**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Centers for Medicare and Medicaid Services (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, medical record review, and interview, the facility failed to ensure residents were accurately assessed for weight loss and Activities of Daily Living (ADL) for 2 of 16 sampled residents (Resident #9 and #15) sampled residents reviewed. The findings include: Review of the CMS LTC Facility RAI 3.0 User's Manual Version 1.17.1 dated October 2019, pages G-24 and K-4 revealed, .Address the resident's unique needs for bathing .should be periodically evaluated .Weight loss can result in debility and adversely affect health, safety, and quality of life .Weight loss may be an important indicator of a change in the resident's status or environment . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE], with diagnoses of Emphysema, Chronic Pulmonary Obstructive Disease, Dementia, Parkinson's Disease, Tremors, Depression, Anxiety, and Atrial Fibrillation. Review of the Registered Dietician notes dated 10/21/2021, revealed Resident #9 had significant weight loss of 12.3 % in 6 months. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #9 was coded as weighing 199 pounds and having no weight loss. During an interview on 3/2/2022 at 6:11 PM, the MDS Coordinator confirmed the MDS should have been coded for a significant weight loss. Review of the medical record, revealed Resident #15 was admitted to the facility on [DATE] with diagnosis of Post Traumatic Stress Disorder, Convulsions, Depressive Disorder, Anxiety, Diabetes Mellitus, Schizophrenia and Psychosis. Review of the annual MDS dated [DATE], revealed Resident #15 was coded as bathing activity did not occur. Review of the quarterly MDS dated [DATE], revealed Resident #15 was coded as bathing activity did not occur. During an interview on 3/1/2022 at 11:50 AM, Certified Nurses Assistant (CNA) #1 confirmed Resident #15 received showers on Wednesday and Saturdays. CNA #1 confirmed Resident #15 enjoyed her showers and does not refuse them. During an interview on 3/1/2022 at 6:25 PM, The MDS Coordinator stated, .I do not honestly feel Resident #15 did not receive a shower . The MDS Coordinator confirmed she should have questioned the staff further related to bathing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow its policy for weighing residents for 2 of 3 sampled residents (Resident #9 and #16) reviewed for nutritional status. The findings include: Review of the facility's policy titled, WEIGHTS: OBTAINING AND DOCUMENTING, dated 12/27/2017, revealed .Weights will also be taken upon admission .The DON or designee, the Dietary Manager, and the RD will review the weights for the current month and compare the current weight to the 30 and 180 day weights to determine significant weight losses and variances .Weekly: Admissions, readmissions, and residents .should be weighed weekly for 4 weeks or until stable .Reweighs will be done if there is a 3% [percent] or greater change from the last documented weight . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE], discharged to the hospital on 9/26/2021, and readmitted to the facility on [DATE], with diagnoses of Emphysema, Chronic Pulmonary Obstructive Disease, Aortic Valve Stenosis, Atrial Fibrillation, Gastroesophageal Reflux Disease, Dementia, Parkinson's Disease, and Tremors. Review of the entry MDS (Minimum Data Set) assessment dated [DATE], revealed Resident #9 returned from a hospital stay on 9/28/2021. Review of the Weights and Vitals Summary for Resident #9, revealed .8/2/2021 224.9 lbs, 9/1/2021 210 lbs, 10/4/2021 205 lbs, 10/18/2021 198.8 lbs, 10/25/2021 200.6 lbs . The facility failed to obtain Resident #9's weight upon readmission from the hospital on 9/28/2021 and obtain a weekly weight for the week of 10/11/2021. During an interview on 3/2/2022 at 9:47 AM, the Registered Dietician (RD) confirmed Resident #9 had a hospitalization from 9/26/2021 to 9/28/2021 and should have been weighed upon readmission to the facility and a weekly weight should have been obtained for the week of 10/11/2021. During an interview on 3/2/2022 at 6:26 PM, the Director of Nursing confirmed Resident #9 should have had a weight upon readmission from the hospital on 9/28/2021 and a weekly weight should have been obtained for the week of 10/11/2021. Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses of Intracranial Shunt, Dementia, Hemiplegia, Hemiparesis, Aphasia, Anxiety, and Depression. Review of the Progress Notes revealed Resident #16 was re-hospitalized on [DATE] and returned to the facility on [DATE]. Review of the Weights and Vitals Summary revealed Resident #16 weighed 104 pounds on 10/18/2021 and 97.4 pounds on 11/15/2021. Review of the Weights and Vitals Summary revealed Resident #16 was not weighed when she returned from the hospital until 11/2/2021, 4 days later. During a telephone interview on 3/2/2022 at 12:20 PM, the RD confirmed Resident #16 should have been weighed when she returned from the hospital. During an interview on 3/2/2022 at 6:28 PM, the Director of Nursing (DON) confirmed Resident #16 went to the hospital on [DATE] and returned to the facility on [DATE]. The DON confirmed Resident #16 was not weighed when she returned from the hospital until 11/2/2021.

Based on policy review, observation, and interview, the facility failed to ensure medications were stored properly when opened multidose bottles without an opened date and expired medications were observed in 2 of 4 medication storage areas (West Hall Medication Cart and the Treatment Cart). The findings include: Review of the facility's policy titled, Storage of Medications, dated 9/5/2012, revealed .Medications and biologicals are stored safely, securely, and properly .Outdated, contaminated, or deteriorated medications .are removed from stock, disposed of according to procedures for medication disposal . Observation of the [NAME] Hall Medication Cart on 3/2/22 at 8:00 AM and at 5:13 PM, revealed an opened multidose bottle of Multivitamin with minerals without an opened date. Observation of the [NAME] Hall Medication Cart on 3/2/2022 at 5:16 PM, revealed an opened multidose bottle of Loratadine (an Antihistamine) without an opened date. Observation of the Treatment Cart on 3/2/2022 at 5:23 PM, revealed an expired tube of Moisturizing Hydrogel (a medication for dressing and management of wounds) with an expiration date of 6/2020. During an interview on 3/2/2022 at 8:07 AM, Licensed Practical Nurse #1 confirmed opened bottles of multidose medications should be labeled with an opened date. During an interview on 3/2/2022 at 5:25 PM, the Director of Nursing confirmed that opened multidose vials should be labeled with an opened date and expired medications should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain clean equipment in 1 of 25 (room [ROOM NUMBER]) resident rooms. The findings include: Observations in room [ROOM NUMBER]B on 8/12/19 at 8:55 AM, 9:51 AM, 11:45 AM, 2:20 PM, and 4:42 PM, and on 8/13/19 at 7:49 AM, revealed Resident #5 had a tracheostomy (trach) (a tube placed through a hole and directly into the windpipe to assist breathing) and the bottom of the dressing to the trach was unsecured. A stand up fan with a dirty, dusty outer grid was at the foot of the bed blowing air directly toward Resident #5's unsecured trach dressing. Observations in room [ROOM NUMBER]B on 8/13/19 at 10:55 AM, revealed Registered Nurse (RN) #1 performed a trach dressing change. A stand up fan with a dirty dusty outer grid was at the foot of the bed blowing air directly toward Resident #5 during the trach care. Interview with RN #1 on 8/14/19 at 11:02 AM, in Resident #5's room, RN #1 was asked if the outer grid of the fan was dirty and dusty. RN #1 stated, Yes, ma'am. RN #1 was asked if the fan should have been blowing directly toward Resident #5. RN #1 stated, No, ma'am.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when food was thawed using improper procedures, 1 of 4 (Dietary Aide #1) staff members failed to perform hand hygiene, and unlabeled and undated food items were stored in 1 of 2 (Break Room) nourishment refrigerators. The facility had a census of 28 residents, with 27 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's undated Safe Food Preparation policy documented, .Many steps in safe food preparation must be controlled and monitored to prevent foodborne illness .Recommended methods to safely thaw frozen foods include .Thawing in the refrigerator .Completely submerging the item under cold water .that is running fast enough to agitate and float off loose ice particles .Thawing the item in a microwave oven, then cooking and serving it immediately .Thawing as part of a continuous cooking process . Observations in the Kitchen on 8/12/19 at 8:40 AM, revealed 3 packages of bologna thawing in a pan of standing water. Interview with the Dietary Manager on 8/12/19 at 8:50 AM, in the Kitchen, the Dietary Manager was asked about the bologna thawing in the water. The Dietary Manager stated, .they told me I could thaw it like that. 2. The facility's undated HANDWASHING PROCEDURE FOR DINING SERVICES policy documented, .Hand hygiene continues to be primary means of preventing the transmission of infection .some situations that require hand hygiene .After handling dirty dishes . Observations in the Kitchen on 8/13/19 at 1:35 PM, revealed Dietary Aide #1 rinsed dirty dishes using her bare hands, placed the dirty dishes on the dish ware rack, and into the dish ware washer. Dietary Aide #1 pulled out the clean dishes with her bare hands without washing her hands. Dietary Aide #1 removed a large container from the clean rack and placed it onto the drying rack using her bare hands, and then continued to rinse the dirty dishes. Interview with Dietary Aide #1 on 8/13/19 at 1:45 PM, in the Kitchen, Dietary Aide #1 was asked if she should have washed her hands between clean and dirty dishes. Dietary Aide #1 stated, Yes. Interview with the Dietary Manager on 8/13/19 at 2:00 PM, in the [NAME] Hall, the Dietary Manager was asked what staff should do between loading the dish ware washer with dirty dishes and handling clean dishes. The Dietary Manager stated, Wash their hands . 3. The facility's Food Storage policy dated 8/18/11 documented, .All foods stored in refrigerators and freezers that have been opened, will be .labeled with the date and name of food if appropriate, and will be discarded within the appropriate time frame . Observations in the Break Room refrigerator on 8/13/19 at 1:56 PM, revealed 24 Boost Plus supplements, 3 Boost supplements, and 3 Nephro supplements stored in this refrigerator. There was 1 half-full gallon container of whole milk with no opened date, 1 half-full gallon container of orange juice with no opened date, 1 pitcher with a small amount of orange liquid with no label or date. Interview with the Dietary Manager on 8/13/19 at 2:00 PM, in the [NAME] Hall, the Dietary Manager stated, We don't take care of those refrigerators. Interview with the Director of Nursing (DON) on 8/13/19 at 4:39 PM, in the Conference Room, the DON was asked where resident supplements and snacks were stored. The DON stated, We have some in the Break Room, and then in the med [medication] room, we have a mini [miniature] refrigerator that also has puddings that we use for med administration. It's not like a snack refrigerator. The DON was asked who was responsible for maintaining the refrigerators. The DON stated, I need to check on that. The DON was asked if she expected food items to be labeled and dated when opened. The DON stated, Resident items, yes for sure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, 2 of 2 (Licensed Practical Nurse (LPN) #1 and 2) nurses failed to ensure a gastrostomy (a tube inserted through the abdomen that delivers nutrition directly to the stomach) tube was flushed according to facility policy and physician's orders during medication administration observations. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Traumatic Subdural Hemorrhage, Intracranial Injury, and Gastrostomy. The physician's orders dated 8/1/18 documented, .Crush each med [medication] and give individually flushing with 5ml [milliliters] H2O [water] between each med [medication] .Flush with 60ml before and after med pass .Baclofen Tablet 20 MG [milligram] Give 1 tablet via [by way of] PEG [Percutaneous Endoscopic Gastrostomy]-Tube three times a day . Observations in Resident #9's room on 8/28/18 at 2:29 PM, revealed LPN #1 administered medications though Resident #9's feeding tube. LPN #1 flushed the tube with 5 ml of water by gravity, administered Baclofen, flushed the tube with 5 ml of water, removed her gloves, washed her hands, and exited the room. LPN #1 stated, .it says to flush with 5 ml before and after meds . LPN #1 did not flush the PEG with 60 ml before and after the medication as ordered by the physician. Observations in Resident #9's room on 8/29/18 at 1:06 PM, revealed LPN #2 administered medications through Resident #9's feeding tube. LPN #2 flushed the tube with 30 ml of water, administered Baclofen, flushed the tube with water, removed his gloves, washed his hands, and exited the room. LPN #2 did not flush the PEG with 60 ml before and after the medication as ordered by the physician. Interview with the Director of Nursing (DON) on 8/29/18 at 1:42 PM in the conference room, the DON was asked how much water should be used to flush Resident #9's gastrostomy tube prior to and after administering medications through the PEG. The DON stated, .It looks like, based on this, we need clarification [of the order] for either of them [LPN #1 and #2] to get it right .