Based on record review and staff interview, the facility failed to submit a Five-Day Follow-Up Investigation report to the required agencies following an Initial Reporting of Allegations. This failed practice had the potential to affect a limited number of residents. Facility census: 54. Findings included: a) On 05/13/25, a Facility Reported Incident (FRI) dated 09/24/24 was reviewed. Fax confirmation sheets were not found for the Five-Day Follow-Up Investigation. On 05/13/25 at 12:24 PM, the Administrator confirmed they did not have the fax confirmation sheets. The Administrator asked the state surveyor to contact the Office of Health Facility Licensure and Certification (OHFLAC) to obtain the Five-Day Follow-Up. The state surveyor replied OHFLAC did not have the follow-up investigation on file. The Administrator stated, I'll go look for it. The Administrator stated she was going to contact the fax company to see if they can trace the job number. No additional information was provided.

Based on staff interview and observation the facility failed to post, in a form and manner accessible and understandable to residents a list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, and the Medicaid Fraud Control Unit. This deficient practice had the potential to affect a limited number of residents in the facility. Resident #16. Resident census: 60. Findings included: a) Required Postings Observation on 10/02/24 at 9:00 AM found the required postings were placed high on the wall. During an interview with Resident #16, on 10/02/24 at 10:45 AM, the resident was asked to read the required postings from her wheelchair. Resident #16 responded by saying, That's way too high!!! I can't see that from here. During an interview, on 10/02/24 at approximately 11:00 AM, the Administrator acknowledged that the required posting was too high for residents in a wheelchair to be able to read.

Based on record review and staff interview, the facility failed to provide evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: 22. Facility census: 60. Findings included: a) Resident #22 On 10/01/24 at 2:08 PM, a review was completed regarding the beneficiary protection notification liability notice(s) given for Resident #22 who was discharged to home following her last covered day of Medicare Part A services. Resident #22's last covered day of Part A Services was on 04/05/24. The facility failed to produce evidence that the required Notification of Medicare Non-Coverage (NOMNC) was issued. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 state: The NOMNC must be delivered at least two calendar days before Medicare covered services end . The instructions also state: A NOMNC must be delivered even if the beneficiary agrees with the termination of services. On 10/01/24 at 2:30 PM, the Director of Rehab stated that Resident #22 had met her goals in therapy and was ready to be discharged home since she was performing at her baseline. During an interview, on 10/01/24 at 3:15 PM, the Business Office Manager acknowledged the facility was unable to provide evidence that the appropriate notice was issued to Resident #22 prior to her last covered day of Medicare Part A skilled services and subsequent discharge to home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to honor a resident's right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure the bathroom door and a wall in a resident room were in good repair. Room identifier: 205. Facility Census: 60. Findings included: a) room [ROOM NUMBER] On 09/30/24 at 3:40 PM, it was observed that the lower section of the bathroom door in room [ROOM NUMBER] had many multiple scrapes and scratches on it. In addition, the wall to the right of the sink in room [ROOM NUMBER] had what appeared to have been four (4) nail holes that had been plastered over leaving uneven, rough splotches on the wall in the shape of a bow tie approximately two (2) feet wide. During an interview, on 10/01/24 at 3:40 PM, the Director of Maintenance acknowledged the patched wall was visible from the hallway and did not honor the residents' right to a homelike environment. When asked, the Director of maintenance reported the wall had been patched approximately four (4) or five (5) months ago when an old towel rack had been taken down. He also stated the room was on the list to be painted. Additionally, he reported that the facility had identified the need to place a new order for the bathroom door to be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a written Notice of Transfer / Discharge was provided to the long-term care Ombudsman for one (1) of two (2) residents reviewed for hospitalizations during the long-term care survey process. This had the potential to affect all residents being transferred or discharged . Resident identifier: 57. Facility census: 60. Findings included: a) Resident #57 A medical record review was completed on 10/01/24 at 12:43 PM. The record review revealed Resident #57 was transferred to the hospital on [DATE]. The record reflected the resident/resident's representative was provided with a written Notice of Transfer indicating the reason for transfer, the effective date of transfer, the location to which the resident was being transferred, and a statement of the resident's appeal rights. There was nothing in the electronic medical record to indicate the long-term care Ombudsman had been notified. During an interview on 10/01/24 at 2:55 PM, the Administrator reported the facility could produce no evidence that the long-term care Ombudsman was notified of the transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to coordinate with the appropriate, State-designated authority, to ensure individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs. This was true for one (1) of three (3) residents reviewed during the survey process. Resident identifier: #12. Facility Census: 60. Findings included: a) Resident #12 Record review on 10/01/24 at approximately 2:30 PM revealed that the resident was admitted to the facility on [DATE] with no diagnosis of a Level II mental illness. Record review indicated Resident #12 was diagnosed with Major Depressive Disorder on 7/31/24, and the PASARR was not revised to reflect this diagnosis. During an interview with the Admissions Director (AD) #14, and the Executive Director (ED) #79 on 10/01/24 at approximately 3:30 PM, they reviewed Resident #12's records and confirmed that the PASARR had not been revised to reflect the new diagnosis of Major Depressive Disorder.

. Based on observation, record review, and interview, the facility failed to provide proper care and treatment, including assistive devices, to prevent a decline, maintain, or improve the resident's communication abilities, or other functional communication system. This was a random opportunity for discovery. Resident Identifier: #44. Facility Census: 60. Findings included: a) Resident #44 During the initial brief screening process on 09/30/24 at approximately 1:16 PM, Resident #44 gestured that he was unable to converse with this surveyor because he did not have his hearing aid. Upon being asked where his hearing aid was, the resident managed to imply that his hearing aid was broken. Resident motioned that he was unsure when he had lost the use of his hearing aid. Further investigation, and an interview with Licensed Practical Nurse (LPN) #24 on 10/01/24 at approximately 3:08 PM, revealed that resident's broken hearing aid had been turned into the nursing staff on 09/03/24. LPN #24 then produced a blue sticky tab dated 09/02 with a hearing aid taped to it. A review of Facility's grievance policy on 10/01/24 revealed the following statement: Grievances will be resolved in a reasonable time frame, generally within 5 business days, consistent with the type of grievance. A review of Resident #44's care plan on 10/01/24 at approximately 3:00 PM, found no information regarding the use of a hearing aid. During an interview with the facility's Executive Director (ED) #79 on 10/01/24 at approximately 3:11 PM, related to Resident #44's hearing aid, and any orders or appointments related to his hearing, the ED #79 produced the following documents, and stated that they were all the documentation she had on resident's appointments and hearing aid. a) A nursing note dated 08/02/24 at 11:17 AM by LPN #27 which stated: Resident left at this time to go to appointment with (hospital name) Audiology. Transported by facility van. b) Another nursing note, also dated 08/02/24 at 1:16 PM, by LPN #27 which stated: Resident returned from appointment at this time, no new orders follow up appointment on June 2, 2025, at 12:30. c) A handwritten note that stated: [Resident #44] 9/30/24 - Eye Center @ the (hospital name) 2/11/25 @ 8 AM - May see Audiology 8a -2p to get hearing aid checked Walk in Clinic Further record review confirmed the eye center appointment in a nursing note dated 9/30/2024 at 12:16 PM which stated: Residents eye center appointment at the (clinic name) Clinic rescheduled to 2/11/25 at 8 am facility to transport. Message left for MPOA to call facility to be updated on new orders. The results of this investigation reveal that the facility had made no effort to schedule appointments, or provide services, to prevent a decline, maintain, or improve the resident's communication abilities, or other functional communication system.

Based on observation, record review, and interview, the facility failed to ensure the resident received the proper treatment and assistive devices to maintain his hearing abilities. This was a random opportunity for discovery. Resident identifier: #44. Facility Census: 60. Findings include: a) Resident #44 During the initial brief screening process on 09/30/24 at approximately 1:16 PM, Resident #44 gestured that he was unable to converse with this surveyor because he did not have his hearing aid. Upon being asked where his hearing aid was, the resident managed to imply that his hearing aid was broken. The resident motioned that he was unsure when he had lost the use of his hearing aid. An interview with Licensed Practical Nurse (LPN) #24 on 10/01/24 at approximately 3:08 PM, revealed that the resident's broken hearing aid had been turned into the nursing staff on 09/03/24. LPN #24 then produced a blue sticky tab dated 09/02/24 with a hearing aid taped to it. A review of Facility's grievance policy on 10/01/24 revealed the following statement: Grievances will be resolved in a reasonable time frame, generally within 5 business days, consistent with the type of grievance. Further record review revealed no notes, or interventions, regarding resident's hearing aid. During an interview with the facility's Executive Director (ED) #79 on 10/01/24 at approximately 3:11 PM, related to Resident #44's hearing aid, and any orders or appointments related to his hearing, ED #79 produced the following documents, and stated that they were all the documentation she had on resident's appointments and hearing aid. a) A nursing note dated 08/02/24 at 11:17 AM by LPN #27 which stated: Resident left at this time to go to appointment with VA Audiology. Transported by facility van. b) Another nursing note also dated 08/02/24 at 1:16 PM by LPN #27 which stated: Resident returned from appointment at this time, no new orders follow up appointment on June 2, 2025, at 12:30. c) A handwritten note that stated: [Resident #44] 9/30/24 - Eye Center @ the VA 2/11/25 @ 8 AM - May see Audiology 8a -2p to get hearing aid checked Walk in Clinic Further record review confirmed the eye center appointment in a nursing note dated 9/30/24 at 12:16 PM which stated: Residents eye center appointment at the VA Clinic rescheduled to 2/11/25 at 8 am facility to transport. Message left for MPOA to call facility to be updated on new orders. A review of the progress notes after the interview with ED #79 revealed the following notes: A note dated 10/1/2024 at 3:29 PM by RN #42, which stated: Spoke to Audiology clinic regarding residents broken hearing aid. We can drop off hearing aids between 8am and 2 pm M-F to be fixed. And another note on 10/02/24 at 10:43 AM which stated: Resident's hearing aid sent with facility van driver at this time to VA Audiology to be dropped off for repair.

Based on observation, interview and record review the facility failed to deliver respiratory care services consistent with professional standards of practice. The physician's order for oxygen was not followed. This practice affected one (1) of three (3) residents reviewed for respiratory care during the Long-Term Care Survey Process (LTCSP). Resident identifier: #2. Facility Census: 60. Finding included: a) Resident #2 A review of American Association for Respiratory Care Clinical Practice Guideline -Oxygen Therapy in the Home or Alternate Site Health Care Facility -2007 Revision & Update P1063-1067- Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia. Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. An observation of Resident #2, on 10/01/24 at 9:41 AM, revealed the resident was receiving oxygen at four and a half (4.5) Liters Per Minute (LPM) via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A second observation of Resident #2, on 10/02/24 at 3:40 PM, revealed the resident was receiving oxygen at four and a half (4.5) LPM via nasal cannula from an oxygen concentrator. A review of the Resident's physician order on 10/03/24 at 9:45 AM, revealed the order Oxygen via nasal cannula two (2) LPM, continuous. Every day and night shift for shortness of breath, with an order date of 02/21/24. An interview with Licensed Practical Nurse (LPN) #59 on 10/03/24 at 10:09 AM, verified Resident #2 was receiving oxygen at about five (5) LPM. She verified the resident was ordered oxygen at two (2) LPM via nasal cannula continuous. The LPN verified the oxygen level was wrong and corrected the flow liter at that time.

Based on record review, observation and staff interview the facility failed to ensure Resident #9 who required dialysis received such services, consistent with professional standards of practice, by documenting/taking a Blood Pressure (BP) on residents left arm. This was found true for 1 of 1 resident reviewed for dialysis during the long-term care survey process. Facility census: 60. Resident identifier: 9. Findings included: a) Resident #9 1) A record review on 10/03/24 at approximately 8:40 AM found physicians' orders: -- Observe permcath to right upper chest every shift for s/s of infection and or bleeding every day and night shift. Order date active 5/7/2024. --No blood draws or blood pressure to left arm every day and night shift. Order date active 5/7/2024. --Check fistula to left arm for +thrill and +bruit every shift every day and night shift. Order date active 05/07/24. A review of Resident #9s care plan revealed an intervention: - AV Fistula in the left arm. stating not to take BP in left arm. A review of the Treatment Administration Record (TAR) found documentation from nursing checking Resident #9's AV Fistula in the left arm. The TAR stated not to take BP in left arm starting 05/07/24 being checked off as completed with no issues noted from check. 10/03/24 09:05 AM found nurses documenting BP being taken in the left arm. Record review of weights/Vital summary revealed between 05/07/24 through 10/03/24, documentation that Resident #9 had a BP taken in the left arm on 74 different occasions. An observation on 10/03/24 at approximately 9:30 AM revealed Resident #9 had no signage in the room, bringing awareness to identify AV Fistula in the left arm. stating not to take BP in left arm. On 10/03/24 at 9:52 AM a call was placed to Resident #9's dialysis center revealed the order for no BP in left arm did not come from the dialysis center or Neurologist. There was no reason not to take B/P in left arm from them. The representative from the dialysis center stated that Resident #9's fistula was not functioning and would never be used for a dialysis port. On 10/03/24 at 9:20 AM, The Director of nursing (DON) stated, The orders and care plan should have been followed to not take a B/P in the left arm and the nursing staff should not have been documenting the AV Fistula was working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide information, and/or offer the Respiratory Syncytial Virus (RSV) immunization per recommendation of the CDC in a timely manner. This failed practice affected more than a limited number of residents who currently resided in the facility. Resident identifiers: #3, #6, #7, #29, #33, #36, #37, #45, and #46. Facility census: 60 Findings included: a) RSV immunization During an interview, on 10/02/24 at approximately 11:18 AM, the Infection Preventionist (IP) #36 stated the facility had contended with an outbreak of RSV in January 2024. During a follow up interview with IP #36 on 10/03/24 at approximately 10:55 AM, she confirmed that to her knowledge, the residents had not been provided with educational information about the risks and benefits of receiving the Respiratory Syncytial Virus (RSV) vaccination. She further confirmed that the facility had not offered the RSV vaccine during the Fall immunization period of 2023. Record review for Residents #3, #6, #7, #29, #33, #36, #37, #45, and #46, on 10/03/24 at approximately 11:12 AM, revealed that the facility had failed to offer education on the RSV vaccine, failed to offer the RSV vaccine, and failed to notify the residents of locations where they could obtain a vaccine, if they so desired. The Centers for Disease Control and Prevention (CDC) has provided guidance that states: Respiratory syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization. Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV. The CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making. According to the CDC the RSV vaccine was made available in early August of 2023. b) Resident #3 Record review revealed that Resident #3 tested positive for RSV on 02/07/2024. A nursing note on 02/7/2024 at 9:30 PM by LPN #96 stated: Resident positive for RSV. Resident has bilateral chest congestion and diminished lung sounds. O2 sat 92% room air. Is receiving Doxycycline Hyclate 100mg po BID for cough/congestion and Duo nebulizer treatments as per order. Is on droplet precautions. contact droplet precautions. Wearing oxygen @2.5L/min via nasal cannula for breathing comfort. A note by RN #55 on 02/8/2024 at 1:40 PM which stated: [AGE] year-old female, positive for RSV and is in isolation. contact droplet precautions. Contact / Droplet Precautions due to positive RSV test every day and night shift for RSV for 10 Days. A note on 02/9/2024 at 5:24 AM by LPN #96 stated: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for Shortness of breath for 3 Days PRN Administration was: Effective Follow-up Pain Scale was: 5 Resident appears to look more comfortable now and not as distressed, anxious and labored breathing A note on 02/9/2024 at 7:00 AM by LPN #24 stated: No injuries noted with witnessed fall Resident was not transferred to the hospital Physician was not notified Family/Responsible party was not notified No C/O PAIN A note on 02/12/2024 at 10:26 AM by LPN #24 which stated: NP #95 notified via telephone at 08:00 of residents fall on 02/9/2024. Resident was lowered to the floor related to weakness due to currently having RSV. Resident is now a 2 assist for transfers. c) Resident #6 Record review revealed that Resident #6 tested positive for RSV on 01/15/24. A nursing note on 01/16/2024 at 11:00 AM by Licensed Practical Nurse (LPN) #59 which stated: Lung sounds diminished with faint expiratory wheezes. Does have a non-productive cough and reports a runny nose. Receives Guaifenesin 400mg po BID daily for cough and congestion. Change in Condition tested positive for RSV, had a cxr and it's negative for pneumonia. A note by Nurse Practitioner (NP) #95 on 01/19/2024 at 02:14 PM stated: Resident #6 is [AGE] year-old female who resides at Bridgeport Healthcare Center. She is seen as a follow up for a call for shortness of breath and hypoxia. She was started on oxygen overnight at 2 LNC. She tested positive for RSV on 1/15. Staff report she has had increased confusion overnight. CBC and BMP are ordered today. A nursing note on 01/18/2024 at 4:49 AM by LPN #13 stated: Resident c/o dyspnea, spo2 was at 82% on room air, this nurse called after hours and [physician] gave verbal orders for o2 @ 2l per n/c PRN and duo nebs q 4hrs PRN, resident's o2 went up to 94 with 2l O2 n/c, resident is currently resting in bed comfortably A nursing note on 01/18/2024 at 11:45 AM by Registered Nurse (RN) #61 which stated: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 3 ml inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer Resident wheezing at this time and needing redirected with continuous O2. Another nursing note by RN #61 on 01/18/2024 at 11:45 AM stated: Furosemide Solution 10 MG/ML Inject 4 ml intramuscularly one time only for fluid retention until 01/18/2024 17:59 2 injection sites R and L deltoids A further nursing note on 10/18/2024 at 11:54 AM by RN #61 which stated: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally every 4 hours as needed for SOB or Wheezing via nebulizer PRN Administration was: Effective Resident's wheezing reduced at this time and resident does not appear short of breath. Complaint with O2 therapy. Wet sounding cough. A note on 01/18/2024 at 6:47 PM by RN #61 which stated: Resident's Medical Power of Attorney (MPOA) notified of resident's worsening shortness of breath, new PRN ipratropium, O2 via 2L via NC and one time dose of 40 mg Lasix. MPOA made aware of elevated blood pressure that lowered following medications readministered per NP orders this am after previous pills found by this LN spit out by resident in bites of food on resident's bedside table. A nursing note on 01/19/2024 at 12:13 PM by LPN #96 which stated: Resident continues Medrol dose pack and O2 as prescribed for RSV. No s/s of adverse reaction. Resident resting in bed quietly with oxygen 2 L via NC and denies any distress at this time. A note by NP #95 on 02/15/2024 at 10:43 PM which stated: Resident #6 is [AGE] year-old female who resides at Bridgeport Healthcare Center. She is being seen today for the management of chronic conditions. She has a history of RSV on 1/15. She continues to have a loose cough at times, but her lung sounds are clear. d) Resident #7 Record review revealed that Resident #7 tested positive for RSV on 2/13/2024. A note by NP #95 on 02/13/2024 at 10:34 PM which stated: RSV (acute bronchiolitis due to respiratory syncytial virus) tested positive on 2/13. Start Medrol dose pack and Mucinex. A nursing note on 02/13/2024 at 12:30 PM by LPN #27 which stated: Resident has nasal drainage, cough and congestion. States she is just tired and wants to take a nap. Resident eating lunch at this time with no other complaints. On 02/13/2024 at 7:04 PM by RN #42 Resident is RSV +, orders for isolation x 10 days. Message left for MPOA to call facility to be updated on new orders and results. Awaiting return call. A nursing note on 02/14/2024 at 4:30 AM by LPN #69 which stated: Resident remains alert with confusion, and in pleasant mood. Sat up in wheelchair this shift before being assisted with HS care and transferring to bed. Has not exhibited cough this shift. Vital signs remain stable. Currently resting in bed with eyes closed and respirations at ease. Call bell within reach. A note on 02/20/2024 at 7:03 PM by NP #95 which stated: Resident #7 is a [AGE] year-old female member who resides at Bridgeport Healthcare Center. She is a DNR and lacks medical decision-making capacity. She tested positive for RSV on 2/13 and has continued to decline since that time. Staff report she has had poor oral intake. She is seen and examined lying in bed. She has crusting to both of her eyes. She reports she is having difficulty taking a deep breath. Her lung sounds are diminished. She continues to have a loose cough. Another note by NP #95 on 02/21/2024 at 9:40 which stated: Resident #7 is a [AGE] year-old female member who resides at Bridgeport Healthcare Center. She is a DNR and lacks medical decision-making capacity. She tested positive for RSV on 2/13 and has continued to decline since that time. Had a portable chest x-ray yesterday which was positive for pneumonia. She was given clysis of normal saline yesterday x 1 L, although due to her dementia and confusion she continued to remove the needles from her abdomen requiring the discontinuation of the fluids with only 500 cc infused. Today she is seen and examined lying in her room. She reports she is not feeling well. She has a cough. Will start Rocephin 1 g daily for 5 days and doxycycline 100 mg p.o. twice daily for 7 days. e) Resident #29 Record review revealed that Resident #29 tested positive for RSV on 01/15/24. A nursing note on 01/15/2024 at 12:06 PM by RN #61 stated: Resident had complaints of nasal drainage, sore throat, headache, and general malaise this am. Rapid Covid and flu tests done by this LN, with negative results. NP [NAME] made aware and new orders for 4 plex testing today and guaifenesin 400 mg BID x 5 days. Resident's MPOA called and notified of change and new orders. A note by LPN #27 on 01/16/2024 at 12:06 PM which stated: 4 plex results came back positive for RSV. (name) in facility at time and made aware. Resident quarantined to room for 10 days. new order for solumedrol 40mg X1 and Medrol dose pack. MPOA aware of new orders. Droplet isolation precautions maintained. A note on 01/19/2024 at 1:49 AM by NP #95 which stated: Resident #29 is an (age/gender) who is being seen today for follow up. She tested positive for RSV on 1/15. She denies any shortness of breath. She reports she still has a cough, but is feeling better overall. Her lungs are clear. LPN #69 entered a note on 01/20/2024 at 3:15 AM which stated: Resident remains alert and oriented x3, and in pleasant mood. Remains in isolation for RSV. Denies shortness of breath and cough; does report clear nasal drainage. Vital signs remain stable to resident's baseline. Received HS medications without difficulty. Currently resting in bed with eyes closed and respirations at ease. Call bell within reach. f) Resident #33 Record review revealed that Resident #33 tested positive for RSV on 02/07/24. A nursing note on 02/7/2024 at 2:52 PM by RN #55 stated: Contact / Droplet Precautions due to testing positive for RSV. every day and night shift for RSV for 10 Days. Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally BID for 5 days. Guaifenesin ER Tablet Extended Release 12 Hour 600 MG, give 1 tablet by mouth every 12 hours. oxygen @2L/min via nasal cannula for breathing comfort, O2 sat 94%. She reports pain with deep breathing to her right side. Gabapentin Capsule 100MG Capsule. Give 1 capsule by mouth two times a day for Nerve Pain A note by NP #95 on 02/13/2024 at 9:19 PM stated: Resident #33 is a [AGE] year-old female who is being seen today for an RSV follow up. She tested positive on 2/7. She reports pain with deep breathing to her right side. She continues to have a cough. Will order chest Xray and DuoNeb for 5 days. A nursing note on 02/13/24 at 10:04 AM by LPN #59 stated: Potential COVID-19 symptom of 'Cough-dry or productive' has been identified in the COVID-19 Symptoms Evaluation UDA. Resident is RSV +, continue to maintain contact droplet precautions. Lung sounds diminished with expiratory wheezes. Reports a productive cough of white colored sputum and clear nasal drainage. Wearing oxygen @2L/min via nasal cannula for breathing comfort, O2 sat 94%. g) Resident #36 Record review revealed that Resident #33 tested positive for RSV on 02/07/24. A nursing note on 02/7/2024 at 9:00 AM by LPN #59 which stated: Positive for RSV Contact / Droplet Precautions due to RSV positive. every day and night shift for RSV for 10 Days. Continues to receive guaifenesin 400mg BID for cough, prednisone 30mg po and nebulizer treatments as per order. Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML. 1 vial inhale orally three times a day for URI Resident refused this medication. NP in facility and is aware of this refusal. h) Resident #37 Record review revealed that Resident #33 tested positive for RSV on 02/07/24. A nursing note by RN #61 on 01/23/2024 at 8:39 AM stated: Resident assessed this morning to be short of breath with labored breathing, using accessory muscles. Resident's vitals taken with respirations at 23 breaths/min ad O2 81% on 2L O2. Diaphoretic, bounding radial pulses bilaterally, not responding to verbal or physical stimuli. NP [NAME] made aware of situation and new orders for 1 gram Rocephin now and 50 mls/hr. of 0.9% normal saline for 1 Liter. MPOA called and made aware of situation and orders at this time A nursing note on 01/23/2024 at 9:25 AM by LPN #27 stated: Clysis and Rocephin administered and resident continues to decline at this time blood pressure 63/32, oxygen 84 on 4L via nasal cannula. MPOA made aware of resident's condition and would like resident sent out. Resident continues to not respond to verbal commands. NP #95 made aware and gave orders to send resident out. A nursing note by LPN # 69 on 01/25/2024 at 4:19 AM stated: Resident returned to facility at 6:25 PM via [NAME] County EMS with two attendants. Remains alert with confusion, and in pleasant mood. States she is happy to be back and did not enjoy her time at the hospital. Resident denies pain and discomfort. Respirations are even and unlabored. Receiving supplemental oxygen via nasal cannula at 2LPM. Lung sounds diminished bilaterally with crackles heard in lower lobes. Abdomen is soft, not distended, and not tender. Bowel sounds active x4 quadrants. Resident was incontinent of small bowel movement upon arrival. 16 fr 10mL foley cath draining medium yellow urine to bedside bag. Peri and cath care provided by staff. Bruising from insulin administration observed to resident's RLQ and LLQ. 4cm x 4cm unstageable pressure injury observed to left buttock, red and blue in appearance. Resident reoriented to room. Food and fluids supplied. Resident currently resting in bed with eyes closed and respirations at ease. Call bell within reach. i) Resident #45 Record review revealed that Resident #45 tested positive for RSV on 02/07/24. A note on 02/8/2024 at 1:40 PM by RN #55 stated: positive for RSV and is in isolation. contact droplet precautions. Contact / Droplet Precautions due to positive RSV test. every day and night shift for RSV for 10 Days. j) Resident #46 Record review revealed that Resident #46 tested positive for RSV on 02/16/24. A note on 02/16/2024 at 6:00 AM by LPN #24 stated: Resident has a nonproductive cough, lung sounds diminished throughout lobes, currently resting in chair in room, denies pain or discomfort, Tested positive for RSV. A nursing note by LPN #69 on 02/16/2024 at 10:00 PB stated: Resident has rested in bed this shift. Remains alert and oriented x3, and in pleasant mood. Has denied pain and discomfort thus far this shift. Continues to have nonproductive cough. Denies shortness of breath. Vital signs remain stable to resident's baseline. Received HS medications without difficulty. Currently resting in bed with eyes closed and respirations at ease. Call bell within reach. A nursing note on0 2/18/2024 at 10:55 AM by LPN #27 stated: Resident continues on ceftriaxone Sodium Injection Solution Reconstituted 1 GM and Azithromycin 250mg for cough and congestion. Has had no adverse reactions and is tolerating medications well. Resident sitting up in wheelchair at bedside at this time with call bell in reach.

Based on observation and staff interviews, the facility failed to have clean sanitized, steam table, freezer, refrigerators and dish room. This had the potential to affect all residents that get their nutrition from the kitchen. Facility census. 60. Findings included: a) Kitchen tour Initial tour on 09/30/24 at 11:30 AM found: 1. Floor in walk in freezer had debris and dirt 2. Floors in the walk-in refrigerator had debris and dirt 3. The reach in refrigerator had debris and food spillage in the inside and spillage on the outside. 4. The Floor in the dish room had multiple missing floor tiles with brown and black substances in area making it an issue to have a clean floor and area around the dish machine. 5. A black substance on the walls around the dish machine. During an interview with the Dietary Manager during the initial tour all the issues above were verified. The Dietary Manager said the issues would be fixed. She stated the corporate representative provided her with a cleaning schedule form that had not been implemented at this time. DM also stated the dish room floor had been in that condition since she has taken over as DM three (3) months earlier. During a second tour in the kitchen on 10/03/24 at 11:55 AM an observation of the steam table found old food debris in the well. During an interview with the Dietary Manager and corporate dietary manager it was verified that the steam table needed to be cleaned and sanitized. During an interview, on 10/03/24 12:12 PM, with the kitchen manager and corporate dietary manager verified the disrepair in the dish room, had previously been in put in the maintenance program to be fixed but has never been completed. During an interview, on 10/03/24, the Executive Director revealed that the Maintenance Director obtained a quote for the dish room floor on August 21, 2024, but nothing else was completed and no further documentation was provided.

. Based on observations, medical record review, and staff interviews, the facility failed to ensure the Pharmaceutical services of provision, monitoring and/or the use of medication-related devices were completed on a consistent basis. This deficient practice was found during a random opportunity for discovery. Facility census: 59. Findings included: a) Emergency Kit Pharmaceutical Services refers to: The provision, monitoring and/or the use of medication-related devices per the definition by the Centers for Medicare and Medicaid Services (CMS). On 11/14/23 at 12:45 PM during an inspection of the medication room, the locked emergency kit had a note that an item in the box expired on 09/01/23. Licensed Practical Nurse (LPN) #48 acknowledged that the note indicated something had expired. LPN #48 took the box to the Director of Nursing (DON) and the Corporate Nurse. The box tie was then cut off and contents observed. Four (4) 1 cc (centimeters) syringes were identified to have expired on 06/30/23. LPN #48 removed the syringes at that time. The DON and Corporate Nurse acknowledged that the emergency kit had not been updated and the 1 cc syringes were expired. The pharmacy policy was provided on 11/14/23 at 1:00 PM, the pharmacy policy stated that the On-Site unit is not exchanged regularly, a pharmacy representative will perform an on-site inspection and remove expired drugs on a consistent basis. The Corporate Nurse on 11/14/23 at 2:22 PM, provided an email from the pharmacy of the medication storage review completed per policy on 09/06/23. The Emergency Kit was not listed on this medication storage review list as being completed at that time. .

. Based on medical record review and staff interview, the facility failed to ensure a psychotropic mediation had the appropriate diagnoses. This deficient practice was found for one (1) of five (5) residents reviewed for the use of unnecessary psychotropic medications. Resident identifier: 10. Facility census: 59. Findings included: a) Resident #10 A medical record review on 11/14/23 revealed the annual Minimum Data Set (MDS) assessment with an Annual Reference Date of 10/25/23 under Section I Active Diagnoses: listed anxiety disorder, depression and insomnia as current diagnoses. The comprehensive care plan was developed for the use of Trazodone for the diagnoses of anxiety disorder, depression, and insomnia. The physician's order was for Trazodone to be given daily for insomnia only. In a interview with the Registered Nurse (RN) consultant on 11/15/23 at 10:10 AM, verified the physician's order was incomplete and should include the diagnoses of anxiety disorder and depression. .

. Based on observation and staff interview, the facility failed to maintain appropriate infection control standards for the disposal of soiled linen. This was a random opportunity for discovery. Resident Identifier: #54. Facility Census: 59. Findings Included: a) Resident #54 On 11/13/23 at 11:21 AM, soiled linens were observed laying on the floor next to bed 114-B. On 11/13/23 at 11:23 AM, Licensed Practical Nurse (LPN) #31 confirmed the soiled linens were laying on the floor. LPN # 31 stated, let me get those right now. On 11/15/23 at approximately 11:30 AM, Corporate Nurse #122 was notified and confirmed soiled linens should not be in floor. No further information was obtained during the survey process. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to prepare meal trays in a safe and sanitary manner. Staff wore jewelry on the tray line. This practice has the potential to affect more than a limited number of residents. Facility census 59. Findings included: a) On 11/14/23 at 12:00 PM observations in the kitchen noted the Dietician with no gloves, a stone ring on each hand and a [NAME] bracelet on the left wrist, repeatedly taking temperatures of food without donning gloves. On 11/14/23 at 1:37 PM, Culinary Director (CD) #23 reported staff are permitted to wear a plain wedding band during meal tray service but nothing else. The above observation was reviewed with the CD #23, he agreed the dietician was stirring and checking food temperatures with her jewelry on and no gloves. At 1:45 PM on 11/14/23, the Registered Dietician (RD) #124 approached the survey team and was found to be wearing a white silicone wedding band and no other jewelry. RD #124 acknowledged she was wearing a bracelet and two stone rings during temperature checks of the lunch tray line on 11/14/23. .

. Based on record review and staff interview, the facility failed to maintain pharmacy related information, pertaining to the monthly medication regimen review, for each resident, that was readily accessible. This deficient practice was found true for five (5) of five (5) residents reviewed for the care area of unnecessary medications and for one (1) of one (1) residents reviewed for the care area of anticoagulants. Resident identifiers: Residents #28, #52, #17, # 33, #10, and #31. Census: 59. Findings included: a) Resident #28 A record review on 11/14/23, for Resident #28, showed no evidence of a monthly medication review, by the pharmacist, for the months of 08/23, 09/23 and 10/23. An interview, with the Director of Nursing (DON), on 11/14/23 at 10:45 AM, revealed there was no information noted in the medical record or in any facility documentation, showing a medication regimen review for the dates of 08/23, 09/23 and 10/23. An interview, with Registered Nurse (RN) #122, on 11/14/23 at 11:59 AM, revealed the pharmacist was contacted and was requested to send the results of the monthly medication regimen reviews for 08/23, 09/23 and 10/23, because the results of the reviews were not located in the building. An additional interview, with RN #122, on 11/14/23 at 3:00 PM, confirmed the facility was not aware of the results of the 08/23, 09/23 and 10/23 medication regimen reviews, prior to obtaining a copy of the results on 11/14/23, after surveyor interaction. b) Resident (R) #17 On 11/14/23 a review of the medical record revealed no evidence of monthly medication regimen reviews (MRR) by the pharmacist. At 10:45 AM on 11/14/23, The Director of Nursing (DON) confirmed the MRRs were not in the electronic medical record. The DON presented a notebook with reviews for May, June and July 2023. On 11/14/23 at 11:59 AM, the consultant Registered Nurse (RN) #122, reported the pharmacist was contacted to send MRR results for the residents. Later on 11/14/23 colored copies of MRR reviews were presented from the pharmacist for April, August, September, and October 2023. c) R#31 Review of the medical record on 11/14/23, revealed one (1) pharmacy medication regimen review (MRR) in the past six (6) months. The review dated 09/05/23 was completed on readmission and noted no concerns. At 10:45 AM on 11/14/23, The Director of Nursing (DON) confirmed the MRRs were not in the electronic medical record. The DON presented a notebook with MRRs for April, May, June, July, and November 2023. The form dated 09/05/23 was an admission reconciliation of R#31's medications. On 11/14/23 at 11:59 AM, the consultant Registered Nurse (RN) #122, reported the pharmacist was contacted to send MRR results for the residents. Later on 11/14/23 colored copies of MRR reviews were presented from the pharmacist for September, and October 2023. No MRR for August 2023 was received. d) Resident #52 A review of the medial record on 11/14/23 revealed there were no monthly medication regimen reviews (MRR) by the pharmacist for the months of July, August, September, and October 2023. On 11/14/23 at 10:45 AM, the Director of Nursing (DON) confirmed the MMRs were not in the electronic medical record. e) Resident #10 A review of the medial record on 11/14/23 revealed there were no monthly medication regimen reviews (MRR) by the pharmacist for the months of August, September, and October, 2023 On 11/14/23 at 10:45 AM, the Director of Nursing (DON) confirmed the MMRs were not in the electronic medical record. f) Resident #33 On 11/14/23 at 10:00 AM, a record review was completed for Resident #33. The review showed no evidence of the monthly medication reviews, by the pharmacist, for 08/23, 09/23 and 10/23. An interview, with the Director of Nursing (DON), on 11/14/23 at 10:45 AM, revealed there was no information noted in the medical record or in any facility documentation showing a medication regimen review for the dates of 08/23, 09/23 and 10/23. On 11/14/23 at 11:59 AM, an interview with the Corporate Nurse #122, revealed the pharmacist was contacted to send the results of the monthly medication regimen reviews for 08/23, 09/23 and 10/23, because the results of the reviews were not located in the building. An additional interview, with Corporate Nurse #122, on 11/14/23 at 3:00 PM, confirmed the facility was not aware of the results of the 08/23, 09/23 and 10/23 medication regimen reviews, prior to obtaining the results on 11/14/23, after surveyor interaction.

. Based on record review and staff interview, the facility failed to develop and/or implement the care plan regarding showers for Resident #2 and #29. This was true for two (2) of four (4) residents reviewed during the survey process. Resident identifiers: #2 and #29. Facility Census: 58. Findings included: a) Resident #2 On 09/05/23 at 1:00 PM, a record review was completed for Resident #2. The care plan was reviewed as well. Under the focus area of ADL (activities of daily living) self-care deficit r/t (related to) weakness, Parkinson's and Dementia, an intervention stating Bathing: assist of one. Shower three times a week and as needed or requested. (Typed as written.) The week of 08/13/23, the resident received one (1) shower, the week of 08/20/23, the resident received one (1) shower, and the week of 08/27/23 the resident did not receive any showers. This information was found documented under the tasks tab of the electronic medical record. Upon review of residents listed as dependent for bathing, Resident #2 was listed. On 09/05/23 at 3:00 PM, the Administrator was notified and confirmed the resident was not given showers three (3) times weekly and the care plan was not implemented as written. b) Resident #29 On 09/05/23 at 2:00 PM, a record review was completed for Resident #29. The care plan was reviewed as well. Under the focus area of ADL self-care performance deficit r/t weakness and pain with left hip fx (fracture) repair, an intervention stating Bathing/Shower: assist of 2 (two), 3x (three times) weekly with partial bed bath in between. (Typed as written.) The week of 08/06/23, the resident received two (2) showers, the week of 08/20/23, the resident received one (1) shower, and the week of 08/27/23 the resident received (1) one shower. This information was found under the tasks tab in the electronic medical record. Upon review of the residents listed as needing assistance, Resident #29 was found. On 09/05/23 at 3:30 PM, the Administrator was notified and confirmed the resident was not given showers three (3) times weekly and the care plan was not implemented as written.

. Based on record review and staff interview, the facility failed to provide activities of daily living (ADL) care for a dependent resident. This is true for one (1) of four (4) residents reviewed during the survey process. Resident identifier: #2. Facility Census: 58. Findings included: a) Resident #2 On 09/05/23 at 1:00 PM, a record review was completed for Resident #2. The care plan was reviewed as well. Under the focus area of ADL (activities of daily living) self care deficit r/t (related to) weakness, Parkinson's and Dementia, an intervention stating Bathing: assist of one. Shower three (3) times a week and as needed or requested. (Typed as written.) The week of 08/13/23, the resident received one (1) shower, the week of 08/20/23, the resident received one(1) shower, and the week of 08/27/23, the resident did not receive any showers. This information was found documented under the tasks tab of the electronic medical record. Upon review of residents listed as dependent for bathing, Resident #2 was listed. On 09/05/23 at 3:00 PM, the Administrator was notified and confirmed the resident was not given showers three (3) times weekly as care planned and was dependent for care. .

. Based on record review and staff interview, the facility failed to ensure a complete and accurate Physician Orders for Scope of Treatment (POST) form for one (1) of 18 residents reviewed during the survey process. Resident identifier: #18. Facility census: 59. Findings included: a) Resident #18 Review of Resident #18's medical records showed the resident completed a Physician Orders for Scope of Treatment (POST) form on 10/04/21 to convey end-of-life wishes. The POST form indicated the resident did not want cardiopulmonary resuscitation or a feeding tube. The POST form indicated the resident wanted limited additional medical interventions and intravenous (IV) fluids for a trial period of no longer than two (2) weeks. Resident #18 completed an updated POST form on 12/07/21. This POST form indicated the resident did not want cardiopulmonary resuscitation or IV fluids. The resident wanted comfort measures instead of limited additional medical interventions. The POST form did not indicate whether or not the resident wanted a feeding tube. This area was left blank. According to the POST form, Any selection not completed indicates full treatment for that section. During an interview on 04/26/22 at 12:18 PM, the Social Worker (SW) verified Resident #18's current POST form did not indicate whether or not the resident wanted a feeding tube. The SW stated that she thought the resident did not want a feeding tube, as indicated on the previous POST form. No further information was provided through the completion of the survey process. .

. Based on observation and staff interview the facility failed to provide a safe, comfortable and homelike environment. This was a random opportunity for discovery. Resident identifier: #36 Facility census: 59. Findings included: a) Resident #36 On 4-26-22 at 11:28 AM during the initial survey interview with Resident #36 it was observed the room needed attention from housekeeping and maintenance. The front of the wardrobe had multiple pieces of clear tape on it, it was scratched and one bottom drawer needed repaired. The towel rack by the sink in the room was falling off of the wall. The privacy curtain by the door had large dark brown stains and had dark brown specks on it. The air mattress pump on the foot of her bed was falling off due to one missing bracket. The above observations were confirmed with Licensed Practical Nurse #49 on 04/26/22 at 11:40 AM. .

. Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one (1) of 18 residents reviewed during the survey. Resident identifier: #30. Facility census: 59 Findings included: a) Resident #30 Review of Resident #30's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 03/07/22 indicated the resident had received seven (7) days of insulin injections during the seven (7) day look-back period. Review of Resident #30's medical records showed the resident was no longer receiving insulin injections during the look-back period for this MDS assessment. During an interview on 04/26/22 at 10:51 AM, the Registered Nurse (RN) MDS Coordinator confirmed Resident #30 was not receiving insulin injections during the look-back period for the MDS with ARD 03/07/22, and that the MDS was incorrect. No further information was provided through the completion of the survey process. .

. c) Resident #26 Record review shows Resident #26 had an unwitnessed fall and hit her head on 02/28/22 at 4:50 PM. This fall required her to be transferred to a local hospital for further evaluation due to her guarding her head. She was at the hospital on 2-28-22 from 5:00 PM until 8:00 PM. Upon her return the facility started neurological assessments per procedure. There was a neurological assessment completed on 03/01/22 at 08:45 AM. The next assessment was due at 12:45 PM, 4:45 PM and again at 8:45 PM. Licensed Practical Nurse #68 failed to complete the 12:45 PM and 4:45 PM assessments, leaving the Resident for a 12 hour period without having a neurological assessment documented. This was confirmed with the Administrator on 04/27/22 at 12:25 PM. Based on record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Neurological checks after unwitnessed falls were not complete for two (2) of four (4) residents reviewed for the care area of falls. Resident identifiers: #18, #26. Facility census: 59. Findings included: a) Policy review The facility's document titled, Falls Management Program with date of August 202, stated that neurological checks would be initiated for resident falls not witnessed by staff or visitors. The neurological evaluations would be completed every 15 minutes for four (4) times, every 30 minutes for four (4) times, every hour for four (4) hours, every four (4) hours for five (5) times, and every eight (8) hours for six (6) times. The facility's neurological assessment flow sheet contained areas for the nurse to record level of consciousness, pupil response, motor function, presence or absence of pain, vital signs, and other observations. b) Resident #18 Review of Resident #18's medical records showed the resident experienced a fall on 02/11/22 at 8:30 AM. Neurological evaluations were initiated. While neurological evaluations were on-going, Resident #18 experienced another fall on 02/11/22 at 5:30 PM. Neurological evaluations were restarted at the frequency of every 15 minutes. However, from 7:00 PM on 02/11/22 through 1:30 AM on 02/12/22 only vital signs were recorded along with the observation that the the resident was in bed. The level of consciousness, pupil response, motor function, and presence or absence of pain were not recorded. Vital signs were within normal limits. On 02/12/22 at 1:45 AM, the resident experienced another fall. Neurological evaluations were restarted at the frequency of every 15 minutes. At this time and through the completion of the neurological evaluations, all items indicated on the neurological assessment flow sheet were assessed. During an interview on 04/26/22 at 3:09 PM, Corporate Nurse #68 stated she had talked to the nurse who had performed the neurological evaluations from 7:00 PM on 02/11/22 through 1:30 AM on 02/12/22. The nurse stated the resident had been sleeping and had not been awakened when vital signs were obtained. The Corporate Nurse was asked how the nurse could have determined the resident was sleeping rather than having an adverse neurological event related to the fall. The Corporate Nurse stated Resident #18 had received a scheduled dose of Norco (hydrocodone-acetaminophen) at 8:00 PM, and this medication could have made the resident sleepy. The Corporate Nurse also provided an additional assessment for Resident #18 that had been performed on 02/11/22 at 10:00 PM and recorded the resident's vital signs and absence of worsening cough, shortness of breath, tachycardia, subjective cough, nausea, or vomiting. The level of consciousness, pupil response, and motor function was not recorded on this assessment. No further information was provided through the completion of the survey. .

. Based on record review and staff interview, the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days or that the physician documented the duration of the PRN order in the resident ' s medical record. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #18. Facility census: 59. Findings included: a) Resident #18 Review of Resident #18's medical records showed an order written on 03/24/22 for Ativan (lorazepam) solution 2 mg/ml, give 0.25 ml sublingually every two (2) hours as needed for anxiety, restless, sleeplessness, or insomnia. The order did not have a duration of use indicated. Further review of Resident #18's medical records showed a physician's note written on 04/06/22 which stated that the resident needed PRN Ativan for periodic and situational anxiety, and that the medication would be used sporadically, periodically, and sparingly. The physician indicated the medication benefits outweighed the risks. However, a duration of use for PRN Ativan was not indicated. During an interview on 04/26/22 at 03:09 PM, Corporate Registered Nurse (RN) #86 confirmed a duration of use was not indicated for Resident #18's PRN Ativan order. No further information was provided through the completion of the survey process. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations and staff interviews the facility failed to store food in accordance with professional standards for food service safety. It was discovered during the kitchen and nutrition pantry tour, perishable foods were not refrigerated, several food items were not dated after opening, and the ice machine was not draining properly. These failed practices had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 59 Findings included: a) Kitchen tour During the kitchen tour on 04/25/22 at 1:40 PM, it was discovered five (5) five-pound packages of lettuce and five (5) five-pound packages of cabbage were found setting in the hallway. Further investigation revealed a two (2) pound bag of brown sugar, a quart container of whipping cream, a five (5) pound bag of elbow macaroni, and a 64 ounce container of vegetable oil were not dated after opening. Also, the ice machine water drain pipe was touching the floor drain, which did not allow for proper prevention of back flow. On 04/25/22 at 1:45 PM, the Certified Dietary Manager (CDM) was present during the tour and reported the food items had been delivered around 9:00 AM that morning. This allowed the perishable foods to go without refrigeration for more than four (4) hours and they had started to [NAME]. The CDM verified the perishable foods, were not refrigerated properly, the food items were not dated after opening and the ice machine was not draining properly. b) Nutrition pantry During an observation of the Nutrition pantry on 04/26/22 at 12:002 PM, it was discovered the refrigerator in the nutrition pantry had a 46 ounce carton of lemon nectar thickening, which was not dated after opening. An interview with Licensed Practical Nurse (LPN) #4 on 04/26/22 at 12:04 PM, verified the nectar thickening had not been dated after opening. .

. Based on observation and staff interview, the facility failed to dispose of garbage and refuse properly. The lids to dumpsters were not closed. This was a random opportunity for discovery that had the potential to affect a limited number of residents. Facility census: 59. Findings included: a) Garbage disposal During observation on 04/27/22 09:25 AM, the facility's two (2) dumpsters were noted to have lids that were not closed. Bags of trash almost reaching the top of the dumpster could be viewed in the larger dumpster. The smaller dumpster was higher, and the contents could not be observed. On 04/27/22 at 09:28 AM, the Environmental Services Director confirmed the dumpster lids were not closed, and he closed them at this time. No further information was provided through the completion of the survey process. .

. Based on medical record review and staff interview, the facility failed to collaborate with hospice services to develop a coordinated care plan for one (1) of one (1) residents reviewed for the care area of hospice during the Long Term Care Survey Process. The care plan for Resident #53 did not specify when and what services were to be provided by the hospice staff. Resident identifier: #53. Facility census: 59. Findings included: a) Resident #53 During a medical record review on 04/26/22 for Resident #53, it revealed the care plan did not include any information regarding when hospice nurse aides and nurses would visit and what specific services to be provided. An interview with Minimum Data Set (MDS) Coordinator on 04/26/22 at 10:45 AM, verified the care plan for Resident #53 did not specify care and services to be provided by hospice staff. .