**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 8 residents (Resident #95) reviewed for unnecessary drugs. The facility failed to ensure Resident #95 had a duration for antibiotic therapy. This failure could place residents at risk of nausea, diarrhea, and multi-drug resistant organisms. Findings included: Record review of Resident #95's face sheet, dated 2/20/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #95's admission MDS, dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. Section I-Active Diagnoses included personal history of urinary tract infections, cognitive communication deficit (difficulty communicating thoughts), and unspecified dementia (a disease process that affects thinking process and memory). Record review of Resident #95's Acute Care Plan Antibiotic, dated 02/17/2025, revealed under Problem/Need relate to a handwritten prophylactic (preventative) in the last blank provided, Resulting in with handwritten Amoxicillin 250mg QD open-ended, Target/Review date was left empty and Interventions with monitor vital sign freq. with handwritten Q 8 in the blank provided. No boxes were checked on the form. Record review of Resident #95's care plan, dated 02/20/2025, revealed [Resident #95] has history of urinary tract infection and is at risk for UTIs r/t incontinence, debility (physical weakness). Is on prophylactic [NAME]. Approach included administer antibiotics as ordered and observe for effectiveness/adverse side effects. Record review of Resident #95's physician order dated 02/1/2025 revealed Amoxicillin 250mg 1 po qd -UTI prophylaxis. Record review of Resident #95's physician notes written by the nephrologist (kidney specialist) dated 02/18/2025 revealed Patient is to take amoxicillin 250mg every day until further notice, if any questions please call my office. Record review of Resident #95's antibiotic surveillance form revealed Infection Category and other circled. The sections titled nosocomial (facility acquired) or community acquired and symptoms present were not completed. The section titled related dx revealed prophylactic. Under other interventions and precautions taken revealed Amoxicillin 250mg QD open-ended During an interview on 03/19/2025 at 02:15 PM with the ICPC, she stated she had been employed with the facility for 2 years. She stated that she had specialty training in infection prevention and control and was responsible for overseeing infection prevention and control. She stated that she expected all antibiotic orders to meet the criteria of McGeer (a tool designed to support facility healthcare-associated infection surveillance). The ICPC stated all antibiotic orders needed a diagnosis, and end date or duration, and have a 72 hour follow up. She stated if an order for antibiotics did not meet criteria, then she would contact the NP to discontinue the order, and if needed the MD would have been contacted related to the appropriateness of the antibiotic. The ICPC stated if a prophylactic antibiotic was written by a nephrologist , then she would not question the order. She stated she did not complete the McGeer's for prophylactic antibiotics. The ICPC stated a resident could become resistant to the antibiotic or have side effects like nausea and diarrhea if they were to take antibiotics for a long period of time or if it was not needed. During an interview on 03/19/2025 at 04:17 PM with the DON, she stated that doing a McGeer assessment was not required for prophylactic antibiotic orders. During an interview on 03/19/2025 at 05:03 PM with the DON, she stated that she was unaware that all prophylactic antibiotic orders required an end date or duration. Attempted interview on 03/20/2025 at 01:07 PM with MD, left voicemail and no return call received prior to exiting the facility. Attempted interview on 03/20/2025 at 01:15 PM with RPh, left voicemail and no return call received prior to exiting the facility. During an interview on 03/20/2025 at 01:35 PM with the NP, she stated that she does not prescribe any prophylactic antibiotic orders. She stated that she was aware of the prophylactic antibiotic order for Resident #95, but the nephrologist wrote the order. The NP stated the resident could develop antibiotic resistance if on antibiotics for extended periods of time. During an interview on 03/20/2025 at 04:10 PM with LVN F, he stated he had been employed with the facility for about 8 months. LVN F stated if he received a new order for antibiotics, he was expected to check for a duration/end date. He stated if there was not an end date then he was expected to contact the provider for clarification. He stated any prophylactic antibiotic orders required notification of the responsible party and a care plan. He stated they monitored for side effects of the antibiotics like nausea, diarrhea, and rash. LVN F stated over time residents could become resistant to the antibiotics. He stated if the doctor and family know it is all right. I mean they have the right to prescribe the medication. During an interview on 03/20/2025 at 04:40 PM with LVN G, she stated she had worked at the facility for 10 years. She stated that a diagnosis and duration are required on all antibiotic orders. She stated if something were missing from the order, she would have contacted the provider for clarification. LVN G stated all nursing staff were responsible for ensuring antibiotics were being prescribed appropriately because residents could develop side effects like rash, hives, diarrhea, or resistance to antibiotics. During an interview on 03/20/2025 at 05:08 PM with the DON, she stated she expected nurses to ensure new orders for antibiotics included a diagnosis and a stop date. She stated if any component of the order was missing, then she expected the nurse to contact the provider for clarification. The DON stated it was her and the ICPC's responsibility to ensure antibiotics were appropriate and follow up cultures or labs were ordered. She stated if there was any question about the order then it was her or the ICPC's responsibility to contact the provider to obtain clarification. She stated she could question an order for antibiotics, but the provider did not always change the order. She stated she did not always find prophylactic antibiotics to be helpful, but she was not a provider and she just wanted to follow best practices. The DON stated if a resident were on antibiotics long term or when not needed it could cause a multi-drug resistant organism. During an interview on 03/20/2025 at 05:21 PM with the ADM, she stated her expectations for nurses when they received an order for antibiotics were to ensure there was a reason for taking the antibiotics. She stated she did not know why an antibiotic would be ordered if there was not a current infection. She stated she was aware of a prophylactic antibiotic order, but the order was prescribed by an outside doctor that was a specialist. She stated she believed there should have been an end date on all the antibiotic orders. The ADM stated she expected the DON and the ICPC to get with the NP or MD to figure out a plan if there was not a clear diagnosis and end date. The ADM stated the resident's immune system could get to where the antibiotic is not working for them anymore. Record review of facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, dated 2001 and revised in 12/2016, revealed. Policy Statement Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretations and Implementation . 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if. 1. The organism is not susceptible to antibiotic chosen. 2. The organism is susceptible to narrower spectrum antibiotic. 3. Therapy was ordered for prolonged surgical prophylaxis; or 4. Therapy was started awaiting culture, but culture results and clinical findings do no t indicate continued need for antibiotics . 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. Resident name and medical record number. b. Unit and room number. c. Date symptoms appeared. d. Name of antibiotic. e. Start date of antibiotic. f. Pathogen identified. g. Site of infection. h. Date of culture. i. Stop date. j. Total days of therapy. k. Outcome; and l. Adverse events.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #12, Resident #81, and Resident #93) reviewed for rights. The facility failed to ensure CNA D and RA C knocked on Resident #12's, Resident #81's, and Resident #93's door when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #12's Face Sheet dated 03/19/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #12's diagnoses included anxiety (feeling of uneasiness or worry), dementia (memory, thinking, difficulty), mood disturbances, anemia (not enough healthy red blood cells), viral hepatitis C, repeated falls, muscle wasting, chronic kidney disease, pain in left wrist, dry eye syndrome, abnormalities with gait and mobility, and chronic pain. Record review of Resident #12's Quarterly MDS dated [DATE] revealed Resident #12 had a BIMS score of 13 indicating intact cognitive Response. Review of Resident #81's Face Sheet dated 03/19/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #81's diagnoses included flu, muscle wasting, nausea with vomiting, headache, constipation, cough, urinary tract infection, insomnia (difficulty sleeping), muscle weakness, hypertension (high blood pressure), hyperlipidemia (high cholesterol), muscle spasm, retention of urine, injury to bladder, and anxiety (feeling of uneasiness or worry). Record review of Resident #81's Quarterly MDS dated [DATE] revealed Resident #81 had a BIMS score of 15 indicating intact cognitive Response. Review of Resident #93's Face Sheet dated 03/19/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #93's diagnoses included pneumonia, cerebral infarction (long term effects of a stroke), heart disease, obstructive sleep apnea (breathing pauses while sleeping), muscle wasting, lack of coordination, speech and language deficits, constipation, cough, hypertension (high blood pressure), hyperlipidemia (high cholesterol), shortness of breath, and other chronic pain. Record review of Resident #93's Quarterly MDS dated [DATE] revealed Resident #93 had a BIMS score of 15 indicating intact cognitive Response. Observation of 300 hall on 03/18/2025 at 09:15 a.m., revealed CNA D did not knock on Resident #81's and Resident #93's door before entering. Observation of 200 hall on 03/19/2025 at 1:17 p.m., revealed RA C walked into Resident #12's room without knocking. During an interview with Resident #81 on 03/19/2025 at 10:25 a.m., he said that staff do not always knock on his door. He said there were times he would be in the bathroom and not hear the staff knock and the staff come into his room and open the bathroom door without knocking. He said it upsets him that staff just open the bathroom door when he is going to the bathroom and invading his privacy. He said he wanted staff to knock on his door and the bathroom door all the time. During an interview with Resident #93 on 03/20/2025 at 8:30a.m., he said that staff do not always knock. He said that he would like for staff to knock all the time. He said he gets irritated when staff just walk into his room. He said especially when he had the door closed. During an interview with Resident #12 on 03/20/2025 at 10:29 a.m., she said that staff do not always knock on her door. She said that she wanted them to knock all the time because that was what people are supposed to do when going into someone's room. She said it really upsets her when staff do not knock, especially when she is in the bathroom. During an interview with CNA D on 03/19/2025 at 1:11 p.m., she said that she had been trained on resident rights. She said the policy for knocking was that staff were supposed to knock, introduce themselves and let the resident know what you are there for. She said staff were to knock anytime they wanted to enter a resident's room. She said that staff were supposed to knock on the resident's bathroom door if the resident was in there. She also said that it was important to knock on the resident's door because it was their right to have privacy. She said if staff do not knock the resident may get startled. She said that nurses monitor to ensure staff are knocking on the resident's doors by observation. She said she did not realize she did not knock on Resident #81's and Resident #93's door. During an interview with RA C on 03/20/2025 at 11:51 a.m., she said that she had been trained on resident rights. She said that staff were supposed to knock on all residents' doors before entering. She also said that staff were supposed to introduce themselves and tell the resident what they were going to do. She said there was no reason staff should not knock on the resident's door before entering. She said by staff not knocking the resident may get angry. She said the nurses and management monitored to ensure staff were knocking on the residents doors. She said that the nurses and management would walk down the hall and remind staff to knock and do observations. She said that she thought she might have been nervous. During an interview with the ADM on 03/20/2025 at 11:29 a.m., she said that she and staff had been trained on resident rights and knocking on residents' doors. She said the policy was to knock on the door and inform the resident what they are there to do. She said all staff were supposed to knock before entering the resident's room. She said that it was important for staff to knock on the resident's door for their privacy. She said it was the resident's right. She also said that it was no different than someone coming to her house and not knocking. She said the resident had the right to be respected. She said the resident may feel like their rights are being invaded or the staff do not respect them. She said that all managers should be monitoring that staff are knocking on the door. She said management monitors it by observation. She said she did not know why staff were not knocking on resident's doors before entering. During an interview with the DON on 03/20/2025 at 4:53 p.m., she said she and staff had been trained on resident rights. She said the policy was that staff were to knock on the door no matter what you are going in there for except if it is an emergency such as the resident on the floor. She said it was important for staff to knock because it was the resident's right. She also said that the resident had the right to tell staff they did not want them in the room. She said that all management was responsible for monitoring to ensure staff are knocking. She said that management monitors it by going down the halls and reminding staff. She said she did not know why staff were not knocking on the residents' doors. She said it was not due to lack of education. Record Review of Quality of Care- Dignity Policy dated February 2020 revealed that staff are expected to knock and request permission before entering residents' rooms. Residents' private space and property are respected at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the facility established and maintained an infection prevention program designed to provide a safe environment and to help prevent the transmission of communicable diseases for 3 of 5 staff (LVN A, MA B and Certified Nurse Aide D ) observed for infection control LVN A and MA B failed to disinfect the blood pressure cuff while using it on Residents #94, Residents #19 , Residents #39 , Residents #301. The facility failed to ensure Certified Nurse Aide D conducted hand hygiene in between feeding assistants of residents during dining. These failures could place residents at increased risk of healthcare associated infections. Findings included: 1. Review of Resident #19's Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #19 had diagnoses of Heart failure, Repeated falls, Acute Respiratory Disease, Muscle wasting and Atrophy, Chronic pain syndrome, Vitamin D deficiency, Hypertension, Lack of coordination and Abnormalities of gait and Mobility. Review of Resident #19's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated she was cognitively intact. Review of Resident #19's Care Plan dated 01/22/2025 reflected; Resident #19 with diagnosis of hypertension, potential for complications. The relevant intervention was observing for changes in condition that may warrant increased supervision/assistance and notify MD/NP as needed. Review of Resident #19's physician's order reflected : Metoprolol Tartrate tablet; 100 mg; amt: 1; oral. Special Instructions: Hold SBP less than 110, HR less than 60. Review of Resident #94's Face Sheet reflected she was an [AGE] year-old female admitted on [DATE]. Resident #94 had diagnoses of Shortness of breath, Allergy, Deficiency of other vitamins, Insomnia, Hypertension, Chronic obstructive pulmonary disease (condition with difficulty to breath), Constipation, Muscle weakness , History of falling and Nausea with vomiting. Review of Resident #94's initial MDS dated [DATE] reflected a BIMS score of 09 which indicated she had moderately impaired cognition. Review of Resident #94's Care Plan 02/19/2025 reflected; Resident #94 with CHF has the potential for elevated BP and at risk for exacerbation. The relevant intervention was observing for abnormal respirations/lung sounds and blood pressure. Review of Resident #94's physician's order reflected : Amlodipine tablet; 10 mg; 1 TAB; oral .Special Instructions: Hold for SBP less than 110 or SBP less than 60. Review of Resident #39's Face Sheet reflected she was an [AGE] year-old female admitted on [DATE]. Resident #39 had diagnoses of Constipation, Osteoporosis (weak and fragile bones) , Depressive disorders, History of falling, Muscle wasting, Muscle weakness , Generalized anxiety disorder, Hypertension, Chronic obstructive pulmonary disease (condition with breathing difficulty) and Allergy. Review of Resident #39's quarterly MDS dated [DATE] reflected a BIMS score of 13 which indicated she was cognitively intact. Review of Resident #39's undated Care Plan reflected; Resident #39 with hypertension and had the potential for change in blood pressure and fluid volume, dehydration, fluctuations in weight and complications related to the diagnosis. The relevant intervention was monitoring blood pressure, vital signs as per protocol /as ordered. Review of Resident #301's Face Sheet reflected she was an [AGE] year-old female admitted on [DATE]. Resident #301 had diagnoses of Alzheimer's disease, UTI, Chronic kidney disease, Hypertension, Constipation and Nausea with vomiting. Review of Resident #301's initial MDS dated [DATE] reflected a BIMS score of 02 which indicated she had severely impaired cognition. Review of Resident #301's Care Plan 01/22/2025 reflected; Resident #301 with hypertension and had the potential for change in blood pressure and complications related to the diagnosis. The relevant intervention was observing for signs and symptoms of elevated blood pressure. Review of Resident #301's physician's order reflected : Losartan tablet; 25 mg; amt: 1/2 tab (12.5 mg); oral. Special Instructions: hold for SBP<100, DBP<60, or HR<60. Observation on 03/18/25 beginning at 9:20 AM revealed MA B was administering medications to the residents in Hall 200. While taking blood pressure of Resident #19 and Resident #94, MA B had not sanitized the blood pressure cuff before Resident #19 , in between Resident #19 and Resident #94 and after checking blood pressure of Resident #94. During an interview on 03/18/25 at 10:10 AM MA B stated she did not sanitize the blood pressure cuff in between residents though she knew it was necessary . She stated she forgot to do so as she was nervous. She stated sanitizing the blood pressure cuff in between each resident was necessary to ensure infection control by reducing the risk of transferring the germs from one resident to another. MA B said she received on going in-services pertaining to infection, abuse and neglect and falls however could not recall any trainings provided specifically for sanitizing medical equipment, including blood pressure cuffs. During an observation on 03/20/25 starting at 9:50 AM LVN A was administering medications to the residents in Hall 200. It was observed that LVN A, without sanitizing the wrist blood pressure monitor used it on Resident #39 and Resident#301. She took the blood pressure of Resident #39 without sanitizing the cuff and after the completion without sanitizing she used the same blood pressure cuff on Resident #301. After completing the process she kept it on the medication cart, completed administering medications to Resident #301 and then moved on to the next resident. In an interview on 03/20/25 at 10:20AM LVN A stated she administer medications to the residents when there was no MA s available. She stated the correct process of using blood pressure cuffs on residents was, wiping it down (sanitize) in between each resident to avoid passing germs. LVN A stated she forgot to sanitize the blood pressure cuffs. She stated she received in services on sanitizing blood pressure cuffs sometime in the past however unable to recollect the exact month as it was not recently. 2. Record review of Resident #27's Face Sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnoses include Dementia (symptoms affecting memory, thinking, and social abilities, which interfere with daily life), Cognitive Communication Deficit (problems with communication caused by impaired cognitive processes), Dysphagia (difficulty swallowing), Muscle Wasting and Atrophy (loss of muscle mass and strength), Age-related Osteoporosis (bone formation is not keeping up with bone removal), Chronic Kidney Disease (condition characterized by progressive damage and loss of function in the kidneys), and Gastro-Esophageal Reflux Disease (stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). Record review of Resident #27's Care Plan, dated 03/05/2025, reflected resident had impaired cognitive function/dementia. The goal was for Resident #27 to maintain current level of cognitive functions. Interventions for Resident #27 included: resident will not have an allergic reaction to ingestion. Resident will not exhibit signs and symptoms of drug related: hypotension (low blood pressure), sedation (in a relaxed easy state), anticholinergic (substances or drugs that oppose or block the effects of acetylcholine,) or extrapyramidal (involved in coordinating movement and motor control) symptoms/behaviors as evidenced by decreased behaviors thru next review date. Will remain comfortable and have needs met as promptly as possible. Resident will not exhibit signs of activity intolerance (fatigue, shortness of breath, pallor or cyanosis, vertigo, and weakness). Resident will be nourished, hydrated, and will maintain within 5% loss/gain of current weight. Resident needs will be anticipated, and resident will receive assistance with assisted daily living. Resident will maintain memory/recall ability as evidenced by recalling staff names, stating he/she is in a nursing home, and recognizing staff faces. Record review of Resident #27's quarterly Minimum Data Set, dated [DATE], reflected a Brief Interview for Mental Status Score of 99, which indicated cognitive impairment. The Minimum Data Set also reflected Resident #27 was dependent with eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Record review of Resident #75's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident's diagnoses include Degeneration of brain (progressive loss of structure or function of neurons), Ulcerative Blepharitis left eye (inflammation of the eyelid margins), Hypokalemia (lower-than-normal levels of potassium in the bloodstream), Muscle weakness (lack of muscle strength), Muscle wasting and Atrophy (loss of muscle mass and strength), Hypothyroidism (underactive thyroid), Chronic Kidney Disease (gradual loss of kidney function), Dysphagia (difficulty swallowing), Edema (swelling caused by too much fluid trapped in the body's tissues), Pulmonary Hypertension (high blood pressure affects arteries of the lungs, and right side of the heart), and Hypothyroidism (abnormally low activity of the thyroid gland, resulting in slowing of growth metabolic changes in adults). Record review of Resident #75's Care Plan, dated 01/08/2025, reflected resident has Dysphagia and Chronic Kidney Dieses. Resident #75's goal's are: for to have needs met with as little frustration or distress as possible. Resident will not have an allergic reaction to ingestion. Resident will verbalize relief of pain. Resident will be kept comfortable. Resident will be nourished, hydrated and will maintain within 5% loss/gain of current weight. Resident needs will be met. Record review of Resident #75's quarterly Minimum Data Set, dated [DATE], reflected a Brief Interview for Mental Status Score of 99, which indicated cognitive impairment. The Minimum Data Set also reflected Resident #75 was dependent with eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene as well as is not applicable to shower/bathe and personal hygiene. Observation on 03/18/2025 at 12:10 PM during dining services, Certified Nurse Aide E was providing Resident #27 and Resident #75 with feeding assistance at the same time in which it was observed Certified Nurse Aide E was not hand sanitizing in between touching residents, food, and utensils. Attempt interview on 03/20/2025 at 10:37 AM, with Resident #27 was conducted. It was confirmed Resident #27 is unable to answer questions and is nonverbal. Attempt interview on 03/20/2025 at 10:45 AM, with Certified Nurse Aide E in which it was advised by facility staff that Certified Nurse Aide E was not on duty nor will be in later to be available for conversation. Interview on 03/20/2025 at 11:15 AM, with Resident #75 conducted. Resident #75 stated her hands doesn't work well due to being over [AGE] years old. Resident stated staff help her with feeding, sometimes staff help with feeding another resident. Resident stated sometimes she see's staff wash hands and sanitize, but sometimes not. Resident stated hand washing and sanitization in between glove usage doesn't always happen or sometimes staff don't wear gloves during meal service. Resident stated when staff are feeding another resident, she doesn't know where the staff's hands could have been if the staff is not sanitizing them in between feeding or if staff gets up to go somewhere else and return without cleaning their hands. Resident stated she knows it can affect her, but she doesn't know exactly how with germs. Resident stated staff have to be careful, and she has to be careful of the staff if they aren't cleaning hands. Resident stated if staff don't sanitize their hands, it makes her feel like she doesn't want to eat. Resident stated she sees staff not following hand hygiene during feeding her, she keeps it to herself. Resident stated she doesn't remember which staff or who they are since she is older. Resident stated she doesn't know what the staff can be spreading from resident to resident or to her when feeding them and not sanitizing. Resident stated she feels that she's seen it multiple times but can't recall when it happens in the dining room. Resident stated she doesn't remember which staff members who help with feeding her or other residents she's seen it happen to and she can't remember the times it's happened since she's older, but she's seen the staff not sanitize or clean hands when feeding her. Attempt interview on 03/20/2025 at 11:55 AM, with two Family Representatives for Resident #27 was conducted. I attempted to speak with Family Representatives via phone, there was no answer. Two call-out attempts were made for Family Representatives, a voicemail was left with a call back number. No return call was received. Interview on 03/20/2025 at 12:13 PM, with Certified Nurse Aide E via phone. Certified Nurse Aide E stated he doesn't speak English and only speaks Spanish in which he was priorly observed during dining services communicating with residents in English. I spoke to Certified Nurse Aide E in Spanish and attempted to speak with him in regard to Resident #27 and Resident #75. Certified Nurse Aide E stated that he is at work elsewhere and can't be on his phone and is unable to answer questions. When asked if there is a time he can speak, Certified Nurse Aide E stated that he is at work and has an appointment to get to in between which he can't speak to me. When asked what time he can speak after his shift, he didn't provide me a time. My contact number was provided in which no call back was returned. Interview on 03/20/2025 at 12:34 PM, with Certified Nurse Aide D was conducted. Certified Nurse Aide D stated the following: she has been trained in hand hygiene in which it went over, staff have to wash hands for 20 seconds and under fingernails. Not to contaminate from touching things and anything that would require providing resident care, hand sanitizing or washing, as well as sanitizing or washing hands in between gloves usage. Certified Nurse Aide D stated staff are to be sanitizing in between feeding more than one resident, or wash hands if they get up to do something and return back to feed residents. Certified Nurse Aide D stated staff not washing hands can affect residents if hand hygiene isn't being followed such as, passing germs, contamination, diseases, and potentially be fatal to some residents depending on their health conditions. Certified Nurse Aide D stated her expectations are for all staff to follow hand hygiene and enforce staff to keep practicing safe hand sanitization. Certified Nurse Aide D stated if staff don't follow hand hygiene when assisting two residents, like in this case it can affect Resident #75 since she has respiratory issues, and it can affect Resident #27 wellbeing since she has health issues as well. Certified Nurse Aide D stated it can affect resident's quality of life if staff are not properly following hand hygiene policies. Interview on 03/20/2025 at 4:50 PM, with Director of Nursing was conducted. Director of Nursing stated the following: she's been trained in hand washing and hand hygiene in which it went over all stated is what goes over. Director of Nursing stated she is in charge of making sure all staff are following hand hygiene, anytime she goes through the facility she reminds staff. Director of Nursing stated if staff don't follow hand hygiene policy, it can be an infection control issue and pass on pathogens to residents. Director of Nursing stated resident's quality of life can be affected if staff don't wash and or sanitize hands during feeding. Director of Nursing stated in regard to Resident #27 and Resident #75, it can affect them because their immune systems are compromised, and due to their older age, it can affect them and potentially be fatal. Director of Nursing stated her expectation for staff is to maintain hand hygiene and to follow the process they are taught. Director of Nursing stated the policy for hand sanitization is for staff to wash or sanitize before and after when assisting in between residents as well as between all food trays or assisting with feeding meals to resident in order to prevent contamination. Director of Nursing stated if staff are feeding more than one resident at a time, they must sanitize in between if their hands touch the resident or if they are cleaning the residents, including if staff come back to assist residents, staff must sanitize. The Director of Nursing stated staff are supposed to wipe blood pressure cuffs down with wipes in between each resident . She stated , skipping infection control protocols like hand hygiene, and sanitizing medical equipment could risk the spreading of contagious diseases through contamination. The Director of Nursing stated staff received in-services anytime they found any type of noncompliance in the facility. Interview on 03/20/2025 at 5:20 PM, with Administrator was conducted. Administrator stated the following: she has been trained in hand washing and hand hygiene in which it went over to make sure staff wash their hands for 20 seconds in the dining room and while providing resident care, use hand sanitizer in between passing trays, and including when feeding residents in between. Administrator stated the process of feeding multiple residents at once is that the staff member should not be touching each resident without hand sanitizing in between, if the staff member gets up and comes back, they should be washing their hands and or sanitizing. Administrator stated the last time hand hygiene and sanitization in-service was completed took place in the last two months to her knowledge. Administrator stated resident's quality of life can be affected in terms of infections especially if their immune system is low and staff pass something due to not following hand hygiene. Administrator stated Resident #27 and Resident #75 can be affected because they are older and have health issues. Administrator stated her expectations for staff are to follow hand hygiene and follow their training. Record review of in services since October ,2024 revealed an in-service conducted on hand sanitization on 11/13/2024 and no in-service provided on cleaning and disinfection of resident-care items and equipment . Review of facility Policy Cleaning and disinfection of resident-care items and equipment revised in October 2018 reflected: Policy Statement: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation: . 1. (d). Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . 2. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. Record review of the facility's Infection Control: Handwashing/Hand Hygiene Policy revised on August 2019 stated: this facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation. -Before moving from a contaminated body site to a clean body site during resident care; after contact with a resident's intact skin, after removing gloves, before and after eating or handling food, and before and after assisting a resident with meals. - All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. - Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. - Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. - The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to establish an infection and prevention and control program that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 3 of 8 residents (Residents #48, #52, and #95) reviewed for antibiotic stewardship program. The facility failed to follow the antibiotic stewardship policy for Residents #48, #52, and #95 by not ensuring an infection surveillance form was completed to ensure the appropriateness of the antibiotic per facility policy. This deficient practice could place residents at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased multi drug resistant organisms. Findings include: Record review of Resident #48's face sheet, dated 3/20/2025, revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and the most recent admission was 02/17/2025. Record review of Resident #48's readmission MDS, dated [DATE], revealed a BIMS score of 06, which indicated severe cognitive impairment. Section I-Active Diagnoses included acute kidney failure (the kidneys sudden inability to adequately filter waste), neurogenic bladder (lack of bladder control because of a nerve problem), non-Alzheimer's dementia (a progressive degeneration of memory, cognitive, and motor functions), and retention of urine. Record review of Resident #48's physician orders, dated 02/17/2025, revealed Cephalexin 500mg po BID for UTI x 5 days. Record review of Resident #48's infection surveillance form, dated 02/17/2025, revealed infection category with urinary circled. Nothing was circled under the category Nosocomial (facility acquired) or community acquired or symptoms present (check all that apply). After Related Dx: was UTI handwritten in the blank provided. After the section Other interventions and Precautions taken: was Cephalexin 500 mg BID x 5 days, handwritten in the blank provided. In the margin of the paper form, handwritten, was Returned from hospital with ABX. Record review of Resident #48's undated Acute Care Plan Antibiotic revealed Problem/Need relate to with a handwritten check next to UTI, Resulting in with handwritten Cephalexin 500mg BID x 5 days, Target/Review date with handwritten 1 week and Interventions with monitor vital sign freq. with handwritten Q8 in blank provided. The box next to UTI at the top of the form had a handwritten check. No check was indicated next to antibiotic therapy under resulting in. No check marks or handwritten comments were noted under strengths to draw on. No checkmarks or handwritten notes were under goal next to infection will resolve without complication. No checkmarks noted under interventions .nursing next to monitor vital signs Q8, give medication as ordered. Monitor for adverse/side effects., anticipate & provide PRN meds: cough, pain/discomfort, fever, anxiety, and no further interventions written in to blank space provided. No further interventions were written under Dietary, Social Services, or Activities. Record review of Resident #48's nurses progress notes titled Resident Acute Follow-up Documentation dated 02/17/2025-02/20/2025 revealed F/U readmit handwritten on form. A handwritten nurses' note was documented in boxes provided for every 8-hour shift with vital signs but no mention of antibiotics in any notes. Record review of Resident #48's progress note written by the NP, dated 02/17/2025, revealed Pt is seen today for readmission .Her initial urinalysis showed possible UTI, but urine culture showed mixed flora. She received 5 days of IV Rocephin for possible infection then transitioned to oral Keflex course .continue Keflex course. Record review of Resident #52's face sheet, dated 03/20/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #52's quarterly MDS, dated [DATE], revealed a BIMS score of 13, which indicated no cognitive impairment. Section I-Active Diagnoses included quadriplegia (significant loss of motor function below the neck), Cerebrovascular Accident (damage to the brain when blood flow is stopped), hypertension (high blood pressure), and muscle wasting and atrophy (tingling, numbness or weakness in your arms and legs). Record review of Resident #52's physician orders, dated 02/18/2025, revealed Levaquin 500mg PO Daily x 7 days (Dx: acute URI). Record review of Resident #52's infection surveillance form, dated 02/18/2025, revealed infection category with respiratory circled. Nothing was circled under the category Nosocomial or community acquired or symptoms present (check all that apply). After Related Dx: was URI handwritten in the blank provided. After the section Other interventions and Precautions taken: was Levaquin 500mg x 7 days, handwritten in the blank provided. Record review of Resident #52's Acute Care Plan Antibiotic, dated 02/18/2025, revealed Problem/Need relate to with a handwritten check next to handwritten URI, Resulting in with handwritten Levaquin 500mg po QD x 7 days, Target/Review date with handwritten 1 week and Interventions with monitor vital sign freq. with handwritten Q8 in the blank provided. The box next to handwritten URI at the top of the form had a handwritten check. No check was indicated next to antibiotic therapy under resulting in. No check marks or handwritten comments were noted under strengths to draw on next to able to communicate needs or able to follow instructions. No checkmarks or handwritten notes were under goal next to infection will resolve without complication. No checkmarks noted under interventions .nursing next to monitor vital signs Q8, give medication as ordered. Monitor for adverse/side effects., anticipate & provide PRN meds: cough, pain/discomfort, fever, anxiety, and no further interventions written in to blank space provided. No further interventions were written under Dietary, Social Services, or Activities. Record review of Resident #52's nurses noted dated 02/18/2025-02/25/25 revealed a nurses note every shift with vital signs and no adverse reactions noted. Record review of Resident #52's progress note written by the NP, dated 02/18/2025, revealed Pt is seen today per nursing request. Nursing reports Pt c/o persistent cough and congestion .No acute fever, pain, SOB, wheezing, N/V/D, or AMS. He continues to have nasal congestion and reports having productive cough with greenish sputum(mucus that is coughed up). Will start pt on Levaquin 500mg PO daily x 7 days for treatment of acute URI . Record review of Resident #52's physician orders, dated 03/04/2025, revealed Augmentin 875mg PO BID x 10 days (Dx: Acute bronchitis [an inflammation of the lining of the tubes that carry air to and from the lungs]). Record review of Resident #52's undated infection surveillance form revealed infection category with respiratory circled. Nothing was circled under the category Nosocomial or community acquired or symptoms present (check all that apply). After Related Dx: was Acute Bronchitis handwritten in the blank provided. After the section Other interventions and Precautions taken: was Augmentin 875mg po BID x 10 days, handwritten in the blank provided. Record review of Resident #52's undated Acute Care Plan Antibiotic revealed Problem/Need relate to with a handwritten check next to Acute Infection and a handwritten check next to handwritten Acute Bronchitis, Resulting in with handwritten Augmentin 875mg po BID x 10 days, Target/Review date with handwritten 2 weeks and Interventions with monitor vital sign freq. with handwritten Q8 in blank provided. The boxes next to Acute Infection and Acute Bronchitis at the top of the form had a handwritten check. No check was indicated next to antibiotic therapy under resulting in. No check marks or handwritten comments were noted under strengths to draw on next to able to communicate needs or able to follow instructions. No checkmarks or handwritten notes were under goal next to infection will resolve without complication. No checkmarks noted under interventions .nursing next to monitor vital signs Q8, give medication as ordered. Monitor for adverse/side effects., anticipate & provide PRN meds: cough, pain/discomfort, fever, anxiety, and no further interventions written in to blank space provided. No further interventions were written under Dietary, Social Services, or Activities. Record review of Resident #52's nurses' noted dated 03/04/2025-03/13/25 revealed a nurses note every shift with vital signs and no adverse reactions noted. Record review of Resident #52's progress note written by the NP, dated 03/04/2025, revealed Pt is seen today per Pt's request .He c/o still having persistent cough and chest congestion. He reports he is coughing up yellow/greenish sputum at times. No fever, HA, sore throat, chills, SOB, N/V/D, or other symptoms. There are rhonchi (abnormal lung sounds) to upper lobes of lungs . Record review of Resident #95's face sheet, dated 2/20/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #95's admission MDS, dated [DATE], revealed a BIMS score of 0, which indicated severe cognitive impairment. Section I-Active Diagnoses included personal history of urinary tract infections, cognitive communication deficit (difficulty communicating thoughts), and unspecified dementia (a disease process that affects thinking process and memory). Record review of Resident #95's physician order dated 02/17/2025 revealed Amoxicillin 250mg 1 po qd -UTI prophylaxis. Record review of Resident #95's infection surveillance form, dated 02/17/2025, revealed infection category with other circled. Nothing was circled under the category Nosocomial or community acquired or symptoms present (check all that apply). After Related Dx: was Prophylactic handwritten in the blank provided. After the section Other interventions and Precautions taken: was Amoxicillin 250mg QD open-ended, handwritten in the blank provided. Record review of Resident #95's Acute Care Plan Antibiotic, dated 02/17/2025, revealed under Problem/Need relate to a handwritten prophylactic in the last blank provided, Resulting in with handwritten Amoxicillin 250mg QD open-ended, Target/Review date was left empty and Interventions with monitor vital sign freq. with handwritten Q8 in the blank provided. The box next to prophylactic at the top of the form was not marked. No check was indicated next to antibiotic therapy under resulting in. No check marks or handwritten comments were noted under strengths to draw on next to able to communicate needs or able to follow instructions. No checkmarks or handwritten notes were under goal next to infection will resolve without complication. No checkmarks noted under interventions .nursing next to monitor vital signs Q8, give medication as ordered. Monitor for adverse/side effects., anticipate & provide PRN meds: cough, pain/discomfort, fever, anxiety, and no further interventions written in to blank space provided. No further interventions were written under Dietary, Social Services, or Activities. Record review of Resident #95's care plan, dated 02/20/2025, revealed [Resident #95] has history of urinary tract infection and is at risk for UTIs r/t incontinence, debility(physical weakness). Is on prophylactic [NAME]. Approach included administer antibiotics as ordered and observe for effectiveness/adverse side effects. Record review of Resident #95's physician notes dated 02/18/2025 revealed Patient is to take amoxicillin 250mg every day until further notice, if any questions please call my office. During an interview on 03/19/2025 at 02:15 PM with the ICPC, she said she had been employed with the facility for 2 years. She stated that she had specialty training in infection prevention and control and was responsible for overseeing infection prevention and control. She stated that she utilized a mapping tool to monitor infections. She stated she was responsible for completing the infection surveillance form and care plan when a resident is started on antibiotics. The ICPC stated all antibiotic orders needed a diagnosis, and end date or duration, and have a 72 hour follow up. She stated if an order for antibiotics did not meet criteria, then she would contact the NP to discontinue the order, and if needed the MD would have been contacted related to the appropriateness of the antibiotic. The ICPC stated a resident could become resistant to the antibiotic or have side effects like nausea and diarrhea if they were to take antibiotics for a long period of time or if it was not needed. During an interview on 03/19/2025 at 04:17 PM with the DON, she stated that doing a McGeer assessment was not required for prophylactic antibiotics or antibiotic orders that were received with the discharge order from the hospital. Attempted interview on 03/20/2025 at 01:07 PM with MD, left voicemail and no return call received prior to exiting the facility. Attempted interview on 03/20/2025 at 01:15 PM with RPh, left voicemail and no return call received prior to exiting the facility. During an interview on 03/20/2025 at 01:35 PM with the NP, she stated that she does not prescribe any prophylactic antibiotic orders. She stated that she was aware of the prophylactic antibiotic order for Resident #95, but the nephrologist wrote the order. She stated that infections needed to meet criteria lined out on the infection surveillance form. The NP stated the resident could develop antibiotic resistance if on antibiotics unnecessarily or for extended periods of time. During an interview on 03/20/2025 at 04:10 PM with LVN F, he stated he had been employed with the facility for about 8 months. LVN F stated if he received a new order for antibiotics, he was expected to check for all components of the orders, then administer the medication within 4 hours. He stated all residents needed to be monitored for side effects of the antibiotics like nausea, diarrhea, and rash and their vital signs for the duration of antibiotic therapy and 72 hours afterwards. LVN F stated over time residents could become resistant to the antibiotics. During an interview on 03/20/2025 at 04:40 PM with LVN G, she stated she had worked at the facility for 10 years. She stated all antibiotic orders must have the resident's name, name of the medication, dosage, frequency, duration, diagnosis, and route. She stated if something were missing from the order, she would have contacted the provider for clarification. LVN G stated all nursing staff were responsible for ensuring antibiotics were being prescribed appropriately because residents could develop side effects like rash, hives, diarrhea, or resistance to antibiotics. During an interview on 03/20/2025 at 05:08 PM with the DON, she stated she expected nurses to ensure new orders for antibiotics included all necessary components. She stated if any component of the order was missing, then she expected the nurse to contact the provider for clarification. The DON stated it was her and the ICPC's responsibility to ensure antibiotics were appropriate by using the surveillance form and to follow up on cultures or labs were needed or ordered. She stated if a resident was admitted from the hospital, they did not always get the labs and cultures, so the surveillance was not done. She stated if there was any question about the order then it was her or the ICPC's responsibility to contact the provider to obtain clarification. She stated she could question an order for antibiotics, but the provider did not always change the order. The DON stated if a resident were on antibiotics long term or when not needed it could cause a multi-drug resistant organism. During an interview on 03/20/2025 at 05:21 PM with the ADM, she stated her expectations for nurses when they received an order for antibiotics were to ensure there was a reason for taking the antibiotics. She stated she expected the IPCP or the DON to complete the infection surveillance form anytime an antibiotic was prescribed. She stated she was unaware of any situation that a surveillance form would not have been completed with a new antibiotic order. The ADM stated the resident's immune system could get to where the antibiotic is not working for them anymore or the antibiotic could make them sick. Record review of facility policy titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes, dated 2001 and revised in 12/2016, revealed. Policy Statement Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. Policy Interpretations and Implementation 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. a. Therapy may require further review and possible changes if. 1) The organism is not susceptible to antibiotic chosen. 2) The organism is susceptible to narrower spectrum antibiotic. 3) Therapy was ordered for prolonged surgical prophylaxis; or 4) Therapy was started awaiting culture, but culture results and clinical findings do no indicate continued need for antibiotics . 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: a. Resident name and medical record number. b. Unit and room number. c. Date symptoms appeared. d. Name of antibiotic. e. Start date of antibiotic. f. Pathogen identified. g. Site of infection. h. Date of culture. i. Stop date. j. Total days of therapy. k. Outcome; and l. Adverse events. Record review of facility policy titled Infection Prevention and Control Program, dated 2001 and revised 8/2016 revealed. Policy Statement 1. The infection prevention and control program are a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 2. The element of the infection prevention and control program consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Policy Interpretation and Implementation . . 3. Surveillance a. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens wit infection control implications. c. Standard criteria are used to distinguish community-acquired from facility-acquired infections. 4. Antibiotic Stewardship a. Culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. b. Medical criteria and standardized definitions are used to help recognize and manage infections. c. Antibiotic usage is evaluated, and practitioners are provided feedback on reviews . Record review of facility policy titled Surveillance for Infections, dated 2001 and revised 09/2017, revealed. Policy Statement The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. Policy Interpretations and Implementation 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections. 2. The criteria for such infections are based on the current standard definitions of infections .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 2 of 8 residents (Resident #12 and Resident #288) reviewed for resident rights. 1. The facility failed to ensure that Resident #12 had full visual privacy providing a functioning ceiling hung curtain that surrounded his bed. 2. The facility failed to ensure Resident #228's privacy by providing a privacy bag to shield his catheter bag from view. These failures placed residents at risk of diminished quality of life and embarrassment. Findings included: 1. Record review of Resident # 12's Quarterly MDS , dated 1-14-2024, reflected a [AGE] year-old male , who was admitted to the facility on [DATE].Resident #12's BIMS Score Summary reflected a score of 3, which indicated Resident #12 had severe cognitive impairment. Resident #12 had no impairment in either upper extremities (shoulders, elbows, wrist, and hands) or lower extremities (hips, knees, ankles, and feet.) Resident #12 utilized a wheelchair for mobility assistance. Resident #12 received [Substantial/Maximum Assistance] for toileting hygiene, showering and bathing self, lower body dressing, (which meant the helper did more than half of the effort.) Resident #12 received [Partial/Moderate Assistance] for upper body dressing (which meant the helper did less than half of the effort.) Resident #12 was always incontinent of bladder and bowel. Resident #12 was diagnosed with coronary artery disease (which was a disease where plaque buildup in the arteries interrupted supply blood to the heart) and Non-Alzheimer's Dementia (which was a common form of dementia evidenced by an impaired ability to remember, think, or make decisions that interfered with performing everyday activities.) Record review of Resident 12's care plan reflected a [Problem Area Categorized as: ADL Functional Status/Rehabilitation Potential] initiated on 4-14-2023, evidenced by Resident #12 declining and functionable mobility needs extensive total assist with ADL. Needs extensive total assist with ADLs. Resident liked to stay in bed most of the time. An [Approach,] edited on 4-14-2023, indicated CNA and nursing staff encourage resident to participate in ADLs and tasks of daily living and assist as needed; provide care such as but not limited to bathing, grooming, and ADL; provide incontinent care after each incontinence and as needed. An interview and observation on 1-29-2024 at 10:28 AM with Resident #12 revealed he felt fine and did not have any issues or concerns with the care he received. He was lying in bed under the covers watching television. He made appropriate eye contact and was able to respond to probing questions. Resident's privacy curtain, which hung from the ceiling on a metal track, was not operating correctly. The mechanisms that connected the privacy curtain to the track were wedged on the track, which only allowed Resident #12 partial privacy. The ceiling hung privacy curtain only shielded Resident #12's head to his knees. An interview on 1-30-2024 at 1:00 PM with Resident #12 revealed that his privacy curtain has been broken for a long time. Staff have tried to pull the curtain to provide care, but they could not close it any further than it already was. Resident #12 stated they never informed him they would get it fixed. He stated he has gotten used to it but responded appreciatively when he thought of it being fixed. An interview on 1-31-2024 at 11:45 AM with Administrator revealed there was no facility policy that covered maintenance and reporting broken equipment. There was a maintenance book, and it was kept at the nurse's station. Even though there was no policy, the maintenance book was common knowledge and staff knew to write down maintenance issues in the book. An interview on 1-31-2024 at 11:49 PM with the DON revealed that staff tell the nurse when something is broken and then the nurse contacted maintenance and wrote the broken item in the book. She stated maintenance checked the book daily. An interview on 1-31-2024 at 11:52 with CNA D revealed staff were trained to close the door, draw the curtain, and close the blinds (if applicable) for each resident when they received care that required privacy. When staff discovered a broken privacy curtain, they would have told the nurse know, would have told maintenance know, and would have written it in the maintenance book. She was not aware of any resident's privacy curtain not working properly. The purpose of the privacy curtain was to shield the resident from view when they received care to avoid them from having felt uncomfortable or embarrassed. An interview on 1-31-24 12:04 with LVN C revealed staff were trained to close the door, draw the curtain, and close the blinds (if applicable) for each resident when they received care that required privacy. If the curtain were inoperable, she stated she would try to find a different way to provide care while providing privacy. She suggested walking the resident to the restroom or asking the other roommate to excuse themselves momentarily. Broken items were reported to maintenance and were written in the maintenance book at the nurse's stations. Privacy curtains supported a resident's right to dignity and the lack of privacy placed the resident at risk of feelings such as embarrassment, shame, and vulnerability. An interview on 1-31-2024 at 12:25 with the Maintenance Director revealed he had not been informed of any residents that did not have a functioning privacy curtain, nor was there an entry in the maintenance book and he checked it daily. Furthermore, he periodically took down privacy curtains to have them washed. He stated that he would have fixed any resident's issue with a privacy curtain right away had he known. The Maintenance Director stated managers walk through rooms and conducted room rounds, where those items were supposed to be checked. Residents were supposed to be provided privacy when they received care so they would not have been embarrassed. An interview on 1-31-2024 at 12:59 PM with MA H stated staff were trained to close the door, close the curtain, and close the blinds (if applicable) to provide the resident privacy when the resident received care. If a curtain was broken, staff were supposed to tell the nurse and let maintenance know right away. If the curtain was broken and the resident was not provided privacy, they may have felt ashamed, embarrassed, on undignified. An interview on 1-31-2024 at 1:53 PM with the DON revealed staff were trained to close the door, close the curtain, and close the blinds (if applicable) to provide privacy when a resident received care. If the curtain was broken, staff were supposed to write it in the book, report it to nursing staff, and report it to maintenance. A resident who received care without privacy was placed at risk of a dignity concerns or embarrassment. An interview and observation on 1-31-2024 at 2:12 PM reflected Resident #12's ceiling hung privacy curtain was inoperable and only shielded Resident #12's head to his knees. Resident # 12 responded with a smile when he learned his curtain would be fixed. An interview and record review on 1-31-2024 at 3:28 PM with the Administrator revealed staff were supposed to close the door, close the curtain, and close the blinds (if applicable) when a resident received care that required privacy. It was the resident's right to have privacy and it did not matter if the curtain was broken for a while and the resident was used to it. The resident was supposed to be comfortable when they received care and not risk having been embarrassed. The Administrator stated there were room rounds performed where items, such as the privacy curtains were checked. The Administrator provided a copy of a completed Manager Room Rounds Checklist, both dated 1-26-2024. The check list was filled out by the SW and the space provided on the check list under the heading [PRIVACY CURTAIN CLEAN AND IN GOOD CONDITION] was marked with a [Y,] which indicated [yes,] the privacy curtain in Resident #12's room was clean and in good condition. Record review of the facility maintenance log, dated from 9-20-2023 to 1-31-2024. did not contain an entry for Resident #12's room having an inoperable privacy curtain. Record review of a Manager Room Rounds Checklist, dated 1-26-2024, reflected the SW reported the privacy curtain in Residents #12's room was clean and in good condition. 2. Review of the face sheet for Resident #288 revealed a [AGE] year-old female with an admission date of 01/25/2024. Resident #288's diagnoses included: Cancer of the uterus ; mild protein-calorie malnutrition, history of falling, constipation, unspecified, nausea with vomiting, unspecified, other dysphagia , pain, unspecified, age-related physical debility, anxiety disorder, unspecified, conversion disorder with seizures or convulsions, essential (primary) hypertension, acute respiratory failure with lack of oxygen in the tissue , disturbances of salivary secretion , vitamin D deficiency, unspecified, and type 2 diabetes mellitus with hyperglycemia . Record Review of Resident #288's orders dated 01/29/2024 revealed privacy bag in place on bed at all times. Foley collection bag off the floor at all times. Observation on 01/29/2024 at 10:13 AM revealed Resident #288 lying in bed. Observed resident's catheter bag uncovered and hanging on the bed. Resident was alert but not interviewable. Observation on 01/29/2024 at 12:07 AM revealed Resident #288 lying in bed, resident's catheter bag was still uncovered at that time. An interview on 01/30/2024 at 1:24 PM with CNA F revealed CNAs were responsible for providing catheter dignity to the residents. CNA F stated they are responsible for putting the catheter bag in a privacy bag. She stated that the policy was that the catheter should always be in a privacy bag when in the room or out of the room. She stated that she has been trained on how to clean the catheters, empty them, clean the lines and how to put them in the privacy bag. She stated she unsure why Resident #288's catheter was not in a privacy bag. CNA F stated that it is important to put in a privacy bag to protect the resident's privacy. An interview on 01/30/2024 at 1:33 PM RN A revealed everyone was responsible for providing dignity care to the residents. RN stated that the policy on catheters was that it should always be placed in a privacy bag. She stated she has been trained on catheter care. She stated the training covered monitoring the urine, the privacy bag, and catheter care. RN stated it was important to have the catheter in a privacy bag for the privacy of the resident. An interview on 01/30/2024 at 1:37 PM with the DON revealed that everyone was responsible for providing dignity care to the residents. The DON stated she would have to look up the policy, but she is sure it says the catheter must be in a privacy bag at all times especially when out of the room. She stated she was trained on catheter care. She stated everything was covered in the training from insertion, changing, flushing, and discontinuing. She stated it is important to have the catheter in a privacy bag for the dignity of the resident. DON stated they do daily room checks and that the administration checks specific rooms every day for issues and to ensure resident rooms are clean and resident is getting the proper care. An interview on 01/31/2024 at 3:35 PM with the DON revealed all nursing staff are responsible for providing catheter dignity to the residents. She stated the policy was catheters are to be covered with a privacy bag. The DON stated privacy bags are supposed to be on the catheters at all times. She stated that her staff were trained on catheter care and putting the privacy bag on the catheters. She stated the training covered how to change them, clean them, sanitize their hands, and the privacy bag. DON stated nurses and aids are supposed to check the catheters daily and ensure they are in a privacy bag. She stated it is important to put the privacy bag on the catheter, so the resident would not feel embarrassed, and others won't see they have a catheter. She stated they do room checks on Monday, Wednesday, and Fridays. Administrator stated that each manager was assigned rooms that they check. Stated rooms were assigned from each hall and the managers have a check list they turn into her. She stated she did not think catheter privacy bags were on the check list. Record review of Walking Rounds Checklist provided by the DON, (used to do daily checks, not dated) revealed under dignity that Foley Bags with covers were supposed to be checked when doing the rounds. Asked for room checks done on Resident #288 they were not provided. Record Review of Nursing Services Policy and Procedures [NAME] for Long Term Care (Revised February 2020) revealed each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self- worth and self-esteem. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For Example: Help the resident to keep urinary catheter bags covered. Record review of the facility's Quality of Life- Dignity policy, dated February 2020, stated (10) staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #28) of 8 residents reviewed for quality of care. 1. The facility failed to ensure Resident #28 received weekly skin assessments. 2. The facility failed to ensure Resident #28 was turned frequently per her care plan interventions. These failures placed residents at risk of skin breakdown. Findings included: A record review of Resident #28's face sheet dated 1/31/2024 reflected a [AGE] year-old female readmitted on [DATE] with diagnoses of lack of coordination, abnormalities of gate and mobility, muscle weakness, dysphagia (difficulty swallowing), cerebral infarction (stroke), and hemiplegia and hemiparesis (loss of motor skills on one side of body) following cerebral infarction affecting right dominant side. Resident #28's face sheet reflected she resided in room [ROOM NUMBER]. A record review of Resident #28's quarterly MDS assessment dated [DATE] reflected Resident #28 had impaired mobility in the upper and lower extremities and was dependent on staff for all ADLs including rolling left and right, going from sitting to lying, and transferring. A record review of Resident #28's quarterly MDS assessment dated [DATE] reflected she was not assessed for a BIMS score due to rarely/never being understood. Section M (Skin Conditions) reflected Resident #28 was at risk of developing pressure ulcers/injuries and had no current unhealed pressure ulcers/injuries. A record review of Resident #28's care plan last reviewed on 1/10/2024 reflected she had a G-tube (feeding tube), decreased mobility, incontinence and had potential for skin breakdown. Resident #28's care plan approaches reflected nursing staff were to observe her skin daily during care and during weekly skin checks as per protocol. Other approaches reflected staff were to turn and reposition frequently as needed, utilize a pressure relieving device as ordered/if indicated, may use LAL mattress as prophylactic measure and may use wedge for repositioning. A record review of Resident #28's orders reflected a physician order dated 6/25/2021 for MAY USE WEDGE FOR REPOSITIONING CHECK PLACEMENT Q SHIFT. A record review of Resident #28's skin assessments reflected that from 8/21/2023 to 10/01/2023, Resident #28 had three skin assessments completed on 8/21/2023, 9/11/2023 and 10/01/2023. There was no record of Resident #28 having received a skin assessment between 8/21/2023 and 9/11/2023 or between 9/11/2023 and 10/01/2023. All three skin assessment reflected Resident #28's skin was intact. During an observation and interview on 1/29/2024 at 3:04 p.m., Resident #28 was observed lying in bed on her back on a low air loss mattress. Observed a turning schedule posted on Resident #28's walls which reflected she was to be on her right side from 4-6, on her back from 6-8, on her left side from 8-10, on her right side from 10-12, on her back from 12-2 and on her left side from 2-4. Resident #28 was non-interviewable and unable to be interviewed. Resident #28's family member stated the turning instructions came from the hospital when she was admitted to the facility after having a stroke. Resident #28's family member said no staff did not follow the turning schedule posted. Resident #28's family member stated Resident #28 had no current skin issues. An observation on 1/30/2024 at 9:54 a.m. revealed Resident #28 was lying in bed on her back with the head of bed elevated to a 45° angle. An observation on 1/30/2024 at 12:37 p.m. revealed Resident #28 was lying in bed on her back with the head of bed elevated to a 45° angle. During an interview on 1/30/2024 at 1:40 p.m., CNA G stated she worked on the 200 hall that day and the residents who needed to be repositioned were residents in rooms 201, 202, 203, 204, 207, 208 and 206, where Resident #28 resided. An observation on 1/30/2024 at 1:59 p.m. revealed Resident #28 was lying on her back in bed with the head of bed elevated to a 45° angle. During an observation and interview on 1/30/2024 at 2:15 p.m., Resident #28 was observed lying on her back in bed with two wedges on either side of her. The Treatment Nurse stated usually staff only placed one wedge to keep Resident #28 on one side or the other and I'd have to check why staff did that. The Treatment Nurse stated sometimes Resident #28's family member liked things a certain way but having two wedges was not offloading Resident #28. During an interview on 1/30/2024 at 2:34 p.m., the Treatment Nurse stated she had spoken with the DON, and she said the DON said having two wedges was fine. The Treatment Nurse stated, I assumed Resident #28 had been repositioned from one side to her back, and that was why she had two wedges. The Treatment Nurse stated in order to offload one side or the other, they would need one wedge. The Treatment Nurse stated CNA G said that Resident #28's family member liked Resident #28 to have two wedges. An observation on 1/31/2024 at 8:33 a.m. revealed Resident #28 was lying in bed on her back with two wedges on either side of her and the head of bed elevated to a 30° angle. During an observation and interview on 1/31/2024 at 9:58 a.m., Resident #28's family member stated he had not observed staff reposition Resident #28 the day prior on 1/30/2024. Resident #28 was observed lying down on her back with two wedges on either side of her. Resident #28's family member stated Resident #28 could not move herself and having the two wedges there was the facility's idea, not his. Resident #28's family member stated he believed the facility wanted two wedges in place to prevent Resident #28 from getting knocked out of bed after a previous incident had occurred in the facility over one year ago. Resident #28's family member stated this incident had occurred prior to the facility's last recertification survey. During an interview on 1/31/2024 at 10:58 a.m., the Treatment Nurse stated skin assessments were supposed to be done weekly. An observation on 1/31/2024 at 11:00 a.m. revealed Resident #28 was lying in bed on her back with two wedges on either side of her and the head of bed elevated to a 30° angle. A nurse surveyor observation on 1/31/2024 at 1:34 p.m. revealed Resident #28's skin was intact. Resident #28 was observed lying on her back with the head of bed elevated to a 30° angle. During an interview translated via HHSC translating services on 1/31/2024 at 1:38 p.m., CNA G stated repositioning a resident meant turning them over and if they were flat, it meant turning them on their side. CNA G stated residents who could not move themselves needed to be repositioned every one or two hours. CNA G stated she had worked with Resident #28 that day (1/31/2024) and the day prior (1/30/2024). CNA G stated yes she followed the repositioning guideline posted in Resident #28's room. When asked why Resident #28 had not been repositioned between 10:00 am - 2:00 p.m. on 1/30/2024 and from 8:30 a.m. - 1:00 p.m. that morning (1/31/2024), CNA G stated, I put her flat and then I moved her feet, but I didn't reposition her to get on her side. When asked why, CNA G stated, I didn't do it. CNA G stated she had never put Resident #28 on her side before. CNA G stated, when we move her, we move her to the side, but we have to put the wedges back on because I'm afraid she's going to fall and then we're going to have a problem with her husband. CNA G stated they had problems with Resident #28's family member before. CNA G stated the DON had not instructed her to place two wedges on either side of Resident #28, but she had received instruction to do so from Resident #28's family member. During an interview on 1/31/2024 at 2:10 p.m., the DOR stated the repositioning chart posted in Resident #28's room was a nursing-driven repositioning program. The DOR stated repositioning meant moving a resident from one position to another and stated as long as Resident #28's head of bed was not super elevated, she could be turned to one side. The DOR stated having two wedges would not offload Resident #28. PT B stated if Resident #28 was lying on her back, staff should turn her on the side, and that if the head of bed was elevated slightly, staff could use one wedge to place Resident #28 on her side. PT B stated Resident #28 was not supposed to have two wedges, just one wedge on the side of Resident #28's body. PT B and the DOR stated yes Resident #28 should be repositioned if it was in her care plan to be repositioned. During an interview on 1/31/2024 at 2:38 p.m., the DON stated typically the Treatment Nurse did skin assessments but if she was off, herself, the ADON, or the floor nurses did them. The DON stated she would have to check if the Treatment Nurse was off in September or October of 2023. The DON stated the skin assessments should be in a binder and if something got missed, we would have them do a late entry. The DON stated she would find out whether an assessment was done through talking to the person assigned to do the assessment. The DON stated skin assessment should be done weekly. The DON stated nurses were trained on completing skin assessments upon hire. The DON stated everybody who works with residents was responsible for repositioning residents. The DON stated if residents were not on an air mattress, they needed to be repositioned every two hours. The DON stated with an air mattress, residents did not need to be repositioned as frequently-she said they would need repositioned at least every 5-6 hours. The DON stated, you take the patient into account and their skin and said Resident #28 had beautiful skin. The DON stated no she did not consider every 5-6 hours to be often and said that would be decreased frequency. The DON stated Resident #28 did not need to be turned every two hours, staff did not need to follow that schedule, she would have to look at the repositioning sign posted in her room, and I might have to take it off Resident #28's wall. The DON stated CNAs were trained on repositioning residents as a part of their annual competency assessments and through in-service training. The DON stated yes CNA G had completed the skills checklist. The DON stated Resident #28 was offloaded that day (1/31/2024) when she received a brief change and said Resident #28's family member was going to be sure of that. The DON stated herself or the ADON monitored nurses by checking the assessment book to ensure weekly skin assessments were completed. The DON stated nurses monitored CNAs to ensure they were repositioning residents by going into residents' rooms. The DON stated if skin assessments were not completed weekly and if residents were not being repositioned regularly, it could cause skin breakdown. During an interview on 1/31/2024 at 3:16 p.m., the DON stated the Treatment Nurse started in her role in October of 2023, the previous treatment nurse no longer worked in the facility. The DON stated she typically did her stuff but the DON said she could not get a hold of her. During an interview on 1/31/2024 at 3:17 p.m., the Administrator stated the Treatment Nurse started as the ADON and then moved into her current role in October of 2023. The Administrator stated the Treatment Nurse was responsible for completing skin assessments weekly and staff were trained on completing skin assessments through their CEU education. The Administrator stated CNAs or therapy were responsible for repositioning residents and residents should be repositioned every two hours. The Administrator stated since Resident #28 had a low air loss mattress, she did not need to be repositioned every two hours, but she did not know the exact frequency. The Administrator stated usually therapy trained CNAs if residents needed to be repositioned a certain way. The Administrator stated the DON, ADON, and Treatment Nurse monitored through rounding to ensure skin assessments were being completed and that residents were being repositioned. The Administrator stated skin assessments for Resident #28 could have been done and they didn't document it. The Administrator stated Resident #28's family member was there all the time and he knows what we're doing. The Administrator stated, there could be a potential negative outcome for residents if they were not repositioned or checked regularly for skin conditions but I don't see that with [Resident #28]. During an interview on 1/31/2024 at 4:00 p.m., the DON stated she could not find any guidance that reflected residents did not need to be turned with an air mattress, just that the air mattress changed the pressure every ten minutes. A record review of the facility's in-service dated 4/19/2023 titled HOB elevation reflected nursing staff were trained on the following: Keeping the head of the bed elevated when residents are in bed can have various benefits, such as reducing the risk for aspiration, improving breathing, and enhancing comfort during sleep. However, it is important to regularly assess and adjust the elevation to prevent discomfort and pressure injuries. A record review of the facility's document titled Nursing Assistant Clinical Skills Checklist and Competency Evaluation dated 12/15/2023 reflected CNA G received a competency-based assessment on positioning residents on their side. A record review of the facility's policy titled Prevention of Pressure Ulcers/Injuries dated April 2020 reflected the following: Purpose The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. e. Reposition resident as indicated on the care plan Prevention Mobility/Repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance from a resident's private bathroom through a communication system, which relays the call directly to a staff member or to a centralized staff work area, while lying on the floor for 3 of 5 residents (Residents #7, #12, and Resident #62) reviewed for physical environment. The facility failed to ensure the call light pull string in a Residents #7, #12, and #62's bathroom stretched its intended length from the junction box to the floor.; therefore, ensuring each resident had the least distance between their hands and the call light pull string. This failure placed residents at risk of having their needs unmet and not being able to reach the call light pull string during an emergency in the restroom. Findings included: 1. Record review of Resident # 7's undated face sheet reflected a [AGE] year-old male , who was admitted to the facility on [DATE]. He was diagnosed with Essential Hypertension (which was an abnormally high blood pressure without a medical condition) and Type II Diabetes (which was a disruption in the way the body used sugar as fuel.) Record review of Resident #7's Quarterly MDS, dated [DATE] reflected a BIMS score of 11, which indicated Resident #7 had moderate cognitive impairment. Section GG reflected Resident #7 had no impairment in either upper extremities (shoulders, elbows, wrist, and hands) or lower extremities (hips, knees, ankles, and feet.) This section also indicated Resident #7 did not use an assistive device for mobility assistance and required set-up assistance for toileting hygiene (which meant the helper set up or cleaned up, but the resident completed the activity.) Section H (Bladder and Bowel) indicated Resident #7 was occasionally incontinent of bladder and always continent of bowel. Record review of Resident 7's care plan reflected a [Problem Area Categorized as: Falls] initiated on 8-31-2023, was evidenced by Resident #7 having had a history of falls. The [Approach,] edited on 8-31-2023, indicated CNA, CMA, and nursing staff kept the call light in reach and encouraged Resident #7 to call for assistance when needed. During an interview and observation on 1-29-2023 at 11:10 PM, Resident #7 stated he was doing fine and that he did not have any issues or concerns with the care he received. He was seated in a recliner chair watching television, fully dressed, and well-groomed. He maintained appropriate eye contact and responded to probing questions in the same manner. He felt safe at the facility and denied being the recipient of any physical or emotional abuse. Observation on 1-29-2024 at 11:12 AM revealed Resident #7's call switch located in Resident #7's bathroom. The call switch, which was a device to alert staff for assistance, was located on the wall next to the commode. The device consisted of a metal junction box, which contained a vertical switch. The vertical switch had a cord attached to it, which hung in the direction to the floor. Instead of the cord hanging free in the direction of the floor, the cord extended in a 45-degree angle towards the commode and was wedged in a crevasse between the toilet paper dispenser and the wall. The cord did not hang freely to the floor as intended. Therefore, the cord was not located in the intended position. Observation on 1-30-2024 at 8:13 AM revealed Resident #7's call switch located in Resident #7's bathroom. The call switch, which was a device to alert staff for assistance, was located on the wall next to the commode. The device consisted of a metal junction box, which contained a vertical switch. The vertical switch had a cord attached to it, which hung in the direction to the floor. Instead of the cord hanging free in the direction of the floor, the cord extended in a 45-degree angle towards the commode and was wedged in a crevasse between the toilet paper dispenser and the wall. The cord did not hang freely to the floor as intended; therefore, the cord was not located in the intended position. With the use of a measurement tool on a state issued iPhone 13, the actual position of the call light pull string was thirteen horizontal inches away and 2 vertical inches higher than the intended position if the cord hung freely towards the direction of the floor. Observation and interview on 1-30-2024 at 01:22 PM revealed Resident #7's call switch located in Resident #7's bathroom. The call switch, which was a device to alert staff for assistance, was located on the wall next to the commode. The device consisted of a metal junction box, which contained a vertical switch. The vertical switch had a cord attached to it, which hung in the direction to the floor. Instead of the cord hanging free in the direction of the floor, the cord extended in a 45-degree angle towards the commode and was wedged in a crevasse between the toilet paper dispenser and the wall. The cord did not hang freely to the floor as intended; therefore, the cord was not located in the intended position. With the use of a measurement tool on a state issued iPhone 13, the actual position of the call light pull string was thirteen horizontal inches away and 2 vertical inches higher than the intended position of the cord hung freely towards the direction of the floor. Resident #7 stated that he was able to ambulate on his own and utilize the bathroom on his own. He stated that he utilized the pull cord in the bathroom for help before, but it was always from the seated position, and he pulled the cord from the portion that was higher than the toilet paper dispenser. He had not imagined having to have used the pull cord if he were lying on the floor. When he thought of falling and lying on the floor, he stated he would have been mad if he could not reach, or activate, the pull cord for assistance. For safety measures, the cord was removed and hung as intended. 2. Record review of Resident # 12's Quarterly MDS, reflected a [AGE] year-old male admitted to the facility on [DATE] with a BIMS score of 3, which indicated Resident #12 had severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected Resident #12 had no impairment in either upper extremities (shoulders, elbows, wrist, and hands) or lower extremities (hips, knees, ankles, and feet.) This section also reflected Resident #12 utilized a wheelchair for mobility assistance and received [Substantial/Maximum Assistance] for toileting hygiene (which meant the helper did more than half of the effort.) Section H (Bladder and Bowel) reflected Resident #12 was always incontinent of bladder and bowel. Section I, Active Diagnosis reflected Resident #12 was diagnosed with Coronary Artery Disease (disease where plaque buildup in the arteries interrupted supply blood to the heart) and Non-Alzheimer's Dementia (common form of dementia). Record review of Resident 12's care plan reflected a [Problem Area Categorized as: Falls] initiated on 4-14-2023, was evidenced by Resident #12 having had a potential for falls. The [Approach,] edited on 4-14-2023, indicated CNA and nursing staff kept the call light in reach. Interview and observation on 1-29-2024 at 10:28 AM with Resident #12 revealed he felt fine and did not have any issues or concerns with the care he received. He was lying in bed under the covers watching television. He made appropriate eye contact and was able to respond to probing questions. Interview and observation on 1-29-2024 at 10:31 AM reflected Resident #12's call switch located in Resident #12's bathroom. The call switch, which was a device to alert staff for assistance, was located on the wall next to the commode. The device consisted of a metal junction box, which contained a vertical switch. The vertical switch had a cord attached to it, which hung in the direction to the floor. Instead of the cord hanging free in the direction of the floor, the cord was loosely wrapped 2 times around a horizontal metal bar that was connected to the wall for stability. The pull cord was not in the intended position if the cord hung freely towards the direction of the floor. Resident #12 stated that he had utilized the call light for staff assistance in the past, but he stated he had not had to use the pull cord from lying on the floor. Observation on 1-30-2024 at 8:09 AM reflected the pull cord in Resident 12's bathroom hung freely down from the junction box and was in its intended location. Interview and observation on 1-30-2024 at 1:05 PM revealed Resident #12 was concerned that the pull cord in his bathroom might not work having been wrapped around the horizontal bar. He stated he unwrapped it himself. He stated he would have been pretty upset if he fell to the floor in the bathroom and was unable to call for help. 3. Record review of Resident #62's undated face sheet reflected a [AGE] year-old woman, born 2-6-1959, who was admitted to the facility on [DATE]. She was diagnosed with Essential Hypertension (which was an abnormally high blood pressure without a medical condition) and Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (which was an impaired ability to remember, think, or make decisions that interfered with performing everyday activities.) Record review of Resident #62's admission MDS, dated [DATE], indicated Section C- Cognitive Patterns, Sub-Section C 0500., BIMS Score Summary reflected a score of 7, which indicated Resident #62 had severe cognitive impairment. Section GG- Functional Abilities and Goals, Sub-Section GG 0115., Functional Limitation in Range of Motion, indicated Resident #62 had no impairment in either upper extremities (shoulders, elbows, wrist, and hands) or lower extremities (hips, knees, ankles, and feet.) Sub-Section GG 0120., Mobility Devices, indicated Resident #62 utilized a walker for mobility assistance. Sub-Section GG 0130., Self-Care, indicated Resident #62 received [Set-up Assistance] for toileting hygiene (which meant the helper set up or cleaned up, but the resident completed the activity.) Section H-Bladder and Bowel, Sub-Section H 0300., Urinary Continence, indicated Resident #62 was occasionally incontinent. Sub-Section H 0400., Bowel Continence, indicated Resident #62 was frequently incontinent. Record review of Resident 62's care plan reflected a [Problem Area Categorized as: Falls] initiated on 11-10-2023, evidenced by Resident #62 having had a potential for falls. The [Approach,] edited on 11-10-2023, indicated CNA, CMA, and nursing staff kept the call light in reach and encouraged Resident #62 to call for assistance when needed. Observation on 1-29-2024 at 1:20 PM reflected Resident #62 lying in bed. She was appropriately dressed, well groomed, and made appropriate eye contact. She stated she did not have any issues or concerns with the medical care she received. She was able to get up and move throughout the facility with a walker for assistance. Observation on 1-29-2024 at 3:17 PM reflected Resident #62's call switch located in Resident #62's bathroom. The call switch, which was a device to alert staff for assistance, was located on the wall next to the commode. The device consisted of a metal junction box, which contained a vertical switch. The vertical switch had a string attached to it, which hung in the direction to the floor. Instead of the string hanging free in the direction of the floor, the string extended in a 45-degree angle towards the commode and was wedged in a crevasse between the toilet paper dispenser and the wall. The string did not hang freely to the floor as intended; therefore, the cord was not located in the intended position. Observation on 1-30-2024 at 8:20 AM reflected Resident #62's call switch located in Resident #62's bathroom. The call switch, which was a device to alert staff for assistance, was located on the wall next to the commode. The device consisted of a metal junction box, which contained a vertical switch. The vertical switch had a string attached to it, which hung in the direction to the floor. Instead of the string hanging free in the direction of the floor, the string extended in a 45-degree angle towards the commode and was wedged in a crevasse between the toilet paper dispenser and the wall. The string did not hang freely to the floor as intended; therefore, the cord was not located in the intended position. Based on calculations from a measurement tool on a state issued iPhone 13, the actual position of the call light pull string was thirteen horizontal inches away and 2 vertical inches higher than the intended position if the cord hung freely towards the direction of the floor. Interview and observation on 1-30-2024 at 1:34 PM reflected Resident #62's call switch located in Resident #62's bathroom. The call switch, which was a device to alert staff for assistance, was located on the wall next to the commode. The device consisted of a metal junction box, which contained a vertical switch. The vertical switch had a string attached to it, which hung in the direction to the floor. Instead of the string hanging free in the direction of the floor, the string extended in a 45-degree angle towards the commode and was wedged in a crevasse between the toilet paper dispenser and the wall. The string did not hang freely to the floor as intended; therefore, the cord was not located in the intended position. Resident #62 was intrigued when she heard that the call light string in her bathroom was not hanging to the floor like it was intended. She stated if she fell on the floor in the bathroom and could not call for help, she would be mad. For safety measures, the cord was removed and hung as intended. Interview on 01-31-2024 at 12:31 PM with the Maintenance Director revealed the purpose for the call light pull string in the residents' bathrooms was so residents had the ability to call staff if they needed help. He stated the string was supposed to be hanging straight to the floor, not wrapped around the horizontal support bar, or draped around the toilet paper dispenser. The string was supposed to fall freely in the direction of the floor. The Maintenance Director stated a resident that could not reach a call light pull string from the floor might waited an expended period for help and felt abandoned. Interview on 1-31-2024 at 12:49 PM with MA H revealed call light pull strings in the bathroom were used for instances when residents needed help, whether they were in the shower, on the toilet, or if they had fallen. The strings were supposed to hang straight from the junction box to the direction of the floor; and were not supposed to be wrapped around the horizontal stability bar or tucked behind the toilet paper dispenser. At times, she stated she had noticed the call light pull string wrapped around the horizontal bar und unwrapped it, so it hung straight down in the direction of the floor. If the call light pull string was not in its correct position, or caught behind the toilet paper dispenser, a resident could have had trouble reaching it and calling for help if they were lying on the floor. She stated some risks for a resident's inability to reach the call light pull string could have resulted in an extended time to receive help, possible prolonged periods of pain, agitation, and having felt abandoned. The management team, such as the DON the ADM, performed room rounds on a regular basis to check for inconsistences, such as call lights and emergency call lights, but everyone who entered the room was responsible to make sure the room's call button systems were available to the resident and operated correctly. Interview on 1-31-2024 at 1:14 PM with CNA E revealed the call light pull strings located in the residents' restrooms were supposed to hang from the junction box in the direction of the floor. The strings were not supposed to be wrapped around the horizontal support bar or tucked behind the toilet paper dispenser. If a resident was not able to reach the call light pull string from the floor, the resident was placed at risk for longer response times, exposed to elongated periods of pain, sadness, or anger. Interview on 1-31-2024 at 01:42 PM with the DON revealed an unawareness of her staff's responsibility for the correct placement of the residents' bathroom call light pull strings. She stated that the call light pull strings, regardless if they were wrapped around the horizontal stability bar or tucked behind the toilet paper dispenser, were easily accessible to the residents when they needed help. The DON mimicked the body movements of a resident pulling the call light pull string as if they were on the toilet from the seated position; however, she did not express awareness that the call light pull strings were supposed to be accessible to the residents if they were lying on the floor. After the DON processed the idea of a resident needing help from lying on the floor, she stated the string's not reaching the floor was a risk for a resident; a resident risked a lengthy response time or prolonged exposure to pain. The DON stated there was a system in place, called room rounds, where members of management staff looked at specific rooms each day to check for abnormalities. Interview and record review on 1-31-2024 at 3:24 PM with the Administrator revealed she expected her to staff to ensure the residents' call light pull strings in the bathroom extended to the floor and were not wrapped around the horizontal stability bar or tucked behind the toilet paper dispenser. When a call light pull string was not placed correctly, the residents were placed at risk of extended times for help, prolonged periods of pain, or panic. The Administer stated there was a system in place, called room rounds, which was designed to recognize and correct concerns with the call light system. She stated the failure for the correct placement of the call light pull strings was the staff failing to accurately check. The Administrator provided a two copies of a completed Manager Room Rounds Checklist , both dated 1-26-2024. One was filled out by the SW and the space provided on the check list under the heading [CALL LIGHT IN REACH AND WORKING] was marked with a [Y,] which indicated [yes,] the call light in Resident #12's room was in reach and working. The second was filled out by LVN L and the space provided on the check list under the heading [CALL LIGHT IN REACH AND WORKING] was marked with a [Y,] which indicated [yes,] the call lights in Resident #7 and Resident #62's rooms were in reach and working. Record review of 2 Manager Room Rounds Checklists, both dated 1-26-2024, indicated the call lights in Residents #7, #12, and Resident #62's rooms were in reach and working. Record review of the facility's [Physical Environment and Resident Call System Policy,] dated 11-28-2017, indicated the policy's objective was to protect the health and safety of residents, personnel, and the public. The facility was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from the resident's bedside.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for food and nutrition services. 1. The facility failed to ensure all foods were stored off the ground. 2. The facility failed to ensure all foods were dated with an opened date and discarded prior to their best-if-used-by date. 3. The facility failed to ensure the Dietary Manager wore a hair restraint which properly covered her hair. 4. The facility failed to ensure DW I washed dishes using sanitizer water at a PPM of 50 or greater. These failures placed residents at risk for foodborne illness. Findings included: An observation on 1/29/2024 at 9:40 a.m. revealed DW I was washing dishes using the dish machine and the dish log had no values recorded for sanitizer concentration for the breakfast dishes on 1/29/2024. During an interview and observation on 1/29/2024 at 9:45 a.m., DA J was observed measuring the chemical concentration of the dishwater in the dish machine. DA J was observed comparing the test strip to the visual guide, which indicated the color of the strip matched a concentration 25-50 ppm. DA J and DW I stated, it's good and DA J stated the concentration just needed to be less than 50 ppm. Observed DW I continue to wash dishes. Observations of the kitchen's walk-in refrigerator on 1/29/2024 from 9:47 a.m.-9:55 a.m. revealed the following: At 9:47 a.m., the walk-in refrigerator had two containers of cottage cheese, one opened and one sealed, dated 1/21/2024 with best-if-used by dates of 1/26/2024. At 9:49 a.m., the walk-in refrigerator contained a yellow beverage dated 1/28/2024, a red beverage labeled 1/28/2024, and an orange beverage dated 1/28/2024-none were labeled with what the contents were. At 9:52 a.m., the walk-in refrigerator contained an opened container of golden Italian dressing with a received date of 1/08/2024 but no opened date. At 9:54 a.m., the walk-in refrigerator contained an opened container of cottage cheese dated 12/23/2023 with a best-if-used by date of 1/06/2024. At 9:55 a.m., the walk-in refrigerator contained three boxes of bananas sitting on the floor. During an interview on 1/29/2024 at 9:56 a.m., CK K stated all item, such as condiments, should have an opened date. CK K stated the bananas being on the floor was no good and said they were placed there because of lack of space in the walk-in refrigerator. CK K stated there were too many people working and sometimes they did not remember to put a date on things. During an observation and interview on 1/29/2024 at 11:04 a.m., the Dietary Manager was observed walking through the kitchen wearing a baseball cap which exposed approximately 2-3 inches of hair in the back. The Dietary Manager stated all items should be dated with an opened date, the bananas should not have been on the floor, and yes the facility adhered to best-if-used-by dates. The In regard to the bananas on the floor, the Dietary Manager stated, maybe one of the girls moved them and did not put them back on the shelf. The Dietary Manager stated the bananas should not have been on the floor. The Dietary Manager stated DW I was trained on using the dish machine, checking the temperature, and checking the concentration through demonstrative training. The Dietary Supervisor stated a concentration of between 25-50 ppm was not okay, and that it needed to be between 50-100 ppm. The Dietary Manager then stated the sanitizer was an extra step and that because the dish machine heated the water up to 120° F, the heat killed germs. An observation on 1/29/2024 at 11:19 a.m. revealed the Dietary Manager removed the out-of-date cottage cheese containers from the walk-in, discarded them, and said, these are brand new and they didn't even get to use them. During an interview on 1/29/2024 at 11:20 a.m., the RDN stated she started monitoring the facility in September of 2023. The RDN stated bananas should not be stored on the floor. Food should be stored six inches from the floor. The RDN stated, usually, staff stored the bananas in the dry storage room, so she thought it was strange that they were in the walk-in refrigerator. The RDN stated if it was not evident what an item is, it should be labeled with what it was. The RDN stated yeah that staff should discard items prior to its best-if-used-by date. The RDN said items should be dated with the date they are opened. The RDN stated everyone who goes in the kitchen should wear a hair net, a few inches of hair in the back was debatable, and in general, the policy said hair should be covered. The RDN stated the dish machine was a low temperature dish machine which needed sanitizer in a concentration of 50 ppm. The RDN stated the Dietary Manager monitored the kitchen daily, trained staff, and conducted orientation. The RDN stated she monitored the kitchen monthly by conducting audits and if she saw something that was a trend, she would have the Dietary Manager in-service staff. The RDN stated the Dietary Manager demonstrated to staff how to use the dish machine and maybe it was a translation issue with DW I when the Dietary Manager had trained her. The RDN stated if food storage and sanitization policies were not followed, there could be contamination in the food which could lead to foodborne illness. During an interview on 1/30/2024 at 12:13 p.m., the RDN stated the Dietary Manager started in October of 2023 and had not done any in-services with staff. The RDN stated she had not done any in-services with staff either. The RDN stated, usually [the Dietary Manager] does it. During an interview on 1/31/2024 at 12:37 p.m., the Dietary Manager stated on Monday 1/29/2024, she did not have a hair net on, usually she kept her hair short, this year it was long, and she did not have it on when she first came in the kitchen. During an interview on 1/31/2024 at 3:23 p.m., the Administrator stated food needed to be off the floor, labeled, dated, and the sanitizer needed to be the right concentration for the dishwasher. The Administrator stated staff did annual food safety training and the Dietary Manager did in-services with them. The Administrator stated food should be dated with the date it was taken out of the package and yeah all hair should be covered. The Administrator stated the RDN did training with the Dietary Manager and she checks everything. The Administrator stated the Dietary Manager monitored the kitchen weekly through inventory and making sure everything was labeled and dated. The Administrator stated having food items on the floor was a sanitation issue and someone could get sick with outdated food. A record review of the kitchen's in-services from November 2022-January 2023 reflected no in-service educations had been conducted with staff. A record review of the facility's policy titled Food Storage dated 2013 reflected the following: Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Foods is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 3. Food items will be stored on shelves, with heavier and bulker items stored on lower shelves. 8. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of foods. a. Old stock is always used first (first in - first out method). d. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high risk food (see chart on next page). 11. Food is stored a minimum of 6 inches above the floor, 18 inches from the ceiling and 2 inches from the wall on clean racks or other clean surfaces, and is protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.). 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. (Also see policy on Use of Leftovers in this section.) Check state regulations for more detail. 14. Refrigerated Food Storage: f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. h. Refrigerated foods should be stored upon delivery and careful rotation procedures should be followed. i. All foods will be stored off the floor. A record review of the facility's policy titled Food Safety and Sanitation dated 2013 reflected the following: Policy: All local, state and federal standards and regulation are followed in order to assure a safe and sanitary food service department. Procedure: 2. Employees c. All staff are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes and shoes. Hair restraints are required and should cover all hair on the head. A record review of the facility's policy titled Food Safety - Food Service Manager's Responsibility dated 2013 reflected the following: Policy: The food service manager is responsible for providing safe foods to all individuals. Procedure: The food service manager assures all of the following: 1. Good sanitary food handling practices. 2. Sanitary conditions are maintained in the storage, preparation and serving areas. 3. Dishwashing guidelines and techniques are understood by staff and carried out in compliance with the state and local health codes. 5. All refrigerated and frozen foods are stored and handled properly. All dry and staple food items are stored properly. 6. Personnel follow sanitary practices and good personal hygiene at all times. 9. Regular inspections are made by the food service manager or designee to assure food safety. A record review of the facility's policy titled Cleaning Dishes/Dish Machine dated 2013 reflected the following: Policy: All flatware, serving dishes, and cookware will be washed, rinsed, and sanitized after each use. Dish machines will be checked prior to meals to assure proper functioning and appropriate temperature for cleaning and sanitation. Procedure: 1. Prior to use, run the machine until verification of proper temperatures and machine function is made. Verify that soap and rinse dispensers are filled and have enough cleaning product for the shift. Note: Staff should check the dish machine gauges throughout the cycle to assure proper temperatures for sanitation. Thermal strips may be used as verification that the temperature is adequately hot, but cannot verify actual temperatures. Those machines installed after the Food Code 2001 was implemented must automatically dispense detergents and sanitizers, and must incorporate visual means or other visual audible alarm to alert the user to any concerns (such as the soap or sanitizer not dispensing properly). The facility's policy titled Cleaning Dishes/Dish Machine dated 2013 reflected a low temperature dishwasher needed to be at 120° F with a sanitization of 50 ppm. A record review of the facility's policy titled Dish Machine Temperature Log dated 2013 reflected the following: Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: 1. The food service manager will provide the dishwashing staff with a log to be posted near the dish machine. (See sample form next page.) 2. The food service manager will train dishwashing staff to monitor dish machine temperatures throughout the dishwashing process. 4. Dishwashing staff will be trained to report any problem with the dish machine to the food service manager as soon as they occur. A record review of the FDA's 2017 Food Code reflected the following: 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety.

Based on interview and record review, the facility failed to designate an RN to serve as DON on a full-time basis in that: The facility had no full time DON from 04/14/23 through present [05/05/23]. This failure could place all residents at risk for not receiving necessary care and services. Findings included: An interview on 05/05/23 at 11:45 AM with the ADON revealed she was an LVN. She stated there was no DON at the facility since 04/14/23. The ADON stated RCRN typically came to the facility at least once a week and accomplished DON related tasks. She said RCRN was also available for consultation over the phone anytime. The ADON said currently in the absence of a DON at the facility she consults RCRN when any nursing management issues occurred. Interview on 05/05/23 at 12:10PM with the RCRN who was present at the facility during the investigation revealed the facility had not employed a DON since 04/14/23. She stated they had been trying to hire someone for the DON position but had not been successful at this time. RCRN said since there was no full time DON at the facility, she was covering the facility as much as possible. She stated as she had three other facilities to supervise, she was unable to be on site all the time however made a point to visit this facility at least once a week. RCRN said the days when she was not onsite, she was available over the phone anytime of the day. During an interview on 05/05/23 at 12:45PM the Administrator (ADM) stated the facility did not employ a DON since the last DON left the facility's employment on 04/14/23. She said the facility hired another candidate on 04/03/23 however did last only till 04/12/23 and the facility was trying to recruit a DON ever since. The ADM stated few interviews were scheduled starting from 05/05/2023. When the investigator asked how the facility was managing without a DON, the ADM stated there are two or more experienced full time RNs who work as charge nurses and were capable of addressing most of the nursing management decision making. She said the facility already had RCRN as back up at any point of time, also could get the help of MDS nurse if necessary. When the investigator asked if the absence of a full time DON posed any risk to the residents, the ADM stated she did not feel that way as RNs or RCRN were available to the staff all the time, on site or on call for accomplishing the duties of the DON until a new full time DON was recruited. During an interview on 05/05/23 at 1:45pm RN A stated she was working at the facility for more than three years and this was the first time there was no DON at the facility. When the investigator asked who she would consult for DON related issues in the absence of a full time DON, she stated the ADM was there always for help. RN A said the RCRN also was available anytime either on site or on call. Record review on 05/05/23 of EDON's personnel file reflected that she was hired on 05/02/22 and her last day of work at the facility as DON was on 04/14/23. Record review on 05/05 23 of the facility policy Director of Nurses revised in August 2006 reflected: The Nursing Services department is under the direct supervision of a Registered Nurse. 1.The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing. 2.The Director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: a. Developing and periodically updating the nursing service objectives and statements of philosophy. b. Developing standards of nursing practice. c. Developing and maintaining nursing policy and procedure manuals. d. Developing and maintaining written job descriptions for each level of nursing personnel. e. Scheduling of daily rounds to visit residents. f. developing methods for coordination of nursing services with other resident services. g. Recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care needs of each resident. h. Developing staff training programs for nursing service personnel. I. Participating in the planning and budgeting for Nursing Services. j. Ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the resident's response to his or her care. k. Assessing the nursing requirements for each resident admitted and assisting the Attending Physician in planning for the resident's care. l. Participating in the development and implementation of the resident assessment (MDS) and comprehensive care plan. m. Establishing resident selection criteria for determining which residents may be fed by paid feeding assistants; and n. Assuring that nursing care personnel are administering care and services in accordance with the resident's assessment and care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 (Resident #45) of 24 residents reviewed for advance directives, in that: The facility did not obtain a signed Out-of-Hospital Do Not Resuscitate (OOHDNR) for Resident #45 as ordered by the physician. This deficient practice could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings were: Record review of Resident #45's face sheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia with Behavioral Disturbance, Alzheimer's Disease, and Cognitive Communication Deficit. Record review of Resident #45's Quarterly MDS, dated [DATE], revealed the resident was rarely/never understood and a staff assessment for mental status was completed which indicated the resident had short-term and long-term memory problems. Record review of Resident #45's Care Plan, revised [DATE], revealed a problem, [Resident #45] is DO NOT RESUSCITATE (sic). Is under Hospice care, a goal, Respect wishes of Resident & Family; do not initiate resuscitation, and approaches including, Send copy of OOHDNR during ambulance transport, and Show copy of OOHDNR to Emergency Medical Personnel treating Resident inside facility. Record review of Resident #45's Physician Order Report, dated [DATE] to [DATE], revealed, an order dated [DATE], DNR code status. Record review of Resident #45's OOH-DNR, dated [DATE], revealed the notary's signature was missing from the last section of the document. During an interview with the Social Worker on [DATE] at 2:48 p.m., the Social Worker affirmed she had notarized Resident #45's OOH-DNR, and that she had failed to sign the last section of the document. The Social Worker reported she was responsible for ensuring the accuracy of residents' advance directives and stated the missing signature was an oversight. Record review of the Texas Health and Safety Code Title 2 Health, Subtitle H Public Health Provisions, Chapter 166 Advance Directives, Section 166.083 Form of Out-Of-Hospital DNR order, effective [DATE], revealed, (a) A written out-of-hospital DNR order shall be in the standard form specified by department rule as recommended by the department. (b) The standard form of an out-of-hospital DNR order specified by department rule must, at a minimum, contain the following: . (13) a statement at the bottom of the document, with places for the signature of each person executing the document, that the document has been properly completed. Record review of the Texas Health and Human Services webpage titled, Out of Hospital Do Not Resuscitate Program, updated [DATE], revealed, Frequently Asked Questions for DNR: What happens if the form is not filled out correctly or EMS has doubts about any of the information? Health professionals can refuse to honor a DNR if they think: The form is not signed twice by all who need to sign it or is filled out incorrectly. Record review of the facility's policy titled, Advance Directives, revised 12/2016, revealed, Advance directives will be respected in accordance with state law and facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to make prompt efforts to resolve grievances the resident may have for 1 of 8 Residents (Resident #19) whose records were reviewed for grievances. The facility Social Worker (SW) failed to write and follow up on Resident #19's grievance when she reported 10 items of clothing were missing. This deficient practice could affect residents and place them at risk of their own concerns being left unresolved and lead to misappropriations of resident property. The findings were: Record review of Resident #19's face sheet, computer dated 10/26/2022 revealed Resident #19's was admitted to the facility on [DATE] with diagnoses to include Radiculopathy lumbar region(Lumbar radiculopathy is irritation or inflammation of a nerve root in the low back.), Spinal Stenosis(happens when the space inside the backbone is too small.), other vertebral disc degeneration(A condition where one or more discs in the spine deteriorates due to age, which results in back or neck pain.) Record review of Resident#19's quarterly MDS(The Minimum Data Set (MDS) is a standardized assessment tool that measures health status in nursing home residents.), dated 8/10/2022, revealed her BIMS (Brief interview for Mental Status) score was a 12 indicating moderately impaired cognition. Record review of Resident grievances from 5/1/2022 to 10/23/2022 did not reveal any grievances documented for Resident #19. During an interview on 10/23/2022 at 11:06 a.m. Resident #19 revealed she had reported to the SW that she had missing clothing since she had been at this facility which has been about 6 months. She further revealed she had 10 clothing items which she had provided a copy of drawn pictures to the SW. She said she had told the laundry person who delivers her clothing that she was missing items and had provided a drawn picture to the laundry. She stated there had been no clothing articles found and returned to her as of 10/23/2022. Resident #19 said this was very upsetting to her to not have her clothing returned to her and she became teary eyed during the interview. She stated that all her clothing was marked with her name on them, and she always placed them in a bag with her name on them when she sent them to the laundry. She further revealed that she will be leaving the facility in 4 days and does not feel she will have any clothing articles returned to her before she leaves. During an interview on 10/24/2022 at 12:06 p.m. the facility Social Worker (SW) stated that she could not find any lost clothing for Resident #19. Facility SW stated the facility would replace missing articles of clothing and she had been looking for them in the laundry. She further revealed she was responsible for ensuring grievance forms were completed and that staff followed up on resident concerns. The SW did not produce a grievance form for Resident #19's complaint of clothing missing until after surveyor intervention. The SW stated that if she could not find Resident #19's clothing, that the facility would replace them. She stated she had not written a grievance report, and stated, I have been very busy and just hadn't written one. The SW confirmed telling Resident #19 that the facility would replace items of clothing or provide payment for the value of them, if they were not found. During an observation and interview on 10/24/2022 at 12:30 p.m. the facility Activity Director escorted surveyor to the laundry. Observation of a clothing rack with unmarked clothing belonging to residents was noted. A laundry personnel, through language interpretation revealed this was lost and found area. She further revealed she knew that Resident #19 had articles of clothing missing and showed surveyor a copy of the articles that were drawn by Resident#19. She stated she had not found any articles of clothing that Resident #19 was missing as of the day of interview. During an interview on 10/24/2022 at 3:30 p.m. the facility Administrator revealed she had heard Resident #19 was missing clothing. The Administrator stated the SW and laundry were aware and were looking for the missing clothing. She further revealed that the facility would replace items of clothing or provide payment for the value of them, if they were not found. Record review of facility policy,dated 2001 and revised April 2017, titled: Grievances/Complaints Filing, policy statement: Residents and their representatives have the right to grievances , either orally or in writing, to the facility staff or to the agency designated to hear grievances( eg, state ombudsman).

Based on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 4 hallways (Hall 400), in that: The Beauty Shop on Hall 400 contained hazardous materials and was open and unlocked. This failure could result in residents becoming ill or injured as a result of exposure to a hazardous resident environment. The findings were: Observation on 10/23/2022 at 2:32 p.m. revealed the Beauty Shop on Hall 400 was unlocked and the door was ajar. Further observation revealed the Beauty Shop contained a container of cleaning liquid which was labeled, Hazardous Material, Harmful if Swallowed, and Keep Out of Reach of Children. Further observation revealed the Beauty Shop contained two aerosol containers labeled, Danger and Keep Out of Reach of Children. During an interview with RN A on 10/23/2022 at 2:34 p.m., RN A affirmed the Beauty Shop on Hall 400 was unlocked, the door was ajar, and the shop contained a container of cleaning liquid which was labeled, Hazardous Material, Harmful if Swallowed, and Keep Out of Reach of Children, as well as two aerosol containers labeled, Danger and Keep Out of Reach of Children. RN A also affirmed that the secure memory care unit was next to the Beauty Shop on Hall 400. During an interview with RN A and the AD on 10/23/2022 at 2:34 p.m., RN A and the AD affirmed residents who wander could encounter the hazardous materials in the unsecured Beauty Shop and become ill or injured. RN A and the AD affirmed the shop was usually locked and stated it may have been accidently left open earlier in the day when donations were delivered to the facility. During an interview with RN A on 10/23/2022 at 2:42 p.m., RN A affirmed that some residents of the secure memory care unit on Hall 400 were independently ambulatory and that all had severe cognitive deficit. During an interview with the AD on 10/25/2022 at 3:36 p.m., the AD reported residents from the secure memory care unit leave secure unit and walk past Beauty Shop to attend group activities. Record review of the facility policy, Hazardous Areas, Devices, and Equipment, revised July 2017, revealed, All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.

Based on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 6 Residents (Resident #76) whose records were reviewed for pharmacy services. Nursing staff failed to store Resident 76's blister pack of Midodrine ( used to treat low blood pressure) in the nurse's medication cart. This deficient practice could affect any resident receiving medications and could result in drug diversion or residents not receiving their medications per physician orders. The findings were: Review of Resident #76's face sheet, undated, revealed she was admitted into the facility on 4/1/20 with diagnoses including Hypertension and End Stage Renal Disease. Review of Resident #76''s physician orders dated October 2022 revealed a prescription for Midodrine, 10 mg, 1 oral NURSES PLEASE SEND WITH RESIDENT EVERY DIALYSIS DAYS FOR DIALYSIS NURSE TO GIVE IT. Once a Day on Tuesday, Thursday, Saturday, FYI night nurse. The start date was 4/20/22 and the order was open ended. Observation and interview on 10/24/22 at 1:30 PM revealed a blister pack of Midodrine prescribed to Resident #76's in her Dialysis binder at the nurse's station. It was not locked. Further observation revealed 7 tablets remaining in the blister pack. Interview with the DON revealed the blister pack containing 7 tablets of Midodrine was inside the Dialysis binder. The DON stated the nurse who last pulled the blister pack for Resident #76's Dialysis treatment date (10/22/22) did not put it back in the medication cart. The DON stated all medications should be under lock and key to prevent drug diversion or other residents taking the medication by mistake. Review of a facility policy, Storage of Medications revised April 2007 read in part: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a clean, comfortable and homelike environment for daily living for 11 of 11 resident rooms ( Residents #8,11,68,48,65,19,47,41,56,78,1 ) reviewed for environmental conditions and for 12 of 12 Residents (Residents #8,11,68,48,65,19,47,41,56,78,1 and #50 ) reviewed for personal equipment in that : 1. The facility failed to maintain fans from being covered in gray fuzzy matter in residents rooms (Residents #8,11,68,48,65,19,47,41,56,78,1 and #50) 2. The facility failed to maintain air conditioning and heating vents in rooms above resident beds from having gray fuzzy matter on them (Residents #8,11,68,48,65,19,47,41,56,78,1 and #50). 3. Nursing staff failed to clean Resident #50's wheelchair as evidenced with dried food residue on the right armrest, on the frame of the wheelchair and on the spokes of the right wheel. 4. The facility failed to provide Resident #4 with a clock in his room in a timely manner when he had requested one for 20 days. These failures could affect residents who reside at the facility and could place them at risk of living in an unsafe, unclean, uncomfortable, and un-homelike environment. Findings include: 1. Observation on 10/23/2022 on initial rounds beginning at 10:37 a.m. of facility revealed in Residents rooms (residents #8,11,68,48,65,19,47,41,56,78,1 and #50 )there were fans with gray fuzzy matter covering the front and back of each fan. During an interview on 10/23/2022 at 11:48 a.m. Housekeeping aide stated she did not know who cleaned the residents fans. She stated she cleaned the floors and bathrooms in the residents rooms. During an interview on 10/23/2022 at 2:00 p.m. the DON, she stated I believe housekeeping cleans the fans in the residents rooms, but not sure because housekeeping duties here are not your typical duties performed. She further revealed that maintenance may also be responsible for cleaning the fans. During an interview on 10/24/2022 at 11:30 a.m. the Housekeeping Director stated she was not sure who cleaned the fans in the residents rooms. During an interview on 10/24/2022 at 1:45 p.m. with CNA F stated , I think housekeeping cleans the residents fans in their rooms. 2. During an observation on 10/26/2022 beginning at 9:30 a.m. of resident rooms 201 a, 202 a,204 a,206 a,309b,501 a,b,506 a,b, 514b,515 a. the vents above residents beds had gray fuzzy matter on them. During an interview on 10/26/2022 at 10:25 a.m. the maintenance director stated he cleaned the vents in the residents rooms monthly if he could . He stated there was no set time or log to identify when they were to get cleaned. He stated I just clean them, I will clean them right now. During an interview on 10/26/2022 at 10:30 a.m. with the Administrator she stated maintenance should clean the vents above the residents beds. She further revealed the vents should be cleaned to protect the residents from potential respiratory illness. 3. Observation and interview on 10/26/22 at 02:00 PM revealed Resident 50's wheelchair looked like there was dried up food spillage on the right side. The right armrest, the frame of the wheelchair and the spokes of the right wheel had dried up residue. Attempted interview with Resident #50 revealed she did not engage in conversation and did not make eye contact when asking her questions. Interview on 10/26/22 at 02:05 PM with CNA F revealed she started working during January 2022. She stated the armrest and the frame of Resident #50's wheelchair was dirty. CNA F stated she thought the night staff cleaned the wheelchairs but was not sure if it was the aides or maintenance staff. CNA F revealed she had not noticed the spillage on Resident #50's wheelchair but stated it looked like dried food residue. CNA F stated she had not reported it to the charge nurse because she had not noticed it. She stated she had so many residents to get up in the morning and to provide ADL care for during the day she had not noticed. Interview on 10/26/22 at 02:15 PM with LVN D revealed she looked at Resident #50's wheelchair and stated it was not clean. She stated anyone in their right mind, her included, would not be comfortable sitting in a dirty wheelchair. LVN D stated the night CNA's were supposed to clean the wheelchairs as needed. Interview on 10/26/22 at 4:00 PM with the ADON revealed the night aides were responsible for cleaning the resident wheelchairs. The ADON stated they did not maintain a log of when the wheelchairs were cleaned. 4. Record review of Resident #41's face sheet, computer dated 10/26/2022, revealed he was admitted to the facility on admit 1/29/2018 with diagnosis which included age related debility(mobility decline), abnormalities of gate(walking),unspecified dementia(A group of symptoms that affects memory, thinking and interfere with daily life.) Record review of Resident #41's quarterly MDS, dated [DATE] revealed his BIMS (Brief interview for Mental Status) score was an 11 indicating moderately impaired cognition. Record review of facility maintenance record logbook with dates from 6/1/2022 to 10/23/2022 revealed an entry on 10/7/2022 for Resident #41 requesting a wall clock for his room. Entry was not checked with initials to indicate request was completed. Observation on 10/26/2022 at 9:30 a.m. revealed Resident #41 was in his room. No clock was observed in his room. Interview on 10/26/2022 at 11:30 a.m. with Resident #41 stated he wanted a wall clock and asked for one but had not received one. He stated he could not remember when he had asked for the clock. He further stated it would help him know what time it was. Interview on 10/26/2022 at 3:30 p.m. with facility Maintenance Director and Administrator confirmed by viewing the maintenance record logbook with an entry date of 10/7/2022, Resident #41 wanting a wall clock. Maintenance Director and Administrator confirmed by viewing the log that Resident #41 had not received a wall clock as of 10/26/2022. The Maintenance Director stated that Maintenance book should be checked every day and requests resolved within 24 hrs -48 hrs unless something has to be ordered. The Administrator confirmed during interview that she had not checked the maintenance logbook for accuracy. Record review of facility policy titled; Infection Control undated , Purpose: This facility has established the Infection Control Policies and Procedures with guidelines to follow to provide a safe, sanitary and comfortable environment for the residents and employees as well. It is also designed to help prevent the development and transmission of disease and infection. Objective: 2. Maintain a safe, clean and sanitary, comfortable environment for personnel , residents, visitors, and the general public. Record review of facility policy titled: Housekeeping services, dated 2012, Purpose: To promote a safe and sanitary environment which is maintained by a contracted service, by employees of the facility, or a combination of both.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care, are provided such care, consistent with professional standards of practice for 4 of 8 Residents (Resident #11, 68, 47,and 73) reviewed for respiratory care in that: 1. Resident #11 and #68's oxygen concentrator bottle's and n/c did not have a date on it that reflected the facility's changing schedule. 2. Resident #47 had a suction machine at his bedside that was not covered or dated to reflect the facility's changing schedule. 3. Resident #73 was receiving 2 liters of oxygen instead of 4 liters via n/c continuously per physician orders; the oxygen concentrator filter had a layer of lint on it and there was a nebulizer machine on the nightstand that was not secured in a plastic bag when not being used. These deficient practices could affect residents dependent on respiratory care and could contribute to upper respiratory infections and worsening of their physical condition. The findings were: 1. Record review of Resident #11's face sheet, computer dated 10/26/2022, revealed Resident #11 had an initial admission date to the facility on 7/29/2021 with diagnoses to include dysphagia(A condition with difficulty in swallowing food or liquid. This may interfere in a person ' s ability to eat and drink.), adult failure to thrive(Indicates insufficient weight gain), Gerd(Gastro-esophageal reflux disease-A chronic digestive disease where the liquid content of the stomach refluxes into the esophagus, the tube connecting the mouth and stomach.), copd(chronic obstructive pulmonary disease-It is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.). Record review of Resident #11's Quarterly MDS dated [DATE], revealed Resident #11's BIMS score was 11 indicating moderately impaired cognition. Record review of Resident #11's care plan dated 11/5/2021 and update 8/2/2022: Problem: Respiratory , start 11/5/2021: Resident has diagnosis of copd has potential for respiratory distress and complications due to diagnosis Goal : Resident will not exhibit signs of activity intolerance. Approach: Provide 02(oxygen) as ordered/needed. Observation and interview on 10/23/2022 at 10:37 a.m. revealed Resident #11 had a nasal cannula's with oxygen at 2 lpm on her. Resident #11's oxygen concentrator water bottle and nasal cannula's had a date written on it of 10/13/2022. Resident #11 stated she was on oxygen all the time. She stated she uses a portable oxygen tank when up in her wheelchair and then a concentrator when she is in bed. She further revealed staff place the nasal cannula's on her nose for her and change the bottle on the concentrator. She stated she did not know how often the staff changed the bottle or the nasal cannula's. During an interview on 10/23/2022 at 11:00 a.m. LVN D confirmed Resident #11's disposable oxygen bottle and nasal 11's oxygen concentrator water bottle and nasal cannula's had a date written on it of 10/13/2022, indicating when it had been opened or placed. LVN D stated the oxygen bottles and nasal cannulas should have a date written on them to indicate when they are opened or changed. LVN D further revealed night shift change the oxygen bottles and nasal cannulas weekly on Thursdays or when they are empty or dirty, and the date is to be written on the bottles and nasal cannulas. LVN D further revealed this is to prevent infection or bacteria build up. She further revealed there is documentation method in the residents medical records for the nurse to indicate that the cannula or bottle has been changed. During an interview on 10/23/2022 at 2:15 p.m., the DON stated the oxygen bottles for the concentrators and nasal cannulas are to be dated when opened or changed. She further revealed the night shift changes the bottles weekly on Thursday nights. She stated the oxygen bottles and nasal cannulas should be thrown away every 7 days or when they are empty of water in order to keep bacteria from building up. The staff are also expected to place a date on the oxygen bottles and nasal cannulas when a new one is opened. Record review of Resident #11's physician orders dated 8/24/2021 revealed O2(oxygen) @ 2Liters per minute via nasal cannula as needed to maintain O2 saturations greater than 92%. Record review of Resident #68's face sheet computer dated 10/26/2022, revealed Resident #68 had an initial date of admission to the facility on [DATE] with diagnoses which included afib(Atrial fibrillation (A-fib) is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart.), Hypertension(High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache.),chronic resp failure with hypoxia( Low blood oxygen levels cause hypoxemic respiratory failure.), chronic heart failure( Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping power of your heart muscle.) Record review of Resident #68's Quarterly MDS dated [DATE] , revealed Resident #68's BIMS score was 5 indicating severe cognitive impairment. Observation on 10/23/2022 at 10:15 a.m. revealed Resident #68 was on oxygen. Resident #68's oxygen concentrator water bottle and nasal cannula did not have a date written on it, to indicate when they had been changed. During an interview on 10/23/2022 at 2:15 p.m. , the DON stated the oxygen bottles for the concentrators and nasal cannulas are to be dated when opened. She further revealed the night shift changes the bottles and nasal cannulas weekly on Thursdays. She stated the oxygen bottles and nasal cannulas should be thrown away every 7 days or when they are empty of water in order to keep bacteria from building up. The staff are also expected to place a date on the bottles when a new one is opened. She further revealed the residents suction machines should be covered to prevent dust accumulation. The tubing for the suction machines should be changed every 7 days and dated. 2. Record review of Resident #47's face sheet computer dated 10/26/2022, revealed Resident #47 had an initial date of admission to the facility on 5/27/2022 with diagnoses which included afib,svt, Alzheimer's disease. Generalized anxiety disorder. Record review of Resident #47's Quarterly MDS dated [DATE] revealed Resident #2's BIMS score was 2 indicating severe cognitive impairment. Observation on 10/23/2022 at 11:22 a.m. revealed Resident #47 suction machine at his bedside that was not covered or dated to reflect the facility's changing schedule. the suction tubing was left open to air and lying on the bedside table uncovered. During an interview on 10/23/2022 at 11:25 a.m. CNA I stated she worked on the 300 hall. She stated the nurses cleaned the residents suction machines. During an interview on 10/23/2022 at 2:15 p.m., the DON stated the nurses clean the residents suction machines. She further revealed they should be covered to prevent dust accumulation. 3. Review of Resident #73's face sheet, undated, revealed her latest return to the facility was on 4/24/21 with diagnoses including acute respiratory infection, unspecified and COPD. Review of Resident #73's quarterly MDS, dated [DATE], revealed her BIMS score was 15 indicative no cognitive impairment and she received oxygen therapy. Review of Resident #73's Care Plan updated on 10/1/22 revealed she had diagnoses of COPD and history of respiratory failure with hypoxia. Some of the staff approaches included to administer medications, nebulizer treatments and oxygen per physician orders. Review of physician orders, dated October 2022, read: May have oxygen at 4 liters via nc continuously. Every shift; Day, Evening, Night. Further review revealed change and label nebulizer treatment tubing and mask every week on Thursday and PRN. Change and label oxygen tubing and clean oxygen concentrator filter every week on Thursday and PRN. Observation and interview on 10/23/22 at 01:45 PM revealed Resident #73 lying in bed with O2 infusing at 2.5 liters via n/c. The tubing was hanging to the floor and it was not in a plastic bag. Further observation revealed the oxygen concentrator filter had a layer of lint on it. Resident #73 stated she did not know when the filter was cleaned and that she had never seen staff clean it. During an interview on 10/23/2022 at 2:15 p.m., the DON stated the nurses clean the residents suction machines. She further stated the suction machines should be covered to prevent dust accumulation. Observation and interview with RN L on 10/26/22 at 4:55 PM revealed Resident #73 was lying in bed receiving O2 via n/c at 2 liters. RN L stated Resident #73 was receiving O2 at 2 liters and further stated the oxygen filter was not clean. Further observation revealed a nebulizer machine on top of the nightstand. RN L stated the nebulizer was not secured in a plastic bag to prevent contamination. RN L stated the oxygen filter and the humidifier were cleaned once weekly. RN L stated Resident #73 used the humidifier all the time; she self-administered and this was probably why it was not secured in a plastic bag. Resident #73 stated she used the nebulizer about 3 times a day and that she was supposed to receive 4 liters of oxygen not 2 liters. RN L reviewed Resident #73's physician orders and stated Resident #73 should receive 4 liters of oxygen via n/c continuously per physician orders but would not verbalize how it would affect the Resident. She stated it should be given at 4 liters per physician orders. Interview on 10/26/22 at 5:10 PM with the ADON revealed Resident #73 was receiving 2 liters of oxygen which meant she was receiving less oxygen than she should be receiving per physician orders. The ADON stated the nebulizer machine should be secured in a plastic bag when not in use to keep it from becoming contaminated. She further stated nursing staff should clean the oxygen concentrator filter weekly to allow free oxygen flow. Record review of facility policy dated 2001 revised August 2019, titled: Cleaning and Disinfection of Environmental Surfaces,Policy statement: Envrionmental surfaces will be cleaned and disinfected according to current CDC recommendations. Section b. Semi-critical items consist of items that may come into contact with mucous membranes(eg respiratory equipment).

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 secure memory care common room, in that: 1. The floor under the open refrigerator door was marked with a substance that appeared to be a dried liquid spill. 2. Observation of 3 of 4 Linen Closets revealed the presence of \resident personal clothing and plastic containers overflowing to the floor. 3. The privacy curtains in 2 resident rooms (Residents #56 and #78) had a brown substance on them. 4. There were brown yellow colored stains around the base of toilets in residents rooms 11 of 11 (residents 8, 11, 12, 19, 41, 47, 48, 56, 65, 68, 78) residents' rooms. 5. There was a black substance on tile in 200 hall main shower room. These failures could result in residents, staff, and the public residing, working, and visiting in an environment that was not safe, functional, sanitary, and comfortable. The findings were: 1. Observation on 10/23/2022 at 2:48 p.m. revealed a refrigerator was located in the common room of the secure memory care unit. Further observation revealed the floor under the open refrigerator door was marked with a substance that appeared to be a dried liquid spill, approximately 12 inches by 8 inches and rusty brown in color. During an interview with CNA B on 10/23/2022 at 2:48 p.m., CNA B affirmed the floor under the open refrigerator door was marked with a substance that appeared to be a dried liquid spill. CNA B reported that all staff were responsible for cleaning liquid spills at the time of the spill, and affirmed liquid spills had the potential to be a fall hazard for staff and residents or to encourage insect activity. During an interview with the Administrator on 10/25/2022 at 4:25 p.m., the Administrator affirmed the facility should provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. 2. During an observation on 10/23/2022 at 11:19 a.m. of Linen Closet #1 in hall 300 revealed the presence of bagged clothing , plastic bins overflowing to floor with socks and personal clothing of residents. During an interview and observation on 10/23/2022 at 11:19 a.m. the HR Director stated, the staff knows that the linen closet is for the storage of cleaned linen, and bagged clothing , plastic bins overflowing to floor with socks and personal clothing of residents should not happen. During an interview on 10/24/2022 at 11:30 a.m. the Housekeeping Supervisor confirmed Linen Closet #1 in hall 300 revealed the presence of bagged clothing , plastic bins overflowing to floor with socks and personal clothing of residents. The Housekeeping Supervisor stated, we clean and straighten the linen closets everyday, but nursing staff does not always help us keep it clean and clutter free. 3. During an observation on 10/26/2022 at 9:40 a.m. in resident rooms (Residents #56 and #78), the resident privacy curtains had 2 brown substance's midway down on the curtain, approximately the size of a quarter. During an observation and interview on 10/26/2022 at 10:00 am the facility ADON confirmed by observation that resident rooms (Residents #56 and #78), the resident privacy curtains had brown substance on them. The ADON further revealed maintenance changed the privacy curtains but did not know the schedule. During an interview on 10/26/2022 at 10:30 a.m. with Maintenance Director and Adminsitrator both confirmed that resident privacy curtains should be clean. The Maintenance Director stated he, changed the curtains whenever they were dirty. The Maintenance Director stated the staff would tell him if the curtains were dirty and he would change them. The Maintenance Director further revealed he did not know the two curtains (Residents #56 and #78) were dirty. The Maintenance Director stated he did not have a set schedule or log. The Maintenance Director further revealed it took him about a full month to change all of the privacy curtains in the facility. The Administrator stated, a schedule log, would be started. 4. During observations on 10/26/2022 of residents rooms(residents 8,11,12,19,41,47,48,56,65,68,78), brown yellow colored stains around the bases of toilets in 11 of 11 residents rooms reveiewed for cleanliness. During an interview on 10/26/2022 at 10:30 a.m. with Maintenance Director stated he was aware of the caulk around the residents toilets needing to be changed. He confirmed by observation the brown yellow colored stains around base of toilets in residents rooms was present and needed to be cleaned and repaired. 5. During an interview on 10/26/2022 at 11:15 a.m. with Resident #12 she informed surveyor that there was a black substance on tile in 200 hall main shower room. She stated she received her showers in the shower room and she did not like the way it looked. I am concerned it is mold. She stated she could not remember who she had told about it but she said she did. During an observation on 10/26/2022 at 11:30 a.m. there was a black substance on 6 of the shower tiles located at the base of the shower stall in the 200 hall main shower room. The Facility Treatment Nurse was present at time of observation and confirmed by observation black substance on tile in 200 hall main shower room. The Facility Treatment Nurse stated, I do not know what that is and it does not come off when rubbed. During an interview on 10/26/2022 at 11:45 a.m. with the Maintenance Director, he said he did not know anything about a black substance on tile in 200 hall main shower room. The Maintenance Director stated he would fix it. He further revealed there is a maintence log book at the nrses station for the staff to log in any repairs or concerns. Record review with the Maintenance Director revealed no entry for black substance on tile in 200 hall main shower room. Record review of the facility's Policies and Procedures with guidelines to follow to provide a safe, sanitary and comfortable environment for the residents and the employees as well. It is also designed to help prevent the development and transmission of disease and infection. Record review of facility policy, dated 2012 and titled: Housekeeping Services revealed: Purpose: To promote a safe and sanitary environment which is maintained by a contracted service, by employees of the facility, or a combination of both. Policy: 1. Frictional Cleaning A. Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. III. Routine Cleaning of Horizontal Areas A. In resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. Record review of the facility policy, Quality of Life -Homelike Environment, revised May 2017, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment .