**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #24) reviewed for care plans in that: Resident #24 did not have a care plan addressing the use of her ankle splint. This failure could affect resident by placing her at risk of not receiving individualized care and services to meet her needs. The findings included: Review of Resident #24's admission Record dated 9/26/24 revealed she was a [AGE] year-old female admitted to the facility for paralysis following a stroke affecting her dominant side. Review of Resident #24's Quarterly MDS Assessment, dated 9/12/24 revealed: She scored a 13 of 15 on her mental status exam (indicating she was cognitively intact); She had range of motion impairment of the upper and lower extremities on one side; She used a walker and wheelchair; She needed supervision to walk 150 feet. She received 170 minutes of physical therapy in the previous 7 days. Splint use was not identified. Review of Resident #24 Care Plan, last reviewed 9/19/24, revealed no care plan for the splint. Review of Resident #24' 9/26/24 revealed no order for the splint. Observation and interview on 9/24/24 at 10:26 a.m. revealed Resident #24 had a hard ankle splint at the end of her bed. Resident #24 stated it was bed because she had a stroke, and her foot did not work right. In an interview on 09/26/24 at 1:38 PM the MDS Coordinator and DON stated Resident #24 was a stroke victim who came to the facility within the last three months. The DON stated Resident #24's main issue was balance. The DON stated Resident #24 used a specialized walker with therapy and an electric wheelchair when not with therapy. The DON stated Resident #24 did have a brace. The MDS Coordinator stated she was unaware of a brace. The DON told the MDS Coordinator it was to prevent drop foot (a condition where the front of the foot/toes drag). The MDS Coordinator said she did not see the brace on Resident #24's care plan or MDS. The MDS Coordinator stated Resident #24 just had a care plan update on 9/19/24. The DON said Resident #24 came in with the brace, but now that surveyor asked, she could picture Resident #24 wearing it. The DON stated Resident #24 took it on and off at will. Review of the facility's policy and procedure on Care Planning - Interdisciplinary Team, revised March 2022, revealed: The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation. Resident care plans are developed according to the timeframes and criteria established by regulation. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. Review of the facility's policy and procedure on Resident Mobility and Range of Motion, revised July 2017, revealed: Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents reviewed for quality of care. (Resident #24) The facility did not assess, obtain orders or monitor Resident #24's ankle splint. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #24's admission Record dated 9/26/24 revealed she was a [AGE] year-old female admitted to the facility for paralysis following a stroke affecting her dominant side. Review of Resident #24's Quarterly MDS Assessment, dated 9/12/24 revealed: She scored a 13 of 15 on her mental status exam (indicating she was cognitively intact); She had range of motion impairment of the upper and lower extremities on one side; She used a walker and wheelchair; She needed supervision to walk 150 feet. She received 170 minutes of physical therapy in the previous 7 days. Splint use was not identified. Review of Resident #24 Care Plan, last reviewed 9/19/24, revealed no care plan for the splint. Review of Resident #24's Order Summary Report, dated 9/26/24, revealed orders: There was no order for the ankle splint. OT/PT evaluate and treat for decline in personal hygiene, toileting and bed mobility beginning 6/17/24. Observation and interview on 9/24/24 at 10:26 a.m. revealed Resident #24 had an ankle splint at the end of her bed. Resident #24 stated it was bed because she had a stroke, and her foot did not work right. In an interview on 09/26/24 at 01:38 PM the MDS Coordinator and DON stated Resident #24 was a stroke victim who came to the facility within the last three months. The DON stated Resident #24's main issue was balance. The DON stated Resident #24 used a specialized walker with therapy and an electric wheelchair when not with therapy. The DON stated Resident #24 did have a brace. The MDS Coordinator stated she was unaware of a brace. The DON told the MDS Coordinator it was to prevent drop foot (a condition where the front of the foot/toes drag). The MDS Coordinator said she did not see the brace on Resident #24's care plan or MDS. The MDS Coordinator stated Resident #24 just had a care plan update on 9/19/24. The DON said Resident #24 came in with the brace, but now that surveyor asked, she could picture Resident #24 wearing it. The DON stated Resident #24 took it on and off at will. The DON said the nurses checked Resident #24's skin to make sure there was no break down from the brace. In an interview on 09/26/24 at 01:48 PM the DON said Resident #24 got the splint from an outpatient rehabilitation provider prior to coming to the facility. The DON said the staff were aware Resident #24 had the splint but were not aware that therapy did not initiate the order for the splint. The DON said Resident #24 could take the splint on and off at will so she was probably not wearing it when Resident #24 was admitted . In an interview on 09/26/24 at 01:56 PM the DON stated the therapist who originally worked with Resident #24 and was aware of the splint no longer worked with the facility. The DON said the nurses were educated about taking on and off the splint and checking skin integrity. The DON said they called for orders that just didn't get initiated here. Review of the facility's policy and procedure on Resident Mobility and Range of Motion, revised July 2017, revealed: Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. During the resident's assessment, the nurse will identify the underlying factors that contribute to his or her range of motion or mobility problems, if any, including: conditions that limit or immobilize movement of limbs or digits (e.g. splints). The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency and duration of interventions, as well as measurable goals and objectives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #19) of 6 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was on Resident #19's doorway. This failure could place residents at risk of not receiving appropriate respiratory care. The findings were: Record review of Resident #19 's admission record dated 09/26/2024 revealed Resident #19 was a [AGE] year-old male with an admission date to the facility of 07/19/2024. admission record revealed Resident #19 had diagnoses that included Chronic obstructive pulmonary disease (progressive lung disease characterized by chronic respiratory symptoms and airflow limitation), shortness of breath, heart failure, dependence on supplemental oxygen, and muscle weakness. Record review of Resident #19 's MDS revealed the resident had a BIMS of 14 indicating the resident was cognitively intact. Record review of Resident #19 's order summary dated 09/26/24 revealed an order of OXYGEN AT 2-5 LITERS PER NASAL CANNULA. every day and night shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED (COPD). Record review of Resident #19 's Care plan dated 08/15/2024 revealed a focus of is dependent on staff for meeting physical and social needs. He has Heart Failure. SOB (Shortness of breath) r/t (Related to) COPD and is on oxygen. chooses not to attend activities or monthly events. He prefers to stay in his room. Observation on 09/24/24 at 09:52 AM during revealed that there was not a No smoking oxygen in use sign on Resident #19's door. Interview on 09/26/24 at 01:55 PM the DON stated that the residents who had an oxygen sign on the doorway was to inform anyone who entered the resident's, room that the resident was on oxygen. The DON stated that the sign was for safety, even though no one was supposed to smoke inside the facility, they had to put the sign indicating there was a combustible material in the room. The DON stated the sign was on the room that Resident #19 was in previously to being moved on 09/11/2024. The DON states that the medical record staff was responsible for ensuring the residents had a No smoking oxygen in use sign on the door. Interview on 09/26/24 at 02:16 PM with the Medical Records, stated that she was responsible for ensuring the residents who were admitted into the facility that were on oxygen received the sign for the door. The Medical Records stated that she was aware that the resident had moved rooms but did not know the sign was not moved. The Medical Records stated that if the residents were moved when she was off that the floor staff would move the sign to the new room. The Medical Records stated that the sign was used to indicate who was using oxygen in the building. The Medical Records did not think there was a negative outcome of not having the sign on the door. Record review of the facility's policy titled Oxygen Administration with a revision date of October 2010 revealed that under the section steps in the procedure - 2. Place an Oxygen in Use sign on the outside of the room entrance door.

Deficiency Text Not Available

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's one of one kitchen. The facility failed to ensure: Food debris was not on the floor in the freezer. Staff did not transport dishes by holding them against their body. Staff completed hand hygiene appropriately. Dishes were stored in a manner to prevent contamination. Prevention of contamination of salad bar containers by staff handling practices. Frozen meat was stored in a manner to prevent contamination in the event of thawing. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination. Findings included: Observation on 9/24/24 between 9:18 a.m. and 9:36 a.m. revealed: Bowls stored against the long wall of the kitchen were stored face up. The outside walk-in refrigerator had a bucket of pickles on the ground. The walk-in freezer had meat stored over vegetables and bread. The dry storage had individual serving of jelly and packets of sugar on the floor under the shelves. The inside of the walk-in refrigerator had a brisket thawing over pickles, eggs and bacon. During the noon meal preparation on 9/25/24 beginning at 9:50 a.m. and 11:35 a.m. revealed: Cook B was observed washing her hands turning off the faucet with her bare hands three times. DA D had a stack of dishes she was putting up from the clean dish area. DA D had the plates stacked directly against her body as she brought them to the storage area. DA C had containers for the salad bar that she carried from the clean dish area to the food preparation area with her bare hands and her fingers in each container touching the food surface. DA D returned from outside of the kitchen, did not wash her hands, did don gloves and continued with food preparation. In an interview on 9/26/24 at 2:03 p.m. the Dietary Manager said the staff knew to have dishes face down, she clarified which bowls were face up and stated those were the bowls used for the salad bowls. The Dietary Manager said the pickle bucket was the only thing that would be on the floor in the refrigerator, but everything needed to be at least six inches off the floor due to contamination. The Dietary Manager said staff needed to wash their hands when they returned in from the kitchen due to cross contamination issues. The Dietary Manager asked for clarification on the salad bar container food surface being touched all at once, she said she had previously had numerous conversations with that staff member about that and that putting clean dishes against dirty scrubs just contaminated the dishes. The Dietary Manager said it did not matter what kind of container the meat was being thawed in it still could not be thawed over other food. In an interview on 9/26/24 at 2:22 p.m. the Administrator was informed of the kitchen observations, he stated they were pretty straight forward, and they would monitor it. Review of the Cleaning Schedule revealed the cook was responsible for cleaning the refrigerator and freezer and the outside coolers were last documented as completed on 9/24/24. Review of the 5/24/24 in-service on Maintaining a Clean Kitchen revealed: food items are not stored on the floor. Example of Monthly list: clean under and behind equipment Review of the Dietary In-service dated 1/25/24 revealed: Dry storage - what items, how far off the ground and proper storage methods. Store food at least 6 inches from the floor to prevent contamination and allow cleaning. Cold Storage - Don't store any items on the floor. Keeping appliances and equipment clean - cleaning interior and exterior Floors - keeping floors free of debris and trash to prevent accidents and help to prevent rodent and pest infestations. Keeping interior walk-ins free of spills, meat or food drippings etc. Personal Hygiene - when and how often to wash hands. Avoid cross-contamination - letting microorganisms from one food get into another store meats on the bottom shelf of your refrigerator so juices will not contaminate other foods.

Based on observation, interview, 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 residents, for 1 of 2 Medication Carts and 1 of 2 Treatment Carts reviewed for pharmacy services. - The facility failed to ensure the Medication Cart did not include the following expired medications: Eszopiclone 1 mg tablets, Olmesartan Medoxomil 40mg tablets, Aspirin 81mg, and Carboxymethylcellulose Sodium 0.5% lubricating eye drops. These failures could place residents at risk of receiving expired medications. Findings included: Medication Cart In an observation on 08/16/23 at 09:18AM, inventory of the Medication Cart with LVN A revealed: - one card (28 tablets) of Eszopiclone 1mg, expired 05/17/23 - one card (30 tablets) of Olmesartan Medoxomil 40mg, expired 07/23 - one bottle (29 tablets) of Aspirin 81mg, expired 02/22 - one opened box (4 sealed packages inside) of Carboxymethylcellulose Sodium Lubricating eye drops Single Use, expired 05/23 In an interview on 08/16/23 at 10:40 AM, the LVN stated the carts are checked for expired medications one time monthly. The LVN stated they try to check the carts for expired medications before the Pharmacist comes each month. The LVN stated there was no documentation to validate if the medication cart had been checked for expired medications. The LVN stated she knew the importance of checking the expiration date prior to administration. In an interview on 08/17/23 at 10:55 AM, the DON stated the Pharmacist month and reviews the medications in the medication carts and medication room storage areas for expiration dates. The DON stated the CNA's review the medication carts weekly for expired medications and review the medication expiration dates as they are being administered. Review of the facility policy titled Storage of Medications revised April 2019, reads in part: Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in locked compartments , for 1 of 2 Medication Carts and 1 of 2 Treatment Carts reviewed for pharmacy services. - The facility failed to ensure the Medication Cart did not include the following medications found loose in the medication drawer: Gabapentin 100mg x 2 capsules, Namenda 10 mg x 1 tablet, Buspar 15 mg x 1 tablet and Buspar 5mg x 1 tablet. - The Treatment Cart was unlocked and had Insulin, Oral Glucose, syringes, and lancets. These failures could place residents at risk of receiving expired medications. Findings included: Medication Cart In an observation on 08/16/23 at 09:18AM, inventory of the Medication Cart with LVN A revealed: - two capsules of Gabapentin 100 mg, found loose in medication drawer - one tablet of Namenda 10 mg found loose in medication drawer - one tablet of Buspar 15 mg found loose in medication drawer - one tablet of Buspar 5 mg found loose in medication drawer Treatment Cart In an observation on 08/15/23 10:00AM, the treatment cart was found unlocked. The following items were identified: Top Drawer: - 2 tubes Oral glucose gel lemon flavored 15 grams - 6 packages of Sani-Cloth Germicidal Disposable Wipes - 1 pen Novolog Flex Pen 100Units/ML (Insulin) Second Drawer: - 1 box of approximately 33 count Insulin pen needles - 1 box of approximately 50 count Lancets Fourth drawer: - 2 boxes of 100 count lancets - One box of approximately 100 count 1ml Insulin Safety Syringes In an interview on 08/16/23 at 10:40 AM, the LVN stated the loose pills in the cart were a result of the cards coming loose or missing the cups when pills were being popped out of the cards. The LVN stated she knew the importance of keeping the medication carts and treatment carts locked when not in use. In an interview on 08/17/23 at 10:55 AM, the DON stated she believed the loose pills were related to accidental puncture of the cards as well as excessive inventory in the medication cart storage areas. The DON also stated the reason the treatment cart was open was because the nurse responsible for that cart was busy with a resident admission and it was an oversight. The DON stated all nurses know the medication carts and treatment carts must be always locked when not in use. Review of the facility policy titled Storage of Medications revised April 2019, reads in part: Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.

Based on observations, interviews and record review it was determined the facility failed to ensure medications were discarded when expired and dated when opened for 2 of 2 medication rooms reviewed for pharmacy services in that: The east hall medication room refrigerator had a Tuberculin vial that was not dated when opened. The west hall medication room refrigerator had a Tuberculin vial that was expired. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: During an observation and interview on 07/13/22 at 04:20 PM, an inspection of the facility east side medication room was conducted with LVN A present. There was a small refrigerator that contained several medications to include a 1 ml Tuberculin vial that had been opened but not dated. LVN A said she would have to dispose of that vial as it did not have an open date on it. LVN A said she was not aware of the vial not being dated. During an observation and interview on 07/13/22 at 04:38 PM, an inspection of the facility west side medication room was conducted with LVN B present. There was a small refrigerator that contained several medications to include a 1 ml Tuberculin vial that had been opened and dated 06/07/22. LVN B said the vial was expired as it had been over 30 days since it was opened. LVN B said she was aware of the Tuberculin only being good for 30 days after being opened and had just now noticed it was expired. LVN B said she would dispose of the vial and said that it was their responsibility to keep up with removing the expired medications from the medication room. During an interview on 07/14/22 at 02:10 PM, the DON said it was everyone's responsibility to keep up with the medications in the medication rooms to include removing expired meds. The DON said there was no one person assigned to keep up with inspecting the medication rooms. The DON said the issue occurred because there was no one assigned to inspect the medication room for expired medications or medications that were not dated when opened. The DON said expired and none dated Tuberculin solutions could lead to false positives and staff not aware as to when a none dated vial was expected to expire. During an interview on 07/14/22 at 02:24 PM, the Administrator said it was every nursing staff's responsibility to remove medications that had expired or had not been dated when opened from the medication room. The Administrator said he believed the failure occurred because there was no one specifically assigned to keep up with removing the expired or none dated medications from the medication room. The Administrator said expired or none dated Tuberculin solutions could lead to false test results. Record review of the Tuberculin vial manufacturers instructional pamphlet dated April 2016, indicated in part: Storage - A vial of Tubersol which has been entered and in use for 30 days should be discarded. Record review of the facility's policy titled Storage of medications and dated April 2019 indicated in part: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure: Holding temperatures for 8 dishes were taken of the meal prior to serving; Food was labeled and dated so they could be thrown out when appropriate; Food in the walk-in refrigerator was sealed to prevent contamination and was left open to air. These deficient practices could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination. Findings included: Observation beginning 7/12/22 between 10:15 AM and 10:45 AM of the facility's only kitchen revealed: The walk-in refrigerator had: macaroni salad dated 6/5/22; A bag of cheese dated 7/2 but open to air; A pan of pears labeled as expired 7/7; A pan of guacamole that was completely brown. The FSS stated As much as I love guacamole, I wouldn't eat it A baking sheet of bacon dated 7/13 but open to air - The FSS agreed it was open to air. The dishwashing area had a particle board backing on the wall that was bubbled up indicating it was porous and not sanitizable from water exposure. The dishwasher was rusted. [NAME] C stated the dishwasher was new. Observation on 7/12/22 between 11:35 AM and 12:46 PM of the noon meal preparation and meal service revealed: Cook C made the regular, mechanical soft, and puree meals and placed them in a pan. At 12:14 PM she began to serve the meal. She did not take the holding temperature of the regular protein, the mechanical soft protein, either kind of pureed protein (pudding thick or regular puree). She did not take the holding temperature of the BBQ beans - regular, the pudding thick puree or the regular puree. She did not take the temperature of the regular potato salad. (For a total of 8 of 9 dishes not having their holding temperature taken). Interview on 7/13/22 at 1:51 PM, [NAME] C stated she usually worked as the cook in the facility and had since 12/2021. [NAME] C stated she took temperatures of the food prior to putting it on the steam table. She stated she did not take temperatures of the puree food because she was thinking it would be the same as the food on the steam table but when she thought about it said, it would be because of the water. She said she did not take holding temperatures of the noon meal. [NAME] C stated the particle board on the back of the dirty dish area was bubbled and up and was hard enough to get clean She stated it had been that way since the facility got the new dishwasher in 3/2022 or 4/2022. Interview on 7/14/22 at 1:29 PM, the FSS said she was responsible for ensuring that temperatures of the food were taken. She stated [NAME] C missed the temperature on the potato salad. The FSS stated the food that was open to air and/or out of date was not normal practice. She said the food was checked daily. The FSS said that on 7/12/22 she was getting ready for care plans and did not make it into the refrigerator to check the dates. The FSS said the board on the back of the wall was not particle board and it was supposed to be sanitizable but did say if it's bubbling up at the edges it needs to be replaced. Interview and observation on 7/14/22 at 01:57 PM, the Administrator was informed of the kitchen findings and shown the dirty dish area with the rusted dishwasher and the back wall. He was showed the dishwasher and back wall over dish area. He said ok to the back wall. The Administrator said the facility just replaced the dishwasher but did state the facility's water was very hard, so they used a lot of salt in the water softener. Review of the facility's policy and procedure on Food receiving and Storage, undated, documented: Foods shall be received and stored in a manner that complies with safe food handling practices. Food Services/designee will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled and dated with an open date and a use by date. Food that has been served to residents without temperature controls will be discarded if not eaten within two hours.