**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 resident assessments were completed at the time of a fall and that a post fall assessment was completed after falls for 1 of 12 (Resident #29) residents reviewed for falls. The findings include: 1. Review of the facility's policy titled, Fall Documentation Protocol, with a revised date of 2/13/2025, revealed An incident report must be completed whenever there is a fall by the nurse on duty in [Named Electronic Medical Record] .MD [Medical Doctor], RP [Responsible Party], and DON [Director of Nursing] must be contacted .all falls must have neuro checks (witnessed or unwitnessed) .Fall investigation .statements .from staff on duty .Fall assessment should be completed .Fall assessment should be completed in [Named Electronic Medical Record] .care plan should be updated .72 hour follow up nurse's note must be done after each fall every shift .Ensure each section is completed. It's not completed until you have signed the last section. Review of the facility's policy titled, Fall Prevention Program, dated 10/21/2024, revealed .Each resident's risk factors and environment hazards will be evaluated when developing the resident's comprehensive plan of care.Interventions will be monitored for effectiveness.The plan of care will be revised as needed.When any resident experiences a fall, the facility will.Assess the resident.Complete a post-fall assessment.Complete an incident report.Document all assessments and actions.Obtain witness statements. 2. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Dementia with Psychotic Disturbance, Obsessive Compulsive Behavior, and Anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #29 had severe cognitive impairment. Review of the Care Plan dated 4/29/2025, revealed .fall no injuries obtain UA [urinalysis] .fall 5/26/2025 no injuries- Staff to do frequent checks while resident is in restroom he stays for extended periods of time .6/5/2025 fall no injuries Staff will encourage to use bigger bathroom with more room and transfer bars . Review of the facility's Fall investigation, dated 4/29/2025, revealed Resident #29 .Fell in the bathroom when resident got up to bathroom . Review of the Incident report dated 4/29/2025, revealed .[Resident #29] observed on floor on butt in bathroom. [named Resident #29] said I fell off the toilet . Review of the Progress Note for Resident #29 dated 4/30/2025, revealed continue f/u [follow up] observance, falling star safety measures in effect, neuro negative, no new c/o [complaints] . Review of the Fall Risk Evaluation dated 4/29/2025, revealed a score of 12, which indicated Resident #29 was a high risk for the falls. The facility was not able to provide a Resident assessment, the post fall assessment, or staff statements for Resident #29's fall on 4/29/2025. Review of the facility's Incident Report dated 5/26/2025, revealed Resident #29 was .observed in bathroom on floor upright in front of toilet. Review of the Progress Note dated 5/26/2025, revealed observed [Resident #29] at 0715 [7:15 AM] on floor in bathroom sitting upright in front of toilet, he says I fell getting off the toilet . Review of the Fall Risk Evaluation dated 5/16/2025, revealed a score of 14, which indicated Resident #29 was a high risk for falls. The facility was not able to provide a Resident assessment, the post fall assessment for the fall, or staff statements for Resident #29's fall on 5/26/2025. Review of the facility's Progress Note' dated 6/5/2025, revealed .Went in bathroom to check on resident and he was noted to be lying on the bathroom floor on his right side . Review of the Fall Risk Evaluation dated 6/5/2025, revealed a score of 11 which indicated Resident #29 was a high risk for falls. Review of the facility's Incident Report dated 6/5/2025, revealed .went to check on resident [Resident #29] and he was noted to be lying on the floor on his right side. The facility was not able to provide the Resident assessment or the post fall assessment for Resident #29's fall on 6/5/2025. During an interview on 7/1/2025 at 4:36 PM, the Director of Nursing (DON) was asked are these the complete fall investigations for Resident #29. The DON stated, Yes . During an interview on 7/2/2025 at 10:35 AM, the DON was asked if any statements were obtained from staff related to falls. The DON stated, Yes, ma'am .I found a statement for the fall on 6/5/2025, but no other statements. The DON was asked should staff get witness statements for falls. The DON stated, Yes . The DON was asked if the nurses should document Resident assessments for falls. The DON stated Yes, ma'am. The DON was asked do you see any Resident assessments or post fall assessments. The DON stated, No.

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when frozen food was not stored on a shelf to allow circulation, the corn meal, sugar, and flour bins were undated and unlabeled, expired food and frozen food was observed with thick build-up of ice crystals in 2 of 2 reach-in freezers and 1 of 1 reach-in refrigerators, and a pink/brown substance found in 1 of 1 ice machines. The findings include: 1. Review of the facility's policy titled, Food Storage, with a revised date of 11/1/2014, revealed .Any expired or outdated food products should be discarded.All products should be dated upon receipt and when they are prepared. Use use-by-dates on all food stored in refrigerators. Review of the undated facility's policy titled, Infection Control Policy, revealed .Ice may be contaminated and may cause and [an] outbreak of nosocomial infections [an infection acquired in a hospital or healthcare facility].The following procedures should be followed to reduce contamination of the ice [ch]ests and machines .Maintenance is responsible for [ensuring] cleaning is done. Cleaning should be carried out with a detergent solution, after disconnecting the unit, removing and discarding all ice, and allowing the chest to warm to room temperature. Use clean rags or disposable wipes to scrub all surfaces. 2. Observation in the single door reach-in freezer on 6/30/2025 at 8:38 AM, 7/1/2025 at 8:49 AM, and 7/2/2025 at 9:09 AM, revealed 4 chocolate meringue pies on the floor of the freezer, not stored on a shelf to allow circulation. Observation in the kitchen on 6/30/2025 at 8:40 AM, revealed the corn meal, sugar and flour bins were undated and unlabeled. Observation in the double door reach-in freezer on 6/30/2025 at 8:47 AM, revealed the following: a. A bag of hot dogs with a use by date of 6/27/2025. b. A bag of Salisbury steaks with a use by date of 6/27/20205. c. A bag of Tater Kegs with a use by date of 6/19/2025. d. A bag of chicken with a thick white build-up of ice in the bag frozen to the bottom of the freezer. e. A bag of fried steaks with a thick white build-up of ice in the bag. f. 6 bags of frozen chicken stored on the floor of the freezer, not stored on a shelf to allow circulation. g. 4 packages of ground beef stored on the floor of the freezer, not stored on a shelf to allow circulation. h. 8 packaged rack of ribs stored on the floor of the freezer, not stored on a shelf to allow circulation. i. 3 packaged hams stored on the floor of the freezer, not stored on a shelf to allow circulation. Observation in the double door reach-in refrigerator on 7/1/2025 at 8:51 AM and 7/2/2025 at 9:11 AM, revealed a bag with 5 heads of lettuce stored on the floor of the refrigerator, not stored on a shelf to allow circulation. Observation in the double door reach-in freezer on 7/1/2025 at 8:53 AM and 7/2/2025 at 9:16 AM, revealed the following: a. 6 bags of frozen chicken stored on the floor of the freezer, not stored on a shelf to allow circulation. b. 4 packages of ground beef stored on the floor of the freezer, not stored on a shelf to allow circulation. c. 8 packaged rack of ribs stored on the floor of the freezer, not stored on a shelf to allow circulation. d. 3 packaged hams stored on the floor of the freezer, not stored on a shelf to allow circulation. During an observation and interview on 7/1/2025 at 8:30 AM, the Certified Dietary Manger (CDM) was asked what was the pink/brown substance on the inside of the ice machine along the entire width of the plastic dispenser. The CDM stated, I think it's mildew. The CDM wiped an area with a paper towel, a pink residue was left on the paper towel. 3. During an interview on 7/1/2025 at 3:26 PM, the CDM confirmed food items should not be stored beyond the use by date and food should not have a thick white build-up of ice crystals on it. During an interview on 7/1/2025 at 4:09 PM, the Maintenance Supervisor was asked whose responsibility it is to clean the ice machine. The Maintenance Supervisor stated, We are going to assign that to the floor tech . During an interview on 7/2/2025 at 9:28 AM, the CDM confirmed food items/storage bins should be labeled and dated to reflect its contents. The CDM was asked if food items should be stored without a rack or shelf on the bottom of the freezer/refrigerator to allow circulation. The CDM stated, .we try to keep it stacked to allow circulation .

**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 infection were maintained when 1 of 2 (Licensed Practical Nurse (LPN A) failed to don Personal Protective Equipment (PPE) while administering medications and performing wound care to 2 of 3 (Resident #22 and #33) residents reviewed for Percutaneous Endoscopic Gastronomy (PEG) (a tube in the stomach that provides nutrition) tube and pressure ulcers. The findings include: 1. Review of the facility policy titled, Enhanced Barrier Precautions, dated 4/25/2025, revealed .Enhanced Barrier Precautions .EBP .refer to .an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and gloves use during high contact resident care activities .An order for enhanced barrier precautions will be obtained for residents with any of the following .wounds .feeding tubes .High contact resident care activities include .device care or use .feeding tubes .wound care . 2. Review of the medical record revealed Resident #22 was admitted [DATE], with diagnoses including Hemiplegia, Diabetes, and Encounter for Surgical Aftercare Following Surgery on the Digestive System. Review of the Physician Order dated 4/10/2025, revealed .Enhanced Barrier Precautions R/T [related to] indwelling medical device [Gastronomy Tube] [PEG tube] . Observation in the Resident's room on 7/1/2025 at 11:30 AM, revealed LPN A accessed the PEG tube of Resident #22 for medication administration without donning PPE in an enhanced barrier room. 3. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Anxiety, Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Review of the Care Plan for Resident #33 dated 5/13/2025, revealed .The resident has (stage 3) pressure ulcer to left hip r/t HxA [History] of ulcers . Observation in the Resident's room on 7/1/2025 at 2:18 PM, revealed LPN A performed wound care on Resident #33's pressure ulcer without donning PPE in an enhanced barrier room. During an interview on 4/2/2025 at 11:55 AM, the Director of Nursing confirmed that nurses should don PPE when administering medication through a PEG tube and when performing wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the resident's status for dialysis for 1 of 1 (Resident #7) sampled residents reviewed for dialysis. The findings include: Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Diabetes, Insomnia, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and End Stage Renal Disease. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Dialysis was not documented. During an interview on 9/18/2024 at 8:36 AM, the MDS Coordinator was asked should dialysis be coded on the annual MDS. MDS Coordinator stated, Yes dialysis should be on there .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to revise and update a care plan for 1 of 2 (Resident #11) residents reviewed for care plans. The Findings include: 1. Review of the facility's policy titled Fall Prevention Program, dated 4/2/2024, revealed .when any resident experiences a fall, the facility will .review the resident's care plan and update as indicated . 2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Alzheimer's, Gastronomy, and Dysphagia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #11 had severe cognitive impairment without behaviors and was dependent on staff for all care. Further review of the MDS revealed Resident #11 was always incontinent of bowel and bladder, and no falls since admission. Review of Nursing Progress notes on 8/1/2024, revealed that Resident #11 was found lying on the floor next to her bed wrapped up in a blanket. Staff was unable to come to a conclusion of how she got out of the bed since she was bedridden. Resident #11's care plan was not revised or updated to reflect the 8/1/2024 fall and interventions for the fall. During an interview on 9/18/2024 at 8:54 AM, the Director of Nursing confirmed that the care plan should have been updated to reflect an actual fall and intervention.

**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 staff followed physician orders for 1 of 1 (Resident #88) sampled residents reviewed receiving oxygen. The findings include: 1. Review of the facility's policy titled Oxygen Administration, dated 4/2/2024, revealed .Oxygen is administered under the orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control . 2. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE], with diagnoses including Sepsis, Multiple Myeloma, Anxiety, Congestive Heart Failure, Depression, and Chronic Respiratory Failure. Review of the Physician's Order dated 8/29/2024, revealed .oxygen at 2L [Liters] per BNC [Binasal Cannula] every shift . Review of the Medication Administration Record dated 9/2024, revealed Oxygen at 2 liters per BNC every shift was assessed by staff and initialed for completion. Review of the Minimum Data Set, dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated Resident #88 was cognitively intact. Observation in the resident's room on 9/16/2024 at 4:44 PM, revealed Resident #88 was receiving 3 liters of oxygen per minute with binasal cannula. Observation in the resident's room on 9/17/2024 at 7:38 AM and 8:10 AM, revealed Resident #88 was receiving oxygen at 4.5 liters per minute by nasal cannula. During an interview on 9/17/2024 at 8:24 AM, the Director of Nursing (DON) was asked to confirm what Resident #88's oxygen was set at. The DON confirmed that the resident's oxygen was set at 4.5 liters per minute. The DON confirmed resident's oxygen order was for 2 liters per minute and should be set at 2 liters per minute.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review and interview, the facility failed to have a physician's order to provide dialysis for 1 of 1 (Resident #7) sampled residents reviewed for dialysis. The findings include: 1. Review of the facility's policy titled .Dialysis Policy, dated 8/12/2015, revealed .Residents who have End Stage Renal Disease [ESRD] and receive dialysis shall be provided care consistent with professional standards of practice, the physicians/practitioner's orders, and in accordance with the resident goals and preferences .Vascular Access [is] a connection made between an artery and a vein to provide good blood flow for dialysis. Bruit [is] a constant rumbling sound such as swishing or whoosh sound heard via stethoscope placed on the access .Thrill [is] a steady vibration or rumbling sensation felt at the AV [Arteriovenous] graft/fistula site .Medical conditions shall be monitored and managed to prevent complications .Licensed nurses shall participate in the management of medical conditions by following physicians orders, assessing the resident, and reporting changes in condition or behavior to the physician .Infection control practices shall be followed .Documentation shall include .Skin integrity at the access site [document every shift] .Prescence of thrill and bruit of the AV graft/fistula [document every shift] .Evidence of infection, bleeding, and other complications . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Diabetes, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and End Stage Renal Disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Dialysis was not documented on the assessment. Review of the facility's Order Summary Report, dated 9/17/2024 revealed there was no order for dialysis. During an interview on 9/17/2024 at 8:40 AM, the Director of Nursing (DON) was asked should Resident #7 have a Physician's order for dialysis. The DON confirmed it should be documented and she did not see dialysis coded.

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when 4 bags of frozen chicken breasts and a thick build up of ice crystals were found in 1 of 2 reach-in freezers, and 1 of 1 nourishment refrigerator had unlabeled, undated foods, and a dirty freezer that did not have a thermometer or temperature logs. The findings include: 1. Review of the facility's undated policy titled FOOD FROM OUTSIDE SOURCES, revealed .Perishable food should be sealed and dated with a use-by date and placed in refrigeration .and/or nourishment room refrigerators .clean the refrigerators .discard outdated or uneaten foods . Review of the facility's policy FOOD STORAGE, dated 11/1/2014, revealed .Frozen Meat/Poultry and Foods .store items .at 0 degrees or less . 2. Observation in the reach-in freezer on 9/16/2024 at 9:38 AM and 9/17/2024 at 11:47 AM, revealed 4 bags of frozen chicken breasts with a thick white build-up of ice in all 4 bags. The bags were frozen together at the bottom of the freezer. 3. Observation in the Nutrition Refrigerator on 9/18/2024 at 7:46 AM, revealed the following: a. An unlabeled and undated bag containing a water bottle and peanut butter crackers. b. An unlabeled and undated bag containing a bottle of lemonade, a banana, and a container of food. c. The freezer had multiple brown sticky spots and food particles on both the top and bottom area and on the door shelves. d. The freezer did not have a thermometer or a temperature log. 4. During an interview on 9/18/2024 at 8:24 AM, the Certified Dietary Manager (CDM) confirmed the Nutrition Freezer should be clean and that all food put in the freezer or refrigerator should be initialed and dated. The CDM confirmed that there should be a thermometer in the freezer and a freezer log to monitor the temperature. The DM also confirmed that the Kitchen's freezer should not contain compromised frozen foods.

Based on review of staff in-services, and interview the facility failed to ensure the mandatory annual 12 hours of Certified Nursing Assistant (CNA) in-service training hours were completed for 4 of 19 sampled CNA's (CNA A, B, C and D) reviewed for inservices. The findings include: Review of a list of CNA staff provided by the facility revealed CNA A was hired on 10/6/1999, CNA B was hired on 5/19/2005, CNA C was hired on 7/15/2014, and CNA D was hired on 5/2/2022. The facility was unable to provide documentation of 12 hours of required in-service training for CNAs A, B, C, and D for the past 12 months. During an interview on 9/18/2024 at 10:44 AM, the DON was asked about the CNA in-service hours. The DON confirmed she was unable to provide the documentation. The facility was unable to provide documentation of the mandatory annual CNA in-service hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to convey the funds to the estate of a deceased resident within the 30 days requirement for 1 of 1 (Resident #97) resident reviewed for personal fund account. The findings include: 1. Review of the facility's policy titled Resident Personal Funds, dated 2023, revealed .Conveyance upon Discharge, Eviction, or Death .Upon the discharge, eviction or death of a resident who has paid a patient liability in advance, the facility will convey a refund within 30 days to the individual .administering the resident's affairs . 2. Review of the medical record revealed Resident #97 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Urinary Incontinence, Schizophrenia, Anxiety, and Parkinson's Disease. Review of the facility's INTERDISCIPLINARY DISCHARGE SUMMARY, dated [DATE], revealed admission date [DATE] discharge date [DATE] .Reason for discharge .Expired . Review of the refund check for the Responsible Party of Resident #97 was dated [DATE]. This refund was 54 days past the date of death . During an interview on [DATE] at 3:30 PM, the Business Office Manager (BOM), was asked how long until the refund check is to be provided to the family after the resident's death. the BOM stated, We try to turn it around [refund] in a week .That was unusual. During an interview on [DATE] at 4:45 PM, the BOM, was asked when the policy stated upon death of a resident a refund should be within 30 days. Therefore, was the refund for Resident #97 past the timeframe for the refund. The BOM stated, I couldn't get in touch with her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the [Named facility] HEALTH & REHABILITATION CENTER FINANCIAL RESPONSIBILITY AGREEMENT), medical record review, and interview, the facility failed to provide 3 of 4 sampled residents (Resident #23, #32, and #40) with the Advanced Beneficiary Notice (ABN), Center for Medicare and Medicaid Services (CMS)-10055 when therapy services were discontinued and the resident remained in the facility for long-term care services or was discharged from the facility. This failure left residents without information related to the cost of therapy services if they desired to continue the services in the facility and did not allow for them to have an informed choice. The findings include: 1. Review of the facility's [Named facility] HEALTH & REHABILITATION CENTER FINANCIAL RESPONSIBILITY AGREEMENT) undated, revealed .Medicare/Skilled: The Resident is considered a Medicare beneficiary if the Resident is eligible to receive benefits from the Federal Medicare Program. The maximum number of Medicare days is 100; however, If the Resident does not meet the Medicare coverage criteria, coverage will end regardless of the number of allotted days left in the current benefit period. Medicare will pay 100% [percent] of all skilled nursing charge for up to the first 20 days of the Resident's skilled nursing home stay (this is a total of all days of skilled care by all skilled care providers for this period of illness). Beginning on day 21, Medicare will not pay for the total charges for that day or any days thereafter. The portion of charges which Medicare will not pay after the first 20 days is called the Resident's co-insurance. The current rate of coinsurance is $194.50 per day. The Resident/Legal Representative will receive a bill on day 21 the co-insurance balance for the co-insurance balance for the days left in the current month of the Resident's stay at the facility. If applicable, Medicare supplemental insurance may cover payment for the co-payments (normally this coverage is only for 21 days through 100 unless you have extended coverage with your insurance carrier). Upon expiration of Medicare benefits, the Resident may remain in the Facility if arrangements for timely payments are in place through either Medicaid or private pay . 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Myocardial Infarction, Acute Kidney Failure, Dysphagia, and Diabetes. Review of the Occupational Therapy (OT) Recert [Recertification], Progress Report & [and] Updated Therapy Plan dated 9/25/2023, revealed Resident #23 was in OT for certification Period 9/25/2023 - 10/24/2023. Payer Source was Medicare A. Review of the Physical Therapy (PT) Recert, Progress Report & Updated Therapy Plan dated 8/4/2023, revealed Resident #23 was in PT for certification Period 8/4/2023 - 9/2/2023. Payer Source Medicare A. The facility was unable to provide an ABN letter for Resident #23 at the end of the skilled services. 3. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses of Gastrostomy, Aphasia, Hemiplegia and Hypertension. Review of the Therapy Discharge Summary revealed Resident #32 was discharged from Speech Therapy (SPL) on 10/13/2023, discharged from Physical Therapy (PT) on 9/1/2023, and discharged from Occupational Therapy (OT) on 8/30/2023. Payer Source Medicare A. The facility was unable to provide an ABN letter for Resident #32 at the end of the skilled services. 4. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Sepsis, Diabetes, Dementia, and Heart Failure. Review of the Therapy Discharge Summary revealed Resident #40 was discharged from Speech Therapy (SLP) on 5/2/2023, discharged from Physical Therapy (PT) on 5/2/2023, and discharged from Occupational Therapy (OT) on 5/2/2023. Payer Source was Medicare A. The facility was unable to provide an ABN letter for Resident #40 at the end of the skilled services. During an interview on 11/9/2023 at 9:07 AM, the Minimum Data Set (MDS) Coordinator stated, .We have not sent any letters .

**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 choices to receive showers was provided for 1 of 1 (Resident #41) sampled residents reviewed for ADL care. The findings included: 1. Review of the facility's policy titled, Activities of Daily Living (ADLs) dated 11/29/2022, revealed .The facility will .Care and services will be provided for the following activities of daily living: Bathing, dressing, grooming and oral care .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 2. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Cerebral Infarction, Morbid Obesity, Dementia, Depression, Epilepsy, and Chronic Pain. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, required assistance from staff for bathing and dressing, and was incontinent of bowel and bladder. Review of the quarterly MDS dated [DATE], revealed Resident #41 had a BIMS score of 11, indicating moderately impaired cognition, required extensive assistance from staff for personal hygiene and dressing, totally dependent upon staff for bathing, and was incontinent of bowel and bladder. Review of the Shower List: South revealed Resident #41 is scheduled for showers on Tuesday, Thursday, and Saturday. Review of the facility's Skin Monitoring: Comprehensive CNA (certified nursing assistant) Shower Review sheets revealed Resident #41 did not receive any showers for the following days: 7/4/2023, 7/6/2023, 7/8/2023, 7/13/2023, 7/15/2023, 7/18/2023, 7/20/2023, 7/22/2023, 7/25/2023, 8/1/2023, 8/3/2023, 8/5/2023, 8/8/2023, 8/10/2023, 8/12/2023, 8/15/2023, 8/17/2023, 8/19/2023, 9/2/2023, 9/7/2023, 9/9/2023, 9/12/2023, 9/16/2023, 9/19/2023, 9/21/2023, 9/30/2023, 10/3/2023, 10/5/2023, 10/7/2023, 10/10/2023, 10/12/2023, 10/14/2023, 10/17/2023, 10/19/2023, 10/24/2023, 10/26/2023, 10/28/203, and 10/31/2023. The facility was unable to provide documentation that Resident #41 received showers from 3/2023 until 7/2023. During an interview on 11/8/2023 at 8:51 AM, Resident #41 confirmed she prefers to have showers and is not receiving showers. During an interview on 11/9/2023 at 3:16 PM, the Director of Nursing (DON) confirmed that documentation on the Skin Monitoring: Comprehensive CNA Shower Review sheets shows when a resident received a shower. The DON was asked is there any more documentation indicating when Resident #41 received a shower from 3/1/2023 to 6/30/2023. The DON stated, No . there are not. The DON confirmed the residents' showers should be documented. The DON confirmed Resident #41 should be getting showers.

**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 staff was following physician orders for automatic [auto] flush for a Percutaneous Gastrostomy (PEG) tube feeding for 1 of 1 (Resident #25) sampled residents reviewed for enteral feedings. The findings include: 1. Review of the facility's policy titled, Flushing a Feeding Tube, dated 1/2/2023, revealed .Verify physician orders for tube feeding flush amount . 2. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Abnormal Weight Loss, Anemia, Dementia, and Gastrostomy. Review of a Physician's Order dated 10/25/2023, revealed .Enteral Feed Order every shift ISOSOURCE 1.5 @ [symbol for at] 45 ml (milliliters) hr (hour) with 40ml/hr Auto Flush continuous pump . Review of the Care Plan revised 10/26/2023, revealed .10/26/2023 noted weight gain, reduced rate of tube feeding to 45ml/hr . Review of the Medication Administration Record dated November 2023, revealed .Enteral Feeding Order every shift ISOSOURCE 1.5 @ (symbol for at) 45ML/HR WITH 40ML/HR H20 (water) AUTO FLUSH CONTINUOUS PER PUMP . Start Date 10/26/2023 . Observation in Resident #25's room on 11/5/23 at 10:09 AM, 1:00 PM, and 1:47 PM, and on 11/06/23 at 8:58 AM, 11:13 AM, revealed IsoSource 1.5 Enteral Feeding infusing at 45ml/hr with an Auto Flush infusing at 45ml/hr. The auto flush was not infusing at 40 ml/hour as ordered. During observation and interview in Resident #25's room on 11/6/23 at 11:13 AM, the Director of Nursing (DON) was asked what rate the enteral feeding and automatic flush should be infusing at. The DON confirmed the enteral feeding should be infusing at 45ml/hr and the automatic flush should be infusing at 40ml/hr. The DON confirmed that staff should be following physician orders for the infusion of the automatic flush rate.

**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 medications were properly stored and secured when during random observations 1 of 3 (Licensed Practical Nurse (LPN) #2) nurses failed to remain at the bedside when administering Resident #33 and #41's medications and when 1 of 1 (LPN #2) failed to ensure medications were properly secured during PEG (percutaneous endoscopic gastrostomy) site care for Resident #25. The findings include: 1. Review of the facility's policy titled, Medication Administration revised on 1/2/2020, revealed Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .Administer medication as ordered .Observe resident consumption of medication . Review of the facility's policy titled, Medication Storage, dated 1/2/2020, revealed It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to manufacturer's recommendations and sufficient to ensure proper .security .All drugs and biologicals will be stored in locked compartments .medication carts, cabinets, drawers, refrigerators, medication rooms .During medication pass, medications must be under direct observation of the person administering medications or locked in the medication storage area/cart . Review of the facility's policy titled Resident Self-Administration of Medications, dated 1/2/2023, revealed .A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms . 2. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses of Glaucoma, Schizophrenia, Mental Disorder, and Insomnia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status score (BIMS) of 12, indicating the resident was moderately cognitively impaired and received antipsychotic, antidepressant, and diuretic medications. Review of the medical record revealed no Resident Self-Administration of Medication form had been completed. Random observation in the South hall at the medication cart on 11/5/2023 at 8:30 AM, revealed, LPN #2, standing at the medication cart across the hall near Resident 43's room with her back to Resident #33's room preparing medications. Observation in Resident #33's room in passing revealed the resident sitting on bedside and an undetermined amount of pills spread out on the over the bed table. Resident #33 picked up the medication one by one and put them into his mouth and swallowed them with a cup of water, the medications were unsecured and out of sight of LPN #2. During an interview on 11/07/23 at 11:18 AM, the Director of Nursing (DON) was asked does the facility have any residents who can self-administer their own medications. The DON confirmed no resident in the facility has been assessed and can administer their own medications. During an interview on 11/8/23 at 4:36 PM, the Assistant Director of Nursing (ADON) was asked should residents have possession of medications and administer the medication without the nurse being present at the bedside. The ADON confirmed no resident should have possession of medications to self-administer unless they have a self-administration form that states they are safe to self-administer and have possession of their medication. The ADON confirmed that a nurse should be present at bedside when a resident is taking their medications. 3. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses of Left Side Hemiplegia and Hemiparesis, Cerebral Infarction, Morbid Obesity, Mild Dementia, Depression, Epilepsy, and Chronic Pain. Review of the quarterly MDS dated [DATE], revealed Resident #41 had a BIMS score of 11, indicating moderately impaired cognition and received Antianxiety, Antidepressants, and Opioid. Review of the Order Summary Report revealed .Gabapentin Oral Capsule 300 MG [milligrams] (Gabapentin) Give 1 capsule by mouth three times a day for seizure .Order Date 3/17/2023 . Guaifenesin Syrup Give 15 ml [millimeters] by mouth every 6 hours as needed for cough .Order Date 5/15/2023 . Observation in the Resident #41's room on 11/5/2023 at 12:38 PM, revealed LPN #2 entered Resident's #41's room and laid a medicine cup with a pill in it on the resident's over the bed table and stated, Here is your Gabapentin, make sure you take it. and exited the room before the resident took the medication. LPN #2 failed to stay at the resident's bedside to observe Resident #41 take her medication. Observation in the Resident #41's room on 11/5/2023 at 12:52 PM, revealed LPN #2 entered Resident #41's room with a clear medication cup containing a red liquid, placed it on the resident's over the bed table and proceeded to exit the room. LPN #2 was what is the liquid in the clear medication cup. LPN#2 stated, cough medicine and exited the resident's room. LPN #2 failed to stay at the resident's bedside to observe Resident #41 take her medication. 4. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Abnormal Weight Loss, Anemia, Dementia, and Gastrostomy. Review of the facility's Order Summary Report dated 10/25/2023, revealed .Feeding Tube Site Care .Cleanse area around tube daily and prn [as needed] with wound cleanser or soap and water. Cover with dry 4 x 4 dressing . Observation on the South hall at the South hall Treatment cart on 11/7/2023 at 1:15 PM, revealed LPN #2 removed the 4 x 4's, dermal wound cleanser, and gloves from the treatment cart, to administer PEG site care to Resident #25. LPN #2 entered the resident's room, placed the supplies on a barrier on the over the bed table, entered the bathroom to wash her hands, leaving the dermal wound cleanser out of site, unattended, and unsecured on the over the bed table. LPN #2 returned to the resident's bedside, then exited the room and walked down the hall to the treatment cart leaving the dermal wound cleanser out of site, unattended, and unsecured, for an undetermined amount of time and then returned to the resident's room. During an interview on 11/8/2023 at 8:39 AM, the Director of Nursing (DON) was asked should wound cleanser be left out of site, unattended, and unsecured, on top of the over the bed table while the nurse is in the bathroom and when nurse leaves the resident's room and walks down the hall. The DON confirmed the nurse should take the wound cleanser with her when leaving the residents room or when stepping into the bathroom.

Based on policy review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 7 of 43 (Resident #1, #4, #13. #15, #24, #25 and #40) resident rooms. The findings include: 1. Review of the facility's policy titled, Safe and Homelike Environment, dated 1/2020, revealed .the facility will provide a safe, clean, comfortable and homelike environment .Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the resident's room .Sanitary includes, but is not limited to preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment includes, but is not limited to, equipment used in the completion of the activities of daily living . Review of the facility's undated Housekeeping and Janitorial Department Cleaning Schedule, revealed .Monday .CLEAN OVERBED TABLES IN RESIDENT ROOMS .TUESDAY .CLEAN BED IN RESIDENT ROOMS THIS INCLUDE HEAD AND FOOT BOARDS, BED RAILS AND BED SPRINGS . 1. Review of the facility's undated Housekeeper, job description revealed .The primary purpose of your job position is to perform the day-to-day activities of the Housekeeping Department in accordance with current federal, state, and local standards guidelines and regulations governing our facility, and as may be directed by the Administrator, and/or the Director of Housekeeping, to assure that our facility is maintained in a clean, safe, and comfortable manner .Perform day to day housekeeping functions as assigned .Clean/polish furnishings, fixtures, ledges, room heating/cooling units .in residents rooms .Clean walls .by washing, wiping, dusting, spot cleaning, disinfecting, deodorizing . 2. Observation in Resident #1's room on 11/5/2023 at 9:45 AM and 2:18 PM, and on 11/6/2023 at 11:01 AM and 4:28 PM, revealed a tan colored substance on the enteral feeding pump and the base of the pole. During an interview on 11/6/2023 at 4:28 PM, the Administrator confirmed Resident #1 had splatters of enteral feeding formula on the enteral feeding pump and on the pole and should have been cleaned. 3. Observation in Resident #4's room on 11/5/2023 at 10:22 AM, 10:45 AM, 1:05 PM, and 11/6/2023 at 8:37 AM, and 11:37 AM, revealed the following: a. The wall on the right side of the bed nearest the bathroom with dark brown running/dripping stain all down the wall. b. The wall behind headboard of the bed with dark brown running / dripping stain extending the wall. c. The left and right side of the bed on the bed rail with dark brown running / dripping stain. d. The bed had dust particles on the bed frame underneath the bed. e. The over bed table had a white dried substances on top. f. The over the bed light had thick dust particles. 4. Observations in the Resident #13's room on 11/5/2023 at 9:41 AM and 10:54 AM, and on 11/6/2023 at 10:52 AM and 4:36 PM, revealed the over bed table had a brown buildup of an unknown sticky, brown substance and foods crumbs and the legs of the over bed table had a dark brown buildup of an unknown substance. During an interview on 11/6/2023 at 4:36 PM, the Administrator was asked did he see the crumbs of food and the buildup of the unknown brown spilled stains on Resident #13's over the bed table. The Administrator stated, I see . The Administrator was asked to describe what he saw on the base/legs of the over the bed table. The Administrator stated, That is grime. The Administrator confirmed it is his responsibility to ensure that the residents rooms are clean and sanitary. The Administrator confirmed the residents rooms should be cleaned daily and as needed. 5. Observation in Resident #15's room on 11/5/2023 at 10:10 AM, 1:00 PM, 1:47 PM, and 11/6/2023 at 8:58 AM, and at 11:25 AM, revealed the following: a. The bedrail on right side of the bed had dried dark brown stains. b. The wall behind the bed had a dried brownish white substance running down the wall. c. The over bed light had thick dust particles. d. The fall mat had a dried brownish white substance. e. The enteral feeding pole had a dried brownish milky white substance on the pole and base of the pole. 6. Observations in Resident #24's room on 11/5/2023 at 10:00 AM and 2:26 PM, and on 11/6/2023 at 4:23 PM, revealed splatters of a tan substance on the enteral feeding pump, the base of the pole, and on the wall and the bumper behind the headboard of the bed. During an interview on 11/6/2023 at 4:23 PM the Administrator confirmed the splatters on the enteral feeding pump, on the base of the pole, on the wall and on the bumper of the wall in Resident #24's room was enteral feeding and should not be there. 7. Observation in Resident #25's room on 11/5/23 at 10:09 AM, 1:00 PM, 1:47 PM, and 11/6/2023 at 8:58 AM, and at 11:25 AM, revealed the following: a. The enteral feeding pole had a brownish milky dried stains down the pole and on the base of the pole. b. The bed rail on the left and right side of the bed had a brownish milky dried stains. c. The bed frame had thick dust particles. d. The headboard had dried white milky stains. e. The over bed light with thick dust particles. 8. Observation in Resident #40's room on 11/5/2023 at 10:22 AM, 10:45 AM, 1:05 PM, and 11/6/2023 at 8:37 AM, and 11:37 AM, revealed the following: a. Dark brownish stains on the wall behind the headboard of the bed. b. The air condition/heating unit vent had a thick white and beige dried particles. c. The air condition/heating unit vent had thick dust like particles. d. The enteral feeding pole and base had a brownish milky white dried stains. e. The wall had dried brownish milky white stains. 9. Observation and interview in Resident #15 and #25, on 11/6/23 at 4:20 PM, the Administrator was asked how often residents' rooms are cleaned. The Administrator confirmed resident rooms are cleaned daily. The Administrator was asked how often the enteral feeding poles and bases are cleaned, walls wiped down and beds and bed frames cleaned and dusted, and over the bed lights dusted. The Administrator confirmed those areas are part of the resident's rooms and they are cleaned daily. The Administrator was shown the walls, headboards, bed frames, and the over the bed lights, and was asked if they appear to have been cleaned daily. The Administrator stated, No, ma'am. Observation and interview in Resident #4 and #40's rooms on 11/6/2023 at 4:20 PM, the Administrator confirmed that the room, equipment, and air condition/ heating unit did not appear to have been cleaned. During an interview on 11/7/2023 at 3:06 PM, Housekeeper #2 was asked how often resident rooms are cleaned. Housekeeper #2 confirmed that not all rooms are cleaned daily.

Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during random observations when 1 of 1 (Licensed Practical Nurse (LPN) #2) failed to use courtesy titles when addressing residents, and during dining when 8 of 10 staff members (Certified Nursing Assistant (CNA) #1), CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, and LPN #2, and LPN #3, failed to knock and/or announce themselves, stood to assist with dining, failed to use courtesy titles when addressing residents, and when 1 of 1 (LPN #2) failed to knock or announce self before entering a resident's room during medication administration. The findings include: 1. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 1/2/2023, 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 .All staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents rights . Review of the facility's policy titled, Medication Administration, dated 1/2/2020, revealed .Knock or announce presence . 2. Random observation in the Activities Room on 11/5/2023 at 8:35 AM, revealed Resident # 43 entered the Activities Room and LPN #2 states to the resident, Let me help you sweet girl . LPN #2 failed to use a courtesy title when addressing Resident #43. Random observation in the South hall at the medication cart on 11/5/2023 a 8:45 AM, revealed LPN #2, stated to Resident #43, Where are you going baby girl .what did you say baby . LPN #2 failed to use a courtesy title when addressing Resident #43. Observation during dining on the South hall on 11/5/2023 at 11:30 AM, revealed LPN #2 removed a tray from the meal cart, entered Resident #43's room and placed the tray on the over the bed table. LPN #2 failed to knock or announce self before entering the resident's room. Observation during dining on the South hall on 11/5/2023 at 11:38 AM, revealed LPN #2 standing at the bedside assisting Resident #1 with her meal. Observation during dining on the North hall on 11/5/2023 at 11:14 AM, revealed CNA #6 entered Resident #25's room placed and the tray on the over the bed table and stated, .welcome love. CNA #6 exited the room and returned to the meal cart, removed a tray, entered Resident #42's room, served the resident her meal tray and stated, girl them beans good for you, and exited the room. CNA #6 failed to use courtesy titles when addressing the residents. Observation during dining on the North hall on 11/5/2023 at 11:18 AM, revealed LPN #2, stated, Alright sweet girl to Resident #16 while setting up her meal tray and applying condiments to the resident's food. LPN #2 exited the room and returned to the meal cart, engaged in conversation with LPN #3 at the meal cart in the North hall. LPN #2 stated out loud in the hallway to LPN #3, She is a feeder, with LPN #2 repeating out loud She is a feeder. LPN #2 failed to address Resident #16 using courtesy titles. Observation during dining on 11/5/2023 at 11:47 AM, revealed CNA #5 removed tray from the meal cart, entered Resident #12's room, placed the tray on the over the bed table adjusted the resident in bed with the hand held control, assisted the resident with their meal while standing. CNA #5 failed to knock or announce self before entering the resident's room and stood to assist the resident with their meal. Observation during dining on the on the North hall on 11/6/2023 at 7:24 AM, revealed LPN #2 failed to knock or announce herself before entering the Resident #39's room. Observation during dining on the South hall on 11/6/2023 at 7:25 AM, revealed CNA #7 entered Resident #37's room, failed to knock or announce self, exited the room and returned back to the resident's room, placed meal tray on the over the bed table, adjusted the resident in bed and stated to Resident #37 You not going to eat friend, turned around and stated to Resident #31, There you go friend. CNA #7 failed to address Resident #31 and Resident #37 with courtesy titles. Observation during dining in the South hall on 11/6/2023 at 7:38 AM, revealed CNA #1 removed a tray from the meal cart entered Resident #28's room. CNA #1 failed to knock or announce self before entering the resident's room. Observation during dining on the on the North Hall on 11/6/2023 at 7:42 AM, revealed LPN #2 entered Resident #10's room and sat the tray on the over bed table and stated, Good girl. LPN #2 failed to use a courtesy title when addressing Resident #10. Observation during dining on 11/6/2023 at 7:46 AM, revealed CNA #2 was in Resident #30's room when CNA #3 entered the room asked CNA #2 who needed to be assisted with their meals, CNA #2 stated, [names of Resident #1 and Resident #12] on the front hall are feeders. CNA #2 exited the room returned to the meal cart and yelled from the hallway to CNA #3, [Name of Resident #11] in the middle bed is a feeder. Observation during dining on 11/6/2023 at 7:55 AM, revealed CNA #2 entered Resident #30's room, placed the tray on the over the bed table, set up the tray and stood to assist Resident #30 with his meal. Observation on the North hall medication cart on 11/7/2023 at 1:15 PM, revealed LPN #2 sanitized her hands and removed medications for Resident #16, locked the medication cart, entered the resident's room, administered the medications to Resident #16 and exited the room. LPN #2 failed to knock or acknowledge herself before entering Resident #16's room. During an interview on 11/8/23 at 8:39 AM, the Director of Nursing (DON) was asked what should staff do before entering a resident's room. The DON confirmed that staff should knock and announce themselves before entering a resident's room. The DON was asked how you expect staff to address residents when speaking to them. The DON confirmed staff should always use resident's name when addressing them and no pet names should be used. The DON was asked what position staff should be in when assisting residents with their meals. The DON confirmed staff should be in the sitting position when assisting residents with their meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to ensure the facility assessments were signed by a Registered Nurse (RN) as required by Federal Regulations for 12 of 12 (Resident #1, #9, #10, #20, #25, #31, #33, #39, #41, #43, #44, and #146) sampled residents reviewed. The findings include: 1. Review of the Centers for Medicare Services (CMS) RAI Manual Version 3.0 Manual dated October 2023 pages Z6- Z7 revealed, .the person signing the attestation must review the information to assure accuracy and sign for those portions on the date the review was conducted .Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete .use the actual date that the MDS was completed, reviewed, and signed as complete by the RN assessment coordinator . 2. Review of the medical record revealed Resident #1 was admitted the facility on 7/14/2014 with diagnoses of Depression, Gastrostomy, Dementia, and Heart Failure. Review of the annual MDS dated [DATE] revealed Resident #1 had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/Licensed Practical Nurse (LPN). Review of the quarterly MDS dated [DATE] revealed Resident #1 had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 3. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Diabetes, and Heart Failure. Review of the quarterly MDS dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE] revealed Resident #9 had a BIMS score of 15, indicating intact cognition. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 4. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Hypertension, Diabetes, Alzheimer's Disease, Anorexia, and Anemia. Review of the quarterly MDS dated [DATE] revealed Resident #10 had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the admission MDS dated [DATE] revealed Resident #10 had a BIMS score of 3, indicating the resident had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 5. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Dementia, Greater Trochanter of Right Femur Fracture, Anxiety, Arteriovenous Fistula, Peripheral Vascular Disease, and Chronic Kidney Disease Stage 4. Review of the quarterly MDS dated [DATE] revealed Resident #20 had a BIMS score of 00, which indicated severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 6. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis, Depression, Torticollis, Gastrostomy Tube, Abnormal Weight Loss, Anemia, Dementia, and Psychosis. Review of the annual MDS dated [DATE] revealed Resident #25 had a BIMS score of 99, indicating that the resident had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE] revealed Resident #25 had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 7. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Dysphagia, Dementia, Epilepsy, Schizoaffective Disorders, and Anxiety. Review of the quarterly MDS dated [DATE] revealed Resident #31 had a BIMS score of 3, which indicated severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the annual MDS dated [DATE] revealed Resident #31 had a BIMS score of 10, which indicated moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 8. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of Fracture [NAME] Leg, Glaucoma, Gout, Anemia, Obesity, Schizophrenia, Mental Disorder, and Insomnia. Review of the annual MDS assessment dated [DATE] revealed Resident #33 had a BIMS score of 14, indicating the resident was cognitively intact. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had a BIMS score of 12, indicating the resident had moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 9. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Disease, Insomnia, Pain, Anxiety, and Depression. Review of the annual MDS dated [DATE], revealed Resident #39 had a BIMS score of 99, which indicated severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE], revealed Resident #39 had a BIMS score of 9, which indicated moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 10. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction, Morbid Obesity, Dementia, Depression, Epilepsy, and Chronic Pain. Review of the admission MDS dated [DATE], revealed Resident #41 had a BIMS score of 15, which indicated intact cognition. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE], revealed Resident #41 had a BIMS score of 11, indicating moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 11. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses of Dementia, Urinary Tract Infection, Anxiety, Insomnia, and Cerebral Infarction. Review of the admission MDS dated [DATE] revealed Resident #43 had a BIMS score of 8, indicating that the resident had moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the quarterly MDS dated [DATE] revealed Resident #43 had a BIMS score of 10, indicating the resident had moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. 12. Review of the medical record revealed Resident #44 was admitted the facility on 7/28/2023 with diagnoses of Abdominal Cancer, Asthma, and Benign Prostatic Hyperplasia. Review of the admission MDS dated [DATE] revealed Resident #44 had a BIMS score of 9, which indicated moderate cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/Licensed Practical Nurse (LPN). 13. Review of the medical record revealed Resident #146 was admitted to the facility on [DATE] with diagnoses of Alzheimer's, Anorexia, Glaucoma, Anemia, Dementia, and Schizophrenia. Review of the quarterly MDS dated [DATE] revealed Resident #146 had a BIMS score of 00, indicating the resident had severe cognitive impairment. The signature of the RN Assessment Coordinator verifying assessment completion was signed off by the MDS Coordinator/LPN. Review of the admission MDS dated [DATE] revealed Resident #146 was severely cognitively impaired. The signature of the RN Assessment Coordinator verifying assessment completion was not signed off by the MDS Coordinator/LPN or the RN. 14. During an interview on 11/8/2023 at 11:31 AM, the Director of Nursing (DON) was asked what RN signs that the MDS assessments are completed. The DON confirmed she is the RN who is responsible to sign that the MDS assessments were completed but she has not signed any completed assessments since October 2022. During an interview on 11/8/2023 at 2:18 PM, the MDS Coordinator was asked who the RN is signing for the completion of the MDS assessment. The MDS Coordinator stated, .no RN has been signing for the completion of the MDS assessment. The MDS Coordinator was asked should there be a RN signing for the completion of the MDS assessment. The MDS Coordinator confirmed a RN should be signing for the completion of the MDS.

**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 residents were free of accident hazards when the facility failed to ensure fall risk assessments were complete for 1 of 1 (Resident #10) reviewed for falls, chemicals were observed 1 of 1 unsecured and unattended storage room, and when sharps were left unsecured on top of 1 of 4 (South Medication cart) medication carts. The findings include: 1. Review of the facility's policy titled, Fall Prevention Program, dated 1/2/2023, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls .The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categorizes residents according to low, moderate, or high risk .Complete a fall risk assessment every 90 days and as indicated when the resident's condition changes . Review of the facility's guidelines titled, Fall Program Guidelines, dated 11/2015, revealed .When a fall occurs the following assessments .will be completed to assist in the investigation .Fall Assessment . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with the diagnoses of End Stage Renal Disease, Hypertension, Anorexia, Reduced Mobility, Legal Blindness, and Alzheimer's Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #10 was assessed as being severely cognitively impaired, and required extensive assistance with activities of daily living, walking did not occur, was total dependent on staff for toileting, incontinent of both bowel and bladder, and had 2 or more falls with no injuries. Review of the Care Plan revealed, .Risk for Falls .6/28/2023 fall with no injuries, 7/9/23 fall with no injuries, 7/13/23 fall with no injuries .Bed alarm to alert staff of attempts to transfer out of bed without assistance .Ensure bed is kept in lowest position .Ensure call light is available .Evaluate fall risk on admission and PRN (as needed) .Floor mats to both sides of bed .has limited physical mobility . Review of the medical record revealed Resident # 10 had unwitnessed falls on 7/9/2023, 7/13/2023, 10/18/2023, 10/26/2023 and on 10/31/2023. Review of the medical record revealed no fall risk assessments were completed for the falls that occurred on 7/9/2023, 7/13/2023, 10/18/2023, 10/26/2023, 10/31/2023 until 11/9/2023 and no fall risk assessment was completed for the quarterly MDS assessment dated [DATE] until 11/9/203. During an interview on 11/9/2023 at 9:10 AM, the MDS Coordinator confirmed fall risk assessments should be completed quarterly. During an interview on 11/9/2023 at 9:15 AM, the Director of Nursing (DON) confirmed nursing should complete fall risk assessments on admission, quarterly and when a resident falls. During an interview on 11/9/2023 at 9:38 AM, the DON confirmed the fall risk assessment for the falls that occurred on 7/9/2023, 7/13/2023, 10/18/2023, 10/26/2023, 10/31/2023 and the quarterly MDS fall risk assessment dated [DATE] were not completed until 11/9/2023 when she completed them, and they should have been completed when the fall occurred and when the quarterly MDS assessment was due. 3. Review of the medical record revealed Resident #43 was admitted to the facility 2/28/2023 with diagnoses of Dementia, Diabetes, Insomnia, Disorder of the Brain, Anxiety, and Seizures. Review of the quarterly MDS dated [DATE] revealed Resident #43 was assessed with a Brief Interview for Mental Status score of 10, indicating the resident was moderately cognitively impaired. Review of the Care Plan revealed, .Risk for Wandering .date initiated 3/17/2023 . Review of the facility's wandering list revealed Resident #43 was on the list for wandering. Observation in the Activities Room on 11/5/2023 at 8:35 AM, revealed Resident #43 enters the Activities Room on the South hall looking for her room. LPN #2 enters the room and redirects the resident back to the South hallway. Observation in the South hall at the medication cart on 11/5/2023 a 8:45 AM, revealed Resident #43 asked LPN #2 where her room was. LPN #2 then redirects the resident back to her room. Observation on 11/5/2023 at 9:30 AM, revealed Resident #43 self-propelling in wheelchair on the South hall looking for her room. Observation on the South hall in an unsecured and unattended storage room on 11/5/2023 at 9:21 AM, revealed a door left ajar and containing the following items: a.1 unlocked, unsecured and unattended housekeeping cart with 1- 24 ounce bottle of clear liquid labeled NEUTRAL DISINFECANT SPRAY, DANGER KEEP OUT OF REACH OF CHILDREN stored unsecured and unattended on top of the housekeeping cart, 1- 24 ounce bottle of a yellow solution labeled PEROXIDE SURFACE CLEANER AND DISINFECTANT KEEP OUT OF REACH OF CHILDREN stored unsecured and unattended on top of the housekeeping cart, and 1 red handle metal scraper stored unsecured and unattended on top of the housekeeping cart, and 1-12 ounce can of WD-40 spray stored inside of the unlocked unsecured housekeeping cart. Observation in the South hall at the STORAGE AREA on 11/5/2023 at 9:29 AM, 9:32 AM, revealed the door remained ajar, and the storage room remained unsecured and unattended. Observation on 11/5/2023 at 9:33 AM, revealed the Business Office Manager entered into the door labeled STORAGE AREA, and immediately exited the room and failed to lock or secure the door. The Business Office Manager spoke to Resident #43 in the South hall and the resident stated, I am trying to find my room. Observation and interview in the STORAGE AREA room on the South hall on 11/5/2023 at 9:35 AM, the Housekeeping staff confirmed the room was a storage room. The Housekeeping Staff confirmed that some chemicals are stored in the STORAGE AREA room and that staff sometimes store the housekeeping cart in the room. The Housekeeping staff confirmed that some maintenance tools are also stored in the STORAGE AREA room. The Housekeeping staff was asked if the house keeping cart, chemicals and tools are stored in the room should the room be secured at all times to ensure the safety of residents. The Housekeeping staff was shown the house keeping cart with the chemicals and the red handled scraper with the metal edge and was asked should these chemicals be stored inside of the housekeeping cart and should this cart be locked and secured at all times. The Housekeeping staff confirmed the room should be locked and secured at all times and the chemicals should be stored on the locked housekeeping cart. The Housekeeping staff stated, We do not have a key (pointing to the housekeeping cart). The Housekeeping staff was asked who has the key to the housekeeping cart. The Housekeeping staff stated, Well we never had a key made to it . The Housekeeping staff was asked should chemicals or sharp tools be stored on top of a housekeeping cart that is unlocked and unsecured and stored inside of a storage room that is unlocked, unsecured and unattended. The Housekeeping staff stated, Yes, it should be locked . Observation in the South hall on 11/5/2023 at 9:57 AM, revealed Resident #43 self-propelling in the hallway looking for her room. Observation revealed the STORAGE AREA remained unlocked, unsecured, and unattended containing the following items on a metal shelf: a. 3 1-gallon plastic jugs of floor adhesive remover on a metal shelf b. 2 cans of furniture polish remover, c. 1 27-ounce plastic container of hardwood floor [NAME] d. 1 32-ounce container of sewer drainage remover e. 1 gallon of defoamer for carpet machinery f. 1 gallon plastic jug of general-purpose cleaner g. 1 red metal tool cabinet containing nuts, bolts, screes, and wires. h. 6 1-liter containers of hand sanitizer containing 70% alcohol i. 19 1-liter containers of fragrance hand sanitizer with labeled KEEP OUT OF REACH OF C HILDREN Observation on the North hall on 11/5/2023 at 10:38 AM, revealed Resident #43 self-propelling in wheelchair asking is it time to smoke. Observation on the North hall on 11/5/2023 at 1:39 PM, revealed Resident #43 in wheelchair near the front entrance. During an interview on 11/9/2023 at 10:08 AM, the Administrator was asked should the room on the South hall labeled STORAGE AREA be left with the door left ajar, with a housekeeping cart with chemicals and sharps stored on top of the cart, and with chemicals stored on a metal rack and a tool chest with items be left with the door ajar, unsecured, and unattended with wandering residents. The Administrator confirmed the door should not be left ajar and the room should not be left unlocked, unsecured, and unattended. The Administrator confirmed that the facility has residents who are at risk for wandering. Observation on the South hall medication cart on 11/5/2023 at 1:10 PM, 1:15 PM, and 1:18 PM, revealed 1 pair of hemostat scissors and 1 pair of bandage scissors on top of the medication cart unsecured and unattended. Observation on the South hall medication cart on 11/5/2023 at 2:14 PM, revealed 1 pair of bandage scissors on top of the medication cart unsecured and unattended. During an interview at the South medication cart on 11/5/2023 at 3:51 PM, the Director of Nursing (DON) was asked should the bandage scissors and hemostats be stored on top of the medication cart unattended and unsecured. The DON stated, No. The DON was asked where they should be stored. The DON confirmed the bandage scissors and hemostats should be stored on the treatment cart under lock and key away from residents.

Based on the facility Monthly Schedules, Report of Nursing Staff Direct Responsible Resident Care Report, Registered Nurse (RN) Time Punches, and Daily Work Up Sheets, the facility failed to ensure there was RN coverage for 8 consecutive hours a day on Saturday and Sunday weekend days from April 1, 2023, to June 24, 2023 and October 14, 2023 to October 22, 2023. The facility census was 44. The findings include: 1.Review of the facility's Nurses Monthly Schedule for April 2023, revealed there was no RN scheduled to work 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/23/2023, 4/29/2023, and 4/30/2023. Review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, postings for April 2023, revealed there was no RN coverage, which indicated no RN worked 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/23/2023, 4/29/2023, and 4/30/2023. Review of the facility's RN Time Punch report for April 2023, revealed no RN punched in or out, which indicated no RN worked 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/23/2023, 4/29/2023, and 4/30/2023. Review of the facility's Daily Work Up, schedule for April 2023, revealed no RN listed which indicated that no RN was on duty and covered for 8 consecutive hours on 4/1/2023, 4/2/2023, 4/8/2023, 4/9/2023, 4/15/2023, 4/16/2023, 4/23/2023, 4/29/2023, and 4/30/2023. 2. Review of the facility's Nurses Monthly Schedule for May 2023, revealed there was no RN scheduled to work 8 consecutive hours on 5/6/2023, 5/13/2023, 5/20/2023, and 5/27/2023. Review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, postings for May 2023, revealed there was no RN coverage, which indicated no RN worked 8 consecutive hours on 5/6/2023, 5/13/2023, 5/20/2023, and 5/27/2023. Review of the facility's RN Time Punch report for April 2023, revealed no RN punched in or out, which indicated no RN worked 8 consecutive hours on 5/6/2023, 5/13/2023, 5/20/2023, and 5/27/2023. Review of the facility's Daily Work Up, schedule for May 2023, revealed no RN listed on the daily work up schedule, which indicated no RN was on duty and covered for 8 consecutive hours on 5/6/2023, 5/13/2023, 5/20/2023, and 5/27/2023. 3. Review of the facility's Nurses Monthly Schedule for June 2023, revealed there was no RN schedule to work 8 consecutive hours on 6/3/2023, 6/10/2023, 6/11/2023, 6/17/2023, and 6/24/2023. Review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, postings for June 2023, revealed there was no RN coverage, which indicated no RN worked 8 consecutive hours on 6/3/2023, 6/10/2023, 6/11/2023, 6/17/2023, and 6/24/2023. Review of the facility's RN Time Punch report for June 2023, revealed no RN punched in or out, which indicated no RN worked 8 consecutive hours on 6/3/2023, 6/10/2023, 6/11/2023, 6/17/2023, and 6/24/2023. Review of the facility's Daily Work Up, schedule for June 2023, revealed no RN was listed on the daily work up schedule which indicated indicating no RN was on duty and covered for 8 consecutive hours on 6/3/2023, 6/10/2023, 6/11/2023, 6/17/2023, and 6/24/2023. 4. Review of the facility's Nurses Monthly Schedule for October 2023, revealed there was no RN scheduled to work 8 consecutive hours on 10/14/2023, 10/21/2023, and 10/22/2023. Review of the facility's Report of Nursing Staff Directly Responsible for Resident Care, postings for June 2023, revealed there was no RN coverage, which indicated no RN worked 8 consecutive hours on 10/14/2023, 10/21/2023, and 10/22/2023. Review of the facility's RN Time Punch report for June 2023, revealed no RN punched in or out, which indicated no RN worked 8 consecutive hours on 10/14/2023, 10/21/2023, and 10/22/2023. Review of the facility's Daily Work Up, schedule for June 2023, revealed no RN listed on the daily work up schedule, which indicated no RN was on duty and covered for 8 consecutive hours on 10/14/2023, 10/21/2023, and 10/22/2023. During an interview on 11/5/2023 at 9:11 AM, LPN #1 was asked who the RN on duty is today. LPN #2 stated, It is the DON (Director of Nursing) .she was here, but she had to run some errands and said she would be back . During an interview on 11/5/2023 at 6:23 PM, LPN #2 was asked do you work on weekends (Saturday and Sunday). LPN #2 confirmed she does work weekends at the facility. LPN #2 was asked is there a RN who works the weekends as a RN charge nurse. LPN #2 was asked is there a RN covering for at least 8 hours consecutive on Saturday and Sundays on the weekend. LPN #2 confirmed there is not always a RN covering but the DON will come in at times and check on the staff but does not always stay. LPN #2 stated, She is in and out . LPN #2 was asked if there ever a time when there is no RN coverage. LPN confirmed there are times when there is no RN coverage in the facility and that the RN will come and go and run errands and come back and check on them. During an interview on 11/8/2023 at 11:31 AM, the DON was asked do you have RN coverage for 8 consecutive hours on Saturday and Sundays weekends. The DON confirmed there is not always weekend RN coverage on Saturday and Sunday weekends and that she will cover at times. The DON was asked are there any RNs on staff other than yourself. The DON confirmed she has a RN that works on the 11-7 shift on Monday through Friday and a RN who works day shift on Mondays, 2 PRN (as needed) RNs. The DON was asked does the PRN RNs cover the weekends. The DON confirmed they do cover but if they do not cover and she does not cover then there is no RN on duty. The DON confirmed that if a PRN RN covered the shift they would clock in and it would show on the time punch sheet for RNs. The DON confirmed she has covered at times on the weekend but she does not clock in and there is no way to tell if she was covering in April 2023, May 2023, June 2023, and October 2023. The DON was asked if she was aware that there should be RN coverage for 8 consecutive hours, 7 days a week to include Saturday and Sunday weekends. The DON confirmed she was aware that there should be RN coverage for 8 consecutive hours for 7 days a week to include Saturday and Sunday weekends. The DON confirmed that the facility doesn't always have RN coverage for 8 consecutive hours 7 days a week to include Saturday and Sunday weekends. The DON confirmed if the time punches do not show a RN working then there was no RN coverage.

**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 proper infection control practices were followed when 3 of 3 (Licensed Practical Nurse (LPN #1, #2, and #3) nurses failed to perform proper hand hygiene during medication administration, when 1 of 1 (LPN #3) failed to clean reusable equipment, and when 1 of 1 (LPN #2) failed to clean medical supplies after dropping it on the floor during Percutaneous Endoscopic Gastrostomy (PEG) site care, and when the facility failed to maintain and monitor for an effective infection prevention and control program for 3 of 3 (Resident #15, #24, and #30) sample residents reviewed for Legionella Disease. The findings include: 1. Review of the facility's policy titled Hand Hygiene, dated 1/2/2023, revealed .Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table .The use of gloves does not replace hygiene. If your task require gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .Either Soap and Water or Alcohol Based Hand Rub .Before performing invasive procedures .Before applying and after removing personal protective equipment (PPE), including gloves .Before preparing or handling medications. Before performing resident care procedures . Review of the facility's policy titled, Legionella Surveillance, dated 6/14/2023, revealed .It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections .Legionella is a bacteria found in water that can cause a serious type of pneumonia, Legionnaires' disease .Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water system .Residents with health-associated pneumonia or who have failed antibiotic therapy for community acquired pneumonia shall be tested for Legionella . 2. Observation during medication administration in the South hall on 11/6/2023 at 9:10 AM, revealed LPN #1, removed medications for Resident #44, entered the resident's room and administered the oral medications. LPN #1 donned a pair of clean gloves and removed the old Fentanyl patch (pain patch) 25 micrograms mcg transdermal patch from the resident's left upper chest area. Then cleaned the right upper chest area and applied the new Fentanyl transdermal patch, removed her gloves, and exited the resident's room and returned to the medication cart. LPN #1 failed to perform hand hygiene after the removal of the gloves. 3. Observation during medication administration on the North hall at the North hall medication cart on 11/7/2023 at 1:15 PM, revealed LPN #2 donned a pair of clean gloves and removed medications for Resident #16, locked her cart and removed her gloves. LPN #2 then entered the resident's room, donned a clean pair of gloves, and failed to perform hand hygiene upon removal and before donning a clean pair of gloves. LPN #2 administered 2 puffs from an Atrovent inhaler (for improved breathing) to Resident #16 and administered the oral medications. LPN #2 removed her gloves, exited the room, and returned to the medication cart. LPN #2 failed to perform hand hygiene upon removal of the gloves. 4. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses of Hemiplegia and Hemiparesis, Anemia, Dementia, and Gastrostomy. Review of the facility's Order Summary Report, dated 10/25/2023, revealed .Feeding Tube Site Care .Cleanse area around tube daily and prn [as needed] with wound cleanser or soap and water. Cover with dry 4 x 4 dressing . Observation in the North hall at the North hall treatment cart on 11/7/2023 at 1:18 PM, revealed LPN #2 removed the 4 x 4's, gloves, and a bottle of dermal wound cleanser from the treatment cart to perform PEG site care for Resident #25. LPN #2 entered the resident's room, placed the supplies on top of a barrier on the over the bed table. LPN #2 pulled the curtain and shut the door, entered the bathroom, washed her hands, returned to the bedside, then exited the room. Returned to the resident's room with a roll of tape. LPN #2 donned a clean pair of gloves and failed to perform hand hygiene. LPN #2 picked up the dermal wound cleanser and dropped it onto the floor. LPN #2 picked up the wound cleanser and placed it back on the barrier on top of the over bed table, pulled Resident #25's shirt up, placed a towel over her lower abdomen, removed the old dressing to the PEG site, sprayed the dermal wound cleanser to the PEG site. LPN #2 failed to clean or sanitize the dermal wound cleanser bottle prior to using it to perform PEG site care. LPN #2 dried the PEG site with 4 x 4 gauze, removed her gloves, donned a clean pair of gloves, placed a drainage sponge over the PEG tube site and secured with the tape, and failed to perform hand hygiene after removing her gloves. LPN #2 pulled Resident #25's shirt down, removed the towel, exited the room. 5. Observation during medication administration on the North hall at the North hall medication cart on 11/7/2023 at 4:10 PM, revealed LPN #3 donned a clean pair of gloves, removed oral medications for Resident #34 and placed on a barrier on top of the medication cart, removed a vial of Levemir insulin [lowers blood sugar], cleaned the top of the insulin bottle and withdrew 14 units of the insulin into an insulin syringe and placed on top of a barrier on top of the medication cart. LPN #3 removed her gloves, knocked, and entered the resident's room, placed the insulin syringe on top of a barrier on the over the bed table, and administered the oral medications. LPN #3 failed to perform hand hygiene after removing her gloves. LPN #3 donned a clean pair of gloves and then instilled 1 eye drop into each of the resident's eyes, removed her gloves, failed to perform hand hygiene, exited the room and returned to the medication cart, donned a clean pair of gloves and removed the blood glucose test strip, removed her gloves, failed to perform hand hygiene, locked the medication cart and returned to Resident #34's room. LPN #3 donned a clean pair of gloves, performed the blood glucose test on Resident #34, administered the 14 units of insulin into Resident #34's right upper arm, removed her gloves and returned to the medication cart, failed to perform hand hygiene. LPN #3 donned a clean pair of gloves and disposed of the trash and syringe into the sharps container on the medication cart, entered the resident's bathroom washed her hands, returned to the medication cart, donned a clean pair of gloves, removed a Cavi wipe (disinfectant wipe) and cleaned the accucheck [blood glucose meter] machine, removed her gloves, and failed to perform hand hygiene. 6. Observation during medication administration on the North hall at the North hall medication cart on 11/7/2023 at 4:50 PM, revealed LPN #3 entered Resident #25's room, with medications, donned clean pair of gloves, dropped the cap to the syringe on the floor, removed her gloves, exited the room. LPN #3 failed to perform hand hygiene after removing her gloves. LPN #25's room, removed the stethoscope from around her neck, checked for PEG tube placement and checked residual, LPN #3 replaced the stethoscope back around her neck. LPN #3 failed to clean or disinfect the stethoscope after use. LPN #3 administered the medications through the PEG tube, entered the bathroom and rinsed the syringe and plunger, and replaced back in the plastic bag with visible water particles. LPN #3 failed to thoroughly dry the syringe before replacing back in the bag. LPN #3 removed her gloves, adjusted the resident in bed, placed the call light within reach of the resident and exited the room. LPN #3 failed to perform hand hygiene after the removal of her gloves and after touching the resident and objects in the resident's room. During an interview on 11/8/2023 at 8:39 AM, the Director of Nursing (DON) was asked what process staff should use when removing and donning clean gloves. The DON confirmed the staff should use hand sanitizer or wash hands after removing gloves. The DON was asked what should staff do if they drop supplies on the floor when performing a treatment. The DON confirmed they should discard the item or clean and sanitize the item before using on a resident. The DON was asked what should staff do after using reusable medical equipment such as a stethoscope on a resident. The DON confirmed the equipment should be cleaned and disinfected after use on a resident. The DON was asked how the enteral feeding syringe should be stored after use. The DON confirmed the syringe should be cleaned, rinsed, and dried thoroughly before replacing back in the plastic bag. 7. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses of Alzheimer's, Hypertension, and Chronic Obstructive Pulmonary Disease. Review of the (Named Imaging) dated 8/18/2023, revealed .XRAY [Electromagnetic radiation] CHEST .increased right hilar density that may be due to atelectasis or Pneumonia. Review of the August Infection Control, tracking and trending sheet revealed Resident #15 had Pneumonia. 8. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Hypertension, Alzheimer's, and Schizophrenia. Review of the (Named Imaging) dated 9/1/2023, revealed XRAY CHEST .Mild right upper lobe infiltrate .includes atelectasis or infection .The findings are new from 05JAN2023 [January 5, 2023] . Review of the September Infection Control, tracking and trending sheet, revealed Resident #24 had Pneumonia. 9. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses of Above the Knee Amputation of the Left Leg, Depression, and Hypertension. Review of the (Named Imaging) dated 9/19/2023, revealed .XRAY CHEST .Left lower lobe atelectasis, aspiration, or pneumonia. A new finding since prior exam . Review of the September Infection Control, tracking and trending sheet, revealed Resident #30 had Pneumonia. During an interview on 11/9/2023 at 12:08 PM, the Maintenance Supervisor was asked what is being done to track and prevent Legionella and other bacteria in the water system. The Maintenance Supervisor stated, I do not know what that is . The Maintenance Supervisor was asked are you testing the facility's water. The Maintenance Supervisor stated, .not testing the water at all . During an interview on 11/9/2023 at 12:27 PM, the Administrator was asked if the facility was doing anything for the detection and prevention of Legionella. The Administrator stated, I do not know of anything. During an interview on 11/9/2023 at 4:51 PM, the Infection Control Preventionist was asked are you doing anything to track Legionella in the water system. The Infection Control Preventionist stated, No, I am not doing anything .