**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS assessment was electronically transmitted to the CMS System within 14 days after completion for 1 of 4 residents (Resident #22) reviewed for encoding/transmitting assessments. The facility failed to transmit a death record assessment for Resident #22 within 14 days of completion. This failure could place residents at risk of not having records completed and submitted in a timely manner as required. Findings include:Record review of a face sheet dated [DATE] indicated Resident #22 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included cirrhosis of the liver (chronic liver damage leading to scarring and liver failure), hepatitis (inflammation of the liver), and hepatomegaly (enlarged liver). Record review of progress notes dated [DATE] indicated Resident #22 expired on the evening of [DATE] while a resident in the facility. Record review of Resident #22's electronic medical record indicated a death in facility tracking record was completed with an A2000 (date of death ) of [DATE]. There was no evidence in the medical record to indicate the record had been electronically transmitted.Record review of a MDS 3.0 NH Final Validation report dated [DATE] indicated the death in facility tracking form assessment was submitted after surveyor intervention. The Validation report included the following information: Warning: Record Submitted Late: The submission date is more than 14 days after A2000 on this new death in facility tracking record.During an interview on [DATE] at 02:10 PM with the MDS Coordinator, she said she was not an employee of the facility at the time of Resident #22's death and was not aware the death in facility tracking form assessment had not been submitted. She said she did not know why it had not been transmitted to the CMS system. The MDS Coordinator said the death in facility tracking record assessment should have been completed and submitted via electronic transmission to the MDS data base within 14 days of Resident #22's death. The MDS Coordinator said it was important to complete and transmit the MDS assessments timely because they affect quality of care measures. She said failure to complete and transmit discharge MDS assessments could result in inaccurate Quality Measures. The MDS Coordinator said the facility used the RAI 3.0 Manual's schedule for completing and transmitting all MDS assessments. During an interview with the Administrator on [DATE] at 02:20 PM, she said she expected the MDS Coordinator to complete and transmit the MDS assessments as scheduled and required by state and federal governing agencies. Record review of the CMS's RAI Version 3.0 Manual dated [DATE], Chapter 5: Submission and Correction of Resident Assessments indicated the following: Tracking Information Transmission: For Death in Facility tracking records, information must be transmitted within 14 days of the date of death (recorded in section A2000 for Death in Facility records).

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation.The facility failed to ensure:- the dish machine was not sanitizing- the ice machine ice chute and air intake vent were not clean- in the reach in cooler chocolate milk pints were out of date - 2 packages of dry pasta were no re-closed after opening- freezer #1 had a package of frozen fried eggs open and not secured closed- the pan rack had 8 pans stacked wet, 1 with food debris present and 1 greasy full size baking sheet- the deep fryer had cornmeal-like debris floating on the surface of the oil, stuck to both fry baskets, and covering the drain tray.- the spice rack had brown sugar and powdered sugar packages opened and not re-sealed.- the 3 compartment sink was not sanitizing and the QA test strips were out of date.These failures could place residents who ate food from the kitchen at risk of foodborne illness. Findings included:During observations, interviews and record reviews on 08/04/2025 of the kitchen the following was noted:At 10:43 AM the DM tested the dishwashing machine and the chlorine test strip did not react indicating it was not sanitizing. The container of sanitizer connected to the machine was empty. She said when she checked the machine earlier around 8:30 AM and it was sanitizing and she logged it on the sanitizer log. The dish machine sanitizing log indicated it tested at breakfast on 08/04/2025 at 50 ppm. The manufacturer's recommendations accepts 50 ppm-200 ppm as adequate for sanitizing. At 10:46 AM the ice chute inside the ice machine was swiped with a clean paper towel and returned with some black and brown debris and discoloration. The air vent above the ice machine door was caked with greasy, black lint-type debris. At 10:47 AM the DM said the ice machine vendor cleaned the machine and was at the facility on Friday, 07/25/2025 and Monday, 07/28/ 2025. She said dietary did not clean the inside of the machine and said the vendor only came every 6 months and maintenance called them to come do the routine cleaning. She said she had only been at the facility for 4.5 months and this was the first time she had seen him. She said dietary wiped down the gasket area and the lid routinely as needed or daily.At 11:00 AM in the 2 door reach in cooler there were 23 pints of chocolate milk dated 08/01/25. The DM removed the out of date chocolate milk pints from the cooler. She said they only had 1 resident that drank chocolate milk.At 11:08 AM in the dry pantry there was 1-16 oz box of lasagna sheets opened and not re-sealed and 1-10 lb. bag of elbow macaroni that was open and not re-sealed. The DM said staff were to close up bags and boxes after opening or place items in zippered bags. At 11:10 AM in freezer #1 in the pantry there was 1 unlabeled, thin plastic bag containing what appeared to be frozen, fried eggs that was opened and the product was visible with nothing covering the product. Freezer frost had fallen from the shelf above the frozen fried eggs into the bag. The DM said 2 residents ate the frozen fried eggs because they could eat them easily with their fingers. She took the bag and tied it in a knot so it was closed and returned it to the freezer.At 11:20 AM the following pans on the pan rack were stacked wet.1-full size 4 deep stainless steel pan1-1/2 size 6 deep stainless steel pan1-1/2 size 8 deep stainless steel pan3-1/4 size 6 deep stainless steel pan-1 had visible white food debris 1-1/4 size square 4 deep stainless steel pan1-1/4 size square 2 deep stainless steel pan 1-full size baking sheet was greasy and had visible solidified grease droplets in the center of the sheet. The baking sheet was greasy to the touch on the cooking surface and the bottom of the tray. At 11:23 AM the deep fryer had cornmeal-like debris floating on the surface of very dark oil, cornmeal-like debris was stuck to both fry baskets, and cornmeal-like debris was covering the drain tray. At 11:25 AM on the spice rack there was 1-1 lb. bag of brown sugar opened and not re-sealed and 2-1 lb. boxes of powdered sugar were opened and placed inside an open zip bag.At 11:40 AM the DM said she knew the dishes and pans were not to be stacked wet. She said she was not sure if the staff knew the pans had to be dry when stacked. She said she would have to ask [NAME] A which she did not do. She said she was responsible for training staff on kitchen procedures and monitoring them to ensure compliance with regulations and policyAt 11:42 AM [NAME] A said the pots, stainless steel pans, and dishes were to be stacked when they had air dried.At 11:48 AM the dish machine was checked again after the DM had connected a fresh container of sanitizing solution and the solution was not pumping into the machine. The DM said maybe the maintenance man could get it fixed.At 11:55 AM the DM said the three compartment sink was not used for sanitizing. She said dishes, pans, pots and other items were washed in the sink and then placed in the dish machine for sanitizing. Quaternary Ammonium (QA) was used for sanitizing/disinfecting in the three-compartment sink and also in the red buckets staff used to wipe down prep surfaces and kitchen areas. A red bucket with clear solution and a kitchen cloth was on the stainless steel surface that held items to be washed leading into the dish machine The DM said she had prepared the bucket around 10:30 AM that morning. The solution was tested with a QA strip and it indicated a zero reading. The dispenser above the three compartment sink that provided a pre-mixed QA solution was added to a clean bucket and tested. It did not react to the QA strip and indicated zero also. The QA test strips being used had an expiration date of February 2025. She said she had extra slips in the dietary office desk. She produced 2 test strip bottles for QA and 4 test strip bottles for chlorine and she said had all expired with various dates back to 2021. She said she was responsible for ensuring there are unexpired supplies in the kitchenAt 12:02 PM the DM said her one bottle of chlorine test strips she had used that morning and had reacted when used. The expiration date was torn off the bottle.At 12:30 PM the dish machine vendor was at the facility and fixed the dish machine sanitizing problem. He said the straw in the sanitizer container had been broken off at the tip and could not pump sanitizer to the machine. The dish machine was tested and it was tested at 50 ppm. He checked the QA solution at the 3 compartment sink and the QA solution container was empty. He replaced the container and the QA solution tested at 400 ppm. He said the dish machine and the 3 compartment sink sanitizing solutions were providing the correct sanitation.During an interview on 08/06/2025 at 9:10 AM the administrator said she had the CDM from another facility come about 2 weeks ago and assist the current DM with cleaning and setting up the dietary department because it was in disarray. She said she had had her come back again on 08/05/2025 after the findings on 08/04/2025. She said the deep fryer was usually cleaned after they had fried fish because it did cause a lot of the batter to fall off into the oil during the frying process. She said usually when the oil was nearing the time to be changed they would fry the fish, drain the old oil and clean the fryer and replenish with fresh oil.Review of undated facility Dietary Policy indicated the following: Cleaning and Sanitizing Equipment and Work Surfaces.sanitize all work surfaces with a double-strength sanitizing solution and with clean cloths used only for this purpose. Food Handling and Preparation.use clean, sanitized equipment and worktables.keep foods covered whenever possible unless in immediate use. Manual Ware Washing.use a 3 compartment sink.sanitize using manufacturer's recommendations for chemical sanitizer.drain and air dry. Sanitation.1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair.6. Ice which is used in connection with food or drink shall be from a sanitary source.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 12 residents reviewed for ADLs (Residents #1.) The facility did not apply moisturizer on the cracked and dry lips of Resident #1. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity, and health. The findings were: Review of Resident #1's Electronic Face Sheet dated 07/24/24 revealed she was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), constipation (passing fewer than three stools a week or having a difficult time passing stool), and hypothyroidism (deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism). Record review of Resident #1's Significant Change MDS dated [DATE] revealed a BIMS with a score of 00, which indicated resident #1 had severely impaired cognition. The MDS also revealed, Resident #1, required total dependance with personal hygiene. Record review of Resident #1's Care Plan dated 05/02/24 revealed Resident #1 had a problem initiated on 5/02/24 for ADLs. Shows that Resident #1 required assistance with her ADLs. During an interview and observation on 7/22/24 at 1:55 p.m., Resident #1 was observed with dry lips, they were cracked with the skin peeling off the bottom lip. Skin was peeling off from the right side of her lip all the way to the left side of her bottom lip. She said that she didn't know if staff put any type of product on her lips to moisturize them. During an interview and observation on 7/22/24 at 3:48 p.m., Resident #1 was observed with dry cracked lips with the skin peeling off. She said that she licked her lips. She said that no one had put any moisturizer on her lips today. She said that staff told her they couldn't find her moisturizer. She said she doesn't know if anyone had ever put moisturizer on her lips. During an interview and observation on 7/23/24 at 8:12 a.m., Resident #1 was observed with dry cracked lips with the skin peeling off. She said no one had put any moisturizer on her lips since the surveyor talked to her last. During an interview on 7/22/24 at 1:40 p.m., CNA E said that they have medicated lip balm to put on the lips of residents that have dry lips. She said that Resident #1 sometimes avoided getting some of her ADLs taken care of. During an interview on 7/23/24 at 9:32 a.m., the DON she said she expected that resident's dependent for care would not have dry cracked lips. She stated that it was the responsibility of the CNAs to ensure residents had a moisturizing product applied to their lips if they were dry and cracked. She said that she had product in her room that was there just for her lips to be moisturized. During an interview on 7/23/24 at 9:39 a.m., the ADM said she expected that resident's dependent for care have their activities of daily living tended to. She said that she expected that if a resident presented with dry lips that the facility staff would assist them by applying some kind of moisturizer. Review of an undated facility policy and procedure on care of Mouth Care - Brushing Teeth/Care of, Oral Care revealed that A resident should be assisted with mouth care as needed. Policy provided by facility did not specifically address application of moisturizer to a resident's lips.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 (Resident's #6 and #38) reviewed for infection control. 1. CNA B did not change her gloves when going from dirty to clean after performing incontinent care. CNA B did not sanitize or wash her hands after performing incontinent care when she applied Resident #6's clean brief. 2. LVN A did not change her gloves when going from dirty to clean when providing indwelling urinary catheter care. LVN A did not sanitize or wash her hands after performing Resident #38's indwelling urinary catheter care when she changed her gloves. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1. Record review of Resident #6's undated face sheet indicated she was a [AGE] year-old female that admitted [DATE] with diagnoses that included: urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine), hemiplegia following cerebral infraction affect right nondominant side (a symptom that causes severe or complete paralysis on one side of the body), need for assistance with personal care (is a type of care that can help people with their bodies, hygiene, appearance and movement), and displaced fracture of lesser trochanter of right femur, sequela (a rare injury with good prognosis). Record review of Resident #6's physician's orders indicated: 2/19/20 required 1 personal staff assist with ADL's/transfers. Record review of the admission MDS dated [DATE] indicated Resident #6 had clear speech, understood others, and was understood by others. She had a BIMS score of 6 indicating severe cognitive impairment. She required partial/moderate assistance with personal hygiene. Record review of the care plan dated 10/6/23 indicated Resident #6 was to be observed for bleeding (hematuria, tarry stools, blood-tinged urine, ect). The care plan dated 4/24/24 indicated active range of motion to the right upper extremity every day to reduce risk of contracture development related to right hemiparesis. During an observation on 07/23/24 at 10:55 AM, CNA B performed incontinent care on Resident #6 and was assisted by CNA E. CNA B failed to perform hand hygiene and don clean gloves after removing Resident #6's soiled brief and prior to applying a clean brief to Resident #6. During an interview on 7/23/24 at 11:00 AM CNA B said she should have removed her gloves before she applied the clean brief on Resident #6. She said she was nervous, but not removing the gloves could cause infections with the resident. During an interview on 7/23/24 at 11:03 AM CNA E said CNA B should have removed her gloves before she applied the clean brief on Resident #6. She said that could cause infections with the residents. During an interview on 07/24/24 at 9:41 AM CNA G said after incontinent care was performed the dirty gloves should have been removed and used hand sanitizer, then apply clean gloves. She said after clean gloves were applied, then the clean brief applied to the resident. CNA G said after the brief was applied to finish dressing the resident or reposition them in bed. She said if dirty gloves were not changed after incontinent care that could cause cross contamination. During an interview on 07/24/24 at 9:46 AM, LVN F said after incontinent care was performed, the CNA should have changed their gloves and sanitized their hands, then applied clean gloves before the clean brief was applied to the resident to prevent transferred infections. 2. Record review of the undated face sheet revealed Resident #38 was a [AGE] year-old male that admitted [DATE]. Record review of the physician's orders dated July 2024 revealed Resident #38 had diagnoses that included: bladder neck obstruction (abnormal emptying of bladder, incomplete emptying of bladder, urgency or pain), vascular dementia (cognitive difficulty with memory loss and poor judgement), mild intellectual disabilities (slower in all areas of conceptual development including social and daily living skills), and anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness). Record review of the quarterly MDS dated [DATE] revealed Resident #38 had unclear speech, was sometimes understood by others, and sometimes understood others. His BIMS score was a 99 indicating severe cognitive impairment in that he was unable to complete the interview. Resident #38 was dependent on staff for toileting hygiene (required staff to perform) and had an indwelling urinary catheter. Record review of the care plan dated 7/3/24 indicated Resident #38 had an indwelling urinary catheter due to bladder-neck obstruction and required indwelling urinary catheter care every shift. The care plan indicated Resident #38 required 1 person assist for ADL's. During an observation on 07/23/24 at 9:11, LVN A performed indwelling urinary catheter care for Resident #38. After performing indwelling urinary catheter care she did not change her gloves or wash/sanitize her hands. She then pulled up his clean brief, repositioned him touching his hip, and his shirt. LVN A then changed her gloves but did not wash or sanitize her hands. During an interview on 07/23/24 at 9:19 AM, LVN A said she should have changed her gloves after Foley [indwelling urinary catheter] care and before touching Resident #38's brief, shirt, and hip. She said she was nervous. She said she should have changed her gloves and sanitized or washed her hands to prevent infection, or the resident getting a UTI. She said failing to change gloves or wash her hands could cause infection. She said she was taught to change gloves and wash or sanitize her hands after a dirty procedure. She said she did not use hand sanitizer when she changed her gloves because she did not have any. During an interview on 7/23/24 at 1:52 PM, CNA B said she would always change her gloves and wash her hands after performing indwelling uninary catheter care and before touching anything clean. She said using dirty gloves to touch clean items or a resident could cause an infection control issue which could cause a lot of problems. She said staff had to wash or sanitize hands with every glove change. During and interview on 7/23/24 at 2:01 PM, LVN C said after performing indwelling urinary catheter care, she would change gloves and wash her hands before touching anything clean, including the resident. She said if dirty gloves were used to touch clean things it could be a risk of infection to the resident and to staff. She said she learned how to properly perform indwelling urinary catheter care in nursing school and then again at this facility. During an interview on 7/23/24 at 2:21 PM, the ADON said after performing indwelling urinary catheter care or incontinent care, staff should take their gloves off, use hand sanitizer or wash hands, and re-glove before touching the resident's clean brief, clothing, or the resident. She said after performing indwelling urinary catheter care staff gloves would be considered dirty. She said the resident, resident's clothing, and brief would be considered clean. She said using dirty gloves to touch a resident, resident's brief, or resident's clothing would be an infection control problem. She said it could spread infection and germs to the resident and to other staff. During an interview on 07/24/24 at 8:27 AM, the DON said after performing incontinent care or indwelling urinary catheter care staff should take off their gloves, sanitize or wash their hands, and re-glove for infection control sanitation purposes. She said if staff used gloves that were considered dirty to touch the resident's clothing, brief, or the resident there was a risk of spreading infection to the resident or staff and could make the resident sick. During an interview on 7/24/24 at 8:33 AM, the ADM said after performing incontinent care or Foley [indwelling urinary catheter] care, gloves would be considered soiled, so staff should take off their gloves, wash or sanitize their hands, and re-glove before touching the resident, resident''s clothing, or the resident's brief. She said if staff did not change their gloves and clean their hands, they would be contaminating everything they touched. During an interview on 7/24/24 at 9:24 AM, CNA D said after performing incontinent care or [indwelling urinary] catheter care his gloves would be considered dirty and he was taught staff cannot touch anything considered clean with dirty gloves. He said after performing incontinent care or indwelling urinary catheter care he would always take his dirty gloves off, sanitize his hands, and put on clean gloves before touching the resident, resident's clothing, resident's brief, or anything considered clean. He said if he touched clean things with dirty gloves there was a risk of infection to the resident and staff. Record review of a Hand Hygiene policy dated May 2023, provided by the ADM on 7/23/24 indicated .Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . 6.a. The use of gloves does not replace hand washing. Wash hands before donning and after removing gloves . Record review of an undated Incontinence Care Procedure provided by the ADM did not address washing hands or changing gloves after removing a resident's soiled brief and before applying a clean brief to a resident. Record review of an undated Urinary Catheter Care policy provided by the ADM indicated after indwelling urinary catheter care was performed indicated .10. Discard disposable items into designated container. Remove gloves and discard into designated container. Wash hands. 11.Position the resident for comfort and safety. 12.Wash your hands . Record review of an Infection Prevention and Control Program Policy dated May 2023, provided by the ADM indicated .Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .7.a. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 15 residents reviewed for ADLs (Residents #27 and Resident #1) The facility did not shave Resident #27's facial hair. The facility did not trim Resident #1's long nails. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. The findings are: 1.Review of Resident #27's undated electronic face sheet revealed she was admitted to the facility on [DATE] with diagnoses of: Need for assistance with personal care Urinary tract infection, Alzheimer's disease with late onset, Other seasonal allergic rhinitis, Hyperlipidemia (too many lipids (fats) in your blood), Pectoris (chest pain or discomfort due to coronary heart disease) Essential (primary) hypertension, Gastro-esophageal reflux disease without esophagitis (inflammation of the esophagus), Chronic pain, not elsewhere classified, Muscle weakness (generalized), Weakness, Other lack of coordination. Record review of Resident #27's annual MDS dated [DATE] revealed a BIMS with a score of 0, which indicated resident #27 was never or rarely understood. The MDS also revealed, Resident #27, required total assistance with personal hygiene. Record review of Resident #27's care plan revealed that Resident #27 required one person assistance with grooming and personal hygiene. During an observation on 05/22/2023 at 2:27 p.m. Resident #27 was observed lying in her wheelchair next to her bed. She was appropriately dressed and there were no foul odors. She had long facial hair which was approximately half an inch long. During an observation on 05/23/2023 at 1:24 p.m. Resident #27 was observed sitting in her wheelchair next to her bed. She was appropriately dressed and there were no foul odors. She had long facial hair which was approximately half an inch long. During an observation and interview on 05/24/2023 at 10:02 a.m. Resident #27 was observed lying in her wheelchair next to her bed. She was appropriately dressed and there were no foul odors. She had long facial hair which was approximately half an inch long. Resident #27 stated, Yes when asked if she prefers to be shaved and not have long hair on her upper lip and chin and neck area. During an interview with CNA D on 05/24/23 at 10:13 a.m. she stated that she has worked for the facility almost four years. She stated that Resident #27 was sweet and very compliant with her treatments. She said she only sometimes refused food. She stated that Resident #27 required total care and staff had to do everything for her including shaving and all other ADLs. She stated that she never refused to be shaved. She stated that she gets shaved every other day. During an interview with the Administrator on 05/24/2023 at 10:30 a.m. He stated that he expects his staff to follow all facility policies regarding ADL care for residents who were totally dependent. He stated that if a resident had unwanted facial hair they could be placed at risk for being embarrassed or loss of dignity. During an interview with the DON on 05/24/2023 at 12:10 p.m. she stated that residents who were totally dependent required personal hygiene such as shaving to be completed by a staff. She stated that Resident #27's facial hair should have been shaved on bath days which were Monday, Wednesday, and Friday. The DON stated that if hospice fails to shave the resident, then facility staff should ensure that the resident's personal grooming care is still provided. She stated that a resident could be placed at risk for loss of dignity from having unwanted facial hair. 2.Record review of the face sheet for Resident #1 indicated he was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, need for assistance with personal care, heart disease, heart failure, chronic pulmonary edema (an abnormal buildup of fluid in the lungs. This buildup of fluid leads to shortness of breath), Chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), dementia, and stage 4 chronic kidney disease (kidneys do not work as well as they should to filter waste out of the blood there are 5 stages each with progression in severity). Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and usually made himself understood. The MDS indicated he had severe cognitive impairment (BIMS of 1). The MDS indicated Resident #1 required extensive assistance bed mobility, transfers, locomotion in his wheelchair, dressing, toilet use, and personal hygiene. The MDS indicated he was totally dependent on staff for bathing. Record review of the care plan revised on 5/2/23 indicated Resident #1 required ADL assistance and indicated all his care needs would be met. During an observation and interview on 5/22/23 at 10:45 a.m., Resident #1 laid in his bed. His nails on both hands were long (approximately 1 centimeter). The nails to the first and second finger on the right hand had a black substance caked underneath them. Resident #1 said he did not want long fingernails because they (long fingernails) were for ladies. Resident #1 said he could not remember when his nails were last trimmed During an observation and interview on 5/23/23 at 10:30 a.m., Resident #1 laid in his bed. His nails on both hands were long (approximately 1 centimeter). Resident #1 said no one had offered to cut his nails and said he would like to have them trimmed. During an observation and interview on 5/24/23 at 10:50 a.m., Resident #1 laid in his bed. His nails on both hands were long (approximately 1 centimeter). Resident #1 said no one had offered to cut his nails and said he wanted them trimmed. During an interview on 5/24/23 at 11:03 a.m., CNA D said she regularly took care of Resident #1. CNA D said CNAs normally trim and clean residents' fingernails unless they are diabetics. CNA D said she was not sure if Resident #1 was a diabetic. CNA D said usually nails are trimmed by CNAs every Sunday and as needed. CNA D said she had not noticed Resident #1's nails were long. CNA D said there was a place for CNAs to document nail care in the EMR system. CNA D said it was important for nail care to be completed so residents did not accidently scratch themselves. During an interview on 5/24/23 at 11:07 a.m., CNA T said he regularly took care of Resident #1. CNA T said CNAs were responsible for trimming and cleaning residents' nails and provided the nail care to residents every Sunday. CNA T said he did not think Resident #1 was a diabetic. CNA T indicated nail care would also be performed on other days (in between Sundays) if it needed to be done. CNA T said he had emptied Resident #1's catheter earlier in the day but had not noticed his nails were long. CNA T said it was important for residents' nails to be cleaned and trimmed in order to avoid skin tears, injuries. CNA T said it was also important to keep residents' nails trimmed because residents could get stool or dirt under their nails which could lead to infections. During an observation on 5/24/23 at 11:10 a.m., LVN Q viewed Resident #1's nails. His nails on both hands were long (approximately 1 centimeter). LVN Q told Resident #1 she would make sure his nails were trimmed. Resident #1 said Okay then. Record review of Resident #1's hygiene documentation indicated nail care had not been provided since 5/12/23. During an interview on 5/24/23 at 11:20 a.m., the DON said CNA R cared for Resident #1 on Sunday (5/21/23) from 6:00 a.m.- 6:00 p.m. and CNA S cared for Resident #1 on Sunday (5/21/23) from 6:00 p.m.- 6:00 a.m. Phone interviews were attempted with CNA R (5/25/23 at 8:30 a.m.) and CNA S (5/25/23 at 8:38 a.m.) but were not completed. During an interview on 5/25/23 at 11:00 a.m., The DON said she expected CNAs to trim and clean residents' nails every Sunday. The DON said nurses would perform nail care if the resident was a diabetic. The DON said there was not a system in place to monitor if CNAs were performing nail care every Sunday. The DON said it was important for Residents to have their nails cleaned and trimmed to prevent injuries and cross contamination. During an interview on 5/25/23 at 11:15 a.m., the Administrator said he expected staff to ensure residents' nails were trimmed and cleaned because long dirty nails were unhygienic. The Administrator said it was especially important that Resident #1 have his nails trimmed so he could not injure staff. He (the Administrator) clarified Resident #1 had been combative with staff ion the past. The Administrator added residents could also unintentionally injure themselves with long nails. The Administrator said he was not aware of any system in place that monitored staff to ensure nail care was provided. Review of an undated facility document, Shaving the resident provided by the administrator revealed: The purpose of this procedure is to promote cleanliness and to provide skin care. The time that the procedure was performed. (Note on daily flow sheet or record.) The policy did not specify timeframe in which residents should be shaved. Record review of the undated facility policy and procedure titled, Fingernails/Toenails, Care of, stated, .(6) Nail care includes daily cleaning and regularly trimming (7) Proper nail care can aid in prevention of skin problems around the nail bed. (8) Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise when the facility failed to implement significant interventions for three (Residents #16, #28, and #39) of nineteen residents reviewed for significant weight loss. There were residents with significant weight variances (both for weight loss and weight gains) that were not identified until after surveyor intervention. This system failure allowed significant weight loss and weight gains to go undetected and untreated. 1. Resident #16 had an unexplained fifteen-pound weight loss (8.57%) in 11 days from 05/12/2023 to 05/23/2023 that was not identified until after surveyor entrance on 05/22/2023. 2. Resident #28 had an unexplained twenty-four-pound weight gain (12.98%) in 11 days from 05/12/2023 to 05/23/2023 that was not identified until after surveyor entrance on 05/22/2023. 3. Resident #39 had an unexplained fifty-one-pound weight loss (27.27%) in 11 days from 05/12/2023 to 05/23/2023 that was not identified until after surveyor entrance on 05/22/2023. Due to the weights not being done according to the facility's policy, the facility was unable to intervene and provide dietary recommendations until after surveyor intervention. This failure could place other residents at risk of unplanned weight losses and weight gains and place them at risk of not having their nutritional needs addressed. The findings include: 1. Review of Resident #16's electronic undated face sheet revealed he was admitted to the facility on [DATE] with diagnoses of Congestive heart failure (the heart can not pump well enough to give the body a normal supply), Pure hypercholesterolemia (high amounts of cholesterol), Esophageal reflux (stomach acid flows back into the esophagus), Unspecified essential hypertension (high blood pressure, Diarrhea (loose stools). During an observation on 05/24/23 at 4:01 p.m., it was observed that Resident #16 was weighed using a Hoyer lift scale by the DON. Resident #16 weighed 160 pounds. Resident was attempted to be interviewed and was unable to answer any questions. Record Review of Resident #16's care plan revealed: 1. Dated 10/31/2022 Ensure plus supplement twice daily for poor appetite. 2. Dated 10/31/2022 Monitor assistance needed with nurtitional intake and notify physician of changes. 3. Dated 10/31/2022 Weigh weekly. 4. Dated 10/31/2022 Weigh monthly. 5. Dated 10/31/2022 Refer to dietician for evaluation of current nutritional status. 6. Dated 10/31/2022 Provide between meal snacks. 7. Dated 10/31/2022 Offer food alternatives when appropriate for any meal. Record review of Resident #16's annual MDS dated [DATE] revealed a BIMS with a score of 0, which indicated Resident #16 was never or rarely understood. The MDS revealed, Resident #16, required total dependance with eating assistance. The MDS revealed, Resident #16 had no weight loss recorded. Record review of Resident #16's weight for March 7th, 2023, indicated that resident #16 weighed 180 pounds. Record review of Resident #16's weight for April 6th, 2023, indicated that resident #16 weighed 181.3 pounds. Record review of Resident #16's weight for May 12th, 2023, indicated that resident #16 weighed 175 pounds. During an observation on 05/24/23 at 4:01 p.m., it was observed that Resident #16 was weighed using a Hoyer lift scale by the DON. Resident #16 weighed 160 pounds. 2. Review of Resident #28's electronic face sheet dated 04/29/2022 revealed he was admitted to the facility on [DATE] with diagnoses of Chronic obstructive pulmonary disease (causes airflow blockage and breathing related problems), Gastro-esophageal reflux disease without esophagitis (stomach acid that flows into the esophagus), Aphasia following cerebral infarction (loss of ability to produce language), Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (unable to move the right side of the body), Dysphagia (swallowing problems), Edema (swelling). Record Review of Resident #28's care plan revealed: 1. Dated 7/26/2022 encourage diet compliance. Discuss diet as prescribed. 2. Dated 7/26/2022 Diet as ordered by MD. 3. Dated 7/26/2022 DM to evaluate every 3 months and as needed. 4. Dated 7/26/2022 Encourage diet compliance. Discuss prescribed diet as needed. 5. Dated 7/26/2022 Monitor % of meals eaten and offer replacement if resident consumes 50% or less. 6. Dated 7/26/2022 Obtain weights as ordered and as needed. 7. Dated 7/26/2022 Diet: Mechanical soft, no salt on tray, and nectar thick liquids. Record review of Resident #28's annual MDS dated [DATE] revealed a BIMS with a score of 0, which indicated Resident #28 was never or rarely understood. The MDS revealed, Resident #28 required supervision - oversight, encouragement or cueing while eating. The MDS revealed, Resident #16 had no weight loss recorded. Record review of Resident #28's weight for March 7th, 2023, indicated that resident #28 weighed 191.2 pounds. Record review of Resident #28's weight for April 12th, 2023, indicated that resident #28 weighed 193 pounds. Record review of Resident #28's weight for May 12th, 2023, indicated that resident #28 weighed 191 pounds. During an observation on 05/24/23 at 4:08 p.m., it was observed that Resident #28 was weighed using a Hoyer lift scale by the DON. Resident #28 weighed 215.8 pounds. Resident was attempted to be interviewed but did not answer any questions. 3. Review of Resident #39's electronic face sheet dated 05/24/2023 revealed he was admitted to the facility on [DATE] with diagnoses of Human Immunodeficiency Virus (HIV), Transient Ischemic Attack (stroke), and Spastic Hemiplegia (muscle stiffness impacting the total left side of his body). Record Review of Resident #39's care plan dated 7/26/2022 revealed: 1. Encourage diet compliance and discuss diet as prescribed. 2. Dated 7/26/2022 diet as ordered. 3. Dated 7/26/2022 DM to evaluate Q 3 months and PRN. 4. Dated 7/26/2022 Fluids and snacks to be offered midmorning, midafternoon, and at bedtime unless otherwise indicated. 5. Dated 7/26/2022 Monitor % of meals eaten and offer replacement if resident consumes 50% or less. 6. Dated 7/26/2022 Obtain weights A/O and PRN. 7. Dated 7/26/2022 RD to evaluate yearly and PRN. 8. Dated 7/26/2022 monitor for and report signs of malnutrition. 9. Dated 7/26/2022 weekly body audit. 10. Dated 7/26/2022 take food preferences into consideration during meal planning, obtain food preferences form relatives or friends as needed. 11. Dated 7/26/2022 comprehensive assessment and monitoring of nutritional status, habits, needs and intake. 12. Dated 1/5/2023 diet change to two bowls of cereal for breakfast per resident request. 13. Dated 3/20/2023 resident eats sweets and junk food throughout the day. 14. Dated 3/20/2023 change diet to: regular consistencies with thin liquids. Record Review of Resident #39's physician orders dated May 2023 revealed a diet order: mechanical soft/ground, thin liquids, NSOT (no salt on tray). Record review of Resident #39's quarterly MDS dated [DATE] revealed a BIMS a score of 15, which indicated resident #39 was cognitively intact. The MDS revealed, Resident #39 required supervision - oversight, encouragement or cueing while eating. The MDS revealed, Resident #39 had no weight loss recorded. Record review of Resident #39's weight for July 18th, 2022 prior to admission to facility indicated resident #39 weighed 195.0 pounds. Record review of Resident #39's weight for July 26th, 2022, indicated that resident #39 weighed 183.0 pounds. Record review of Resident #39's weight for August 1st, 2022, indicated that resident #39 weighed 184.0 pounds. Record review of Resident #39's weight for September 2022, indicated that resident #39 was not weighed. Record review of Resident #39's weight for October 5th, 2022, indicated that resident #39 weighed 185.1 pounds. Record review of Resident #39's weight for November 4th, 2022, indicated that resident #39 weighed 184.1 pounds. Record review of Resident #39's weight for December 10th, 2022, indicated that resident #39 weighed 185.2 pounds. Record review of Resident #39's weight for January 13th, 2023, indicated that resident #39 weighed 185.0 pounds. Record review of Resident #39's weight for February 8th, 2023, indicated that resident #39 weighed 184.4 pounds. Record review of Resident #39's weight for March 8th, 2023, indicated that resident #39 weighed 185.3 pounds. Record review of Resident #39's weight for April 12th, 2023, indicated that resident #39 weighed 185 pounds. Record review of Resident #39's weight for May 12th, 2023, indicated that resident #39 weighed 187 pounds. During an observation on 05/23/23 at 1:27 p.m., it was observed that Resident #39 was weighed using a Hoyer lift scale by the CNA A and CNA G. Resident #39 weighed 136 pounds. During an interview on 05/22/23 at 10:13 AM Resident # 39 said he does not like the food here and said they give him food that he can't chew. Resident #39 said he wanted soups because they are easier to eat. Resident # 39 said he had asked multiple times in the past and they will not bring him a substitute. During an observation on 05/22/23 at 11:45 AM of the lunch meal revealed Resident #39 ate the pecan pie for dessert but did not eat the main entrée. Resident #39 ate approximately 25 percent of his lunch. During an interview on 05/22/23 at 11:48 AM Resident #39 said he could not chew vegtables or sphagetti so he only ate his dessert. Resident #39 said he was not offered a substitute or supplement. Record Review of Resident #39's meal intake documentation for 5/22/2023 lunch meal revealed Resident ate 100% of the meal. During an interview on 5/23/2023 at 1:26 PM with CNA G, she said she has worked here for 7 years. CNA G said she does not remember if she had seen Resident #39 being weighed. CNA G said she knows that if resident eats 50% or less of a meal she is to offer the resident a substitute or health shake. CNA G said that resident #39 likes health shakes and drinks 5-6 a day. CNA G said she had not noticed a weight loss for Resident #39. During an interview on 05/23/23 at 03:27 PM with LVN B, she said that Resident # 39's diet has been changed back and forth multiple times due to personal preferences and not because of any identified weight loss. Said she has not noticed a weight loss for Resident # 39. During an interview on 05/23/23 at 03:31 PM with Resident # 39, he said the last time he was weighed has been about 6 months ago and he weighed 168.0 at that time but has not been weighed since then until today. Resident # 39 said he was weighed about an hour ago and weighed 136.0 today. Resident #39 said his weight loss was not planned or wanted. Resident #39 said he doesn't know if his clothes fit differently because he never wears anything but a hospital gown. During an interview on 05/23/23 at 03:38 PM with CNA E, she said she had worked here for over 10 years and had only seen Resident # 39 get weighed one time. During an interview on 05/23/23 03:50 PM with the CNA A, said she sometimes used the wheelchair scales and sometimes used the Hoyer lift to weigh Resident # 39. She said she couldn't remember which months she had used the wheelchair or the Hoyer lift and did not have that documented. She said at the beginning of April 2023 she remembered the facility had to replace the charging cord on the Hoyer lift but other than that she has not had a problem with weighing Resident # 39. During an interview on 05/23/23 04:06 PM with CNA D, she said she has worked at the facility for about 3 years and sometimes helped CNA A with weights. She said she had helped CNA A specifically weigh Resident # 39 and sometimes it was done with the wheelchair scales and sometimes with the Hoyer lift but could not remember specifically when. During an interview on 05/24/23 at 09:00 AM with the DON, she said she has worked here since December of 2022 and has no reason to believe the CNA A has not been weighing residents accurately. The DON said she had noticed that there was about a 10-pound difference with the chair scales and the Hoyer lift scales and said she had trained the CNA A on how to calibrate the scales. The DON said no one had noticed a weight loss with Resident # 39 except CNA C who came to her about 2 weeks ago and notified her and the DM that Resident # 39 was not eating. The DON said she checked Resident # 39's weight history in his medical record and did not see a weight loss, so no action was required at that time. The DON said she did not have a system in place to spot check or recheck residents weights that are in normal range for that resident, she said she occasionally will go weigh a resident if the residents weight is out of normal range for that resident. The DON said there is not a system in place to ensure accuaracy of weights if the weight given to her by CNA A is within normal range for that resident. During an interview on 05/24/23 at 09:25 AM with CNA C, he said he has worked here for 3 years and 3 months. CNA C said he has reported to the DON on 5 to 6 occasions and to the DM 2 to 3 times over the last 3 months that Resident # 39 was not eating, and Resident # 39 had gone down in brief size. CNA C said the DON would look in the computer and tell him that Resident # 39 weights were stable. CNA C said Resident # 39 asks for things to eat that are not on the substitute menu and said he has never asked him for soup. CNA C said the last time he reported to the DON about Resident # 39 not eating was the end of last month (April 2023). During an interview on 05/24/23 at 09:30 AM with CNA F, she said she has worked here since 2014. She said she has not noticed a weight loss with Resident # 39. CNA F said she knows if residents eats 50% or less of a meal then they are supposed to offer a substitute. She said that normally Resident # 39 does not really eat the facility meals but will drink the health shakes. During an interview on 05/24/23 at 09:38 AM with the facility Nurse Practitioner, she said she has taken care of Resident # 39 since 3/9/2020 prior to his admission to this facility. She said she does not believe that Resident # 39 has lost 51 pounds and gone from 187.0 pounds on 5/12/23 to 136.0 pounds on 5/23/23 and there must have been some inaccuracy somewhere along the way. The Nurse Practitioner said she was able to look back in her records of Resident # 39 before resident was admitted to the facility on [DATE] and resident weighed 195.0 pounds. During an interview on 05/24/23 at 10:40 AM with the RD, she said this was only her second visit to this facility and has never seen Resident # 39 before today. She said Resident # 39's body mass index is 20 which is still in the healthy category, she said a body mass index of 18.5 would be considered underweight. During an observation on 05/24/2023 at 11:10 AM Resident #39 was weighed by the DON using the hoyer lift scales and weighed 134.6 pounds During an interview on 05/24/23 at 11:25 AM with the Administrator, he said Resident # 39 does not look like he has lost weight. He said he does not know why there is a discrepancy, and the CNA A has been trained on how to properly do weights. He said his expectation was to have zero weight loss except for hospice residents in his facility. He said he expects the staff to do the weights correctly and accurately document, he said failure to do so places the residents at risk for improper caloric intake that could cause systemic failure within the body. During an interview on 05/25/23 at 09:22 AM with the DM, she said she has worked here for 12 years. She said she was not aware the resident has lost weight or was not eating until last Friday (05/19/2023) when CNA C reported to her that resident was not eating. She said she went to Resident # 39's room and assessed his chewing ability by placing a glove in his mouth to see if his gums meet, she also said she had Resident # 39 try to chew a piece of sausage and Resident # 39 was not able to chew it and spit the sausage back out. She said he did not want puree or chopped meat at that time and only requested soups. The DM said that she assesses residents quarterly or as needed for likes/dislikes and makes those changes to the residents dietary list. Record Review of the facility weight monitoring policy undated revealed: 1. Residents will be weighed on admission, readmission and monthly unless otherwise indicated. 3. Weights will be reviewed promptly by the DON or designee for accuracy and entered into the medical record only after approval. 4. A weight loss of 5% in 30 days or less, 7.5% in 90 days or less, or 10% in 6 months or less will be considered a significant weight loss regardless of the resident's ideal body weight. 15. A weight gain of 5% in 30 days or less or 10% in 6 months or less will be considered significant and will be reported to the physician and responsible party as soon as is practical by the Nursing Department. Documentation of this notification will be entered into the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 15 residents reviewed for respiratory care. (Resident #205). The facility failed to ensure Resident #205 received continuous oxygen per physician's orders. These failures could place residents at an increased risk of respiratory complications. Findings included: Record review of Resident #205's face sheet dated 5/25/23 revealed she was a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #205 had diagnoses of chronic obstructive pulmonary disease (lung disease that damages lung tissue and causes difficulty or discomfort in breathing), end stage renal disease (permanent cease of function of the kidneys), dependence on oxygen, and heart failure. Record review of Resident #205's MDS revealed it had not been completed. Record review of Resident #205's Care Plan dated 5/24/23 revealed Resident #205 was receiving oxygen therapy. Resident #205's oxygen therapy interventions were to ensure that supply was available at all times and to administer oxygen therapy as ordered. Record review of Resident #205's Physician Orders for the month of May 2023 revealed an order for oxygen at 3 liters per minute by nasal cannula continuous for a diagnosis of dependence on supplemental oxygen. Record review of Resident #205's MAR dated for month of May 2023 revealed an order for oxygen at 3 liters per minute by nasal cannula continuous. The MAR also revealed LVN B had administered Resident #205's 4:00 PM dose of Midodrine (used to increase blood pressure) and checked the resident's blood pressure on 5/23/23. During an observation and interview on 5/23/23 beginning at 1:40 PM Resident #205 was sitting up in a wheelchair in her room. Resident #205's oxygen concentrator was on 3 liters per minute and her nasal cannula was in her nose, the oxygen tubing was connected to the humidifier bottle, but the tubing from the humidifier bottle to the oxygen concentrator was not connected, therefore no oxygen was being delivered to Resident #205. Resident #205 said she wore oxygen most of the time because she becomes short of breath at times. Resident #205 said she was not having any shortness of breath at that time. Resident #205 said she was ready to return to bed and she pushed her call light for assistance. CNA M and CNA N entered resident's room and said they would assist her to transfer from her wheelchair to her bed. During an observation and interview on 5/23/23 at 2:28 PM revealed Resident #205 was lying in bed. Resident #205's nasal cannula was in her nose and the oxygen tubing was connected to the humidifier bottle, but the tubing from the humidifier bottle to the oxygen concentrator continued to be not connected, resulting in no oxygen being delivered to Resident #205. Resident #205 said she was not having any shortness of breath. During an observation and interview on 5/23/23 at 4:22 PM revealed Resident #205 was lying in bed. Resident #205's nasal cannula was in her nose and the oxygen tubing was connected to the humidifier bottle, but the tubing from the humidifier bottle to the oxygen concentrator continued to be not connected, resulting in no oxygen being delivered to Resident #205. Resident #205 said she was not having any shortness of breath. During an interview and observation with surveyor intervention on 5/23/23 beginning at 5:25 PM, LVN B said she had been in Resident #205's room to administer medications at least twice since lunch. LVN B said she always looked the resident over to ensure they were doing okay when she entered a resident's room. LVN B said Resident #205 was wearing her oxygen when she gave her medications. With surveyor intervention, LVN B entered Resident #205's room to assess her oxygen. LVN B said, Oh my, your oxygen is not connected, and you are not getting any oxygen. LVN B then removed the humidifier bottle with the unattached tubing and directly connected the resident's nasal cannula tubing to the oxygen concentrator. LVN B then asked Resident #205 if she was having any shortness of breath. Resident #205 said she was not having any shortness of breath or any trouble breathing. During an interview on 5/23/23 at 5:28 PM, LVN B said she did not know how Resident #205's oxygen tubing became unattached from the concentrator. LVN B said Resident #205 was not receiving any oxygen with the tubing unhooked. LVN B said Resident #205 was on continuous oxygen and she could have had increased shortness of breath and respiratory distress (trouble breathing). LVN B said it was the responsibility of anyone who entered the resident's room to ensure the resident was receiving their oxygen as ordered by the physician. LVN B said she remembered observing Resident #205 was wearing her oxygen when she administered her medications after lunch, but she did not remember actually assessing to ensure the tubing was connected to the concentrator, but she would make it a point to assess it going forward. During an interview on 5/23/23 at 5:30 PM, CNA M and CNA N said they were the CNAs who assisted Resident #205 from her wheelchair to her bed at approximately 1:40 PM and remembered surveyor was in the room upon them entering the room. CNA M and CNA N said they checked Resident #205's oxygen to make sure her nasal cannula was in her nose and the oxygen tubing was hooked to the humidifier bottle before leaving the resident's room. CNA M and CNA N said they did not check or realize the tube from the humidifier bottle to the oxygen concentrator was not attached to the oxygen concentrator. CNA M and CNA N said if they had realized the tubing from the humidifier bottle was not connected to the concentrator, they would have tried to fix it or would have reported it to the nurse. CNA M and CNA N said a resident who needed oxygen continuously could have breathing problems if they were not getting their needed oxygen. During an interview on 5/24/23 at 8:29 AM, the DON said she would expect when staff enter a room of a resident on oxygen, they would ensure the resident's oxygen was connected properly. The DON said all staff were responsible when in a resident's room to ensure everything was in working order, but it would ultimately be the responsibility of the nurse to ensure the resident was receiving the oxygen as ordered. The DON said a resident that required continuous oxygen could have shortness of breath and low oxygen saturation (low oxygen in the blood) if they were not receiving the needed oxygen. During an interview on 5/25/23 at 10:48 AM, the Administrator said Resident #205 was on continuous oxygen and not having oxygen during the timeframe the tubing was not connected to the oxygen concentrator could have had an adverse effect on the resident. The Administrator said he would expect staff to be checking and ensuring residents were receiving their oxygen as ordered. Review of the facility's undated policy titled Oxygen Administration indicated . the purpose is to provide guidelines for safe oxygen administration . oxygen therapy is administered by way of oxygen mask, nasal cannula, and/or catheter . check the tubing connected to the oxygen cylinder to assure that it is free of kinks . check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 15 residents (Residents #26 and Resident #35) reviewed for infection control practices. CNA O failed to remove her dirty gloves and perform hand hygiene (general term referring to any action of hand cleansing) before touching multiple clean items in the Resident's environment during incontinent care for Resident #26. CNA P failed to remove her dirty gloves and perform hand hygiene before touching clean items in the Resident's environment during incontinent care for Resident #35. These failures could place residents at risk for cross contamination and infections. Findings included: 1.Record review of the face sheet dated 5/23/23 for Resident #26 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including, peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs.), chronic obstructive pulmonary disease ( a group of diseases that cause airflow blockage and breathing-related problems), muscle weakness, dementia, history of pneumonia, history of traumatic hemorrhage of the left cerebrum (an intracerebral hemorrhage is usually caused by rupture of tiny arteries within the brain tissue) and high blood pressure. Record review of the MDS dated [DATE] indicated Resident #26 rarely/never understood others and sometimes made herself understood. The MDS indicated Resident #26 had severe cognitive impairment (BIMS of 4). The MDS indicated Resident #26 had no behavior of rejecting care. The MDS indicated she required extensive assistance with bed mobility, transfers, locomotion in her wheelchair, dressing, toilet use, and personal hygiene. The MDS indicated she was totally dependent on staff for bathing. The MDS indicated Resident #26 was always incontinent of bowel and bladder. Record review of the care plan revised on 3/20/23 indicated Resident #26 required ADL assistance and indicated all her care needs would be met. During an observation on 5/23/23 at 9:30 a.m., CNA O and CNA P provided incontinent care to Resident #26 after an episode of urinary incontinence. CNA O wiped Resident #26 clean and removed the dirty brief. CNA O did not remove her dirty gloves or perform hand hygiene. With the same dirty gloves, CNA O placed a clean brief under Resident #26, opened a set of drawers next to Resident #26's bed, and removed barrier cream from the drawer. CNA O squeezed some barrier cream onto her dirty glove and applied the barrier cream to Resident 26's buttock and perineum. CNA O and CNA P secured the new brief. CNA O then, without changing her gloves or performing hand hygiene, adjusted the leg sleeves on Resident #26's legs, pulled up Resident #26's covers, used the bed control to lower Resident #26's bed and then adjusted her (Resident #26) pillows. During an interview on 5/23/23 at 9:58 a.m., CNA O said she should have removed her dirty gloves, used hand sanitizer and put new gloves on before touching any clean items in the room. CNA O said she did not remove her dirty gloves before touching clean items because she forgot. CNA O said it did not matter that Resident #26 had only been incontinent of urine. CNA O said there was still a risk for cross contamination. 2. Record review of the face sheet for Resident #35 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses including Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), need for assistance with personal care, history of unspecified fever, and dementia. Record review of the MDS dated [DATE] indicated Resident #35 usually made herself understood and usually understood others. The MDS indicated she had severely impaired cognitive functions (BIMS of 3). The MDS indicated Resident #35 had no behavior of rejection of care. The MDS indicated she required extensive assistance with bed mobility, and locomotion in her wheelchair. The MDS indicated Resident #35 was totally dependent on staff for transfers, dressing, toilet use, personal hygiene, and bathing. The MDS indicated she was always incontinent of bowel and bladder. Record review of the care plan revised on 4/21/23 indicated Resident #35 required ADL assistance and indicated all her care needs would be met. During an observation on 5/23/23 at 9:45 a.m., CNA P and CNA O provided incontinent care for Resident #35 after an episode of bowel and bladder incontinence. CNA P wiped Resident #35 clean of urine then rolled her on her side and wiped her clean of stool. CNA P did not remove her gloves or perform hand hygiene. CNA P, with her dirty gloves, placed a clean brief under Resident #35, opened a drawer at the bedside and removed barrier cream from the drawer. CNA P squeezed some of the barrier cream onto her dirty glove and then and applied the barrier cream to Resident #35's buttock and perineum. During an interview on 5/23/23 at 10:00 a.m., CNA P said she should have removed her gloves and used hand sanitizer before placing the clean brief on Resident #35 and before applying the barrier cream. CNA P said she didn't realize she had not removed her dirty gloves before continuing with the incontinent care. CNA P said it did not matter if there was no stool visible on her gloves because bacteria could still be on the gloves. CNA P said she could have inadvertently transferred the bacteria to anything she (CNA P) touched. CNA P said not having removed her dirty gloves was an infection control issue. During an interview on 5/24/23 at 11:03 a.m., CNA D said nurse aides should change their gloves and wash their hands after cleaning a resident that was incontinent. She said nurse aides should put clean gloves on before placing a clean brief on a resident or touching any items in the room. CNA D said CNAs could unintentionally spread germs by not removing dirty gloves and touching clean items. During an interview on 5/24/23 at 11:07 a.m., LVN Q said she expected nurse aides to change their gloves/perform hand hygiene after cleaning a resident/removing the soiled brief and before touching any clean items in the room. LVN Q said CNAs not changing their gloves or performing hand hygiene while providing incontinent care to Residents was an infection control issue. During an interview on 5/25/23 at 11:00 a.m., the DON said she expected nurse aides to ensure cross contamination did not occur during incontinent care. The DON said CNAs should have removed their gloves after cleaning the stool/urine from a resident/removing the soiled brief, performed hand hygiene and put on clean gloves before they touched the clean items in the room. The DON indicated these actions (failure to remove dirty gloves and touching clean items in the room and the resident) were an infection control issue. The DON said the system in place to ensure nurse aides performed incontinent care correctly was the annual skills check off, which included evaluation of the incontinent care they provided. The DON said in addition to the annual skills check off she (the DON) performed random monthly checks to ensure CNAs continued to provide incontinent care correctly. The DON indicated there had been no issues with annual skills check offs or spot checks for CNA O or CNA P. During an interview on 5/25/23 at 11:15 a.m., the Administrator indicated he expected staff to follow appropriate infection control practices while incontinent care was provided to residents. The undated facility policy and procedure titled Incontinence Care, stated, .(1) Wash your hands thoroughly before beginning the procedure (2) Put on gloves .(i) Wash the rectal area thoroughly .(l) apply skin protectant .(13) Remove gloves . The National Library of Medicine website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152476/ accessed on 5/31/23 stated, .STANDARD PRECAUTIONS. Use Standard Precautions, or the equivalent, for the care of all patients .GLOVES- Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments .

Based on observation, interview, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 1 of 1 smoking area reviewed. The facility failed to keep trash out of the red metal trash cans designated for cigarette butts in the smoking area and failed to implement their smoking safety policy. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. The Findings Included: Record review of List of smokers undated revealed there were 2 residents listed as smokers. During an observation on 05/23/23 at 09:45 AM revealed in the smoking area 2 red metal trashcans with automatic closing lids. Observed in the trashcan on the right side of the smoking area red trashcan #1 was filled to the top with multiple empty cigarette packs, napkins, straws, chip bags and soda cans. Observed on the left of the smoking area in red trashcan #2 was 3/4 of the way full of cigarette butts with a Styrofoam cup on top. Observed all the smoking area with no fire extinguisher available. On 05/23/23 at 10:00 AM During an Interview, the Maintenance Director said he has worked here for 10 years. The Maintenance Director said there has never been a fire extinguisher in the smoking area, he said the closest one is inside the building in the dining room. The Maintenance Director said you would have to put in a code to the door to enter the dining room to obtain a fire extinguisher and then put in a code to exit the door back to the smoking area if there was a fire. The Maintenance Director said he empties cigarette butts from the ashtrays and puts them in the red cans and pours water over them, he lets them sit and dumps them in the dumpster. The Maintenance Director said he has had an ongoing problem with keeping staff and residents from putting regular trash in red metal trash cans designated for cigarette butts. During an observation on 05/23/23 at 10:22 AM, the nearest fire extinguisher was on the inside of the building in the dining area through a locked door in which a code was required to enter and exit door. During an interview on 05/24/23 at 10:40 AM The Administrator said there is not supposed to be regular trash in the red metal trash cans that are designated for cigarette butts. The Administrator said you can't put a fire extinguisher everywhere there is a fire hazard and there has never been one in the smoking area in 54 years. The Administrator said the policy states accessible but does not have to be in the smoking area. Record Review of the smoking policy for residents revised undated revealed,6. C. Accessible metal containers, with self-closing cover into which ashtrays can be emptied. D. Accessible fire extinguisher. 7. Metal containers with self-closing cover devices will be available in all smoking areas. 8. Ashtrays will only be emptied into designated receptacles.

Based on observation, interviews 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 kitchen reviewed for kitchen sanitation in that: 1. Hairnets were not worn or were worn unproperly. 2. Food was not labeled or dated. 3. Expired food was not thrown away. These deficient practices could place residents who received meals from the main kitchen at risk for food borne illness. The findings were: During an observation on 05/22/23 at 8:40 a.m., it was observed that hairnets were not worn by [NAME] L while preparing lunch service. Hardboiled eggs were in a one-gallon sized zip lock bag that were not labeled or dated nor had an expiration date stored in the refrigerator. Whole buttermilk was past its expiration date of 05/04/23 stored in the refrigerator. Cabbage stored in a plastic bag inside the refrigerator was past its expiration date of 03/18/23. It was observed that [NAME] L and the Dietary Manager were not properly wearing their hairnets as they had their hair coming out the bottom and sides. During an observation on 05/23/23 at 10:55 a.m., it was observed that hairnets were not worn properly by the Dietary Manager or [NAME] L. Hair was observed coming out of the sides of the hairnet by approximately 6 inches and was loose. During an interview on 05/25/23 at 8:30 a.m., the Dietary Manager stated that it is not proper to not wear a hairnet while preparing food. She stated that it was not proper to wear a hairnet with loose hair coming out of the sides of the hairnet and that all hair must be secured by the hairnet. She stated that hardboiled eggs should be labeled and dated if they are to be stored in a zip lock bag. She stated that all expired food should be thrown away. She stated that the residents could be placed at risk for foodborne illness, food poisoning, or hospitalization from improperly stored food, improper hairnet use, and from eating expired food. During an interview on 05/25/23 at 10:30 a.m., the Administrator stated that staff would handle food according to their policy and procedures. He said that kitchen staff should wear their hairnets while in the kitchen and it would not be proper to wear a hairnet with loose hair coming out of the sides. He stated that kitchen staff should throw away all expired food. He stated that food should be labeled and dated if stored in the kitchen to avoid out of date food from being served. He said that residents could be placed at risk of foodborne illness and sickness from improper food handling practices. Review of the undated facility document, Food: Handling and Preparation provided by the Administrator revealed: We face two major sanitation problems when handling and preparing food. The first is cross contamination, which is the transfer of bacteria to food from another food or from equipment, work surfaces or hands. Review of the facility document dated 6/1/2019, Storage: Freezer and Storage: Refrigerator provided by the Administrator revealed: Label and date all items.