**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 resident (Resident #76) of 15 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Misappropriation of Property, Exploitation, and Injuries of Unknown Source, dated 9/26/2023, revealed .It is the organization's intention to attempt to prevent the occurrence of abuse .Abuse includes .verbal abuse .Verbal abuse is use of oral .gestured language that includes any threat, or any frightening disparaging or derogatory language to residents .regardless of their .ability to comprehend or disability . Review of the medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #76 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #76 required a wheelchair for mobility and was dependent on staff for transfers. Review of the medical record revealed Resident #56 (witness) was admitted to the facility on [DATE] with diagnoses including Hemiplegia (one sided paralysis or weakness) Affecting Left Nondominant Side, Absence of Right Leg Below Knee, Abnormalities of Gait and Mobility. Review of a quarterly MDS assessment dated [DATE], revealed Resident #56 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Resident #56 required a wheelchair for mobility and required substantial/maximal assistance from staff for transfers. Review of the facility's investigation documentation revealed there was an altercation on 6/12/2024 at approximately 7:00 PM, at the west wing nurses' station. Licensed Practical Nurse (LPN) G asked Certified Nursing Assistant (CNA) L (agency employee) to complete her charting prior to leaving her shift. CNA L began yelling loudly explicit language towards staff. CNA L stated she did not need this [explicit language] place and needed to be in Chattanooga. Residents #56 and #76 were seated in wheelchairs outside the nurse's station and witnessed the confrontation between CNA L and LPN G. Resident #56 told CNA L to leave LPN G alone. CNA L then leaned over nurse station and told Resident #76 It's none of your business and you can meet me out in the parking lot. LPN K was at the east wing nurses' station and heard the commotion and responded to the west wing to see what was going on. LPN K arrived at the west wing nurse's station and observed CNA L cursing at facility staff with residents close by. LPN K told CNA L she needed to leave the facility and escorted CNA L out of the building. CNA L continued to speak poorly about the facility and staff while walking out. LPN G immediately assessed Residents #56 and #76 with no injuries noted. Resident #76 stated she was scared initially during the confrontation and stated she was fine and no longer afraid after CNA L was escorted out of the facility. The facility staff immediately notified the Director of Nursing (DON) and Administrator, and an investigation was started. CNA L was placed on Blocked from working list. The Administrator notified CNA L's staffing agency, Adult Protective Services, police, and the Ombudsman of the altercation. Review of CNA H's witness statement dated 6/13/2024, revealed .I was walking up [NAME] 2 Hall going to the Nurses Station .[LPN G] was trying to help [CNA L] Log in to .[computer program] and [CNA L] started screaming and cussing saying she didn't have time to chart .she had to leave and was told [CNA L] she needed to finish her charting before she left .it was part of the CNA Job .[CNA L then jumped up swinging her arms .up in [LPN G's] face .the residents was .screaming get out of our nurse's face .[CNA L] then turned .Cussing .[Resident #76] .Nurse came from East Hall and walked [CNA L] out the door .[CNA L] was Screaming down the hallway, she didn't need this place and we were all [NAME] Crackers . Review of RN I's emailed witness statement dated 6/14/2024, revealed .Incident took place on the evening of June 12, 2024 .As I [RN I] came up the hallway .could hear shouting coming from the nursing station .witnessed .[CNA L] and [LPN G] involved in an altercation .[CNA L] was verbally attacking .[LPN G] .proceeded to step between them in an effort to deescalate the situation .two female residents in wheelchairs .were sitting across from the nursing station .asked .[CNA L] repeatedly to leave the facility .advised [CNA L] if she did not leave that I was going to call the Law at which time [CNA L] stated she was not going to leave .another nurse came .and was able to get .[CNA L] .to exit the building .[CNA L] continued with profane, insulting, and abusive language towards .[LPN G] and other staff .until [CNA L] .was out of my area of observation . Review of Resident #76's undated witness statement, revealed .at the end of shift I was sitting at the nurses desk and I looked over at [CNA L] and [CNA L] stated .I am going to get you [Resident #76] too, if you want to run your mouth you can meet me out in the parking lot .Then she [CNA L] started cussing LPN G out . Review of Resident #56's undated witness statement, revealed .[CNA L] stated she needed to leave to go home. [LPN G] was trying to help [CNA L] log in to .the computer to do her charting. Then [CNA L] started yelling at [LPN G]. [CNA L] called [LPN G] a Gay Cracker. [Resident #56] stated to leave [LPN G] alone and that [CNA L] needed to leave. [CNA L] got in [Resident #76's] face threatening [Resident #76] . Review of LPN G's undated witness statement, revealed .[CNA L] was upset she had to chart .[LPN G] asked [CNA L] to use the Desktop computer so [LPN G] could use the Laptop [computer] for .med pass [medication administration] [CNA L] proceeded to tell [LPN G] she didn't have a log in .[LPN G] explained .would text supervisor and get [CNA L] a log in .[CNA L] said everyone was being rude. [LPN G] told [CNA L] no one was being rude that she just needed to .finish charting .[CNA L] got upset and got up in [LPN G's] face .[CNA L] became angry and started screaming at staff and residents [no named residents] .nurse on East came down and was able to escort [CNA L] .out of the building . Review of CNA J's undated witness statement, revealed .On 6/12/2024 [CNA J] witnessed [CNA L] stand up and get in [LPN G's] Face screaming .Calling [LPN G] derogatory names .[CNA L] turned .to .[Resident #76] .screaming .Shut the [Explicit language] up .It's none of your business .[LPN K] .walked [CNA L] out of the builidng . Review of the Psychiatric Follow-Up Note for Resident #76 dated 6/12/2024, revealed .Patient was involved in an incident with the CNA who has since been dismissed from the facility. No signs of psychosocial harm at this time. She continues at her baseline resting in room .Patient stable . Review of the Nurse's Notes for Resident #76 dated 6/13/2024, revealed .f/u [follow up] with psychosocial wellbeing check; pt [patient] has been up in w/c [wheelchair], pleasant, laughing, interacting well with staff, has been attending activities; ate lunch in dining room; good appetite; no voiced needs or wants . Review of the Nurse's Notes for Resident #76 dated 6/14/2024, revealed .Psychosocial well check visit .Resident in great spirits this am out and about visiting residents, states to this worker she is feeling and doing well . Review of the Nurse's Notes for Resident #76 dated 6/17/2024, revealed . follow up with [Resident #76] to last week's incident states she is doing great and no lasting effects from the event . During an observation and interview on 6/24/2024 at 10:30 AM, Resident #76 was sitting up in a wheelchair at the nurses' station. Resident #76 rolled herself back into her room. Resident #76 stated there had been an incident a couple of weeks ago where a CNA was yelling at a nurse. Another resident (Resident #56) told the CNA to stop, and the CNA stated to the resident the CNA would meet Resident #76 out in the parking lot. Resident #76 stated she felt the CNA meant she wanted to fight the resident when she stated she would meet the resident in the parking lot. Facility staff escorted the CNA out of the building and the resident felt the facility staff acted promptly and had protected her. Resident #76 stated she felt safe during the incident and had not experienced any ill effects from it. During an interview on 6/24/2024 at 11:19 AM, Resident #56 stated she had not been abused or witnessed a resident be abused by anyone at the facility. During a telephone interview on 6/25/2024 at 10:09 AM, CNA J stated on 6/12/2024 at approximately 7:00 PM she was walking towards west wing's Nurse's station. Resident #56 and Resident #76 were sitting at the nurses' station. LPN G asked CNA L to complete her charting before she left. CNA L stood up in LPN G's face, screaming at him and called LPN G derogatory names. LPN G told CNA L to complete charting before leaving the facility. CNA L screamed, .I don't need this [Explicit language] place . CNA L stated to LPN G, .You need to fix your hair you [Explicit Language] fag . CNA J stated LPN K came over from the other unit and told CNA L she needed to leave. CNA J stated that in the middle of this, Resident #56 leaned over the desk and tried to get CNA L away from LPN G. CNA J stated Resident #76 said something, and CNA L told Resident #76, .Well you can meet me out in the parking lot . LPN K escorted CNA L out of the building. CNA J stated she checked on Resident #76 and the resident reported feeling safe. During an interview on 6/25/2024 at 10:46 AM, CNA H stated on 6/12/2024 at approximately 7:00 PM, she was walking up to west wing nurse's desk and heard loud voices. LPG G was telling CNA L she needed to finish her charting before leaving. CNA L was screaming saying that she had to leave and go to [Explicit Language] Chattanooga and did not need this place. LPN G told CNA L that it was her job and CNA L got up in LPN G's face, started slinging her arms and cursing at LPN G. CNA H stated Residents #56 and #76 were seated outside the nurse's station during the confrontation. LPN G told CNA L nicely to please get out of his face and the residents were screaming .get out of our nurse's face . CNA L said to Resident #76, .it's not your problem and we can meet out in the parking lot . LPN K then came and walked CNA L to the door. CNA L continued to scream that she did not need this place and that we were all .white crackers . CNA H stated she checked on Resident #76 and initially she was scared but felt safe after CNA L was escorted out of the facility. During an interview on 6/25/2024 at 8:23 PM, LPN K (worked 7:00 PM-7:00 AM on 6/12/2024) stated she heard yelling from the west wing nurse's station and was concerned that it could be a resident and proceeded down hallway towards the west nurse's station. When LPN K got to the west wing nurse's station she observed Resident #56 and Resident #76 seated outside the nurse's station. LPN K stated CNA L was yelling and cursing at staff. LPN G told CNA L she needed to leave and if she didn't leave, they would call 911. LPN K perceived CNA L's behavior as hostile. LPN K escorted CNA L out of the facility. LPN K stated CNA L continued speaking with slanderous words about the facility and staff while escorting her out of the building. During an interview on 6/25/2024 at 3:15 PM, Resident #56 stated she had not been abused or cursed by anyone at the facility. The resident also stated she had not witnessed a resident be abused or cursed by anyone at the facility. During a telephone interview on 6/26/2024 at 8:12 AM, LPN G stated he worked 7:00PM-7:00 AM on 6/12/2024. LPN G stated CNA L was sitting at the nursing station using a laptop computer. LPN G explained to CNA L he needed to use the laptop to complete a medication administration pass to the residents. LPN G asked CNA L if she could use the desktop computer and the CNA stated she did have a log in for the computer. LPN G explained he would contact a supervisor to obtain a log in for the CNA. CNA L stated everyone was being rude, did not have time to complete her documentation, and she needed to be in Chattanooga. LPN G explained to CNA L that no one was being rude, and her charting needed to be finished. CNA L was upset and got in LPN G's face. Residents #56 and #76 were seated outside the nurse's station and told CNA L .You better leave (LPN G) alone . CNA H arrived and told (LPN G) to walk away. The nurse on east wing, LPN K, arrived to escort CNA L out of the building. The supervisor notified the DON and Administrator of the altercation and the adminstrator came to the facility to start an immediate investigation. During an interview on 6/26/2024 at 1:20 PM, Resident #56 (when directly asked about an alleged incident from 6/12/2024) stated she remembered an incident which involved CNA L. Resident #56 and Resident #76 were seated at the nurse'ss station on the west wing around 7:00 PM. LPN G asked CNA L to complete her charting. CNA L got up in LPN G's face and stated she needed to go home. Resident #56 stated she told CNA L to be quiet and not talk to LPN G that way. CNA L turned to Resident #76 and said, .It's not your problem and you and can meet me out in the parking lot . Resident #56 stated staff immediately protected her and Resident #76. CNA L was escorted out of the building. Resident #56 stated she was not affected from the incident. During an interview on 6/26/2024 at 4:15 PM, the Administrator confirmed CNA L verbally abused Resident #76 when CNA L used profantity and threatened the resident.

**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 develop a person-centered care plan related to smoking for 1 resident (Resident #71) of 3 residents reviewed for smoking. The findings include: Review of the facility's undated policy titled, Comprehensive Care Plans, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with .needs that are identified .The care planning process will include .Services provided or arranged by the facility .the comprehensive care plan will describe at minimum .The services that are to be furnished .Resident specific interventions that reflect the resident's needs and preferences . Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including Infection of the Left Lower Leg, Kidney Failure, and Heart Attack. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #71 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Record review of a comprehensive care plan for Resident #71 revised 5/30/2024, revealed the resident did not have a smoking care plan. During an observation at the east hall smoking area on 6/25/2024 at 9:44 AM, revealed Resident #71 was smoking a cigarette while wearing a smoking apron during the supervised scheduled smoke break for residents. During an observation at the east hall smoking area on 6/25/2024 at 4:30 PM, revealed Resident #71 was smoking a cigarette while wearing a smoking apron during the supervised scheduled smoke break for residents. During an interview in the conference room on 6/25/2024 at 10:52 AM, the Administrator stated Resident #71 started smoking in 5/2024. During an interview on 6/25/2024 at 11:11 AM, the Director of Nursing stated Resident #71 smoked at the facility and confirmed a smoking care plan was not developed for Resident #71.

**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 assess 1 resident (Resident #71) for smoking of 3 residents reviewed for smoking. The findings include: Review of the facility's undated policy titled Smoking Procedures for Residents, revealed .Residents who desire to smoke will be assessed for safety with smoking materials upon admission or initially request to smoke as well as on a quarterly basis . Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including Infection of the Left Lower Leg, Kidney Failure, and Heart Attack. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #71 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Record review of Resident #71's assessments revealed the resident was not assessed for smoking. During an observation at the east hall smoking area on 6/25/2024 at 9:44 AM, revealed Resident #71 was smoking a cigarette while wearing a smoking apron during the supervised scheduled smoke break for residents. During an observation at the east hall smoking area on 6/25/2024 at 4:30 PM, revealed Resident #71 was smoking a cigarette while wearing a smoking apron during the supervised scheduled smoke break for residents. During an interview in the conference room on 6/25/2024 at 10:52 AM, the Administrator stated Resident #71 started smoking in 5/2024. During an interview on 6/25/2024 at 11:11 AM, the Director of Nursing stated Resident #71 smoked at the facility and confirmed the resident was not assessed for smoking.

**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 store the Continuous Positive Airway Pressure (CPAP - equipment used for individuals with sleep apnea) mask appropriately for 1 resident (Resident #31) of 5 residents reviewed for CPAP. The findings include: Review of the facility's undated policy titled, CPAP/BiPAP [Bilevel Positive Airway Pressure] Cleaning Guidelines, revealed .Cover with plastic bag . Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Type 2 Diabetes Mellitus, and Obstructive Sleep Apnea. Review of a comprehensive care plan dated 4/25/2023, revealed .Respiratory Status Care Plan .At risk for impaired respiratory status . Review of the Physician's Orders for Resident #31 dated 3/24/2024, revealed .CPAP Mode of Therapy .on at hs [bed time] and off upon waking and prn [as needed] . Review of an annual Minimum Data Set assessment dated [DATE], revealed Resident #31 scored a 15 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact. During an observation and interview on 6/24/2024 at 12:10 PM, in Resident #31's room, the resident's CPAP mask was lying uncovered on the bedside table. The resident stated the staff never offered to put the mask in a bag. During an observation on 6/25/2024 at 10:15 AM, in Resident #31's room, the resident's CPAP mask was lying uncovered on the bedside table exposed to room air. During an observation and interview on 6/25/2024 at 10:17 AM, in Resident #31's room, Licensed Practical Nurse M observed Resident #31's CPAP mask lying uncovered and exposed to room air on the resident's bedside table. The LPN confirmed the mask should be stored in a bag while it was not in use. The LPN confirmed there was no storage bag in the room and had to leave the room to obtain a storage bag. During an interview on 6/26/2024 at 9:43 AM, the Physician's Assistant stated the resident had not had any respiratory infections recently. During an interview on 6/26/2024 at 10:35 AM, the DON stated it was her expectation when CPAP masks were not in use, they would be stored in a plastic bag. The DON confirmed the CPAP mask uncovered and exposed to room air on Resident #31's bedside table was not stored appropriately.

Based on facility policy review, facility document review, and interview, the facility failed to provide the services of a Registered Nurse (RN) for the minimum requirement of 8 hours a day for 1 day (6/23/2024) of 32 days reviewed between the period of 5/23/2024 and 6/23/2024. The findings include: Review of the facility's undated policy titled, Nursing Services and Sufficient Staff, revealed .The facility will provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . Review of the facility document titled, Daily Staffing Form, dated 6/23/2024, revealed no RN was on duty working in the facility. During an interview on 6/26/2024 at 9:15 AM, The Administrator confirmed the facility failed to provide the minimum requirement of 8 hours RN coverage on 6/23/2024.

Based on facility policy review, observations, and interviews the facility failed to ensure expired supplies were not available for resident use in 2 of 2 medication rooms observed. The findings include: Review of the facility's undated policy titled, Medical Products & Supplies Use and Storage, revealed .The facility will follow manufacturers' guidelines when using medical devices .which includes syringes, tubes .expired item will not be used . During an observation and interview in the east medication room on 6/26/2024 at 3:49 PM, with Licensed Practical Nurse (LPN) A and LPN B revealed 25- 3 mL (milliliter) blue top blood collection tubes with an expiration date of 3/31/2024. LPN A and LPN B stated the facility occasionally collected blood specimens. LPN A and LPN B confirmed the 25- 3 mL blue top blood collection tubes were expired and available for resident use. During an observation and interview in the west medication room on 6/26/2024 at 4:02 PM, with LPN C, revealed 10- 28 gauge (ga) x (by) ½ inch (in) syringes with an expiration date of 11/30/2023, and 77- 28 ga x ½ in syringes with an expiration date of 4/20/2023 (a total of 87 syringes). LPN C confirmed the 87- 28 ga x ½ in syringes were expired and available for resident use. During an observation and interview with the Director of Nursing (DON) in the west medication room on 6/26/2024 at 4:08 PM, the DON stated CNA D/Central Supply was responsible to check medication rooms weekly and discard expired supplies. The DON confirmed the expired 25- mL blue top blood collection tubes in the east medication room and the 87- 28 ga x ½ in syringes in the west medication room should have been removed from the medication room and not available for resident use. During an observation and interview on 6/26/2024 at 4:10 PM, with CNA D/Central Supply in the west medication room, on 6/26/2024 at 4:10 PM, CNA D/Central Supply stated she was responsible to check the medication rooms for expired medications and supplies. CNA D/Central Supply stated, .I try to check them twice a month . CNA D/Central Supply stated the expired syringes should have been discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure 1 resident (Resident #1) of 4 residents reviewed were referred to the appropriate designated authority for Level 2 PASARR (Pre-admission Screening and Annual Resident Review) evaluation and determination after a newly evident medical diagnosis. The findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses including Acute Hematuria, Dysphagia, Major Depressive Disorder and Dementia. Medical record review showed the resident had the diagnosis of Psychosis added on 11/19/2019. Interview with the Health Information Manager on 6/7/2021 at 1:29 PM, showed she was responsible for submission request of PASARR Level II to the appropriate designated authority when needed. Continued interview confirmed the Health Information Manager failed to notify the designated authority of the newly diagnosed Psychosis for resident #1.

Based on facility policy review, observation, and interview, the facility failed to maintain a sanitary environment in 1 of 1 kitchen, in 1 of 1 walk-in refrigerator, in 1 of 1 walk-in freezer, in 1 of 1 stand-alone refrigerator, and in 1 of 1 food and paper storage room observed, potentially affecting 61 of 65 residents in the facility. The findings include: Review of the facility policy Food Storage: Dry Goods, dated 9/2017, showed .Dining Services Director or designee regularly inspects [food service areas] [for] contamination . Review of the facility policy Foods Storage, dated 4/2018, showed .foods will be stored wrapped or in covered containers, labeled and dated . Review of the facility policy Food Safe Handling for Foods from Visitors, dated 7/2019 showed .discard .any food items that have been stored for [equal to or greater than] 7 days . Observation and interview with the Lead [NAME] (LC) #1 on 6/6/2021 at 9:36 AM, in the kitchen, showed 30 uncovered small bowls of stewed apple dessert on an uncovered rack and 2 cups of loose cornmeal in a pitcher, covered with plastic wrap dated 2/2021, inside a confectioner sugar bin. Interview confirmed the facility failed to ensure the 30 uncovered small bowls of stewed apple dessert was labeled, and dated. Continued interview confirmed the facility failed to discard expired food items available for resident use. Observation and interview with LC #1 on 6/6/2021 at 9:45 AM, in the walk-in refrigerator showed the following: 2 boiled eggs, unshelled, in yellow liquid in a sealed plastic bag, dated 5/21/2021 1 opened 45-ounce jar of spaghetti sauce containing 1 cup, undated 15 opened unwrapped blueberry muffins, loose in box, undated Interview with LC #1 confirmed the facility failed to ensure resident food was labeled and dated and failed to discard expired food items available for resident use. Observation and interview with LC #1 on 6/6/2021 at 9:50 AM, in the walk-in fridge showed the following staff food items: One 16-ounce yogurt One 9-ounce frozen orange chicken dinner One 16-ounce salad dressing, ¾ full One 8-ounce frozen dinner, undated Interview with LC #1 confirmed the facility failed to store staff food items in a separate refrigerator from resident use. Observation and interview with LC #1 on 6/6/2021 at 9:55 AM, in the walk-in freezer, showed 10 uncovered, undated frozen breadsticks. Interview confirmed the facility failed to ensure resident food was covered, labeled and dated. Observation and interview with LC #1 on 6/6/2021 at 10:00 AM, in the kitchen at the stand-alone refrigerator showed the following: One opened employee 20-ounce bottle sports drink, undated One 46 fluid ounce thickened orange juice, approximately ¾ remaining, undated One 32 fluid ounce thickened dairy drink, approximately 1 cup remaining, undated One 32 fluid ounce thickened dairy drink, approximately ¾ cup remaining, undated One 32 fluid ounce thickened dairy drink, approximately ½ cup remaining, undated One 32 fluid ounce chicken broth, opened and undated 4 cups of tea remaining in covered pitcher, dated 5/21/21(expired 9 days) 4-ounce cup pineapple snack, undated 3 pre-made cheese sandwiches, undated Individually poured liquids uncovered: Three 8-ounce nectar thick milk Three 8-ounce nectar thick water Two 8-ounce nectar thick tea Two 8-ounce fruit punch Two 8-ounce cranberry juice Two 4-ounce cranberry juice Two 8-ounce apple juice One 8-ounce orange juice Interview with LC #1 confirmed the facility failed to ensure resident food was labeled, covered, dated, and failed to discard expired food items available for resident use. Continued interview confirmed the facility failed to store an employee sports drink in a separate refrigerator. Observation and interview with LC #1 on 6/6/2021 at 10:10 AM, in the food and paper storage room showed the following: One 128 fluid ounce pancake syrup, approximately 1/4 cup remaining, undated One 5-pound bag cornbread mix, 2.5 pounds remaining, undated 6 cups corn cereal opened in large zipped bag, undated 42 ounces oats, ¾ cup remaining, undated One 5-pound bag cornbread mix, 3/4 mix remaining, undated 1.5 cups cake mix in box opened, undated Interview with LC #1 confirmed the facility failed to ensure resident food was labeled and dated. Observation with LC #1 on 6/6/2021 at 10:21 AM, in the food and paper storage room showed, upon entry, two damaged areas in the left far corner ceiling of the room. Proximal damaged area, approximately eight inches in diameter, with actual break in ceiling tile. The distal damaged area was approximately four inches in diameter. Both areas were light brown in color, with a darker brown ring surrounding each perimeter. Continued observation showed two boxes situated directly underneath the discolorations on a food storage rack. Both boxes and contents were stained and misshapen. Continued observation showed black debris on 2 of 2 ceiling vent covers. Interview with LC #1 on 6/6/2021 at 10:25 AM, in the food and paper storage room, confirmed she had not noticed or reported the damaged boxes in the corner on the food storage rack, or the damaged ceiling above the food storage rack. Continued interview confirmed the facility did not maintain a sanitary environment. Observation with LC #1 on 6/6/2021 at 12:05 PM, in the kitchen, showed black debris on 6 of 6 ceiling vent covers. Interview with LC #1 on 6/6/2021 at 12:15 PM, in the kitchen, confirmed black debris on 6 of 6 ceiling vent covers. Continued interview confirmed the facility had not maintain a sanitary environment in the kitchen. Observation with the District Manager (DM) and Director of Maintenance on 6/6/2021 at 12:35 PM, in the food and paper storage room, confirmed the presence of two discolored and damaged areas in the left far corner ceiling of the room and black debris in 8 out of 8 ceiling vent covers in the storage room and kitchen area. Interview with the DM and Director of Maintenance on 6/6/2021 at 12:45 PM, confirmed the facility failed to maintain a sanitary environment. Continued interview showed he was responsible for all vent cover cleaning and he was not aware of the leaks in the ceiling.

Based on facility policy review, observation, pest control documentation review, and interview, the facility failed to maintain an effective pest control program in 1 of 1 paper storage rooms, potentially affecting 61 of 65 residents. The findings include: Review of facility policy, Pest Control [Infection Prevention] revised 4/2021, showed .emphasis on the pest control program in kitchens .monitoring environment will be done by the center's staff. Pest control problems will be reported promptly . Review of facility policy, Pest Control, revised 9/2017, showed .Dining Services Director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis or as needed .all food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin . Review of (named) pest control company invoice, dated 5/15/2021, showed rodent services consisting of bait-trap (mouse and insect glue board, pre-baited to attract mice and insects) were placed at the facility in May 2021. Observation with the Lead [NAME] (LC) #1 on 6/6/2021 at 10:21 AM, in the food and paper storage room showed two boxes, with contents stained and misshapen, situated on the top of a food storage rack. Continued observation showed one box contained discolored labels and the second box contained a glue board rat tray with three dead mice affixed to the surface of the board and six boxes of toothpicks. Interview with LC #1 on 6/6/2021 at 10:25 AM, in the kitchen, confirmed .there was three mice on that board . Interview with the District Manager on 6/6/2021 at 12:40 PM, confirmed LC#1 had communicated the discovery of three mice on a glue board on a top food rack in the food and paper storage room on 6/6/2021. Continued interview confirmed food storage areas were to be checked regularly for any signs of pests by all staff and problems reported to the pest control company. Continued interview confirmed the facility failed to monitor for rodents and pests. Interview with the Director of Maintenance on 6/6/2021 at 12:45 PM, confirmed he was made aware of the three dead mice stuck on the glue board on 6/6/2021. Continued interview showed he was unaware of a rodent issue. Interview with the Director of Maintenance on 6/7/2021 at 10:45 AM, confirmed he was responsible for reporting issues promptly to the extermination company. Continued interview confirmed the facility failed to monitor for rodents and pests.

Based on facility policy review, observation, and interview, the facility failed to properly label and store medications for 1 of 3 medication carts observed. The findings include: Review of the facility policy Storage and Expiration of Medications, Biologicals, Syringes, and Needles last revised 10/31/16 revealed .Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received . Review of the facility policy Medication Administration revised 6/2008 revealed .Never administer medications from an unmarked container .Prepare medication immediately prior to administration . Interview and observation of the 100 hall medication cart with Licensed Practical Nurse (LPN) #1 on 7/9/19 at 7:48 AM, in the 100 hallway, revealed 2 medicine cups sitting in the top drawer of the medication cart with unlabeled medications in the cups. Further interview confirmed LPN #1 had placed the medications in the medicine cups for administration. Continued interview confirmed the residents were not in their rooms and the LPN had placed the cups of medication in the top drawer of the medication cart to administer at a later time. Interview with the Director of Nursing (DON) on 7/10/19 at 11:20 AM, in the activity room, confirmed the facility failed to properly label and store medications in the medication cart.

Observation of medication administration with Licensed Practical Nurse (LPN) #1 on 7/9/19 at 7:33 AM, on the 100 hallway, revealed LPN #1 preparing a resident's medications for administration. Further observation revealed LPN #1 opened a stock bottle (bottle of over the counter medications used for more than one resident) of Colace (stool softener medication) poured 2 pills into the cap of the bottle, held one pill with the bare hands and placed the other pill into the medication cup. Continued observation revealed LPN #1 placed the extra pill back into the bottle after she had touched it with the bare hands. Continued observation revealed LPN #1 repeated this same practice with a bottle of Fish oil (a supplement), and a bottle of Aspirin (a pain reliever/fever reducing medication). Interview with LPN #1 on 7/9/19 at 7:48 AM, in the 100 hallway, confirmed the LPN had placed the pills back into the bottles after she had touched them with the bare hands. Interview with the DON on 7/10/19 at 11:20 AM, in the activity room, confirmed the facility failed to maintain proper infection control practices during medication administration. Based on facility policy review, observation, and interview the facility failed to follow infection control practices during dining observation in 1 of 1 dining rooms with 22 residents observed and during 1 of 2 medication administration observations. The findings include: Review of the facility policy Meal Distribution revised 9/2017 revealed .Meals are transported .in a manner that .protects against contamination .Proper food handling techniques to prevent contamination .will be used for point-of-service dining . Review of the facility policy Hand Hygiene undated revealed .Purpose .To decrease the risk of transmission of infection by appropriate hand hygiene .Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections .Using an alcohol-based hand rub is appropriate for decontaminating the hands before .after contact with inanimate objects . Review of the facility policy Medication Administration revised 6/2008 revealed .Use sanitary technique to place medications into a .medicine cup . Observation on 7/8/19 at 12:21 PM, in the dining room, revealed Certified Nurse Assistant (CNA) #1 delivering meal trays in the main dining room. Further observation revealed CNA #1 touched Resident #20's wheel chair and clothing then positioned the resident at the table. Continued observation revealed CNA #1 had not sanitized the hands after direct contact with Resident #20's wheel chair and clothing and delivered a lunch tray to Resident #62. Further observation revealed CNA #1 assisted Resident #62 with cutting his meat into small pieces and failed to sanitize the hands after she delivered the meal tray and assisted with cutting the meat. Continued observation revealed CNA #1 delivered a meal tray to Resident #20, set the meal tray up for the resident and failed to sanitize the hands. Further observation revealed CNA #1 delivered a meal tray to Resident #64, set the tray up and failed to sanitize the hands. Interview with CNA #1 on 7/8/19 at 12:35 PM, in the dining room, confirmed the CNA failed to sanitize the hands while delivering meal trays to residents #20, #62, and #64 in the dining room. Interview with the Director of Nursing (DON) on 7/10/19 at 10:20 AM, in the DON's office, confirmed the facility failed to follow infection control practices during dining observation.