Based on observation and staff interview, staff failed to change contaminated gloves after performing perineal care and before touching clean resident gown and linens. This was true for one (1) of one (1) residents observed during perineal care. Resident identifier: # 70. Facility census: 90. Based on observation and staff interview, staff failed to change contaminated gloves after performing perineal care and before touching clean resident gown and linens. This was true for one (1) of one (1) residents observed during perineal care. Resident identifier: # 70. Facility census: 90.Findings included:a) Resident #70On 06/24/25 at 11:05 AM an observation of perineal care for Resident #70 found that Nurse Aide (NA) #14 completed perineal care with no issues observed with the procedure. Upon completion of the perineal care, NA #14 failed to change the contaminated gloves and assisted the resident to put on a clean gown. The surveyor intervened and stopped the continued use of the contaminated gloves. NA #14 confirmed she should have changed her gloves after completed perineal care. NA #14 immediately removed the contaminated gloves, performed hand hygiene, and donned new gloves.

Based on record review and staff interview the facility failed to revise the resident's person-centered, comprehensive care plan, and ensure that the transfer status was care planned correctly. This was an issue for one (1) of 32 residents whose care plan was reviewed. Resident Identifier: #52 Facility Census: #91 Findings include: a) Resident #57 On 03/11/25 02:30 PM record review shows that Resident #52 was care planned for a Hoyer lift for all transfers X 2 staff. The Activities of Daily Living Task report shows he was best care stander for transfers. The Resident had been observed in a power wheelchair throughout the survey. On 03/11/25 at 02:45 PM during an interview with Resident #52 (BIMS 15) he stated, They use a people mover with one staff member, gets me up in the morning and back in bed at bedtime. On 03/11/25 at 02:50 PM during an interview with the Assistant Director of Nursing (ADON) #165, the ADON stated the facility called it a best care stander and confirmed that it was the same thing as a people mover. The ADON said the resident did not require a Hoyer lift. She also confirmed the care plan was incorrect.

Based on Record Review and Staff Interview, the facility failed to ensure activities were individualized and patient-centered for Residents #40, #19, #191, #32, #12, and #49. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: #40, #19, #191, #32, #12, and #49. Facility census: 91. Findings included: a) Residents #40, #19, #191, #32, #12, and #49 had the exact same care plan listed for the Activities Section in the residents' care plans. The facility's care plans stated the following: ACTIVITIES: the resident prefers to participate in activities such as H the resident will report satisfaction with their activities of choice thru review period H Assist resident to activities functions as needed [ACTD,ACTA] H Interview the resident and family as needed to determine the resident's prior level of activity involvement and interests [ACTD,ACTA] H Provide activities calendar [ACTD,ACTA] H b) On 03/11/25 at 08:40 AM, the interim Assistant Director of Nursing (ADON), Registered Nurse #165 confirmed the resident's care plans were the same for the Activities Section of the care plans.

Based on observation, record review and staff interview the facility failed to follow Physicians orders in relation to a peripherally inserted central catheter (PICC) dressing and a Advanced Directive order. Resident identifier: #74 and #89. Facility census: #91 Finding Include: a) Resident #74 On 03/11/25 at 9:16 AM observation of an Intravenous (IV) dressing indicated it was changed on 03/03/25 in the PM. Review of the Physicians order dated 03/03/25 reads Change PICC/Mid Line dressing to Right Upper Extremity (RUE) every evening shift every 7 days for PICC maintenance. This would indicate the dressing should have been changed on 03/10/25 on the evening shift. A PICC line is an IV where the catheter's tip is positioned in a large vein near the heart, allowing for easier and more reliable access to the bloodstream On 03/11/25 at 9:17 AM an interview with Licensed Practical Nurse (LPN) #28 on duty as to why the dressing had not been changed. She stated I should have changed it yesterday evening but I could not find the dressings, I will look again. On 03/11/25 at 09:17 AM it was confirmed with this LPN and the Assistant Director of Nursing #165(ADON) that the dressing should have been changed on 03/10/25 on the evening shift. All agreed. The ADON stated, we have the dressings.

Based on record review and staff interview, the facility failed to assess and treat pressure ulcers in accordance with professional standards of practice. This was true for one (1) of four (4) residents reviewed for the care area of pressure ulcers. Resident identifier: #4. Facility census: 91. Findings included: a) Resident #4 Review of the policy titled, Pressure Injury Prevention Management, with original date 10/01/21 and revision date 10/19/22, showed evaluation and assessment of pressure ulcers would be completed weekly and documented in the resident's medical record. On 12/06/24, Resident #4 was noted to have an open area to the right and left buttock, measuring 0.3-0.6 centimeters (cm) with a depth of 0.1 cm. The area was assessed as a pressure ulcer stage II. An order was written to cleanse the open areas to both buttocks and apply silicone dressings, three (3) times a week on Monday, Wednesday, and Friday. On 12/12/24, a weekly skin assessment recorded open areas to the bilateral lower buttocks measuring 0.5 cm by 0.5 cm by 0.1 cm. The area was assessed as stage II. On 12/20/24, a weekly skin assessment recorded open areas to bilateral buttocks. The measurement and staging of the areas were not recorded. Three (3) times a week dressing changes continued through 01/13/25. No further pressure ulcer assessments were documented through this time. On 01/13/25, a new electronic health record system was obtained by the facility. Pressure ulcer dressing changes were not ordered in the new system. A weekly skin observation assessment performed on 03/01/25 documented no bruises, open wounds, surgical incisions, skin tears, reddened areas of other skin conditions were noted. A weekly skin observation assessment performed on 03/03/25 documented no bruises, open wounds, surgical incisions, skin tears, reddened areas of other skin conditions were noted. A weekly wound evaluation performed on 03/05/25 documented a stage II pressure ulcer to the right buttock, measuring 0.5 cm by 0.5 cm by 0 cm. An order was written to cleanse the wound and apply Duoderm every three (3) days and as needed. On 03/11/25 at 8:46 AM, Assistant Director of Nursing (ADON) #165 confirmed the resident's pressure ulcers had not been assessed weekly. She was unable to determine if the pressure ulcer had healed and reoccurred, or if the pressure ulcer had been present since identified on 12/06/24. She stated she was not aware the resident had a pressure ulcer develop in December 2024.

Based on observation, record review, resident interview, and staff interview, the facility failed to provide oxygen services in accordance with accepted standards of care. This was true for one (1) of one (1) residents reviewed for the care area of respiratory care. Resident identifier: #16. Facility census: 91. Findings included: a) Resident #16 Review of the facility's undated policy titled, Oxygen Administration, stated to verify that there was a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. On 03/03/25 at 1:34 PM, Resident #16 was observed using supplemental oxygen via nasal cannula, three (3) liters/minute. The resident stated she always utilized supplemental oxygen. Review of Resident #16's diagnoses showed she had diagnoses of chronic obstructive pulmonary disorder (COPD) and chronic respiratory failure with hypoxia and hypercapnia. On 03/04/25 at 2:16 PM, Regional Nurse #168 confirmed Resident #16 was utilizing supplemental oxygen but did not have an order. The resident stated she had been using oxygen a long time. It was noted that the oxygen tubing had been dated 03/03/25.

Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. This was true for one (1) of 31 residents in the long-term care survey sample. Resident identifier: #32. Facility census: 91. Findings included: a) Resident #32 Review of Resident #32's physician's orders showed an order for gabapentin (Neurontin) 600 milligrams (mg), give one (1) tablet orally, three (3) times a day for seizures. Resident #32's diagnoses list did not contain a diagnosis of seizures. On 03/11/25 at 9:28 AM, Assistant Director of Nursing (ADON) #165 stated Resident #32's gabapentin order was incorrect. She confirmed Resident #32 did not have a diagnosis of seizures. ADON #165 stated Resident #32 had started receiving gabapentin in 2020 for diabetic neuropathy. She stated she did not know why the order now showed the medication was given for seizures.

Based on observation and record review, the facility failed to ensure a dignified exsistance took place during dining. The staaff did not ask the residents in the dining room if they wanted to wear clothing protectors. The staff served Resident #23 and #68 meals in large vegetable serving bowls. Residents were not served meals together when they were sitting together at the same table. This failure was a random opportunity for discovery and had the potential to affect more than a limited number of resdients. Resident identifiers: #23 and #68. Facility Census: 91. Findings included: a) On 03/03/25 at 11:55 AM during the Dining Observation, the residents were not asked if they would like to wear a clothing protector. The clothing protectors were placed on the residents in the main dining room by nursing staff. b) On 03/03/25 at 12:10 PM, Resident #23 was served his lunch meal in a large vegetable serving bowl. No adaptive equipment for a bowl/plate was documented on the resident's tray card or found in the resident's orders. c) On 03/03/25 at 12:15 PM, Resident #68 was served his lunch in a large vegetable serving bowl. No adaptive equipment for a bowl/plate was documented on the resident's tray card or found in the resident's orders. Nursing Assistant #4 stated it was, easier for him to eat out of. d) According to the facility's policy titled, Policy and Procedure Manual for The Dining Experience: Staff Responsibilities, Individuals at the same table will be served and assisted at the same time. On 03/03/25, Resident #68 was not served a tray with his table mate until surveyor intervention after five minutes.

Based on observation and staff interview, the facility failed to provide a clean and home like environment for all residents in the facility. Facility census 91. Findings included: a) On 03/04/25 at approximately 9:30 a.m., observed a stained ceiling located in the main hallway near the main entrance. b) On 03/04/25 at approximately 9:41 a.m., observed a stained ceiling located in the C Hall soiled utility room. c) On 03/04/25 at approximately 9:54 a.m., observed a stained ceiling located in the main hallway near the main entrance. e) Interview with the facility's staff at the time of discovery verified these findings. These findings were acknowledged by the Interiem Administrator upon the exit interview on 03/12/25 at approximately 2:45 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** e) Resident #60 Activities Based upon record review and staff interview, the facility failed to complete a Care Plan personalized for Resident #60's preferred activities. The Care plan stated, ACTIVITIES: the resident prefers to participate in activities such as The sentence in the Care Plan was incomplete. The care plan is not personalized with any resident preferences, or examples. On 03/11/25 at 1:47 PM, an interview with the Director of Nursing (DON) was held, and the Care Plan for Resident #60 was reviewed. When asked about personal preferences for activities for Resident #60, DON responded, Yes, we seem to have a problem with these. (These, referring to Care Plans.) f) Resident #64 A review of Resident #64's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the Interim Assistant Director of Nursing (IADON) confirmed there were no activities care planned for Resident #64. She stated, I'll let her know. G) Resident #85 A review of Resident #85's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the IADON confirmed there were no activities were care planned for Resident #85. She stated, I'll let her know. h) Resident #342 A review of Resident #342's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the Interim Assistant Director of Nursing (IADON) confirmed there were no activities care planned for Resident #342. She stated, I'll let her know. Based on record review and staff interviews, the facility failed to develop and implement a person-centered comprehensive care plan to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. This was an issue for one (1) of 32 residents whose care plans were reviewed. Resident Identifiers: #52, #293, #74, #43, #60, #64, #16. Facility Census: #91 Findings Include: a) Resident #52 On 03/03/25 at 11: 50 AM observation was made of Resident #52 on a power wheelchair. Throughout the two-week survey he has been observed numerous times on the power wheelchair. On 03/10/25 at 10:45 AM a review of Resident #52's care plan found the following Focus areas were not resident centered. Activities: Focus states the resident prefers to participate in activities such as (left blank) Interventions: interview resident and family as needed to determine the resident's prior level of activity involvement and interest. Provide activities calendar, assist resident to activities functions as needed. Risk for falls: FOCUS states the resident is at risk for falls related to (left blank) Interventions: bed locked and in lowered position, beside table within reach, encourage the resident to wear their glasses when out of bed, lab or diagnostics per physician, placed common items within reach of the resident, refer to therapy for screening, remind the resident to use their call light to ask for assistance with ADLS. Resident #52 is required a best care stander for transfers to and from his power wheelchair. There are no interventions relating to these items. The resident was admitted on [DATE]. The care plan should have been updated to be resident centered. An interview with the Director of Nursing (DON) on 03/11/25 at 4:08 PM confirmed Resident #52's care plan should have been updated. b) Resident #293 On 03/03/25 at 1:30 PM the record review showed Resident #293 had a medical diagnosis of Post Traumatic Stress Disorder (PTSD) and was on Venlafaxine HCL 225 mg (milligram) one time a day for PTSD. On 03/10/25 at 10:50 AM review of Resident #293's care plan found the following Focus areas were not resident centered. Risk for falls: Focus states the resident is at risk for falls related to: . (left blank) Interventions: are generic and not resident centered. Footwear to prevent slipping, gripper socks, therapy for screening, use their call light for assistance, bedside table within reach. Activities: FOCUS The resident prefers to participate in activities such as . (left blank) Interventions: Interview the resident and family as needed to determine the resident's prior level of activity involvement and interest. Provide activities calendar, assist resident to activities functions as needed. History of trauma: Focus the resident reported trauma during their trauma screening related to a history of military combat, PTSD. Interventions: Attempt to determine any triggers that the resident may have related to their past trauma and work with staff to avoid those when possible, trauma screen as indicated. HOSPICE Resident is admitted to hospice services with expected decline in condition due to terminal progressive disease related to protein calorie malnutrition. There are no specific interventions relating to hospice visits, assessments, care, etc. It is not resident centered, only states see hospice POC. The resident was admitted on [DATE]. He is on medication for PTSD, which is not addressed on the care plan, triggers have not been identified. The care plan should have been updated to be resident centered. An interview with the DON on 03/11/25 at 4:08 PM confirmed Resident #293's care plan needed to be updated. c) Resident #74 On 03/04/25 at 1:35 PM record review of Resident #74s care plan found the following areas were not resident centered. Risk for falls: Focus the resident is at risk for falls related to: (left blank) Interventions: lab or diagnostics per physician, refer to therapy for screening Nutritional status: Focus: The resident is at risk for weight loss, malnutrition or poor hydration status related to hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia, PI injury to left heel, PI stage 2, a-fib, anemia, hypokalemia, gastrointestinal hemorrhage, and GERD w/o esophagitis. Intervention: two cal supplement 90 ml BID (Resident has an additional order for Two Cal two times a day for supplement 90 ml which is missing under this focus) Activities: Focus the resident prefers to participate in activities that are individual or with 1-1 other. Interventions, interview the resident and family as needed to determine the resident's prior level of activity involvement and interest, Assist resident to activities as needed and provide 1-1 visits utilizing cats and reading, and pet therapy dogs. Assist to spend time outdoors. Risk for pain: Focus the resident has a risk for pain or pain related to chronic conditions. Interventions, administer pain medication as ordered, administer pain interview as indicated, attempt nonpharmacological interventions for pain such as repositioning, comfort therapy or passive ROM as tolerated, pain assessment as needed. (no mention of pain due to wound vac dressing changes) Enteral Feeding: Focus the resident is at risk for complications related to the need for an enteral tube feeding. Interventions: Osmolite 1.5 cal 237 ml after each meal with speficics listed, however resident was also on Two cal 90 ml twice a day which is not listed on this focus of the care plan. Feeding is according to the amount of her meals she eats and this was also not care planned. Skin impairment Focus: the resident has a skin impairment of pressure ulcer to coccyx. Interventions are not resident specific as they do not mention the wound vacuum nor the specifics related to that, no intervention to PICC IV, PEG tube, turn and reposition schedule, Resident #74 has an order for: Adaptive Equipment: Dayshift: [NAME] at beginning of shift and doff at end of shift. Edema glove on RUE and Resting hand splints on both hand with skin integrity check. Store splints and edema glove on in top drawer of dresser. No care plan in place for these pieces of equipment. An interview with the DON on 03/11/25 at 4:08 PM confirmed Resident #74's care plan needed to be updated. d) Resident #43 On 03/03/25 at 12:35 PM observation found Resident #43 to have apraxia causing him to be unable to verbally communicate. He can understand questions and shakes his head yes or no. He has a white dry erase board on his nightstand. On 03/10/25 at 10:25 AM review of Resident #43's care plan found the following Focus areas were not resident centered. Activities: Focus states the resident prefers to participate in activities such as individual and with one other person. Interventions: are generic and not resident centered. Assist resident to activities functions as needed providing direction to the location, interview the resident and family as needed to determine the resident's prior level of activity involvement and interest, Provide activities calendar and check to see about puzzle needs. Communication: the resident has risk for complications related to impairment of communication due to a history of cerebrovascular disease (CVA) the resident is rarely to never understood. Interventions: anticipate needs as able, ask the resident yes no questions, observe resident for nonverbal clues that may indicate a care need as able. The resident was admitted on [DATE]. There were no interventions specific for his whiteboard for communicating. The care plan should have been updated to be resident centered. An interview with the DON on 03/11/25 at 4:08 PM confirmed Resident #43's care plan needed to be updated. E) Resident #60 Activities Based upon record review and staff interview, the facility failed to complete a Care Plan personalized for Resident #60's preferred activities. The Care plan stated, ACTIVITIES: the resident prefers to participate in activities such as The sentence in the Care Plan was incomplete. The care plan is not personalized with any resident preferences, or examples. On 03/11/25 at 1:47 PM, an interview with the Director of Nursing (DON) was held, and the Care Plan for Resident #60 was reviewed. When asked about personal preferences for activities for Resident #60, DON responded, Yes, we seem to have a problem with these. (These, referring to Care Plans.) f) Resident #64 A review of Resident #64's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the Interim Assistant Director of Nursing (IADON) confirmed there were no activities care planned for Resident #64. She stated, I'll let her know. G) Resident #85 A review of Resident #85's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the IADON confirmed there were no activities were care planned for Resident #85. She stated, I'll let her know. h) Resident #342 A review of Resident #342's comprehensive care plan found the care plan to be void of person-centered activities. On 03/11/25 at 8:40 AM the Interim Assistant Director of Nursing (IADON) confirmed there were no activities care planned for Resident #342. She stated, I'll let her know. i) Resident #16 Review of Resident #16's diagnoses list showed the resident had diagnoses of depression and anxiety disorder. Review of Resident #16's physician's orders showed the resident had an order for the following medications: buspirone for anxiety disorder, trazodone for depression, and duloxetine for depression. Resident #16 also had the following physician's orders: - Anti-Depressant - Monitor behavior of: (1) Sadness; (2) Tearfulness; (3) Withdrawn. Non-Pharmacological Intervention Codes: (1) Encourage Activities; (2) 1:1; (3) Encourage to verbalize feelings; (4) other-chart in progress notes. Document A) Behavior Code; B) Non-Pharmacological Intervention Code; C) Non-Pharmacological Outcome Code. - Anti-Anxiety - Monitor behavior of: (1) Restless; (2) Agitated; (3) uncontrollable feeling of worry. Non-Pharmacological Intervention Codes: (1) redirect; (2) 1:1; (3) activities; (4) toilet; (5) give food or fluids; (6) reposition; (7) back rub; (8) other-chart in progress notes. - Monitor for side effects of Anti-Depressant medication: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity(skin), excess weight gain If side effects observed, enter a progress note, every shift. - Monitor side effects of antianxiety medication: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, and skin rash. If side effect observed, enter a progress note, behaviors and side-effects monitored every shift. Resident #16's comprehensive care plan had the following focus initiated on 02/18/25, Psychoactive medications: the resident is at risk for complications related to psychoactive (antidepressant, anxiolytic) medications use secondary to diagnoses of: anxiety disorder, depressive disorder. The goal was, The resident will not have adverse reactions to psychoactive medication thru [sic] review period. The interventions were as follows: - Administer medications as ordered - Monitor for behaviors related to medication use - Observe for signs and symptoms of adverse side effects related to medication use and notify MD as indicated On 03/11/25 at 8:40 AM, Assistant Director of Nursing #165 confirmed Resident #16's comprehensive care plan did not contain information regarding the resident's specific signs and symptoms of anxiety and depression nor specific non-pharmacological interventions effective for managing the resident's symptoms. No further information was provided through the completion of the survey. i) Resident #16 Review of Resident #16's diagnoses list showed the resident had diagnoses of depression and anxiety disorder. Review of Resident #16's physician's orders showed the resident had an order for the following medications: buspirone for anxiety disorder, trazodone for depression, and duloxetine for depression. Resident #16 also had the following physician's orders: - Anti-Depressant - Monitor behavior of: (1) Sadness; (2) Tearfulness; (3) Withdrawn. Non-Pharmacological Intervention Codes: (1) Encourage Activities; (2) 1:1; (3) Encourage to verbalize feelings; (4) other-chart in progress notes. Document A) Behavior Code; B) Non-Pharmacological Intervention Code; C) Non-Pharmacological Outcome Code. - Anti-Anxiety - Monitor behavior of: (1) Restless; (2) Agitated; (3) uncontrollable feeling of worry. Non-Pharmacological Intervention Codes: (1) redirect; (2) 1:1; (3) activities; (4) toilet; (5) give food or fluids; (6) reposition; (7) back rub; (8) other-chart in progress notes. - Monitor for side effects of Anti-Depressant medication: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity(skin), excess weight gain If side effects observed, enter a progress note, every shift. - Monitor side effects of antianxiety medication: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, and skin rash. If side effect observed, enter a progress note, behaviors and side-effects monitored every shift. Resident #16's comprehensive care plan had the following focus initiated on 02/18/25, Psychoactive medications: the resident is at risk for complications related to psychoactive (antidepressant, anxiolytic) medications use secondary to diagnoses of: anxiety disorder, depressive disorder. The goal was, The resident will not have adverse reactions to psychoactive medication thru [sic] review period. The interventions were as follows: - Administer medications as ordered - Monitor for behaviors related to medication use - Observe for signs and symptoms of adverse side effects related to medication use and notify MD as indicated On 03/11/25 at 8:40 AM, Assistant Director of Nursing #165 confirmed Resident #16's comprehensive care plan did not contain information regarding the resident's specific signs and symptoms of anxiety and depression nor specific non-pharmacological interventions effective for managing the resident's symptoms. No further information was provided through the completion of the survey.

Based on resident interview, record review, and staff interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for six (6) of 10 residents reviewed for the care area of activities of daily living. Resident identifiers: #12, #45, #16, #58, #40, and #47. Facility census: 91. Findings included: a) Resident #12 During an interview, on 03/03/25 at 3:18 PM, Resident #12 stated, I don't get showers like I am supposed to. They are too short-staffed. Review of the shower schedule showed the resident was scheduled to receive showers on Tuesdays and Fridays. Review of Resident #12's bathing/showering task reports for 30 days, from 02/11/25 to 03/11/25 showed the resident had received tub baths on 02/25/25, 02/28/25, 03/03/25, 03/04/25, 03/05/25, 03/07/25, and 03/11/25. No bathing activities were documented from 02/11/25-02/24/25. The above findings were confirmed by the Director of Nursing on 03/12/25 at 12:07 PM. b) Resident #45 During an interview on 03/03/25 at 12:32 PM, Resident #45 stated she does not get showers twice a week as scheduled. She stated she would like to have a shower at least once a week but she had gone over a week without having a shower before. Review of the shower schedule showed the resident was scheduled to receive showers on Wednesdays and Saturdays. Review of Resident #45's bathing/showering task reports for 30 days, from 02/04/25 to 03/03/25 showed the resident had received a shower on 02/06/25 and a tub bath on 03/01/25. No other bathing activities were documented during this time period. Resident #45's care plan showed the resident required assistance with her activities of daily living related to advanced age. On 03/05/25 at 3:24 PM, the Director of Nursing (DON) confirmed Resident #45's bathing/showering task reports showed one (1) shower and one (1) tub bath for 30 days. On 03/05/25 at 4:09 PM, the DON stated she had spoken to the Nursing Assistant who stated the resident had received more showers than documented and the resident also refused showers at times. The DON acknowledged this was not documented. c) Resident #16 On 03/03/25 at 12:50 PM, Resident #16 stated she only got one (1) shower a week because, they're too short-staffed. She stated she would like more frequent showers. Review of the shower schedule showed the resident was scheduled to receive showers on Mondays and Thursdays. Review of Resident #16's bathing/showering task reports for 30 days, from 02/04/25 to 03/03/25 showed the resident had received bathing activities on 02/06/25, 02/08/25, 02/25/25, 02/27/25, 02/28/25, 03/01/25, 03/03/25, and 03/04/25. The report did not specify whether showers, tub baths, or bed baths were given, only how much assistance the resident required. On Thursday 02/06/25, Monday 02/10/25, Thursday 02/13/25, Monday 02/17/25, and Monday 02/24/25, not applicable was marked for bathing activities. On Thursday 02/20/25, there was no documentation of bathing activities for the day. Resident #45's care plan showed the resident required assistance with her activities of daily living related to advanced age. On 03/05/25 at 3:37 PM, the Director of Nursing confirmed bathing activities had not been documented twice weekly for Resident #16. She also confirmed the specific bathing activity had not been documented. She stated this was an error in how the task had been set up in the electronic health record and is being corrected. d) Resident #47 Based upon record review and staff interview, the facility failed to provide showers or baths on a routine basis for Resident #47. A review of the Care Plan for Resident #47 stated, PERSONAL HYGIENE/DENTAL: the resident requires assistance with their dental care and personal hygiene, and Maintenance: requires assistance with their ADL's related to advanced age and chronic health conditions. ·the resident's personal hygiene needs will be met thru the review period ·observe resident for complaints of oral pain, discomfort or difficulty with chewing diet and refer to therapy as needed [LPN,RN] provide dependent assistance for personal hygiene and grooming [CNA,LPN,RN] ·provide oral care for the resident as they are not able to perform it for themselves [CNA,LPN,RN,RT] A review of the ADL (Assisted Daily Living) tasks for bathing/showering for last 30 days, the findings were: No showering/bathing reported for: 02/15/25 02/16/25 02/17/25 02/18/25 02/19/25 02/20/25 02/21/25 02/22/25 02/23/25 02/24/25 02/25/25 02/27/25 02/28/25 03/01/25 03/02/25 03/03/25 In summary, the Longest stretch between showers/bath was1 (eleven) days straight. On 03/11/25 at 11:54 AM, an interview was conducted with Director of Nursing (DON) and RN #168. When asked about the period of time between 02/15/25 and 02/25/25, where no showers or baths were documented for Resident #47, their response was,Tis was during the time that we were training the staff on Point of Care system and they did not know how to document in the new system. We may have a paper copy of showering schedule. We will look. At the time of exit, no additional documentation was provided to verify the resident was bathed during the above listed dates. On 03/11/25 at 1:48 PM, on A hallway nursing assistants were interviewed regarding showers not being given twice weekly as scheduled. A confidential Interview with two (2) Nursing Assistants (NAs) #30 and #50 03/11/25 1:55 PM revealed They stated they are unable to give residents twice weekly showers because they do not have enough staff. They stated that between serving lunch and dinner and getting residents up for therapy, they do not have enough time to perform residents' showers. They stated it is difficult enough when there are two (2) NAs scheduled for the hallway but sometimes there is only one scheduled for the hallway. e) Resident #58 On 03/03/25 at 01:33 PM Resident #58 voiced her concerns on not getting her showers as scheduled. On 03/04/25 at 11:34 AM record review showed she was scheduled for a shower on Monday and Thursday day shift and as needed. The care plan stated .required assistance with their activities of daily living (ADL) related to advanced age, one assist. Record review of showers received for the last thirty (30) days showed Resident #58 had received two (2) baths out of nine (9) that were scheduled. Showers due: Showers received: 02/03/25 02/27/25 (bath) 02/06/25 03/03/25 (bath) 02/10/25 02/13/25 02/17/25 02/20/25 02/24/25 02/27/25 03/03/25 On 03/04/25 at 12:10 PM it was confirmed with the Director of Nursing that Resident #58 had not received her showers as scheduled. f) Resident #40 During the initial interview process, Resident #40 stated, I need a shave. A follow-up observation by the state surveyor on 03/10/25 at 2:20 PM was completed. Resident #40 reported she had not been shaved. The resident stated, Does it look like it? Licensed Practical Nurse (LPN) #88 confirmed Resident #40 still had facial hair and had not been shaved. LPN #88 reported she would make sure the resident's facial hair was removed.

Based on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Sharp objects were in unlocked rooms accessible to residents. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents. Facility census: 91. Findings included: a) Biohazard room On 03/03/25 at 11:08 AM, a door in A hallway labeled biohazard, authorized personnel only was found to be unlocked. Behind the door was a series of three (3) rooms. The first room contained locked cabinets. The second room contained a linen cart. The third room contained a small shower. In the shower was a sharps container, a puncture-resistant container for safely disposing of sharp objects. The sharps container was overflowing with razor blades. This finding was confirmed by Unit Secretary #148. She stated the door was not kept locked because hazardous items were locked in cabinets. She confirmed the sharps container overflowing with razor blades posed a potential risk to residents and stated she would have it emptied. b) Storage room On 03/03/25 at 1:54 PM, a door in A hallway labeled storage, no admittance, nurses and ward clerks only was found to be unlocked. Behind the door was a supply room containing hygiene products including razor blades. The Administrator confirmed the room was unlocked and contained items potentially hazardous to residents. On 03/03/25 at 2:06 PM, the Administrator stated the storage room was supposed to be locked but the locked had malfunctioned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and resident interview, the facility failed to ensure the food served was attractive, palatable and at a safe and appetizing temperature for Residents #21, #23, #33, #66, #85, #17 and #40. This failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #21, #23, #33, #66, #17, and #40. Facility Census: 91. Findings included: a) Policy Review According to the facility's Policy and Procedure Manual for The Dining Experience: Staff Responsibilities, the dining experience will enhance each individual's quality of life through person-entered dining: providing nourishing, palatable and attractive meals that meet the individuals daily nutritional needs and food and beverage preferences. Food will be served at the proper temperature, texture and/or consistency to meet each individual's needs and desires. b) Resident Council Meeting Minutes Resident Council Meeting Minutes were reviewed for the previous six months. Multiple dietary and food issues/complaints were expressed by the residents. A Food Committee was to be formed. On 03/04/25 at 10:30 AM, during the Resident Council meeting with the State Surveyor, the residents reported the food was cold and awful. The residents reported the food comes out cold. One resident stated, I'm tired of eating cold food. Minutes of the Resident Council for December 27, 2024, stated (First name, last name of discharged resident) the food she has received on [NAME] has been cold, the meal served on Christmas Eve she would be embarrassed to serve, and the portions are too small.(First Name, Last Name Resident # 10) stated that her meals are always cold. c) Dining Observations On 03/03/25 at 12:21 PM, during the Dining Observation, the residents were served pork chops at the lunch meal. The pork chops were observed to be hard to chew and difficult to cut. d) Resident Interviews On 03/03/25 at 3:04 PM, during the resident interview process, Resident #66 stated, the food was cold and It's awful .not edible. She reported, breakfast so bad, so cold .toast is white bread cut in two. On 03/04/25 at 5:51 PM, Resident #33 and Resident #21 were observed eating in the dining room. They both reported that their hamburgers were hard. The hamburgers appeared dark in color, hard, and dry. Resident #33 stated she could eat one end of the burger. Neither one of the residents wanted alternate food because Bingo was starting soon. On 03/04/25 at 5:56 PM, Resident #23 reported the hamburger was too hard and dry to eat. The resident's hamburger was chopped into bite-sized pieces. The patient requested a potted meat' sandwich. The Dietary Staff was notified the resident wanted an alternate. On 03/03/25 at 1:20 PM , during the resident interview process, Resident #85 reported, beginning food was good, then it changed hands. The resident stated, It's always cold . I eat cheerios because they can't mess it up. Resident #85 stated, Just to have a hot meal again. On 03/03/25, during the resident interview process, Resident #17 reported some of the food was good and some of the food wasn't. No temperature problems were reported by this resident. On 03/03/25, during the resident interview process, Resident #40 stated, I don't like it. I don't like what they're having. On 03/10/25 at 3:30 PM, the resident stated, I didn't eat. The resident reported it doesn't taste good. During an interview with Resident #78 on 03/03/25 01:37 PM Interview with Resident #78 stated, Food is bland and cold. During an interview with Resident #58 on 03/03/25 at 04:14 PM, the resident stated, food is not good and it is cold. During an interview with Resident #15 on 03/03/25 at 12:45 PM, the resident stated, new food menu is crap. During an interview with Resident #65 on 03/03/25 at 3:46 PM, the resident stated, food not hot enough. e) Temperatures On 03/04/25 at 12:35 PM, the Surveyor observed lunch service to residents on C Hall. Plates were covered with a plastic lid, but lids were not insulated. There were no plate warmers. The surveyor requested the Regional Dietary Director #167 to perform the temperature readings on the last tray served on C Hall. Results were: Mashed potatoes with gravy: 165 degrees Breaded chicken: 173 degrees Cauliflower: 171.9 degrees Fruit Cocktail: 71.9 degrees Grape juice: 39.5 degrees The surveyor asked Director #167 if the temperatures were within acceptable standards. He responded, No, the fruit cocktail is a little warm. On 03/04/25 at 5:10 PM, the surveyor began observing food being served in [NAME] Hall dining room. The surveyor observed Diet Aide #21 while she performed temperature testing of food on the steam table. Results were: Burger patties 160 degrees (Appearance was dry and hard) Baked beans 140 degrees Coleslaw 38 degrees Mashed potatoes 161 degrees Baked beans puree 150 degrees Gravy 150 degrees Sliced carrots 170 degrees Ground beef pieces 160 degrees Meat puree 120 degrees When asked if these were within range, Diet Aide #21 said no. I will need to call (first name, Dietary Manager #44). She went to the phone and called her. She removed the container from the steam table. DM #44 arrived approximately 10 minutes later and wrapped the puree with plastic wrap and took it back to the kitchen. At 6:40 PM, the meat puree is returned to the B dining hall steam table. The temperature was taken as 180 degrees by Diet Aide #21. On 03/05/25, the Surveyor observed lunch service in [NAME] dining hall around midday. Temperatures were taken of the food on steam table by [NAME] #3 while surveyor observed. All temperatures except pureed vegetables were within range. Puree vegetables were at 120. These were sent back to the kitchen and new packages were brought out. These registered a temperature of 160. On 03/11/25 at 12:05 PM, the Survey team tasted a sample lunch tray. The food was warm. The squash and zucchini mixture were overcooked, mushy in appearance and taste, not seasoned. One surveyor said it tasted gritty. Ham was prepared well. Sweet potatoes were sliced, without seasoning. On 03/12/25 at 11:38 AM, the Surveyor observed while Dietary Manager #44 performed temperatures on the last resident lunch tray on A Hall. Temperatures were as follows: Green Beans 90 degrees Lasagna 110 degrees Pudding 50 degrees The Dietary Manager agreed these temperatures were not within a suitable range.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, observation, testing, resident interviews and staff interviews, the facility failed to store, and serve food in accordance with professional standards for food service safety. This has the potential to affect all residents currently residing in the facility. Facility census 91. Findings included: a) Expired product: On 03/03/25 at 10:50 AM during an Initial walk through of dry storage area with Dietary Manager #44, a box of Quaker grits, with expiration date of 01/31/25, was found. When surveyor pointed it out, Dietary Manager said thank you, and she threw the box into the trash. B) Improper Food Holding temperatures On 03/04/25 at 5:10 PM, surveyor began observing serving of food in [NAME] Hall dining room. Surveyor observed Diet Aide #21 while she performed temperature testing of food on the steam table. Results were: Burger patties 160 degrees (Appearance was dry and hard) Baked beans 140 degrees Coleslaw 38 degrees Mashed potatoes 161 degrees Baked beans puree 150 degrees Gravy 150 degrees Sliced carrots 170 degrees Ground beef pieces 160 degrees Meat puree 120 degrees When asked if these were within range, Diet Aide #21 said no. I will need to call (first name, Dietary Manager #44). She went to the phone and called her. She removed the container from the steam table. DM #44 arrived approximately 10 minutes later, and wrapped the puree with plastic wrap and took it back to the kitchen. At 6:40 PM, the meat puree is returned to the B dining hall steam table. Temperature was taken as 180 degrees by Diet Aide #21. On 03/05/25, surveyor observed lunch service in [NAME] dining hall around mid-day. Temperatures were taken of the food on steam table by [NAME] #3 while surveyor observed. All temperatures except pureed vegetables were within range. Puree vegetables were at 120. These were sent back to the kitchen and new packages were brought out. These registered a temperature of 160. c) Hygiene On 03/05/25 around mid-day, surveyor observation of the lunch service in [NAME] dining hall. NA#6 was assisting the cook on the serving line. First tray was prepared and checked by NHA. Male NA #6 has longish hair which appeared as oily and unclean (about inch below the ear level). He did not don a hair net before stepping into the serving line. When surveyor pointed out the need for a hair net, he did not know where these were kept. [NAME] #3 reached up and got him one from the shelf above the sink. NHA reminded NA #6 to change his gloves before going back to serving. d) Facility Policy: According to the facility's Policy and Procedure Manual for The Dining Experience: Staff Responsibilities, The dining experience will enhance each individual's quality of life through person-entered dining: providing nourishing, palatable and attractive meals that meet the individuals daily nutritional needs and food and beverage preferences. Food will be served at the proper temperature, texture and/or consistency to meet each individual's needs and desires.

Based on observation, record review and staff interview the facility failed to implement an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible. The practices described below had the potential to affect more than an isolated number of residents. Resident identifiers: #74. Facility census: #91 Findings include: a) On 03/04/25 at 8:48 AM medication administration observation with Register Nurse (RN) #43 revealed the nurse broke Resident #73's Atorvastatin 40 milligram pill in half with no gloves in place. She then placed the broken pill in the medication cup and proceeded to administer it to the Resident. On 03/04/25 at 8:50 AM it was confirmed with the RN that she was required to use gloves when touching residents medications. It was also confirmed with the Administrator on 03/04/25 at 9:00 AM. b) Resident #74 On 03/10/25 at 1:24 PM observation of a pressure ulcer dressing change (wound vacuum) was performed. Licensed Practical Nurse (LPN) #117, LPN #28 and Nurse Aide (CNA) #20 were performing or assisting in this procedure. None of the three (3) staff members were wearing isolation gowns. Resident #74 was on Enhanced Barrier Precautions (EBP) which required everyone must clean their hands before entering and when leaving the room. EBP also required providers wear gloves and a gown for the following resident care activities: Dressing Bathing/showering Transferring Changing Linens Providing Hygiene Changing Briefs or assisting with toileting Devise care or use: central line, urinary catheter, feeding tube, tracheostomy Wound care: any skin opening requiring a dressing Resident #74 had an active order that stated EBP related to wounds/peripherally inserted central catheter (PICC)/Percutaneous endoscopic gastrostomy (PEG) feeding tube. (A PICC line is when the IV catheter's tip is positioned in a large vein near the heart, allowing for easier and more reliable access to the bloodstream). Resident #74 was care planned for skin impairment related to a pressure ulcer to the coccyx. The care plan interventions included: enhanced barrier precautions.The appropriate signage from the Centers for Disease Control and Prevention (CDC) was posted above the residents bed. The appropriate PPE was available outside the residents door. The facility Enhanced Barrier Precautions (EBP) policy states: Specific Procedures/Guidance 4. High-contact Resident Care Activities Requiring EBP: Dressing Bathing/showering Transferring Changing Linens Providing Hygiene Changing Briefs or assisting with toileting Devise care or use: central line, urinary catheter, feeding tube, tracheostomy Wound care: any skin opening requiring a dressing On 03/10/25 at 02:01 PM it was confirmed with the three (3) staff members they should have had the required PPE in placed. Their response was Oh yea. It was confirmed with the Director of Nursing on 03/10/25 at 02:03 PM. c) On 03/03/25 at 12:07 PM during the Dining Observation at lunch, hand hygiene was not completed by staff for the residents in the main dining room. The Interim Nursing Home Administrator (NHA) confirmed hand hygiene should be completed prior to meals. The NHA stated, hand hygiene was, usually before the meal. The NHA reported hand wipes used to be on the resident's trays, but they were implementing a new system of delivering the plate only from the serving/holding station located in the dining room.

Based upon record review and staff interview, the facility failed to complete a minimum of 12 (twelve) hours training during 2024 for nurse aides, including training in caring for residents with dementia and Alzheimer's. This was true for four (4) of five (5) Nurse Aide (NA) personnel files reviewed during this recertification survey. Facility census: 91 Findings included: a) NA #5, #13 and #15 Record review revealed that NA #5, #13, and #15 did not have a minimum of 12 hours of training, and there was no training on dementia or Alzheimer's. NA # 110 was a new hire in 2025. NA #57 - no dementia or Alzheimer's training On 03/12/25 around mid-morning, during an interview with HR Manager #170, surveyor reviewed the lack of reaching the 12 hours of annual training required for Nurses' Aides during 2024. The files contained several posttests where education on various subjects appeared to have taken place. However, no one had scored the post test to determine the knowledge level of the student. There was also no indication of the amount of time spent educating on the subject prior to administering the posttest. HR Manager #170 stated their nursing educator had resigned several months ago.

. Based on record review and staff interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. This was true for one (1) of one (1) residents reviewed under the Respiratory Pathway in the annual Long-Term Care Survey Process. The facility failed to document the reason why blood glucose levels were not obtained on two (2) dates for Resident #64. Resident identifier: #64. Facility census: 85. Findings included: a) Resident #64 A medical record review, completed on 08/01/23 at 7:49 PM, revealed the following orders: -[Lantus] Insulin Glargine 100 Unit/ML Solution sub-Q 16 units 8:00 PM. -[HumaLOG KwikPen] Insulin Lispro (1 unit dial) 100 Unit/ML Solution Pen-Injector Lispro sub-Q 5 daily 8:00 AM. -Blood Glucose Checks pattern: 1st, 2nd, 3rd, 4th, 5th, 6th, and 7th at 5:00 AM. -Blood Glucose Checks pattern: 8th, 9th, 10th, 11th, 12th, 13th, and 14th at 10:30 AM. -Blood Glucose Checks pattern: 15th, 16th, 17th 18th, 19th, 20th, 21st, at 2:00 PM. -Blood Glucose Checks pattern: 22nd, 23rd, 24th, 25th, 26th, 27th, and 28th at 9:00 PM. A review of the June 2023 and July 2023 Medication Administration Records (MAR) was completed on 08/02/23 at 11:32 AM. The following issues were identified: -The 06/03/23 blood glucose was not taken as ordered. The MAR was left blank for that date. -The 07/16/23 blood glucose was not taken as ordered. The MAR was left blank for that date. During an interview, on 08/02/23 at 12:20 PM, the Director of Nursing (DON) confirmed the above dates were left blank on the June 2023 MAR and the July 2023 MAR. The DON agreed the professional standard would be for the nurse on duty at the time to note the reason why Resident #64's blood glucose check was not completed. The DON agreed there was no explanation on MAR or in the Nursing Notes for either of the two (2) days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, family member interview, policy review, and staff interview, the facility failed to ensure that a resident who needed supplemental oxygen was provided such care, consistent with professional standards of practice. The facility failed to change the oxygen tubing for Resident #59. This was true for one (1) of one (1) residents reviewed under the respiratory pathway in the annual Long-Term Care Survey Process. Resident identifier: #59. Facility census: 85. Findings included: a) Resident #59 During an interview on 07/31/23 at 1:25 PM, Resident #59 and her family member stated they were not sure resident's oxygen tubing had ever been changed since the resident's admission to the facility on [DATE]. They stated they would like to know more about when the oxygen tubing should be changed. Surveyor, Resident, and Resident's family member, looked and did not locate any label on the tubing with the date it was last changed. During a follow-up visit to Resident #59's room on 08/01/23 at 3:15 PM, the oxygen tubing was labeled with a sticky label dated 07/15/23. Resident #59 reported there was a female staff member going around earlier in the day putting stickers on tubing. Resident was not sure if her tubing was actually replaced or if the dated sticky label was just added to her current tubing. A review of the Oxygen Auxiliary Equipment policy, completed on 08/01/23 at 8:03 PM, revealed the following directives: -All oxygen tubing will be changed on the 15th of each month. -The 11-7 shift will label the tubing on the 15th, and check for the label daily. -A sticky label will be placed on the tubing with the date. -Any time tubing is found not to have a label, the tubing will be changed and labeled. -The label must be placed so that it is not easily removed. Additional record review revealed: -The admission five (5)-Day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/30/23, reflected Resident #59 had a Brief Interview for Mental Status (BIMS) score of 15, reflecting the resident was cognitively intact. -The Physician Determination of Capacity, dated 07/02/23, reflected the resident had capacity. During an interview, on 08/02/23 at 12:42 PM, the Director of Nursing (DON) acknowledged that Surveyor, resident, and resident's family member all witnessed there was no label on resident's oxygen tubing on 07/31/23 and conceded there was not a label on the oxygen tubing at that point in time.

. Based on record review, and staff interview, the facility failed to ensure a complete and accurate medical record. The facility failed to ensure the Physician's Orders for Scope of Treatment (POST) form was completed per directions specified by the [NAME] Virginia Center for End-of-Life Care. This was true for one (1) of 21 sample residents reviewed for the Long-Term Care Survey Process. Resident identifier: #60. Facility census: 85. Findings included: a) Resident #60 During a medical record review on 08/01/23 at 11:50 AM, it was discovered the POST form for Resident #60 on 04/07/22 had no contact phone number for the physician. In an interview with the Nursing Home Administrator (NHA) on 08/01/23 at 1:39 PM, verified the contact phone number for the physician had not been completed for the POST form for Resident #60 on 04/07/22.

. Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered debris in the walk-in freezer and the ice machine was not draining properly. This deficient practice had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 85. Findings included: a) Kitchen tour During the kitchen tour on 07/31/23 at 11:45 AM, it was discovered the floor in the walk-in freezer had debris under the shelves along the back wall. The drain pipes from the ice machine were in direct physical contact with the drain. There was no gap between the drip lines and the drain to prevent backflow from back siphonage or back pressure. The Dietary Manager was present for the kitchen tour on 07/31/23 at 11:45 AM, and verified the floor in the walk-in freezer needed to be cleaned and the ice machine was not draining properly.

. Based on observation, staff interview and policy review, the facility failed to maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections when the nurse administrating medications handled the medications with bare hands. This had the potential to affect more than a limited number of residents. Resident identifiers: #14 and #23. Facility census: 85. Findings included: a) On 08/01/23 at 8:15 AM Registered Nurse (RN) #139 was observed popping the medications from the medication punch cards for Resident #14 and #23 with bare hands while passing medications on B Hall. When brought to her attention she stated well the pills are hard to get out of the cards sometimes. The Administering Medications policy for the facility dated November 2020 states . Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. On 8/01/23 at 8:40 AM the above findings were reviewed with the Administrator and she stated the nurses are not to touch medications with their bare hands.

. Based on observation and staff interview, the facility failed to ensure residents were treated in a dignified manner. Resident #5's indwelling urinary catheter bedside urine collection bag did not have a privacy cover to hide the urine. This was a random opportunity for discovery. Resident identifier: #5. Facility census: 69. Findings included: During observation on 03/28/22 at 9:59 AM, Resident #5 was noted to be sitting up in the chair in her room. The resident's indwelling urinary catheter bedside urine collection bag was hanging from the resident's walker. The urine collection bag was visible from the hallway and did not have a privacy cover to hide the urine. On 03/28/22 at 10:20 AM, Nursing Assistant (NA) #111 confirmed Resident #5's urine collection bag did not have a privacy cover. NA #111 stated she would obtain a cover. No further information was provided through the completion of the survey. .

. Based on observation and staff interview, the facility failed to post the most recent state survey results in a place readily accessible to all residents, family members and legal representatives of residents. The recent survey was attached to a chain and unable to be reached from a sitting position. This was a random opportunity for discovery. Facility Census 69 Findings Included: On 03/28/22 at 12:15 PM, observation of the most recent state survey revealed the survey was chained to a column at the nurses station desk. The chain would not allow the survey book to be taken below the desk top level. On 03/28/22 at 12:40 PM, when Receptionist # 13 was asked if a Resident or visitor in a wheelchair would be able to reach the survey book; Receptionist # 13 stated, sometimes the chain gets tangled. When the chain was untangled the survey book was still unable to reach below countertop level of the nurses station. On 03/28/22 at 12:58 PM, the Administrator acknowledged the most recent state survey needed to be accessible at a level that all Residents and visitors could reach. .

. Based on medical record review and staff interview, the facility failed to ensure a resident's Physician's Order for Scope of Treatment (POST) form, conveying end-of-life wishes was complete. One (1) of 18 POST forms reviewed during the Long-Term Care Survey Process (LTCSP) was not dated by the professional assisting with completion of the POST form. Resident identifier: #40 Facility census: 69. Findings included: a) Resident #40 During a medical record review on 03/29/22, it was discovered the POST form completed on 02/14/22 was not dated by the professional assisting with the completion of the form. An interview on 03/29/22 at 10:04 AM with Business Office Manager #24, verified she had not dated the POST form when assisting the family with completion of the POST form for Resident #40 on 02/14/22. .

. Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered the drip pan for the stove was dirty from a large amount of grease build up and temperatures were not recorded for two (2) days for the refrigerators and freezers. This deficient practice had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 69. Findings included: a) Kitchen tour During the kitchen tour on 03/27/22 at 11:25 AM, it was discovered the drip pan for the stove was dirty from a large amount of grease build up. A review of the temperature logs revealed no temperatures were recorded on 03/26/22 and 03/27/22 for the six (6) refrigerators and the three (3) freezers. An interview with the Dietary Manager on 03/27/22 at 11:28 AM, confirmed the drip pan for the stove was dirty and needed to be cleaned and also verified there were no temperatures recorded on 03/26/22 and 03/27/22 for the refrigerators and freezers. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on policy review, medical record review and staff interview, the facility failed to ensure the resident's medical record includes documentation for the influenza and pneumococcal vaccines and failed to update their immunization acknowledgement form and provide current vaccine information statement (VIS) sheets for the pneumococcal series. This is true for two (2) of five (5) residents reviewed for the influenza vaccine and three (3) of five (5) reviewed for the pneumonia vaccines. This practice has the potential to affect more than a limited number of residents eligible for the vaccines. Resident identifiers: #44, #12, and #47. Facility census: 69. Findings included: a) Influenza vaccine 1. The facility policy titled Influenza Vaccine revised December 2017, states the resident or resident's legal representative will be educated on the risks and benefits of the flu vaccine and given the current VIS sheet from the Centers for Disease Control (CDC), prior to annual vaccination. The signed informed consent or refusal will be placed in the resident's medical record. 2. Review of the medical records on 03/29/22, revealed no evidence R #12 and R #44 or their legal representatives were educated and/or given the opportunity to accept or refuse the influenza vaccine for the period of 10/01/21 through 03/31/22. 3. During an interview on 03/29/22 at 1:35 PM, the Infection Preventionist (IP) #85 confirmed the medical record lacks information for R #12 and R #44 indicating education on the risk and benefits of the flu vaccine was given to the resident or their legal representative for the current influenza season. IP #85 also confirmed the medical records for both residents lacks a signed consent/refusal for the influenza vaccine for the period of 10/01/21 through 03/31/22. b) Pneumonia Vaccine The facility policy titled Pneumococcal Vaccine (Series) dated February 2022, states the facility's policy is to offer the residents immunizations against pneumococcal disease in accordance with the current CDC guidelines. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23/PPSV) offered will depend on the resident's age, susceptibility to pneumonia, and in accordance with the current CDC guidelines. Prior to administration of the vaccine, the resident or legal representative will receive education regarding the risks and benefits of the vaccine. The resident or legal representative's signed acceptance or decline of the vaccine will be documented in the medical record. The Immunization acknowledgement form the staff currently utilizes to obtain consents prior to the administration of the pneumonia vaccine fails to identify the PCV15 and PCV20 pneumonia vaccines. The Vaccine Information Statement (VIS) sheets currently utilized by the facility were given to the survey team by IP #85 on 03/29/22. The forms are for the PPSV23 dated 04/24/15 and for the PCV13 dated 11/05/2015. **The staff was unaware there were updated VIS forms on the CDC website. Review of the immunization records on 03/29/22, revealed the following: a. R #44's medical record lacks any information on this [AGE] year olds pneumococcal vaccine history. The record does not identify education provided on the pneumococcal vaccine series and an immunization acknowledgement form indicating he accepted or declined the vaccine. b. R #12's medical record notes she received a pneumovax vaccine on 01/23/20. The record fails to identify the type of pneumonia vaccine given to this [AGE] year old. In addition, there is no consent or proof of education on the vaccine in the medical record. c. R #47's medical record notes he received the Prevnar 13 vaccine on 11/05/18. The record lacks information indicating this [AGE] year old was offered any other pneumonia vaccines, proof of education prior to administration and a consent for the vaccine. IP #85 reviewed the medical records during an interview on 03/30/22 at 9:30 AM, and confirmed the Cortland Acres Association Immunization Acknowledgement form is not updated to match the facility's current pneumococcal vaccine policy and does not include the PCV15 and PCV20. IP #85 confirmed the medical records for R #44, R #12 and R #47 lacks complete information regarding regarding the pneumococcal vaccine series, education of the pneumococcal vaccine series and consents or refusals for the pneumonia vaccines. .