MEADOWBROOK CARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 8 of 15 resident rooms on the [NAME] Hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8) reviewed for environment.The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, #7, and #8 were thoroughly cleaned and sanitized.This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings include: An observation on 07/01/25 at 10:13 AM of resident room [ROOM NUMBER] reflected a mini fridge with brown stains on the bottom of the inside of it. The room floor had thick dark dirt stains along the edges and corners of the floor. The bathroom floors had dark stains along the corners of the floor and behind the toilet. The bathroom sink had stains inside the bowl of the sink. The air vent had black dirt on the vents. An observation on 07/01/25 at 10:16 AM of resident room [ROOM NUMBER] reflected a mini fridge with brownish and reddish stains on the bottom of the inside of it. The room floor had thick dark dirt stains along the edges, behind the bed, and corners of the floor. The inside resident door had red stains on the bottom portion of the door. An observation on 07/01/25 at 10:19 AM of resident room [ROOM NUMBER] reflected the air conditioning unit filters had thick dust in them. The air vents had black dirt on the vents. The room floor had thick dark dirt stains along the edges and corners of the floor. The bathroom floor had dark reddish stains behind the toilet and the bathroom had a strong unpleasant odor. The bathroom wall near the door had brown stains streaking down the bathroom tile and door frame. An observation on 07/01/25 at 10:24 AM of resident room [ROOM NUMBER] reflected the room floor had thick dark dirt stains along the edges, near a resident bed, and corners of the floor. A wall near a resident's bed had large scrapings. The air vent had black dirt on the vents. An observation on 07/01/25 at 10:27 AM of resident room [ROOM NUMBER] reflected a mini fridge with brownish and reddish stains on the bottom of the inside of it and on the floor in front of the fridge. The room floor had thick dark dirt stains along the edges and corners of the floor. An observation on 07/01/25 at 10:29 AM of resident room [ROOM NUMBER] reflected the room floor had thick dark dirt stains along the edges and corners of the floor. An observation on 07/01/25 at 10:33 AM of resident room [ROOM NUMBER] reflected the room floor had thick dark dirt stains along the edges and corners of the floor. An observation on 07/01/25 at 10:35 AM of resident room [ROOM NUMBER] reflected the room floor had thick dark dirt stains along the edges and corners of the floor. In an interview on 07/03/25 at 09:16 AM, Housekeeping J stated he was responsible for cleaning the rooms on the [NAME] side of the facility. He stated he was supposed to clean the floor, air vents, bathrooms, and wipe down the walls. He stated he did not clean the resident mini fridges in the rooms unless they asked him to. He was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, #6, #7, and #8. He stated he normally cleaned the areas observed. He did not state why the areas of concern were not cleaned. He stated not cleaning the rooms and the hallway floors could result in germs being spread. In an interview on 07/03/25 at 9:21 AM, the Maintenance/Housekeeping Director, stated he was responsible for supervising the staff on cleaning the facility. He stated staff was responsible for cleaning the floors, empty the trashcans, dust the vents, clean the bathrooms, wiping down the walls, and the hallway floors. He stated the nursing staff was responsible for checking the mini fridges in the resident rooms but they could clean them if needed. He was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, and #8. He stated he currently did not have a working buffer to thoroughly clean the floors. He stated he was responsible for repairing any damaged walls. He stated during Angels rounds, staff was responsible for checking the rooms for cleanliness and he also checked rooms for cleanliness multiple times a week. He stated if the rooms and halls were not thoroughly cleaned it could result in health issues for the residents. In an interview on 07/03/25 at 9:45 AM, the Administrator stated she had met with the Maintenance/Housekeeping Director, and he had briefed her on the concerns observed. She was shown pictures of the concerns observed in Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, and #8. She stated her staff cleaned the rooms and they typically were told by others that they had a clean facility. She stated they completed Angel rounds daily and one of the areas observed was the cleanliness of the resident rooms. She stated it was the entire staff's responsibility to clean the resident refrigerators in the resident rooms. She stated she expected the housekeeping staff to thoroughly clean the resident rooms and hall floors. She stated not cleaning the areas mentioned could present sanitary concerns. Record review of the facility's policy on Environment That Preserves Dignity-Resident Right For (2017) reflected The facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self-image.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for two (Resident #1 and Resident #7) of fifteen residents reviewed for dignity.1. The facility failed to ensure CNA F properly covered Resident #1 while repositioning the resident in the hallway on 07/02/2025.2. The facility failed to ensure CNA D did not stand in front of Resident #7 while assisting the resident to eat during lunchtime on 07/01/2025.These failures could place the residents at risk of not having their right to a dignified existence maintained.Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with contracture (tightening or shortening of the muscles) and muscle weakness.Record review of Resident #1's Quarterly MDS Assessment, dated 06/20/2025, reflected the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated that the resident was dependent on staff for dressing and personal hygiene.Record review of Resident #1's Comprehensive Care Plan, dated 06/20/2025, reflected the resident had contractures and one of the approaches was to assist with repositioning.Record review of Resident #1's Comprehensive Care Plan, dated 06/20/2025, reflected the resident was experiencing weakness and one of the approaches was to assist with ADLs.Observation on 07/02/2025 at 10:29 AM revealed after Resident #1 was transferred to her wheelchair, CNA F pushed the resident's wheelchair to the hallway. In the hallway, CNA F asked CNA G for assistance in repositioning the resident. The resident was facing the hallway, did not have any cover on her lower part of the body, and half of her thighs were visible. CNA G asked CNA F if she would get a blanket to cover the resident, but CNA F said to finish repositioning the resident first. Both CNAs repositioned the resident and placed some pillows under the resident's arms.In an interview on 07/02/2025 at 10:35 AM, CNA F stated he should have covered Resident #1 or pulled her clothes while repositioning her in the hallway to provide dignity and so that her brief would not be visible to other residents, staff, or visitors. He said the resident had the right to be treated with dignity and one of his duties was to provide it.Observation and interview on 07/02/2025 at 1:38 PM revealed Resident #1 was in the lobby eating snacks. When asked if it was ok with her when the staff did not cover her up in the hallway, the resident did not reply.2. Record review of Resident #7's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with legal blindness (vision impairment that affects central or peripheral visions or both) and lack of coordination.Record review of Resident #7's Quarterly MDS Assessment, dated 06/20/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated that the resident was dependent on staff for eating.Record review of Resident #7's Comprehensive Care Plan, dated 05/12/2025, reflected the resident required assistance with ADLs and one of the approaches was to assist with eating.Record review of Resident #7's Physician Order, dated 05/28/2019, reflected EATING with assist of 1 staff.Observation on 07/01/2025 at 11:53 AM revealed CNA D was assisting Resident #7 for lunch in the dining area. CNA D was standing in front of the resident while she was feeding the resident. In an interview on 07/01/2025 at 12:17 PM, CNAD stated she should be sitting down when assisting somebody in the dining area. She said she assisted Resident #7 during lunch until somebody relieved her. She said, when assisting somebody during mealtimes, she should sit down so she would be face to face with the resident. She said standing up in front of the resident was not a way of showing respect and dignity and as if she was implying to the resident to hurry up. She said her mind was already on the trays on the hallway that she needed to pass. She said he ADON whispered to her that she should be sitting down but somebody already came to relieve her so she could pass the trays. Observation and interview on 07/01/2025 at 2:07 PM revealed when asked if it was ok when staff were standing up when assisting her during mealtimes, Resident #7 did not reply.In an interview on 07/02/2025 at 2:28 PM, the DON stated staff should cover the residents before ushering them in the hallway to prevent improper exposure of the resident as well as a feeling of embarrassment. She said before pushing the residents out of their rooms, the residents should be well-groomed and decent. She said the staff should sit down next to the resident when assisting them during mealtimes. She said sitting beside the resident also allowed close observation of the resident's eating habits like if the residents were swallowing the food, if there was a problem in swallowing, if the resident was pocketing the food, if the residents were choking. She said standing up behind the resident gave the impression that the staff was in a hurry. She said not covering the residents and not sitting beside the resident to assist in eating did not uphold dignity and respect. She said she already initiated an in-service about dignity specifically about sitting down when providing assistance during mealtimes. She said the expectation was for all the staff to provide all the residents a dignified existence. She said she would add to the in-service to make sure the residents were covered and decent when ushered to the hallway. In an interview on 07/02/2025 at 2:52 PM, the ADON stated the staff assisting a resident during mealtime should be sitting alongside the residents to provide dignity. She said sitting beside the residents would allow better observation of the residents' needs during mealtime. She also said sitting beside the resident encouraged interaction and promoted safety when eating. She said she saw CNA D standing up while assisting Resident #7 during lunch and told her she needed to sit down. She said when ushering the residents in the hallway, the staff must make sure the residents were appropriately covered to prevent embarrassment. She said the expectation was for the staff to provide dignity, not only during mealtime but every time the staff provide care to the residents. She said the DON already started an in-service about dignity.In an interview on 07/02/2025 at 3:13 PM, The Administrator stated the expectation was for the staff to always have in mind that the residents have the right for a dignified existence and it should be provided during all interactions with the residents, not just in the dining room and in the hallway. She said both incidents were disrespectful and a dignity issue. She said she would collaborate with the DON and the ADON to re-educate the staff about the importance of dignity.Record review of the facility's policy, ENVIRONMENT THAT PRESERVES DIGNITY Resident Rights revised 11/01/2017 revealed POLICY: The Facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self-image.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for seven (Resident #1, #2, #16, #20, #22, #24, and #25) of seventeen residents reviewed for privacy and confidentiality.1. The facility failed to ensure a list of hospice residents (Residents #2, #22, #24) was not left on top of the CNA's cubicle unattended on 07/01/2025.2. The facility failed to ensure MA B did not leave Resident #16's blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing) for potassium on top of the medication cart unattended on 07/01/2025.3. The facility failed to ensure RN A did not leave Resident #25's order for wound care on top of treatment cart unattended on 07/02/2025.4. The facility failed to ensure MA C did not leave the names of the medications to be re-ordered for Resident #20 and Resident #25 on top of the medication cart unattended on 07/02/2025. 5. The facility failed to ensure CNA F and CNA G would close Resident #1's door while doing transfer via mechanical lift (a device used to lift, transfer, or position an individual with limited mobility), did not perform ADLs in the hallway, and did not reposition the resident in the hallway on 07/02/2025.These failures could place the residents at risk of not having their personal privacy maintained during transfer and ADLs and their medical information exposed to unauthorized individuals.Findings included: 1. Record review of Resident #2's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with multiple sclerosis (a disease that causes breakdown of the protective covering of the nerves). Record review of Resident #2's Quarterly MDS Assessment, dated 06/06/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated the resident was on hospice. Record review of Resident #2's Care Plan, dated 06/09/2025, reflected the resident required hospice due to terminal illness of multiple sclerosis and one of the approaches was to report decline in condition to hospice agency.Record review of Resident #22's Face Sheet, dated 07/01/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #22's Quarterly MDS Assessment, dated 05/14/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated the resident was on hospice. Record review of Resident #22's Care Plan, dated 05/13/2025, reflected the resident required Hospice due to terminal illness of chronic obstructive pulmonary disease and one of the approaches was to report decline in condition to hospice agency.Record review of Resident #24's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with coronary artery disease (heart disease caused by plaque buildup in the arteries). Record review of Resident #24's Quarterly MDS Assessment, dated 06/06/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was on hospice. Record review of Resident #24's Care Plan, dated 06/13/2025, reflected the resident required Hospice due to terminal illness of coronary artery and one of the approaches was to call hospice for any concerns.Observation on 07/01/2025 at 8:44 AM revealed a piece of paper was on top of a cubicle on the hallway. On the piece of paper were names of residents who were on hospice.Observation and interview on 07/01/2025 at 9:12 AM, RN A stated the list of residents on hospice should not be left in the hallway because those were medical information and a HIPAA (law protecting health information aimed to ensure confidentiality) violation. RN A took the paper from the cubicle and said she would place it somewhere in the nurse's station. 2. Record review of Resident #16's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle wasting. Record review of Resident #16's Quarterly MDS Assessment, dated 04/29/2025, reflected the resident had severe impairment (requires significant assistance and support in daily life) in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated the resident had muscle wasting. Record review of Resident #16's Care Plan, dated 05/01/2025, reflected the resident had nine or more medications required and one of the approaches was to monitor laboratory results.Record review of Resident #16's Physician Order, dated 12/90/2020, reflected potassium chloride 20 meq 1 tablet Once A DayObservation on 07/01/2025 at 8:45 AM revealed Resident #16's blister pack was on top of the medication cart. The blister pack had the resident's name, name of medication, the prescription number, the name of the medical doctor, and the instruction on how to take the medication, and the name of the resident's pharmacy.In an interview on 07/01/2025 at 10:45 AM, MA B stated different facilities had different policies with regards to leaving the blister packs on top of the medication cart and said she had been doing it at other facilities, and it was not an issue. When asked if the medical information about the resident exposed, she said she should have flipped it before leaving her cart unattended so others would not know what medications Resident #16 was taking.3. Record review of Resident #25's Face Sheet, dated 07/02/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with non-pressure chronic ulcer (wound on the skin caused by prolonged pressure to specific area of the body) to left heel. Record review of Resident #25's Quarterly MDS Assessment, dated 04/01/2025, reflected the resident was cognitively with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had non-pressure chronic ulcer of left heel. Record review of Resident #25's Care Plan, dated 06/30/2025, reflected the resident had surgical wound to left foot and one of the approaches was to change the dressing as ordered.Record review of Resident #25's Physician Order, dated 05/31/2025, reflected Daily Wound Treatment: Clean Left Ankle with Wound Cleanser, Apply Collagen and Dry Dressing Daily.Observation on 07/02/2025 at 10:44 AM revealed RN A was about to do Resident #25's wound care. She prepared the things needed for wound care and entered inside the resident's room. She left the MAR opened and the resident's treatment flowsheet was visible. The order for the resident's wound care was visible to others. On the flowsheet was the resident's name, code status, wound care orders, time of treatments, name and phone number of the resident's physician, medications that the resident was allergic to, diagnosis and the resident's date of birth .In an interview on 07/02/2025 at 10:55 AM, RN A stated she should have closed the MAR's binder before going inside Resident #25's room to perform wound care because the medical information and the order for wound care for the resident was exposed. She said she saw it while she was doing wound care but was already in the middle of the process and it was already too late for her to close the binder. She said it was a HIPAA violation and the information should be confidential.4. Record review of Resident #20's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depression (persistent feeling of sadness or loss of interest). Record review of Resident #20's Quarterly MDS Assessment, dated 04/28/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated the resident had depression. Record review of Resident #20's Care Plan, dated 04/28/2025, reflected the resident had depression and one of the approaches was administer medication as ordered.Record review of Resident #20's Physician Order, dated 05/05/2025, reflected mirtazapine tablet 7.5 mg Once A Day Antidepressants.Record review of Resident #25's Face Sheet, dated 07/02/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with Parkinson's Disease (movement disorder). Record review of Resident #25's Quarterly MDS Assessment, dated 04/01/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had Parkinson's Disease. Record review of Resident #25's Care Plan, dated 06/30/2025, reflected the resident had Parkinson's and one of the approaches was to provide drug therapy.Record review of Resident #25's Physician Order, dated 03/27/2025, reflected amantadine HCl capsule 100 mg Twice A Day for Parkinsonism.Observation on 07/02/2025 at 3:59 PM revealed a re-order form for medications was on top of a medication cart. On the form were posted two stickers showing Residents #20 and #25's names and the medications to be re-ordered for them. Observation and interview on 07/02/2025 at 4:00 PM revealed RN A also saw the re-order form and flipped it. She said the staff should have flipped it so the medications of the residents were not showing.Observation and interview on 07/02/2025 at 4:01 PM revealed MA C was exiting one of the residents room and saw RN A flipped the re-order form on top of her cart. she said she had been flipping the form the whole day but forgot to do so for that particular moment. She said the said those were medical information and should not be seen by unauthorized individuals.5. Record review of Resident #1's Face Sheet, dated 07/02/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with contracture and muscle weakness.Record review of Resident #1's Quarterly MDS Assessment, dated 06/20/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 09. The Quarterly MDS Assessment indicated that the resident was dependent on staff for transfer, bed mobility, and personal hygiene.Record review of Resident #1's Comprehensive Care Plan, dated 06/20/2025, reflected the resident required assistance with ADLs and the approaches were to transfer times 2 with mechanical lift, assist with bed mobility, and assist with ADL care.Record review of Resident #1's Physician Order, dated 10/18/2016, reflected Transfer with assist of 2 staff and Hoyer lift.Observation on 07/02/2025 at 10:20 AM revealed CNA F and CNA G were about to transfer Resident #1 from bed to wheelchair via mechanical lift. Both CNAs washed their hands, put on their gloves, and proceeded with transfer. They did not close the resident's door when they were performing the transfer and the procedure could be seen from the hallway. Both CNAs hooked the loops of the mechanical sling, which was under the resident, to the sling attachment of the mechanical lift, and started to raise the resident. CNA G then went to the resident's wheelchair and CNA F started to maneuver the mechanical lift towards the wheelchair using its remote control. They lowered the resident to her wheelchair, unhooked the mechanical sling, and ushered the resident to the hallway. It was observed that the resident did not have a roommate and the other bed inside the room was parallel to the wall and perpendicular to the resident's bed rendering a square-shaped space inside the room. In the hallway CNA F started to clean the resident's face and combed her hair and asked CNA G to reposition the resident.In an interview on 07/02/2025 at 10:35 AM, CNA F stated the door should had been closed when they were transferring Resident #1 to her wheelchair to provide privacy and dignity. He said he also should had cleaned the resident's face, combed her hair, and repositioned the resident inside her room with the door closed. He said Resident #1 might be embarrassed because other residents or visitors might see how she was being transferred and that she needed somebody else to clean her face and comb her hair. He said he would make sure to close the door every time he would do a transfer and do all the ADLs and repositioning inside the room with the door closed as well. In an interview on 07/02/2025 at 11:44 AM, CNA G stated the door should be closed when Resident #1 was transferred and her ADLs should had been done inside the room to provide privacy.In an interview on 07/02/2025 at 2:28 PM, the DON stated the door should be closed when transferring the residents to provide privacy. She said ADLs such as cleaning the face, combing the hair, and repositioning the residents should be done inside the room and not in the hallway for the same reason. She said privacy should be provided during care to avoid awkwardness. She said some residents could not communicate and even though they were feeling embarrassed, they could not verbalize it. The DON stated medical information about a resident should be protected and not be visible for everybody to see because those were confidential information. She said the health information of a resident could not be shared without the permission of the resident or the resident's responsible party. She said the staff should have made sure the MAR was closed before going inside the resident's room, the blister pack and the re-order form were flipped, and the list of hospice resident was not exposed. She said if the confidential information were exposed, non-nursing staff, other resident, and visitors will be able to see it. She said all staff, including her, were expected to provide full privacy during care and confidentiality of all the residents' personal and medical information. The DON stated she would start an in-service about privacy and confidentiality of the residents' information.In an interview on 07/02/2025 at 2:52 PM, the ADON stated all transfers and ADLs should be done in the privacy of the residents' room so other staff, other residents, or even the visitors would not see the care being provided. She said it did not matter if the residents care or not, the door should be closed to ensure the residents would not be embarrassed. The ADON said it was a HIPAA violation to leave the residents' health information out for everyone to see. She said the expectation was for the staff to provide privacy during care and to secure the medical information of the residents.to the residents. She said she would coordinate with the DON to do an in-service about privacy during care and confidentiality of medical records.In an interview on 07/02/2025 at 3:13 PM, The Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent embarrassment and that the medical information of the residents were safeguarded to prevent embarrassment or unlawful use of their information. She said the expectation was for the staff to be mindful about privacy and confidentiality. She said she would collaborate with the DON and the ADON to do an in-service about privacy and confidentiality.Record review of the facility's policy, SAFEGUARDING PROTECTED HEALTH INFORMATION Health Information Management Policies and Procedures revised 03/01/2013 revealed POLICY: Health Information Management (HlM staff will set up access controls and physical safeguards to prevent prohibited uses and disclosure of Protected Health Information (PHI) . 2. SAFEGUARDS FOR WRITTEN PHI . A. Active Records on Nursing Unit . 1) Active Medical Records are stored in an area or manner that secures the records from unauthorized access . 3) Active Medical Record are not left unattended or unsecured on the nurses' station desk or other areas where patients/residents, visitors and unauthorized individuals could easily view the records . 4) Medication Administration Records, Treatment Administration Records, report sheets and other documents containing PHI are not left open.Record review of the facility's policy, PRIVACY AND SECURITY Resident Rights revised 11/01/2017 revealed POLICY: The Facility staff will provide the patient/resident with his/her right to privacy . 2. Staff . D. Closes privacy curtains or doors as appropriate during treatment or daily care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #5) reviewed for respiratory care in that:<BR/>The facility failed to ensure Resident #1's oxygen tubing was dated.<BR/>This deficient practice could place residents that receive oxygen therapy at risk for inadequate care and respiratory distress and serious infections.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 02/6/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, Pneumonia unspecified (lung infection); Chronic Obstructive Pulmonary Disorder ( lung disease causing airflow blockage), unspecified; Acute Respiratory Failure with hypoxia. (difficulty with oxygen levels in blood). <BR/>Record review of Resident #1's baseline care plan, dated 02/02/2023, revealed, in part, [Resident #1's] has a Goal to be free of pain, Free of infection, Free of falls, and free of weight changes/ admission to skilled nursing with medication management and treatment per physician orders. Additional documentation listed at the end of their plan stated to continue Oxygen 2 l per minute. <BR/>Record review of Resident #1's physician's orders on 02/06/2023 revealed no physician's order for an oxygen therapy by concentrator.<BR/>Record review of Resident #1's TAR and MAR for February 2023 revealed no documentation of orders for oxygen therapy.<BR/>In an observation and interview on 02/06/2023 at 12:00 PM revealed Resident #1 was lying in bed with her head of bed elevated. She was on oxygen via N/C which was properly positioned in nose. The N/C was connected to an oxygen concentrator, and it was set to deliver 2 Liters Per Minute. The N/C and the humidifier bottler were undated. Resident #1 stated she did not know why she was on oxygen, but she was at the facility for therapy to improve mobility. <BR/>In an interview on 02/06/2023 at 12:30 PM, the DON said it was the 10pm to 6am nurse's job to replace and date oxygen tubing weekly on Wednesdays, and Resident #1 had not been at the facility a full week. She stated she would change the tubing and humidifier bottle and date them immediately. The DON stated it was her expectation for the admitting nurse or night nurse to change and date the oxygen tubing weekly or at the time of admissions if the resident entered with an undated tube. The DON stated Resident #1 was admitted from the hospital on Thursday 02-02-2023. The DON stated each shift nurse was responsible for checking patient oxygen tubing during patient rounds. The DON stated she and the ADON were responsible for reviewing, auditing, and monitoring treatment task. <BR/>In interview on 02/06/23 at 12:50 PM, with LVN E revealed that she was the admitting nurse on 02/02/2023, however the resident was admitted at the time of shift change, so she initiated base line care plan and passed the information on verbally to the ADON to complete. She stated she was so busy she forgot to assess upon returning to work on 02/06/2023. LVN E stated that the nurse assigned to each shift was in charge of assessing tubing and checking for dates. LVN E stated once the tubing was viewed as undated it should have been changed, dated, and documented in the patient's treatment records. LVN E said undated tubing could lead to overuse of the tubing, increased bacteria, and respiratory complications. <BR/>Record review of Resident #1's treatment records on 02/06/2023 revealed no treatment administration per the MD orders.<BR/>Review of the facility's policy titled Respiratory Policies and Procedures , dated 04/01/2022, revealed, . Subject: Equipment Change schedules. Procedure: Equipment will be changed as follows: Aerosol Tubing and aerosol Nebulizer should be changed Every week or per Statre regulations and or Manufactured guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #51) of ten residents reviewed for pharmaceutical services. 1. The facility failed to ensure MA B did not leave Resident #51's medications inside the resident's room for the resident to take unsupervised on 07/01/2025 2. The facility failed to ensure MA C did not put her personal beverage on the medication cart while passing medications on 07/02/2025. 3. The facility failed to ensure that there was no expired nasal sprays inside the medication room on 07/02/2025. These failures could place the residents at risk of not receiving medications as ordered by the physician. Findings included: 1. Record review of Resident #51's Face Sheet, dated 07/01/2021, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #51's Comprehensive MDS Assessment, dated 06/30/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had generalized weakness. Record review of Resident #51's Comprehensive Care Plan, dated 06/20/2025, reflected the resident had a decline in her ability to ambulate and one of the approaches was to provide supplements and vitamins as ordered. Record review of Resident #51's Physician's Order, dated 06/24/2025, reflected provitalize 2 capsules Once A Day. Record review of Resident #51's Assessment Notes on 07/01/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. Observation and interview on 07/01/2025 at 8:54 AM revealed Resident #51 was in her bed finishing her breakfast. It was observed that there was a small cup on her overbed table with two yellow capsules. The resident said it was left by her nurse for her to take and she was done with the rest of the pills. The resident said she would take the capsules after she was done with breakfast. In an interview on 07/01/2025 at 9:12 AM, RN A stated Resident #51's medication should not be left with the resident for her to take unsupervised. She said staff should have made sure the medications were swallowed and there was no issue while taking the medication. She said the resident might not take the pills or hide them or choke on them and nobody was there to initiate help. In an interview on 07/01/2025 at 10:45 AM, MA B stated she was inside Resident #51's room waiting for the resident to finish her medications. She said a CNA called her for assistance so she stepped out of the room and forgot to go back. She said she should have told the staff that she could not be distracted when she was administering medications. She said the resident might throw the medication or hide them. She said she would check if the resident already took the medications. She said the two yellow capsules were provitalize, a probiotic. 2. Observation on 07/02/2025 at 7:15 AM revealed MA C's personal tumbler was on top of the medication cart that she was using to pass medications. Observation and interview on 07/02/2025 at 12:27 PM revealed MA C's personal tumbler was still on top of the medication cart that she was using to pass medications. She said she always had her tumbler every time she passed medications and nobody told her she could not put it there. In an interview on 07/03/2025 at 9:12 AM, MA C stated the DON already explained to her why she could not have her personal tumbler on the cart when passing medications. She said it could be an infection control issue or could create clutter on the medication cart. She was told that only required supplies and medications should be on the medication cart. 3. Observation on 07/02/2025 at 8:15 AM revealed during inspection of the medication room, three bottles of nasal spray were dated 05/25. Observation and interview on 07/02/2025 at 8:16 AM, RN A stated the nasal sprays were expired and should not be inside the medication room. She said they were supposed to be disposed so they would not be used for the residents. She said the ADON was responsible in auditing the medication room but she would sometimes help in the checking the med room. She said they missed the three expired nasal sprays. She said the expired nasal sprays might be less effective or could cause adverse reactions. RN A took the three bottles of nasal spray and showed them to the DON. In an interview on 07/02/2025 at 2:28 PM, the DON stated a staff should never leave the medications at the bedside for the resident to take later unsupervised. She said the staff must ensure the resident took the medications before leaving the room. She said the resident could hoard or hide the pills to avoid taking them. She said the residents could overdose on hoarded pills. She said the staff should have told the staff that asked for assistance that she was passing meds and could not be distracted. She said there should be no expired medications inside the medication room or inside the medication carts. She said the effects of expired medications could range from reduced effectiveness to unfavorable side effects. She said she already talked to MA C that she could not put any personal items on the medication carts. She said aside from the risk of cross contamination, some residents might take it and drink the content. She said the expectations were for the staff not to leave any medication inside the room for the residents to take unsupervised, for the medication room to be audited thoroughly for expired medications, and no personal beverages were in any cart. The DON said she would do an in-service pertaining to all the issues mentioned and would closely monitor the staffs' compliance. In an interview on 07/02/2025 at 2:52 PM, the ADON stated she was the one responsible for auditing the medication room for what to order and for expired medications. She said it was an oversight on her part that she missed seeing the expired nasal sprays. She said she already checked the medications inside the medication room to see if there were other expired medications. She said expired medications lose their effectiveness and would not address the medical needs of the residents. She said medications were not left with the residents to take unsupervised. She said the staff administering the medications should stay with the resident until the resident was done taking them. She said the resident might not take them or someone else might, like another resident or a visitor. She said the resident might aspirate while taking the medications and nobody was with her. She said if somebody asked for help, the staff could help after the resident was done taking the medications. She said no personal beverages should be on the carts because aside from being a clutter that might contribute to medication error, staff might bring some microorganism from their home to the medication cart. She said she would coordinate with the DON to do an in-service about not leaving the medications with the residents and not distracting the staff that was passing medications. In an interview on 07/02/2025 at 3:13 PM, The Administrator stated she was made aware of the issues about the expired medications in the medication room and personal beverages on the cart, and the staff leaving the resident's medications for the resident to take alone. She said if the pills were left unattended, the resident might not take them or the pills might not be taken on time. She said she would coordinate with the DON and the ADON to do an in-service about not leaving the medications with the resident during med pass, not disturbing the staff that was passing meds, make sure there no expired medications in the med room, and no personal beverages on the carts. Record review of the facility's policy, MEDICATION MANAGEMENT PROGRAM Nursing Policies and Procedures revised 01/15/2025 revealed 2. Nursing services . E. educate staff . that during medication pass . the medication aide . is not to be interrupted . 5. person authorized . prepares, administer . the medications . 8. The authorized staff member must remain with the resident while the medication is swallowed. Do not leave the medication in a resident room without order to do so . Preparing for the Medication Pass . F. No employee beverages should be on the medication/treatment cart . Security and Safety Guidelines . 15. Outdated medication is destroyed or returned to the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for two (Resident #2 and Resident #25) of sixteen residents reviewed for medication storage. 1. The facility failed to ensure #Resident #2's anti-fungal powder was not left on top of the resident's side table on 07/01/2025. 2. The facility failed to ensure Resident #25 did not have a bottle of eyedrops on her overbed table on 07/01/2025. These failures could place the residents at risk of accidental overdose, misuse of medications, not receiving the medication's full therapeutic benefits, and possible side effects. Findings included: 1. Record review of Resident #2's Face Sheet, dated 07/01/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with depressive disorder (persistent feeling of sadness or loss of interest) and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #2's Comprehensive MDS Assessment, dated 06/06/2025, reflected the resident had a moderate impairment in cognition with a BIMS score of 09 (resident may need additional support and monitoring). The Comprehensive MDS Assessment indicated the resident had depression. Record review of Resident #2's Comprehensive Care Plan, dated 06/09/2025, reflected the resident took an antidepressant and one of the approaches was to monitor the resident's mood and response to medication. Record review of Resident #2' Physician Order, dated 11/10/2022, reflected Anti-fungal powder to affected area. Record review of Resident #2's Assessment Notes on 07/01/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. Observation and interview on 07/01/2025 at 8:50 AM revealed Resident #2 was in her bed, awake. It was observed that there was an antifungal powder on the resident's side table. When asked if she was using it, the resident just shrugged her shoulders. 2. Record review of Resident #25's Face Sheet, dated 07/02/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with diabetes mellitus (high blood sugar that could potentially have an effect on the eye sight). Record review of Resident #25's Quarterly MDS Assessment, dated 04/01/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had diabetes mellitus. Record review of Resident #25's Care Plan, dated 06/30/2025, reflected the resident had diabetes mellitus and one of the approaches was to monitor potential signs and symptoms . blurry eyes. Record review of Resident #25's Assessment Notes on 07/01/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage their own medications. Record review of Resident #25's Physician orders on 07/01/2025 reflected no order for eye drops. Record review of Resident #25's Physician Order, dated 12/23/2024, reflected RESIDENT MAY NOT SELF-ADMINISTER MEDICATIONS Observation and interview on 07/01/2025 at 10:08 AM revealed Resident #25 was in her bed, awake. It was observed that there was a container of eyedrops on the resident's overbed table. She said she was using it every morning because her eyes were dry when she woke up. She said the eyedrops had always been on top of her table. She said she did not know if the staff saw it or knew about it but it had been on her table. Observation and interview on 07/01/2025 at 10:23 AM, RN A stated the eyedrops should not be inside Resident #25's room unless she had an assessment that she could administer it herself. She said if the resident needed eyedrops, the staff should be the one administering it and it should be stored inside the cart. She went inside Resident #25's room and talked to the resident. She said she would also call the doctor to get an order for the eyedrops. RN A then went to Resident #2's room and saw the anti-fungal powder on the side table. She said she did not know who left it on the side table. She took the anti-fungal from the side table and said she would put it inside the cart because it was a medicated powder. She said she did not see the eyedrops and the anti-fungal powder when she made her morning round. In an interview on 07/02/2025 at 2:28 PM, the DON stated no medications should be stored inside the resident's room. She said if Resident #25 needed eyedrops, the staff should be the one administering it to ensure proper use of the medication and there should be an order for. She said the anti-fungal powder is a form of medication and should be in the cart. She said whoever applied it should have not left it in Resident #2's side table because the resident, other confused residents, or a visitor might accidentally ingest it and could result in allergic reactions or other adverse outcomes. She said the expectations were for the staff to always scan the residents' rooms to make sure the residents were not storing any medications and for staff to put the medicated powder back to the medication cart. She said she would do an in-service for all the issues mentioned and would closely monitor the staffs' compliance. In an interview on 07/02/2025 at 2:52 PM, the ADON stated no medications should be stored inside the residents' rooms because the residents might administer them incorrectly and there should be physician orders for such medications as well. She said the medicated powder should be stored in the cart and not inside the room because it had chemicals that could be toxic when consumed. She said the expectation was for the staff to be compliant with the policies regarding medication storage to ensure a safe medication administration. She said she would coordinate with the DON to do an in-service about medication storage. In an interview on 07/02/2025 at 3:13 PM, The Administrator stated she was made aware of the issues about medication inside the residents' rooms. She said the expectation was for the staff to be mindful with all the discussed medication storage issues to ensure safety of the residents. She said she would coordinate with the DON and the ADON on what to so the issues mentioned would not happen again. Record review of the facility policy, MEDICATION MANAGEMENT PROGRAM Nursing Policies and Procedures revised 05/05/2023 revealed 2. Nursing services . 5. person authorized . prepares, administer . the medications . Security and safety Guidelines . 3. The medication cart is locked when not in use and in direct line insight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #17) of eight residents observed for infection control. <BR/>The facility failed to ensure that CNA A and CNA B did not place the used bed padding on top of Resident #17's open, clean, and new brief.<BR/>This failure could place the residents at risk of cross-contamination and development of infection.<BR/>Findings included: <BR/>Review of Resident #17's Face Sheet, dated 06/05/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included diarrhea and urinary incontinence.<BR/>Review of Resident #17's Comprehensive MDS Assessment, dated 05/09/2024, reflected Resident #17 had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment also indicated Resident #17 was always incontinent for bowel and bladder.<BR/>Review of Resident #17's Care Plan, dated 05/16/2024, reflected resident required assistance with ADLs and one of the interventions was assist with all ADLs as needed.<BR/>Observation on 06/05/2024 starting at 8:05 AM revealed Resident was on her bed awake. It was observed that the resident had a cloth padding placed beneath her torso. CNA A and CNA B were about to prepare the resident for her doctor's appointment. Both CNAs washed their hands and put on gloves. CNA A prepared the things needed and told Resident #17 that they would be cleaning her. CNA A positioned herself on Resident #17's left side and CNA B on the right side. CNA A unfastened the tape on both sides of the brief, rolled the front half of the brief and then pushed it between the resident's thighs. CNA A cleaned the front part of the resident using the front to back technique. CNA A then instructed and assisted the resident to turn towards CNA B. When the resident was on the side lying position, it was observed that the resident just had a bowel movement. CNA A and CNA B begun cleaning the resident's bottom. Both CNAs placed the wipes used to clean the resident's bottom on the soiled brief. Some of the soiled wipes touched the cloth padding. After cleaning the resident's bottom, CNA A took off her gloves, washed her hands, and put on new gloves. While CNA A was washing her hands, CNA B transferred to the other side, pulled the rest of the soiled brief, and threw it. CNA B rolled the padding halfway. CNA B took off her gloves, sanitized her hands, and put on new gloves. CNA A then took the new brief, opened it, placed it beside the resident's bottom, and tucked it under the used and soiled padding. The used padding was on top of the open, new brief. CNA A then instructed the resident to roll to the other side. CNA A pulled the padding and asked the resident to roll back. CNA B then fixed the new brief. <BR/>In an interview with CNA A on 06/05/2024 at 8: 30 AM, CNA A stated she washed her hands before and after doing incontinent care. She said she also changed her gloves after touching the soiled items. CNA A then acknowledged that she tucked the brief under the padding. She said that during incontinent care, the soiled wipes could had touched the padding making dirty. She said she should had pulled the soiled padding first before tucking the new brief under the resident's bottom. She said the germs from the padding could transfer to the new brief and the resident could had urinary tract infection. <BR/>In an interview with CNA B on 06/05/2024 at 8: 37 AM, CNA B stated she also washed her hands before and after doing incontinent care and sanitized her hands when she changed her gloves. CNA B then acknowledged that the padding touched the new brief when it was tucked under the resident. She said the padding, whether clean or not, should not the touch the clean brief to prevent cross contamination. She said the resident might catch an infection if dirty items touched the clean items.<BR/>In an interview with RN C on 06/05/2024 at 8:45 AM, RN C stated the right procedure was to wash to do hand hygiene before and after any care. She said it was also important to change and sanitize the hands during the duration of any care if soiled items were touched. RN C added that any soiled items should not touch the clean items to prevent cross contamination and possible infection. She said, for the same reason, the used and soiled padding should not be placed on top of an open and clean brief because female residents were prone to urinary tract infections. She said everything soiled should had been taken away before placement of the clean item.<BR/>In an interview with the Interim DON on 06/06/2024 at 7:22 AM, the Interim DON stated she was made aware about the infection control issue during incontinent care. The Interim DON said the soiled items should be removed first before placing the clean brief to prevent possible infections. She said there should be not contact between the clean items and the dirty items. The Interim DON said the DON and the ADON were responsible in making sure the staff were adhering to the infection control practices. The interim DON said the expectation was for the staff to carry out care without the possibility of cross contamination and introduction of infection. The interim DON said she would do an infection control in-service pertaining to incontinent care for all the staff. She also said she did a check off with CNA A and B about peri-care and would do spot checks for all the staff pertaining to peri-care. She concluded that she would continually remind the staff to be attentive to the procedures for infection control.<BR/>In an interview with the ADON on 06/06/2024 at 7:48 AM, the ADON stated placing the soiled padding on top of the new brief could result to cross contamination because if the soiled wipes and brief touched the padding, the padding was considered not clean. The same reason applied when the used and soiled padding touched the clean brief. She continued that cross contamination could lead to infection such as urinary tract infection. The ADON said the expectation was for the staff not to put the soiled or the used padding on top of a clean brief. The ADON said they would do an in-service to correct the issue and would monitor their adherence to the procedure of separation of clean and dirty items.<BR/>In an interview with the Administrator on 06/06/2024 at 8:23 AM, the Administrator stated clean and dirty items should not be touching each other to prevent infection. She said the expectation was for the staff to be mindful and do the right and proper way of care to protect the residents. The Administrator said she would collaborate with the clinicals to address the issue.<BR/>Record review of CNA A and B's competency check-off for Peri-Care Competency, dated 06/06/2024, revealed Performance Criteria . 24. Apply clean undergarment.<BR/>Record review of facility's procedure, Perineal Care revealed Perineal care, which includes care of the external genitalia and anal area . promotes cleanliness and prevents infection . Completing the procedure . dispose of soiled articles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #17) of eight residents observed for infection control. <BR/>The facility failed to ensure that CNA A and CNA B did not place the used bed padding on top of Resident #17's open, clean, and new brief.<BR/>This failure could place the residents at risk of cross-contamination and development of infection.<BR/>Findings included: <BR/>Review of Resident #17's Face Sheet, dated 06/05/2024, reflected resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included diarrhea and urinary incontinence.<BR/>Review of Resident #17's Comprehensive MDS Assessment, dated 05/09/2024, reflected Resident #17 had a severe impairment in cognition with a BIMS score of 03. The Comprehensive MDS Assessment also indicated Resident #17 was always incontinent for bowel and bladder.<BR/>Review of Resident #17's Care Plan, dated 05/16/2024, reflected resident required assistance with ADLs and one of the interventions was assist with all ADLs as needed.<BR/>Observation on 06/05/2024 starting at 8:05 AM revealed Resident was on her bed awake. It was observed that the resident had a cloth padding placed beneath her torso. CNA A and CNA B were about to prepare the resident for her doctor's appointment. Both CNAs washed their hands and put on gloves. CNA A prepared the things needed and told Resident #17 that they would be cleaning her. CNA A positioned herself on Resident #17's left side and CNA B on the right side. CNA A unfastened the tape on both sides of the brief, rolled the front half of the brief and then pushed it between the resident's thighs. CNA A cleaned the front part of the resident using the front to back technique. CNA A then instructed and assisted the resident to turn towards CNA B. When the resident was on the side lying position, it was observed that the resident just had a bowel movement. CNA A and CNA B begun cleaning the resident's bottom. Both CNAs placed the wipes used to clean the resident's bottom on the soiled brief. Some of the soiled wipes touched the cloth padding. After cleaning the resident's bottom, CNA A took off her gloves, washed her hands, and put on new gloves. While CNA A was washing her hands, CNA B transferred to the other side, pulled the rest of the soiled brief, and threw it. CNA B rolled the padding halfway. CNA B took off her gloves, sanitized her hands, and put on new gloves. CNA A then took the new brief, opened it, placed it beside the resident's bottom, and tucked it under the used and soiled padding. The used padding was on top of the open, new brief. CNA A then instructed the resident to roll to the other side. CNA A pulled the padding and asked the resident to roll back. CNA B then fixed the new brief. <BR/>In an interview with CNA A on 06/05/2024 at 8: 30 AM, CNA A stated she washed her hands before and after doing incontinent care. She said she also changed her gloves after touching the soiled items. CNA A then acknowledged that she tucked the brief under the padding. She said that during incontinent care, the soiled wipes could had touched the padding making dirty. She said she should had pulled the soiled padding first before tucking the new brief under the resident's bottom. She said the germs from the padding could transfer to the new brief and the resident could had urinary tract infection. <BR/>In an interview with CNA B on 06/05/2024 at 8: 37 AM, CNA B stated she also washed her hands before and after doing incontinent care and sanitized her hands when she changed her gloves. CNA B then acknowledged that the padding touched the new brief when it was tucked under the resident. She said the padding, whether clean or not, should not the touch the clean brief to prevent cross contamination. She said the resident might catch an infection if dirty items touched the clean items.<BR/>In an interview with RN C on 06/05/2024 at 8:45 AM, RN C stated the right procedure was to wash to do hand hygiene before and after any care. She said it was also important to change and sanitize the hands during the duration of any care if soiled items were touched. RN C added that any soiled items should not touch the clean items to prevent cross contamination and possible infection. She said, for the same reason, the used and soiled padding should not be placed on top of an open and clean brief because female residents were prone to urinary tract infections. She said everything soiled should had been taken away before placement of the clean item.<BR/>In an interview with the Interim DON on 06/06/2024 at 7:22 AM, the Interim DON stated she was made aware about the infection control issue during incontinent care. The Interim DON said the soiled items should be removed first before placing the clean brief to prevent possible infections. She said there should be not contact between the clean items and the dirty items. The Interim DON said the DON and the ADON were responsible in making sure the staff were adhering to the infection control practices. The interim DON said the expectation was for the staff to carry out care without the possibility of cross contamination and introduction of infection. The interim DON said she would do an infection control in-service pertaining to incontinent care for all the staff. She also said she did a check off with CNA A and B about peri-care and would do spot checks for all the staff pertaining to peri-care. She concluded that she would continually remind the staff to be attentive to the procedures for infection control.<BR/>In an interview with the ADON on 06/06/2024 at 7:48 AM, the ADON stated placing the soiled padding on top of the new brief could result to cross contamination because if the soiled wipes and brief touched the padding, the padding was considered not clean. The same reason applied when the used and soiled padding touched the clean brief. She continued that cross contamination could lead to infection such as urinary tract infection. The ADON said the expectation was for the staff not to put the soiled or the used padding on top of a clean brief. The ADON said they would do an in-service to correct the issue and would monitor their adherence to the procedure of separation of clean and dirty items.<BR/>In an interview with the Administrator on 06/06/2024 at 8:23 AM, the Administrator stated clean and dirty items should not be touching each other to prevent infection. She said the expectation was for the staff to be mindful and do the right and proper way of care to protect the residents. The Administrator said she would collaborate with the clinicals to address the issue.<BR/>Record review of CNA A and B's competency check-off for Peri-Care Competency, dated 06/06/2024, revealed Performance Criteria . 24. Apply clean undergarment.<BR/>Record review of facility's procedure, Perineal Care revealed Perineal care, which includes care of the external genitalia and anal area . promotes cleanliness and prevents infection . Completing the procedure . dispose of soiled articles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, at the time each resident is admitted , the facility failed to have physician orders for the resident's immediate care for 1 of 5 residents (Resident #1) reviewed for physician's orders.<BR/>The facility failed to ensure Resident #1 had a physician's order for an oxygen concentrator and oxygen therapy.<BR/>These failures could place residents at risk of not receiving necessary care and services resulting in serious health complications. <BR/>The findings include: <BR/>Record review of Resident #1's face sheet, dated 02/6/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, Pneumonia unspecified (lung infection; Chronic Obstructive Pulmonary Disorder (airflow blockage), unspecified; Acute Respiratory Failure with hypoxia. Difficulty with oxygen levels vs blood). <BR/>Request for Resident #1s MDS revealed that the resident was admitted on [DATE] and the MDS was not due. <BR/>Record review of Resident #1's baseline care plan, dated 02/02/2023, revealed, in part, [Resident #1's] has a Goal to be free of pain, Free of infection, Free of falls, and free of weight changes/ admission to skilled nursing with medication management and treatment per physician orders. Additional documentation listed at the end of the baseline care plan documented continue Oxygen 2 l per minute.<BR/>Record review of Resident #1's physician's orders on 02/06/2023 revealed no physician's order for an oxygen therapy by concentrator.<BR/>Record review of Resident #1's TAR and MAR for February 2023 revealed no documentation of orders for oxygen therapy.<BR/>During an interview on 02/06/2023 at 11:33 AM, LVN E stated if there was not an order for oxygen therapy at the time of admission the nurse should call physician to obtain an order. LVN E stated that she did not contact the MD for clarification of order. LVN E reviewed the TAR and hospital records and she said that there was not an order for oxygen therapy. She stated that the oxygen tube was not dated, because EMS brought resident to room and installed oxygen. LVN E stated, it is always best to have an order and foley catheters were usually changed once per month.<BR/>During an interview on 02/06/2023 at 1:43 PM, the DON stated the ADON was on leave and could not be interviewed. The DON stated that it was her expectation for nursing staff to follow-up on MD orders at the time of admission to prevent an error in medication and care of residents with oxygen. The DON stated the nurse on duty should have changed and dated the tubing after contacting the MD to clarify the order. She stated that failing to obtain and accurate order could result in residents contracting respiratory infections and respiratory discomfort . The DON conducted an in-service with nursing and provided sign in documents to review.<BR/>A review of an in-service document dated 02/06/2023 revealed documentation that all admission nursing staff were required to contact the physician to review, confirm, and approve resident treatment and medical orders of care at the point of entry.<BR/>In an interview with the MD on 02/06/2023 at 3:00 PM, revealed he was not contacted by nursing to clarify orders on Resident #1's oxygen. He stated the admitting nurse was responsible for contacting him to review and clarify oxygen. Once notified he would follow up with the hospital to confirm. Failing to contact the MD could pose severe medical issues for residents who received oxygen and should not. The MD stated it was very important that nursing had an order for residents to receive oxygen from an MD.<BR/>A policy regarding following physician's orders was requested but not provided before exiting the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 3 residents (Resident #5) reviewed for respiratory care in that:<BR/>The facility failed to ensure Resident #1's oxygen tubing was dated.<BR/>This deficient practice could place residents that receive oxygen therapy at risk for inadequate care and respiratory distress and serious infections.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet, dated 02/6/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, Pneumonia unspecified (lung infection); Chronic Obstructive Pulmonary Disorder ( lung disease causing airflow blockage), unspecified; Acute Respiratory Failure with hypoxia. (difficulty with oxygen levels in blood). <BR/>Record review of Resident #1's baseline care plan, dated 02/02/2023, revealed, in part, [Resident #1's] has a Goal to be free of pain, Free of infection, Free of falls, and free of weight changes/ admission to skilled nursing with medication management and treatment per physician orders. Additional documentation listed at the end of their plan stated to continue Oxygen 2 l per minute. <BR/>Record review of Resident #1's physician's orders on 02/06/2023 revealed no physician's order for an oxygen therapy by concentrator.<BR/>Record review of Resident #1's TAR and MAR for February 2023 revealed no documentation of orders for oxygen therapy.<BR/>In an observation and interview on 02/06/2023 at 12:00 PM revealed Resident #1 was lying in bed with her head of bed elevated. She was on oxygen via N/C which was properly positioned in nose. The N/C was connected to an oxygen concentrator, and it was set to deliver 2 Liters Per Minute. The N/C and the humidifier bottler were undated. Resident #1 stated she did not know why she was on oxygen, but she was at the facility for therapy to improve mobility. <BR/>In an interview on 02/06/2023 at 12:30 PM, the DON said it was the 10pm to 6am nurse's job to replace and date oxygen tubing weekly on Wednesdays, and Resident #1 had not been at the facility a full week. She stated she would change the tubing and humidifier bottle and date them immediately. The DON stated it was her expectation for the admitting nurse or night nurse to change and date the oxygen tubing weekly or at the time of admissions if the resident entered with an undated tube. The DON stated Resident #1 was admitted from the hospital on Thursday 02-02-2023. The DON stated each shift nurse was responsible for checking patient oxygen tubing during patient rounds. The DON stated she and the ADON were responsible for reviewing, auditing, and monitoring treatment task. <BR/>In interview on 02/06/23 at 12:50 PM, with LVN E revealed that she was the admitting nurse on 02/02/2023, however the resident was admitted at the time of shift change, so she initiated base line care plan and passed the information on verbally to the ADON to complete. She stated she was so busy she forgot to assess upon returning to work on 02/06/2023. LVN E stated that the nurse assigned to each shift was in charge of assessing tubing and checking for dates. LVN E stated once the tubing was viewed as undated it should have been changed, dated, and documented in the patient's treatment records. LVN E said undated tubing could lead to overuse of the tubing, increased bacteria, and respiratory complications. <BR/>Record review of Resident #1's treatment records on 02/06/2023 revealed no treatment administration per the MD orders.<BR/>Review of the facility's policy titled Respiratory Policies and Procedures , dated 04/01/2022, revealed, . Subject: Equipment Change schedules. Procedure: Equipment will be changed as follows: Aerosol Tubing and aerosol Nebulizer should be changed Every week or per Statre regulations and or Manufactured guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person centered careplan, and the resident's goals and preferences for 1 (Resident #1) of 6 residents reviewed for pain management. <BR/>1. The facility failed to administer Resident #1's Hydrocodone as ordered for 14.5 hours while the prescribed medication was available in the emergency kit.<BR/>These failures placed residents at risk of increased pain due to not having their pain medication administered and resulted in Resident #1 enduring an extended period of time with no pain relief. <BR/>Findings included: <BR/>Record review of Resident #1's Minimum Data Set Assessment, dated 06/15/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His cognition was moderately impaired. He required extensive two-person assist for bed mobility, limited one-person assist for transfer, dressing, personal hygiene, limited two-person assist for toilet use, and supervision with one-person assist for walk in room. The resident was always continent. His diagnoses included aftercare following joint replacement surgery on right knee, pain, muscle spasm, muscle weakness, unspecified lack of coordination, unsteadiness on feet, cognitive communication deficit, and Type 2 Diabetes. <BR/>Record review of the Physician's Order revealed:<BR/>06/13/23 Oxycodone/Tylenol Tablet 10-325 MG by mouth three times a day for pain. <BR/>Record Review of the Care Plan, which was last updated on 06/24/23 for Resident #1, revealed the resident had a decline in ability to ambulate at prior level of functioning. <BR/>Record Review on 06/29/23 at 11:43 AM of Nurse's Notes dated 06/13/23 at 10:15 PM, for Resident #1 reflected, Late Entry: report received regarding new admission of resident. S/P (Surgical Procedure) right knew replacement, ice machine not complete so is unusable at this time, also narcotic pain medication unavailable from pharmacy at this time. - LVN A<BR/>Record Review on 06/29/23 at 11:43 AM of Nurse's Notes dated 06/13/23 at 10:30 PM, for Resident #1 reflected, c/o (complaint of) uncontrolled, extreme pain, zero pain med (medication) available, ice packs and Tylenol 650 mg given at this time with very little results. Resident assisted for comfort in bed, mostly ineffective. At 10:30 PM, checked on resident, resident complaining of increased pain, explained to resident that we can try some Tylenol and an ice pack to relieve pain, resident agreeable. N.O. (New Order) written for Tylenol 650 mg two tablets to be taken by mouth every six hours as needed, until narcotic medication available from pharmacy. At 10:45 PM, resident assisted to lay down and into position of comfort after administering Tylenol 650 mg. Ice pack prepared .a towel placed over right knee and large ice pack applied at this time. On 06/14/23 at 1:00 AM, resident continued to rest at this time without distress. Eyes closed, resp (respiratory) even, unlabored and regular. -LVN A<BR/>Record Review on 06/29/23 at 11:43 AM of Nurse's Notes dated 06/14/23 at 2:30 AM, for Resident #1 reflected, resident c/o increased extreme pain, called spouse and 24-hour pharmacy to attempt to get pain medications filled. Informed nurse that his wife will be picking him up to get pain meds then will return to facility. On 06/14/23 at 4:15 AM, resident returned to facility and was assisted into bed. Told nurse that pharmacy was closed and that his wife will return in the morning to pick up meds and bring to facility. Resident requested Tylenol 650 mg and ice pack. Staff assisted resident to position of comfort, administered PRN Tylenol 650 mg as ordered. Towel placed over right knew and large ice pack in place. At 4:45 AM, continued with frequent visual checks by nurse and C.N.A., for any pain symptoms, resident continues to rest in with eyes closed, resp even, unlabored and regular. At 5:30 AM resident continues to rest at this time, no noted pain symptoms. Eyes closed, resp even unlabored, and regular. - LVN A<BR/>Review of a written statement from the DON, dated 06/14/23 reflected, I was informed in the Clinical Meeting this [NAME] at 0915, that the above resident (Resident #1) was admitted yesterday, a few minutes before 1800 and still did not have anything for pain except Tylenol I text the charge nurse (LVN A) and asked her if the resident complained of pain last night. She text back yes I charted about it. I ask her why she didn't get it out of ER box she said she was not an agent. She also stated she did all she could for the man (Resident #1) see attached nurse note. Administrator asked her why she didn't call DON for assist and stated she never thought about it. She said it should have been taken care of by prior shift. DON told her it was her responsibility on her shift that residents are taken care of and she should have notified DON of the need for pain medication and notified the doctor to send a script to our pharmacy. LVN B was interview by Administrator and DON. She stated she ordered his (Resident #1) medications shortly after the resident arrived, however, none of his medications arrived on the night delivery due to horders were not received by 6:00 PM for night delivery. Resident came in with orders for Hydrocodone, however, physician sent triplicate for Oxycodone to local pharmacy. She also stated she was not aware that you have to have a triplicate in order to get medications. She stated she did go down there and check on resident during her shift, she just did not document it. She stated she did text LVN C around 10:00 PM, but did not get a response back. LVN C stated she did not see the text until to late. DON instructed LVN B to always report immediately to DON, ADON anytime she needed something for a resident, also that the doctor has to be notified immediately of anything that is ordered for resident and if we don't have it. Employee suspended until further investigation.<BR/>Review of undated written statement of interview with C.N.A. D rebealed, she was interviewed by phone by the DON on 06/16/23 at 11:00 PM. LVN B stated on the night of 06/13/23, she assisted LVN A with placing an ice pack early in the shift and knew the nurse had given him pills but did not know what kind. She also stated she checked on the resident throughout the shift and he was resting. She also stated they assisted him to the care so he could go to the pharmacy. She stated, other than that, she did not know of anything going.<BR/>Review of undated written statement of interview with LVN A revealed, she did all she knew to do for Resident #1 the night that the resident was admitted from the hospital. She stated she gave him Tylenol twice during the night and repositioned him along with providing ice packs, due to the ice machine which was sent from the hospital was missing a chord. She stated the resident was in a pleasant mood and resting through most of the shift. The DON instructed LVN A to do a late entry, stating all of the care that was provided throughout the shift. LVN A stated it did not occur to her to call the DON for assistance in getting the resident stronger pain medication. The DON and Administrator informed her when she takes report it is her responsibility to make sure all residents are cared for in a timely manner, no matter what the prior shift had done. LVN A admitted she was wrong and that she had made a mistake. She was suspended until further investigation could be completed.<BR/>Record review of in-services dated 06/14/23 revealed, staff were in-serviced on Abuse and Neglect and Pain Management.<BR/>Observation of Resident #1 was not possible, as the resident was discharged from the facility on 06/24/23.<BR/>An interview on 06/29/23 at 1:08 PM with the Administrator, revealed the Oxycodone medication was not administered to Resident #1 on the evening of 06/13/23 and night hours of 06/14/23. She stated she did not fully understand why LVN A did not access the Emergency Kit, so she could administer the Oxycodone to the resident. She stated LVN A eventually admitted that she knew what should had done, however, she was trying to prove a point, in order to invoke change. The Administrator stated LVN B was new to the facility, but not new to long term care nursing. She stated LVN B was the admitting nurse and she did submit the facility physician's orders to the pharmacy, however, it was too late for them to be delivered to the facility that night. She stated LVN B should have contacted herself or the DON, when she realized the medications would not be delivered that night. She stated she was not sure if LVN A had access to the Emergency Kit or not, however, she did know that she could have called herself or the DON for guidance on how to access it. She stated the Resident #1 did not have to be uncomfortable at all, had the nurses did what they were supposed to do.<BR/>Attempts to contact LVN A and LVN B on 06/29/23 at 2:00 PM, were unsuccessful, as neither nurse returned the calls.<BR/>A phone interview on 06/29/23 at 5:15 PM with Resident #1 revealed, he stated he felt fine when he arrived at the facility on 06/13/23. He stated he remembered first complaining of pain around 10:30 PM, that night. He stated he started feeling pain before then, but it was not bad enough to complain about. He stated he could not remember what time he first started to feel discomfort. He stated the nurse told him they did not have his medications and could only give him Tylenol. He stated he was fine with that. He stated his pain was at a nine when he complained to the nurse. He stated the Tylenol took it to an eight. He stated he dealt with it because he was able to fall asleep. He stated he had gotten text earlier in the evening about his prescription being ready, so he decided to go get it, since the facility did not have anything stronger than the Tylenol, however, the pharmacy was closed when he got there. He stated the nurse gave him more Tylenol when he returned to the facility and placed another ice pack on his knee. He stated he felt the staff did what they could do to accommodate him, so he did not have any complaints. He stated he did not feel neglected. He stated he was a strong man and he made it through the night and he did not have any complaints about his care that night.<BR/>An interview on 06/30/29 at 10:00 AM with the DON, revealed LVN A had access to the Emergency Kit, however, she admitted ly did not access the medications needed. She stated LVN B should have called the DON or the Administrator to receive instruction as to how to gain access to the Emergency Kit. She stated Resident #1's pain could have been properly relieved had the nurses done what they had been educated to do. The DON stated the she accessed the Emergency Kit and administered Hydrocodone to the resident, after speaking with him and assessing him. His medication from the pharmacy arrived in time for the next dose.<BR/>Review of an undated document entitled How to Access Narcotics from the ER Kit reflected 7. CALL DON OR ADON WITH ANY ISSUES. <BR/>Review of the facility policy, Pain Management, dated 05/05/23, reflected:<BR/>The purpose of this policy is to ensure that residents receive treatment and care in accordance with professional standards of practice., the comprehensive care plan, and the resident's choices, related to pain management .If the resident's pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated .

Based on observation, interview and record review, the facility failed to ensure each resident received food prepared by methods that conserve nutritive value, flavor, and appearance that is palatable, attractive, and at a safe and appetizing temperature for 6 of 6 Residents (Resident #20, #6, #31, #17, #14, #35) reviewed for food and nutrition services.<BR/>The facility failed to ensure the pureed chicken was prepared in a way to preserve vitamins and taste by not following required measuring when adding thickener to the pureed chicken. <BR/>This failure could place residents at risk of nutrition and hydration and negatively impact the recovery from, illness or injury.<BR/>Findings include:<BR/>Interview on 04/05/23 at 10:30 AM at the Resident Council Meeting revealed the resident in attendance (Resident #8, #9, #11, #21, and #27) complained about the food being lukewarm and tasting very salty.<BR/>Observation on 04/05/2023 at 11:55 AM revealed [NAME] A grabbing the powered thickener container and pouring in straight into the pot that contained the chicken and no measurement device was used.<BR/>Observations and Interview attempts on 04/05/2023 at 1:00 PM of Residents #20, #6, #31, #17, #14, and #35 to obtain feedback on Pureed diet, revealed none of these residents were interviewable. <BR/>Observation and interview with Dietary Manager on 04/05/2023 at 1:00 PM revealed three test trays that contained Regular Diet, Mechanical Diet, and Pureed Diet. The food temperature was hot/warm. The Dietary Manager tasted the food and stated the meat was flavorful, the egg noodles needed more butter, and the mixed vegetables were good. Her comments were the same for each texture of food. She stated the pureed chicken tasted like chicken and the pureed noodles tasted like noodles and that they also needed more butter. She stated she was pleased with the food, except for the noodles needing more butter. The test tray was observed and tested by three members of the Survey Team and all three members determined that the Regular Diet Chicken and Mechanical Diet Chicken tasted very salty. All three members tasted the Pureed Chicken and all three members agreed that it tasted nothing like chicken. The Dietary Manager was advised that [NAME] A was observed pouring powdered thickener straight into the pot with the chicken, without measuring it. The Dietary Manager stated there were recipes for the different pureed meals. She stated there were standard guidelines for liquids. She stated she thought there was a standard guideline for proteins. She stated they were supposed to use broth instead of water because water compromises the consistency and how the thickener reacts to the liquid. She stated the possible risk to a resident would be choking. She stated if it was too thick, they could choke and if it was too thin, they could choke.<BR/>Interview with [NAME] B and Dietary Aide on 04/06/2023 at 10:21 AM revealed [NAME] B stated they usually use a scoop to measure out the thickener and they go by the guide which was printed on the containers. [NAME] B searched for the scooper; however, it was not where he said it should be kept. He asked the Dietary Aide where the scooper was located, and she stated she didn't know where it was either. Dietary Aide stated they did not really need it because they just add the thickener a little bit at a time, until the mixture reaches the desired consistency. She stated they have been doing it so long, they know how it is supposed to look and [NAME] B agreed with her. Dietary Aide then said, You have to be careful when adding the powder because if you add too much, it won't taste like food anymore and it won't be enjoyable for the person eating it. The Dietary Manager then entered and said there used to be a guideline taped to the refrigerator, however, when she retired and returned, it was no longer there. She stated she could pull it up and print it out for me if I wanted to see it. She stated they had just been adding the thickener until it reached the desired consistency.<BR/>Interview on 04/06/23 at 01:14 PM with Director of Nursing revealed she was advised of the concerns with the Puree diet and the lack of measurement being used to add thickener to the food and she stated the risk of pureed foods not being the right consistency, would be aspiration. She stated all residents deserve to have a palliative meal. She stated the resident who are on pureed diets, have communication deficits and are not able to voice their displeasure. She stated one day, the dietitian was in the facility, and she was talking with staff at the nurses station about the taste of pureed food. She stated she does not recall them saying anything bad.<BR/>Interview on 04/06/23 at 01:39 PM with the Administrator revealed she was advised of the concerns with the Puree diet and the lack of measurement being used to add thickener to the food and she stated if the pureed food is prepared and the cook is not using the correct amount of thickener, it could cause the resident to choke. She stated too much thickener could cause aspiration. She stated it would dilute the nutritional value of food, which would cause weight loss and/or loss of vitamin. She stated residents have a right to receive nutritional food that also tastes good.<BR/>The Nutritional Policies and Procedures for Sanitation & Food Safety in Food and Nutrition Services, dated 08/01/2020, reflected, Food and beverages prepared by the culinary staff are tasted in a sanitary manner to test for proper flavor, seasoning and texture.<BR/>Procedures: The facility will use the International Dysphagia Diet Standardization Initiative as the foundation for texture modified foods and thickened drinks provided to the residents.

Based on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment for residents residing on the west hall and who ate in their rooms. <BR/>The facility failed to ensure that soiled laundry (sheets) were stored in a secured closed area away from residents and food carts.<BR/>This deficient practice could place residents at risk of exposure to an environment that is unsanitary. <BR/>Findings included:<BR/>Observation of the west hallway on 02/06/2023 at 12:00 PM, revealed soiled white linen with brown spots outside in the hallway not far from uncovered food trays and ambulating residents. <BR/>During an interview on 02/06/2023 at 1:30 PM, CNA A stated that she was trained to take soiled clothing, place in a plastic bag and place in soiled laundry room.<BR/>During an interview on 02/06/2023 at 2:30 PM, the DON stated that it was her expectation for nursing staff to store the soiled linen in the room designated to prevent others from having access and exposure to infections. The DON said laundry will come and retrieve the soiled laundry with safe handling.<BR/>During an interview on 02/06/2023 at 2:47 PM, the Maintenance Director stated staff were trained to take soiled laundry immediately to the biohazard room to prevent exposure to human fluids that can carry bacteria that was unsanitary. The Maintenance Director stated The laundry had to be handled properly to prevent access and handling that could be unsanitary and cause infections.<BR/>During an interview on 02/06/2023 at 3:20 PM, the DON stated she had not noticed the soiled laundry on the hall at the same time as uncovered food, and this was unsanitary. She said she expected dining to serve food consistent with policy for maintaining sanitary conditions and soiled laundry should be stored away from residents on the hall .<BR/>Record review of in-service conducted on 02/06/2023 with nursing staff addressed the policies and procedures for appropriate sanitation after personal with soiled linen. <BR/>Record review of the Personal Care Area Policies - Environment dated 09/2011 Section Titled B. Soiled Laundry is 1) Handle with minimum agitation to avoid contamination of air, surfaces and persons. 2) Kept away from clothing of the person handling. 3) Bag at the point of collection and transport directly to soiled linen area. 4) Handle potentially contaminated using standard precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure they assisted residents in obtaining routine dental care for 1 of 8 residents (Resident #3) reviewed for dental services.<BR/>The facility failed to refer Resident #3 for dental services.<BR/>This failure could put residents needing dental services at risk of oral complications or weight loss, resulting in a decreased quality of life. <BR/>Findings included:<BR/>Record review of Resident 3's Annual MDS assessment , dated 03/07/24, reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her cognitive status was moderately impaired. Her diagnoses included stroke, non-Alzheimer's dementia, multiple sclerosis (a long-lasting disease of the central nervous system), malnutrition, and contractures. The record showed she was dependent on staff for oral care.<BR/>Record review of Resident 3's Care Plan, revised on 03/07/24, reflected the resident had oral/dental problems. The plan was to obtain a dental consult. <BR/>An observation and interview on 06/04/24 at 12:11 PM with Resident #3 revealed she was lying in bed with her headphones on. Her teeth were thick with some kind of yellow-brown build-up on them. She did not appear to be missing teeth, but it was difficult to tell because the teeth were so misshapen and caked with the yellow-brown build-up. The resident said she was able to eat and staff fed her. <BR/>An interview on 06/05/24 at 2:45 PM with the ADON revealed she did not know when Resident #3 last saw the dentist. The ADON said she did not know the resident had a care plan to obtain a dental consult. The ADON said poor dental health could affect the resident's health and cause them to not be able to drink and eat well. <BR/>An interview on 06/06/24 at 11:01 AM with the MDS nurse revealed she reviewed the care plan for Resident #3. She said she knew about the dental consult but thought the SW would see the care plan and get the referral. The MDS nurse said the SW was responsible for obtaining referrals. <BR/>An interview on 06/06/24 at 11:24 AM with the SW revealed she worked part-time at the facility for the last 2 months and did the facility referrals if she knew about them. She said she did not know about the referral for Resident #3. She said Resident #3 did not have a referral to see the dentist and she did not know when the resident last saw the dentist. She said if residents did not get the referrals they needed, then their needs would not be met. <BR/>]An interview on 06/06/24 at 12:11 PM with the Administrator revealed she did not know why Resident #3 did not have a referral to see the dentist. She said if a resident did not get the referrals they needed, then they would not receive the care they needed. <BR/>Review of the facility policy, Subject: Coordination of Ancillary Services, revised 2023, reflected:<BR/>Policy:<BR/>The Facility has a process to coordinate the care of patients and residents among the professional services involved. The Social Services department or designee coordinates ancillary medical services such as psychological services, dentistry, podiatry, optometry, audiologist and hospice as signed.

Based on observation, interview and record review, the facility failed to store, prepare , distribute and serve food in accordance with professional stards for food service safety one (west hall) of of one halls reviewed for food sanitation. <BR/>Dining staff A failed to cover resident food served on the west hall. <BR/>These failures could have affected residents by possible exposure to infections and cross contamination to the residents, that could cause illness. <BR/>Findings include:<BR/>Observation on 02/06/2023 at 12:00 PM, resident trays was observed on a food cart residing on the west hall with 3 residents and 2 staff passing by the uncovered food located on the cart. Approximately 4 rooms down the west hall there was a laundry basket with soiled uncovered laundry.<BR/>In an interview on 02/06/2023 at 12:30 PM, the Dietary Supervisor revealed that the kitchen had one staff on duty and she forgot to cover the food before taking the cart out to serve the residents She stated it was not good sanitation to serve food on the hall uncovered, as the uncovered food was exposed to pathogen's in the air that could lead to food contamination and exposure to environmental bacteria. <BR/>Interview on 02/06/2023 12:46 PM, the Administrator revealed kitchen staff were expected to cover the residents food prior to serving to prevent environmental exposure to bacteria from soiled and dirty laundry. The Administrator stated she recalls having this conversation with the dining staff previously and did not realize they had not covered the food.<BR/>Interview on 02/06/2023 1:22 PM, CNA A said residents were either fed in the dining room or in their rooms. CNA A said there were more residents in the dining room than normal. She stated it was very unsanitary to bring food on the hall where residents receive incontinent care and dirty laundry, this could lead to cross contamination and infections bacteria. <BR/>In an interview with the DON on 02/06/2023 3:00 PM, the DON revealed she was not the Infection Preventionist (IP). The DON said she had been employed by the facility for nine months. The DON said she had several conversations with dietary about covering food prior to bringing to the hall to maintain food sanitation and prevent exposure of food that could lead to illnesses. <BR/>. <BR/> Record review of facility policy Meal Delivery dated 08/01/2020 revealed, Nutrition Policies and Procedures Subject: Meal Delivery Policy: Nursing and Culinary staff will work together to enhance the quality of the dining experience. Satisfaction with the dining experience leads to improved appetite and can enhance quality of life. Room trays will be delivered promptly to maintain food temperatures Procedures: # #8Nursing unit manager and Nutrition Services Director . a list for proper tray delivery order that nutrition services use to set up the carts. #9. All food and beverages are covered for hall trays, despite being transported in an enclosed cart. Pass meals promptly upon tray cart's delivery to the nursing unit.

Based on observation, interview and record review, the facility failed to store, prepare , distribute and serve food in accordance with professional stards for food service safety one (west hall) of of one halls reviewed for food sanitation. <BR/>Dining staff A failed to cover resident food served on the west hall. <BR/>These failures could have affected residents by possible exposure to infections and cross contamination to the residents, that could cause illness. <BR/>Findings include:<BR/>Observation on 02/06/2023 at 12:00 PM, resident trays was observed on a food cart residing on the west hall with 3 residents and 2 staff passing by the uncovered food located on the cart. Approximately 4 rooms down the west hall there was a laundry basket with soiled uncovered laundry.<BR/>In an interview on 02/06/2023 at 12:30 PM, the Dietary Supervisor revealed that the kitchen had one staff on duty and she forgot to cover the food before taking the cart out to serve the residents She stated it was not good sanitation to serve food on the hall uncovered, as the uncovered food was exposed to pathogen's in the air that could lead to food contamination and exposure to environmental bacteria. <BR/>Interview on 02/06/2023 12:46 PM, the Administrator revealed kitchen staff were expected to cover the residents food prior to serving to prevent environmental exposure to bacteria from soiled and dirty laundry. The Administrator stated she recalls having this conversation with the dining staff previously and did not realize they had not covered the food.<BR/>Interview on 02/06/2023 1:22 PM, CNA A said residents were either fed in the dining room or in their rooms. CNA A said there were more residents in the dining room than normal. She stated it was very unsanitary to bring food on the hall where residents receive incontinent care and dirty laundry, this could lead to cross contamination and infections bacteria. <BR/>In an interview with the DON on 02/06/2023 3:00 PM, the DON revealed she was not the Infection Preventionist (IP). The DON said she had been employed by the facility for nine months. The DON said she had several conversations with dietary about covering food prior to bringing to the hall to maintain food sanitation and prevent exposure of food that could lead to illnesses. <BR/>. <BR/> Record review of facility policy Meal Delivery dated 08/01/2020 revealed, Nutrition Policies and Procedures Subject: Meal Delivery Policy: Nursing and Culinary staff will work together to enhance the quality of the dining experience. Satisfaction with the dining experience leads to improved appetite and can enhance quality of life. Room trays will be delivered promptly to maintain food temperatures Procedures: # #8Nursing unit manager and Nutrition Services Director . a list for proper tray delivery order that nutrition services use to set up the carts. #9. All food and beverages are covered for hall trays, despite being transported in an enclosed cart. Pass meals promptly upon tray cart's delivery to the nursing unit.

Based on observation, interview and record review, the facility failed to store, prepare , distribute and serve food in accordance with professional stards for food service safety one (west hall) of of one halls reviewed for food sanitation. <BR/>Dining staff A failed to cover resident food served on the west hall. <BR/>These failures could have affected residents by possible exposure to infections and cross contamination to the residents, that could cause illness. <BR/>Findings include:<BR/>Observation on 02/06/2023 at 12:00 PM, resident trays was observed on a food cart residing on the west hall with 3 residents and 2 staff passing by the uncovered food located on the cart. Approximately 4 rooms down the west hall there was a laundry basket with soiled uncovered laundry.<BR/>In an interview on 02/06/2023 at 12:30 PM, the Dietary Supervisor revealed that the kitchen had one staff on duty and she forgot to cover the food before taking the cart out to serve the residents She stated it was not good sanitation to serve food on the hall uncovered, as the uncovered food was exposed to pathogen's in the air that could lead to food contamination and exposure to environmental bacteria. <BR/>Interview on 02/06/2023 12:46 PM, the Administrator revealed kitchen staff were expected to cover the residents food prior to serving to prevent environmental exposure to bacteria from soiled and dirty laundry. The Administrator stated she recalls having this conversation with the dining staff previously and did not realize they had not covered the food.<BR/>Interview on 02/06/2023 1:22 PM, CNA A said residents were either fed in the dining room or in their rooms. CNA A said there were more residents in the dining room than normal. She stated it was very unsanitary to bring food on the hall where residents receive incontinent care and dirty laundry, this could lead to cross contamination and infections bacteria. <BR/>In an interview with the DON on 02/06/2023 3:00 PM, the DON revealed she was not the Infection Preventionist (IP). The DON said she had been employed by the facility for nine months. The DON said she had several conversations with dietary about covering food prior to bringing to the hall to maintain food sanitation and prevent exposure of food that could lead to illnesses. <BR/>. <BR/> Record review of facility policy Meal Delivery dated 08/01/2020 revealed, Nutrition Policies and Procedures Subject: Meal Delivery Policy: Nursing and Culinary staff will work together to enhance the quality of the dining experience. Satisfaction with the dining experience leads to improved appetite and can enhance quality of life. Room trays will be delivered promptly to maintain food temperatures Procedures: # #8Nursing unit manager and Nutrition Services Director . a list for proper tray delivery order that nutrition services use to set up the carts. #9. All food and beverages are covered for hall trays, despite being transported in an enclosed cart. Pass meals promptly upon tray cart's delivery to the nursing unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Resident #22) reviewed for accident prevention. The facility failed to ensure Resident #22's fall mat was place alongside his bed for fall prevention. This failure could prevent the resident from having an environment that was free and clear of accidents and hazards. Findings include: Record review of Resident #22's Face Sheet, dated 07/01/25, reflected he was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included repeated falls, and dementia (memory loss). Record review of Resident #22's Quarterly MDS assessment, dated 05/14/25, reflected he had a BIMS score of 9 (moderate cognitive impairment). For ADL care, it reflected the resident required extensive assistance and an active diagnosis included quadriplegia (paralysis of lower extremity). Record review of Resident #22's Comprehensive Care Plan, dated 05/14/25, reflected the resident was a fall risk and two of the interventions was to be ensure a fall mat placed alongside the resident's bed. An observation on 07/02/25 at 9:45 AM of Resident #22 revealed the resident lying in bed sleeping. There was a bed side table positioned over him and the fall mat was folded and leaning against the foot of his bed. In an interview and observation on 07/02/25 at 9:48 AM, the ADON observed the resident's fall mat folded up and leaning against the foot of Resident #22's bed. She stated she had confirmed with the DON that the resident had a recent fall and required the fall mat to be placed alongside the resident's bed while he was lying in it to prevent him from injuring himself if he fell. She stated Hospice may have provided care to the resident and had forgotten to remove the bedside table and place the fall mat alongside the bed. In an interview on 07/02/25 at 11:22 AM, the DON stated she had spoken with the ADON about Resident #22 not having the fall mat placed alongside his bed after he had finished his breakfast. She stated she thought Hospice had forgotten to place the fall mat back alongside the resident's bed. She was advised that the resident was observed earlier in the morning eating his breakfast and was later observed with the bedside table still over his bed while he was lying in it and the fall mat leaning against the foot of the bed. She stated the fall mat should have been placed alongside the resident's bed to assist in preventing him from injuring himself if he fell out of the bed. She stated the resident was a fall risk. Record review of the facility's policy Fall Management (5/05/23) reflected The facility will identify each patient/resident who is at risk for falls and will plan care and implement interventions to manage falls.