**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 a safe, clean, comfortable and homelike environment for 1 of 66 rooms (room B-34) reviewed. The findings include: Review of the facility's undated policy titled, 502 Patient Rooms-Routine Cleaning (High-touch surfaces, floors, and bathroom), revealed, .Routine cleaning of patient areas occurs while the patient is admitted , focuses on patient zones, and aims to remove organic material and reduce microbial contamination to provide a visually clean environment .At least once daily, high-touch surfaces, floors, and handwashing sinks should be cleaned .Clean other surfaces of the bathroom, including grab bars, shower fixtures, walls .check restroom for toilet tissue . Review of the facility's policy titled, Quality of Life-Homelike Environment, revised 5/2017, revealed, .Residents are provided with a safe, clean, comfortable and homelike environment .Staff shall provide person-centered care that emphasizes the residents' comfort .clean, sanitary and orderly environment . Review of the medical record revealed Resident #21 was admitted on [DATE] with diagnoses which included Acute Respiratory Disease, Hypertensive Heart Disease, and Cerebral Infarction. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Observation of room #B-34 on 9/20/2022 at 8:00 AM, revealed the room had debris on the floor and was sticky and there was a meal tray on top of the trash can. The tops of the overbed tables were dirty with shiny dried substance. Observation and interview in room #B-34 on 9/20/2022 at 10:38 AM, revealed a bag of dirty linen and a bag of trash beside the door sitting on the floor. Debris which included spilled water and milk, various fruit pieces and oatmeal was scattered on the floor around B bed. Fruit pieces were smeared across the wall on the left side of the bed. There were cartons containing the leftovers from breakfast on the bedside table. Resident #240's catheter bag was lying on the floor full of urine on the right side of the bed. There was not a trash can beside the door to dispose of used Personal Protective Equipment (PPE). Observation in the bathroom revealed black and red debris around the base of the shower walls and on the floor of the shower. The equipment used to hold the shower head was off of the bracket and lying on the soap dish. There were two empty toilet paper rolls on the holder and a small roll of toilet paper placed on top of the handrail. During an interview, Resident #21 stated no one had cleaned the room in several days. She stated she tried to keep things picked up off the floor and around her side of the room. Observation and interview in room #B-34 on 9/20/2022 at 10:45 AM, revealed the room continued to be dirty, Resident #240's catheter bag continued to be laying on the floor beside the bed. During an interview, the Director of Nursing (DON) confirmed there was food scattered around the bed, on the bed and the catheter bag was laying on the floor. She confirmed there was black and red debris, which had the appearance of mold, around the bases of the shower wall and on the floor of the shower. Observation and interview in room #B-34 on 9/20/2022 at 10:50 AM, the Environmental Services Director stated the black and red debris around the base of the shower and shower floor appeared to be mold or mildew. She confirmed there were two empty toilet paper rolls in the holder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to report an injury of unknown source for 1 of 42 sampled resident (Resident #7) reviewed. The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, with revision date 12/11/2017 revealed .Injuries of Unknown Source: An injury should be classified as a [injury of unknown source] when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the patient; and, the injury is suspicious because of the extent of the injury or the location of the injury [ .the injury is located in an area not generally vulnerable to trauma] or the number of injuries observed at one particular point in time or the incidence of injuries over time .Any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation of either abuse, neglect .any allegation [or] indication of possible willful infliction of injury to include unexplained bruising .any partner having either direct or indirect knowledge of any event that might constitute abuse .must report the event immediately, but no later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse or result in serious bodily injury .It is the policy of this facility that [abuse] allegations [abuse, neglect, exploitation or mistreatment, including injuries of unknown source] .are reported immediately, but not later than 2 hours . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's Disease and Unspecified Fracture of Shaft of Unspecified Tibia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #7 required extensive assistance of two+ persons for bed mobility and transfers. Further review of the MDS revealed Resident #7 required total assist of one person physical assist with toileting and two+ person assist with bathing. Review of the current Care Plan for Resident #7 revealed care plans which included risk for behaviors, rejection of care, risk for falls, and cognitive loss/Dementia. Review of the Resident Progress Notes dated 6/20/2022 through 6/21/2022, revealed, .6/20/2022 10:20 AM Right leg noted with increased warmth, swelling an [and] discoloration from knee to ankle .Nurse Practitioner [NP] here to see new order received .venous ultrasound of right lower extremity .Premier Radiology notified and states they cannot obtain until Tuesday or Wednesday .6/20/2022 8:01 PM Resident continues to display bruising to interior thighs and BLE [Bilateral Lower Extremities]; FNP [Facility Nurse Practitioner] visited resident earlier in the day regarding bruising concerns .6/21/2022 6:52 AM Right Lower Extremity continues with increased warmth, edema from right knee to right foot and discoloration from right inner thigh to right inner ankle .6/21/2022 12:45 PM Results of x-ray obtained on 6/21/2022 with the following impression: Evaluation .findings are concerning for an acute lateral tibial plateau fracture . Review of the Resident Progress Notes for NP dated 6/20/2022 at 2:33 PM, revealed, .6/20/2022 at 2:33 PM .Patient seen for right lower extremity erythema, edema and warmth. Patient has multiple bruises in various stages of healing noted to her right ankle lower extremity extending from her medial ankle, calf, knee and thigh. Right knee has swelling and warmth .staff report no recent trauma .Patient unable to verbalize pain related to her cognitive status but did grimace during exam with palpation to RLE [Right Lower Extremity] areas .New orders .X-ray right knee for increased swelling, decreased ROM [Range of Motion] . Review of the SNF/NF [Skilled Nursing Facility] Transfer Form dated 6/21/2022, revealed, .Reason for transfer Fracture of right lower extremity . Review of the hospital computed tomography dated 6/21/2022, revealed, .Acute fractures of the RIGHT proximal tibia and fibula . During an interview on 9/21/2022 at 1:05 PM, the Director of Nursing confirmed, We treated the incident as an injury of unknown origin, so we investigated the injury. During an interview on 9/21/2022 at 3:00 PM, the Administrator confirmed, I was notified of the injury. I was unaware of how it occurred. The Administrator confirmed the State Agency was not notified of the injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) screen was completed after an identified mental health diagnosis for 1 of 5 sampled residents (Resident #35) reviewed. The findings include: Review of the facility's policy titled, Pre-admission SCREENING AND RESIDENT REVIEW (PASARR), dated on 11/2016, revealed, .For those patients found nursing facility appropriate under the Level II review, the Center should incorporate the recommendations from the PASSAR Level II determination and evaluation report into the patient's assessment, care planning, and transitions of care. Center should refer any patient for Level II resident review upon a significant change in status/condition such as newly evident or possible serious mental disorder, intellectual disability or a related condition . Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia, Essential (primary) Hypertension, and Type 2 Diabetes Mellitus. Continued review revealed the resident received a diagnosis of Psychotic Disorder with Delusions on 11/26/2018. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Continued review of the MDS revealed Resident #35 received an antipsychotic over the last 7 days. Review of Resident #35 current Order Summary Report revealed an order for Seroquel (Antipsychotic Medication) started on 6/7/2019 50 milligram (mg) give 1 tablet at bedtime (hs) and Nuplazid (Antipsychotic Medication) started on 7/10/2021 34 mg give 1 capsule daily. Review of Resident #35 Level II PASARR dated 2/21/2017 revealed, .Diagnoses relevant to applicant's functional and/or skilled nursing needs: major depression . During an interview on 9/20/2022 at 1:08 PM, the Social Services Director confirmed Resident #35 had a Level II PASARR completed on 2/21/2017 for diagnosis of Depression. Continued interview, she confirmed Resident #35 received a diagnosis of Psychotic Disorders with Delusions on 11/26/2018 and an updated PASARR was not completed for Resident #35 after receiving the diagnosis.

**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 implement a Care Plan for 3 of 42 sampled residents (Residents #29, #61 and #240) reviewed. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Incorporate identified problem areas .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The Interdisciplinary Team must review and update the care plan: When the resident has been readmitted to the facility from a hospital stay; and at least quarterly . Review of the medical record for Resident #29 revealed she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Convulsions, Collapsed Vertebra and Type 2 Diabetes Mellitus. Review of the current Physician Order Report for Resident #29 revealed an order dated 9/10/2022-9/24/2022 .Droplet/Contact isolation precautions (DX: PRESUMPTIVE COVID 19) Special instructions: All care provided in room by staff . Review of the Care Plan for Resident #29 revealed no care plan problem for droplet isolation precautions. Review of the medical record for Resident #61 revealed she was admitted to the facility on [DATE] with diagnoses of Hypertensive Heart Disease and Chronic Kidney Failure. Review of the current Physician Order Report for Resident #61 revealed no order for isolation precautions. Review of the current Care Plan for Resident #61 revealed no care plan problem for isolation precautions. Review of the medical record revealed Resident #240 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Peritoneal Abscess, 2019-nCoV Acute Respiratory Disease, and Presence of Other Specified Devices. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #240 had an Indwelling catheter and an Ostomy. Review of the Physician Order Report dated 9/1/2022-9/20/2022, revealed Resident #240 had orders which included, .9/14/2022 Suprapubic Catheter .Routine Ostomy Care . Review of the Care Plan for Resident #240 revealed no care plan problem for a Suprapubic Catheter and/or Ostomy. Observation on 9/19/2022 at 1:20 PM revealed an isolation sign on the door of Residents #29 and #61's room indicating the staff must use precautions when entering the room and caring for residents in Droplet Isolation. During an interview on 9/19/2022 at 1:35 PM with LPN 1, also known as the Unit Manager, she confirmed Residents #29 and #61 were on Droplet Isolation precautions because they may have been exposed to Covid-19. During an interview on 9/20/2022 at 4:20 PM, MDS Coordinator/Licensed Practical Nurse (LPN) #5 confirmed Resident #240's care plan did not have an indwelling catheter or ostomy problem. During an interview on 9/20/2022 at 4:25 PM, the Director of Nursing (DON) confirmed there was not an indwelling catheter or ostomy problem on the care plan for Resident #240. During an interview on 9/21/2022 at 9:49 AM, the DON confirmed there was no care plan problem for droplet isolation precautions for Residents #29 and #61.

**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 provide Activities of Daily Living (ADL) care for 1 of 42 sampled residents (Resident #240) reviewed. The findings include: Review of the facility's undated policy titled, Activities of Daily Living (ADL), Supporting, revealed, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene . Review of the medical record revealed Resident #240 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Peritoneal Abscess, 2019-nCoV Acute Respiratory Disease, and Presence of Other Specified Devices. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE], revealed the assessment was coded for Discharge assessment-return anticipated. Continued review revealed Resident #240 had an indwelling catheter and an ostomy. Continued review revealed the resident had a continuously present altered level of consciousness and required extensive to total dependence with all ADLs. Review of the current Care Plan for Resident #240 revealed interventions for Activities of Daily Living: Limited ability to perform self-care. Goal included, .Will have clean, neat appearance daily . Observation and interview in Resident #240's room on 9/20/2022 at 10:38 AM, revealed she was lying in bed with her hair unkempt, with various fruit pieces and oatmeal scattered and smeared on her gown and bed linens. There was dried food debris on her fingers and around her mouth. Resident #240's catheter bag was lying on the floor full of urine on the right side of the bed. Observation and interview in Resident #240's room on 9/20/2022 at 10:45 AM, the Director of Nursing (DON) confirmed there was food scattered around the bed, on the resident's bed linens and gown, and the catheter bag was lying on the floor. During an interview on 9/20/2022 at 10:55 AM, Licensed Practical Nurse (LPN) #3 stated she had not been in Resident #240's room to provide care for her since beginning work at 6:00 AM. During an interview on 9/20/2022 at 10:56 AM, Certified Nursing Assistant (CNA) #3 stated she had not been in Resident #240's room since delivery of her breakfast meal sometime around or before 8:00 AM. She stated she did not assist Resident #240 with eating. She stated she waits until after she has provided care to everyone else to enter the isolation rooms to provide routine care of the residents.

**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 obtain a physician's order for 1 of 42 sampled residents (Resident #61) reviewed. The findings include: Review of the facility's policy titled, Documentation Guidelines-Orders, reviewed and updated 10/2021, revealed, .The center must ensure that the written medical care of each patient is supervised by a physician. Written and verbal orders constitute the attending physician's directions for the treatment of the patient in the center .General policies for orders: All orders should be directly entered into the EHR [Electronic Health Record] upon receipt, or if handwritten by a provider, should be entered into the EHR from the written orders. All written orders will be scanned into the EHR . Review of the medical record for Resident #61 revealed she was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease and Chronic Kidney Failure. Review of the current Physician Order Report for Resident #61 revealed no order for droplet isolation precautions. Observation on 9/19/2022 at 1:20 PM, revealed an isolation sign on the door of Resident #61's room indicating the staff must use precautions when entering the room and caring for residents on Droplet Isolation. During an interview on 9/19/2022 at 1:35 PM, with Licensed Practical Nurse (LPN) #1, also known as the Unit Manager, she confirmed Resident #61 was on Droplet Isolation precautions because she may have been exposed to Covid-19. She confirmed any staff member who entered the room should be wearing an N95 (NIOSH-National Institute of Occupational Safety and Health) mask, gown, eye protection or face shield and gloves. During an interview on 9/21/2022 at 9:49 AM, the Director of Nursing (DON) confirmed there was no physician's order for isolation for Resident #61.

**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 provide accurate documentation in the medical record for 1 of 42 sampled residents (Resident #240) reviewed. The findings include: Review of the facility's policy titled, Section VIII: NURSING SERVICES, reviewed and updated 10/2021, revealed, The goal of nursing documentation is to provide a timely recording of pertinent information regarding the safe and appropriate treatment, interventions, and responses in the patient's individual medical record .Documentation Purpose: Accurately reflect care given .What information should the nurse document? 6) All treatments and procedures noted after they have been done . Review of the medical record revealed Resident #240 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Peritoneal Abscess, 2019-nCoV Acute Respiratory Disease, and Presence of Other Specified Devices. Review of the Physician Order Report dated 9/1/2022-9/20/2022, revealed Resident #240 had orders which included, .9/14/2022 Perineal Drain-cleanse with normal saline, pat dry, and apply drain sponge daily . Review of the Treatment Administration Record (TAR) for Resident #240 dated 9/1/2022-9/20/2022, revealed, .Perineal Drain-cleanse with normal saline, pat dry, apply drain sponge daily . had been documented as administered by Licensed Practical Nurse (LPN) #3 on 9/20/2022. Observation and interview in Resident #240's room on 9/20/2022 at 3:56 PM, revealed there was no dressing present on the Perineal Drain for Resident #240. During interview Registered Nurse (RN) #2 confirmed there was no sponge dressing present on the Perineal Drain for Resident #240. During an interview on 9/20/2022 at 10:55 AM, LPN #3 stated she had not been in room #B-34 to provide care for Resident #240 since beginning work at 6:00 AM. She stated the resident's medication was not scheduled during her shift. She stated the resident did not have any treatments ordered for her to provide. During an interview on 9/20/2022 at 3:16 PM, LPN #3 stated Resident #240 had been moved back to her room on B Closed Hall. She stated she did not provide any medications or treatments to the resident during her shift because all of the resident's medications were ordered at 5:00 AM. During interview on 9/20/2022 at 3:50 PM, the Director of Nursing reviewed Resident #240's TAR dated 9/1/2022-9/20/2022 with LPN #3 present, and confirmed LPN #3 had documented administration of a treatment due 6:00 AM-6:00 PM. She stated the documentation indicated the treatment had been done prior to being noted on the TAR. LPN #3 confirmed she had not completed the treatment administration.

Based on facility policy review, observations, and interview, the facility failed to maintain sanitary dietary equipment related to unclean dry food storage bins; failed to label dry food storage bins; and failed to label and date leftover food kept in the walk-in refrigerator. The findings include: Review of the facility's policy titled, Safety & Sanitation Best Practice Guidelines, dated 11/2017, revealed, .Foods will be stored in their original packages, if possible. Products that are not easily identified should be clearly labeled with the common name of the food when removed from original packages .All ready-to-eat food prepped in-house and leftover, cooked food items must be labeled with the following information: name of food item and the date by which it should be eaten or discarded . Observation and interview in the Dietary Department on 9/19/2022 at 11:25 AM, the Registered Dietician (RD) confirmed 2 storage bins ¼ full of food in the dry storage room were not labeled. Continued interview, the RD confirmed the storage bins had an accumulation of dried brown debris on the top of the bins. Observation and interview in the Dietary Department on 9/19/2022 at 11:27 AM, the RD confirmed a bowl of rice was not dated; ½ peanut butter sandwich and 1 bowl of broccoli were not dated or labeled. Observation and interview in the Dietary Department on 9/19/2022 at 2:00 PM, the Dietary Manager confirmed 2 of the dry storage bins were not cleaned or labeled and continued to have an accumulation of dried brown debris on top of the bins.

**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 proper Personal Protective Equipment (PPE) was used when entering 1 of 5 Transmission Based Precautions (TBP) rooms, and failed to properly clean 1 of 4 TBP rooms on the Covid Unit. The facility also failed to ensure an indwelling urinary catheter collection bag was kept off of the floor for 1 of 8 sampled residents (Resident #240) reviewed who required an indwelling urinary catheter. Review of the facility's undated policy titled, Catheter Care, Urinary, revealed, .purpose of this procedure is to prevent catheter-associated urinary tract infections .Infection Control .Be sure the catheter tubing and drainage bag are kept off the floor . Review of the facility's Infection Control Manual Volume 1, updated 2/2022, revealed, .Prevention of Infection .Infection Control policies and procedures are developed for practice by partners to aid in the prevention and control of infectious processes . Review of undated facility's policy titled, 502 Patient Rooms-Routine Cleaning (High-touch surfaces, floors, and bathroom) revealed, .With a clean microfiber mop or clean cotton mop, using Neutral Disinfectant Cleaner, mop the floor beginning in the far corner of the room. Be sure to move furniture, clean under the bed, moving toward the bathroom and the door . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Convulsions, Collapsed Vertebra and Type 2 Diabetes Mellitus. Review of the current Physician Order Report for Resident #29 revealed an order dated 9/10/2022-9/24/2022 .Droplet/Contact isolation precautions (DX: PRESUMPTIVE COVID 19) Special instructions: All care provided in room by staff . Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Heart Disease and Chronic Kidney Failure. Further review revealed she was in the room with Resident #29, who was in isolation for Presumptive COVID-19. Observation and interview outside Resident #29 and #61's room on 9/19/2022 at 1:20 PM, revealed Licensed Practical Nurse (LPN) #4 exiting the room wearing a surgical mask and a face shield. When asked what the isolation sign on the door said, she stated, It says you should wear a N95 [NIOSH National Institute of Occupational Safety and Health] mask, gown, gloves and face shield. When asked where the Personal Protective Equipment (PPE) for the resident room was, she stated, I don't see any PPE outside of the room. Observation and interview outside Resident #29 and #61's room on 9/19/2022 at 1:30 PM, revealed the Social Service Director (SSD) for B Wing in the resident's room assisting Resident #61 up in the bed. The SSD was wearing a surgical mask and face shield. She was not wearing a gown or gloves. When asked what PPE she should be wearing she stated, I should have an N95 mask, a gown and gloves on. During an interview with LPN #1, also known as the Unit Manager, she confirmed Residents #29 and #61 were on Droplet Isolation precautions because they may have been exposed to Covid-19. She confirmed any staff member who entered the room should be wearing an N95 mask, gown, eye protection or face shield, and gloves. When asked if she had been in their room today she stated, I passed meds to them this morning and I did not wear an N95 mask or a gown. Observation in the Covid Unit on 9/19/2022 at 11:49 AM, Certified Nursing Assistant (CNA) #4 cleaned an empty TBP Room, #A-20, after a resident was transferred off of the Covid Unit. CNA #4 did not mop the floor. During an interview on 9/19/2022 at 11:52 AM, CNA #4 confirmed she did not mop the floor in Room #A-20. During an interview on 9/20/2022 at 10:55 AM, the Environmental Services Director stated she trained the nursing staff to clean the TBP rooms on the Covid Unit. She stated, When a room is empty the room should be deep cleaned, all surfaces cleaned with disinfectant, and floors swept and mopped per policy. During an interview on 9/21/2022 at 1:16 PM, the DON confirmed the CNAs were trained and responsible for cleaning the TBP rooms in the Covid Unit. She stated she expected the TBP rooms to be cleaned and the floor to be mopped prior to admitting new residents. Review of the medical record revealed Resident #240 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Peritoneal Abscess, 2019-nCoV Acute Respiratory Disease, and Presence of Other Specified Devices. Review of the Physician Order Report dated 9/1/2022-9/20/2022, revealed Resident #240 had orders which included, .9/14/2022 Suprapubic Catheter . Observation in Resident #240's room on 9/20/2022 at 10:38 AM, revealed her catheter bag was laying on the floor full of urine on the right side of the bed. Observation and interview in Resident #240's room on 9/20/2022 at 10:45 AM, revealed her catheter bag continued to be laying on the floor beside the bed. During an interview, the Director of Nursing (DON) confirmed the catheter bag was laying on the floor. Observation and interview in Resident #240's room on 9/20/2022 at 3:56 PM, revealed Resident #240 in bed with her catheter bag laying on the floor beside the bed. During an interview, Registered Nurse (RN) #3 confirmed the catheter bag was laying on the floor beside the bed.

Based on facility policy review, observation and interview the facility failed to clean exhaust filters and a food processor in the kitchen. The findings include: Facility policy review, Safety and Sanitation Best Practice Guidelines, revised 1/2011, revealed .Place filters and drip pan on dish rack and run through automatic dish machine, using complete wash and rinse cycle. Allow to air dry . Facility policy review, Food Processor, Blender, Chopper, Cutting Boards, revised 1/2011 revealed .Disassemble parts and take the bowl, lid and blade assembly to pot and pan sink. Flush with water to remove loose soil. Wash and sanitize parts in three-compartment sink. After each use . Observation on 6/3/19 at 9:03 AM and 11:27 AM in the kitchen revealed the filters over the stove had a build-up of dark brown debris. Observation on 6/3/19 at 12:07 PM in the kitchen revealed food processor blades and base were dirty with white paste-like dried debris. Interview with the Certified Dietary Manger (CDM) on 6/3/19 at 11:27 AM in the kitchen revealed he would expect the filter to be clean. Continued interview revealed when asked if the facility could clean the filters, the CDM confirmed Yes. Interview with the CDM on 6/3/19 at 12:07 PM in the kitchen confirmed .We use it [the food processor] for pureed meals, and it should be cleaned after each use . Interview with Administrator on 6/3/19 at 11:26 AM in the conference room confirmed he expected staff to follow the facility policy when it came to cleaning equipment.

**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 report an injury of unknown origin for 1 resident (#20) of 3 residents reviewed for abuse. The findings include: Review of the facility policy Administrative Procedures Manual revised 12/11/17 revealed .The facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses included Dementia, Anxiety Disorder, Delusional Disorder, Hypertension, and Muscle Weakness. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Medical record review of the Facility Investigation dated 6/27/18 revealed an injury of unknown origin was found on the back of Resident #20's head. Further review revealed the physician, family and the corporate office was notified on 6/27/18. Interview with Director of Nursing (DON) on 7/31/18 at 3:18 PM in her office revealed the DON had notified the regional nurse and the administrator immediately. The DON stated We did not notify the state, but the Ombudsman was made aware, we would never not report something intentionally, we felt we were following the steps we were supposed to follow. Interview with the Administrator on 8/1/18 at 4:54 PM in the DON's office confirmed the facility failed to report an injury of unknown origin. The Administrator stated correct when questioned if the facility had failed to report an injury of unknown origin to the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, and interview, the facility failed to conduct a completed investigation for 1 resident (#20) of 3 residents reviewed for abuse. The findings include: Review of the facility policy Administrative Procedures Manual revised 12/11/17 revealed .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, misappropriation of the patient property or exploitation did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident . Medical record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses included Dementia, Anxiety Disorder, Delusional Disorder, Hypertension, and Muscle Weakness. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Interview with the Administrator on 7/31/18 at 8:30 AM in the conference room revealed a request was made to the Administrator to view the facility's investigation. Review of the facility investigation dated 7/27/18 revealed the facility investigation failed to demonstrate interviews for cognitive residents and determination of the root cause analysis for the injury of unknown origin. Interview with the Administrator on 8/1/18 at 4:54 PM in the Director of Nursing's (DON) office confirmed the facility failed to report an injury of unknown origin. The Administrator stated correct when questioned if the facility had failed to have a completed investigation for a injury of unknown origin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to follow the care plan for securing the smoking materials for 1 of 43 residents (#53) reviewed. The findings include: Medical record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses included Postpolio Syndrome, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Overactive Bladder, Migraine, Essential Hypertension, and Nicotine Dependence. Medical record review of the Annual Miniminum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Medical record review of Smoking Risk assessment dated [DATE] revealed resident #53 assessed to safely use cigarettes and lighter. Further review revealed resident with a score of 2 indicating low risk. Medical record review of the plan of care, dated 1/18/18 and updated 7/16/18 revealed resident #53 may keep cigars without lighter in drawer. Observation on 7/30/18 at 3:00 PM in the smoking area revealed Resident #53 had a cigar and a lighter in a pouch around his neck. Interview with Resident #53 on 7/30/18 at 3:00 PM in the smoking area revealed the resident kept smoking materials in his room. Interview with Certified Nursing Assistant (CNA) #1 on 7/30/18 at 4:54 PM on B Hallway revealed, I did not attempt to take the lighter from the resident after returning from smoking and I should have taken the lighter from the resident when he returned from smoking. Interview with the Director of Nursing (DON) on 7/30/18 at 4:43 PM in her office stated Resident #53 should not have a lighter in his room. Further interview with the DON in B Hall with CNA #1 present revealed CNA#1 should have taken the lighter from the resident and had the nurse to lock it up in the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview it was determined that the facility failed to administer oxygen at the physician's prescribed rate for 2 of 27 residents (#21 and #43) reviewed for receiving oxygen The findings include: Review of the facility policy Medication Administration-General Guidelines, dated 6/2016 revealed .Medications are administered in accordance with written orders of the prescriber . Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses included Hypertensive Chronic Kidney Disease with Stage 3, Essential Hypertension, Heart Failure, and Anemia. Medical record review of the Quarterly Mininum data set dated [DATE] revealed the resident's Brief Interview for Mental Status score of 14 indicating she was cognitively intact. Medical record review of Physician Orders dated 6/22/18 revealed .Oxygen 4 liters per minute to keep O2 (Oxygen) saturations above 92% . and .Check oxygen saturation levels every shift . Medical record review of the Medication Administration Record dated July 2018 revealed oxygen saturation on 7/30/18 was 93% and 95% and on 7/31/18 oxygen saturation was 94%. Observation on 7/30/18 at 11:19 AM revealed Resident #21 was in her room with the nasal canula in place. Further observation revealed the oxygen concentrator was set at zero liters per minute. Interview with Resident #21 on 7/30/18 at 11:25 AM in the resident's room revealed she stated I can't feel anything coming out of the tubing. Observation and interview on 7/30/18 at 11:25 AM with LPN #1 present revealed the oxygen concentrator was set on zero liters per minute. Interview with LPN#1 stated, Oxygen is on one and one-half liters per minute. Observation of LPN #1 revealed she turned the oxygen concentrator up to 3 liters per minute and stated, Oxygen is suppose to be between 2 and 4 liters per minute. Observation on 7/31/18 at 7:15 AM and 10:45 AM and 2:00 PM in Resident #21's room revealed the resident in her room with nasal cannula in place and the oxygen concentrator set at 3 liters per minute per nasal cannula. Interview with the DON on 7/31/18 at 2:00 PM in Resident #21's room revealed Oxygen is on 3 and one-half, and should be followed by the physician orders. Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses included Unspecified Congestive Heart Failure, Peripheral Vascular Disease, Stage 3 Chronic Kidney Disease, Adult Failure to Thrive, Unspecified Protein-Calorie Malnutrition, and Iron Deficiency Anemia. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident received oxygen therapy. Medical record review of the July 2018 Physicians orders, with original order date 4/19/18, revealed .Oxygen (02) at 2 liters per minute per NC (nasal cannula) .continuous . Observation on 7/30/18 at 11:17 AM, 3:05 PM, and 5:41 PM in the resident's room revealed Resident #43 was receiving oxygen by nasal cannula (n/c) at 1.5 liters per minute. Interview with Licensed Practical Nurse (LPN) #2 on 7/30/18 at 5:41 PM in the resident's room revealed the resident's oxygen was to be administered at 2 liters per minute via n/c. LPN #2 looked at the oxygen concentrator and said it's not quite 2, it's at 1.5.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide a sanitary environment for 1 of 3 residents (#52) reviewed receiving feeding per feeding pumps. The findings include: Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses included Cerebral Palsy, Dysphagia, Oropharyngeal phase, Other Symbolic Dysfunctions, Muscle Weakness, and Gastrostomy status. Medical record review of Physician Orders dated 11/08/17 revealed the resident was to receive Jevity 1.5 (therapeutic nutrition) continuous 65 milliliters (ml) hour per PEG (Percutaneous endoscopic gastrostomy) tube from 7 PM to 8 AM. Further medical record review of Physician Orders dated 7/19/18 revealed the resident was to receive Jevity 1.5 120 ml per PEG tube 4 times a day. Observation on 7/30/18 at 11:05 AM and 2:40 PM and on 7/31/18 at 7:10 AM and 11:10 AM in Resident #52's room revealed a feeding pump and pole with dried tan debris. Observation on 7/31/18 at 1:38 PM in Resident #52's room in the presence of the Director of Nursing (DON) revealed a feeding pump and pole with dried tan debris. Interview with the DON on 7/31/18 at 1:38 PM in Resident #52's room confirmed the feeding pump and pole should not be covered with dried tan debris. Further interview confirmed the nurses were responsible for cleaning the feeding pumps and poles daily. The DON stated, I have been doing weekly monitoring to ensure pumps and poles are cleaned but I must have missed this one.