**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to treat residents with respect and dignity when 1 of 13 (Certified Nursing Assistant (CNA) G) staff members stood over a resident (Resident #66) to assist with the meal, and when 2 of 13 (CNA M, CNA H) staff members observed during dining failed to use courtesy titles when addressing two residents (Resident #22, #26, and #83). The findings include: 1. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated August 2024, revealed .It is the practice of this facility to protect and promote resident rights and treat each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . 2. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], with diagnoses including Heart Disease, Dementia, and Depression. Observation in Resident's #66 room on 1/13/2025 at 12:14 PM, revealed CNA G stood over Resident #66, put food on the utensil, and put it to the resident's mouth to encourage and assist with her lunch meal. During an interview on 400 Hall on 1/13/2025 at 12:27 PM, CNA G was asked, should you have stood over the resident to assist her with her meal. CNA G stated, No, ma'am. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Diabetes, Heart Failure, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #26 had a BIMS score of 3, which indicated the resident was severely impaired cognition, and required set-up assistance from staff for eating. Observation in Resident #26's room on 1/14/2025 at 7:48 AM, revealed CNA H entered the resident's room set up the resident's meal tray and stated to Resident #26, .You are being sweet today, girl . 3. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Central Cord Syndrome Spinal Cord, Quadriplegia, and Atrial Fibrillation. Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed Resident #22 had a Brief Interview for Mental Status score (BIMS) of 15, which indicated the resident was cognitively intact, and required set up for meals. 4. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Diabetes, Hypertension, Alcoholic Cirrhosis of the Liver, Hepatic Encephalopathy, and Epilepsy. Review of the admission MDS dated [DATE], revealed Resident #83 did not have a BIMs score, had short-and-long term memory loss, was severely cognitively impaired, and required supervision for eating. 5. Observation during dining on the 300 Hall on 1/13/2025 at 11:48 AM, revealed CNA M removed a tray from the meal cart and pointed to 2 trays left on the meal cart and stated out loud in the hallway, These two are feeders. CNA M was asked who the trays belong to. CNA M stated, [Named Resident #22 and Named Resident #83]. During an interview on 1/16/25 at 5:08 PM, the Director of Nursing (DON) confirmed that staff should use courtesy titles when addressing residents and residents should not be referred to as feeders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure a clean, safe, and sanitary environment in 7 of 64 (Resident #2, #12, #13, #30, #36, #51, #53, #54, #57, #62, #72, #73, #78, and #79) resident shared bathrooms when personal hygiene items were found unlabeled and uncontained. The findings include: 1. Resident #2 and Resident #72 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Malignant Neoplasm of Nasal Cavity, and Pneumonia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #2 had a Brief Interview for Mental status (BIMS) score of 9, indicating the resident was moderately cognitively impaired, required assistance with Activities of Daily Living Skills (ADLS), required supervision with toileting hygiene, and was incontinent of both bowel and bladder. b. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Ulcerative Colitis, Dementia, and Gastroparesis. Review of the annual MDS dated [DATE], revealed Resident #72 had a BIMS score of 11, indicating the resident was moderately cognitively impaired, required moderate assistance with ADLS, and incontinent of both bowel and bladder. c. Observation in Resident #2 and Resident #72's shared bathroom on 1/13/2025 at 9:19 AM, 10:00 AM, and 11:15 AM, revealed the following: A gray wash basin on the back of the toilet unlabeled and uncontained. Four (4) gray wash basins stacked inside of each other on the floor beside the toilet unlabeled and uncontained. A gray bedpan on the floor beside the toilet unlabeled and uncontained. A peach colored toothbrush holder on the sink unlabeled and uncontained. A plunger resting on the floor beside the toilet uncontained. 2. Resident #12 and Resident #30 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Chronic Obstructive Pulmonary Disease, Depression, and Malignant Neoplasm of the Large Intestine. Review of the admission MDS dated [DATE], revealed Resident #12 had a BIMS score of 3, indicating the resident was severely cognitively impaired, required maximal assistance with toileting, and incontinent of both bowel and bladder. b. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses including Myocardial Infarction, Atrial Fibrillation, Need for Assistance with Personal Care, and Muscle Weakness. Review of the quarterly MDS dated [DATE], revealed Resident #30 had a BIMS score of 15, indicating the resident was cognitively intact, required moderate assistance with ADLs, and maximal assistance with toileting. c. Observation in Resident #12 and #30's shared bathroom on 1/13/2024 at 9:29 AM, 10:00 AM, 11:20 AM, and on 1/14/2024 at 8:10 AM, revealed a gray wash basin on the back of the toilet unlabeled and uncontained 3. Resident #54 and Resident #57 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident # 54 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Osteomyelitis, and Atherosclerosis. Review of the annual MDS dated [DATE], revealed Resident #54 had a BIMS score of 3, indicating the resident was severely cognitive impaired, and dependent on staff for ADLS and toileting. b. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including Osteomyelitis, Respiratory Failure, Obesity, Muscle Weakness, and Need for Assistance with Personal Care. Review of the quarterly MDS dated [DATE], revealed Resident #57 had a BIMS score of 10, indicating the resident was moderately cognitively impaired, dependent on staff for ADLS, and incontinent of both bowel and bladder. c. Observation in Resident #54 and #57's shared bathroom on 1/13/2025 at 9:34 AM, 10:14 AM, and 11:55 AM, revealed the following: A gray wash basin on the back of toilet unlabeled and uncontained. A urinal sitting on the assist bar unlabeled and uncontained. 4. Resident #13 and Resident #53 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Obesity, Pneumonia, Bradycardia, and Atrioventricular Block. Review of the quarterly MDS dated [DATE], revealed Resident #13 had a BIMS score of 12, indicating the resident was cognitively intact, dependent on staff for ADLS, and incontinent of both bowel and bladder. b. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE], with diagnoses including Hypothyroidism, Hypertension, Anxiety, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #53 had a BIMS score of 15, indicating the resident was cognitively intact, independent with ADLS, and incontinent of both bowel and bladder. c. Observation in Resident #13 and Resident #53's shared bathroom on 1/13/2025 at 9:38 AM and 11:55 AM, revealed the following: A gray bedpan on the floor underneath the sink unlabeled and uncontained. Two gray wash basins on the back of the toilet unlabeled and uncontained. 5. Resident #78 and Resident #79 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE], with diagnoses including Compression Fracture of Vertebra, Osteomyelitis, Delirium, Muscle Weakness, Overactive Bladder, and Cognitive Communication Deficit. Review of the quarterly MDS dated [DATE], revealed Resident #78 had a BIMS score of 9, indicating the resident was moderately cognitively intact, required maximal assistance with toileting, set up for personal hygiene, and continent of both bowel and bladder. b. Review of the medical record revealed Resident #79 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, Macular Degeneration, and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #79 had a BIMS score of 13, indicating the resident was cognitively intact, required set up for personal hygiene, moderate assistance for toileting, and incontinent of both bowel and bladder. c. Observation in Resident #78 and Resident #79's shared bathroom on 1/13/2024 at 9:43 AM and 11:15 AM, revealed a gray bed pan stacked inside of a gray wash basin on the back of the toilet unlabeled and uncontained. 6. Resident #36 and Resident #62 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Anxiety, Congestive Heart Failure, and Insomnia Review of the annual MDS dated [DATE], revealed Resident #36 had a BIMS score of 3, indicating the resident was severely cognitively impaired, dependent on staff for ADLS, and incontinent of both bowel and bladder. b. Review of the medical record revealed Resident #62 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Hypertension, Osteoporosis, Shortness of Breath, Hearing Loss, and Pneumonia. Review of the quarterly MDS dated [DATE], revealed Resident #62 had a BIMS score of 3, indicating the resident was severely cognitively impaired, dependent on staff for all ADLS, and incontinent of both bowel and bladder. c. Observation in Resident #36 and Resident #62's shared bathroom on 1/13/2025 at 9:44 AM and 11:35 AM, revealed the following: A gray wash basin on the back of the toilet unlabeled and uncontained. A green denture cup on top of the sink unlabeled and uncontained. 7. Resident #51 and Resident #73 resided in rooms with a shared bathroom. a. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Diabetes, Quadriplegia, and Neuromuscular Dysfunction of Bladder. Review of the quarterly MDS dated [DATE], revealed Resident #51 had a BIMS score of 15, indicating the resident was cognitively intact, and dependent on staff for all ADLS. b. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE], with diagnoses including Alcoholic Cirrhosis of the Liver, Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Depression. Review of the annual MDS dated [DATE], revealed Resident #73 had a BIMS score of 14, indicating the resident was cognitively intact, required supervision with ADLS, and continent of both bowel and bladder. c. Observation in Resident #51's and Resident #73's shared bathroom on 1/13/2025 at 9:50 AM, 11:45 AM, and on 1/14/2025 at 8:03 AM, revealed the following: A gray wash basin on back of the toilet unlabeled and uncontained. A graduate dispenser on back of the toilet unlabeled and uncontained. A large dark gray bowl sitting on top of the sink unlabeled and uncontained. A clear plastic storage container sitting on top of the sink unlabeled and uncontained. 8. During an interview on 1/16/2025 at 5:08 PM, the Director of Nursing confirmed that all personal hygiene items should be placed in plastic bags and stored in the bottom drawer of the residents' bedside table or on the top shelf of the residents' wardrobe and should not be left in the bathroom unlabeled and uncontained. The DON confirmed that all denture cups should be labeled with the resident's name and placed in the top drawer of the bedside table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to revise care plans for 4 of 18 (Resident #12, #38, #80, and #92) resident care plans reviewed for Pressure Ulcers, COVID, Transmission Based Precautions (TBP), and Influenza. The findings include: 1. Review of the facility's policy titled, Care Plan Revisions Upon Status Change, dated 12/1/2024, revealed .The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change .The comprehensive care plan will be reviewed, and revised .when a resident experiences a status change . Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 12/1/2024, revealed .The staging of pressure injuries will be clearly identified .the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .Assessments of pressure injuries will be .documented on the Initial and / or Weekly Wound Assessment .the staging of pressure injuries will be clearly identified .interventions will be documented in the care plan . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Anxiety, Peripheral Vascular Disease, and Malignant Neoplasm of the Intestine. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #12 had a Brief Interview for Mental Status score (BIMS) of 3, which indicated the resident was severely cognitively impaired, dependent on staff for Activities of Daily Living skills, and incontinent of both bowel and bladder. Review of the Care Plan dated 9/30/2024, revealed no care plan for being at risk, the development, prevention, and treatment of pressure ulcers. Review of a Weekly Wound assessment dated [DATE], confirmed Resident #12 had pressure ulcers to both her left and right heel. Review of the facility's undated Pressure Ulcer list revealed .[Resident #12] .DTPI [deep tissue pressure injury] .L [left] heel .DTPI .R [right] heel .FA [facility acquired] .12/27/2024 . Review of a [Named Wound Care Company] INITIAL WOUND EVALUATION & MANAGMENT SUMMARY, dated 1/14/2025, revealed .Patient presents with wounds on her left heel .right heel .UNSTAGEABLE [DUE TO NECROSIS (dead tissue] OF THE RIGHT HEEL .Etiology .Pressure .Stage .Unstageable Necrosis .Duration .> [greater than] 14 days .UNSTAGEABLE .OF THE LEFT HEEL .Etiology .Pressure .Stage .Unstageable Necrosis .duration .> 14 days . Observation in Resident #12's room on 1/15/2025 at 3:30 PM, revealed the Wound Nurse, entered the room, donned PPE (personal protective equipment), removed the dressings to both the right and left heel, and exposed the pressure wounds to the resident's right and left heel. The wounds to the right and left heel were dark brown in color and hard to touch with characteristics of a DTI. The facility failed to revise Resident #12's care plan to prevent or address unstageable pressure ulcers/injuries to the left and right heel. During an interview on 1/16/2025 at 6:20 PM, the Director of Nursing (DON) confirmed the care plan should have been revised to show Resident #12 was at risk, developed, and being treated for pressure ulcers. 3. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Urinary Tract Infection, Acute Kidney Failure, Chronic Obstructive Pulmonary Disease, and Muscle Weakness. Review of the admission MDS dated [DATE], revealed Resident #38 had a BIMS score of 14, which indicated the resident was cognitively intact. Review of a Nurses Note dated 1/9/2025, revealed Resident tested positive for covid .isolation . Review of the Care Plan dated 1/16/2025, revealed .The resident has a Respiratory Infection (COVID 19) .Isolation-droplet precautions .Date Initiated .1/16/2025 .Revision on .1/16/2025 . The facility failed to revise the care plan for COVID 19 and Transmission Based Precautions until 1/16/2025, 7 days after Resident #38 tested positive for COVID 19. Review of a Physicians Order dated 1/16/2025, revealed .Infection .COVID 19 .Precautions Type .contact, droplet .Covid Isolation starting 1/9/2025 . Observation during dining on the 200 hall on 1/13/2025 at 12:15 PM, revealed Certified Nursing Assistant (CNA CC) donned PPE (Personal Protective Equipment) and delivered a meal tray to Resident #38. CNA CC confirmed Resident #38 was in isolation due to COVID 19. Observations on the 200 Hall on 1/14/2025 at 7:48 AM and at 5:00 PM, revealed Resident #38 remained in contact / droplet isolation precautions for COVID. During an interview on 1/16/25 at 11:10 AM, the DON and the Infection Control Preventionist (ICP) confirmed that Resident #38 was positive for COVID on 1/9/2025 and has been in Transmission Based Precautions since 1/9/025. The DON confirmed that Resident #38 should have had a care plan developed and revised for infections related to COVID and Transmission Based Precautions. 4. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Cellulitis of bilateral lower limbs, Pressure Ulcer of Left Buttock, Diabetes, Influenza, Dementia, Cardiomegaly, and Pneumonia. Review of the admission MDS dated [DATE], Resident #80 had a BIMS score of 6, which indicated severe cognitive impairment. Review of the Care Plan dated 10/24/2024, revealed no documentation for Resident #80 being in TBP due to being positive for Influenza. Review of the Nurses' Progress Note dated 1/9/2025, revealed RESIDENT MOVED TO 419A DUE TO POSITIVE FOR THE FLU WILL BE IN DROPLET ISOLATION Resident#80's care plan was not revised to reflect positive for the Flu and droplet isolation. During an interview on 1/16/2025 at 4:05 PM, the DON was asked should Resident #80's care plan have TBP for flu documented. The DON stated, Yes .I don't see it . 5. Review of the medical record revealed Resident #92 was admitted to the facility on [DATE], with diagnoses including COVID 19, Neuromuscular Dysfunction of the Bladder, and Abnormal Gait. Review of the admission MDS dated [DATE], revealed Resident #92 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of a Physician's Order dated 1/7/2025, revealed .contact droplet precautions .in room alone. Observation during dining on the 200 hall on 1/13/2025 at 12:25 PM, revealed Certified Nursing Assistant (CNA CC) donned PPE and delivered a meal tray to Resident #38. CNA CC confirmed Resident #92 was in isolation due to COVID 19. Observation on the 200 hall on 1/14/2025 at 7:48 AM and at 5:00 PM, revealed Resident #92 remained in TBP for COVID. During an interview on 1/16/25 at 11:10 AM, the DON and the Infection Control Preventionist (ICP) confirmed that Resident #92 was positive for COVID on 1/5/2025 and has been in TBP since 1/5/2025 and remains in TBP. The DON confirmed that Resident #92's care plan should be revised to reflect infections related to COVID and TBP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview the facility failed to stage pressure wounds correctly for 1 of 2 (Resident #12) sampled residents reviewed for pressure ulcers. The findings include: 1. Review of the facility's policy titled Pressure Injury Prevention and Management, dated 12/1/2024, revealed .The staging of pressure injuries will be clearly identified .the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions .Assessments of pressure injuries will be .documented on the Initial and / or Weekly Wound Assessment .the staging of pressure injuries will be clearly identified .interventions will be documented in the care plan . 2. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Anxiety, Peripheral Vascular Disease, and Malignant Neoplasm of the Intestine. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired, dependent on staff for ADLs, incontinent of both bowel and bladder. Review of the Care Plan dated 9/30/2024, revealed no care plan for pressure injuries. Review of an Initial Wound assessment dated [DATE], revealed .Non Pressure .Date Wound was Identified .12/27/2024 .Acquired after admission to facility .Non Pressure .Left heel .Type .Vascular .Length .4.5 x Width 4.5 x Depth .utd [unable to determine] .dark purple .Pain Management Plan .off-loading boots . Review of an Initial Wound assessment dated [DATE], revealed .Date wound was identified .12/27/2024 .Type .Non pressure .Right heel .Type .Vascular .Length .5.0 x Width 5.0 x Depth .utd .dark purple .Pain Management Plan .off-loading boots . Review of a Weekly Wound assessment dated [DATE], revealed .Type of Wound .Non Pressure .Vascular . for the Left and Right Heels. Review of a Weekly Wound assessment dated [DATE], revealed .Type of wound .Non-Pressure .Vascular . for the Left and Right Hells. Review of the facility's undated Pressure Ulcer list revealed .DTPI [deep tissue pressure injury] .L [left] heel .DTPI .R [right] heel .FA [facility acquired] .12/27/2025 . Review of a (Named Wound Care Company) INITIAL WOUND EVALUATOIN & MANAGMENT SUMMARY, dated 1/14/2025, revealed .Patient presents with wounds on her left heel .right heel .UNSTAGEABLE (DUE TO NECROSIS) OF THE RIGHT HEEL .Etiology .Pressure .Stage .Unstageable Necrosis .Duration .> (greater than) 14 days .UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT HEEL .Etiology .Pressure .Stage .Unstageable Necrosis .duration .> 14 days . Observation in Resident #12's room on 1/15/25 at 3:30 PM, revealed the Wound Nurse, entered the room and removed the dressings to Resident #12's left and right heels. The right and left heel were both dark brown in color and hardened areas. During an interview on 1/16/25 at 2:51 PM, the Wound Nurse confirmed the wounds on Resident #12's left and right heels were deep tissue injuries and were not vascular. During an interview on 1/16/25 at 5:08 PM, the Director of Nursing (DON) confirmed that in order to classify a wound as vascular that a physician would have to make that diagnosis from a doppler assessment. The DON confirmed that she expects the wound nurse to stage wounds correctly to ensure proper care and treatment of all wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure an environment free of accident hazards when sharps and hazardous personal items were found in 2 of 66 (Resident #2 and Resident #71) resident occupied rooms. The findings include: 1. Review of the facility's undated policy titled, Resident Rights, revealed .Safe Environment .The resident has a right to a safe .environment . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hypertensive Heart Disease, Malignant Neoplasm of the Nasal Cavity, and Pneumonia. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, indicating the resident was moderately cognitively impaired, and required assistance with activities of daily living skills (ADLs). Observation in Resident #2's room on 1/13/2025 at 9:19 AM, at 10:00 AM, and 11:15 AM, revealed the following items sitting on a wooden bookshelf uncontained and easily accessible: An 8.8 oz (ounce) can of air fresher. An 8 oz can of body spray. An 8 oz bottle of cherry lemonade scented body spray. During observation and interview in Resident #2's room on 1/13/2025 at 11:44 AM, revealed Licensed Practical Nurse (LPN) O was shown the air fresher, the body sprays and was asked how these items should be stored. LPN O confirmed they should be stored in plastic bags, in the resident's drawer and out of reach of residents. LPN O confirmed the items could be hazardous to residents' safety. During an interview on 1/16/2025 at 5:08 PM, the Director of Nursing (DON) confirmed that air freshers and body sprays should not be stored on a shelf and easily accessible to residents, they should be stored in a plastic bag out of reach of residents in the bedside table. The DON confirmed these items are hazards to residents' safety. 3. Review of the medical record revealed Resident #71 was admitted to the facility on [DATE], with diagnoses including Left Shoulder Effusion, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease. Review of the admission MDS assessment dated [DATE], revealed Resident #71 had a BIMS score of 12, indicating the resident was moderately cognitively impaired and required supervision from staff for ADLs. Resident #71 was mobile via wheelchair. Observation in Resident #71's bathroom on 1/13/2025 at 10:11 AM, 1/13/2025 at 3:54 PM, and 1/16/2025 at 11:08 AM, revealed an unattended and unsecure disposable razor on the bathroom vanity. During an interview and observation in Resident #71's on 1/16/2025 at 11:18 AM, the Director of Nursing (DON) was asked if the razor should be left in the resident's bathroom unsecured and unattended. The DON confirmed that the razor should not be left in resident's bathroom and should be in the sharp container.

Based on document review and interview, the facility failed to post the scheduled total number of full-time employees (FTEs) scheduled to work a shift, and their total FTEs hours for 31 of 31 sampled days and failed to post the total actual hours worked by the licensed and unlicensed staff responsible for resident care on the facility's Today's Staffing form for 31 of 31 sampled days. The findings include: Review of the facility's Today's Staffing documents dated 12/9/2024 thru 1/10/2025, revealed the facility failed to complete the number of FTEs scheduled to work and failed to total the number of actual hours worked for licensed and non-licensed staff. During an interview on 1/16/2025 at 8:28 AM, the Scheduler was asked to review the daily staff postings for 12/9/2024 to 1/10/2025 and was asked if they were completed. The Scheduler confirmed they were incomplete and should have included the number of FTEs scheduled, the total hours worked every shift for both licensed and non-licensed staff, and they should reflect any changes due to call-ins. During an interview on 1/16/2025 at 9:55 AM, the Director of Nursing confirmed the daily staff postings were incomplete, should be completed daily to reflect the total FTEs, the total hours worked by both licensed and non-licensed staff members, and should reflect any changes due to call-ins.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the Pharmacy Products and Services Agreement, medical record review, review of facility drug destruction documentation, and interview, the facility failed to properly document narcotic medications signed in error or wasted, failed to document administration of narcotics on the Medication Administration Record (MAR), failed to identify and report discrepancies for the narcotic count, and failed to ensure drug destruction sheets were signed by a licensed pharmacist for 3 of 4 months ([DATE], [DATE], and [DATE]) of drug destruction documentation reviewed. The findings include: 1. Review of the facility's policy titled, Medication Administration: Controlled Medications, dated 11/2017, revealed .Provide guidance on promoting safe, high quality resident care, compliant with state and federal regulations regarding monitoring the use of controlled substances .The facility shall have safeguards in place to prevent loss, diversion, or accidental exposure .Controlled substances dispensed from Pharmacy and placed on a non-automated medication cart/refrigerator are sent with a Controlled Drug Receipt/Record Disposition form and once received and place in the cart or cabinet recorded on the Narcotic Control record. Written documentation must be clearly legible with all applicable information provided .The dose noted on the medication record must match the dose recorded on the Medication Administration Record, the controlled Drug receipt/Record/Disposition form and order .The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances .Obtaining/Removing/destroying Medications .The entire amount of controlled substances obtained or dispensed is accounted for .When the dosage form dispensed is larger than the dose, the total dose administered, and that portion destroyed is documented to show the total disposition of the drug on the Controlled Drug Receipt/Record/Disposition form Each removal of medication is documented on the Controlled Drug Receipt/Record/Disposition form .Two licensed staff must witness and disposal or destruction of a controlled substance due to waste or refusal and document same on the Controlled drug Receipt/Record/Disposition form .Disposition of Discontinued/Expired Controlled Medications .Controlled substances are destroyed by a consultant pharmacist and the Director of Nursing (DON) or designee .Discrepancy resolution .Any discrepancies which cannot be resolved must be reported immediately as follows .Notify the DON immediately and the pharmacy .Compete an investigation detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted .DON, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy .Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies . 2. Review of the facility's policy titled, Pharmacy Products and Services Agreement, dated 12/2024, revealed .Supervision of the records and disposition of a controlled drugs and the maintenance of such records in sufficient detail so as to allow an accurate reconciliation of such controlled drugs .Consulting Services .Monthly narcotic destruction . 3. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with diagnoses including Low Back Pain and Chronic Kidney Disease. Review of the Controlled Drug Receipt/Record/Disposition Form revealed Rx# [prescription number] 18857027 Date Dispensed [DATE] .[Resident #57] .Drug/Name/Strength Hydrocodone/APAP [Acetaminophen] [a medication used for pain] 5/325 MG [Milligram] .Directions TAKE ONE TAB [tablet] BY MOUTH THREE TIMES DAILY .Quantity Dispensed 8 .[Licensed Practical Nurse (LPN) R] .nurse receiving medication .9 Quantity Received [DATE] .Every dose must be accounted for and requires charting on the Medication Administration Record. Disposition of Remaining Doses Quantity Destroyed: 4 . Review of the Physicians Order dated [DATE], revealed Lortab [Hydrocodone/APAP] 5 mg [milligram]-325 mg tablet PRN [as needed] Every 8 Hours for 30 Days . Review of the Controlled Drug Receipt/Record/Disposition Form revealed Rx# 18857027 Date Dispensed [DATE] .[Resident #57] .Drug/Name/Strength Hydrocodone/APAP 5/325 MG .Directions TAKE ONE TAB [tablet] BY MOUTH THREE TIMES DAILY . Quantity Destroyed: 4 .Date: [DATE] RN [Registered Nurse] Signature [RN A] . Review of the form's administration documentation revealed the following: The medication was signed as being administered on [DATE] and [DATE], with 6 tablets left after the administration on [DATE]. On [DATE] at 8:00 PM, one tablet was signed as being administered by RN A, with 5 tablets left. On [DATE] at 8:00 PM, one tablet was signed as being administered by LPN T, with 4 tablets left. The entry was crossed through with 1 line stating, Pulled in error not given, written beside LPN T's entry and marked through with several lines. The number 4 was written below LPN T's entry. Review of the Medication Administration Record (MAR) dated [DATE] revealed 1 dose of Lortab 5 mg -325 mg was administered daily on [DATE] and [DATE]. Review of the MAR dated [DATE] revealed no orders for Lortab 5mg-325 mg and no documentation that the medication was administered or attempted to be administered. Review of the Discontinued Narcotic Control Record dated [DATE], revealed 12-9 [[DATE]] [2:10 PM] .[Resident #57] Hydrocodone/APAP 5/325 MG TAB .Qty: 4 .RX: 18857027 .Nurse: [LPN R] Nurse: [LPN Z]. 4 Hydrocodone/APAP 5/325 mg tabs were documented as wasted by a pharmacist and RN A on [DATE]. The medication removed from the cart on [DATE] was not documented as given on the MAR, was not documented as wasted and the administration and note that it was pulled in error were both marked out, resulting in improper documentation of whether it was given or wasted. The discrepancy was not identified by the staff who placed the card in the drop box or by the nurse or pharmacy during drug destruction. 4. Review of the medical record revealed Resident #258 was admitted to the facility on [DATE], with diagnoses including Open Wound, Left Lower Leg, Peripheral Vascular Disease, and Polyneuropathy. Review of the Physician's order dated [DATE] revealed Gabapentin [a medication used to treat seizures and nerve pain] Capsule 300 MG Give 1 capsule by mouth three times a day . Review of the Controlled Drug Receipt/Record/Disposition Form revealed Rx# 19660408 Date Dispensed [DATE] .[Resident #258] .Drug/Name/Strength Gabapentin Capsule 300 MG .Directions TAKE ONE CAPSULE THREE TIMES DAILY .Quantity Dispensed 60 .[LPN N] .nurse receiving medication 60 Quantity Received [DATE] Date .Every dose must be accounted for and requires charting on the Medication Administration Record. Disposition of Remaining Doses Quantity Destroyed: 36 Date: [DATE] RN Signature [RN A] . Review of the forms administration documentation revealed the following: 3 tablets daily are signed out as being administer on [DATE]-[DATE]. On [DATE], 2 doses were signed as being administered, with 37 tablets left to count after the second dose. No other doses were signed out as being administered. Review of the MAR dated [DATE] revealed Gabapentin 300 mg was administered 3 times daily on [DATE]-[DATE] and 2 times at 9 AM and 2 PM on [DATE]. The medication was discontinued after the 2:00 PM dose on [DATE]. Review of the Discontinued Narcotic Control Record dated [DATE], revealed, XXX[DATE] [2025] 6A [6:00 AM] .[Resident #258] Gabapentin CAP (capsule) 300 MG .Qty: 36 .RX: 19660408 .Nurse: [LPN N] Nurse [RN T] . 36 Gabapentin 300 mg tablets were documented as wasted by a pharmacist and RN A on [DATE]. The Controlled Drug Receipt/Record/Disposition Form showed 37 tablets left but 36 tablets were documented as being placed in the drop box and as being disposed of. The discrepancy was not identified by the nurses who placed the medication in the drop box or by the nurse or pharmacist who disposed of the medication. 5. Review of the medical record revealed Resident #353 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Restlessness, Agitation, and Dementia. Review of the Physician's Order, dated [DATE], revealed Lorazepam [a medication used to treat anxiety and agitation] .2 mg/mL (milliliters) oral concentrate PRN Every 4 Hours for 30 Days .Take one quarter (0.25) milliliters by mouth every 4 hours, as needed . Review of the Controlled Drug Receipt/Record/Disposition Form revealed Rx# 19232201 Date Dispensed [DATE] .[Resident 353] .Drug/Name/Strength Lorazepam 2MG/ML LIQ [Liquid] CONC [Concentrate] Directions TAKE .(0.25) Milliliters .EVERY FOUR HOURS AS NEEDED .Quantity Dispensed 30.00 ML .[LPN N] .nurse receiving medication 30 ml Quantity Received [DATE] Date .Every dose must be accounted for and requires charting on the Medication Administration Record. Disposition of Remaining Doses Quantity Destroyed: 29 [ML] Date: [DATE] RN Signature [RN A] . Review of the forms administration documentation revealed the following: The medication was documented as being administered on [DATE], [DATE] and [DATE], with 29.25 ml being left after the dose on [DATE]. On [DATE] at 8:00 AM, LPN O signed out 0.25 ml with 29 ml left, then drew lines through the entry. On [DATE] at 11:00 AM, LPN O signed out 0.25 ml with 28.75 ml left, then drew lines through the entry. On [DATE] at 4:00 PM, LPN O signed out 0.25 ml with 28.75 ml left, then drew one line through the entry. The word Error and LPN O's initials were written 1 time in large letters beside the 3 entries, instead of beside each entry, on [DATE]. The number 29 was written below the third entry made by LPN O, indicating 29 ml was left. There was no documentation of medication being wasted. LPN N documented 29 ml left to count on the right side of the form. Review of the Medication Administration Record, dated [DATE], revealed Resident #353 received 0.25 ml of Lorazepam concentrate 1 time daily on [DATE], [DATE] and [DATE]. There was no other documentation of administration or attempted administration on [DATE]. Review of the Discontinued Narcotic Control Record dated [DATE], revealed .10/30 [[DATE]] 7A [7:00 AM][Resident #353] Lorazepam 2MG/ML LIQ CONC Qty: [12 crossed through and 29 ML written below] .RX: 19232201 .Nurse [LPN N] Nurse [RN Q] . 29 ML of Lorazepam was documented as wasted by a pharmacist and RN A on [DATE]. The medication removed from the bottle on [DATE] was not documented on the MAR as being offered to the resident or on the Controlled Drug Receipt/Record/Disposition Form as having been wasted. The discrepancy was not identified by the staff who placed the medication in the drop box or by the nurse or pharmacy during drug destruction on [DATE]. 6. Review of the facility's Discontinued Narcotic Control Record form revealed the Pharmacist and the Nurse should sign and date the bottom of the form. Review of the drug destruction records for [DATE], revealed 1 undated Discontinued Narcotic Control Record form was not signed by the Pharmacist. During an interview on [DATE] at 3:35 PM, Assistant Director of Nursing (ADON) B confirmed she destroyed medications with the pharmacist on [DATE] and did not notice that 1 of the 4 sheets was not signed by the Pharmacist. ADON B confirmed both the Pharmacist and the nurse destroying the medications should sign the Discontinued Narcotic Control Record. During an interview on [DATE] at 9:40 AM, the Director of Nursing (DON) confirmed the Pharmacist and the nurse destroying the medications should sign the Discontinued Narcotic Control Record. 7. During an interview on [DATE] at 2:23 PM, LPN AA confirmed that 2 nurses count narcotics at the beginning and end of each shift, the off going nurse looks at the Controlled Drug Receipt/Record/Disposition Form and calls out the number of pills that should be left on the card or the amount that should be left in the bottle, the oncoming nurse verifies the correct amount of medication is present. LPN AA confirmed if the narcotic count is not correct, the on call (Nurse Manager) should be notified immediately. LPN AA confirmed errors in documentation on the Controlled Drug Receipt/Record/Disposition Form should be crossed out with 1 line and initialed. LPN AA confirmed narcotic medications that are removed from the medication cart but not given are to be wasted, and a second nurse should witness the disposal of the medication and both nurses should document that it was wasted on the Controlled Drug Receipt/Record/Disposition Form. LPN AA confirmed when medications are placed in the narcotic disposal locked box, in the medication room, 2 nurses verify the count on the Discontinued Narcotic Control Record, only nurses have a key to the medication room and to the top portion of the locked box where meds are placed, only ADON B has a key to the bottom portion of the locked box where medications are removed from. During an interview on [DATE] at 2:55 PM, RN A confirmed she assisted the pharmacist with drug destruction on [DATE] and on [DATE]. RN A confirmed she had never assisted with drug destruction prior to [DATE] and was instructed by the pharmacist to look at the Discontinued Narcotic Control Record and verified the count was correct when they called it out for each Resident's medication. RN A confirmed the pharmacist wrote the quantity of the medication destroyed on the Controlled Drug Receipt/Record/Disposition Form after she signed the sheets. RN A confirmed she was not aware of any discrepancies during the drug destruction process. RN A was shown Resident #353's Lorazepam 2MG Controlled Drug Receipt/Record/Disposition Form and confirmed that LPN O had made the 3 entries with lines through them and LPN N had written 29 ml left to count (with 29 ml circled) on the right side of the form. RN A was asked, if the 3 entries made by LPN O were errored out correctly. RN A stated No. RN A confirmed the medication was not documented correctly as having been wasted. RN A was asked, what was the amount left in the bottle after the last dose that was correctly documented was given. RN A stated, 29.25 ml. RN A was asked what amount was documented as destroyed. RN A stated, 29 [milliliters]. RN A was asked, according to the amount of medication signed as being administered on the Controlled Drug Receipt/Record/Disposition Form, was the correct amount of medication destroyed. RN A stated, I don't think so. RN A was shown Resident #258's Gabapentin 300 MG Controlled Drug Receipt/Record/Disposition Form and confirmed the quantity left after the last capsule was signed as given was 37 but the quantity destroyed of was 36. RN A confirmed there was a discrepancy in the count of Resident #258's Gabapentin 300 mg. RN A was shown Resident #57's Hydrocodone/APAP 5/325 MG Controlled Drug Receipt/Record/Disposition Form and confirmed she signed as administering the medication on [DATE] and that the documentation on [DATE] was by LPN T. RN A confirmed there were 5 tablets left after she administered the medication on [DATE]. RN A confirmed the documentation by LPN T on [DATE] showing one tablet was signed as being administered, then crossed through with one line, with Pulled in error not given written to the side and crossed through was not correct documentation. RN A confirmed she was unable to tell from looking at the Controlled Drug Receipt/Record/Disposition Form if the medication on [DATE] had been given or wasted. RN A was shown the MAR dated [DATE] and confirmed there was no documentation Hydrocodone APAP 5/325 mg was signed out on [DATE] or on [DATE]. RN A was asked should medication be signed out on the MAR when it is given. RN A stated Yes. RN A confirmed there was a discrepancy with Resident # 57's Hydrocodone/APAP 5/325 mg due to the medication not being signed as given or wasted. During an interview with ADON B on [DATE] at 3:35 PM, ADON B was shown Resident #353's Lorazepam 2MG Controlled Drug Receipt/Record/Disposition Form and confirmed that the entries made by LPN O on [DATE] were not errored out correctly and the medication was not signed out as being wasted. ADON B confirmed there was a discrepancy in the quantity documented as remaining after the last dose signed out correctly and the quantity being destroyed. ADON B was shown Resident #258's Gabapentin 300 MG Controlled Drug Receipt/Record/Disposition Form and confirmed the quantity left after the last capsule was signed as given was 37 but the quantity destroyed of was 36. ADON B confirmed there was a discrepancy in the count of Resident #258's Gabapentin 300 mg. ADON B was shown Resident #57's Hydrocodone/APAP 5/325 MG Controlled Drug Receipt/Record/Disposition Form and confirmed she was unable to tell from looking at the form if the medication removed from the cart had been given or wasted on [DATE]. ADON B was shown the MAR dated [DATE] and confirmed there was no documentation Hydrocodone APAP 5/325 mg was signed out on [DATE] or on [DATE]. ADON B confirmed medications should be signed out on the MAR after they are administered. ADON B confirmed there was a discrepancy in the count of Resident #57's Hydrocodone/APAP 5/325 mg. ADON B confirmed she usually wastes medications with the pharmacy but did not assist on [DATE] and [DATE]. ADON B confirmed the pharmacist looks at the actual medication and the Controlled Drug Receipt/Record/Disposition Form, she looks at the Discontinued Narcotic Control Record and confirms the quantity the pharmacist calls out. ADON B confirmed the discrepancies with the medications should have been identified by staff placing medications in the locked box or during drug destruction. ADON B confirmed if medication discrepancies are identified an investigation should be initiated. ADON B was asked if an investigation was initiated to determine the cause of any of these discrepancies. ADON B stated, It doesn't look like it. During an interview on [DATE] at 9:40 AM, the DON confirmed she was not notified until [DATE] about the discrepancies with drug destruction on [DATE] and [DATE]. The DON confirmed 2 nurses count narcotics each shift and 2 nurses verify the count when placing them in the drug destruction lock box for disposal. The DON confirmed the quantity documented as being left and the quantity documented as being destroyed did not match on Resident #258's Gabapentin 300 mg. The DON confirmed medication was errored out incorrectly or not documented correctly as being wasted on Resident #57's Hydrocodone/APAP 5/325 MG Controlled Drug Receipt/Record/Disposition Form and Resident #353's Lorazepam 2MG Controlled Drug Receipt/Record/Disposition Form. The DON confirmed Hydrocodone /APAP 5/325 mg was not documented as administered or wasted on Resident #57's [DATE] MAR. The DON confirmed Gabapentin 300 mg was not documented as given after 2:00 PM on [DATE] on Resident #258's [DATE] MAR. The DON confirmed Lorazepam 2mg was not documented as being wasted or administered on [DATE] on Resident #353's [DATE] MAR. The DON was asked should staff have identified these discrepancies during narcotic count, when placing them in the drug destruction box, or during the drug destruction process. The DON stated, Yes. The DON was asked, should you be notified as soon as discrepancies are identified. The DON stated, Yes .

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 1 staff member (Wound Nurse) left the treatment cart unlocked, unattended, and out of sight. The findings include: Review of the facility's policy Medication Storage, dated 12/1/2024, revealed .All drugs and biologicals will be stored in locked compartments .medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls .Only authorized personnel will have access to the keys to locked compartments. A random observation and interview on the 300 hall on 1/16/2025 at 2:50 PM, revealed an unlocked, and unattended treatment cart. The Director of Nursing (DON) was coming up the hall and was asked, are there medications on this treatment cart. The DON stated, Yes. The DON was asked should the cart be left unlocked and unattended. The DON stated, No. Observation and an interview on the 300/400 hall, at the treatment cart on 1/16/2025 at 5:50 PM, revealed a 0.50 ounce (oz) tube of Medihoney (medication to debride pressure wounds), a 56.7 oz tube of B & C wound dressing (medication used to treat wounds), one pair of nail clippers, a 4oz tube of hydrogel (medication to treat pressure wounds), a 0.22 gram tube of Mipircron ointment (medication used to treat hard to heal wounds), and a 15 gram bottle of Nyamyc topical powder (used to treat wounds with fungus and yeast). The Wound Nurse was asked are these medications used for wounds and skin issues. The Wound Nurse stated, Yes, they are .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, job description review, and interview, the facility failed to ensure comprehensive nutritional assessments were completed timely by a dietitian for 2 of 3 (Resident #256 and Resident #259) residents reviewed for new admissions. The findings include: 1. Review of the facility's policy titled, Nutritional Management, dated 12/1/2024, revealed .The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall conditions .A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission . Review of a Registered Dietitian job description undated and unsigned revealed .Major Duties and Responsibilities .Provides registered dietitian services in one or more sites according to policies and procedures, and federal and state requirements. Plans, organizes, develops, and directs the nutritional care of the resident in accordance with current federal, state, and local standards, guidelines, and regulations. Assesses/Monitors the residents' nutritional status and provides recommendations to clinical/medical staff. Completes nutritional assessments on residents . 2. Review of the medical record revealed Resident #256 was admitted on [DATE], with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, and Dependence on Renal Dialysis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #256 was severely cognitively impaired. Review of the medical record revealed the facility failed to complete a comprehensive nutritional assessment within 72 hours of admission for Resident #256 until 1/16/2025, 6 days after admission. 3. Review of the medical record revealed Resident #259 was readmitted to the facility on [DATE], with diagnoses including Protein-Calorie Malnutrition, Toxic Encephalopathy, and Respiratory Failure. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #259 was cognitively intact. Review of the medical record revealed the facility failed to complete a comprehensive nutritional assessment within 72 hours of admission for Resident #259 until 1/16/2025, the 8th day after admission. During an interview on 1/13/2025 at 8:52 AM, the uncertified Director of Dietary (DD) confirmed the former Registered Dietitian quit after Christmas. The DD was asked who supervises her since she was not certified. The DD stated, No one, I am on my own. During an interview on 1/15/2025 at 3:40 PM, the Director of Nursing (DON) confirmed that the former Registered Dietitian's last day of employment was 12/27/2024 and that the new Dietitian (working remotely) started on 1/13/2025. The DON confirmed that Resident #256 and Resident #259 did not have a comprehensive nutritional assessment completed within 72 hours of admission or readmission.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a dirty ice machine. The facility had a census of 88 residents. The findings include: 1. Review of the facility policy titled, Ice Machines and Portable Ice Carts, dated 12/1/2024, revealed .It is the policy of this facility to ensure that ice machines/carts are working and in proper order, cleaned, and maintained .Ice machines/carts can be prone to microbial contamination due to improper handling or storage of ice, poor cleaning .Proper cleaning, maintenance, and infection control in relation to the ice machines is important to decrease the risk of illness to residents .The ice machines will be cleaned at any time contamination may have occurred or when visibly soiled . 2. During an interview on 1/14/2025 at 11:07 AM, the Dietary Director (DD) stated the cleaning/maintenance of the ice machine was contracted with an outside company. The DD was asked who in the facility was responsible for the ice machine. She stated, I am. Observation of the ice machine located in the Activity Room on 1/14/2025 at 1:18 PM and 2:35 PM, revealed a white chalky substance dripping down the left and right sides of the machine, and down the cart the ice machine was sitting on. During an interview on 1/14/2025 at 2:39 PM, the Administrator confirmed the ice machine should be clean and should not have white chalky substance anywhere on the machine or the cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infections when 1 of 14 staff (Certified Nursing Assistants (CNA) G) failed to properly remove their personal protective equipment (PPE) during dining services, when 2 of 15 staff (CNA F and Certified Occupational Therapist Assistant (COTA) BB) failed to properly disinfect reusable resident equipment before exiting an isolation room, and when 2 of 14 staff (CNA H and CNA I) failed to perform hand hygiene during dining. The findings include: 1. Review of the facility's policy titled, Routine Cleaning and Disinfection, dated 12/2024, revealed .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible .Resident chairs .Standard precautions will be adhered to when cleaning any blood or body fluid spills, or soiled material that have the potential to contain these or other potentially contaminated substances .Use of gloves, gown, mask, eye protection or face shield . Review of the facility's undated policy titled, Resident Rights, revealed .Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment . Review of the facility's policy titled, Infection Prevention and Control Program, dated 12/1/2024, revealed .Equipment Protocol .Single use devises must be discarded after use and are never used for more than one resident .Reusable items potentially contaminated with infectious materials shall be placed in an impervious clear plastic bag. Label bag as CONTAMINATED and place in the soiled utility room for pickup and processing . Review of the facility policy titled, Transmission-Based (Isolation) Precautions, dated 12/1/2024, revealed .It is our policy to take appropriate precautions to prevent transmission of pathogen, based on the pathogens' mode of transmission .Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions . Review of the facility policy titled, Hand Hygiene, dated 12/2024, .All staff will perform proper hand hygiene procedures to prevent the spread of infection .After handling items potentially contaminated with blood, body, fluids, secretions, or excretions .Before applying and after removing personal, protective (PPE), including gloves . 2. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE], with diagnoses including Urinary Tract Infection, Acute Kidney Failure, Chronic Obstructive Pulmonary Disease, and Muscle Weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #38 had a Brief Interview for Mental Status Score (BIMS) of 14, which indicated the resident was cognitively intact. Review of a Nurses Note dated 1/9/2025, revealed Resident tested positive for covid .isolation . Review of a Physicians Order dated 1/16/2025, revealed .Infection .COVID 19 .Precautions Type .contact, droplet .Covid Isolation starting 1/9/2025 . Review of the Care Plan dated 1/16/2025, revealed .The resident has a Respiratory Infection [COVID19] .Isolation-droplet precautions .Date Initiated .1/16/2025 .Revision on .1/16/2025 . Observation and interview on the 200 hall on 1/15/25 at 8:13 AM, revealed COTA BB, was standing outside of the resident's room and was given a wheelchair from inside Resident #38's room, swiped the arms of the wheelchair and the seat of the wheelchair, walked down the hall with her gloves on, entered the therapy gym, and sprayed the wheelchair with a disinfectant spray and let it stand to dry. The COTA BB was asked should you have cleaned the contaminated chair outside in the hallway. The COTA stated, I wiped a little of it down with the cloth . The COTA confirmed the chair should have been cleaned inside of the resident's room thoroughly prior to pushing the chair down the hallway to the therapy gym. During an interview on 1/16/2025 at 11:10 AM, the Director of Nursing (DON) and the Infection Control Preventionist (ICP) confirmed that Resident #38 was positive for COVIID on 1/9/2025 and has been in Transmission Based Precautions since 1/9/025. During an interview on 1/16/2025 at 7:30 PM, the DON confirmed that reusable resident equipment should be cleaned with an approved disinfectant prior to bringing the equipment out of the resident's room who is in transmission-based precautions. The DON confirmed the wheelchair should have been cleaned in the Resident #38's room prior to being transported down the hallway to the therapy gym. 3. Review of the medical record revealed Resident #80 was admitted to the facility on [DATE], with diagnoses including Cellulitis of bilateral lower limbs, Pressure Ulcer of Left Buttock, Diabetes, Influenza, Dementia, Cardiomegaly, and Pneumonia. Review of the admission Minimum Data Set (MDS) dated [DATE], Resident #80 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition. Review of the Physician's Orders dated 1/9/2025, revealed .Droplet isolation for THE FLU .every shift . Observations on the 400 hall on 1/13/2025 at 9:54 AM and 4:59 PM, on 1/14/2025 at 8:20 AM and 4:57 PM, confirmed Resident #80 was in Enhanced Barrier Precautions and should have been in Transmission Based Precautions for influenza. Observation on 400 Hall on 1/13/2025 at 12:12 PM, revealed CNA G applied an isolation gown and gloves prior to entering Resident #80's room with meal tray, exited the isolation room and removed her gown and gloves in the hallway. CNA G rolled up the gown and gloves in her hand and walked down the hall to the shower room to discard of the used isolation gown and gloves. During an interview on 1/13/2025 at 12:26 PM, CNA G was asked where she should have removed her PPE. CNA G stated. In the resident's room. 4. Review of medical record revealed Resident #92 was admitted on [DATE], with diagnoses including Anxiety and COVID-19. Review of the admission MDS dated [DATE], revealed Resident #92 had a BIMS score of 15, which indicated the resident was cognitively intact. Review of the Physician's orders dated 1/11/2025, revealed .Infection: COVID-19 . Precaution Type: droplet . Observation during dining on 1/13/2025 at 12:29 PM, revealed CNA F exited Resident #92's room with goggles on top of her head, and attempted to enter another resident's room, before cleaning her goggles. During an interview on 1/13/2025 at 12:31 PM, CNA F confirmed that she should have removed the goggles before exiting the room. 5. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE], with diagnoses including Diabetes and Acquired Absence of Right Leg Above the Knee. Review of the admission MDS dated [DATE], revealed Resident #49 had a BIMS score of 11, which indicated the resident was moderately cognitively impaired. Observation on 1/14/2025 at 7:48 AM, revealed CNA H entered Resident #49's room, picked up the bed remote to raise the bed, repositioned the resident, picked up a breakfast sandwich with her bare hands, and handed it to Resident #49. CNA H failed to perform hand hygiene after touching a potentially contaminated items and failed to apply gloves before picking up the resident's food and serving it to a resident. 6. Review of the medical record revealed Resident #5 was admitted to the facility 7/30/2021, with diagnoses including Diabetes and Dementia. Review of the quarterly MDS dated [DATE], revealed Resident #5 had a BIMS score of 3, which indicated the resident was severely cognitively impaired. Observation on 1/14/2025 at 8:03 AM, revealed CNA I entered Resident #5's room, picked up and moved a floor mat to the other side of the room, and failed to perform hand hygiene. CNA I then removed Resident #5's lid from the plate, put sugar in the resident's coffee and cut up the resident's food. CNA I failed to perform hand hygiene after touching potentially a contaminated item and before setting up the resident's meal tray. During an interview on 1/16/2025 at 7:52 PM, the DON stated .Reusable equipment should be cleaned thoroughly before exiting a resident's room [isolation], then allowed to dry before transporting to a clean area . During an interview on 1/16/2025 at 5:43 PM, the DON confirmed staff should not use their bare hands to pick up the resident's food, should use gloved hands to pick up the resident's food, and perform hand hygiene before and after applying gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to maintain privacy and confidentiality of resident medical records for 3 of 5 sampled residents (Resident #33, #70, and #339) observed during medication administration. The findings include: Review of the facility's policy titled, Patient Confidentiality with a revision date of 2/2021, revealed .All efforts will be made to protect the confidentiality/privacy of the resident and their health information. This includes privacy in relation to care, medical records protection . Review of the medical record, revealed Resident #70 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Neuropathy, Anxiety, and Hypertension. Observation in the 400 Hall on 7/20/2021 at 8:20 AM, revealed Resident #70's Medication Administration Record (MAR) was left open and unattended on the computer monitor screen on the medication cart. The resident's name and medications were visible on the computer monitor screen. Review of the medical record, revealed Resident #339 was admitted to the facility on [DATE] with diagnoses of Pulmonary Hypertension, Cardiomegaly, and Depressive Disorders. Observation in the 400 Hall on 7/20/2021 at 8:30 AM, revealed Resident #339's MAR was left open and unattended on the computer monitor screen on the medication cart. The resident's name and medications were visible on the computer monitor screen. Review of the medical record, revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Chronic Pain, Depressive Disorders. Observation in the 400 Hall on 7/20/2021 at 8:51 AM, revealed Resident #33's MAR was left open and unattended on the computer monitor screen on the medication cart. The resident's name and medications were visible on the computer monitor screen. During an interview on 7/21/2021 at 7:51 PM, the Director of Nursing (DON) was asked if a resident's personal health information should be visible on the computer monitor screen when the medication cart was unattended. The DON stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Nursing Home Transfers and Discharges Frequently Asked Questions (FAQ), medical record review, and interview, the facility failed to notify the Ombudsman of emergency transfers for 2 of 4 sampled residents (Resident #59 and #61) reviewed for hospitalizations. The findings include: Review of undated document titled Nursing Home Transfers and Discharges FAQ, revealed .This monthly report should include all residents who are transferred out of the facility for care. This includes all emergency room visits, geri-psych [Geriatric-Psychiatric] stays or hospital stays . Review of the medical record, revealed Resident #59 was admitted to the facility on [DATE] with diagnoses of Bariatric Surgery, Hypertension, Adult Failure to Thrive, and Anxiety. Review of a Nurses 'Note dated 3/25/2021, revealed, .NP [Nurse Practitioner] evaluated resident due to BP [blood pressure] 80/40, pulse 105, temp [temperature] 100.4. Noted a very foul odor to wound vac. NP gave order to send to ER [emergency room] for further evaluation . Review of a Nurses' Note dated 3/25/2021, revealed .Called [Named Hospital] for an update on Resident [Resident #59] .RN [Registered Nurse] stated that she was admitted to ICU [Intensive Care Unit] for hypotension and sepsis . Review of the medical record, revealed Resident #61 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Urine Retention, Abnormal Weight Loss, Heart Failure, and Neuromuscular Dysfunction of Bladder. Review of a Physician's Order dated 3/16/2021, revealed Resident #61 was admitted to the hospital for a Right Hip Fracture. There was no documentation that the Ombudsman had been notified of these transfers to the hospital for Resident #59 and #61. During an interview on 7/21/2021 at 8:15 AM, the Administrator stated, .She [Business Office Manager] was not using the correct form and she wasn't sending the hospital discharges to the Ombudsman .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure Care Plan interventions were implemented and followed for 2 of 6 sampled residents (Resident #26 and #65) reviewed for activities of daily living (ADLs). The findings include: Review of the facility's policy titled, .Comprehensive Careplan [Care Plan] ., revised 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, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will be prepared by an interdisciplinary team .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 . Review of the facility's policy titled, .Range of Motion - Prevention of Decline Policy, revised 5/31/2020, revealed .Range of Motion .means the full movement potential of a joint .The facility in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventive care .Licensed nurses will assess resident's range of motion (such as current extent of movement of his/her joints and the identification of limitations) on admission/readmission, quarterly, and upon a significant change .Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion .This includes .Appropriate equipment .Care plan interventions will be developed and delivered through the facility's restorative Program .A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions . Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Cerebral Vascular Accident (CVA), Hypertension, Convulsions, and Aphasia. Review of a Quality Assurance (QA) Contract for Resident #65 dated 4/14/2020, revealed .Please complete hand hygiene of washing and thoroughly drying of bilateral hands daily .After hygiene .place BLUE THERAPY CARROTS in both hands. The larger end of the Therapy Carrot should be placed in thumb with remaining fingers wrapped around rest of Therapy Carrot. The right hand is typically less resistive, however the left hand is more resistive requiring more extensive PROM [Passive Range of Motion] to placing the Therapy Carrot. Pt. [Patient] can wear these at all times with exception of hygiene which should be completely [completed] daily . Review of an Occupational Therapy (OT) Screen dated 3/1/2021, revealed .Patient was d/c'd [discontinued] from OT services in April 2020 with QA written for patient to have Blue Therapy Carrots in bilateral hand [hands], and hands to be thoroughly cleaned daily. Patient did not have carrots in bilateral hands upon writer's assessment . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #65 had severe cognitive impairment, was totally dependent on staff for Activities of Daily Living (ADL), and had impaired range of motion to both upper and lower extremities. Review of the Care Plan dated 9/30/2021 revealed, .hemiplegia to R [Right] side related to CVA Blue therapy carrots (hand rolls) to hands bilaterally daily . The Care Plan did not describe how to place the carrots in both hands and did not specify that the carrots were to be always worn, except for (hand) hygiene. Review of the Resident Care Summary Assessment (a form provided to the Certified Nursing Assistants (CNAs) so they will know how to care for the resident), revealed .carrots/handrolls to hands bilaterally as tolerated . The Resident Care Summary Assessment did not describe how to place the carrots in both hands and did not specify that the carrots were to be always worn, except for (hand) hygiene. Review of an Occupational Therapy Screen dated 6/14/2021 revealed when the therapist entered Resident #65's room, she noted the bilateral hand carrots were in the bedside table. Observation in the resident's room on 7/19/2021 at 2:12 PM, and 7/20/2021 at 10:15 AM, revealed Resident #65 lying in bed. There were no blue carrots in her hands. During an interview on 7/20/2021 at 10:17 AM, CNA #2 confirmed she was the CNA for Resident #65. She was asked if she placed the blue therapy carrots in Resident #65's hands when she performed her ADL care. She stated, .I didn't know we were supposed to . During observation and interview in the resident's room on 7/20/2021 at 11:00 AM, CNA #1 and Restorative CNA #7 confirmed there were no blue therapy carrots or handrolls in Resident #65's hands. Restorative CNA #1 stated she was supposed to have handrolls placed in her hands daily. CNA #1 stated, .I don't know why they forget to put the handrolls on . Restorative CNA #7 was able to open Resident #65's left hand slightly, and a foul odor came from the hand. Both CNAs confirmed the foul odor and CNA #1 stated, .that [left hand] needs to be cleaned . During an interview on 7/21/2021 at 9:05 AM, the MDS/Restorative Coordinator was asked why the application of handrolls instead of carrots was written in the Care Plan for Resident #65. She stated, .I didn't know what a carrot was . During an interview on 7/21/2021 at 9:37 AM, the OT was asked if therapy carrots and handrolls are the same thing. She said they were two different things and stated, .When I discharged her, I recommended the blue therapy carrots in both hands . She confirmed Resident #65 was to always have the blue therapy carrots, except during hand hygiene. She confirmed she made the recommendation during the Interdisciplinary Team Meeting which included the MDS/Restorative Coordinator. She confirmed the recommendations go on the Care Plan and the nurses should carry out the Care Plan. During an interview on 7/21/2021 at 1:19 PM, the MDS/Restorative Coordinator was asked if the facility could provide documentation that CNAs placed the devices in Resident #65's hands daily for the entire day. She stated there was no charting system for that. Review of the facility's policy titled, Hearing and Vision Policy, dated 10/2020, revealed .It is the policy of this facility to ensure that residents receive proper treatment and assistive devices to maintain vision .Employees should refer any identified need for hearing or vision services/appliances to the social worker .Employees will assist the resident with the use of any devices .needed to maintain vision .Assistive devices to maintain vision include glasses . Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Hypertension, Alzheimer's Disease, Dementia, Anxiety, and Depression. Review of the Care Plan dated 12/1/2020, revealed .ability to see in adequate light is impaired .Assist [Resident #26] to clean and put on glasses each morning . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #26 had impaired vision and required extensive to total assistance from staff for all Activities of Daily Living (ADLs). Observation on 7/18/2021 at 9:03 AM, 12:16 PM, and 3:33 PM, on 7/19/2021 at 7:42 AM and 2:10 PM, on 7/20/2021 at 10:28 AM and 4:10 PM, and on 7/21/2021 at 8:40 AM, revealed Resident #26 was not wearing glasses. During an interview on 7/19/2021 at 9:16 AM, Resident #26's family member was asked if there were any concerns about Resident #26. The family member confirmed Resident #26's glasses were missing. During an interview on 7/19/2021 at 5:14 PM, the Social Worker stated she was not aware that Resident #26's glasses were missing. During an interview on 7/21/2021 at 8:40 AM, CNA #6 was asked where Resident #26's glasses were. CNA #6 stated, .thank you for telling me .she does wear glasses .she had them at one time .I know I haven't seen them .we get so busy, we don't think about it . During an interview on 7/21/2021 at 8:45 AM, Licensed Practical Nurse (LPN) #3 was asked about Resident #26's glasses. LPN #3 confirmed she didn't know Resident #26 had glasses and stated, .When she gets a card, we read it to her . During an interview on 7/21/2021 at 3:47 PM, the MDS/Restorative Coordinator was asked if the CNAs who care for Resident #26 should know she had glasses and should assist her with them. She confirmed the CNAs knew she had glasses because it's on the Care Plan and on the Resident Care Summary Assessment. She confirmed the CNAs should have reported the missing glasses to the charge nurse. During an interview on 7/21/2021 at 8:00 PM, the Director of Nursing (DON) confirmed the purpose of the resident's Care Plan was for the facility staff to know how to care for the resident. She confirmed that if the Care Plan included an intervention for staff to clean and apply a resident's glasses, staff should make sure the resident has their glasses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to revise a Care Plan related to dialysis for 1 of 1 sampled resident (Resident #44) reviewed for dialysis care and services. The findings include: Review of the facility's policy titled, Comprehensive Careplan [Care Plan] ., revised 3/25/2021, revealed .The comprehensive care plan will describe at a minimum the following .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the medical record, revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Atrial Fibrillation, End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Kidney Disease Stage 3, and Diabetes. Review of the Physician's Order dated 6/16/2021, revealed .Dialysis Tuesday-Thursday-Saturday Continuous .[Named Dialysis Clinic] . Review of the Care Plan dated 5/27/2021, did not reflect dialysis care and services for Resident #44. During an interview on 7/20/2021 at 4:00 PM, the Minimum Data Set (MDS) Coordinator confirmed Resident #44 started receiving dialysis care and services on 6/16/2021. During an interview on 7/21/2021 at 8:55 AM, the MDS/Restorative Coordinator confirmed Resident #44's Care Plan should have been updated and revised to reflect dialysis care and services.

Based on observation and interview, the facility failed to properly store and maintain medications safely and securely when 1 of 7 medication storage areas (400 Hall Medication Cart) had a large hole in the third drawer from the top of the cart. The findings include: Observation of the 400 Hall Medication Cart on 7/19/2021 at 8:55 AM and 2:59 PM, and on 7/20/2021 at 8:43 AM and 9:40 AM, revealed the medication cart had a large hole in the third drawer from the top of the cart. During an interview on 7/20/2021 at 9:43 AM, Licensed Practical Nurse (LPN) #2 confirmed the drawer was broken, with a large hole in the drawer. She was asked how long the hole had been there. She stated, .at least 2 weeks . She was asked if the medication cart was secure. She stated, It shouldn't have a hole in it. During an interview on 7/20/2021 at 9:49 AM, the Maintenance Director confirmed the large hole in the third drawer of the cart, and it measured it as 3.5 inches by 0.5 inches.

Based on policy review, observation, and interview, the facility failed to maintain or enhance resident dignity and respect when 5 of 17 staff members (Certified Nursing Assistant (CNA) #3, #4, #5, and #6 and Licensed Practical Nurse (LPN) #1) did not use courtesy titles to address Resident #38, #50, #61, #70, #71, and #339 during dining, and 1 of 4 nurses (LPN #2) failed to provide dignity for Resident #33 during medication administration. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity Policy, with a revision date of 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 as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Maintain resident privacy . Observation in the resident's room during dining on 7/19/2021 at 7:36 AM, revealed CNA #3 stated, .she's a feeder, within hearing distance of Resident #61. Observation in the resident's room during dining on 7/19/2021 at 7:43 AM, revealed LPN #1 stated, .he's not a feeder, within hearing distance of Resident #70. Observation in the resident's room during dining on 7/19/2021 at 7:51 AM, revealed CNA #4 stated, .she's a feeder, within hearing distance of Resident #50. Observation in the resident's room during dining on 7/19/2021 at 7:59 AM, revealed CNA #4 stated, .she's not a feeder, within hearing distance of Resident #71. Observation in the resident's room during dining on 7/19/2021 at 8:16 AM, revealed CNA #5 stated, .she's not a feeder, within hearing distance of Resident #38. Observation in the resident's room during dining on 7/19/2021 at 8:35 AM, revealed CNA #6 stated, .she's a feeder, within hearing distance of Resident #339. Observations in the resident's room on 7/20/2021 at 8:41 AM, during medication administration, revealed LPN #2 unzipped Resident #33's gown, exposing her chest and bra, as she looked for an old medication patch to remove before applying a new one. The door to the room was open, and Resident #33 could be seen from the hallway. During an interview on 7/21/2021 at 7:45 PM, The Director of Nursing (DON) confirmed residents should not be called feeders. The DON was asked if a resident's room door should be closed when staff exposed a resident's chest and bra. The DON stated, .yes .

Based on policy review, observation, and interview, the facility failed to deliver meal trays to residents in a timely manner resulting in delayed mealtimes on the 400 Hall. This had the potential to affect 37 of the 89 residents who had received a meal tray. The findings include: Review of the facility's policy titled, Dietary-Dining Services, dated 10/2020, revealed .Cart Delivery Times Meals must be delivered to the residents in a timely fashion . Observation of the 400 Hall meal cart revealed the cart was delivered to the 400 Hall on 7/19/2021 at 7:26 AM. Observation of the 400 Hall meal cart on 7/19/2021, revealed the last meal tray served to a resident was at 8:40 AM. One hour and 14 minutes elapsed between the time the meal cart arrived on the hall and the last tray was served. During an interview on 7/21/2021 at 7:45 PM, the Director of Nursing confirmed meal cart delivery on the hall should be 30 minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Centers for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidance, medical record review, observation, and interview, the facility failed to ensure measures to prevent the potential spread of infection were followed when an indwelling urinary catheter bag was on the floor for 1 of 1 sampled resident (Resident #27) reviewed with an indwelling urinary catheter, and the Activity Director and Certified Nursing Assistant (CNA) #8 entered the front door of the facility and walked throughout the facility prior to being screened. The finding include: Review of the CMS Long-Term Care Facility Guidance dated 4/2/2020, revealed .Long-term care facilities should immediately implement symptom screening for all .In accordance with previous CMS guidance, every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors .) should be asked about COVID-19 symptoms and they must also have their temperature checked. An exception to this is Emergency Medical Service (EMS) workers responding to an urgent medical need. They do not have to be screened, as they are typically screened separately .Facilities should limit access points and ensure that all accessible entrances have a screening station . Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of Hypertension, Chronic Kidney Disease, and Retention of Urine. Review of a Physician's Order dated 5/12/2021, revealed .Change catheter bag .two times monthly .Change foley catheter .as needed . Observations in the resident's room on 7/18/2021 at 8:45 AM and 12:36 PM, 7/19/2021 at 7:31 AM, and on 7/20/2021 at 8:20 AM, revealed Resident #27's bedside drainage bag was hanging on the side of the bed and the bag and tubing were touching the floor. During an interview on 7/21/2021 at 8:20 AM, the Director of Nursing (DON) was asked if a bedside drainage bag should be on the floor. The DON stated, .No, it should never be on the floor. Observation at the front door of the facility on 7/18/2021 at 12:00 PM, the Activity Director was observed entering the front door of the facility, wearing a mask, sanitized her hands, then walked down a short hallway to the main Dining Room, she walked in between the tables of residents that were waiting for lunch, into a hallway next to the Kitchen (where the time clock and screening station was located), prior to being screened for COVID-19 symptoms. During an interview on 7/18/2021 at 12:05 PM, the Activity Director was asked if she screens for symptoms when she enters the building. The Activity Director stated that she screens at the time clock. During an interview on 7/19/2021 at 3:43 PM, Certified Nursing Assistant (CNA) #8 confirmed she comes into the front door of the facility and stated, . I go to the clock, take my temp [temperature] and answer [screening] questions .

Based on policy review, United States Drug Administration (USDA) Refrigeration & Food Safety Chart review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by dust particles on the wall near the steam table and over a tray of dietary bowls, rust and dust particles on the vents over the steam table, when food items were stored opened and undated in the walk-in cooler, walk-in freezer and the reach-in refrigerator, when food was stored past the open dates in the walk-in refrigerator, when 1 of 3 dietary staff (Dietary Staff #1) touched food with her bare hands, and when 1 of 18 staff members (Certified Nursing Assistants (CNA) #1) were observed touching a resident's food. The facility had a census of 87, with 83 of those residents receiving a meal tray from the kitchen. The findings include: Review of the facility's policy titled, Food Service, dated 7/12/2021, revealed .All stored items should have an expiration date or a purchase/delivery date . Review of the USDA Refrigeration & Food Safety Chart guidelines titled, USDA Food Purchased Refrigerated, dated 1/28/2021, revealed .Ham (Pre-Cooked) Fully Cooked Slices .Refrigerator 3-4 days .hot dogs after opening .Refrigerator .1 week . Observation during the initial tour of the Kitchen on 7/18/2021 beginning at 9:05 AM, revealed the following: a. dark dust particles on the wall next to the steam table b. 43 bowls sitting on a tray on top of a stainless-steel meal cart with dark dust particles noted on top of the meal cart and dark dust particles on the ceiling tile above the cart and the bowls. c. Dietary Aide #1 used her bare hands to transfer cake slices from the aluminum package to the serving bowls. d. 15 slices of bread in a clear package stored on a metal rack near the handwashing station, opened and undated, without an expiration date or received date. e. 13 bread halves and 3 hamburger buns stored on top of a box on a metal cart near the entrance of the walk-in freezer undated. f. 6 hot dog buns on the shelf in the walk-in cooler, opened and undated. g. 3 Bratwurst Sausage on the shelf in the walk-in freezer, opened and undated. h. 4 breaded fish fillets on the shelf in the walk-in freezer, opened and undated. i. a large stainless-steel stock pot on the bottom shelf of a metal table outside of the Dietary Manager's office uncovered and with a green film on the top. j. 1/2 of a tomato in a bowl on the top of the steam table uncovered. k. 5 slices of bacon on a plate on the top of the steam table uncovered l. 1 bowel of corn flakes sitting on a metal cart near the steam table uncovered. m. 5 slices of yellow cake in bowls on top of the work-station at the end of the steam table uncovered. Observation in the Kitchen in the dry food storage room on 7/19/2021 beginning at 8:00 AM, revealed the following: a. 1 bag of graham cracker crumbs opened and undated. b. 1 bag of elbow macaroni opened and undated. c. 1 bag of linguine noodles opened and undated. d. 1-21 oz (ounce) plastic container of garlic powder opened and undated. e. 1-16 oz plastic container of whole celery seed opened and undated. f. 1-14 oz plastic container of ground cayenne pepper opened and undated. g. 1-12 oz plastic container of poultry seasoning opened and undated. h. 1-15 oz plastic container of ground cinnamon opened and undated. i. 1-13 oz plastic container of Mediterranean style ground oregano opened and undated. j. 1-12 oz plastic container of ginger powder opened and undated. k. 1- 28 oz plastic container of lemon pepper seasoning salt opened and undated. l. 1-16 oz plastic container of chili powder opened and undated. m. 1-6 oz plastic container of thyme opened and undated. n. 1-16 oz plastic container of ground cinnamon opened and undated. o. 1-64 oz container of Unsweetened Almond Milk opened and undated in the reach in refrigerator. p. 1 Pimento cheese sandwich in a plastic storage bag undated in the reach in refrigerator. n. 1 plastic storage bag with ham slices dated 7/14/2021, stored past the refrigerated storage date in the reach in refrigerator. o. 1-5 lb [pound] plastic container of chicken salad with the seal broken and the lid lifted with no open date in the reach in refrigerator. During an interview on 7/19/2021 at 8:45 AM, the Dietary Manager was asked should dry foods and spices be stored without an open date. The Dietary Manager stated, No, they should have dates [open dates]. The Dietary Manager confirmed that the walls, ceiling tiles and vents should be free of dust and rust. During an interview on 7/20/2021 at 3:45 PM, the Registered Dietician (RD) confirmed that the pimento cheese sandwich should have had a date put on it when it was put into the reach-in refrigerator. The RD confirmed that any food left out should be covered and dated. The RD confirmed that the vents and ceiling tiles should be free of dust and debris. The RD confirmed that food which has been opened should be stored with an open date when placed in the walk-in cooler or the reach in refrigerator. The RD was asked if staff should touch food with their bare hands. The RD stated, No, they shouldn't. Observation in the Dining Room on 7/20/2021 at 7:55 AM, revealed CNA #1 spread jelly on Resident #20's biscuit with her bare hands, without performing hand hygiene. During an interview on 7/21/2021 at 8:25 AM, the Director of Nursing (DON) was asked if staff should handle resident's food with their bare hands. The DON stated, Absolutely not.