**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to revise the comprehensive care plan for 1 Resident (#53) to include pressure ulcer interventions of 3 residents reviewed for pressure ulcers. The findings include: Review of the facility policy titled Person-Centered Care Plan revised 10/24/2022, showed .Care plans will be .revised by the interdisciplinary team .as needed to reflect .care and changing needs . Review of the facility policy titled Skin Integrity and Wound Management revised 2/1/2023, showed .Staff will continuously observe and .implement revisions to the plan of care as needed . Resident #53 was admitted to the facility on [DATE] with diagnoses including Intertrochanteric Fracture of Left Femur, Metabolic Encephalopathy, Muscle Weakness, Type 2 Diabetes, Mild Cognitive Impairment, Need for assistance with Personal Care and History of Falling. Review of a physician's telephone order dated 5/2/2023, showed .Apply sure-prep [a fast drying skin protectant] to right heel wound every Tuesday, Thursday and Saturday on day shift . Review of a physician's order dated 5/10/2023, showed .Heel boot to right heel while in bed or chair . Review of Resident #53's comprehensive care plan revised 5/11/2023, showed no intervention for heel boot to right heel while in bed and chair. Further review showed no intervention to apply sure-prep to right heel wound every Tuesday, Thursday and Saturday on day shift. During an interview on 6/1/2023 at 10:00 AM, the Director of Nursing confirmed the facility failed to revise Resident #53's comprehensive care plan following new physician orders on 5/2/2023 and 5/10/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to investigate a fall for 1 Resident (#53) of 3 falls reviewed. The findings include: Review of the facility policy titled Falls: Care During and After dated 12/01/2006, showed .All residents who experience a fall will receive .investigation of the cause .Complete Resident Fall Investigation Form . Review of the facility policy titled Falls Management revised 6/15/2022, showed .A fall is defined as .coming to rest on the .floor .a fall is considered to have occurred when a patient is found on the floor . Resident #53 was admitted to the facility on [DATE] with diagnoses including Intertrochanteric Fracture of Left Femur, Metabolic Encephalopathy, Muscle Weakness, Type 2 Diabetes, Mild Cognitive Impairment, History of falling, and Frontal Lobe and Executive Function Deficit. Review of a nursing note dated 3/4/2023, showed Resident #53 was observed sitting on the floor in the resident's room, .when asked resident what happened he said he was tired so he sat down to rest .I [Registered Nurse #1] asked why he did not sit on bed resident states he likes to sit in the floor .assisted resident with getting up and sitting on bed .will continue to monitor . There was no documentation a fall investigation form had been completed. Review of a History and Physical dated 3/9/2023, showed .On 3/4/2023 he was found by nursing sitting in the floor in his room. When the nurse asked what happened he said he was tired so he sat down to rest. He does have underlying cognitive impairment and is a poor historian in regards to if he fell or not prior to being found by nursing in the floor .no .signs of trauma . Review of a Practitioner Note dated 3/10/2023, showed .Patient was found sitting on the floor in his room on 3/4 [2023]. He states he was tired and sat down. Due to dementia he is an unreliable historian and it is unclear if he sat himself down or fell . During an interview on 5/31/2023 at 2:25 PM, the Director of Nursing (DON) stated Resident #53 was observed on the floor in his room on 3/4/2023, the resident was assessed for injuries, and none were observed. The DON confirmed RN #1 did not initiate a fall investigation form when the resident was observed on the floor and stated RN #1 .did not consider it a fall since the resident stated he sat in the floor and there was no injury to the resident . The DON confirmed the facility failed to complete a fall investigation form when Resident #53 was found on the floor in his room on 3/4/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to follow the facility policy to obtain a physician's order for an indwelling urinary catheter to include catheter care for 1 resident (#46) and failed to obtain a physician's order for the bulb size of an indwelling urinary catheter for 1 resident (#71) of 3 residents reviewed for catheter use. The findings include: Review of the facility policy titled Catheter: Indwelling Urinary [a tube placed in the bladder to allow urine to drain freely] -Insertion Of reviewed 9/24/2012, showed .Urinary catheters will be inserted in accordance with a physician's order .Verify physician's order .Attach the pre-filled, sterile syringe to the balloon port of the catheter .gently instill the appropriate amount of sterile water/solution (e.g. [for example] 5 cc [cubic centimeter] for 5 cc balloon] .Document: Catheter size, type, and amount of solution used to inflate balloon . Review of the facility policy titled Catheter: Urinary- Justification for Use dated 3/1/2022, showed .obtain physician order .follow Catheter: Indwelling Urinary-Care of procedure . Review of the facility policy titled Catheter: Indwelling Urinary -Care Of dated 2/1/2023, showed .Perform catheter care twice a day and PRN .Document: Catheter care provided . Resident #46 was admitted to the facility on [DATE] with diagnoses including Paraplegia and Neuromuscular Dysfunction of the Bladder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #46 was cognitively intact and had a urinary catheter. Review of the comprehensive care plan dated 3/23/2023, showed the resident required an indwelling urinary catheter due to neurogenic bladder and the resident refused catheter care often. During an observation on 5/30/2023 at 11:00 AM, Resident #46 was seated in a wheelchair with a covered urinary catheter bag in place. Review of Resident #46's current physician's orders showed no order for an indwelling urinary catheter. During an interview on 6/1/2023 at 11:26 AM, the Director of Nursing (DON) stated she expected the resident to have an order a catheter. Resident #71 was admitted to the facility on [DATE] with diagnoses including Hydronephrosis with Renal and Ureteral Calculous Obstruction and Acute Kidney Failure. Review of a physician's order dated 5/3/2023, showed .Indwelling catheter 18 FR [French-size of catheter] with___cc [cubic centimeters-amount of solution used to inflate] balloon . Review of Resident #71's comprehensive care plan dated 5/3/2023, showed .indwelling .catheter due to neurogenic bladder . Review of an admission MDS assessment dated [DATE], showed the resident had an indwelling catheter. During an interview on 6/1/2023 at 10:01 AM, Registered Nurse (RN) #1 stated the admission nurse was responsible to obtain an order for an indwelling urinary catheter which was to include the bulb size. RN #1 confirmed Resident #71's physician's order for the indwelling catheter did not include the bulb size . During an interview on 6/1/2023 at 10:15 AM, the DON confirmed the physician's order did not include the bulb size needed for Resident #71's indwelling catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations and interviews, the facility failed to provide a safe, clean, and homelike environment for 1 Resident (#55) of 39 residents reviewed, failed to maintain the upkeep of painted walls in 2 of 4 hallways, failed to maintain the integrity and cleanliness of 2 speciality chairs of the 30 speciality chairs in the facility, failed to provide a safe, clean, and homelike environment for 1 of 1 shower rooms, and failed to provide a safe, clean, and homelike environment for 1 of 1 dining rooms. The findings include: Review of the facility policy titled Accommodation of Needs revised 2/1/2023, showed .The resident .has the right to a safe, clean, comfortable and homelike environment .The Center must provide: A safe, clean, comfortable, and homelike environment . Resident #55 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Viral Hepatitis C, and Osteomyelitis of Vertebra. Review of Resident 55's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #55's Brief Interview of Mental Status (BIMS) score was 15, indicating the resident was cognitively intact and required assistance of one or more staff members with activities of daily living (ADL's). During an observation/interview on 5/30/2023 at 12:27 PM, Resident #55 voiced concern of the condition of her bathroom. Observations revealed the vinyl had separated from the floor and the baseboard, around the edges of the room and had a gap, ½ to ¾ inches, filled with dark brown/black debris. The light fixture in the bathroom had 1 working bulb, which resulted in dim and inadequate lighting for the bathroom. During an observation on 5/31/2023 at 1:10 PM, Resident #55's air conditioner was noted to have a ¼ inch gap between the unit and the wall. The face plate of the air conditioner unit was loose and not affixed to the main unit. During an observation on 5/31/2023 at 1:15 PM of the upper 100 hallway revealed the walls in the hallway had scrapes along the bottom portion (6-8 inches from the floor) of the wall and the paint was scraped on the wall across from room [ROOM NUMBER] for a total length of 12 feet. On the 100 hallway, a speciality chair was observed to have a ripped left side armrest and another speciality chair was observed to have non adhesive gauze wrapped on the top of the left arm rest. The foam cushion in the second chair had various colored debris present on the top of the cushion. A sit to stand transfer device was also in the hallway with the handles covered with white residue and the floor plate of the device had copious amounts of brown residue present. A tour of the facility's 1 shower room revealed the floor had debris which had led to the discoloration of the grout between the tiles. The lens of the shower room light fixture was not in a secure position with the right side of the lens dangling 2-3 inches and with 2 of the 4 retention clips exposed, not affixed to the light fixture. Observation of the dry wall ceiling of the facility's 1 dining room showed it was cracked at a midpoint seam for the entire length of the room. A retractable louvered access pass through panel, from the kitchen to the dining room, was observed to be unsanitary with the entire length of the panel covered with a thick multi-colored residue. The counter plate of the access door had a ½ inch gap between the plate and the cinder block wall. During an interview on 5/31/2023 at 1:55 PM, the Contracted Account Manager confirmed responsibility for the oversight of the cleaning of the facility and stated the contracted facility staff were to assist the nursing staff with wiping down the speciality chairs, as well as the sit to stand transfer device. During an interview on 5/31/2023 at 2:02 PM, the Administrator confirmed there were many aesthetic environmental challenges in the facility related to a home like environment. During an interview on 6/1/2023 at 12:18 PM, the Director Of Nursing confirmed the facility was in a state of disrepair and there were home like environment concerns which had been overlooked.

Based on facility policy review, observation and interview, the facility failed to maintain a sanitary environment in the kitchen, with the potential to affect 72 of 74 residents in the facility. The findings include: Review of the facility policy titled Equipment revised 9/2018, showed .All foodservice equipment will be clean, sanitary, and in proper working order .All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials .All staff members will be properly trained in the cleaning and maintenance of all equipment .All food contact equipment will be cleaned and sanitized after every use .All non-food contact equipment will be clean and free of debris . During the initial kitchen tour observation on 5/30/2023 at 10:35 AM, with the Certified Dietary Manager (CDM), the stove was found with splashed brown food debris build up on both doors and the right handle of the oven. Observation of the convection oven had dried spattered brown food debris present on the right front of the oven adjacent to the control panel, a copious amount of pooled dried brown food debris was present along the bottom crevasse of the convection oven pilot light access panel. Observation revealed the mobile steam tray cart used to serve resident meals for the dining room and all halls in the facility had brown food debris observed in the bottom in 2 of 3 serving bins. On the bottom shelf of the mobile steam tray cart, a copious amount of bread crumbs were present beside 2 loaves of bread. The sugar bin was 1/3 full, and a scoop was present lying on top of the sugar in the bin. During an interview on 5/30/2023 at 11:30 AM, the CDM confirmed the staff failed to clean and sanitize the kitchen equipment appropriately after use. The CDM also confirmed the scoop was not to be stored inside the sugar bin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to develop a comprehensive care plan for wound management, for 1 resident (#214) of 20 residents reviewed for care plans. The findings include: Review of the facility policy titled ,Person-Centered Care Plan, dated 7/1/2019, showed .A comprehensive, individualized care plan will be developed for each patient that includes measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs . Resident #214 was admitted on [DATE] with diagnoses including Sepsis, Cellulitis of Left Lower Limb, Hypertension, Muscle Weakness, and Cognitive Communication Deficit. Review of a physician's order dated 11/15/2021, showed .Clean non viable tissue to L [left] calf with wound cleanser. Apply xeroform gauze [a petrolatum based gauze]. Secure with kerlix [bandage roll] and ace [an elastic bandage] daily . Review of a nurse practitioner's progress note dated 11/17/2021, showed .On admission he [Resident #214] was noted with BLE [bilateral lower extremity] cellulitis due to infected wounds . Review of Resident #214's medical record showed no comprehensive care plan had been developed for wound management. Interview with the Director of Nursing on 12/7/2021 at 9:45 AM, confirmed a comprehensive care plan for wound management had not been developed for Resident #214.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medications were stored and administered safely for 1 resident (Resident #33) of 7 residents observed and reviewed for medication administration when a nurse left the resident's medication at the bedside unattended. The findings include: Review of the facility policy titled, Medication Administration: General, revised 6/1/2021 showed .provide a safe, effective medication administration process .Remain with patient until administration is complete. Do not leave medications at the patient's bedside . Resident #33 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (ESRD), Dependence on Renal Dialysis, Respiratory Failure with Hypoxia, Shortness of Breath, Major Depressive Disorder, Muscle Wasting, and Contractures of Right and Left Knee. Review of the Minimum Data Set (MDS) 5 day assessment dated [DATE], showed Resident #33 had a Brief Interview for Mental Status (BIMS) of 15, indicating she was cognitively intact. Resident #33 required extensive assistance of 2 staff persons with bed mobility, locomotion on unit, dressing, toileting, and personal hygiene. Required set up assistance with meals. No issues with swallowing with eating or drinking. Review of the Care Plan dated 10/15/2021, showed Resident #33 .at risk for cardiovascular symptoms .administer meds [medications] as ordered .Exhibits impaired renal function and at risk for complications related to (r/t) hemodialysis [a process of purifying the blood of a person whose kidneys are not working] .Medicate as ordered .vision impairment .wears glasses .arrange environment to enhance vision .ensure appropriate visual aid .Orient .to surroundings . Observation on 12/5/2021 at 9:28 AM, of Resident #33 in the resident's room, revealed Resident #33 lying in the bed with eyes closed, a round reddish-brown pill in a plastic medication cup lying on its side was found on the over bed table. Continued observation showed no facility staff was present in the resident's room. Call light was turned on in resident's room, surveyor requested a nurse to come to room. At 9:38 AM, Licensed Practical Nurse #1 (LPN #1) entered Resident #33's room and confirmed it looked like a pill in a medication cup left on the overbed table. LPN #1 stated she was not the one who administered Resident #33's medications. Further observation showed LPN #1 took the medication in the plastic medication cup with her and showed the medication to LPN #2. LPN #2 stated she had administered Resident #33's medication at 7:00 AM. The round reddish-brown pill was identified by LPN #2 as [NAME]-Vite (a dietary supplement) 0.8 mg (milligrams- a unit of measure) daily for renal failure. At 9:41 AM, LPN #1 took the found medication to the Director of Nursing's (DON) office and handed off to her. During an interview with the DON on 12/5/2021 at 9:41 AM, confirmed there was a round reddish-brown pill in a plastic cup. She stated the nurse did not stay with Resident #33 while she took her [NAME]-Vite. During an interview on 12/5/2021 at 2:46 PM, Resident #33 stated she does not like to take her vitamin with her regular medications .it makes me queasy . and waits about 30 minutes later to take after her stomach settles. She further stated she fell asleep and forgot to take her vitamin this morning and left it in the plastic cup on her overbed table. During an interview with the DON on 12/5/2021 at 3:15 PM, confirmed there was no assessment for Resident # 33 to self-administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, job description, observation, and interview, the facility failed to maintain a safe, functional, and comfortable environment for 1 of 38 resident rooms observed. The findings include: Review of the facility policy titled, Preventive Maintenance, dated 6/2007 showed .Perform preventive maintenance on .physical plant on a schedule which factors in operational activity and complies with applicable code requirements . Review of the Maintenance Director's job description dated 10/6/2016, showed .The Maintenance Director is responsible for overall maintenance operation of the center .he is responsible for performing repairs .performing regular daily, weekly, and monthly maintenance checks, as shown on 'Preventive Maintenance Calendar' .Maintains the building in good repair .free of hazards .Maintains the building .in compliance with Federal, State, and local laws . Observation of room [ROOM NUMBER]b on 12/5/2021 at 11:56 AM, showed a large hole in the wallboard behind the bed with crumbled plaster and white dust particles noted on the floor. Observation of room [ROOM NUMBER]b on 12/6/2021 at 12:43 PM, showed a large hole in the wallboard behind the bed with crumbled plaster. During observation and interview on 12/6/2021 at 12:45 PM, the Director of Maintenance confirmed room [ROOM NUMBER]b had a large hole in the wallboard located behind the bed. He stated he was unaware of the hole in the wall; no work order had been placed. Observation of room [ROOM NUMBER]b on 12/7/2021 at 7:55 AM, showed the large hole continued to be visable in the wallboard with crumbled plaster. During an interview with the Administrator on 12/7/2021 at 2:00 PM, revealed his expectations would be for the Director of Maintenance to make safety rounds in the resident rooms weekly. The weekly safety checks to ensure beds, sinks, bathrooms, all equipment is working properly and for any other maintenance needed. Continued interview revealed no weekly safety checks had been documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Myeloid Leukemia, Vascular Dementia with Behavioral Disturbance, Dysphagia, Muscle Weakness, Cerebral Infarction, and Cognitive Communication. Medical record review of the quarterly MDS dated [DATE] revealed Resident #39 had severe cognitive impairment. Continued review revealed no rejection of care had been exhibited. Further review revealed the resident required total assistance of two staff members for bed mobility, dressing, toileting, bathing, and personal hygiene. Medical record review of the care plan revised 4/15/19 revealed .While in the facility .it is important that [the resident] has the opportunity to engage in daily routines that are meaningful relative to their preferences .it is important for me to take a shower . Medical record review of the ADL record dated March 2019 revealed Resident #39 had received a shower on 3/9/19, 3/20/19, 3/27/19, indicating the resident had not received 7 of the scheduled showers for the days of 3/1/19-3/31/19. Medical record review of the ADL record dated April 2019 revealed the resident had received a shower on 4/6/19, 4/17/19, 4/21/19, indicating the resident had not received 5 of the scheduled showers for the days of 4/1/19-4/30/19. Medical record review of the ADL record dated May 2019 revealed the Resident had received a shower on 5/1/19 and 5/4/19, indicating the resident had not received 7 of the scheduled showers between the days of 5/1/19-5/21/19. Observation and interview on 5/19/19 at 3:31 PM, revealed Resident #39 lying in bed, hair disheveled and unshaven. Family member at bedside stated she has asked for [the resident] to be added to the list for a haircut and beard (goatee style beard) to be trimmed and the rest of his face shaven. Continued interview revealed the resident had only had one shower since February 2019. [the resident] is not getting showers .[the resident] needs to go to the shower .I have even offered to come in and shower [the resident] myself . Observation on 5/20/19 at 3:00 PM, in the resident's room revealed Resident #39 lying in bed yelling out for family member. Continued observation revealed Resident #39's hair was disheveled and his face unshaven. Observation on 5/21/19 at 8:17 AM, in the resident's room revealed Resident' #39 lying in bed with the television playing, white tee shirt on and covered with sheet, hair disheveled and unshaven. Interview with Certified Nursing Assistant (CNA) #1 on 5/21/19 at 8:00 AM, in the conference room confirmed she is assigned to resident showers and residents are to be offered a shower two times a week. Continued interview confirmed she is pulled to the floor on a regular basis due to staff call-ins and she is unable to complete the assigned showers. Interview with the Director of Nursing (DON) on 5/21/19 at 9:30 AM, in the conference room, confirmed the residents had not received the scheduled showers. Further interview confirmed it was her expectation the residents received scheduled baths twice weekly. Interview with CNA #2 on 5/21/19 at 11:10 AM, in the conference room, confirmed she was assigned for resident showers. Further interview confirmed there were residents which required total assist and required use of a lift or gurney. Continued interview confirmed the shower required staff 30-45 minutes to complete each shower. Further interview confirmed when there are staff call-ins and she is pulled to the floor, they (staff) will not complete any showers on residents that require use of the lift or gurney because there is not enough time. Based on facility policy review, medical record review, review of the facility's Activities of Daily Living Record (ADL), observations and interviews, the facility failed to provide scheduled showers for 2 dependent residents (#5, #39) of 13 residents reviewed for ADLs of 19 sampled residents. The findings include: Review of the facility policy Activities of Daily Living (ADLs),with a revision date of 11/28/16, revealed .Activities of daily living (ADLs) include .Hygiene-bathing . grooming .To attain or maintain the patient's highest practicable physical, mental, and psychosocial well being .receives necessary services to maintain good .grooming, and personal .hygiene . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Quadriplegia, Muscle Wasting, Acquired Absence of Unspecified Foot, Acute Kidney Failure and Major Depressive Disorder. Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, required extensive assistance of 2 staff for transfers, toileting, personal hygiene and bathing. Medical record review of the ADL record dated May 2019 revealed the resident had not received showers two times a week. Observation of Resident #5 on 5/19/19 at 9:45 AM, in the residents room revealed the resident resting in bed. Interview with Resident #5 on 5/19/19 at 9:45 AM, in the resident's room confirmed he was .lucky to get a shower once a week . Further interview confirmed he preferred to have a shower but staff are unable to get him in the shower two times a week. Continued interview confirmed there are a couple staff on evening shift that sometimes will give him a bed bath.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to administer oxygen therapy as ordered for 1 resident (#47) of 6 residents reviewed for oxygen therapy of 19 residents sampled. The findings include: Review of the facility policy Oxygen revised 12/1/18 revealed .Set liter flow per order .Attach prescribed oxygen delivery device. Apply oxygen delivery to the resident . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Encounter for Palliative Care, Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease, Major Depressive Disorder and Anxiety Disorder. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance of 1 staff bed mobility, transfers, and supervision set up help for toileting, hygiene and eating. Continued review revealed the resident was on oxygen therapy. Medical record review of the Comprehensive Care Plan dated 5/9/19 revealed the resident required assistance for activities of daily living (ADL), and was on hospice service due to end stage COPD. Continued review revealed the resident was at risk for respiratory complications related to end stage COPD and sleep apnea with interventions .O2 [oxygen] as ordered . Medical record review revealed a Physician's Order dated 5/21/19, for Oxygen at 4 liter per minute (l/m) continuous. Observation of Resident #47 on 5/19/19 at 2:25 PM, in the resident's room, revealed the resident was sitting on bed with oxygen in use at 3.5 l/m bnc (by nasal cannula). Observation of Resident #47 on 5/20/19 at 9:53 AM, in the hall outside of the resident's room, revealed the resident was in a wheelchair with oxygen in use bnc. Continued observation revealed the regulator (device to regulate flow of oxygen) was set to deliver oxygen at 3 l/m. Observation of Resident #47 on 5/20/19 at 10:00 AM and 10:04 AM, in the resident's room, revealed the resident was sitting on the bed with oxygen in use at 3 l/m bnc. Observation of Resident #47 and interview with Registered Nurse (RN) #5 on 5/20/19 at 10:04 AM, in the resident's room, revealed the resident's oxygen concentrator flow meter was set .on 3 or 3.5 . l/m bnc. Continued interview confirmed the resident's oxygen was not being administered at 4 l/m as ordered by the Physician. Observation of Resident #47 on 5/20/19 at 5:20 PM, in the resident's room, revealed the resident lying in bed with oxygen in use at 3.5 l/m bnc. Observation of Resident #47 and interview with Licensed Practical Nurse (LPN) #3 on 5/20/19 at 5:25 PM, in the resident's room, revealed the resident was receiving oxygen .between 3 [l/m] and 4 [l/m] but less than 4 [l/m] . Continued interview confirmed the oxygen was not being administered at 4 l/m as ordered by the Physician. Observation of Resident #47 on 5/21/19 at 10:10 AM, in the hall near the dining room, revealed the resident was sitting in a wheelchair with oxygen in use. Continued observation revealed the oxygen regulator was set to administer oxygen at 3 l/m bnc. Further observation revealed the oxygen regulator reflected the oxygen tank was empty. Observation of Resident #47 and interview with RN #3 on 5/21/19 at 10:12 AM, in the hall near the dining room, confirmed the oxygen regulator was set to deliver oxygen at 3 l/m bnc and the tank was empty. Continued interview confirmed the resident's oxygen was not being administered at 4 l/m as ordered by the Physician. Further observation revealed RN #3 transported Resident #47 via wheelchair to the resident's room and applied O2 at 4 l/m bnc. Continued observation revealed RN #3 obtained the oxygen saturation level of Resident #47. Further observation and interview with RN #3 revealed the resident's oxygen level was at 89% (percent). Continued interview revealed the resident's oxygen level was typically in the 89 to low 90% range due to the resident's advanced COPD. Interview with the Director of Nursing (DON) on 5/21/19 at 3:25 PM, in the DON's office, confirmed the facility failed to monitor and administer the oxygen as ordered by the Physician for Resident #47.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to ensure 2 medications were administered per Physician's Orders of 31 opportunities observed for 1 resident (#47) of 4 residents observed for medication administration resulting in an 6.45% medication error rate. The findings include: Review of the facility's policy, Medication Administration: General, revised date 7/24/18 revealed .A licensed nurse .will administer medications to patients. Accepted standards of practice will be followed. Further review revealed .Practice Standards .Doses will be administered within one hour of the prescribed time unless otherwise indicated by the prescriber . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease (PVD), Essential Hypertension, Major Depressive Disorder, Anxiety Disorder and Encounter for Palliative Care. Medical record review of Resident #47's Physician Recapitulation Orders dated 5/19/19 revealed the resident was ordered Lorazepam (anti-anxiety medication) 0.5 mg (milligram) 1 tablet PO (by mouth) three times a day 8:00 AM, 2:00 PM, and 8:00 PM, Oxycodone (narcotic pain medication) 5 mg PO every 8 hours 12:00 AM, 8:00 AM,and 4:00 PM. Observation with Registered Nurse (RN) #1 on 5/19/19 at 10:15 AM, in hallway, revealed RN #1 administered the 8:00 AM scheduled doses of Lorazepam tablet and Oxycodone tablet. Continued observation revealed RN #1 had administered the resident's medications 2 hours and 15 minutes past the scheduled administration time. Interview with RN #1 on 5/19/19 at 10:30 AM, at the nurse's station, confirmed the medications were due to be administered at 8 AM but .it's almost impossible with 40 residents . Interview with the Director of Nursing on 5/19/19 at 11:25 AM, in the conference room, confirmed medications are to be administered 1 hour before or 1 hour after the ordered time. Further interview confirmed the facility failed to follow their policy to administer medications timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility documentation, review of Activities of Daily Living (ADL) records, resident, family, and staff interviews the facility failed to maintain adequate staffing levels to meet the care needs of 2 residents (#5, #39) of 19 sampled residents and failed to ensure medications were administered timely for 1 resident (#47) of 4 residents observed for medication administration. The findings include: Review of the facility policy, Activities of Daily Living (ADLs), revision date 11/28/16, revealed .Activities of daily living (ADLs) include .Hygiene-bathing . grooming .To attain or maintain the patient's highest practicable physical, mental, and psychosocial well being .receives necessary services to maintain good .grooming, and personal .hygiene . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Quadriplegia, Muscle Wasting, Acquired Absence of Unspecified Foot, Acute Kidney Failure and Major Depressive Disorder. Medical record review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, required extensive assistance of 2 staff for transfers, toileting, personal hygiene and bathing. Medical record review of the ADL record dated May 2019 revealed the resident had not received showers two times a week. Interview with Resident #5 on 5/19/19 at 9:45 AM, in the resident's room confirmed he was .lucky to get a shower once a week . Further interview confirmed he preferred to have a shower but staff are unable to get him in the shower two times a week. Continued interview confirmed there are a couple staff on evening shift that sometimes will give him a bed bath. Medical record review revealed Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Myeloid Leukemia, Vascular Dementia, Cerebral Infarction, and Pain., Medical record review of the quarterly MDS dated [DATE] revealed Resident #39 had severe cognitive impairment. Further review revealed the resident required total assistance of two staff members for bed mobility, dressing, toileting, bathing, and personal hygiene. Medical record review of the care plan revised 4/15/19 revealed .While in the facility .it is important that [the resident] has the opportunity to engage in daily routines that are meaningful relative to their preferences .it is important for me to take a shower . Medical record review of the ADL record dated March 2019 revealed Resident #39 had received a shower on 3/9/19, 3/20/19, 3/27/19, indicating the resident had not received 7 of the scheduled showers for the days of 3/1/19 - 3/31/19. Medical record review of the ADL record dated April 2019 revealed Resident #39 had received a shower on 4/6/19, 4/17/19, 4/21/19, indicating the resident had not received 5 of the scheduled showers for the days of 4/1/19 - 4/30/19. Medical record review of the ADL record dated May 2019 revealed Resident #39 had received a shower on 5/1/19 and 5/4/19, indicating the resident had not received 7 of the scheduled showers between the days of 5/1/19 - 5/21/19. Interview with Resident #39's family member on 5/19/19 at 3:31 PM, in Resident #39's room, revealed the resident had only had one shower since February 2019 . [the resident] is not getting showers . [the resident] needs to go to the shower .I have even offered to come in and shower [the resident] myself . Interview with Certified Nursing Assistant (CNA) #1 on 5/21/19 at 8:00 AM, in the conference room confirmed she is assigned to resident showers and residents are to be offered a shower two times a week. Continued interview confirmed she is pulled to the floor on a regular basis due to staff call-ins and she is unable to complete the assigned showers. Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease (PVD), Essential Hypertension, Major Depressive Disorder, Anxiety Disorder, and Encounter for Palliative Care. Medical record review of Resident #47's Physician Recapitulation Orders dated 5/19/19 revealed the resident was ordered Lorazepam (anti-anxiety medication) 0.5 mg (milligram) 1 tablet PO (by mouth) three times a day 8:00 AM, 2:00 PM, and 8:00 PM, Oxycodone (narcotic pain medication) 5 mg PO every 8 hours 12:00 AM, 8:00 AM, and 4:00 PM. Observation with Registered Nurse (RN) #1 on 5/19/19 at 10:15 AM, at the nurse's station, revealed RN #1 administered the 8:00 AM scheduled doses of Lorazepam tablet and Oxycodone tablet. Continued observation revealed RN #1 had administered the resident's medications 2 hours and 15 minutes past the scheduled administration time. Interview with RN #1 on 5/19/19 at 10:30 AM, at the nurse's station, confirmed the medications were due to be administered at 8 AM but .it's almost impossible with 40 residents . Interview with the Director of Nursing (DON) on 5/21/19 at 9:30 AM, in the conference room, confirmed the residents had not received the scheduled showers. Further interview confirmed it was her expectation the residents received scheduled baths twice weekly. Interview with CNA #2 on 5/21/19 at 11:10 AM, in the conference room, confirmed she was assigned for resident showers. Further interview confirmed there were residents which required total assist and required use of a lift or gurney. Continued interview confirmed the shower required staff 30-45 minutes to complete each shower. Further interview confirmed when there are staff call ins and she is pulled to the floor, they will not complete any showers on residents that require use of the lift or gurney because there is not enough time. In summary after medical record review, review of facility documentation, observations, resident, family, and staff interviews the facility failed to ensure adequate staffing was available to provide 2 residents with scheduled showers twice a week and 1 resident with medications timely.

Based on facility policy review, observation, and interview, the facility failed to store clean pans and kitchen equipment under dry sanitary conditions; failed to ensure an expired food additive, expired food items and expired emergency water supply was not available for resident use in 1 of 1 kitchen observed. The findings include: Review of the facility Food and Nutrition Services Policy and Procedures entitled Receiving, with a revised date of 5/2014, revealed .It is the center policy that safe food handling procedures .will be practiced in the .storage of all food items .All food items will be stored in a manner that [insures] appropriate and timely utilization .Foods considered unsafe for consumption or beyond the expiration date will be discarded by staff . Observation and interview with [NAME] #1 on 5/19/19 at 9:00 AM, in the kitchen, revealed 4 of the 8 inch by 12 inch pans, and 2 of the 4 inch by 12 inch pans were stored wet. Continued observation revealed the meat slicer with dry debris; 75 (1) gallon jugs of the emergency water supply with a use by date of 4/22/19 and a powdered thickening agent stored in a 50 gallon barrel, 1/8 full, had an expired date of 1/1/19 was available for resident use . Observation and interview with Certified Dietary Manager (CDM) on 5/19/19 at 9:30 AM, in the nourishment room, revealed a strawberry dessert stored in the resident nourishment refrigerator with no date and was available for resident use. Continued observation and interview revealed 6 of the 8 ounce styrofoam cups were 1/8 full of a frozen clear liquid, uncovered, and stored in the door of the resident nourishment freezer with a date labeled 8/20/18. Further interview confirmed the facility failed to store clean pans and kitchen equipment under dry sanitary conditions; failed to ensure an expired food additive, expired food items and expired emergency water supply were not available for resident use.