oxygen tubing and oxygen humidification bottle should be changed weekly and dated. Review of the medical record revealed Resident #273 was admitted to the facility on [DATE] with diagnoses which included Pleural Effusion, Chronic Diastolic Heart Failure, and Acute Pulmonary Edema. Review of the current Physician's Orders for Resident #273 revealed orders for oxygen and tubing change weekly. Observation in Resident #273's room on 3/27/2022 at 3:44 PM, revealed oxygen in use at 3 LPM via nasal cannula and the oxygen tubing was not dated. Observation and interview in Resident #273's room on 3/27/2022 at 5:59 PM, LPN #1 confirmed the oxygen tubing was not dated. Review of the medical record revealed Resident #274 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #274 received oxygen therapy. Review of the current Physician's Orders for Resident #274 revealed orders for oxygen use. Observation in Resident #274's room on 3/27/2022 at 3:58 PM, revealed the resident had oxygen in use at 3LPM via nasal cannula. Continued observation revealed the oxygen tubing was not dated. Observation and interview in Resident #274's room on 3/27/2022 at 6:02 PM, LPN #1 confirmed the oxygen tubing was not dated. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #54 received oxygen therapy. Review of the current Physician's Orders for Resident #54 revealed, .Oxygen 2 times Daily .Oxygen tubing change Every 1 Week . Continued review revealed the oxygen order did not contain a rate or a delivery method, making it an incomplete order. Review of the Care Plan for Resident #54 dated 11/24/2021 revealed, .Oxygen as ordered . During an interview on 3/30/2022 at 9:06 AM, the DON confirmed Resident #54 did not have a complete order for oxygen. She stated, The order for the oxygen don't include the rate or delivery method. We've been putting the orders in incorrectly.

Based on facility policy review, facility documentation review, observations, and interviews, the facility failed to have the Daily Nurse Staffing form posted on 3/27/2022, and failed to ensure the Daily Nurse Staffing forms were completed and retained for 132 days from 9/1/2020 through 3/27/2022. The findings include: Review of the facility's policy titled, Nurse Staffing Posting Information, dated 11/2017 and revised 11/2018, revealed, .It is the policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident and to make staffing information readily available .The nurse staffing information will be posted on a daily basis . Review of the Daily Nurse Staffing forms dated 9/1/2020 through 3/27/2022, revealed there were no forms for 80 days and there were incomplete forms for 52 days. Observation at the 100/200/300 Hall's Nurses' Station on 3/27/2022 at 3:30 PM, revealed the Daily Nurse Staffing form was dated 3/12/2022. During an interview on 3/27/2022 at 6:02 PM, the Assistant Director of Nursing(ADON), also known as the Staffing Coordinator, confirmed the last posted Daily Nurse Staffing form was dated 3/12/2022. She stated the daily staffing hours for 3/27/2022 was posted after the State Survey Team entered the facility. She confirmed a Daily Nurse Staffing form should be posted every day at the 100/200/300 Hall's Nurses' Station with the updated information (nursing hours) on it, but this has not happened on a consistent basis. During an interview on 3/28/2022 at 3:00 PM, the ADON confirmed there were no Daily Nurse Staffing forms for 80 days and there were 52 incomplete forms in the past 18 month period from 9/1/2020 through 3/27/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain patient confidentiality related to 3 computer screens open with resident health information visualized with no staff attendance. The findings include: Review of the facility policy titled, Patient Confidentiality, dated 2/2021, revealed, .Confidentiality is defined as safeguarding the content of information .or other computer stored information from unauthorized disclosure without the consent of the resident and/or representative .all efforts will be made to protect the confidentiality/privacy of the resident and their health information .this includes medical records .the electronic record is equipped with security features that allow only those with a password to retrieve and review records . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Heart Failure, Pulmonary Hypertension, Respiratory Failure, and Atrial Fibrillation. Observation of the 300 Hall medication cart on 3/27/2022 at 5:37 PM, revealed a computer screen with Resident #18's heath information displayed on the computer screen on the medication cart and no staff in attendance. During an interview on 3/27/2022 at 5:38 PM, the Director of Nursing (DON) confirmed Resident #18's health information was displayed on the computer screen on the medication cart. She stated, The computer screen should be closed for privacy because of HIPPA (Health Insurance Portability and Accountability Act). Observation at the 100 Hall nurse station on 3/28/2022 at 7:35 AM, revealed one computer screen on the nurses desk and one on the medication cart opened with resident health information visible and no staff in attendance. During an interview on 3/28/2022 at 7:38 AM, Registered Nurse (RN) #1 confirmed the 2 computer screens with resident health information were visible to everyone that could visualize the computer screens and there weren't any staff at the desk or at the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility documentation review, medical record review, observations, and interviews, the facility failed to maintain adequate staffing levels to meet the care needs of 5 of 44 sampled residents (Resident #19, #27, #31, #34, #37, and #51) residing on 3 of 5 hallways having the potential to affect the entire facility related to receiving showers/baths, passing meal trays, and turning and repositioning residents every 2 hours. The findings include: Review of the facility's policy titled, Nurse Staffing Posting Information, dated 11/2017 and revised 11/2018, revealed, .It is the policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident . Review of the facility's Full Time Equivalent Staffing sheet revealed there was only 1.9 nursing hours per patient per day (PPD) on 3/6/2022 and 3/16/2022, and the facility did not meet the state required nursing hours per PPD of 2.0. Review of the facility Daily Nurse Staffing sheet dated 3/27/2022, revealed the resident census was 79 (100 Hall contained 19 residents; 200 Hall contained 10 residents; 300 Hall contained 21 residents; 400 Hall contained 10 residents; and 600 Hall contained 19 residents), Continued review revealed 1 Medicare Registered Nurse (responsible for medicare charting), 6 Licensed Practical Nurses (LPN) (charge nurses), and 8 Certified Nurse Aides (CNA) for 5 halls for the 24 hour period. Review of the facility Daily Nurse Staffing sheet dated 3/28/2022, revealed the resident census was 79. Continued review revealed 1 Medicare Registered Nurse (responsible for medicare charting), 7 LPNs (charge nurses), and 7 CNAs scheduled for 12 hour shift and 1 CNA scheduled for 8 hour shift, for 5 halls for the 24 hour period. Review of the facility Daily Nurse Staffing sheet dated 3/29/2022, revealed the resident census was 79. Continued review revealed 1 Medicare Registered Nurse (responsible for medicare charting), 6 LPNs (charge nurses), and 8 CNAs scheduled for 12 hour shifts, 1 of these CNAs was on light duty, and 1 CNA scheduled for a 4 hour shift from 8 PM to 12 AM, for 5 halls for the 24 hour period. Review of the facility Daily Nurse Staffing sheet dated 3/30/2022, revealed the resident census was 79. Continued review revealed 1 Medicare Registered Nurse (responsible for medicare charting), 6 LPNs (charge nurses), and 9 CNAs for 5 halls for the 24 hour period. Review of facility documentation dated 5/28/2014, titled, CNA (Certified Nursing Aide) Assignment Sheet, revealed, .Routine patient care - nail care .Full Bath/Shower - follow facility schedule, patient's preference, or Even numbered rooms on Monday, Wednesday, Friday .Odd numbered rooms on Tuesday, Thursday, Saturday .Sponge bath offered on non-bath days or as requested . Review of an undated facility documentation titled, Shower Days For Facility, revealed, .A [Resident in bed A] bed showers are scheduled/offered on Monday, Wednesday, and Friday. B [Resident in bed B] bed showers are scheduled/offered on Tuesday, Thursday, and Saturday . Review of the undated facility documentation revealed there was 26 residents who required a lift for transfers. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with readmission on [DATE], with diagnoses which included Dementia. Review of the Activities of Daily Living (ADL) Verification Worksheet revealed there was no bathing documented for Resident #19 on 3/26/2022 and 3/27/2022. Observation on 3/27/2022 at 2:45 PM, revealed the 300 Hall smelled strongly of urine. Observation in Resident #19's room on 3/27/2022 at 3:38 PM, revealed the resident had dried brown debris under his fingernails on both hands. Observation and interview in Resident #19's room on 3/27/2022 at 3:40 PM, CNA #1 stated, Residents' fingernails are to be cleaned with bathing and when needed. Continued interview he confirmed Resident #19 had brown dried debris under his fingernails on both hands. Observation and interview in Resident #19's room on 3/27/2022 at 3:53 PM, Licensed Practical Nurse (LPN) #2 stated, residents' nails are cleaned with bathing and as needed. LPN #2 looked at Resident #19's hands and confirmed he had brown dried debris under his fingernails on both hands. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses which included Dysphagia, Hemiplegia, and Cerebrovascular Disease. Review of the ADL Verification Worksheet revealed Resident #27 received 4 showers from 1/3/2022-1/31/2022, 5 showers from 2/2/2022-2/27/2022, and 4 showers from 3/1/2022 -3/28/2022. Continued review revealed there was no bathing documented on 33 days from 1/1/2022 through 3/28/2022. Observation in Resident #27's room on 3/28/2022 at 7:58 AM, revealed the resident's hair was matted and oily. Observation on 3/28/2022 at 6:30 PM, revealed the 300 Hall smelled strongly of urine. Observation and interview in Resident #27's room on 3/28/2022 at 8:42 PM, CNA #6 held the residents head up so surveyor could visualize her hair. Continued observation revealed a crusty, scaly area to the top of the resident's head. The back of the resident's hair was matted in knots, and she had hair loss to the top of her head. CNA #6 stated, Her hair is a wreck; it is pitiful. She has scabs on her head with bald spots. The last time I was able to give her a shower, her hair came out in chunks. I am usually on this hall by myself, [referring to 400 and 600 hall which currently consists of 29 residents]. There is no way I can give all the showers when I have both the halls. Observation and interview in Resident #27's room on 3/28/2022 at 8:42 PM, LPN #6 confirmed the resident's hair was matted and the resident had crusty and scaly areas on her head. During an interview on 3/30/2022 at 4:25 PM, the Director of Nursing (DON) stated, Residents should receive showers three times per week. The DON reviewed the ADL Verification Worksheet for Resident #27 and confirmed the resident did not receive her showers three times per week as scheduled. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses which included Diabetes. Review of the Quarterly Minimum Data Set assessment dated [DATE], revealed Resident #31 had a Brief Interview for Mental Status Score of 14, which indicated the resident had no cognitive impairment. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes Mellitus, and Parkinson's Disease. Review of the ADL Verification Worksheet revealed Resident #34 received no showers from 1/3/2022-1/31/2022, 3 showers from 2/2/2022-2/27/2022, and 3 showers from 3/1/2022 -3/28/2022. Continued review revealed there was no bathing documented on 25 days from 1/3/2022 through 3/28/2022. Observation in Resident #34's room on 3/27/2022 at 4:00 PM, Resident #34 had a disheveled appearance and oily hair. During an interview in Resident #34's room on 3/30/2022 at 9:38 AM, Family Member #1 stated Resident #34 is not receiving her showers regularly. Family Member #1 stated her hair was oily and smelly. Resident #34 stated, All the CNAs do is wash my face. During an interview on 3/31/2022 at 12:23 PM, the DON reviewed the ADL Verification Worksheet and confirmed Resident #34 did not receive her showers as scheduled three times per week. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses which included Dementia. Review of the ADL Verification Worksheet revealed Resident #37 received 1 shower from 1/12/2022-1/31/2022, 3 showers from 2/1/2022-2/27/2022, and 1 shower from 3/1/2022 -3/27/2022. Continued review revealed there was no bathing documented on 23 days from 1/12/2022 through 3/27/2022. Observation in Resident #37's room on 3/27/2022 at 3:34 PM, revealed the resident's feet were exposed and his skin appeared very dry. Observation in Resident #37's room on 3/29/2022 at 11:07 AM, revealed the resident's feet were exposed and his skin still appeared very dry. During an interview on 3/28/2022 at 9:46 AM, CNA #7 stated, We have 13 to 14 residents each. Showers are scheduled for residents in A bed on Mondays, Wednesdays, and Fridays and B bed on Tuesdays, Thursdays, and Saturdays. During an interview on 3/30/2022 at 7:06 PM, the DON confirmed CNAs were to administer scheduled and by choice showers per the facility schedule and she expected the nurses to monitor that showers were completed. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses which included Congestive Heart Failure and Absence of Left Lower Limb above the knee. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #51 had a BIMS score of 14, which indicated no cognitive impairment. Continued review revealed the resident required extensive assist of 2 staff for bathing. Review of the ADL Verification Worksheet revealed Resident #51 received 3 showers from 2/1/2022-2/25/2022 and 1 shower from 3/1/2022-3/26/2022. Continued review revealed there was no bathing documented on 23 days from 2/1/2022 through 3/26/2022. Review of Resident #51's current Care Plan revealed, .bathing: bath/shower 3 x [times] week prn [as needed] as tolerated alternating days with bed baths . Observation and interview in Resident #51's room on 3/27/2022 at 4:55 PM, revealed she was wearing a hospital gown. She stated, I haven't had a shower in three weeks, this upcoming Tuesday. My hair hasn't been washed either. She put her hand on her head and stated, See how greasy it is. It needs washed. She stated, If there's only 1 CNA on this hall, I won't get up to get a shower because they have to use a lift to get me up and that takes 2 people. During observation of supper meal on 3/27/2022 at 6:23 PM, revealed a meal cart was delivered to the 300-hall containing 11 trays with 1 staff member passing trays. Continued observation revealed the last tray was delivered to a resident on 3/27/2022 at 7:29 PM; total time for tray delivery was 1 hour and 6 minutes. Observation on the 400/600 hall on 3/28/2022 at 6:55 PM, revealed CNA #5 doing rounds on the 400 hall with three call lights going off on the 600 hall for over 5 minutes. During an interview on 3/28/2022 at 7:33 AM, RN #1 stated, I am the Medicare Nurse; I only do charting. This is my first time passing trays. During observation of the breakfast meal on 3/28/2022 at 7:52 AM, revealed a meal cart was delivered to the 300-hall containing 11 trays with 1 staff member passing trays. Continued observation revealed the last meal tray was delivered to a resident on 3/28/2022 at 8:44 AM; total time for tray delivery was 52 minutes. During an interview on 3/28/2022 at 7:39 AM with CNA #2, when asked about showers given to Resident #51, she stated, I'm the only aide on this hall [referring to 300 and part of 200 hall]. I have 23 residents with 6 residents who needs assisted dining. Continued interview she stated, if there's 1 aide on this hall, then residents don't get showers whether it's their shower day or not. During an interview on 3/28/2022 at 6:45 PM, CNA #5 stated she was the only CNA on the 400/600 hall for the 6 PM-6 AM shift. CNA #5 stated she was currently responsible for 29 residents, and she reports this is not uncommon for her to be the only CNA for this whole hall. CNA #5 stated 19 residents on this hall required incontinence care and repositioning. She stated she was unable to turn and dry the residents every two hours. She stated there was only one nurse on the hall, and she is limited on how much she can help. She reports she has residents with behaviors on the halls, 4 residents that wander, 4 residents are high risk for falls, 2 residents that require assistance with their meal, and several have to be followed up on to ensure adequate intake. During an interview on 3/29/2022 at 11:41 AM, Resident #31 stated, We have monthly resident meetings. We have complained about staffing in the meetings and there have been times that there have not been enough staff here to take care of us. They will schedule enough staff but sometimes staff calls in and then they are not enough people here; the administrative staff have had to come in and work in place of people who call in; here lately it has happened quite often that there's not enough staff in the building. During an interview on 3/29/2022 at 12:19 PM, LPN #3 stated, When we have only 1 CNA on this hall [referring to the 300 and part of the 200 hall] the residents don't always get their showers. There's no way 1 CNA can get them all done. During an interview on 3/30/2022 at 9:05 AM with the Assistant Director of Nursing, she confirmed the nursing hours PPD on 3/6/2022 and 3/16/2022 was 1.9 hours per patient, and not the required amount of 2.0 hours per PPD. During an interview on 3/30/2022 at 3:09 PM, the Assistant Director of Nursing (who is currently in charge of staffing), stated, We are budgeted for 7 CNAs for day shift and 5 for night shift. The majority of the days have 4 CNAs on day shift and 3 CNAs on night shift. We do not use any agency staff; we have 13 or 14 CNA positions open; we have no CNA applications; we don't have any CNAs to be hired.

Based on facility policy review, observation, and interview, the facility failed to maintain water temperatures for a dish machine at or above 120 F [Fahrenheit] degrees and failed to clean and sanitize 1 of 3 refrigerators located in the nourishment rooms. The facility also failed to deliver food that was covered to residents for 2 of 2 meal observations. The findings include: Review of the facility's policy titled, Dietary: Cleaning dated 7/13/2022, revealed, .Cleaning surfaces, equipment or utensils involve the use of hot water and detergent which removes soil grease, food, and odors .Turn on machine, checking temperatures to assure proper wash and rinse temperature for your machine and cleaning chemicals .Wash and rinse temperatures will be observed and recorded at each meal service. This will be achieved while the dish machine is in operations .Low temperature machines should be between 120 F-140 F. With the low temperature machines, the sanitizer will also be checked and recorded using a PH [Potential of Hydrogen] strip. Any temperatures recorded outside the acceptable levels should be reported to the supervisor immediately. Maintenance should be notified . Review of the facility's policy titled, Dietary: Dining Services, revised 1/30/2021, revealed, .Meals must be delivered to the resident in a timely fashion. Meals are delivered in an enclosed or covered cart . Observation in the kitchen on 3/28/2022 at 2:18 PM, revealed the dish machine was a low temperature machine. Observation on 3/28/2022 at 2:24 PM, revealed [NAME] #1 had already ran a rack of dishes through the dish machine. Continued observation revealed when another rack of dishes were placed in the dish machine, the temperature on the thermometer did not reach 120 degrees F during the wash cycle. Observation and interview on 3/28/2022 at 2:26 PM, the Director of Nutrition Services confirmed the thermometer did not reach to 120 degrees F, but to 110 degrees F, during the wash cycle and the facility would use disposable dining ware for the residents. Continued observation revealed the sanitation for the dish machine was above 50 ppm [parts per million]. Observation in the kitchen on 3/28/2022 at 3:52 PM, the 3 compartment sink sanitation was between 200 and 400 ppm, which was within normal limits. Observation on 3/29/2022 at 12:52 PM, with the Director of Nutrition Services revealed the manual temperature of the water to the dish machine was 90 degrees F. During an interview on 3/28/2022 at 2:30 PM, [NAME] #2 stated, it took 5 to 10 dish cycles before the water temperature reached 120 degrees F. During an interview on 3/28/2022 at 3:29 PM, [NAME] #1 stated, Staff had been filling up the tank as a faster way to fill up the machine. The motor had been changed recently. They have to fill up the tank because the water would run out. We have to run the dish machine 4 to 5 times before the temperature gets to the appropriate temperature of 120 degrees F. We explained the issue about the machine and we spoke to the CDM (Certified Dietary Manager). During an interview on 3/28/2022 at 5:00 PM, the Maintenance Director stated, The staff was pouring water into the tank of the dish machine because it was a faster way than waiting for it to fill up with water. The facility had a tankless water heater which was set at 140 degrees F. Continued interview confirmed the tankless water heater could not circulate enough water to reach a water temperature of at least 120 degrees F. During an interview on 3/29/2022 at 2:42 PM, the Maintenance Director confirmed he knew there were issues with the tankless water heater that it needed to be fixed. During an interview on 3/30/2022 at 11:15 AM, the Director of Nutrition Services confirmed the water temperatures on 3/28/2022 and 3/29/2022 were too low to clean the dishes effectively in the dish machine and they had been washing all dishes in the 3 compartment sink. Observation on the North hall nourishment room on 3/30/2022 at 3:07 PM, revealed the North Hall refrigerator had dead flies on the inside bottom of the refrigerator and on the side door bottom shelf. Continued observation revealed all three shelves in the body of the refrigerator had dried substance on them. Observation and interview on the North Hall nourishment room on 3/30/2022 at 3:10 PM with Licensed Practical Nurse (LPN) #3 confirmed there were dead flies on the refrigerator inside bottom and the shelves were dirty. Observation and interview on 3/30/2022 at 3:23 PM, the Housekeeping Director confirmed there were dead flies inside the refrigerator and there was dried debris on the inside shelves. Continued interview revealed the refrigerator was to be cleaned once a day by housekeeping staff. Observation in the kitchen on 3/27/2022 at 2:42 PM, revealed 49 yellow cake desserts plated and uncovered inside 7 tray carts. Observation on the 600 Hall during supper meal pass on 3/27/2022 at 6:03 PM, revealed staff delivered uncovered dessert cakes from the meal cart to the resident's rooms. Observation and interview in the kitchen on 3/27/2022 at 5:31 PM, with the [NAME] #1 revealed the kitchen had completed the 1st 100 Hall cart and began to deliver the cart outside of the kitchen for delivery of the dinner trays. Continued observation revealed the cakes on the cart were not covered. The cook confirmed the dietary staff did not apply a covering to the cake because the cake was already covered by the trays, and no one had ever told them to cover all of the food for distribution. Observation during the breakfast meal on 3/28/2022 at 7:24 AM, revealed 25 residents had uncovered oatmeal plated on the meal carts. Observation during the breakfast meal on 3/28/2022 at 7:55 AM, 8:01 AM, 8:18 AM, and 8:34 AM, revealed staff delivered uncovered oatmeal from the meal cart to the resident's rooms. During an interview on 3/28/2022 at 7:52 AM, the Director of Nutrition Services stated, Food should be covered when staff are walking the tray to the residents' rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the spread of infection related to: staff failed to provide tracheostomy care in a sterile technique for 1 of 3 sampled residents (Resident #61); provide catheter care in a sanitary manner for 1 of 10 sampled residents (Resident #37) who required an urinary catheter; ensure oxygen tubing was not on the floor for 5 of 36 sampled residents (Resident #18, Resident #30, Resident #32, Resident #61, and Resident #72), and clean nebulizer mask for 1 of 36 sampled residents (Resident #32) who received respiratory treatments, and ensure urinary drainage bag was not laying in the floor for 2 of 10 sampled residents (Resident #64 and Resident #274) who required an urinary catheter. The facility also failed to prevent the spread of infection related to: staff not sanitizing hands between resident contact while passing meal trays during the supper meal on 3/27/2022; dirty linen carts, and a trash barrel were on the hall during the meal cart delivery and meal pass. staff place a dirty tray on a clean tray cart with clean trays; staff sitting on a residents bed; no Transmission Based Precaution (TBP) sign posted on a TBP room; TBP rooms doors not closed; staff did not apply appropriate Personal Protective Equipment (PPE) prior to entering an TBP room. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, dated 6/9/2021, revealed .it is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .a resident with an infection or communicable disease shall be placed on isolation precautions as recommended by current CDC [Centers of Disease Control] Guidelines .isolation signs are used to alert staff, family members and visitors of isolation precautions . Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #61 had Tracheostomy care. Review of current Physician's Orders for Resident #61 revealed, .Tracheostomy cannula care: Clean inner cannula with hydrogen peroxide [antiseptic liquid to kill germs] every one day .Change trach [tracheostomy] ties every one day .Clean with Normal Saline (NACL) every one day .Tracheobronchial suctioning for signs and symptoms of increased secretions [secretions] .Monitor tolerance of Trach Care one time daily .Tracheostomy cannula care Two times Daily . Observation in Resident #61's room on 3/28/2022 at 10:05 AM, during tracheotomy care, revealed the Certified Respiratory Therapist (CRT) dipped a cotton tipped applicator into the peroxide/sterile water solution, then cleaned around the tracheotomy site, and dipped the cotton tipped applicator back into the peroxide/sterile water solution and cleaned around the trach site again. Further observation revealed the CRT removed the inner cannula and placed into the peroxide/sterile water solution, then placed it back into the tracheotomy site. During an interview on 3/28/2022 at 10:08 AM, the CRT confirmed she dipped the cotton tipped applicator into the peroxide/sterile water solution after she cleaned the tracheotomy site, cleaned around the tracheotomy site again, and placed the inner cannula into the peroxide/sterile water solution. She replaced the inner cannula into the tracheotomy site. She stated she should have used a sterile cotton tipped applicator each time she cleaned around the tracheotomy site, but she didn't have enough cotton tipped applicators in the tracheotomy kit. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses which included Urinary Tract Infection and Retention of Urine. Review of the admission MDS assessment dated [DATE] revealed Resident #37 required an urinary catheter. Observation in Resident #37's room on 3/29/2022 at 3:26 PM, during catheter care, revealed Licensed Practical Nurse (LPN) #7 did not clean the catheter lumen. During an interview on 3/29/2022 at 3:30 PM, LPN #7 confirmed she did not clean Resident #37's catheter lumen during catheter care. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Acute on Chronic Diastolic Congestive Heart Failure, Chronic Respiratory Failure with Hypoxia, and Dependency on Supplemental Oxygen. Review of the 5-Day MDS assessment dated [DATE], revealed Resident #18 received oxygen therapy. Review of the current Physician's Orders for Resident #18 revealed, .Oxygen (O2) at 2 L [Liter]/min [minute] per nasal cannula . Observation in Resident #18's room on 3/27/2022 at 4:41 PM, revealed the oxygen cannula and tubing was draped over the arm of the chair, and the nebulizer mask was laying on the bedside table uncovered. During an interview on 3/27/2022 at 5:37 PM, the Director of Nursing (DON) confirmed Resident #18's oxygen tubing was draped across the arm of the chair, and the nebulizer mask was not stored properly. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included Chronic Respiratory Failure, Chronic Diastolic Congestive Heart Failure, and Chronic Obstructive Pulmonary Disease. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #30 received oxygen therapy. Observation in Resident #30's room on 3/27/2022 at 5:04 PM, revealed the oxygen tubing was touching the floor. During an interview on 3/27/2022 at 5:34 PM, the DON confirmed Resident #30's oxygen tubing was touching the floor. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease, Chronic Respiratory Failure with Hypoxia and Pneumonia. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #32 received oxygen therapy. Review of the current Physician's Orders for Resident #32 revealed, .Oxygen at 3Lpm (liters per minute) continuous . Observation in Resident #32's room on 3/27/2022 at 3:40 PM, revealed the oxygen tubing was touching the floor, and the nebulizer mask was laying on the bedside table with dried debris on the inside of the mask, and was not properly stored. Observation and interview in Resident #32's room on 3/27/2022 at 5:32 PM, the DON confirmed Resident #32's oxygen tubing was touching the floor, and the nebulizer mask had dried debris on the inside of the mask and was not properly stored. The DON confirmed oxygen tubing should not touch the floor, and the nebulizer mask should be clean and stored in a plastic bag. Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #61 received oxygen therapy. Review of the current Physician's Orders for Resident #61 revealed an order for oxygen therapy. Observation in Resident #61's room on 3/27/2022 at 3:53 PM, revealed the oxygen tubing was touching the floor. Observation and interview in Resident #61's room on 3/27/2022 at 5:27 PM, the DON confirmed Resident #61's oxygen tubing was touching the floor. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease. Review of the current Physician's Orders for Resident #72 revealed an order for oxygen therapy. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #72 received oxygen therapy. Observation in Resident #72's room on 3/27/2022 at 3:55 PM, revealed the oxygen tubing was touching the floor. Observation and interview in Resident #72's room on 3/27/2022 at 5:36 PM, the DON confirmed Resident #72's oxygen tubing was touching the floor. Review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses which included Retention of Urine. Review of the Significant Change In Status (SCIS) MDS assessment dated [DATE], revealed Resident #64 had an indwelling catheter. Observation in Resident #64's room on 3/27/2022 at 3:47 PM, revealed his urinary drainage bag was laying on the floor. Observation and interview in Resident #64's room on 3/27/2022 at 3:53 PM, LPN #2 confirmed Resident #64's urinary drainage bag was on the floor. She stated the catheter bag should not be on the floor because of infection. Review of the medical record revealed Resident #274 was admitted to the facility on [DATE] with diagnoses which included Fracture Shaft Of Right Femur, Displaced Bimalleol Fracture Left Lower Leg, Morbid Obesity, Congestive Heart Failure, and Chronic Pain Syndrome. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #274 had an indwelling catheter. Observation in Resident #274's room on 3/28/2022 at 8:05 AM, revealed her urinary drainage bag was laying on the floor. Observation and interview in Resident #274's room on 3/28/2022 at 8:06 AM, Occupational Therapist (OT) #1 confirmed Resident #274's urinary drainage bag was laying in the floor. Observation on 3/27/2022 at 5:55 PM to 6:10 PM, during the supper meal, revealed LPN #8 passed meal trays into 4 residents rooms and did not sanitize or wash his hands. During an interview on 3/27/2022 at 6:12 PM, LPN #8 confirmed he did not sanitize his hands after each resident contact while passing the meal tray. He stated, I wash my hands after passing 2 to 3 trays. Observation on 3/28/2022 at 7:32 AM, during the breakfast meal, revealed Registered Nurse (RN) #1 placed a dirty meal tray on the clean meal cart with clean trays. During an interview on 3/28/2022 at 7:33 AM, RN #1 confirmed she placed a dirty tray on the clean cart with clean trays. She stated, This is the first time I have passed trays. Observation on the 300 Hall on 3/28/2022 at 7:44 AM, revealed Dietary staff called for 300 Hall cart to be delivered to the hall. Further observation revealed a soiled linen cart, and a trash barrel on the hall way with the meal trays. Observation on the 300 Hall on 3/28/2022 at 7:52 AM, revealed a second meal cart delivered to the hall, staff passed trays, and the soiled linen and trash barrel remained on hall way with meal trays. During an interview on 3/28/2022 at 8:38 AM the Risk Management LPN confirmed the dirty linen cart and trash barrel was on the hall with the meal trays and should not be on the hall when meals are delivered. Observation on 3/28/2022 at 8:03 AM, revealed staff delivered a meal tray and placed the tray in front of a resident on the overbed table. The staff member then sat down on the resident's bed to assist the resident with the meal. Observation and interview outside a resident's room on 3/28/2022 at 8:05 AM, the DON confirmed staff was sitting on the resident's bed while she assisted the resident with the breakfast meal. The DON stated, She should not be sitting on the bed to assist the resident because of infection control. The DON stated, I would correct her and get linens to change the bed. The DON then left the hall and didn't do anything to correct the situation. Observation on the 200 Hall on 3/28/2022 at 8:10 AM, revealed a TBP cart outside of room [ROOM NUMBER] and no TBP sign on the door. Observation and interview outside of room [ROOM NUMBER] on 3/28/2022 at 8:30 AM, the DON confirmed the resident in room [ROOM NUMBER] was on TBP and there wasn't a TBP sign on the door. Observation on 200 hall on 3/28/2022 at 8:11 AM, revealed 3 TBP rooms with doors open. During an interview on 3/8/2022 at 8:15 AM, Certified Nurse Aide (CNA) #3 confirmed the 3 residents were on TBP and the doors were open. Observation on the 200 Hall on 3/28/2022 at 10:30 AM, revealed CNA #3 went into a TBP room without donning appropriate PPE (she did not don a gown or gloves). During an interview on 3/28/2022 at 10:32 AM, CNA #3 confirmed she did not don a gown or gloves prior to entering a TBP room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure and Anxiety. Medical record review of a Quarterly MDS dated [DATE] revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Further review revealed the resident required extensive assistance of 2 staff member for bed mobility. Continued review revealed Resident #49 required total assistance of 2 staff members with transfers. Further review revealed the resident received oxygen therapy. Medical record review of the Comprehensive Care Plan, dated 9/2018, revealed RESP [respiratory] at risk for shortness of breath related to .diagnosis of TRACH [tube placed in windpipe to help you breathe] COPD [Chronic Obstructive Pulmonary Disease], CHF [Congestive Heart Failure], HX [history] PE [Pulmonary Embolism], ALERGIES [allergies] .Oxygen to be administered per MD [medical doctor] order . Medical record review of the Physician's Orders dated June 2019 revealed .Oxygen .at 5 liters per minute via trach mask . Observation and interview with Resident #49 on 6/11/19 at 8:24 AM, in the resident's room, revealed the resident lying in bed and had oxygen in use via trach mask. Continued observation revealed the resident's oxygen flow meter was set at 3 liters per minute. Interview with Resident #49 revealed .I'm supposed to be on 5 liters . Observation of Resident #49 on 6/11/19 at 1:15 PM, in the resident's room, revealed the resident lying in bed and had oxygen in use via trach mask. Continued observation revealed the resident's oxygen flow meter was set at 3 liters per minute. Observation of Resident #49 and interview with Licensed Practical Nurse (LPN) #1 on 6/11/19 at 1:41 PM, in the resident's room, confirmed the resident was lying in bed with oxygen in use at 3 liters per minute. Further interview confirmed the physician's order was for oxygen at 5 liters per minute via trach mask. Continued interview confirmed the oxygen was not administered as ordered. Interview with the Director of Nursing (DON) on 6/12/19 at 10:20 AM, in the conference room, confirmed the facility failed to implement Resident #49's care planned intervention for oxygen therapy. Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a care plan intervention for 2 residents (#36, #49) of 22 sampled residents. The findings include: Review of the facility policy Comprehensive Care Plans, last revised 11/2016, revealed .it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Hypertension, Osteoarthritis, Dementia Without Behavioral Disturbance, Difficulty Walking, Cortical Blindness, Anxiety, and Fracture Upper End of Right Humerus. Medical record review of an admission Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 7 on the Brief Interview for Mental Status (BIMS) indicating the resident was moderately cognitively impaired and required the extensive assist of 2 staff for transfers and the extensive assist of 1 staff for locomotion of the unit. Continued review revealed Resident #36 utilized a walker and wheelchair for mobility. Medical record review of a fall investigation dated 3/19/19 revealed Resident #36 had a fall on 3/19/19 in the resident's room, and sustained a right humeral fracture [broken bone of the right upper arm]. Further review revealed the resident had been sitting up in a wheelchair prior to the fall. Continued review revealed the facility implemented the following intervention .Patient not to be left alone in room while up in wheelchair . Medical record review of a Significant Change of Status MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident had severe cognitive impairment. Further review revealed the resident required extensive assist of 2 staff members with bed mobility, transfers, and toileting. Medical record review of Resident #36's Care Plan Report updated on 3/25/19 revealed the resident was at risk for falls and was not to be left alone in her room when up in her wheelchair due to her fall on 3/19/19. Observation of Resident #36 on 6/11/19 at 7:34 AM, in the resident's room, revealed Resident #36 was sitting up in a wheelchair and no staff members were present. Observation of Resident #36 on 6/11/19 at 11:08 AM, in the resident's room, revealed the door to the room was closed and the resident was sitting up in a wheelchair with no staff member present. Interview and observation of Resident #36 with Certified Nursing Assistant (CNA) #6 on 6/11/19 at 11:10 AM, in Resident #36's room, confirmed prior to entering the room with CNA #6, Resident #36 was up in a wheelchair without a staff member present, and had attempted to wheel the wheelchair into the bathroom. Continued interview and observation of the Resident Care Summary Assessment (Care plan for CNAs taped to the inside of the resident's closet door) confirmed the resident was not to be left alone in her room while sitting in a wheelchair. Interview with the Restorative Nursing Assistant (RNA) on 6/11/19 at 12:54 PM, in the dining room, confirmed the RNA had assisted Resident #36 to the resident's room and had left the resident sitting in a wheelchair with no staff member present. Continued interview and observation of the Resident Care Summary Assessment confirmed the resident was not be left alone in the room while sitting in a wheelchair. Interview with the Assistant Director of Nursing (ADON) on 6/12/19 at 9:02 AM, in the ADON's office, confirmed the facility failed to implement the care plan intervention for Resident #36 to not be left alone in the wheelchair in her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to administer oxygen as ordered by the physician for 1 resident (#49) of 9 residents reviewed for oxygen therapy of 22 sampled residents. The findings include: Review of the facility's Oxygen Concentrator policy revised 11/2017 revealed .Oxygen should be administered only under orders of the attending physician .Obtain physician's order for the rate of flow and route of administration .Turn the unit on to the desired flow rate . Medical record review revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure and Anxiety. Medical record review of Resident #49's care plan dated 9/2018 revealed the resident was care planned for being at risk for shortness of breath related to having a tracheostomy [tube placed in windpipe to help you breath] and diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Continued review of Resident #49's care plan revealed, .oxygen to be administered per MD [medical doctor] order . Medical record review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Further review revealed the resident required extensive assistance of 2 staff members with bed mobility. Continued review revealed Resident #49 required total assistance of 2 staff members for transfers. Further review revealed the resident received oxygen therapy. Medical record review of the Physician's Orders dated June 2019 revealed .Oxygen .at 5 liters per minute via trach mask . Observation of Resident #49 on 6/11/19 at 8:24 AM, in the resident's room, revealed the resident lying in bed and had oxygen in use via trach mask. Continued observation revealed the resident's oxygen flow meter was set at 3 liters per minute. Interview with Resident #49, at the time of the observation, revealed .I'm supposed to be on 5 liters . Observation of Resident #49 on 6/11/19 at 1:15 PM, in the resident's room, revealed the resident lying in bed with oxygen in use via trach mask with oxygen flow meter set at 3 liters per minute. Observation of Resident #49 and interview with Licensed Practical Nurse (LPN) #1 on 6/11/19 at 1:41 PM, in the resident's room, confirmed the resident was lying in bed with oxygen in use at 3 liters per minute. Further interview confirmed the physician's order was for oxygen at 5 liters per minute via trach mask. Continued interview confirmed the oxygen was not administered as ordered. Interview with the Director of Nursing (DON) on 6/12/19 at 10:20 AM, in the conference room, confirmed the oxygen was not administered as ordered by the physician for Resident #49.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and interview the facility failed to follow standards of infection control for storage of resident care equipment and supplies in 3 of 3 nourishment rooms. The findings include: Review of the facility policy Infection Prevention and Control Program revised 5/2019 revealed .all reusable items and equipment requiring special cleaning or disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfection of soiled or contaminated equipment . Review of the facility cleaning and sanitizing equipment schedule policy, Cleaning and Sanitizing of Equipment, dated 8/30/12, revealed .water pitchers must be brought to the kitchen to be cleaned . Observation and interview with the Dietary Manager (DM) on 6/12/19 from 9:00 AM to 9:20 AM, in the Southside Nourishment Room, under the double working sink, revealed the following: 17 water pitchers; 17 detached lids with reusable straws labeled with resident names; 4 bedpans; 1 container of bleach wipes; and 1 stethoscope and 1 stethoscope bag. Continued observation revealed 1 box with the following: 3 nail clippers; 9 [NAME] boards; 30 orange sticks; 4 nail polish remover wipes; 30 alcohol wipes; one 4 oz. opened liquid spray deodorant; 1 refrigerator shelf; and 1 velcro safety stop sign. Interview with the DM confirmed the facility failed to prevent storage of reusable resident supplies and facility equipment under a working sink, and failed to place the items in a sanitary and clean environment. Observation and interview with the DM on 6/12/19 from 9:25 AM to 9:45 AM, in the Northside Nourishment Room, under the double working sink, revealed 1 pair of gray athletic shoes; 1 black tote bag covered with dust and debris; 1 plastic portable vacuum cleaner holder; 1 plastic scoop holder; and 1 glass vase. Interview with the DM confirmed the facility failed to prevent storage of personal belongings, and facility equipment under a working sink, and failed to place the items in a sanitary and clean environment. Observation and interview with the DM on 6/12/19 from 10:00 AM to 10:25 AM, in the 100 Hall Nourishment Room, under the double working sink, revealed the following: 1 coffee machine and pot; 1 opened 43.8 oz. container of coffee; 1 locked black tool box (unable to physically remove to inspect); loose napkins; and 1 trashcan base with 3 wheels. Interview with the DM confirmed the facility failed to prevent storage of facility equipment under a working sink, and failed to place the items in a sanitary and clean environment. Interview with the Director of Nursing on 6/12/19 at 11:30 AM, in the Conference Room confirmed .nothing should be under a working sink . Further interview confirmed the facility failed to maintain a clean and sanitary environment for 3 of 3 nourishment rooms.

Based on review of facility policy, review of facility cleaning and sanitizing equipment schedule, observation, and interview the facility failed to remove expired food in 1 of 3 nourishment rooms; failed to date and label resident food in 3 of 3 nourishment rooms; failed to separate staff and resident food in 3 of 3 nourishment rooms; and failed to maintain clean, sanitary, and safe equipment in 3 of 3 nourishment rooms potentially affecting 98 residents. The findings include: Review of the facility policy Food Storage, revised 11/2017 revealed .foods are stored in appropriate containers .covered, labeled, and dated .used within .3 days .all stored items should have an expiration date . Review of the facility policy Food Brought in by Family/Visitor revised 1/2019 revealed .all food items that are prepared by the family or visitor must be labeled with name, content and date .prepared food must be consumed by the resident within 3 days .if not consumed within 3 days, food will be discarded by the facility staff . Review of the facility policy Housekeeping-Routine Cleaning and Disinfection, revised 11/2018 revealed .to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare associated infection .removal of visible soil from objects and surfaces . Review of the facility cleaning and sanitizing equipment schedule, Cleaning and Sanitizing of Equipment, dated 8/30/12, revealed .Refrigerators should be kept clean .at all times . Observation and interview with the Dietary Manager (DM) on 6/12/19 from 9:00 AM to 9:20 AM, in the Southside Nourishment Room revealed inside the residents' refrigerator, 1 undated, unlabeled, opened 20 ounce (oz.) bottle of catsup. Further observation revealed thirteen 4 oz. containers of prune juice expired 5/25/19. Interview with the DM confirmed the facility failed to date and label the opened catsup bottle and to remove the expired prune juice available for resident use. Observation and interview with the DM on 6/12/19 from 9:00 AM to 9:20 AM, in the Southside Nourishment Room revealed inside the residents' freezer, the following undated, unlabeled food items: 1 half gallon cookie and cream ice cream, opened with freezer burn; 1 half gallon vanilla frozen yogurt; one 4 quart neapolitan favored ice cream opened with freezer burn. Interview with the DM confirmed the facility failed to date and label the resident frozen ice cream and yogurt. Observation and interview with the DM on 6/12/19 from 9:00 AM to 9:20 AM, in the Southside Nourishment Room, of the microwave, revealed residue of dried debris on the sides, bottom, and top inside the microwave. Interview with the DM confirmed the facility failed to maintain a clean and sanitary resident microwave. Observation and interview with the DM on 6/12/19 from 9:25 AM to 9:45 AM, in the Northside Nourishment Room revealed inside the residents' refrigerator, the following undated, unlabeled items: 1 opened 8 oz. raspberry vinaigrette salad dressing; one 8 oz. cream colored bottled liquid; 1 opened 8 oz. vanilla dietary supplement; 1 plastic bag containing 1 breakfast tart; two 17 oz. black cherry sparkling waters; 2 containers of mandarin oranges; and 2 cans of 12 oz. ginger ale with orangeade. Further review revealed a purple tote bag contained the following: 1 plastic container of cooked, sliced chicken; 1 sleeve of opened cheese crackers; one 5.3 oz. of vanilla greek yogurt; and one 20 oz. blue colored energy drink. Interview with the DM confirmed the facility failed to date and label resident food items. Observation and interview with the DM on 6/12/19 from 9:25 AM to 9:45 AM, in the Northside Nourishment Room inside the residents' freezer revealed the following undated, unlabeled items: 1 open to air pink colored drink with a straw frozen in place and 1 cream colored drink with a straw frozen in place. Interview with the DM confirmed the facility failed to date and label the food items, and failed to store the items in a safe and sanitary manner. Observation and interview with the DM on 6/12/19 from 9:25 AM to 9:45 AM, in the Northside Nourishment Room, of the microwave, revealed residue of dried debris on the sides, bottom, and top inside the microwave. Interview with the DM confirmed the facility failed to maintain a clean and sanitary resident microwave. Interviews with Licensed Practical Nurses (LPN) #5, #6, and #7 on 6/12/19 from 9:45 AM to 9:55 AM, at the Northside Nursing Station revealed .staff puts their food in the nourishment refrigerator .personal items are supposed to be labeled .we have a staff refrigerator in our lounge . Observation and interview with the DM on 6/12/19 from 10:00 AM to 10:25 AM, in the 100 Hall Nourishment Room, of the residents' refrigerator, revealed the following undated, unlabeled food items: 1 container of sliced strawberries; 1 opened 32 oz. blue energy drink; 1 opened 46 oz. box of orange juice; 1 bowl of beef stew; 1 pink and blue tote containing 1 opened bottle of 16.9 oz. water; one 17 oz. strawberry lemon sparkling water, two 16 oz. bottles of water, and one 12 oz. diet cola. Continued review of the refrigerator water/ice dispenser revealed encrusted white debris on and under the removable tray. Interview with the DM confirmed the facility failed to date and label the food items, to store the items in a safe and sanitary manner, and to maintain the cleanliness of the resident refrigerator. Observation and interview with the DM on 6/12/19 from 10:00 AM to 10:25 AM, in the 100 Hall Nourishment Room, of the residents' freezer, revealed the following undated, unlabeled, opened frozen food items: one 14 oz. container of cookie dough ice cream; one 14 oz. container of peanut butter candied ice cream; and 1 bag of sliced strawberries. Interview with the DM confirmed the facility failed to date and label the food items and to store the items in a safe and sanitary manner. Observation and interview with the DM on 6/12/19 from 10:00 AM to 10:25 AM, in the 100 Hall Nourishment Room, of the microwave, revealed damage to the interior ceiling with exposed shards of plastic and/or metal like material. Further review revealed residue of dried, discolored debris on the sides and bottom inside the microwave. Interview with the DM confirmed the facility failed to maintain a clean, safe, and sanitary resident microwave. Interview with Registered Nurse #1 on 6/12/19 at 10:45 AM, at the 100 nursing station, revealed .you can put staff or resident food in the fridge as long as it is labeled . Interview and observation with the Maintenance Director on 6/12/19 at 11:00 AM, in the 100 Nourishment Room revealed .I don't think the microwave should be used . Interview with the Director of Nursing on 6/12/19 at 11:30 AM, in the Conference Room confirmed the staff .not supposed to store staff and resident food items together . Further interview confirmed the facility failed to maintain a clean and sanitary environment for the 3 of 3 nourishment rooms.