**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #14) of 6 residents reviewed for care plans. The facility failed to update Resident #14's care plan to reflect current needs for oxygen as needed. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being. Findings include: Review of Resident #14's face sheet, dated, 05/07/2025, reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Resident #14 had diagnoses which included chronic obstructive pulmonary disease, unspecified ( an ongoing lung condition caused by damage to the lungs), essential hypertension ( a chronic characterized by persistently elevated blood pressure with no identifiable underlying cause), and anemia (leads to a reduced ability to carry oxygen to the body's tissue and organs. Symptoms can include fatigue, weakness, and shortness of breath). Review of Resident #14's Quarterly MDS, dated [DATE], reflected Resident #14 had a BIMS score of 9 which indicated her cognition was moderately impaired. Resident #14 had a diagnoses of chronic obstructive pulmonary disease, anemia, essential hypertension, and pneumonia (a lung infection that causes the air sacs to be filled with fluid). Resident #24 had shortness of breath. Review of Resident 14's Physician's Order dated 04/27/2025 (last order reviewed) reflected Resident #14 had an order for oxygen at 2LPM via N/C as needed for shortness of breath or to keep sats >92 percent. Review of Resident #14's Comprehensive Care Plan, revised on 04/16/2025, reflected Resident #14 had alteration in respiratory status due to chronic obstructive pulmonary disease initiated on 02/202/2025. Interventions: did not include oxygen as needed. Resident #14 had shortness of breath related to chronic obstructive pulmonary disease initiated on 02/25/2025. Intervention: did not include oxygen as needed. Observation and interview on 05/06/2025 at 10:50 AM revealed Resident #14 was in her room lying in bed. She stated she did not feel very well. Resident #14 stated sometimes she could not breathe very well but I am breathing fine right now. Resident #14 stated I am very tired. An oxygen concentrator or any type of oxygen tanks was not located in Resident #14's room. Interview on 05/07/2025 at 3:30 PM LVN B stated Resident #14 was on oxygen as needed. She stated if any resident had a physician's order for oxygen as needed, it was required to be on the care plan. She stated it was the responsibility of the nurse supervisor to monitor any type of equipment any resident needed in their room. She stated the care plan assisted the nursing staff for what type of care a resident needed. LVN B stated if a resident needed oxygen as needed and it was not documented on the resident's care plan, it would be difficult for the nursing staff especially CNAs to know a resident may need oxygen if they reviewed the plan of care in the electronic system the CNAs followed from the care plan. Interview on 05/07/2025 at 4:00 PM CNA E stated she did give care to Resident #14. She stated she was not aware Resident #14 required oxygen as needed. CNA E stated all residents' care was in the electronic medical record for the CNAs. She stated CNAs did not have access to residents' physician's orders or any other medical records except what was documented in the electronic medical record. CNA E stated the information in the CNAs electronic records was from the residents care plan. She stated oxygen was not documented in the CNAs electronic medical record. CNA E stated she did view Resident #14's electronic records for the CNAs and oxygen were not on their records of what type of care a resident needed. Interview and record review on 01/28/2025 at 8:30 AM the MDS Coordinator stated it was her responsibility to ensure the comprehensive care plan was revised as needed. She reviewed the care plans and MDS for Resident #14 in the electronic medical records and stated Resident #14's care plan had not been revised to reflect Resident #14 needed oxygen as needed. She stated Resident #14 did have a physician's order for oxygen as needed when Resident #14's care plan was revised. The MDS Coordinator stated if there were changes in Resident #14's care during the MDS assessment or after the MDS assessment that was to be included in a comprehensive care plan with the other information for staff to follow to give medical, cognitive, and social needs. She stated it would be difficult for the nursing staff to know what type of care to give a resident if there was any change and if the care plan was not updated. The MDS Coordinator stated if Resident #14 began having symptoms of problems with breathing, heart racing or feeling tired throughout the day. She stated if the oxygen was not documented on the care plan in the CNAs' records there was a possibility a CNA may not realize Resident #14 needed oxygen and may not report issues to the nurse. Interview on 05/08/2025 at 11:45 PM the Director of Nurses stated any time there was a change in a resident's treatment the care plan was expected to be updated. She stated Resident #14 was on oxygen as needed per physician's orders. The Director of Nurses stated the physician's order for oxygen was not revised on Resident #14's care plan. She stated CNAs information was transferred from the care plan to the [NAME] (the CNAs information for the care each resident was expected to be provided). The Director of Nurses stated if the CNAs did not know Resident #14 required oxygen as needed there was a possibility Resident #14 may develop symptoms and the CNAs would not realize she needed oxygen to report to the nurse. (Director of nurses did not elaborate on what type of symptoms Resident #14 may develop). She stated it was her responsibility and the MDS Coordinator's responsibility to ensure the care plans are monitored and revised as needed. Review of the facility's Policy on Care Conference Guidelines, dated November 2017, reflected To involve residents, patients and their representatives with goals and preferences of care, and to integrate with those of the interdisciplinary team (IDT). This should be completed at the time of admission, regular intervals, and where there is a change in health status. It should be based on functional/nutritional goals and psycho-social needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, for 1 of 2 residents (Resident # 93) reviewed for the use of oxygen concentrator. The facility failed to ensure Resident #93 had continuous oxygen therapy. This failure could place residents that receive oxygen therapy at risk for inadequate care and respiratory distress. Findings include: Review of Resident #93's face sheet, dated 05/08/2025, reflected an [AGE] year-old female who was admitted on [DATE]. Resident #93 had diagnoses which included acute respiratory failure with hypercapnia (the lungs cannot release enough oxygen into the blood, which prevents organs from functioning properly. Hypercapnia- shortness of breath, headaches, persistent tiredness during the day, and altered mental status), orthostatic hypotension (low blood pressure), and unspecified dementia without behavioral disturbance ( affects the memory, thinking and social abilities without any behaviors). Review of Resident #93's admission MDS, dated [DATE], reflected Resident #93 had a BIMS score of 6, which indicated her cognition was severely impaired. Resident #93 was dependent on staff for toileting, shower, dressing, transfers, and personal hygiene. She had a diagnosis of acute respiratory failure with hypercapnia. Resident #93 had shortness breath or trouble breathing with exertion (walking, bathing, or transferring), and shortness of breath or trouble breathing when lying flat). Resident #93 had a condition or chronic disease may result in a life expectancy of less than six months. She had respiratory treatments and was on oxygen therapy. Review of Resident #93's Comprehensive Care Plan, with completion date of 05/05/2025 reflected Resident #93 was on hospice services related to acute respiratory failure with hypoxia (lack of oxygen) . Interventions: Evaluate effectiveness of medications/interventions to address comfort. Keep family informed of change in condition. Notify hospice of any change in condition or medication changes. Resident #93 had oxygen therapy related to respiratory failure with hypercapnia. Interventions: Oxygen settings: O2 via nasal prongs at 2-4L/min. Monitor for signs and symptoms of respiratory distress and report to Medical Doctor as needed: respirations, pulse, increased heart rate, restlessness, diaphoresis (excessive sweating), headaches, confusion, cough, pain, and skin color. Promote lung expansion and improve air exchange by positioning with proper body alignment. Review of Resident #93's Physician's Order, last order date, 04/27/2025, reflected Resident #93 had a physician's order for oxygen via NC for SOB 2-4 L/min. Review of Resident #93's O2 sats, on 05/08/2025, reflected the last entry for O2 sats was on 05/05/2025 at 10:34 AM and she had 96 percent . Observation and interview on 05/06/2025 at 1:15 PM, revealed an oxygen concentrator was plugged into the outlet in the common area near the nurse's desk (one of one nurse's desk). There was not a resident near the concentrator. After approximately 5-8 minutes it was discovered the oxygen concentrator was Resident #93's. RN A and LVN B went to Resident #93's room and pushed the oxygen concentrator. Resident #93 was lying in bed without oxygen. Resident #93 would not respond to questions. She was not interviewable. Resident #93 had a sad expression on her face such as: furrowed brow, lips turned down, and pouting her lips. Review of Resident #93's nurses notes, dated 05/06/2025 at 2:08 PM , reflected Resident #93 was observed for brief time with no oxygen. RN A applied oxygen via NC @ 4 liter, no signs or symptoms of distress observed, respiratory even and unlabored, no shortness of breath, oxygen saturation 96 % 4 LMP NC. The Nurse Practitioner was informed of the situation with Resident #93. Resident #93 was assessed (unknown who assessed her). Resident #93 did not receive any new orders. Resident #93 denied any pain. Resident #93 vital signs was blood pressure 132/71, and 97.9% O2 setting at 4 LPM NC. Interview on 05/06/2025 at 1:35 PM, CNA D stated she was pushing the mechanical lift past the nurses' desk and she stopped and asked LVN B to assist her with Resident #93's oxygen concentrator. She stated LVN B stated ok. CNA D stated she entered Resident's #93's room with the mechanical lift and CNA E was in Resident #93's room to assist with transferring Resident #93 with the mechanical lift. CNA D stated Resident #93's oxygen concentrator was not in the room until Resident #93 was lying in bed. She stated she did not ask CNA D to move Resident #93's oxygen concentrator from the common area to the Resident #93's room. She stated Resident #93 was in her room without the oxygen concentrator when she was on another hall to locate the mechanical lift. CNA D stated Resident #93 was to always have oxygen. She stated it was approximately 20 minutes from assisting Resident #93 to her room and assisting her to bed prior to Resident #93 received her oxygen. Interview on 05/06/2025 at 1:50 PM, LVN B stated CNA D asked if I was available to assist with transferring Resident #93's oxygen concentrator from the common area to Resident #93's room. She stated CNA D was pushing the mechanical lift to Resident #93's room to transfer her from the wheelchair to the bed. LVN D stated, I was busy with the pharmacist and did not ask anyone else to assist [CNA D] with the oxygen concentrator. LVN B stated RN A was sitting at the nurses' desk. LVN B stated she did not ask RN A or any other staff to assist CNA D with Resident 93's oxygen concentrator. LVN B stated Resident #93 had a potential of having shortness of breath or hypoxia (low levels of oxygen in your body tissues. Symptoms such as: confusion, restlessness, difficulty with breathing, rapid heart rate, and bluish skin). LVN B stated Resident #93 had a physician's order for continuous oxygen. She stated oxygen was expected to be used on Resident #93 continuously throughout the day and night. LVN B stated she did not recall the last in-service the staff had on oxygen care. Interview on 05/06/2025 at 2:05 PM, RN A stated LVN B did not ask her to assist with Resident #93's oxygen concentrator. She stated she was not aware CNA D needed assistance with transferring Resident #93's oxygen concentrator from the common area to Resident # 93's room. She stated Resident #93 had a physician's order for continuous oxygen. RN A stated if a resident was not receiving continuous oxygen there was a possibility a resident may become hypoxia. She stated she did not recall the last time she had in-service on oxygen care and protocol. Interview on 05/06/2025 at 2:10 PM, CNA E stated CNA D asked her to assist transferring Resident #93 from the wheelchair to the bed with a mechanical lift. CNA E stated she was in Resident #93's room waiting for CNA D to locate a mechanical lift to use on Resident #93. She stated it was approximately 5-8 minutes prior to CNA D return to Resident #93's room with the mechanical lift. CNA E stated Resident #93 was not using oxygen. She stated she did not give care to Resident #93 and was not aware Resident #93 required oxygen. CNA E stated no one asked her to assist to move Resident #93's oxygen concentrator from the common area to Resident #93's room. She stated after she assisted with transferring Resident #93 from the wheelchair to her bed, she exited Resident #93's room. Interview via phone on 05/07/2025 at 9:05 AM, Resident #93's family member did not answer phone or return phone call after leaving a message. Interview via phone on 05/07/2025 at 9:40 AM , Resident #93's Physician did not answer phone or return phone call. Interview on 05/08/2025 at 11:45 AM the Director of Nurses stated only nurses could check the oxygen concentrator and place the tubing into a resident's nose. She stated anyone was capable of transferring oxygen concentrator from one area to another area. The Director of Nurses stated any resident not receiving continuous oxygen for several minutes the nurse was to do an assessment on resident to check the residents O2 sats and vital signs. She stated if a staff needed assistance in transferring oxygen concentrator the staff could ask a nurse, a CNA, or come to the nurse administration and asked for assistance. She stated if a resident was not receiving oxygen there was a potential a resident may become hypoxia or had shortness of breath. Record review of the Facility's Oxygen Guideline Policy, updated on 08/01/2024, Medical oxygen is classified by the Food and Drug Administration as a drug and therefore it is provided accordance with a health care provider's order and in accordance with acceptable standards of practice.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication room reviewed for pharmacy services. The facility failed to ensure an expired medication was removed from the medication storage room. This failure could place residents at risk of receiving an expired medication, not reaching the intended therapeutic dose and possible exacerbation of health conditions. Findings included: Observation on 5/06/2025 at 1:40 PM in the medication storage room revealed a bottle of Aspirin 325 mg with an expiration date of 4/2025. In an interview on 05/06/2025 at 1:50 PM RN A stated she had worked at the facility for almost ten years. She stated if an expired medication was given to a resident, it might not have the required potency. She further stated she thought the weekend medication aide might be responsible for checking the storage room for expired medications, but she was unsure. In an interview on 05/08/2025 at 9:31 AM the DON stated she typically checked for expired medications in the medication storage room on Monday mornings. She stated the weekend night MA was also responsible for checking for expired medications in the carts and storage room. She further stated the potential risk of a resident receiving an expired medication was that it would not be as effective. In an interview on 05/08/2025 at 11:48 AM the ADM stated there should not be any expired medications in the storage room. She stated she would assume that an expired medication would not have the proper potency. She further stated nursing leadership would be responsible. Record review of a facility policy and procedure titled Storage of Medications dated 09/2018 and revised on 08/2020 and 08/2024 reflected Policy Medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. Procedures: General guidance: 8. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are removed form inventory, disposed of according to procedures for medication disposal, and recorded from the pharmacy if a current order exists.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure Dietary [NAME] G, and Dietary Aide H used proper hand hygiene during food preparation. These failures could place residents who ate food from the kitchen at risk for foodborne illness. Findings include: Observation on 05/07/2025 at 6:50 AM, revealed Dietary [NAME] G was not wearing gloves. He touched a disinfectant dish cloth and wiped a food prep table. Dietary [NAME] G placed the dish cloth in a container with other disinfectant dish cloths. He proceeded to puree food. Dietary [NAME] G exited from the puree food prep area to the steam table. Dietary [NAME] G placed his middle finger, fore finger, ring finger and small finger from the knuckles to the tip of his fingers inside the silver container sitting on the steam table and carried it the puree food prep table. Dietary [NAME] G did not sanitize or wash his hands after touching the disinfectant dish cloth. He placed puree hashbrowns inside the silver container he obtained from the steam table. Observation on 05/07/2025 at 7:15 AM, revealed Dietary Aide H's right palm and fingers on her right hand touched her top and her pants while she was obtaining a meal tray. Dietary Aide H was not wearing gloves. She gathered cups for the breakfast meal from a shelf. When she picked up the cups she placed her middle, ring, and forefingers from the knuckle to the tip of her fingers on her right hand inside of 5 small plastic cups to be used for breakfast. Dietary Aide H placed the cups on a small food prep area located beside the coffee maker. She also placed her fingers on her right hand inside the breakfast meal trays located on the meal cart. Dietary Aide H did not wash or sanitize her hands. Interview on 05/07/2025 at 1:40 PM Dietary Aide H stated she did touch her shirt and her pants prior to carrying cups to the food prep area by the coffee maker. She stated she did touch inside the cups and was expected to wash her hands after she touched anything that was dirty. She stated germs from her pants and shirt possibly transferred to her hands. She stated the germs on her hands may transfer to the inside of the cups and meal trays. Dietary Aide H stated if germs were inside the cups or on meal trays and transferred to drink or food, there was a potential a resident may become physically ill with stomach virus. She stated she had been in-service on hand hygiene. Dietary Aide H stated she did not recall the date of the in-service. Interview on 05/08/2025 at 10:45 AM Dietary [NAME] G stated on 05/07/2025 he did touch the disinfectant kitchen towel and wiped area on the food prep table. He stated he did not wash his hands and was not wearing any gloves. Dietary [NAME] G stated he did place his fingers inside the silver container when he picked up the silver container from the steam table and placed it by the food puree prep table. He stated he did place puree potatoes inside the silver container. Dietary [NAME] G stated there was a possibility germs transferred on the puree potatoes when they were transferred from the puree blender into the silver container. He stated there was a potential if germs were on the puree potatoes a resident may become ill with food borne illness such as nausea or vomiting. He stated he had been in-service on hand hygiene. He did not recall the date of the last hand hygiene in-service prior to 05/06/2025. Interview on 05/08/2025 at 11:25 AM the District Director of Operations for the kitchen stated the staff was expected to wash their hands between tasks. He stated if the staff were not washing their hands after touching contaminated items there was a potential of cross contamination. He stated the staff was in-serviced on hand hygiene. The District Director of Operations stated he would need to observe the staff not washing their hands prior to responding to any questions. Interview on 05/08/2025 at 12:40 PM the Dietary Manager stated all staff were required to wash their hands between tasks and whenever they touched their clothes or a disinfectant kitchen towel. She stated clothes and disinfectant kitchen towels were considered contaminated. The Dietary Manager stated food may become cross contaminated if there was bacteria on the staffs hands and the staff touched plates, food, plate covers and/or napkins. She stated it was a possibility a resident may become ill with stomach issues such as vomiting if they ingested bacteria transferred from staff's contaminated hands onto their food, silver container, cups, or meal trays. Review of the Facility's Policy on Proper Hand Hygiene, dated 2020, reflected While alcohol-based hand sanitizers containing 60 percent or more alcohol are the preferred method for cleaning your hands in most clinical situations, handwashing is the standard set by the 2017 Food Code, Section 2-301 for kitchen settings. Handwashing with soap and water is required in a dining service setting in the following situations: 1. When you take one step away from your workstation. 2. After touching your hair, face, or clothes. Between tasks: Example- switching between cutting chicken and cutting onion.

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for one of one kitchen. The facility failed to keep overflowing garbage in a container without a lid on the kitchen utility cart away from clean dishes and the food prep area where dietary staff was preparing food for lunch. The failure could place residents at risk for exposure of germs and diseases carried by vermin and rodents. Findings include: Observation on 05/06/2025 at 9:18 AM revealed a kitchen utility cart with a garbage can attached to the utility cart. The garbage was not covered and was overflowing with food and containers. The utility cart was touching the area where staff prepped for drinks and there were clean cups on the small prep area beside the coffee maker. The utility cart was approximately 2-3 feet from the food prep table where food was lying on the food prep table beside the stove. Dietary [NAME] G was not standing near the food prep area. He was on the other side of the kitchen near the dishwasher (approximately 8 feet) from the food prep area and garbage. Observed the garbage container attached to the utility cart approximately 10 minutes. The dietary staff did not throw any food or anything in the garbage container. The dietary staff was not prepping food for lunch during the observation. In an interview on 05/07/2025 at 1:40 PM the Dietary Aide H stated any type of garbage container was expected to have a lid on the container. She stated the garbage was expected to be stored out of the kitchen area. She stated sometimes the cook would bring the garbage container into the kitchen when he needed to throw things away when someone was cooking a meal. She stated she had been in-service not to leave any type of garbage in the kitchen area and to always keep the lid on it. Dietary Aide H stated there was a possibility garbage in the kitchen area may cause bugs to come into the kitchen where food is prepped. She stated she had been in-serviced on garbage disposal. Dietary Aide H stated she did not remember the date of the in-service. Interview on 05/08/2025 at 10:45 AM Dietary [NAME] G stated the garbage is in the kitchen when the staff is preparing or cooking a meal. He stated it was easier and more convenient to have the garbage container in the kitchen area. He also stated if the garbage container was not being used, it should be located out of the kitchen. He stated he was not using the garbage container on 05/06/2025 in AM after breakfast and before lunch. He stated he heard staff answering questions about the garbage container and he stated at that time he was not using the garbage container and he would be the only one who needed the garbage container when he was preparing food and cooking. He stated they had an in-service on disposal of garbage, however, he did not recall the date and time. Interview on 05/08/2025 at 11:25 AM the District Director of Operations for the kitchen stated garbage containers did not require to have a lid on the container. He stated garbage containers were allowed to be in the kitchen. The District Director of Operations stated there was not anything wrong with the garbage being in the kitchen on 05/06/2025. He stated if dietary staff was prepping food, opened garbage containers was allowed in the kitchen. ( QA Reviewer he would not respond when asked during the observation of garbage in the kitchen was anyone prepping food. He would not respond if there was any negative outcome for having overflowing garbage in the kitchen He would not answer the question if garbage was sanitary He would not answer if the staff had been inserviced on garbage and who was responsible to monitor garbage) Interview on 05/08/2025 at 8:40 AM, the Interim Administrator (Regional [NAME] President of the facility) stated all garbage should not be near any food prep area or the stove. She stated the garbage was expected to be located away from the kitchen area around food. The Interim Administrator stated the kitchen did not have any pest issues, however, if there was overflowing garbage located near food prep area and near food there was a possibility the garbage may attract flies. Interview on 05/08/2025 at 12:40 PM the Dietary Manager stated garbage was allowed to remain in the kitchen. She stated the garbage container did not require to have a lid to cover the garbage. She stated any dietary staff could use a plastic bag to cover the top of the garbage. The Dietary Manager stated there was nothing covering the garbage container in the AM on 05/06/2025. She stated no one was prepping for lunch and there was food on the food prep table. She stated the utility cart was near the coffee maker and there were cups on small food prep area next to the coffee machine. The Dietary Manager stated garbage was not considered sanitary. ( this is for the QA reviewer. Dietary Manager was asked what negative outcome could be if there was flies landing on food or if there was rodents or flies in the kitchen. She did not respond. Asked if she considered having garbage next to food and clean dishes sanitary and she did not respond. She would not respond to any other questions and did not feel it was an issue to have uncovered over flowing garbage in the kitchen She would not respond if staff had been inservice on garbage storage or if the staff had been in-service on garbage disposal ) Record review of the facility's Environment policy, revised on 09/20217, reflected All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. All trash will be contained in leak-proof containers that prevent cross contamination; trash container must be covered during meal service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, 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 4 of 10 residents (Resident #27, Resident #22, Resident #32 and Resident #31) reviewed for infection control. 1. The facility failed to ensure MA C cleaned the blood pressure cuff before using it on Residents #27, #22 and #32 during the AM medication pass on 5/07/2025. 2. The facility failed to ensure the ADON, ICP identified a resident who met the criteria for EHP during wound care. The facility failed to ensure RN A and LVN B performed Enhanced Barrier Precaution steps while providing wound care to Resident #31. These deficient practices could place residents in the facility at risk for acquiring MDRO infections that could lead to delayed wound healing, sepsis , and hospitalizations. Findings included: 1. Review of the undated Face Sheet for Resident #27 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Essential (primary) Hypertension (high blood pressure). Review of the Physician's Order dated 02/20/2025 for Resident #27 for a daily diuretic (medication that causes decreased fluid retention leading to lower blood pressure) reflected hold if SBP (systolic blood pressure - top number in a reading) is less than 110. Observation and interview on 05/07/2025 at 7:18 AM revealed MA did not clean the blood pressure cuff before or after taking Resident #27's blood pressure reading. MA C stated her blood pressure was 127/89. Review of the undated Face Sheet for Resident #22 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of Essential (primary) Hypertension (high blood pressure). Review of a Medication Administration Record for Resident #22 reflected her blood pressure reading was recorded on 05/07/2025 by MA C prior to her receiving a morning blood pressure medication. Observation and interview on 05/07/2025 at 7:26 AM revealed MA C did not clean the blood pressure cuff before or after taking Resident #22's blood pressure reading. MA C stated her blood pressure was 134/68. Review of the undated Face Sheet for Resident #32 reflected she was an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Essential (primary) Hypertension (high blood pressure). Review of a Medication Administration Record for Resident #32 reflected her blood pressure reading was recorded on 05/07/2025 by MA C prior to her receiving a morning blood pressure medication. Observation and interview on 05/07/2025 at 7:41 AM revealed MA C did not clean the blood pressure cuff before or after taking Resident #32's blood pressure reading. MA C stated her blood pressure was 142/67. In an interview on 05/07/2025 at 7:58 AM MA C stated he had been an MA since 2012 and had been working at the facility since December 2024. He stated he had received an in-service on infection control and was aware he should have been cleaning the blood pressure cuff between residents. He further stated the blood pressure cuff should be cleaned with the purple top disinfecting cloths so that germs would not go from one person to another. He stated by not cleaning the blood pressure cuffs in between residents it was an issue with cross-contamination. He stated, It just slipped my mind. Observation on 05/07/2025 at 9:40 AM of a facility purple top container of germicidal (germ killing) disposable wipes revealed the wipes disinfected surfaces in two minutes. In an interview on 05/08/2025 at 08:54 AM the ADON, ICP stated equipment that was used for multiple residents, including blood pressure cuffs, should be cleaned in between residents. She stated if the equipment was not cleaned it could potentially spread infections. In an interview on 05/08/2025 at 9:31 AM the DON stated blood pressure cuffs should be sanitized with the purple top wipes before and between each resident use. She stated if the cuff was not cleaned it could spread germs to other residents. In an interview on 05/08/2025 at 11:48 AM the ADM stated her expectation was for a blood pressure cuff to be sanitized before use on a resident and in between residents. She stated there was a potential for cross contamination if the blood pressure cuff was not cleaned. Record review of a facility Policy and Procedure dated 05/2020 and titled Equipment and Departmental Cleaning/Maintenance Policy. Policy: Equipment is to be cleaned and maintained according to manufacturer's instructions. Policy Interpretation and Implementation: Each piece of equipment used for patient/resident care is to be cleaned with a center approved surface disinfectant before and after each patient care. This includes but not limited to: wheelchairs, blood pressure cuffs, glucometers, temperature probes, lifts, all therapy equipment, shower chairs, bedside tables and scales. Each piece of equipment should be cleaned with disinfectant wipe on [facility] formulary or product that is purchased for an approved list of EPA registered disinfectants. The manufacturer's instructions should be reviewed carefully for dry time after cleaning and before next use. Typical dry time is 3 minutes. Equipment should not be used between patients without being appropriately disinfected. 2 . Observation on 05/07/2025 at 9:54 AM of wound care for Resident #31's right heel and right lateral (outer) ankle by LVN B and RN A, revealed they were not wearing gowns during the wound care. RN A's uniform top was touching the resident's bedding during the wound care as she was holding his leg up. There was no signage on the door to indicate Resident #31 should have been on EBP. In an interview on 05/07/2025 at 10:42 AM RN A stated Resident #31 had a chronic wound on his right lateral ankle. RN A stated her uniform had been touching the bed while she was holding Resident #31's leg up for LVN B to perform wound care. In an interview on 05/07/2025 at 11:14 AM LVN B stated residents should have been on EBP if they had an open area on their body, or had devices such as G-tubes , or urinary catheters. She stated they should have been wearing gowns while providing wound care for Resident #31. She stated if they had been wearing gowns, they would have been protecting Resident #31 from any bacteria on them and vice versa. She further stated by not wearing gowns it could have led to cross contamination. (when harmful bacteria or other pathogens transfer from one source to another during wound care procedures) In an interview on 05/07/25 at 11:20 AM RN A stated by not wearing a gown while providing wound care for Resident #31 the nurses, including herself, could have picked up bacteria and spread it to other residents leading to a cross contamination infection. Observation on 05/07/2025 at 3:26 PM revealed EBP signage was still not on Resident #31's door. In an interview on 05/08/2025 at 08:54 AM the ADON, ICP stated Resident #31 probably had a chronic wound, but she was not 100% sure. She stated the concept of EBP was kind of new to her. She stated on 05/08/2025 she had placed an EBP sign on Resident #31's door. She stated the two nurses (RN A and LVN B) who performed his wound care on 05/07/2025 should have been gowned and gloved. She stated by the nurses not wearing gowns during Resident #31's wound care there was an increased risk of pathogens being transferred to him or to other residents. She stated that would be considered cross contamination. She stated it was her responsibility to ensure EBP was put into place for appropriate residents. In an interview on 05/08/2025 at 9:31 AM the DON stated EBP should be used for residents who had catheters, tracheostomies , g-tubes, and chronic wounds. She stated those residents were at a higher risk of infection. She stated EBP should be used for any high contact activity such as wound care, perineal care, and bathing. She stated a gown, and gloves should be worn and if there was a high risk of body fluid splashes, then a face shield and mask should be worn. She stated Resident #31 should have been on EBP due to having a chronic wound. She stated she and the ADON ICP were responsible for ensuring EBPs were set up for the appropriate residents. She stated the potential risk if the EBP procedures were not followed was the transmission of MDRO (bacteria that have become resistant to certain antibiotics) infections to other residents. In an interview on 05/08/2025 at 11:48 AM the ADM stated her expectation was for staff to utilize EBP for residents that meet the criteria. She stated by not utilizing EBP, residents could be exposed to infections. Record review of a CDC document provided by the ADM, dated July 12, 2002, and titled Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) reflected, Key Points: 1. Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. 2. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. 3. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: o Wounds or indwelling medical devices, regardless of MDRO colonization status o Infection or colonization with an MDRO. 4. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. 5. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. Background Residents in nursing homes are at increased risk of becoming colonized and developing infection with MDROs more than 50% of nursing home residents may be colonized with an MDRO, nursing homes have been the setting for MDRO outbreaks, and when these MDROs result in resident infections, limited treatment options are available [1-9]. Implementation of Contact Precautions is perceived to create challenges for nursing homes trying to balance the use of PPE and room restriction to prevent MDRO transmission with residents' quality of life. Thus, many nursing homes only implement Contact Precautions when residents are infected with an MDRO and on treatment. Focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who, by definition, have no symptoms of illness. MDRO colonization may persist for long periods of time (e.g., months) which contributes to the silent spread of MDROs. With the need for an effective response to the detection of serious antibiotic resistance threats, there is growing evidence that the traditional implementation of Contact Precautions in nursing homes is not implementable for most residents for prevention of MDRO transmission. Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing [11-15]. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: o Dressing o Bathing/showering o Transferring o Providing hygiene o Changing linens o Changing briefs or assisting with toileting o Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator o Wound care: any skin opening requiring a dressing In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to Standard Precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on observation, interview and record review, the facility failed to prepared puree food by methods that conserve nutritive value, flavor, and appearance as evidence by mixing the hamburger meat with water The extent is no actual harm with the possibility of more than minimal harm. The puree diet hamburger meat was mixed with water instead of thickener or a broth with nutrient value. This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health. Findings include: Observation on 03/19/2024 at 11:35am revealed CK F pureed hamburger meat with water instead of the thickener on the counter. CK F did not have any recipes out for puree Interview with the Dietary Manager on 03/20/2024 at 1:45pm revealed that CK F was filling in from another facility and the Dietary Manager was not sure what training she had. She stated that when doing puree staff were to follow the puree recipe. The Dietary Manager revealed she is responsible for overseeing puree in the kitchen. She stated that she thought that CK F was trained and knew what to do. She stated if she knew CK F did not know puree she would have just done it herself. She stated staff were never supposed to mix water in puree food because it takes away the nutrients in the food. She stated that she did not realize that CK F mixed water in the puree until after it was served. Interview with CK F on 03/20/2024 at 2:44pm revealed that she had been trained on puree diets. She stated that she normally mixed the puree with broth, orange juice or milk. CK F stated that she got nervous and forgot everything. She stated she realized after that she mixed the hamburger meat with water. She stated that mixing the puree with water takes the nutrients away from the food. She stated by taking the nutrients away from the food it puts the resident at risk of weight loss or other health issues. Record Review of the Essential Functions of the Job no date revealed staff prepare food by methods that conserve nutritive value and flavor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the physician prescribed therapeutic diet to 1 of 8 residents (Resident #3) reviewed for therapeutic diets, in that: Resident #3 was given salt when her meal ticket stated no added salt as ordered. This failure could place residents at risk for further health issues. Findings included: Record review of Resident #3's face-sheet dated 03/212024 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Atrial fibrillation, stiffness of left hand, dehydration, hyperkalemia, personal history of urinary tract infections, hallux varus acquired left foot, stiffness of right hand, muscle wasting, contracture right hand, allergies, history of falling, never pain, age related disability, inner ear infections right ear, age related cognitive decline, difficulty in walking, unsteadiness on feet, unspecified abnormalities of gait and mobility, chronic obstruction pulmonary disease, heart failure, high levels of fat particles in blood, arthritis, high blood pressure, heart disease of coronary artery, contractors to fingers and thumb, muscle weakness, and lack of coordination. Record review of Resident #3's dietary orders dated 07/24/2023 revealed she was on a regular diet with no salt added. Observation of lunch on 03/19/2024 at 12:19pm revealed Resident #3's meal ticket stated she was on a regular diet no added salt. Resident #3 also had physician orders dated 07/24/2023 that stated resident was a no salt added. Resident #3 was given a salt packet with her meal. Interview with Resident #3 on 03/19/2024 at 2:10pm revealed that Resident #3 was on a no salt diet. Resident #3 stated that they give her salt all the time, but she does not use the salt. She stated that she knows she was not supposed to have salt. Observation of Breakfast on 03/21/2024 at 8:54am revealed Resident #3 was given salt with her breakfast. Interview with DA D on 03/21/2024 at 8:56am revealed that she put the condiments on the trays. DA D stated that she had been trained on therapeutic diets and how to read the dietary meal tickets. She stated that she was not aware of Resident #3's diet being a no salt diet. She stated she did not see the no salt on the meal ticket that she missed it. She stated the negative outcome could be the resident have a reaction to something if they were not supposed to have the food item. Interview with the Dietary Supervisor on 03/21/2024 at 9:09am revealed the aides were responsible for checking to ensure the trays are correct before leaving the kitchen. She stated that the nurses were also supposed to check the tray before it gets to the resident. She stated she was not sure why the resident received salt when it said on the meal ticket no salt. She stated the resident could have a reaction if not given the correct diet. Interview with LVN C on 03/21/2024 at 9:34am revealed that the nurses check the trays once they were put on the cart. She stated the condiments were usually clumped together and she was bad about checking the condiments also. She stated if a resident were to get the wrong diet or condiment the resident could have edema, end up in the hospital, all kinds of potential issues. LVN C stated she was not sure who checked Resident #3's tray. Interview with RN E on 03/21/2024 at 10:45am revealed that the nurses were supposed to check meal trays before they were given to the residents. RN E stated they check to ensure the diet was correct and matches the meal ticket. She stated if the diet was not correct, they send it back to the kitchen to be corrected. She stated that if a resident were given the wrong diet, it could cause different health issues depending on the diet. She stated she was not sure who gave Resident #3 her tray or who checked the tray. She also stated the DON and MDS nurse were checking the trays. Interview with the DON on 03/21/2024 at 11:01am revealed that the nurses were to check the trays before giving them to the residents. She stated the nurses check the trays to ensure the resident was getting the correct diet. She stated that if the diet was not correct the resident could choke if given thin liquids instead of thick liquids that were ordered. The DON stated she was not checking trays this morning that the MDS nurse was. She stated the dietary staff usually puts the condiments on the trays automatically. She stated she was not sure if they give residents salt on a regular basis when the resident was not supposed to have salt. Interview with the MDS nurse on 03/21/2024 at 11:12am revealed that the nurses were to check the trays before giving to the residents. Stated there could be several issues with a resident not getting the proper diet. She stated it would depend on if the diet were therapeutic and a resident was not supposed to get sugar because he/she are diabetic it could cause his/her blood sugar to rise. She stated she did check the trays in the morning, but she did not check Resident #3's tray because she came late to breakfast. The MDS nurse stated she was not sure if anyone checked Resident #3's tray. Record Review of Essential Functions of the Job for the Dietary Supervisor (no date) revealed review tray card to assure the current food information is consistent with foods served. Inspect special diet trays to ensure that the correct diet was served to residents.

Based on interview, and record review the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for five of five residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in private without uninvited staff being present. Findings Included: In an interview on 03/19/2024 at 10:12 am, the Activity Director when asked to set up Resident Council meeting revealed the Resident Council meetings were held in the dining room. She stated there was not another area for the residents to meet in private. She stated she would place signs on the privacy curtain. She stated she would notify staff before the meeting not to come in or out of the dining room until after the resident group meeting. The Activity Director offered to move the Resident Council meeting to her office so it would be private. In an interview on 03/20/2024 at 10:15am, during a confidential resident group meeting held in the Activity Director's office with five residents revealed their meetings were normally held in the dining room. The residents in attendance of the resident group meeting stated interruptions occurs every- time they had a Resident Council meeting. Residents in the meeting stated that it was disrespectful and that they had informed the Administrator several times, but staff continued to interrupt their council meetings. The residents in the meeting stated they would like some place private to meet. In an interview with the Activity Director on 03/21/2024 at 8:43am revealed that the resident council normally meets in the dining room. She stated she has signs that she puts on the curtain and tells staff they were not to go into the dining room until the meeting is over. She did not say she does anything to prevent the staff from coming in the dining room. She stated that the residents were supposed to have a private place to meet. She stated that they have asked for a more private place, but the facility did not have anywhere else big enough for them to meet. She stated that residents may feel like the facility was not respecting them or the resident may lash out if staff interrupted their meetings. She stated that when staff have interrupted, they would talk to them and inform them that they are not to go into the dining room when the residents are having their meeting. The Activity Director stated she has been trying to get a private place for the residents to meet. In an interview with the Administrator on 03/21/2024 at 11:32am revealed the residents had the right to meet in a private area, and someone must be invited to attend the meeting. He stated the residents may not feel comfortable voicing their concerns. He stated the facility was small and not a lot of room and that he was finding a private place for the residents to meet. Record Review of the Resident Council Policy dated 5/1/2012 revealed it is the responsibility of the Activity Director/Social Services Designee to provide the Resident Council with a private place to meet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for three of six residents (Resident # 26, Resident #32, and Resident #140). 1. The facility failed to ensure Resident #26's facial hair was removed. 2. The facility failed to ensure Residents # 32's and #140's nails were cleaned and trimmed. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1.Record review of Resident #26's face sheet dated, 03/21/2024 reflected she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included cerebral infarction, unspecified (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it), aphasia (unable to comprehend or unable to formulate language because of damage to specific brain regions), and muscle weakness ( a lack of strength in the muscles). Record review of Resident #26's Quarterly MDS assessment, dated 11/09/2023, reflected Resident #26 was never/ rarely understood and was not capable of completing the BIMS questions. Her cognitive patterns were assessed by the staff. Resident #26 had poor short- and long-term memory recall. Resident #26 was dependent on the staff for ADLs including personal hygiene. Record review of Resident #26's Comprehensive Care Plan, dated 03/04/2024 reflected she was rarely/ never understood. Interventions: Anticipate resident needs. Use simple and direct communication to promote understanding. Resident #26 had neurological status (overall condition of the nervous system function) related to aphasia (unable to comprehend or unable to formulate language because of damage to specific brain regions) CVA (a medical condition that occurs when the blood flow to the brain is disrupted due to issues with the arteries that supply it) Intervention: Resident #26 required ADL assistance. Render care as needed. Observation on 03/19/2024 at 9:58 AM revealed Resident #26 was in bed. She had approximately 3-4 inches of white strands of hair on her chin and on both of her cheeks. Interview on 03/19/2024 at 10:00 AM revealed Resident #26 was not interviewable. Interview via telephone on 03/20/2024 at 9:49 AM Resident #26's family member stated she had reported to staff about the facial hair on Resident #26's face. She stated she did not recall when or who she spoke to about her concern of the facial hair. She also stated the staff had time before 03/20/2024 to remove the facial hair on Resident #26. 2. Record review of Resident #32's face sheet, dated 03/20/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (complete loss of movement on one side of the body - hemiparesis is diminished strength, without total paralysis), unspecified lack of coordination ( muscle control problem that causes an inability to coordinate movements), muscle wasting and atrophy, not elsewhere classified, multiple sites ( the loss of muscle mass and strength due to a lack of physical activity or a condition that affects the muscles or nerves), diabetes (elevated levels of blood sugar, which leads over time to serious damage to the heart, blood vessels, eyes, and kidneys), and unspecified dementia ( affects memory, thinking and social abilities). Record review of Resident #32's admission MDS Assessment, dated 03/08/2024, reflected Resident #32 had a BIMS score of a 7 which indicated his cognition was moderately impaired. Resident #32 did not refuse care. He required assistance with ADLs. Resident #32 required supervision or touching assistance with personal hygiene. Record review of Resident #32's Comprehensive Care Plan dated 03/15/2024 reflected Resident #32 had self-care deficit related to hemiplegia to right side (paralysis of the right side of the body), CVA (poor blood flow to the brain) and impaired cognition (a condition where a person has problems with memory, learning, concentration, or decision making). Interventions: Provide supervision and touching assistance with personal hygiene. Resident #32 had diabetes mellitus. Intervention: nails should always be cut straight across, never cut corners, file rough edges with emery board. Observation on 03/19/2024 at 10:54 AM revealed Resident #32 was sitting in his room watching television. The tips of his nails were not trimmed evenly, and his nails were approximately 2 inches long from the top of his fingers on his right hand. Resident #32 had blackish/brownish substance underneath all his nails on his left and right hand. Interview on 03/19/2024 at 10:56 AM Resident #32 stated he asked someone to cut his fingernails, they were rough and not straight. He also stated he asked someone to clean his nails because he did not know what the black stuff was underneath his fingernails. Resident #32 stated he did not recall the name of the person who trimmed and clean his fingernails. He stated he wished someone would trim and clean them because they were dirty. He stated he was afraid to do it because in the past when he cleaned or trimmed his nails his fingernails had green stuff running out of the side of his fingernail. He stated he went to the doctor, and they told him his finger was infected. Resident #32 stated the infection of his finger happened when he lived at home. Interview and observation on 03/20/24 08:00 AM Resident #32 stated my nails are still dirty. They need to be cleaned; can you get someone to clean them sometime this week. I asked few times, and no one has cleaned my nails He stated he did not recall who he asked to clean nails and trim them His nails were dirty underneath all his nails on both hands. Observation on 03/20/2024 at 8:00 AM revealed Resident #32 was in his room lying in bed. His fingernails were still long and rough around the edges of the nails. There were not any changes in his nails since 03/19/2024 at 10:54 AM. The tips of his nails were not trimmed evenly, and his nails was approximately 2 inches long from the top of his fingers on his right hand. Resident #32's nails had blackish/brownish substance underneath all his nails on his left and right hand. Interview on 03/20/2024 at 8:05 AM Resident #32 stated he did ask someone yesterday (3/19/2024) to cut and clean his nails and they said a nurse would need to clean and trim his nails. He stated no one came to his room on 3/19/2024 to clean or cut his nails. He stated he could try to find something and do it himself, but he was afraid of getting his fingers infected. 3. Record review of Resident #140's face sheet, dated 03/20/2024, reflected Resident #140 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included lymphedema (swelling due to build-up fluid in the body), essential hypertension (high blood pressure that is not due to another medical condition), and hyperlipidemia (high level of lipids -like cholesterol in your blood). Record review of Resident #140's MDS admission Assessment revealed it was in progress. Record review of Resident #140's Baseline Care Plan dated 03/17/2024 reflected Resident #140 needed to improve ADL independence. Resident #140 also had barriers to transition such as: bathing, safety awareness, and self-care. Observation on 03/19/2024 at 11:45 AM revealed, Resident #140 was sitting in the small dining room with other residents. Resident #140's nails were approximately 2-3 inches long (from the tip of her finger) on her right and left hand. She had blackish substance underneath all nails on both hands. Interview with Resident #140 on 03/19/2024 at 11:48 AM she stated she wished someone would cut and clean her nails, they looked bad, and she was embarrassed for anyone to see her dirty nails. She stated she did ask someone to clean them but did not recall their name. She stated she was new at the facility and did not know anyone. Observation on 03/20/2024 at 8:30 AM revealed Resident #140's fingernails had not been trimmed or cleaned since observation on 03/19/2024 at 11:48 AM. Resident #140's nails was approximately 2-3 inches long (from the tip of her finger) on her right and left hand. She had blackish substance underneath all nails on both hands. Interview on 03/20/2024 at 8:33 AM Resident #140 stated she thought she had asked someone to cut her nails and clean her nails yesterday and when she came to this place (facility). She stated she was new and did ask someone to cut and clean her nails but did not recall the person's name. Resident #140 stated her nails looked bad and she did not have anything to clean her nails, or she would try to cut and clean her nails. In an interview on 03/21/24 at 08:35 AM CNA A stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed and cleaned nails during showers. She stated the nails can be cleaned or trimmed by nurses or CNAs as needed. CNA A stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. CNA A stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated a resident may need to be assessed at the emergency room if they became severely ill. CNA A also stated if a female resident had facial hair on their face, it was the nursing staff responsibility to remove the hair with tweezers or a razor whichever the resident preferred. CNA A stated if a female resident had facial hair the resident may not want to come out of the room or be around others due to being embarrassed of her appearance. She stated she had been in-serviced on cleaning nails and removing facial hair on ladies. She stated Residents #26, Resident #32 and Resident #140 did not refuse care. In an interview on 03/21/2024 at 08:53 AM, the Administrator stated it was the CNA'S responsibility to do nail care. He stated nail care was expected to be completed during showers and/or as needed. He also stated any resident with a diagnosis of diabetes it was expected that their nails would be trimmed/cut by a nurse. The Administrator stated a resident had a potential of ingesting bacteria into their mouth. He stated there was a possibility a resident may become ill such as vomiting or diarrhea if the black substance was some type of bacteria. The Administrator stated if a female had facial hair, the nursing staff was responsible to remove the facial hair with tweezers. He also stated for a female with facial hair there was a possibility the female may be embarrassed for other people to see her and could be a dignity issue. The Administrator stated the charge nurse was responsible of monitoring the CNAs to ensure personal hygiene was completed daily. Interview on 03/21/24 at 9:22 AM CNA B stated it was the nurses and the CNAs responsibility to trim, cut, and clean residents' fingernails. She stated only the nurses can trim and clean residents with a diagnosis of diabetes. CNA B stated if there was a blackish substance underneath a resident's nails there was a possibility the substance was feces. She stated if a resident placed their finger in their mouth there was a possibility the feces could transfer from their fingers to their mouth. She also stated if the resident swallowed the feces or other bacteria a resident may develop a stomach problems and resident may become dehydrated and the resident may need to be treated at the emergency room. She stated the symptoms of a stomach infection may include the following: diarrhea or vomiting. She stated if a female had facial hair, the facial hair was expected to be trimmed during showers or as needed. She stated a female may not want other people to look at them with hair on their face. CNA B stated a female resident may isolate themselves in their room due to being embarrassed. She also stated the CNAs completed nail care during showers and the CNAs would notify the nurses at that time if a resident with diagnosis of diabetes needed any nail care completed. She stated she had been in serviced on nail care and trimming female facial hair. She could not recall the last time she was in serviced. CNA B stated in the in-service it covered doing nail care on residents in the shower and as needed. Interview on 03/21/24 at 09:50 AM LVN C stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNA's responsibility to clean and trim all other residents' nails. LVN C stated the CNAs report to nurses of any diabetic resident's nails to be cleaned. She stated the nurses makes rounds and check residents, with diabetes, nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. She stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the resident's nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility could be feces or any type of bacteria underneath the resident's nails. LVN C stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. She also stated a resident may become dehydrated and may require to be transfer to hospital for further medical assessment. LVN C stated if a female resident had facial hair the CNAs was expected to remove the facial hair with tweezers and if it was thick facial hair the CNA was to report to the nurse and the nurse would determine how to remove the hair without causing pain to the resident. She stated a female resident may be embarrassed to be around other people if they had facial hair and the resident may develop low self-esteem. She stated if a resident was not able to express, they wanted the hair removed and the family requested the hair to be removed the staff should remove the hair as soon as possible after the family made the request. She stated she had been in serviced on nail care but did not recall the date of the in-service. In an interview on 03/20/2024 at 10:33 AM, the Director of Nurses stated resident's nails were expected to be trimmed on Sunday's, during shower days, or as needed. She stated if a resident had blackish substance underneath the nails and the resident ingested the substance there was a possibility the resident may become ill such as: vomiting or diarrhea. The director of nurses stated if staff see a blackish substance underneath a resident's nails, he expected the nails to be cleaned immediately. She stated only nurses were assigned to trim or clean residents nails with a diagnosis of diabetes. She stated if a female resident had facial hair it was expected to be remove immediately with tweezers or how the resident preferred the hair to be removed. She stated some female residents preferred the hair to be removed with a razor. She stated if a resident was not able to express how they wanted it to be remove or ask for the hair to be removed but the family requested it the staff would ask the family their preference of how they prefer the hair to be removed. She stated if a resident unable to express they have facial hair, and the family knows the resident did not want facial hair. The nurse supervisor was responsible to monitor the nail care and ensure residents were getting personal care. Record review of the facility's Performing Nail Care (undated) reflected the best time to provide nail care was during a patient's bath. Record review of the facility's policy on Hygiene (not dated) reflected prior to implementing any nail care, use clinical judgment to assess and analyze data about any existing or at-risk nail problems. Record review of all the CNAs Competency and Skills Checklist (dated on the hire date of each CNA) reflected the CNAs was trained on nail care, hair care and shaving male and females.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain an Infection Control Program designed to ensure hand hygiene procedures were followed by staff in the direct care of 3 of 3 residents (Resident #10, Resident #26, and Resident #30) reviewed for infection control in that: CNA G and Speech Therapist did not sanitize or wash hands after touching contaminated items before feeding resident or touching residents' food placing residents at risk of food contamination This failure could place all residents at risk of getting sick from staff not performing proper hand hygiene. The findings were: Record review of Resident #10's face-sheet dated 03/21/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Atrial fibrillation, cognitive communication defect, history of falling, diarrhea, lack of coordination, under immunization status, urinary incontinence, abnormal levels of serum enzymes, vitamin D deficiency, constipation, too little calcium in the blood, high levels of fat particles in blood, high blood pressure, heart disease of coronary artery, kidney failure, anemia, heart failure, absence of left leg below the knee, type 2 diabetes. Record review of Resident #26's face-sheet 03/21/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Dementia with other behavior disturbance, bunion on foot, vitamin D deficiency, lack of coordination, infection of skin, abnormal posture, urinary tract infection, history of COVID 19, muscle wasting, insomnia, high blood pressure, difficulty swallowing, difficulty communicating, stroke, repeated falls, and curvature of the spine. Record review of Resident #30's face-sheet 03/21/2024 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Dementia with agitation, chronic constipation, overactive thyroid, difficulty speaking after a stroke, repeated falls, acute heart disease, and depression. Observation of dining services on 03/19/2024 at 12:16pm revealed the Speech Therapist wiped her nose with her right hand. She then picked up the ground fruit cocktail bowl beside Resident #10's plate. When she picked up the fruit cocktail bowel her right ring finger and her middle finger touched inside the bowl. The Speech Therapist used her ring finger on her right hand to wipe her nose. She did not use a Kleenex or wash her hands before touching Resident #10's fruit cocktail bowel. Observation of dining services on 03/19/2024 at 12:21pm revealed CNA G touched her clothes with her right hand and proceeded to cut Resident #30's hamburger placing her whole palm of her right hand on the top bun and cutting into fourths. CNA G did not wash or sanitize her hands after touching her clothing. CNA G than touched the carpet looking material on the column in the small dining room that had a brown stain on it. CNA G then touched her clothing again. She then proceeded to roll a chair from behind the nurses' station to the small dining room beside Resident #26. CNA G touched a regular chair back and the arms of the two different wheelchairs. CNA G did not was or sanitize her hands after any of the mentioned tasks. CNA G did not sanitize or wash her hands and proceeded to touch the hands of two residents. CNA G sat to feed Resident #26 and cut the resident's burger placing her hand on the hamburger bun while cutting it. She still did not sanitize or wash her hands. CNA G fed Resident #26 the hamburger that she touched with her right hand. Interview with CNA G on 03/21/2024 at 9:31am revealed she had been trained on hand hygiene. She stated that staff were supposed to wash their hands before they touch a tray, anytime they touch something or their clothing. CNA G stated that if staff do not wash or sanitize their hands before touching a tray or after touching something they could cause contamination of the food and the residents could get sick. She stated she did not realize she had not sanitized her hands before touching Resident #26 and Resident #30's food. CNA G stated she wanted to get Resident #26's food cut so she could start eating. Interview with the Speech Therapist on 03/21/2024 at 9:40am revealed that she was trained on hand hygiene. She stated that staff were supposed to wash their hands after every resident and not touch food until you have washed your hands. The Speech Therapist stated that if staff do not wash their hands infections can spread. She stated she did not realize that she had wiped her nose and then touched Resident #10's fruit cocktail. She said that her allergies were bad and if she did not wipe her nose would drip. She stated that she knew better then to not wash her hands after touching her nose. Interview with the Administrator on 03/21/2024 at 11:32am revealed all staff had been trained on hand hygiene. He stated that hand hygiene was covered monthly. He stated that they cover with staff how long they were to wash their hands, how often, the twenty second rule and the reason. The Administrator also stated that he expects all staff to follow the policy. He stated if staff do not wash their hands or change their gloves then it could cause residents to get sick or spread infections. Record Review of the Infection Control Standard Precautions Policy dated 2022 revealed standard precautions are recommended practice for the care of all patients and residents receiving care in the facility. Standard Precautions include hand hygiene before and after patient/resident contact including after gloves are removed. Record Review of the facility policy titled Hand Hygiene Steps no date reviewed with staff revealed the following: When decontaminating hands with an alcohol-based hand rub: Apply product to palm of one hand. Rub together covering all surfaces of the hands and fingers. Rub until hands are dry. Follow the manufacturer's recommendations regarding the volume of the product. When washing hands with soap and water: Wet hands first with water. Apply an amount of product recommended by the manufacturer to hands. Rub together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for foods safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure employees were sanitizing their hands in between tasks. This failure placed residents at risk of foodborne illness. Findings included: Observation of the kitchen on 03/19/2024 at 11:35am revealed CK F did not sanitize or wash her hands after getting the Puree blender from the dishwasher. CK F also did not change her gloves or sanitize or wash her hands after taking the hamburger meat out of the oven. It was also revealed that CK F picked up the pan the hamburger meat was in and folded up the paper liner and threw it away and did not change her gloves afterwards. Observation of CK F on 03/20/2024 at 10:35am revealed that CK F pureed the ham and touched the outside of the recipe manual and touched the recipe pages. CK F continued to puree the ham after touching the recipe manual and pages without changing her gloves. CK F proceeded to move from the prep table and open the oven door and back to the area where she was pureeing the ham. She placed her fore finger and middle finger on her right hand in the container of the puree ham. CK F did not change her gloves between tasks. Interview with the Corporate Dietary Manager on 03/20/2024 at 10:55am revealed CK F was expected to change her gloves after she touched the recipe manual. The Corporate Dietary Manger stated when the cook touched the oven door and the recipe manual CK F was to remove her gloves and wash her hands and place new gloves on. She stated the oven door, and the manual were considered contaminated. Interview with the Dietary Manager on 03/21/2024 at 9:09am revealed she was responsible for all staff in the kitchen and overseeing that they were following policy and procedures. She stated staff had been trained on how to wash their hands and when they should wash their hands. She stated that staff were to wash their hands after each task to prevent cross contamination. The Dietary Manager stated failing to wash or change gloves after each task could put the residents at risk of getting sick. She stated that hand washing is covered every month with the kitchen staff. Interview with the Administrator on 03/21/2024 at 11:32am revealed all staff had been trained on hand hygiene. He stated that hand hygiene was covered monthly. He stated that they cover with staff how long they were to wash their hands, how often, the twenty second rule and the reason. The Administrator also stated that he expects all staff to follow the policy. He stated if staff do not wash their hands or change their gloves then it could cause residents to get sick or spread infections. Record Review of the Food Preparation Policy dated 2/2023 revealed all staff will practice proper hand washing techniques and glove use. Record Review of facility policy titled Hand Hygiene Steps no date that is covered with staff revealed the following: When decontaminating hands with an alcohol-based hand rub: Apply product to palm of one hand. Rub together covering all surfaces of the hands and fingers. Rub until hands are dry. Follow the manufacturer's recommendations regarding the volume of the product. When washing hands with soap and water: Wet hands first with water. Apply an amount of product recommended by the manufacturer to hands. Rub together vigorously for at least 20 seconds covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for two (Resident #1 and Resident #2) out of five residents reviewed for showers, in that: The facility failed to provide showers to Resident #1 and Resident #2 in compliance with their shower schedules. This failure placed residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including end-stage renal disease, type II diabetes, chronic obstructive pulmonary disease (a type of progressive lung disease), and depression. Review of Resident #1's admission MDS assessment, dated 11/13/23, reflected a BIMS of 13, indicating no cognitive impairment. Section G (Functional Status) reflected she required extensive assistance with all ADLs. Review of Resident #1's admission care plan, dated 11/08/23, reflected she had a physical functioning deficit with transfers and required assistance of two people. Review of Resident #1's bathing task in her EMR, from 11/05/23 - 11/14/23, reflected no documentation that a shower/bath had been given. Review of the facility's shower sheets for the month of November 2023, reflected one documented shower sheet for Resident #1 dated 11/09/23. During and observation and interview on 11/14/23 at 9:02 AM revealed Resident #1 was in her room sitting on her bed with her head down. She stated she was upset because she felt dirty. She stated when she was given a shower it was always rushed but she rarely got one. She stated she could not remember the last time she received one and it made her feel bad. Review of Resident #2's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including unspecified dementia, muscle wasting and atrophy (wasting away), bed confinement, need for assistance with personal care, and age-related physical debility. Review of Resident #2's admission MDS assessment, dated 09/20/23, reflected a BIMS of 14, indicating no cognitive impairment. Section G (Functional Status) reflected she was totally dependent for ADL care. Review of Resident #2's admission care plan, dated 09/28/23, reflected she had an ADL self-care performance deficit related to lateral sclerosis (a nervous system disease that affects nerve cells in the brain and spinal cord) with lower extremity paraplegia (paralysis of all or part of your trunk, legs, and pelvic organs) with an intervention of extensive assistance from 1-2 staff with ADLs. Review of Resident #2's bathing task in her EMR, from 10/14/23 - 11/14/23, reflected she received four bed baths on 10/17/23, 10/26/23, 11/02/23, and 11/07/23. Review of the facility's shower sheets for the month of November 2023, reflected no documented shower sheets for Resident #2. During an observation and interview on 11/14/23 at 9:09 AM revealed Resident #2 in bed watching television. Her hair and face were greasy. She stated the aides used to give her bed baths, which she prefers, but they stopped weeks ago. She stated she know obtained her own wipes and tried to wash her chest and arm pits but that was all she could reach. She stated not getting a full bed bath regularly made her feel bad and not too clean. During an interview on 11/14/23 at 10:22 AM, CNA A stated she felt like they were short-staffed and it was hard to get all showers completed and there were some days residents would go without. She stated the aides documented showers in the kiosk and filled out shower sheets. During an interview on 11/14/23 at 12:26 PM, the DON stated it was her responsibility to ensure showers were being given and shower sheets were filed in the binder at the nurses' station. She stated she tried to review the binder every couple of days. She stated the aides were supposed to document showers in the kiosk and on the shower sheets. She stated if a resident refused a shower, the aides were to notify the nurses so they could try encouraging the resident and could document the refusal in their chart. She stated refusals were also to be documented on shower sheets. She stated a potential outcome of not receiving showers regularly was there would be a higher risk of infection. She stated they did not have a policy on ADL care or showers.