DENTON REHABILITATION AND NURSING CENTER

**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 hazards as was possible for 1 (Resident #2) of five residents reviewed for accident hazard. The facility failed to ensure that a container of germicidal (substance that destroys germs and microorganism) wipes was not left inside Residents #2's room on 10/07/2025. This failure could prevent the residents from having an environment that was free from toxic chemicals.Findings include: Record review of Resident #2's Face Sheet, dated 10/07/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with neoplasm (abnormal growth of tissue in the body) of the esophagus (hollow tube that carries food and liquid from the throat to the stomach). Record review of Resident #2's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 09/02/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 13. The Comprehensive MDS Assessment indicated that the resident had a medically complex condition (health issues that involves multiple chronic conditions). Record review of Resident #2's Comprehensive Care Plan, dated 07/17/2025, reflected the resident was at risk for dehydration related to cancer. The Comprehensive Care Plan indicated the resident was at risk for alteration in psychosocial well-being and one of the intervention was to observe and report any changes in mental status. During an observation and interview on 10/07/2025 at 9:54 AM revealed Resident #2 was in her bed, awake. It was observed that there was a container of germicidal wipes on the resident's white rattan table located near the resident's door. The resident said the container had been inside the room for some time and the aides were using the wipes to clean some of the items inside the room. In an interview on 10/07/2025 at 10:58 AM, LVN B stated technically, the germicidal wipes were not supposed to be inside the resident's room because they could cause various adverse effects such as skin irritation. She said she would ask the DON on what to do the germicidal wipes inside Resident #2's room. In an interview on 10/07/2025 at 11:29 AM, CNA C stated the staff used the germicidal wipes to clean the room. She said it should not be left inside the room because the wipes had chemicals that could be harmful to the residents if they were able to use them to wipe their eyes or were able to consume them. She said she did not notice the container of germicidal wipes inside Resident #2 room and did not know who left it there. She said she would if the container of wipes was still inside Resident #2's room and would give it to the nurse if it was still there. She said she would also check the other residents' rooms on her assigned hall. In an interview on 10/07/2025 at 12:08 PM, ADON A stated the container of germicidal wipes should not be inside Resident #2's room or any residents' room for that matter. She said the germicidal wipes should not be kept inside the rooms of the residents because they were not safe and should be kept inside the nurses' cart or MA's carts. She said it did not matter if the resident was confused or not, but the wipes were soaked in chemicals that could be harmful if ingested or used accidentally to wipe the eyes or used for incontinent care. She said it could result to skin irritation and eye irritation. She said the resident was immunocompromised and could have more severe reactions. She said the germicidal wipes were used to destroy microorganisms and were used with gloves on. She said the germicidal wipes should be inside the nurses' cart or the MAs' carts. She said the DON already started an in-service with regards to not leaving germicidal wipes inside the resident's rooms. In an interview on 10/07/2025 at 12:53 PM, the DON stated the germicidal wipes should not inside the residents' rooms because they have chemicals that could cause adverse effects if consumed or had contact with the skin. She said the container of germicidal wipes was closed but somebody could open it pull some wipes with their bare hand. She said the wipes were handled with gloves on because they have chemical on them to eliminate germs on surfaces. She said she was still asking who left it inside Resident #2's room so she could remind them not to leave any germicidal wipes inside the rooms of the residents. She said the container of germicidal wipes was taken out of the room and was placed inside the cart. She said she already started an in-service about not leaving any germicidal wipes inside the rooms for resident safety. In an interview on 10/07/2025 at 1:05 PM, the Administrator stated the container of germicidal wipes should not be left inside the rooms of the residents because they could take some and accidentally use them that could result to skin or eye irritation. He said the DON already started an in-service and he would personally check the rooms that there were no germicidal wipes inside the room. Record review of the facility's policy entitled Storage Areas, Maintenance 2001 MED-PASS, Inc. revised December 2009 reflected 3. Cleaning supplies, etc., must be stored in areas separate from food storage rooms and must be stored as instructed on the labels of such products. Record review of the facility's policy entitled MEDICATION STORAGE Pharmacy Services Policies and Procedures revised 04/17/2024 reflected POLICY . potentially harmful substances (e.g. cleaning supplies and disinfectants) are clearly identified and stored away.

**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 2 of 12 residents (Resident #143 and Resident #194) reviewed for dignity.<BR/>The facility failed to treat Resident #143 and Resident #194 with dignity and promote enhancement of their quality of life when the residents were not provided privacy bags for their catheter bags.<BR/>This failure placed residents at risk of not having their right to a dignified existence maintained.<BR/>Findings included: <BR/>1. <BR/>Review of Resident #143's Face Sheet, dated 05/27/25, reflected a [AGE] year-old male admitted on [DATE]. Resident #143 was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness).<BR/>Review of Resident #143's Quarterly MDS Assessment, dated 05/09/25, reflected Resident #143 was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident had an indwelling catheter.<BR/>Review of Resident #143's Comprehensive Care Plan, dated 05/21/25, reflected Resident #143 had an indwelling catheter related to neurogenic bladder (the normal bladder function is disrupted due to nerve damage) and one of the interventions was catheter care every shift.<BR/>Review of Resident #143's Physician Order, dated 05/27/25, reflected Change catheter and drainage bag monthly on the 15th day every 1 month(s)<BR/>In an observation and interview on 05/27/25 at 9:15 AM, Physical Therapist V was observed walking with Resident #143 down the facility hall providing therapy. The resident was observed with a catheter bag, but it did not have the privacy cover. Physical Therapist V stated the resident had a privacy cover, but it fell off in the therapy room, and she forgot to place it back on. She stated not having the privacy cover over the catheter bag was an infection control and a dignity concern.<BR/>In an interview on 05/27/25 at 9:58 AM, the ADON stated Resident #143 should have had a privacy cover for his catheter bag in place for the resident's dignity. She was advised of Resident #143 conducting therapy in the facility hall and no privacy bag being observed. She stated staff was responsible to ensure residents with catheter bags also had a privacy bag covering them.<BR/>In an interview on 05/29/25 at 09:45 AM, the Director of Therapy advised that she was made aware that Resident #143 did not have a privacy bag attached to his catheter bag when he was doing his therapy on 05/27/25 with Physical Therapist V. She stated staff was responsible for ensuring the resident's privacy bag was in place for the dignity of the resident. <BR/>2. <BR/>Record review of Resident #194's Face Sheet, dated 05/27/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with stage 4 (localized skin injury extending to the bone) pressure ulcers (damage to the skin usually over a bony prominence) to sacral region (area located at the bottom of the spine).<BR/>Record review of Resident #194's Comprehensive MDS Assessment, dated 05/09/2025, reflected resident had a moderately impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had a pressure ulcer to sacral region.<BR/>Record review of Resident #194's Physician Order, dated 05/22/2025, reflected Catheter care Q Shift.<BR/>Record review of Resident #194's Comprehensive Care Plan, dated 05/09/2025, reflected the resident had stage 4 pressure ulcer to sacral region and one of the interventions was assess and clean the pressure ulcer as ordered.<BR/>Record review of Resident #194's Progress Notes, dated 05/22/2025, reflected the MD discussed with the resident the benefits of foley catheter to wound healing. After the resident gave the consent, 16 F (French: unit of measurement for Foley catheter) Foley catheter was inserted.<BR/>Observation and interview on 05/27/2025 at 9:02 AM revealed Resident #194 was in her bed, awake. It was observed that the resident had a catheter bag hanging on the side frame of the bed. The catheter bag, with urine inside, did not have a privacy bag. The resident stated she had a catheter so the wound to her bottom would heal faster. She said she had the catheter for less than a week and had no idea if her catheter bag was inside a privacy bag or not.<BR/>In an interview on 05/28/2025 at 6:44 AM, LVN B stated the catheter bag should be inside a privacy bag even if the resident was in her room to avoid embarrassment in case a visitor would come. sShe said she did not notice that the catheter bag was exposed when she was attending to the resident. She said they were preparing Resident #194 to be sent out but that was not an excuse to leave the catheter bag without a privacy bag. She said she was responsible in providing dignity to the residents with a catheter and making sure the catheter bag was inside a privacy bag. <BR/>In an interview on 05/28/2025 at 6:49 AM, CNA E stated she did notice that Resident #194's catheter bag was exposed. She said there was a privacy bag on the other side of the bed but it did not occur to her to put the catheter bag inside. She said she was busy preparing the resident to be sent out and forgot to put the catheter inside the privacy bag. She said it was also her responsibility to put the catheter bag inside the privacy bag especially if the resident would be transported to avoid humiliation. <BR/>In an interview on 05/28/2025 at 12:08 PM, The ADON stated a catheter bag must have a privacy bag to avoid incidents that could lead to embarrassment. The purpose of the privacy bag was to provide dignity for residents with urinary catheters. The ADON said the expectation was for the staff to make sure the catheter bags had privacy bags when the residents were inside their rooms or outside their room. She said she would continually remind the staff the importance of providing dignity and would start an in-service about dignity.<BR/>In an interview on 05/29/2025 at 8:30 AM, the Administrator stated a catheter bag without a privacy bag was a dignity issue. He said all the staff were responsible in providing dignity to all residents. He said staff must do their due diligence in ensuring the residents had a dignified existence while in the facility. The Administrator said he would coordinate with the ADON to monitor that the catheter bags were not exposed.<BR/>Record review of facility's policy, Quality of Life - Dignity & Privacy Operational Policy and Procedure Manual for Long-Term Care revised August 2009 revealed Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity . Policy Interpretation and Implementation . 11.<BR/>Demeaning practices and standards of care that compromise dignity are prohibited . a. Helping the resident to keep urinary catheter bags covered

**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, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for seven (Resident #195, Resident #200, Resident #193, Resident#202, Resident#65, Resident#16, and Resident #204) of sixteen residents reviewed for Privacy and Confidentiality.<BR/>1. <BR/>The facility failed to ensure LVN C closed the door while flushing Resident #195's IV and disconnecting his IV bag on 05/27/2025.<BR/>2. <BR/>The facility failed to ensure LVN D did not leave Resident #200, Resident #193, Resident #202, Resident #65, Resident #16 and Resident #204, medical information on top of the medication care unattended on 05/27/2025.<BR/>These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals.<BR/>Findings included: <BR/>1. <BR/>Record review of Resident #195's Face Sheet, dated 05/27/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with bacteremia (presence of bacteria in the blood stream).<BR/>Record review of Resident #195's Comprehensive MDS Assessment, dated 05/20/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Quarterly MDS Assessment indicated the resident had bacteremia.<BR/>Record review of Resident #195's Care Plan, dated 05/20/2025, reflected the resident required IV medication for bacteremia and one of the approaches was follow regimen when caring for IV site.<BR/>Record review of Resident #195's Physician Order, dated 05/19/2025, reflected Flush IV line before and after medications and Q shift. Normal Saline Flush (sodium chloride 0.9 %).<BR/>Observation and interview on 05/27/2025 at 9:34 AM, LVN C stated she would disconnect and flush Resident #195's IV because the medication was already done. She sanitized her hands and prepared normal saline bullet, IV flush syringe, green cap, and alcohol wipes. She went inside the resident's room, disconnected the IV, and flushed the IV line. She did not close the door while disconnecting and flushing the resident's IV line.<BR/>In an interview on 05/27/2025 at 1:39 PM, LVN C stated doors should be closed when providing care or treatment to the residents to provide them privacy. She said she was not aware that she did not close the door. She said it did not matter if the resident would mind or not, the door should be closed. She said she would be mindful the next time she would provide care or treatment.<BR/>In an interview on 05/28/2025 at 12:08 PM, The ADON stated all the care and treatment should be done in the privacy of the residents' room. She said every care done by the staff should be behind the door so other staff, other residents, or even the visitors would not see or speculate the medical condition of the residents. She said it did not matter if the residents care or not, the door should still be closed while providing care. She said the expectation was for the staff be mindful when they were providing care. She said she would do an in-service regarding closing the door when providing treatment. <BR/>In an interview on 05/29/2025 at 8:30 AM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care tor treatment to prevent embarrassment. He said the expectation was for the staff to close the door during all treatment provided. He said he would collaborate with the ADON to do an in-service about closing the door to provide privacy.<BR/>2. <BR/>Observation on 05/27/2025 at 9:40 AM revealed a small piece of paper was on top of medication cart parked in the hallway. On the piece of paper was the following:<BR/>*Resident #200's blood pressure, <BR/>*Resident #193's order for Flonase, <BR/>*Resident #202's blood pressure, <BR/>*Resident #65' blood pressure, <BR/>*Resident #16's order for Lasix and potassium, and <BR/>*Resident #204's blood pressure and order for Norco. It was observed that nobody was attending the cart, and the cart was facing the hallway.<BR/>During an interview on 05/27/2025 on 10:10 AM, LVN D stated when she left the cart to administer medication. She said she should not leave any information about residents' medical issues on top of the cart unattended because they have information about the resident. LVN D stated she should have flipped the paper when she left the cart. She stated she did not know putting resident room numbers would be a problem. LVN D would be mindful that no type of information about any resident would be left on top of the cart.<BR/>During an interview on 05/27/25 at 11:30 AM ADON stated that was a HIPAA violation. ADON stated the expectation was for all staff not to leave any personal or medical information about a resident. ADON stated a resident's information is confidential and should not be seen by unauthorized individuals.<BR/>Record review of facility's policy, Quality of Life - Dignity & Privacy Operational Policy and Procedure Manual for Long-Term Care revised August 2009 revealed Policy Statement: Each resident shall be cared for in a manner that promotes and enhances quality of life, . privacy . Policy Interpretation and Implementation . 9.<BR/>Staff shall maintain an environment in which confidential clinical information is protected . 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during nursing treatment procedures.

**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 7 of 15 resident rooms on the 100 hall (Resident rooms #1, #2, #3, #4, #5, #6, and #7), and all the hand rails on the 500 hall, reviewed for environment.<BR/>1. <BR/>The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized.<BR/>2. <BR/>The facility failed to ensure the handrails on the 500 hall were thoroughly cleaned and sanitized. <BR/>These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. <BR/>Findings include:<BR/>An observation on 05/27/25 at 11:00 AM of resident room [ROOM NUMBER] reflected the refrigerator in the resident room had brownish stains on the inside bottom of the refrigerator. The bathroom shower floor had a steel grill, located over the drain, that had a brown rust-like substance on it, and red stains under it. <BR/>An observation on 05/27/25 at 11:05 AM of resident room [ROOM NUMBER] reflected the bathroom shower floor had a steel grill, located over the drain, that had a brown rust-like substance on it, and red stains under it. The drain hole had dark stains surrounding the drain. Behind the toilet was a dark stain on the floor. <BR/>An observation on 05/27/25 at 11:10 AM of resident room [ROOM NUMBER] reflected the bathroom shower floor had a steel grill, located over the drain, that had a brown rust-like substance on it, and dark red stains under it. <BR/>An observation on 05/27/25 at 11:19 AM of resident room [ROOM NUMBER] reflected the bathroom shower floor had a steel grill, located over the drain, that had a brown rust-like substance on it, and dark dirt stains under it. <BR/>An observation on 05/27/25 at 11:20 AM of all the handrails on the 500-hall revealed dirt particles and dead bugs on the inside of the handrails.<BR/>An observation on 05/27/25 at 11:28 AM of resident room [ROOM NUMBER] reflected the bathroom shower floor had a steel grill, located over the drain, that had a brown rust-like substance on it, and dark dirt stains under it.<BR/>An observation on 05/27/25 at 11:31 AM of resident room [ROOM NUMBER] reflected the bathroom shower floor had a steel grill, located over the drain, that had a brown rust-like substance on it, and dark dirt stains under it. A small personal fan in the room had thick dust on the outside of the unit and on the fan blades. The corners of the room floor had dirt particles building up. <BR/>An observation on 05/27/25 at 11:33 AM of resident room [ROOM NUMBER] reflected the bathroom shower floor had a steel grill, located over the drain, that had a brown rust-like substance on it, and dark dirt stains under it. A large personal fan in the room had thick dust on the outside of the unit and on the fan blades. <BR/>In an interview on 05/29/25 at 8:40 AM, the Environmental Supervisor was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, #6, and #7, and the handrails on Hall 500. She stated housekeeping was responsible for ensuring these areas were cleaned and she was responsible for checking to see if the areas were cleaned. She stated she would ensure the concerns were addressed. She stated not ensuring the resident rooms were thoroughly cleaned could result in breathing issues and infections.<BR/>In an interview on 05/29/25 at 10:45 AM, Housekeeping M, stated she normally did not clean Hall 500 and the person assigned to clean Resident rooms #1, #2, #3, #4, #5, #6, and #7, and the handrails in the halls was off today. She stated they were responsible for cleaning all areas of the resident rooms and they were also responsible for cleaning the handrails in the halls. She was shown photos of the concerns observed in the resident rooms and she stated they should have cleaned all of the areas of concerns. She stated the Environmental Supervisor was responsible for cleaning the fans in the resident rooms. She stated not cleaning the areas of concern could result in breathing problems for the residents.<BR/>In an interview on 05/29/25 at 11:10 AM, the Administrator was advised of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, #6, and #7, and the handrails on Hall 500. He stated he had met with the Environmental Supervisor about the concerns observed and they were working on resolving the issues. He stated they had issues with cleaning the rust from the steel grills in the shower area and he did not think housekeeping was aware that the grills could be removed to clean under them. He stated they had issues cleaning white particles stuck on the floor and they did not know how to remove them. He was advised the white particles appeared to be dirt particles not cleaned in the corners of the room floors and the handrails had dead bugs on them. He stated the concerns observed did not present a homelike environment for the residents. <BR/>Record review of the facility's policy on Cleaning and Disinfection of Environmental Surfaces (June 2009) reflected Daily cleaning of resident rooms help to provide a sanitary environment, prevent odors, and prolong the useful life of furniture, equipment, paint, and floor finish.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for three (Residents #196, #197, and #198) of sixteen residents reviewed for Accuracy of Assessments.<BR/>1. <BR/>The facility failed to ensure Resident #196's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open).<BR/>2. <BR/>The facility failed to ensure Resident #197's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on oxygen therapy.<BR/>3. <BR/>The facility failed to ensure Resident #198's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on oxygen therapy.<BR/>These failures could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health.<BR/>Findings included:<BR/>1. <BR/>Record review of Resident #196's Face Sheet, dated 05/27/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). <BR/>Record review of Resident #196's Comprehensive MDS Assessment, dated 05/29/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment did not indicate the resident was using a CPAP.<BR/>Record review of Resident #196's Comprehensive Care Plan, dated 05/26/2025, reflected the resident had sleep apnea and the goal was for the resident to adhere to CPAP therapy. <BR/>Record review of Resident #196's Physician Order, dated 05/22/2025, reflected <BR/>CPAP Q HS.<BR/>Record review of Resident #196's Progress Notes, dated 05/22/2025, reflected THIS [AGE] year old FEMALE ARRIVED VIA PRIVATE TRANSPORT . BROUGHT CPAP . CPAP IS ON.<BR/>Observation on 05/27/2025 at 9:22 AM revealed Resident #196 was not inside the room. A CPAP mask was observed on top of the resident's side table.<BR/>In an interview on 05/29/2025 at 8:13 AM, LVN C stated Resident #196 had been using a CPAP ever since she was admitted to the facility.<BR/>2. <BR/>Record review of Resident #197's Face Sheet, dated 05/27/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure and shortness of breath. <BR/>Record review of Resident #197's Comprehensive MDS Assessment, dated 05/16/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment did not indicate the resident was on oxygen therapy. <BR/>Record review of Resident #197's Comprehensive Care Plan, dated 05/16/2025, reflected the resident had no care plan for oxygen therapy.<BR/>Record review of Resident #197's Progress Notes on 05/27/2025 reflected the resident was on oxygen since admission and onwards. <BR/>Record review of Resident #197's Physician Order, dated 05/13/2025, reflected May apply O2 via nasal cannula to maintain SpO2 greater than 90%, if requiring more than 5 LPM notify provider. PRN.<BR/>Record review of Resident #197's Physician Order on 05/27/2025 reflected no order for continuous oxygen.<BR/>Observation on 05/27/2025 at 9:11 AM revealed Resident #197 was in her bed, awake. It was observed that the resident was on oxygen therapy at 3 liter per minute via nasal cannula. <BR/>In an interview on 05/28/2025 at 8:20 AM, LVN B stated Resident #197 was using oxygen during the day and during night time. She said the resident was continuously using oxygen via nasal cannula.<BR/>3. <BR/>Record review of Resident #198's Face Sheet, dated 05/27/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with pulmonary edema (abnormal build- up of fluid in the lungs) and bronchitis (inflammation of the airways).<BR/>Record review of Resident #198's Comprehensive MDS Assessment, dated 05/27/2025, reflected the resident was unable to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment did not indicate that the resident was on oxygen therapy.<BR/>Record review of Resident #198's Comprehensive Care Plan, dated 05/22/2025, reflected the resident had no care plan for oxygen therapy.<BR/>Record review of Resident #198's Physician Order, dated 05/21/2025, reflected May apply O2 via nasal cannula to maintain SpO2 greater than 90%, if requiring more than 5 LPM notify provider. PRN.<BR/>Record review of Resident #198's Progress Notes, dated 05/21/2025, reflected oxygen in use at 2 liters per minute via nasal cannula.<BR/>Observation on 05/27/2025 at 9:14 AM revealed the Resident #198 was in her wheelchair and was on oxygen therapy via nasal cannula connected to her portable tank behind her wheelchair. <BR/>In an interview on 05/27/2025 at 2:19 PM, Resident #198 stated she was using oxygen day and night because she was experiencing shortness of breath.<BR/>In an interview on 05/28/2025 at 6:44 AM, LVN B said if a resident was using oxygen since she was admitted to the facility and she was using it always.<BR/>In an interview on 05/28/2025 at 10:07 AM, the MDS Coordinator stated the purpose of the MDS was to gather and document significant data about a resident. The data collected were the resident's demographics, cognition, behaviors, functional abilities, diagnosis, and if the resident was using any kind of treatment. She said the MDS was used to do a basic assessment of a resident that could be gathered from the nurses' documentation of the nurses, during her face-to-face evaluation during admission, or from word of mouth. She said since the Residents #196, #197, and #198 were all using oxygen prior to my assessment, their MDS should reflect that. She said it was an oversight on her part and missed that the residents were using oxygen. She said she would audit the MDS of the residents and would make sure that everything was coded appropriately. She said if the residents were not properly assessed, the needs would not be met, and there could be confusion in the provision of care and in doing the care plan. <BR/>In an interview on 05/28/2025 at 12:08 PM, The ADON stated she was not that familiar with the MDS. She said if the residents were using oxygen, then the residents' MDS should reflect it. She said the MDS Nurse was responsible for doing the MDS and if the assessment in the MDS was not accurate, the care given to the residents might not be accurate. <BR/>In an interview on 05/29/2025 at 8:30 AM, the Administrator stated the MDS was done to reflect the current condition of the resident through accurate assessment. He said if there was no accurate assessment, there could be a misunderstanding about the care needed by the residents. He said he would coordinate with the ADON and the MDS Nurses to evaluate and resolve the issue.<BR/>Record review of the facility policy, Comprehensive Assessment and the Care Delivery Process Nursing Services Policy and Procedure Manual for Long-Term Care revised December 2016 revealed Policy Statement: Comprehensive assessments will be conducted to assist in developing person-centered care plans . 2. Assessment and information . a. Assess the individual . (1) Gather relevant information from multiple sources . (a) Observation; (b) Physical assessment; (c) Symptom or condition-related assessments; (d) Resident and family interview . (h) Evaluations from other disciplines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 3 residents (Residents #1) reviewed for assisted nutrition and hydration.<BR/>The facility failed to ensure Resident #1 was weighed monthly, according to her physician orders and her personalized care plan.<BR/>This failure could prevent the facility from detecting if the resident was experiencing excessive weight loss.<BR/>Findings include:<BR/>1. Record review of Resident #1's Face Sheet, dated 05/27/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included nutritional and metabolic disease, and muscle weakness.<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 02/19/25, reflected she had a BIMS score of 15 (intact cognitive response). For ADL care, it reflected the resident required supervision during eating.<BR/>Record review of Resident #1's Physician orders, dated 05/28/25, reflected weigh monthly and PRN.<BR/>Record review of Resident #1's Comprehensive care plan, dated 03/24/25, reflected and intervention of weighing per physician orders.<BR/>Record review of Resident #1's history of weight in the facility's system of records revealed no weight captured for January 2025, February 2025, March 2025, April 2025, and May 2025.<BR/>Record review of Resident #1's progress notes from 2/08/25 to 5/28/25 did not reveal and notes indicating the resident refusal to be weighed.<BR/>In an interview and record review on 05/28/25 at 9:30 AM, LVN A, stated she had been at the facility for nearly a month and was the floor nurse for Resident #1. She reviewed Resident #1's physician orders and the resident's care plan, which indicated a monthly weigh-in to monitor for any weight loss. She reviewed the resident's weight records for the past five months and she stated there were no records indicating the resident was weighed monthly. She stated the resident needed to be weighed at least monthly to ensure of no increased weight loss. She stated it was the responsibility of the nurse to ensure the resident was being weighed monthly. <BR/>In an interview on 05/28/25 at 10:06 AM, Restorative Aide A stated she had been at the facility for 3 years and she was responsible for weighing the residents. She was advised Resident #1 had no records of being weighed for the past 5 months. She stated she had asked the resident to weigh her, but she had refused. She stated she had documented it on a paper and handed it to Medical Records. She stated she had advised the nurses of this, but she could not provide the names of any nurse because the nurses changed often. She stated not weighing the resident monthly could result in her having problems with sudden weight loss and it not being addressed.<BR/>In an interview on 05/28/25 at 10:24 AM, the ADON stated she had been at the facility for 18 months. She was advised of Resident #1 not having any recorded weight for the past five months and she stated that the resident was routinely weighed at the hospital and her weight was recorded on paperwork received from them, but it was not uploaded in their system of records. She stated the resident refused to be weighed. She stated residents who were bed bound were transferred to a wheelchair, and then weighed, but the resident refused to sit in a wheelchair. She stated not weighing the resident monthly could result in them not capturing weight loss properly. She was advised that there were no notes in the system of records indicating the resident refused to be weighed and she stated Restorative Aide A, should have reported it to the floor nurse and the floor nurse should have documented the refusal. <BR/>Record review of the facility's policy Weight Assessment and Intervention (September 2008) reflected The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. The nursing staff will measure resident weights within 72 hours of admission and weekly for four weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter, unless otherwise directed. 2.Weights will be recorded in each individual's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #8) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #8 had oxygen concentrator filters free of sediment and debris.<BR/>These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met.<BR/>Findings Included:<BR/>Review of Resident #8's Face Sheet, dated 02/15/23, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive lung disease, respiratory failure, obstructive sleep apnea, pneumonia, morbid obesity, type 2 diabetes, swelling of extremities, mood disorder, obsessive-compulsive disorder, schizoaffective and anxiety disorder.<BR/>Review of Resident #8's Quarterly MDS, dated [DATE] stated he was cognitively intact with a BIMS score of 15. He required extensive assistance of two staff with bed mobility, toileting, and extensive assistance of one staff with personal hygiene.<BR/>Record review of Resident #8's physician orders revealed: oxygen at 2-3 LPM via nasal cannula continuous for dyspnea/low 02 sats with a date to start 11/10/2022. <BR/>Record review of Resident #8's Comprehensive Care Plan, dated 02/08/2022 revealed that Resident #8 required oxygen therapy R/T low O2 sats with a goal that included resident will not exhibit signs of hypoxia . via express the importance of keeping n/c in place to maintain a satisfactory O2 sat, administer oxygen at 2-3 LPM via N/C .<BR/>In an observation of Resident #8 on 02/14/2023 at 11:30 a.m., revealed him resting in bed with his oxygen concentrator turned on to 3 LPM. Resident #8's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present.<BR/>In an observation and interview with the Housekeeping Supervisor on 02/14/2023 at 11:41 a.m., she was observed bent over inspecting Resident #8's oxygen concentrator filters. She removed the filters from the device and stated they were dirty. She stated she was responsible for cleaning resident oxygen concentrator filters once per week but must have missed it the last time. She stated if resident oxygen concentrator filters become dirty, it clogs up [the concentrator] and they won't run, and then dust gets into resident lungs.<BR/>In an interview with ADON C on 02/16/2023 at 11:08 a.m., she stated that she expected the nurses to take a look at the machine and double check it, but it was housekeeping's responsibility to clean the filters once a week. She stated she was not sure if there was a specific policy on oxygen concentrator filters. She stated that if the oxygen concentrator filters are dirty, it was an infection control issue.<BR/>In an interview with the DON on 02/16/2023 at 11:13 a.m., she stated she expected the nurses to check the entire concentrator when they check the [oxygen] tubing, when the tubing gets changed out once weekly. She stated it was housekeeping responsibility to ensure the oxygen concentrator filters were clean. She stated she was not sure if there was a specific policy on oxygen concentrator filters. She stated if the oxygen concentrator filters are dirty, a fire can occur and the air the resident is inhaling would not be clean which would be an infection control issue. <BR/>In an interview with the Administrator on 02/16/2023 at 1:13 p.m., he stated his expectation was for oxygen concentrator filters be cleaned weekly by the housekeeping staff. He expected the filters to be free of sediment and dust. Stated if this was not performed, he stated he assumed it could affect the way the concentrator runs.<BR/>Review of facility policy, Oxygen Therapy, undated, revealed Policy: 1. To provide quality nursing care by implementing oxygen therapy . per physician's order and implemented by a licensed nurse. Objectives: 1. To administer oxygen under conditions in which insufficient oxygen is carried by the blood to the tissues . Procedure: 10. Discard masks, cannulas, and tubing . when it has become soiled. Change cannulas and humidifier bottles weekly. <BR/>Review of facility policy, Infection Control Program, undated, , revealed Standard: There will be an active, facility-wide Infection Control Program with effective measures to identify, control, and prevent infections acquired or brought into the facility from the community or other health care facilities.

F-812<BR/>Based on observation, interview, and record review, the facility failed to store, prepare, and serve<BR/>food in accordance with professional standards for food safety in 1 of 1 kitchens reviewed. <BR/>1.The facility failed to ensure food located in the facility only kitchen refrigerator, dry food pantry, and prep areas were labeled and dated. <BR/>2.The facility failed to ensure that the dishing machine operating at the appropriate temperature for sanitation of the dishes.<BR/>3.The facility failed to ensure that staff covered used head and beard covering while conducting dietary duties.<BR/>4. The Faility failed to ensure dietary staff doffed used gloves when leaving the kitchen and donned new gloves when re-entereing the kitchen <BR/>5. The facility failed to ensure that the stove burners were clean and free of build up from oil, crumbs, waisted The facility failed to ensure the container for the tea covered and free of air borne substances.<BR/>These failures could place residents at risk to bacteria, and other infectious illness.<BR/>Findings include:<BR/>During the initial tour of the facility's only kitchen revealed the DM wear a hat with the back of his head uncovered exposing short hair. He not wearing a beard covering at the time of entrance. DM later doffed a beard restraint, however it did not cover the full beard. <BR/>In an observation of the kitchen's refrigerator on 02/14/2023 at 10:00 A M. revealed the following food items undated <BR/>2 boxes filled with green leafy lettuce.<BR/>1 box of whole pineapples<BR/>1 box of cantaloupe (5) <BR/>1 box of honey dew melon (5)<BR/>3 half-filled pitchers of beverages (lemonade, tea, cranberry juice) stored on a serving tray undated.<BR/>2 boxes of margarine<BR/>Observation of the facility kitchen on 02/14/2023 at 10:05 A M. revealed , Dietary aide left the serving scoop in the bowl of pineapples to conduct another task. <BR/>Dietary aide observed walking down the hall with disposable gloves on, opening kitchen door and returning to task, left the kitchen with gloves on, walked down the hall touched door handle of and returned to task in kitchen.<BR/>Kitchen burners were observed with a build up from grime, oil, crumbs, food particles.<BR/>5 gallon iced tea dispenser not covered or sealed from environment. <BR/>An observation of DW/CK on 02/14/2023 at 9:28 AM revealed the task of dishes being cleaned in the dish washer. The DW/CK not wearing a hair net, and the sides of his beards were exposed on the sides. <BR/>An observation on 02/14/2023 at 9:32 A.M. revealed a dishwasher temperature of 115.1 The dishwasher temperature after the second cycle revealed a temperature of 117.6. The dishwasher temperature after the third cycle revealed a temperature of 122. <BR/>In an interview with the DM on 02/14/2023 at 9:34 AM revealed that the machine was a low temp sanitation machine that reached 120 sanitation temp for clean sanitized dishes. DM will have the MD to come assess the operations of the machine. DM stated that the machine serviced in January 2023. <BR/>An observation on 02/15/2023 at 11:37 a.m. of the dry storage room revealed the following items were stored undated: Large Square Clear Containers containing equal, Splenda, mayo, grape jelly, ketchup salt, pepper, crackers, ranch dressing, oatmeal pies, food coloring (egg color) and green<BR/>Observation of food prep area for seasoning revealed the following were undated. 16 oz. containers of basil leaves, curry powder, ground cinnamon, ground thyme leaves, mild chili powder, paprika, rubbed sage. <BR/>In an interview with DW/CK 02/14/2023 at 9:25 A M., he was responsible for cleaning dishes, food Prep he does do the cooking. DW/CK stated that normally he will run the dishwashing machine 3 times before the temp registers. He stated that failing to wash the dishes at the appropriate temp could lead to cross contamination, germs and bacteria. He stated that they have received training on beard that they should cover the full beard to prevent hair from getting in the dishes. The dish machine should be on 120 to properly sanitize. He does watch the aide for sanitation. He stated that there a communication gap. Communication for diet changes and they do not receive timely communication. He stated that another DA' cleans daily. He stated that the expectation of his aides were know their job and do their job. Kitchen garbage cans should be covered to prevent cross contamination, but I don't see why? He stated that he does not understand why the seasoning has to be dated. He stated that seasonings doesn't go bad. He stated that the seasoning does not check the expiration date on the seasoning. sanitation for garbage can to keep a top on it.<BR/>In an interview with DA-B on 02/16/2023 at 8:28AM revealed that all staff should wash hands in the kitchen with the change of every task, and wear hair nets while working in the kitchen to prevent the hair from falling in the food and surfaces. DA-B said gloves should be worn when preparing food. DA stated that practicing good handwashing prevents infection and illness for residents. DA-B stated that when preparing food she checks the dates, to know when they expire and discard when the date expires.<BR/>In an interview with DA-C on 02/16/23 at 11:22 AM revealed that she trained to h her hands when changing task and before doffing gloves and after doffing gloves to prevent contamination. DA stated that she has left the scoop in the pineapples for a minute. She said that leaving for a long time could cause contamination. DA said that the garbage can should be covered at all times to prevent cross contamination. <BR/>In an Interview on 02/16/23 at 11:45 AM with DON revealed that she expects dietary staff to practice good food sanitization by washing hands, when changing task. <BR/> Interview second interview with DM on 02/16/2023 at 1:40 PM, revealed that he expects the staff to wear gloves to prepare the food and handwash and change gloves in between cleaning and preparing. He said it was not appropriate for staff to wear same gloves when leaving and re-entering the kitchen, nor leave food scoops in food as it could cause cross contamination. DM said that he has cleaned the stove and has to be sprayed and stove 3 months ago. He has not had the time with staff shortages to clean. It is important to cover the beard Bread, stove, hair nets, beard restraint.<BR/>In an interview with [NAME] S. on 2/16/2023 at 3:00 PM, he said the stove cleaned every shift. [NAME] S stated that it difficult to clean with the cooking duties that are required. [NAME] S said the fire (pilot light) on and it too hot to clean. [NAME] S said that no matter when they clean it, it looks the same. [NAME] S said she encourages the staff to h their hands when they change tasks and wear gloves. [NAME] S has not educated the staff on the importance of utensil sanitation and removing bacteria from food. She stated that everything that comes must be dated and discarded in 3 days. [NAME] S. stated that they date the plastic where it can She denies that the food fully warm during her shifts. She stated that some residents have complained of the food being cold from sitting in the hall until the aides serve. Physically and verbally, she stated that it is not appropriate for kitchen staff to wear the gloves when they leave and return to the kitchen. She has dishwashers, and unless there was a problem with the temperature, she does not check. In the event this occur she will contact the DM, and he makes the report. She's been here for six months. The dishwasher should be set to 120 degrees Fahrenheit. <BR/>In an interview with Administrator 02/16/2023 said he expects the food to be dated upon delivery and expiration dates routinely checked. It is important for dietary staff to date food to prevent food from being used for residents that was old. He stated that the stove has been cleaned. He has contracted outside resources that trained dietary staff and the chef. <BR/>1.The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.<BR/>2.Dishwashing machines must be operated using the following specifications:<BR/>High-Temperature Dishwasher (Heat Sanitization)<BR/>1.Wash temperature (150&deg;- 165&deg;F) for at least forty-five (45) seconds;<BR/>2.Rinse temperature (165&deg;- 180&deg;F for at least twelve (12) seconds.<BR/>Low-Temperature Dishwasher (Chemical Sanitization)<BR/>1.Wash temperature (120&deg;F);<BR/>2.Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds.

**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 #9) of five residents observed for infection control. <BR/>1. The facility failed to ensure LVN Q performed hand hygiene before and after administration of ophthalmic medications for Resident #9 on 02/14/2023. <BR/>This failure placed residents at risk of cross-contamination and infections.<BR/>Findings Included:<BR/>Review of Resident #9's Quarterly MDS, dated [DATE] stated she was severely cognitively impaired with a BIMS score of 05. Resident #9 was totally dependent on one staff member for bed mobility, toileting, and personal hygiene. <BR/>Record review of Resident #9's physician orders revealed Macrobid (nitrofurantoin monohyd/m-cryst) 50 mg capsule twice a day for urinary tract infection to start 10/20/2022. Additionally, Resident #119 had an order for Artificial Tears . ophthalmic (eye) . 1 drop in each eye . for dry eye syndrome . to start 10/11/2022. <BR/>In observation of LVN Q on 02/14/2023 at 9:30 a.m., she was observed on the 400 hallway at her medication cart looking at the computer. LVN Q touched the computer mouse and keyboard with ungloved hands. At 9:32 a.m., LVN Q entered room [ROOM NUMBER] with medications in her ungloved hands and placed the medications on Resident #9's bedside table. LVN Q failed to perform hand hygiene upon entering resident room and prior to providing direct care. LVN Q raised Resident #9's head of bed by touching the control panel attached to the bed. LVN Q then obtained Resident #9's hearing aids and placed them in the resident's ears. LVN Q failed to perform hand hygiene prior to touching the resident's control panel and hearing aids. LVN Q then administered Resident #9's oral medications. At 9:36 a.m., LVN Q obtained Artificial Tears box, opened box, and opened medication. Then, LVN Q raised Resident #9's right eyelid with her left thumb and administered one drop of medication into Resident #9's right eye. LVN Q then raised Resident #9's left eyelid with her left thumb and administered one drop of medication into Resident's left eye. LVN Q failed to perform hand hygiene before administering Resident #9's eye medication. LVN Q then assisted Resident #9 to rotate on her left side and applied a lidocaine patch to her upper right back area. LVN Q failed to perform hand hygiene after administering eye medications and prior to the application of a lidocaine patch. <BR/>Review of facility policy, Hand Washing, 2001, revealed Policy: 1. All personnel are required to wash their hands before and after each direct contact for which hand washing is indicated by accepted professional practice . 2. Before and after resident contact 3. After contact with a source of microorganisms ( . bodily fluids, mucous membranes .)<BR/>Review of facility policy, Passing Medications, undated, received 02/16/2023, Eye Medications: When administering eye medication, the hands should always be washed both before and after the medication is applied . Hand Washing During Medication Pass: 3. Hands should be washed before and after giving eye medications. During this process hands are very close to the resident's mucous membranes which may be both a source and recipient of microorganisms as the eye medication is instilled.<BR/>Review of facility policy, Infection Control Program, undated, received 02/16/2023, revealed Standard: There will be an active, facility-wide Infection Control Program with effective measures to identify, control, and prevent infections acquired or brought into the facility from the community or other health care facilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #45 and Resident #29) of ten residents reviewed for reasonable accommodation of needs. <BR/>The facility failed to ensure the call light system in Resident #45 and Resident #29's rooms was in a position that was accessible to the resident.<BR/>This failure could place the residents at risk of being unable to obtain assistance when needed and not to get help in the event of an emergency.<BR/>Findings included: <BR/>Resident #45 <BR/>Review of Resident #45's Face Sheet dated 04/02/2024 reflected that resident was a 53 -year-old male admitted on [DATE]. Relevant diagnoses included muscle weakness, acquired hammer toes (abnormal bending of the toe), and difficulty in walking.<BR/>Review of Resident #45's Quarterly MDS assessment dated [DATE] reflected Resident #45 was cognitively intact with a BIMS score of 15. Resident #45 required supervision for bed mobility, transfer, eating, and toilet use. <BR/>Review of Resident #45's Comprehensive Care Plan dated 01/25/2024 reflected Resident #45 was at risk for falls and one of the interventions was to increase staff supervision with intensity based on resident need. No intervention noted to put the call light within reach.<BR/>Review of Resident #45's Comprehensive Care Plan dated 01/25/2024 indicated Resident #45 was unable to perform ADL Functions independently due to NWB (non-weight bearing) status and the interventions were to assist with transfer, assist with repositioning, and assist with ADLs. No intervention noted to put the call light within reach.<BR/>Observation and interview with Resident #45 on 04/02/2024 at 9:25 AM revealed resident on his bed, resting. It was noted that the resident's call light was behind the side table of his roommate. When asked where his call light was, the resident searched for it on his side. The resident verbalized he cannot find it. The resident stood up and started to walk towards where the call lights were connected to the wall and started to pull the call light from the back of the table and placed it on the recliner located in front of the roommate's side table. Resident #45 added he did not usually use the call light but in cases of emergencies, he might not be able get up and walk to get to the call light.<BR/>Observation on 04/02/2024 at 11:17 AM revealed RN E was preparing to give Resident #45's medication. RN E went inside the room to administer the medication. After giving the medication, RN E went out of the room and did not notice the call light was not within reach of Resident #45.<BR/>Resident #29<BR/>Review of Resident #29's Face Sheet dated 04/02/2024 reflected that resident was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included history of falling, muscle weakness, and difficulty in walking.<BR/>Review of Resident #29's Quarterly MDS assessment dated [DATE] reflected that Resident #29 had a moderate cognitive impairment with a BIMS score of 10. Resident #29 required supervision for bed mobility, transfer, eating, and toilet use. <BR/>Review of Resident #29's Comprehensive Care Plan dated 03/14/2024 reflected resident was at risk of injury related to falls and one of the interventions was to ensure call light was in reach and answer promptly. The Comprehensive Care Plan also indicated resident had falls on the 09/06/2023, 10/18/2023, and 03/13/2024.<BR/>Observation on 04/02/2024 at 9:35 AM revealed Resident #29 was on her bed sleeping. It was noted that the resident's call light was behind the side table of the resident's roommate.<BR/>Observation and interview with RN E on 04/02/2024 starting at 11:53 AM, RN E stated call lights were important and should be with the residents at all times because these were what the residents used to let the staff know they needed something. RN E said the call lights were used by the residents to call the attention of the staff, if they needed help to go to the restroom, or a refill on their water pitcher. If the call lights were far from the residents, the residents might try to do the activity themselves, and fall in the process. RN E went inside Resident #45's room and took the resident's call light from the recliner and placed it on the resident's bed. RN E then went inside Resident #29's room and tried to pull the resident's call light but was not able to pull it. RN E said the call light was stuck. RN E moved the side table forward to be able to pull the call light and place it on Resident #29's bed.<BR/>In an interview with CNA A on 04/02/2024 at 1:45 PM, CNA A stated the call light should be with the residents all the time whether the resident was dependent or not. CNA A said they needed the call light to call the staff if they needed something or were in distress. She added, Resident #45 was independent, but in cases of emergencies, it might be difficult for him to stand up and look for his call light. CNA A said the staff still needed to ensure the call light was with resident #45. CNA A then stated Resident #29 was the one making her bed. She said the call light could have fallen while she was making the bed and got stuck behind the side table located at the end of her bed. CNA A continued that if the call light was stuck behind the table on the other side, it would be hard for the resident to get the call light. CNA A said the staff should also ensure the call light was accessible even though Resident #29 was the one fixing her bed. CNA A added the staff should monitor if the call light were with the residents all the times they were inside the room. <BR/>In an interview with CNA C on 04/03/2024 at 9:40 AM, CNA C stated call lights were particularly important for the residents. CNA C said the resident needed the call light to ask for assistance or help. In addition, CNA C said if the residents could not reach the call light, the resident could not communicate their needs to the staff. CNA C said the residents might get mad, frustrated, or could start yelling to get the attention of the staff. CNA C said she would make a round to check if the call lights were with the residents.<BR/>In an interview with the DON on 04/04/2024 at 8:42 AM, the DON stated the call lights were significant to the residents. The DON said the call lights were important because this was one way to keep the residents safe. She said the call lights were also provided to be a means of communication between the residents and the staff. She added the resident used the call lights if they needed help or if they needed assistance. The DON further added there should be a conscious effort from the staff to place the call lights where the residents could reach them. She said it was not an excuse to say the resident was independent and not monitor the call light. She explained if the independent resident had an emergency, the resident might not be able to stand up to look for his call light. For other residents, they might fall if they try to stand up because nobody was there to assist them. The DON said the expectation was for the staff to continue their rounds to make sure the call lights were within reach of all the residents. The DON said she would continue to educate the staff through an in-service about the significance of call lights being accessible to the residents.<BR/>In an interview with the Administrator on 04/04/2024 at 9:40 AM, the Administrator stated call lights must always be with the residents so the residents could alert the staff if they needed something, if they were not feeling well, if they were in pain, or if there was an emergency. If the residents did not have their call lights, the residents would not be able to communicate their needs. The Administrator said the expectation was that the staff were to do more rounds and make sure the call lights were within the reach of the residents. The Administrator said they would continue to remind the staff for proper placement of the call lights.<BR/>Record review of the facility's policy Answering the Call Light MED-PASS, Inc. revised September 2022 revealed, Purpose: The purpose of this procedure is to ensure timely responses to the resident's request and needs . General Guidelines . 4. Ensure that the call light is accessible to the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for one (Resident #77) of six residents reviewed for revised Care Plan. <BR/>The facility failed to ensure Resident #77's care plan was revised to reflect discontinued use of tube feeding.<BR/>This failure could place the resident at risk of current needs not being met. <BR/>Findings included:<BR/>Review of Resident #77's Face Sheet dated 04/03/2024 reflected that the resident was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included stomatitis (inflammation of the mouth and lips) and dysphagia (difficulty in swallowing).<BR/>Review of Resident #77's Comprehensive Care Plan dated 01/03/2024 reflected Resident #77 was still on tube feeding. <BR/>Review of Resident #77's Comprehensive MDS assessment dated [DATE] reflected the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment also indicated resident was on mechanically altered diet and did not reflect that Resident #77 was on feeding tube.<BR/>Review of Resident #77's Comprehensive Care Plan dated 01/03/2024 reflected Resident #77 was still on tube feeding. <BR/>Review of Resident 77's Physician Order on 04/03/2024 reflected no order for enteral (delivery of food and medications through a tube in the stomach) feeding.<BR/>Review of Resident #77's Progress Note dated 04/28/2023 reflected, . G-tube had been dc (discontinued) by physician .<BR/>Observation on 04/02/2024 at 9:25 AM revealed Resident #77 was on his bed sleeping. It was also noted that there was no IV pole with feeding formula hanging at bedside.<BR/>Observation and interview with Resident #77 on 04/03/2024 at 8:06 AM revealed that Resident #77 was sitting at the side of his bed eating breakfast. Resident #77 denied he was on tube feeding.<BR/>Observation and interview with RN E on 04/03/2024 at starting at 8:16 AM, RN E stated Resident #77 was not on tube feeding. RN E went to the resident's orders and said there were no orders for enteral feeding. RE N then looked over the resident's care plan and said there was still a care plan for tube feeding. RN E said she would verify with her manager and then would resolve the care plan. RN E said if the resident was not on tube feeding anymore, the care plan should had been updated to show the present health condition of the resident. If the care plan was not updated, there could be a confusion on the care of the residents and the residents might not receive the treatment needed.<BR/>In an interview with MDS Nurse F on 04/04/2024 at 8:07 AM, MDS Nurse F stated the care plan should reflect the plan of care needed by a resident at the present. MDS Nurse F said if the resident was not on tube feeding anymore, it should not be on the care plan anymore. She said this should had been communicated to the MDS Nurse so the care plan was updated. She said the care plan should be updated to assess if the goals were met or not met and then make appropriate changes for the interventions as needed.<BR/>In an interview with the DON on 04/04/2024 at 8:42 AM, the DON stated if a resident was not on tube feeding anymore, goals and interventions for tube feeding should not be reflected on the care plan of the resident. The DON said the care plan should reflect the current care being given to the resident. The DON said if tube feeding was already discontinued, it should had been communicated to the DON or the MDS Nurse so the care plan would have been updated timely. The DON further said if the care plan of the residents were not updated, there could be confusion about the residents' care or some of the care would be missed. The DON said the expectation was for the residents to be properly assessed and communicate any pertinent changes to update the care plan if needed. The DON concluded she would do an in-service with regards to the revising the care plan.<BR/>Interview with the Administrator on 04/04/2024 at 9:40 AM, the Administrator stated every resident should have a care plan that was accurate in order to provide care with consistency. The Administrator said the care plan should reflect the current needs of the residents. The Administrator said the expectation was the care plans would be updated as needed.<BR/>Record review of facility policy, Care Plan, Comprehensive Person-Centered Nursing Services Policy and Procedure Manual for Long-term Care, 2001 MED-PASS revised March 2022 revealed, Policy Statement: A comprehensive, person-centered care plan . implemented for each resident . Policy Interpretation and Implementation . 12. The interdisciplinary team reviews and updates the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #8) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #8 had oxygen concentrator filters free of sediment and debris.<BR/>These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met.<BR/>Findings Included:<BR/>Review of Resident #8's Face Sheet, dated 02/15/23, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive lung disease, respiratory failure, obstructive sleep apnea, pneumonia, morbid obesity, type 2 diabetes, swelling of extremities, mood disorder, obsessive-compulsive disorder, schizoaffective and anxiety disorder.<BR/>Review of Resident #8's Quarterly MDS, dated [DATE] stated he was cognitively intact with a BIMS score of 15. He required extensive assistance of two staff with bed mobility, toileting, and extensive assistance of one staff with personal hygiene.<BR/>Record review of Resident #8's physician orders revealed: oxygen at 2-3 LPM via nasal cannula continuous for dyspnea/low 02 sats with a date to start 11/10/2022. <BR/>Record review of Resident #8's Comprehensive Care Plan, dated 02/08/2022 revealed that Resident #8 required oxygen therapy R/T low O2 sats with a goal that included resident will not exhibit signs of hypoxia . via express the importance of keeping n/c in place to maintain a satisfactory O2 sat, administer oxygen at 2-3 LPM via N/C .<BR/>In an observation of Resident #8 on 02/14/2023 at 11:30 a.m., revealed him resting in bed with his oxygen concentrator turned on to 3 LPM. Resident #8's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present.<BR/>In an observation and interview with the Housekeeping Supervisor on 02/14/2023 at 11:41 a.m., she was observed bent over inspecting Resident #8's oxygen concentrator filters. She removed the filters from the device and stated they were dirty. She stated she was responsible for cleaning resident oxygen concentrator filters once per week but must have missed it the last time. She stated if resident oxygen concentrator filters become dirty, it clogs up [the concentrator] and they won't run, and then dust gets into resident lungs.<BR/>In an interview with ADON C on 02/16/2023 at 11:08 a.m., she stated that she expected the nurses to take a look at the machine and double check it, but it was housekeeping's responsibility to clean the filters once a week. She stated she was not sure if there was a specific policy on oxygen concentrator filters. She stated that if the oxygen concentrator filters are dirty, it was an infection control issue.<BR/>In an interview with the DON on 02/16/2023 at 11:13 a.m., she stated she expected the nurses to check the entire concentrator when they check the [oxygen] tubing, when the tubing gets changed out once weekly. She stated it was housekeeping responsibility to ensure the oxygen concentrator filters were clean. She stated she was not sure if there was a specific policy on oxygen concentrator filters. She stated if the oxygen concentrator filters are dirty, a fire can occur and the air the resident is inhaling would not be clean which would be an infection control issue. <BR/>In an interview with the Administrator on 02/16/2023 at 1:13 p.m., he stated his expectation was for oxygen concentrator filters be cleaned weekly by the housekeeping staff. He expected the filters to be free of sediment and dust. Stated if this was not performed, he stated he assumed it could affect the way the concentrator runs.<BR/>Review of facility policy, Oxygen Therapy, undated, revealed Policy: 1. To provide quality nursing care by implementing oxygen therapy . per physician's order and implemented by a licensed nurse. Objectives: 1. To administer oxygen under conditions in which insufficient oxygen is carried by the blood to the tissues . Procedure: 10. Discard masks, cannulas, and tubing . when it has become soiled. Change cannulas and humidifier bottles weekly. <BR/>Review of facility policy, Infection Control Program, undated, , revealed Standard: There will be an active, facility-wide Infection Control Program with effective measures to identify, control, and prevent infections acquired or brought into the facility from the community or other health care facilities.

F-812<BR/>Based on observation, interview, and record review, the facility failed to store, prepare, and serve<BR/>food in accordance with professional standards for food safety in 1 of 1 kitchens reviewed. <BR/>1.The facility failed to ensure food located in the facility only kitchen refrigerator, dry food pantry, and prep areas were labeled and dated. <BR/>2.The facility failed to ensure that the dishing machine operating at the appropriate temperature for sanitation of the dishes.<BR/>3.The facility failed to ensure that staff covered used head and beard covering while conducting dietary duties.<BR/>4. The Faility failed to ensure dietary staff doffed used gloves when leaving the kitchen and donned new gloves when re-entereing the kitchen <BR/>5. The facility failed to ensure that the stove burners were clean and free of build up from oil, crumbs, waisted The facility failed to ensure the container for the tea covered and free of air borne substances.<BR/>These failures could place residents at risk to bacteria, and other infectious illness.<BR/>Findings include:<BR/>During the initial tour of the facility's only kitchen revealed the DM wear a hat with the back of his head uncovered exposing short hair. He not wearing a beard covering at the time of entrance. DM later doffed a beard restraint, however it did not cover the full beard. <BR/>In an observation of the kitchen's refrigerator on 02/14/2023 at 10:00 A M. revealed the following food items undated <BR/>2 boxes filled with green leafy lettuce.<BR/>1 box of whole pineapples<BR/>1 box of cantaloupe (5) <BR/>1 box of honey dew melon (5)<BR/>3 half-filled pitchers of beverages (lemonade, tea, cranberry juice) stored on a serving tray undated.<BR/>2 boxes of margarine<BR/>Observation of the facility kitchen on 02/14/2023 at 10:05 A M. revealed , Dietary aide left the serving scoop in the bowl of pineapples to conduct another task. <BR/>Dietary aide observed walking down the hall with disposable gloves on, opening kitchen door and returning to task, left the kitchen with gloves on, walked down the hall touched door handle of and returned to task in kitchen.<BR/>Kitchen burners were observed with a build up from grime, oil, crumbs, food particles.<BR/>5 gallon iced tea dispenser not covered or sealed from environment. <BR/>An observation of DW/CK on 02/14/2023 at 9:28 AM revealed the task of dishes being cleaned in the dish washer. The DW/CK not wearing a hair net, and the sides of his beards were exposed on the sides. <BR/>An observation on 02/14/2023 at 9:32 A.M. revealed a dishwasher temperature of 115.1 The dishwasher temperature after the second cycle revealed a temperature of 117.6. The dishwasher temperature after the third cycle revealed a temperature of 122. <BR/>In an interview with the DM on 02/14/2023 at 9:34 AM revealed that the machine was a low temp sanitation machine that reached 120 sanitation temp for clean sanitized dishes. DM will have the MD to come assess the operations of the machine. DM stated that the machine serviced in January 2023. <BR/>An observation on 02/15/2023 at 11:37 a.m. of the dry storage room revealed the following items were stored undated: Large Square Clear Containers containing equal, Splenda, mayo, grape jelly, ketchup salt, pepper, crackers, ranch dressing, oatmeal pies, food coloring (egg color) and green<BR/>Observation of food prep area for seasoning revealed the following were undated. 16 oz. containers of basil leaves, curry powder, ground cinnamon, ground thyme leaves, mild chili powder, paprika, rubbed sage. <BR/>In an interview with DW/CK 02/14/2023 at 9:25 A M., he was responsible for cleaning dishes, food Prep he does do the cooking. DW/CK stated that normally he will run the dishwashing machine 3 times before the temp registers. He stated that failing to wash the dishes at the appropriate temp could lead to cross contamination, germs and bacteria. He stated that they have received training on beard that they should cover the full beard to prevent hair from getting in the dishes. The dish machine should be on 120 to properly sanitize. He does watch the aide for sanitation. He stated that there a communication gap. Communication for diet changes and they do not receive timely communication. He stated that another DA' cleans daily. He stated that the expectation of his aides were know their job and do their job. Kitchen garbage cans should be covered to prevent cross contamination, but I don't see why? He stated that he does not understand why the seasoning has to be dated. He stated that seasonings doesn't go bad. He stated that the seasoning does not check the expiration date on the seasoning. sanitation for garbage can to keep a top on it.<BR/>In an interview with DA-B on 02/16/2023 at 8:28AM revealed that all staff should wash hands in the kitchen with the change of every task, and wear hair nets while working in the kitchen to prevent the hair from falling in the food and surfaces. DA-B said gloves should be worn when preparing food. DA stated that practicing good handwashing prevents infection and illness for residents. DA-B stated that when preparing food she checks the dates, to know when they expire and discard when the date expires.<BR/>In an interview with DA-C on 02/16/23 at 11:22 AM revealed that she trained to h her hands when changing task and before doffing gloves and after doffing gloves to prevent contamination. DA stated that she has left the scoop in the pineapples for a minute. She said that leaving for a long time could cause contamination. DA said that the garbage can should be covered at all times to prevent cross contamination. <BR/>In an Interview on 02/16/23 at 11:45 AM with DON revealed that she expects dietary staff to practice good food sanitization by washing hands, when changing task. <BR/> Interview second interview with DM on 02/16/2023 at 1:40 PM, revealed that he expects the staff to wear gloves to prepare the food and handwash and change gloves in between cleaning and preparing. He said it was not appropriate for staff to wear same gloves when leaving and re-entering the kitchen, nor leave food scoops in food as it could cause cross contamination. DM said that he has cleaned the stove and has to be sprayed and stove 3 months ago. He has not had the time with staff shortages to clean. It is important to cover the beard Bread, stove, hair nets, beard restraint.<BR/>In an interview with [NAME] S. on 2/16/2023 at 3:00 PM, he said the stove cleaned every shift. [NAME] S stated that it difficult to clean with the cooking duties that are required. [NAME] S said the fire (pilot light) on and it too hot to clean. [NAME] S said that no matter when they clean it, it looks the same. [NAME] S said she encourages the staff to h their hands when they change tasks and wear gloves. [NAME] S has not educated the staff on the importance of utensil sanitation and removing bacteria from food. She stated that everything that comes must be dated and discarded in 3 days. [NAME] S. stated that they date the plastic where it can She denies that the food fully warm during her shifts. She stated that some residents have complained of the food being cold from sitting in the hall until the aides serve. Physically and verbally, she stated that it is not appropriate for kitchen staff to wear the gloves when they leave and return to the kitchen. She has dishwashers, and unless there was a problem with the temperature, she does not check. In the event this occur she will contact the DM, and he makes the report. She's been here for six months. The dishwasher should be set to 120 degrees Fahrenheit. <BR/>In an interview with Administrator 02/16/2023 said he expects the food to be dated upon delivery and expiration dates routinely checked. It is important for dietary staff to date food to prevent food from being used for residents that was old. He stated that the stove has been cleaned. He has contracted outside resources that trained dietary staff and the chef. <BR/>1.The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.<BR/>2.Dishwashing machines must be operated using the following specifications:<BR/>High-Temperature Dishwasher (Heat Sanitization)<BR/>1.Wash temperature (150&deg;- 165&deg;F) for at least forty-five (45) seconds;<BR/>2.Rinse temperature (165&deg;- 180&deg;F for at least twelve (12) seconds.<BR/>Low-Temperature Dishwasher (Chemical Sanitization)<BR/>1.Wash temperature (120&deg;F);<BR/>2.Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds.

**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 #9) of five residents observed for infection control. <BR/>1. The facility failed to ensure LVN Q performed hand hygiene before and after administration of ophthalmic medications for Resident #9 on 02/14/2023. <BR/>This failure placed residents at risk of cross-contamination and infections.<BR/>Findings Included:<BR/>Review of Resident #9's Quarterly MDS, dated [DATE] stated she was severely cognitively impaired with a BIMS score of 05. Resident #9 was totally dependent on one staff member for bed mobility, toileting, and personal hygiene. <BR/>Record review of Resident #9's physician orders revealed Macrobid (nitrofurantoin monohyd/m-cryst) 50 mg capsule twice a day for urinary tract infection to start 10/20/2022. Additionally, Resident #119 had an order for Artificial Tears . ophthalmic (eye) . 1 drop in each eye . for dry eye syndrome . to start 10/11/2022. <BR/>In observation of LVN Q on 02/14/2023 at 9:30 a.m., she was observed on the 400 hallway at her medication cart looking at the computer. LVN Q touched the computer mouse and keyboard with ungloved hands. At 9:32 a.m., LVN Q entered room [ROOM NUMBER] with medications in her ungloved hands and placed the medications on Resident #9's bedside table. LVN Q failed to perform hand hygiene upon entering resident room and prior to providing direct care. LVN Q raised Resident #9's head of bed by touching the control panel attached to the bed. LVN Q then obtained Resident #9's hearing aids and placed them in the resident's ears. LVN Q failed to perform hand hygiene prior to touching the resident's control panel and hearing aids. LVN Q then administered Resident #9's oral medications. At 9:36 a.m., LVN Q obtained Artificial Tears box, opened box, and opened medication. Then, LVN Q raised Resident #9's right eyelid with her left thumb and administered one drop of medication into Resident #9's right eye. LVN Q then raised Resident #9's left eyelid with her left thumb and administered one drop of medication into Resident's left eye. LVN Q failed to perform hand hygiene before administering Resident #9's eye medication. LVN Q then assisted Resident #9 to rotate on her left side and applied a lidocaine patch to her upper right back area. LVN Q failed to perform hand hygiene after administering eye medications and prior to the application of a lidocaine patch. <BR/>Review of facility policy, Hand Washing, 2001, revealed Policy: 1. All personnel are required to wash their hands before and after each direct contact for which hand washing is indicated by accepted professional practice . 2. Before and after resident contact 3. After contact with a source of microorganisms ( . bodily fluids, mucous membranes .)<BR/>Review of facility policy, Passing Medications, undated, received 02/16/2023, Eye Medications: When administering eye medication, the hands should always be washed both before and after the medication is applied . Hand Washing During Medication Pass: 3. Hands should be washed before and after giving eye medications. During this process hands are very close to the resident's mucous membranes which may be both a source and recipient of microorganisms as the eye medication is instilled.<BR/>Review of facility policy, Infection Control Program, undated, received 02/16/2023, revealed Standard: There will be an active, facility-wide Infection Control Program with effective measures to identify, control, and prevent infections acquired or brought into the facility from the community or other health care facilities.

Based on interview and record review, the facility failed to implement written policies and procedures that ensure reporting of abuse, neglect, and crimes occurring in federally-funded long term care facilities for one (05/27/23) of two incidents reviewed for reporting. <BR/>The facility failed to follow their policy to report to the State Survey Agency when Agency Aide A made a terroristic threat to shoot up the facility and to shoot CNA B following a physical altercation, which resulted in the police arresting her after finding a handgun in her vehicle in the facility's parking lot.<BR/>This failure could place the residents in the facility at risk of lacking timely reporting of incidents involving terroristic threats. <BR/>Findings included:<BR/>Review of the facility's Prohibition of Abuse, Neglect, and Exploitation (ANE) Standard Practice policy and procedure, updated 10/01/17, reflected the following:<BR/>Standards:<BR/>This Facility's abuse prohibition program includes standards and practice guidelines that address the essential components of an ANE prohibition program to include screening, prevention, identification, investigation, protection, reporting, and response.<BR/> .Reporting<BR/> .4. The Facility will report the allegations and substantiated occurrences of ANE to the state agency and to all other agencies as required by law <BR/>Interview on 06/16/23 at 9:22 AM with the Administrator and the DON revealed during a weekend, 05/27/23, Agency Aide A and CNA B had been involved in a physical altercation on the facility property. It was reported that Agency Aide A stated her back was hurting and wanted to go home during her shift. CNA B heard the comment Agency Aide A said about going home and so she (CNA B) made a remark back to Agency Aide A. Both aides began to yell at each other around the nurses' station on the 500 hall and then decided to take the argument outside of the facility, leaving through an exit door on the 500 hall. Once Agency Aide A and CNA B were outside, they began to physically fight in the parking lot, and the incident was witnessed by three of the facility's staff members. Eventually the two aides were separated by the staff, and the police was called. Sometime during the time they were waiting for the police, Agency Aide A made the comment she was going to shoot up the place and shoot CNA B. Once the police arrived at the facility, they (Administrator) asked Agency Aide A to be arrested due to making the shooting threat. When the police searched Agency Aide A's vehicle, they located a gun, and the Agency Aide was charged with terroristic threat. <BR/>Interview on 06/16/23 at 10:59 AM with the ADON revealed she was working as a charge nurse on the 500 hall. Agency Aide A said she wanted to go home because she had hurt her back then she heard yelling between Agency Aide A and CNA B. The ADON said she went to get LVN B and they saw both Agency Aide A and CNA B going outside to the parking lot. The aides first went to their vehicles, and then met each other in the middle and began physically fight. The ADON called the police and while they were waiting for them to show up, Agency Aide A said, I'm gonna come back and shoot up the whole place including that bitch while pointing at CNA B. Once the police arrived, both aides were questioned. Agency Aide A told the police she had a gun, and the police were seen taking the gun from the vehicle. The ADON further stated she did not recall seeing any residents in the hall when the aides began to yell at each other, but they were quickly taken outside. The ADON stated no resident had mentioned anything to her after the incident. <BR/>Interview on 06/16/23 at 10:41 AM with LVN C revealed he was working the night of the incident, and he had been asked to go to the 500 nurses' station. LVN C could hear yelling as he was approaching the nurses' station, and then he saw Agency Aide A and CNA B exiting outside. Each aide went to their vehicle as they were trying to coordinate where they could go to fight, and then they began to fight. As the other facility staff were trying to separate the two aides, the ADON was calling the police. Once the aides were separated, while they waited on the police, Agency Aide A made the comment she was going to shoot you all and this place. When the police arrived, both the aides were interrogated. LVN C stated the police found a gun in Agency Aide A's vehicle, and she was arrested. LVN C stated he only assumed residents were already in their rooms sleeping or getting ready for bed. He stated they may have overheard the aides yelling, but there were no residents that witnessed the physical altercation outside of the facility. <BR/>Interview on 06/22/23 at 11:06 AM with LVN D revealed Agency Aide A and CNA B began to have words with each other. LVN D stated she told the aides to keep their voices down. Agency Aide A and CNA B began to say they were going to fight each other, and LVN D continued to tell the aides to stop. The aides then exited out of a door on the 500 hall into the parking lot outside and soon began to physically fight. The ADON called the police, and while they waited for them to show up, Agency Aide A said, Y'all can't keep me here and I'm gonna shoot this place up, y'alll and then pointed to CNA B. LVN D further stated the police had taken a gun from Agency Aide A's car, and she was arrested. LVN D said most all of the residents were sleeping at the time of the incident. LVN D stated she only recalled Resident #1 going to his room door when he heard the yelling, but she told him to go back into his room. She stated the resident never mentioned the incident again. <BR/>Interview on 06/16/23 at 11:22 AM with Resident #1 revealed he did not recall any incidents where staff members were arguing and fighting. <BR/>Interview on 06/16/23 from 9:47 AM to 11:56 AM with eight alert and oriented residents revealed they did not recall any incident where the staff were heard arguing or yelling with each other. <BR/>Agency Aide A could not be contacted because did not have a contact number for her. <BR/>Review of the police report dated 05/27/23 at 10:28 PM reflected the following:<BR/> .Offense Code: Terroristic Threat Cause Fear of Imminent SBI (Serious Bodily Injury) <BR/>Arrestee: (Agency Aide A)<BR/>Evidence: Caliber: 9mm pistol recovered from glove box of vehicle 9mm bullets recovered in magazine and chamber <BR/>Interview on 06/16/23 at 11:32 AM with the Administrator revealed this incident was not reported to the State Survey Agency because there were no residents involved, in the hallway, and no resident reported hearing or seeing anything. The staff were only in the building for a short time before they went outside where the physical altercation took place. The Administrator further stated another reason was because the police were very convincing in saying Agency Aide A was being very compliant at the time of the arrest and was very remorseful of what she had done. The police told the Administrator, they felt like there was no real threat because Agency Aide A had volunteered the gun in her vehicle.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately or not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for one of two incidents reviewed for reporting.<BR/>The facility failed to report to the State Survey Agency when Agency Aide A made a terroristic threat to shoot up the facility and to shoot CNA B following a physical altercation, which resulted in the police arresting Agency Aide A in the facility's parking lot after finding a handgun in her vehicle. <BR/>This failure could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment.<BR/>Findings included:<BR/>Interview on 06/16/23 at 9:22 AM with the Administrator and the DON revealed during a weekend, 05/27/23, an Agency Aide A and a CNA B had been involved in a physical altercation on the facility property. It was reported that Agency Aide A stated her back was hurting and wanted to go home during her shift. CNA B heard the comment Agency Aide A said about going home and so she (CNA B) made a remark back to Agency Aide A. Both aides began to yell at each other around the nurses' station on the 500 hall and then decided to take the argument outside of the facility, leaving through an exit door on the 500 hall. Once Agency Aide A and CNA B were outside, they began to physically fight in the parking lot, and the incident was witnessed by three of the facility's staff members. Eventually the two aides were separated by the staff, and the police were called. Sometime during the time they were waiting for the police, Agency Aide A made the comment she was going to shoot up the place and shoot CNA B. Once the police arrived at the facility, they (Administrator) asked Agency Aide A to be arrested due to making the shooting threat and when the police searched Agency Aide A's vehicle, they located a gun, and Agency Aide A was charged with terroristic threat. <BR/>Interview on 06/16/23 at 10:59 AM with the ADON revealed she was working as a charge nurse on the 500 hall. Agency Aide A said she wanted to go home because she had hurt her back then she heard yelling between Agency Aide A and CNA B. The ADON said she went to get LVN B and they saw both Agency Aide A and CNA B going outside to the parking lot. The aides first went to their vehicles, and then met each other in the middle and began physically fight. The ADON called the police and while they were waiting for them to show up, Agency Aide A said, I'm gonna come back and shoot up the whole place including that bitch and was pointing at CNA B. Once the police arrived, both aides were questioned, Agency Aide A told the police she had a gun, and the police were seen taking the gun from the vehicle. The ADON further stated she did not recall seeing any residents in the hall when the aides began to yell at each other, but they were quickly taken outside, and no resident had mentioned anything to her after the incident. <BR/>Interview on 06/16/23 at 10:41 AM with LVN C revealed he was working the night of the incident, and he had been asked to go to the 500 nurses' station. LVN C could hear yelling as he was approaching the nurses' station, and then he saw Agency Aide A and CNA B exiting outside. Each aide went to their vehicle as they were trying to coordinate where they could go to fight, and then they began to fight. As the other facility staff were trying to separate the two aides the ADON was calling the police. Once the aides were separated, while they waited on the police, Agency Aide A made the comment she was going to shoot you all and this place. When the police arrived both the aides were interrogated, and the police found a gun in Agency Aide A's vehicle, and she was arrested. LVN C stated he only assumed residents were already in their rooms sleeping or getting ready for bed. LVN C stated they may have overheard the aides yelling, but there were no residents that witnessed the physical altercation outside of the facility. <BR/>Interview on 06/22/23 at 11:06 AM with LVN D revealed Agency Aide A and CNA B began to have words with each other, and LVN D was telling the aides to keep their voices down. Agency Aide A and CNA B began to say they were going to fight each other, and LVN D continued to tell the aides to stop. The aides then exited out of a door on the 500 hall into the parking lot outside and soon began to physically fight. The ADON called the police and while they waited for them to show up Agency Aide A said, Y'all can't keep me here and I'm gonna shoot this place up, y'all and then pointed to CNA B. LVN D further stated the police had taken a gun from Agency Aide A's vehicle, and she was arrested. LVN D said most all of the residents were sleeping at the time of the incident, and she only recalled Resident #1 going to his room door when he heard the yelling, but she (LVN D) told him to go back into his room and the resident never mentioned the incident again. <BR/>Interview on 06/16/23 at 11:22 AM with Resident #1 revealed he did not recall any incidents where staff members were arguing and fighting. <BR/>Interview on 06/16/23 from 9:47 AM to 11:56 AM with eight alert and oriented residents revealed they did not recall any incident where the staff were heard arguing or yelling with each other. <BR/>Agency Aide A could not be contacted because did not have a contact number for her. <BR/>Review of the police report dated 05/27/23 at 10:28 PM reflected the following:<BR/> .Offense Code: Terroristic Threat Cause Fear of Imminent SBI (Serious Bodily Injury) <BR/>Arrestee: (Agency Aide A)<BR/>Evidence: Caliber: 9mm pistol recovered from glove box of vehicle 9mm bullets recovered in magazine and chamber <BR/>Interview on 06/16/23 at 11:32 AM with the Administrator revealed this incident was not reported to the State Survey Agency because there were no residents involved, in the hallway, and no resident reported hearing or seeing anything. The staff were only in the building for a short time before they went outside where the physical altercation took place. The Administrator further stated another reason was because the police were very convincing in saying Agency Aide A was being very compliant at the time of the arrest and was very remorseful of what she had done. The police told the Administrator, they felt like there was no real threat because Agency Aide A had volunteered the gun in her vehicle. <BR/>Review of the facility's Prohibition of Abuse, Neglect, and Exploitation (ANE) Standard Practice policy and procedure, updated 10/01/17, reflected the following:<BR/>Standards:<BR/>This Facility's abuse prohibition program includes standards and practice guidelines that address the essential components of an ANE prohibition program to include screening, prevention, identification, investigation, protection, reporting, and response.<BR/> .Reporting<BR/> .4. The Facility will report the allegations and substantiated occurrences of ANE to the state agency and to all other agencies as required by law

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 residents (Resident #119) reviewed for intravenous care.<BR/>The facility failed to ensure Resident #119 received intravenous dressing changes to the PICC line at any time during his admission between 02/05/2023 and date of observation 02/14/2023. <BR/>This deficient practice could place residents at risk of serious illness and/or infection.<BR/>Findings included:<BR/>Review of Resident #119's Face Sheet, dated 02/15/23, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included stroke resulting in paralysis affecting left side of his body, heart disease, streptococcus infection, and back surgery with disc replacement. <BR/>Review of Resident #119's admission MDS, dated [DATE] stated he was moderately cognitively impaired with a BIMS score of 10. Functional status was not completed at time of survey.<BR/>Review of Resident #119's Functional Abilities Assessment completed upon admission, dated 02/05/2023, revealed he required partial/moderate assistance with eating and oral hygiene. Toileting and other ADLs were not documented as not attempted due to environmental limitations.<BR/>Record review of Resident #119's physician orders revealed Sodium Chloride 0.9% 10 ml flush injections before and after IV admin, Q shift for IV patency, and antibiotic orders of Ceftriaxone 2 gram intravenous twice a day for streptococcus to start 02/05/2023. No physician orders for intravenous line dressing changes were observed.<BR/>Record review of Resident #119's TAR dated 02/02/2023-02/15/2023 revealed resident received Sodium Chloride 0.9% Ceftriaxone 2 gram intravenously as ordered between 02/06/2023 and 02/15/2023. <BR/>Record review of Resident #119's Comprehensive Care Plan, dated 02/06/2023 revealed that Resident #119's Problem: Resident is on antibiotics and is at risk for adverse reactions . Infection: strep mitis bacteremia with his goal for infection to be resolved . at the end of antibiotic therapy with no adverse reactions noted' via follow universal precautions to prevent cross contamination and spread of infection, monitor resident for adverse reactions to antibiotic therapy, and give medications per order: IV ceftriaxone. No documentation of maintenance or care of intravenous access dressings was observed. <BR/>Record review of Resident #119's Health and Physical, dated 02/06/2023, revealed Assessment and Plan . 1. Bacteremia: secondary to Strep Mitis . IV Ceftriaxone for 6 weeks.<BR/>In an interview and observation with Resident #119 on 02/14/2023 at 11:37 a.m., revealed the resident resting in bed. Resident observed to have a single lumen power PICC intravenous access on the right upper arm. Dressing appeared clean, dry, intact, and the dressing was dated for 11 days ago, 2/3. The resident stated the dressing had not been changed since his admission to the facility. Resident denied any pain at catheter insertion site. <BR/>In an interview and observation with Resident #119 on 02/15/2023 at 10:24 a.m., revealed the resident resting in bed. Resident observed to have a single lumen intravenous access on the right upper arm. Dressing appeared clean, dry, intact and the dressing was dated 02/14/2023 and initialed EM. Resident #119 stated someone changed the dressing yesterday for the first time since admission. Resident denied any pain at catheter insertion site. <BR/>In an interview with LVN P on 02/15/2023 at 10:27 a.m., she stated she was the nurse for Resident #119 yesterday, 02/14/2023 and for today, 02/15/2023. She stated that DON changed the intravenous line dressing yesterday. She stated that she was not sure of the date on the dressing prior to 02/14/2023. She stated that it was the nurse's responsibility to ensure dressing changes are performed every 7 days per policy for infection control purposes. She stated it was nursing leadership's responsibility to audit and ensure dressing changes are performed. <BR/>In an interview with the DON on 02/15/2023 at 12:16 p.m., she stated she changed the intravenous line dressing yesterday [02/14/2023] for Resident #119. She stated the dressing was labeled 02/03 which she stated it must be from the hospital, since he was admitted [DATE]. She stated that the facility policy was for the IV dressing to be changed every 7 days. She stated it was her expectations for the nurses to ensure dressing changes were completed per policy. She stated the intravenous line dressing was not changed, as there was not a physician order. She stated that she did not see any physician orders for IV dressing changes in the computer for Resident #119. She stated that Resident #119 was admitted on a weekend and the weekend supervisor, RN H, was responsible for putting in the physician orders. She stated that her ADON was expected to perform audits to ensure physician orders were properly put in for new admissions. She stated it was important that the facility have a physician order for any care provided. She stated that if intravenous line dressing changes were not performed per policy, infection can occur, which can lead to sepsis.<BR/>In an interview with RN H on 02/15/2023 at 12:44 p.m. ,revealed she was the weekend supervisor when Resident #119 was admitted . She stated she helped put the physician orders in the EMR but did not recall the date on the dressing nor if the resident had an intravenous line. She stated she did not perform the admission assessment of the resident. She stated that the ADON was responsible for audits for new admits on Monday to ensure physician orders were properly inputted into the EMR. <BR/>In an interview with ADON C on 02/15/2023 at 1:13 p.m., revealed her expectations were for the resident's bedside nurse to ensure intravenous dressing changes were performed. She stated she was responsible for ensuring the bedside nurses were completing the dressing changes. She also stated she was responsible for auditing the EMR for new admits on Monday to ensure accuracy. She stated there was not an order currently in the EMR for Resident #119 for intravenous line dressing changes and it was an oversight on me. She stated if intravenous dressing changes were not performed every 7 days, it can lead to sepsis and all kinds of things. <BR/>In an interview with the Administrator on 02/16/2023 at 1:13 p.m., he declined to comment on this as it was clinically related. <BR/>Review of facility policy, . Dressing Changes, rev. 04/2016, revealed Purpose: The purpose of this procedure is to prevent catheter-related infections . General guidelines: 1. Change . dressing . every 5-7 days after insertion .<BR/>Review of facility policy, Infection Control Program, undated, revealed Standard: There will be an active, facility-wide Infection Control Program with effective measures to identify, control, and prevent infections acquired or brought into the facility from the community or other health care facilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #8) reviewed for respiratory care.<BR/>The facility failed to ensure Resident #8 had oxygen concentrator filters free of sediment and debris.<BR/>These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met.<BR/>Findings Included:<BR/>Review of Resident #8's Face Sheet, dated 02/15/23, revealed he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive lung disease, respiratory failure, obstructive sleep apnea, pneumonia, morbid obesity, type 2 diabetes, swelling of extremities, mood disorder, obsessive-compulsive disorder, schizoaffective and anxiety disorder.<BR/>Review of Resident #8's Quarterly MDS, dated [DATE] stated he was cognitively intact with a BIMS score of 15. He required extensive assistance of two staff with bed mobility, toileting, and extensive assistance of one staff with personal hygiene.<BR/>Record review of Resident #8's physician orders revealed: oxygen at 2-3 LPM via nasal cannula continuous for dyspnea/low 02 sats with a date to start 11/10/2022. <BR/>Record review of Resident #8's Comprehensive Care Plan, dated 02/08/2022 revealed that Resident #8 required oxygen therapy R/T low O2 sats with a goal that included resident will not exhibit signs of hypoxia . via express the importance of keeping n/c in place to maintain a satisfactory O2 sat, administer oxygen at 2-3 LPM via N/C .<BR/>In an observation of Resident #8 on 02/14/2023 at 11:30 a.m., revealed him resting in bed with his oxygen concentrator turned on to 3 LPM. Resident #8's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present.<BR/>In an observation and interview with the Housekeeping Supervisor on 02/14/2023 at 11:41 a.m., she was observed bent over inspecting Resident #8's oxygen concentrator filters. She removed the filters from the device and stated they were dirty. She stated she was responsible for cleaning resident oxygen concentrator filters once per week but must have missed it the last time. She stated if resident oxygen concentrator filters become dirty, it clogs up [the concentrator] and they won't run, and then dust gets into resident lungs.<BR/>In an interview with ADON C on 02/16/2023 at 11:08 a.m., she stated that she expected the nurses to take a look at the machine and double check it, but it was housekeeping's responsibility to clean the filters once a week. She stated she was not sure if there was a specific policy on oxygen concentrator filters. She stated that if the oxygen concentrator filters are dirty, it was an infection control issue.<BR/>In an interview with the DON on 02/16/2023 at 11:13 a.m., she stated she expected the nurses to check the entire concentrator when they check the [oxygen] tubing, when the tubing gets changed out once weekly. She stated it was housekeeping responsibility to ensure the oxygen concentrator filters were clean. She stated she was not sure if there was a specific policy on oxygen concentrator filters. She stated if the oxygen concentrator filters are dirty, a fire can occur and the air the resident is inhaling would not be clean which would be an infection control issue. <BR/>In an interview with the Administrator on 02/16/2023 at 1:13 p.m., he stated his expectation was for oxygen concentrator filters be cleaned weekly by the housekeeping staff. He expected the filters to be free of sediment and dust. Stated if this was not performed, he stated he assumed it could affect the way the concentrator runs.<BR/>Review of facility policy, Oxygen Therapy, undated, revealed Policy: 1. To provide quality nursing care by implementing oxygen therapy . per physician's order and implemented by a licensed nurse. Objectives: 1. To administer oxygen under conditions in which insufficient oxygen is carried by the blood to the tissues . Procedure: 10. Discard masks, cannulas, and tubing . when it has become soiled. Change cannulas and humidifier bottles weekly. <BR/>Review of facility policy, Infection Control Program, undated, , revealed Standard: There will be an active, facility-wide Infection Control Program with effective measures to identify, control, and prevent infections acquired or brought into the facility from the community or other health care facilities.

F-812<BR/>Based on observation, interview, and record review, the facility failed to store, prepare, and serve<BR/>food in accordance with professional standards for food safety in 1 of 1 kitchens reviewed. <BR/>1.The facility failed to ensure food located in the facility only kitchen refrigerator, dry food pantry, and prep areas were labeled and dated. <BR/>2.The facility failed to ensure that the dishing machine operating at the appropriate temperature for sanitation of the dishes.<BR/>3.The facility failed to ensure that staff covered used head and beard covering while conducting dietary duties.<BR/>4. The Faility failed to ensure dietary staff doffed used gloves when leaving the kitchen and donned new gloves when re-entereing the kitchen <BR/>5. The facility failed to ensure that the stove burners were clean and free of build up from oil, crumbs, waisted The facility failed to ensure the container for the tea covered and free of air borne substances.<BR/>These failures could place residents at risk to bacteria, and other infectious illness.<BR/>Findings include:<BR/>During the initial tour of the facility's only kitchen revealed the DM wear a hat with the back of his head uncovered exposing short hair. He not wearing a beard covering at the time of entrance. DM later doffed a beard restraint, however it did not cover the full beard. <BR/>In an observation of the kitchen's refrigerator on 02/14/2023 at 10:00 A M. revealed the following food items undated <BR/>2 boxes filled with green leafy lettuce.<BR/>1 box of whole pineapples<BR/>1 box of cantaloupe (5) <BR/>1 box of honey dew melon (5)<BR/>3 half-filled pitchers of beverages (lemonade, tea, cranberry juice) stored on a serving tray undated.<BR/>2 boxes of margarine<BR/>Observation of the facility kitchen on 02/14/2023 at 10:05 A M. revealed , Dietary aide left the serving scoop in the bowl of pineapples to conduct another task. <BR/>Dietary aide observed walking down the hall with disposable gloves on, opening kitchen door and returning to task, left the kitchen with gloves on, walked down the hall touched door handle of and returned to task in kitchen.<BR/>Kitchen burners were observed with a build up from grime, oil, crumbs, food particles.<BR/>5 gallon iced tea dispenser not covered or sealed from environment. <BR/>An observation of DW/CK on 02/14/2023 at 9:28 AM revealed the task of dishes being cleaned in the dish washer. The DW/CK not wearing a hair net, and the sides of his beards were exposed on the sides. <BR/>An observation on 02/14/2023 at 9:32 A.M. revealed a dishwasher temperature of 115.1 The dishwasher temperature after the second cycle revealed a temperature of 117.6. The dishwasher temperature after the third cycle revealed a temperature of 122. <BR/>In an interview with the DM on 02/14/2023 at 9:34 AM revealed that the machine was a low temp sanitation machine that reached 120 sanitation temp for clean sanitized dishes. DM will have the MD to come assess the operations of the machine. DM stated that the machine serviced in January 2023. <BR/>An observation on 02/15/2023 at 11:37 a.m. of the dry storage room revealed the following items were stored undated: Large Square Clear Containers containing equal, Splenda, mayo, grape jelly, ketchup salt, pepper, crackers, ranch dressing, oatmeal pies, food coloring (egg color) and green<BR/>Observation of food prep area for seasoning revealed the following were undated. 16 oz. containers of basil leaves, curry powder, ground cinnamon, ground thyme leaves, mild chili powder, paprika, rubbed sage. <BR/>In an interview with DW/CK 02/14/2023 at 9:25 A M., he was responsible for cleaning dishes, food Prep he does do the cooking. DW/CK stated that normally he will run the dishwashing machine 3 times before the temp registers. He stated that failing to wash the dishes at the appropriate temp could lead to cross contamination, germs and bacteria. He stated that they have received training on beard that they should cover the full beard to prevent hair from getting in the dishes. The dish machine should be on 120 to properly sanitize. He does watch the aide for sanitation. He stated that there a communication gap. Communication for diet changes and they do not receive timely communication. He stated that another DA' cleans daily. He stated that the expectation of his aides were know their job and do their job. Kitchen garbage cans should be covered to prevent cross contamination, but I don't see why? He stated that he does not understand why the seasoning has to be dated. He stated that seasonings doesn't go bad. He stated that the seasoning does not check the expiration date on the seasoning. sanitation for garbage can to keep a top on it.<BR/>In an interview with DA-B on 02/16/2023 at 8:28AM revealed that all staff should wash hands in the kitchen with the change of every task, and wear hair nets while working in the kitchen to prevent the hair from falling in the food and surfaces. DA-B said gloves should be worn when preparing food. DA stated that practicing good handwashing prevents infection and illness for residents. DA-B stated that when preparing food she checks the dates, to know when they expire and discard when the date expires.<BR/>In an interview with DA-C on 02/16/23 at 11:22 AM revealed that she trained to h her hands when changing task and before doffing gloves and after doffing gloves to prevent contamination. DA stated that she has left the scoop in the pineapples for a minute. She said that leaving for a long time could cause contamination. DA said that the garbage can should be covered at all times to prevent cross contamination. <BR/>In an Interview on 02/16/23 at 11:45 AM with DON revealed that she expects dietary staff to practice good food sanitization by washing hands, when changing task. <BR/> Interview second interview with DM on 02/16/2023 at 1:40 PM, revealed that he expects the staff to wear gloves to prepare the food and handwash and change gloves in between cleaning and preparing. He said it was not appropriate for staff to wear same gloves when leaving and re-entering the kitchen, nor leave food scoops in food as it could cause cross contamination. DM said that he has cleaned the stove and has to be sprayed and stove 3 months ago. He has not had the time with staff shortages to clean. It is important to cover the beard Bread, stove, hair nets, beard restraint.<BR/>In an interview with [NAME] S. on 2/16/2023 at 3:00 PM, he said the stove cleaned every shift. [NAME] S stated that it difficult to clean with the cooking duties that are required. [NAME] S said the fire (pilot light) on and it too hot to clean. [NAME] S said that no matter when they clean it, it looks the same. [NAME] S said she encourages the staff to h their hands when they change tasks and wear gloves. [NAME] S has not educated the staff on the importance of utensil sanitation and removing bacteria from food. She stated that everything that comes must be dated and discarded in 3 days. [NAME] S. stated that they date the plastic where it can She denies that the food fully warm during her shifts. She stated that some residents have complained of the food being cold from sitting in the hall until the aides serve. Physically and verbally, she stated that it is not appropriate for kitchen staff to wear the gloves when they leave and return to the kitchen. She has dishwashers, and unless there was a problem with the temperature, she does not check. In the event this occur she will contact the DM, and he makes the report. She's been here for six months. The dishwasher should be set to 120 degrees Fahrenheit. <BR/>In an interview with Administrator 02/16/2023 said he expects the food to be dated upon delivery and expiration dates routinely checked. It is important for dietary staff to date food to prevent food from being used for residents that was old. He stated that the stove has been cleaned. He has contracted outside resources that trained dietary staff and the chef. <BR/>1.The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.<BR/>2.Dishwashing machines must be operated using the following specifications:<BR/>High-Temperature Dishwasher (Heat Sanitization)<BR/>1.Wash temperature (150&deg;- 165&deg;F) for at least forty-five (45) seconds;<BR/>2.Rinse temperature (165&deg;- 180&deg;F for at least twelve (12) seconds.<BR/>Low-Temperature Dishwasher (Chemical Sanitization)<BR/>1.Wash temperature (120&deg;F);<BR/>2.Final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds.

**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 #9) of five residents observed for infection control. <BR/>1. The facility failed to ensure LVN Q performed hand hygiene before and after administration of ophthalmic medications for Resident #9 on 02/14/2023. <BR/>This failure placed residents at risk of cross-contamination and infections.<BR/>Findings Included:<BR/>Review of Resident #9's Quarterly MDS, dated [DATE] stated she was severely cognitively impaired with a BIMS score of 05. Resident #9 was totally dependent on one staff member for bed mobility, toileting, and personal hygiene. <BR/>Record review of Resident #9's physician orders revealed Macrobid (nitrofurantoin monohyd/m-cryst) 50 mg capsule twice a day for urinary tract infection to start 10/20/2022. Additionally, Resident #119 had an order for Artificial Tears . ophthalmic (eye) . 1 drop in each eye . for dry eye syndrome . to start 10/11/2022. <BR/>In observation of LVN Q on 02/14/2023 at 9:30 a.m., she was observed on the 400 hallway at her medication cart looking at the computer. LVN Q touched the computer mouse and keyboard with ungloved hands. At 9:32 a.m., LVN Q entered room [ROOM NUMBER] with medications in her ungloved hands and placed the medications on Resident #9's bedside table. LVN Q failed to perform hand hygiene upon entering resident room and prior to providing direct care. LVN Q raised Resident #9's head of bed by touching the control panel attached to the bed. LVN Q then obtained Resident #9's hearing aids and placed them in the resident's ears. LVN Q failed to perform hand hygiene prior to touching the resident's control panel and hearing aids. LVN Q then administered Resident #9's oral medications. At 9:36 a.m., LVN Q obtained Artificial Tears box, opened box, and opened medication. Then, LVN Q raised Resident #9's right eyelid with her left thumb and administered one drop of medication into Resident #9's right eye. LVN Q then raised Resident #9's left eyelid with her left thumb and administered one drop of medication into Resident's left eye. LVN Q failed to perform hand hygiene before administering Resident #9's eye medication. LVN Q then assisted Resident #9 to rotate on her left side and applied a lidocaine patch to her upper right back area. LVN Q failed to perform hand hygiene after administering eye medications and prior to the application of a lidocaine patch. <BR/>Review of facility policy, Hand Washing, 2001, revealed Policy: 1. All personnel are required to wash their hands before and after each direct contact for which hand washing is indicated by accepted professional practice . 2. Before and after resident contact 3. After contact with a source of microorganisms ( . bodily fluids, mucous membranes .)<BR/>Review of facility policy, Passing Medications, undated, received 02/16/2023, Eye Medications: When administering eye medication, the hands should always be washed both before and after the medication is applied . Hand Washing During Medication Pass: 3. Hands should be washed before and after giving eye medications. During this process hands are very close to the resident's mucous membranes which may be both a source and recipient of microorganisms as the eye medication is instilled.<BR/>Review of facility policy, Infection Control Program, undated, received 02/16/2023, revealed Standard: There will be an active, facility-wide Infection Control Program with effective measures to identify, control, and prevent infections acquired or brought into the facility from the community or other health care facilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop a care plan with measurable goals, and interventions to address the care and treatment for a resident with dementia for 1 of 6 residents (Resident #45) reviewed for Care Plans. <BR/>The facility failed to ensure Resident #45's Dementia was care planned. <BR/>This failure could place residents at risk of needs not being met. <BR/>Findings include:<BR/>Review of Resident #45's face sheet dated 02/15/2023 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included psychotic disturbance (Delusions), Dementia (Memory Impaired), Mood Disturbance (Depression), and Anxiety (Nervousness).<BR/>Review of Resident #45's Minimum Data Set (MDS) dated [DATE], revealed a Care Area triggered for Resident #45 was Dementia. <BR/>Review of Resident #45's Care Plan dated 02/15/2023, revealed the resident's last Quarterly Assessment was completed 11/23/2022. <BR/>Interview on 02/15/23 at 1:35 PM with the DON revealed the resident was receiving care for Dementia. She was asked if this should be care-planned and she said it should be. She stated the MDS coordinator may not have gotten around to updating her care plan. She was shown the date the Care plan was established (February 25, 2022), and she stated the resident's diagnosis of dementia should have been care planned when she was initially admitted to the facility. She stated she was unsure why the resident's dementia care was not initially care planned. She stated the risk to the resident not having an accurate Care plan, could result in the resident missing out on receiving the required individualized care.<BR/>Interview on 02/15/23 at 1:51 PM with MDS Coordinator B revealed she was the MDS coordinator for Resident #45. MDS Coordinator B said Resident #45 had a medical diagnosis of dementia and said it should be care-planned, but it was overlooked. She said the last time the resident's Care Plan was reviewed was reviewed 02/12/23. She stated the risk to the resident not having an accurate care plan is she may miss out on receiving proper care.<BR/>Interview on 02/16/23 at 1:25 PM with the Administrator revealed he was made aware the Care Plan for Resident #45 did not address her Dementia. He advised that the resident's medical diagnosis for Dementia should have been care planned. He advised that the risk to Resident #45 not having her Dementia care planned could result in the resident not receiving proper care.<BR/>Review of the facility's policy on Care Planning/Interdisciplinary Team, dated September 2013, revealed The Care Plan is based on the resident's comprehensive assessment and developed by a Care Planning/Interdisciplinary Team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop a care plan with measurable goals, and interventions to address the care and treatment for a resident with dementia for 1 of 6 residents (Resident #45) reviewed for Care Plans. <BR/>The facility failed to ensure Resident #45's Dementia was care planned. <BR/>This failure could place residents at risk of needs not being met. <BR/>Findings include:<BR/>Review of Resident #45's face sheet dated 02/15/2023 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included psychotic disturbance (Delusions), Dementia (Memory Impaired), Mood Disturbance (Depression), and Anxiety (Nervousness).<BR/>Review of Resident #45's Minimum Data Set (MDS) dated [DATE], revealed a Care Area triggered for Resident #45 was Dementia. <BR/>Review of Resident #45's Care Plan dated 02/15/2023, revealed the resident's last Quarterly Assessment was completed 11/23/2022. <BR/>Interview on 02/15/23 at 1:35 PM with the DON revealed the resident was receiving care for Dementia. She was asked if this should be care-planned and she said it should be. She stated the MDS coordinator may not have gotten around to updating her care plan. She was shown the date the Care plan was established (February 25, 2022), and she stated the resident's diagnosis of dementia should have been care planned when she was initially admitted to the facility. She stated she was unsure why the resident's dementia care was not initially care planned. She stated the risk to the resident not having an accurate Care plan, could result in the resident missing out on receiving the required individualized care.<BR/>Interview on 02/15/23 at 1:51 PM with MDS Coordinator B revealed she was the MDS coordinator for Resident #45. MDS Coordinator B said Resident #45 had a medical diagnosis of dementia and said it should be care-planned, but it was overlooked. She said the last time the resident's Care Plan was reviewed was reviewed 02/12/23. She stated the risk to the resident not having an accurate care plan is she may miss out on receiving proper care.<BR/>Interview on 02/16/23 at 1:25 PM with the Administrator revealed he was made aware the Care Plan for Resident #45 did not address her Dementia. He advised that the resident's medical diagnosis for Dementia should have been care planned. He advised that the risk to Resident #45 not having her Dementia care planned could result in the resident not receiving proper care.<BR/>Review of the facility's policy on Care Planning/Interdisciplinary Team, dated September 2013, revealed The Care Plan is based on the resident's comprehensive assessment and developed by a Care Planning/Interdisciplinary Team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms for 1 of 6 residents (Resident #17) reviewed for physical restraints.<BR/>The facility failed to ensure Residents #17 had physician orders for the bolster pads on the mattress.<BR/>This failure could prevent the residents from moving freely in and out of their beds and not from being restrained. <BR/>Findings include:<BR/>1. Record review of Resident #17's Face Sheet, dated 05/28/25, reflected he was an [AGE] year-old male admitted on [DATE]. Relevant diagnoses included dementia (cognitive decline), and macular degeneration (loss of sight).<BR/>Record review of Resident #17's Quarterly MDS assessment, dated 04/15/25, reflected he had a BIMS score of 14 (intact cognitive response). For ADL care, it reflected the resident required total assistance.<BR/>Record review of Resident #17's physician orders, dated 05/28/25, reflected no physician orders for the bolster pads.<BR/>In an observation on 05/28/25 at 11:07 AM, Resident #17 was observed to have bolster pads on his bed. The padding was approximately 4 inches in thickness and approximately 8 inches high. The padding was positioned on both sides of the upper portion of the bed and lower portion of the bed, with a slight opening along the middle of the bed.<BR/>In an interview on 05/28/25 at 12:30 PM, LVN A stated Resident #17 had bolster pads on his bed because he was a fall risk. She stated she had checked the resident's physician orders and he did not have physician orders for the bolster pads. She stated physician orders were needed to ensure the bolster pads were not a restraint for the resident.<BR/>In an interview on 05/29/25 at 9:30 AM, the ADON stated she was made aware of Resident #17 having the bolster pads on his air mattress and not having physician orders. She stated physician orders were needed for everything that pertained to the resident and it would look like a form of a restraint for the resident. She stated the resident's family had purchased the padding for the resident. She stated the padding had been removed from the air mattress.<BR/>Record review of the facility's policy RESIDENT RESTRAINT POLICY (undated) reflected The facility does not restrain residents for any reason except for acute behavioral issues that endanger the resident, staff, or other individuals. In such cases, the resident's physician & responsible party will be contacted for an immediate plan of action. The least restrictive device will be used until the behavior subsides or until appropriate alternative placement can be made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to develop a care plan with measurable goals, and interventions to address the care and treatment for a resident with dementia for 1 of 6 residents (Resident #45) reviewed for Care Plans. <BR/>The facility failed to ensure Resident #45's Dementia was care planned. <BR/>This failure could place residents at risk of needs not being met. <BR/>Findings include:<BR/>Review of Resident #45's face sheet dated 02/15/2023 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included psychotic disturbance (Delusions), Dementia (Memory Impaired), Mood Disturbance (Depression), and Anxiety (Nervousness).<BR/>Review of Resident #45's Minimum Data Set (MDS) dated [DATE], revealed a Care Area triggered for Resident #45 was Dementia. <BR/>Review of Resident #45's Care Plan dated 02/15/2023, revealed the resident's last Quarterly Assessment was completed 11/23/2022. <BR/>Interview on 02/15/23 at 1:35 PM with the DON revealed the resident was receiving care for Dementia. She was asked if this should be care-planned and she said it should be. She stated the MDS coordinator may not have gotten around to updating her care plan. She was shown the date the Care plan was established (February 25, 2022), and she stated the resident's diagnosis of dementia should have been care planned when she was initially admitted to the facility. She stated she was unsure why the resident's dementia care was not initially care planned. She stated the risk to the resident not having an accurate Care plan, could result in the resident missing out on receiving the required individualized care.<BR/>Interview on 02/15/23 at 1:51 PM with MDS Coordinator B revealed she was the MDS coordinator for Resident #45. MDS Coordinator B said Resident #45 had a medical diagnosis of dementia and said it should be care-planned, but it was overlooked. She said the last time the resident's Care Plan was reviewed was reviewed 02/12/23. She stated the risk to the resident not having an accurate care plan is she may miss out on receiving proper care.<BR/>Interview on 02/16/23 at 1:25 PM with the Administrator revealed he was made aware the Care Plan for Resident #45 did not address her Dementia. He advised that the resident's medical diagnosis for Dementia should have been care planned. He advised that the risk to Resident #45 not having her Dementia care planned could result in the resident not receiving proper care.<BR/>Review of the facility's policy on Care Planning/Interdisciplinary Team, dated September 2013, revealed The Care Plan is based on the resident's comprehensive assessment and developed by a Care Planning/Interdisciplinary Team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents for one (400 Hall medication cart) of two medication carts.<BR/>The facility failed to ensure medications were secure on the 400 Hall medication cart.<BR/>These failures placed the residents at risk for drug diversion, drug overdose, and accidental administration of medications to the wrong resident.<BR/>Findings included:<BR/>In an observation on 02/14/2023 at 9:18 a.m., an unidentified white and blue capsule was observed in a plastic medication cup on top of the medication cart on the 400 hall. LVN Q was observed placing carbonated beverages in a refrigerator in room [ROOM NUMBER], outside of the view of the 400 Hall medication cart. At 9:19 a.m., LVN Q exited room [ROOM NUMBER] with cardboard boxes in her hands, and then disposed of the boxes. <BR/>In an interview with LVN Q on 02/14/2023 at 9:40 a.m., she stated that Resident #9's roommate hollered and she left the medication on the cart to go check on her. She stated she did not mean to leave it, and that it was not best practice. She stated that someone could walk by and take the medication. <BR/>In an interview with ADON C on 02/16/2023 at 9:48 a.m., she stated that medications should never be left out unattended. She stated that anyone could take it and an adverse medication reaction could occur. <BR/>In an interview with the DON on 02/16/2023 at 11:13 a.m., she stated that medications should never be left out unattended. She stated she does not have a specific policy on that but she re-iterated that it was best practice for medications to never be left unattended. She stated that anyone could take the medication, be consumed, and could have adverse reactions. <BR/>In an interview with the Administrator on 02/16/2023 at 1:12 p.m., he stated his expectations were for medications to never be left unattended. He stated that if medications were left unattended, someone could take them. He declined to comment any further. <BR/>The facility was given opportunities to provide additional documentation on medication storage prior to exit on 02/16/2023. No additional information, policies, procedures were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in multiple resident bedrooms for 57 (Rooms 101, 103, 104, 111, 112, 113, 114, 115, 201, 202, 205, 206, 207, 208, 209, 210, 302, 303, 304, 305, 306, 307, 309, 310, 311, 312, 313, 314, 601, 602, 604, 605, 606, 607, 609, 610, 611, 612, 701, 703, 704, 706, 707, 708, 709, 710, 801, 803, 804, 806, 807, 809, 811, 812, 813, 814, 815) of 101 resident bedrooms.<BR/>The facility failed to ensure the following multiple resident bedrooms measured at least 80 square feet per resident: Rooms 101, 103, 104, 111, 112, 113, 114, 115, 201, 202, 204, 205, 206, 207, 208, 209, 210, 302, 303, 304, 305, 306, 307, 309, 310, 311, 312, 313, 314, 601, 602, 604, 605, 606, 607, 609, 610, 611, 612, 701, 703, 704, 706, 707, 708, 709, 710, 801, 803, 804, 806, 807, 809, 811, 812, 813, 814 and 815. <BR/>This failure could at place residents at risk of not having adequate space for their personal belongings.<BR/>Findings included:<BR/>During entrance conference with the Administrator on 02/14/2023 at 9:25 a.m., he was asked to provide a list of multiple resident bedrooms with less square footage than 80 square feet per resident. The Administrator stated there had not been any room size changes since the most recent annual survey. The Administrator provided a list of bedrooms with less square footage than required on 02/15/2023, which reflected the following rooms did not have at least 80 square feet per resident, which would require a room-size waiver: Rooms 101, 103, 104, 111, 112, 113, 114, 115, 201, 202, 204, 205, 206, 207, 208, 209, 210, 302, 303, 304, 305, 306, 307, 309, 310, 311, 312, 313, 314, 601, 602, 604, 605, 606, 607, 609, 610, 611, 612, 701, 703, 704, 706, 707, 708, 709, 710, 801, 803, 804, 806, 807, 809, 811, 812, 813, 814 and 815.<BR/>Review of the waiver issued to the facility on [DATE] indicated that the following waiver was approved and would remain in effect unless conditions are found to exist that would cause reconsideration or rescission. The waiver is subject to re-evaluation at the time of each subsequent standard survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents for one (400 Hall medication cart) of two medication carts.<BR/>The facility failed to ensure medications were secure on the 400 Hall medication cart.<BR/>These failures placed the residents at risk for drug diversion, drug overdose, and accidental administration of medications to the wrong resident.<BR/>Findings included:<BR/>In an observation on 02/14/2023 at 9:18 a.m., an unidentified white and blue capsule was observed in a plastic medication cup on top of the medication cart on the 400 hall. LVN Q was observed placing carbonated beverages in a refrigerator in room [ROOM NUMBER], outside of the view of the 400 Hall medication cart. At 9:19 a.m., LVN Q exited room [ROOM NUMBER] with cardboard boxes in her hands, and then disposed of the boxes. <BR/>In an interview with LVN Q on 02/14/2023 at 9:40 a.m., she stated that Resident #9's roommate hollered and she left the medication on the cart to go check on her. She stated she did not mean to leave it, and that it was not best practice. She stated that someone could walk by and take the medication. <BR/>In an interview with ADON C on 02/16/2023 at 9:48 a.m., she stated that medications should never be left out unattended. She stated that anyone could take it and an adverse medication reaction could occur. <BR/>In an interview with the DON on 02/16/2023 at 11:13 a.m., she stated that medications should never be left out unattended. She stated she does not have a specific policy on that but she re-iterated that it was best practice for medications to never be left unattended. She stated that anyone could take the medication, be consumed, and could have adverse reactions. <BR/>In an interview with the Administrator on 02/16/2023 at 1:12 p.m., he stated his expectations were for medications to never be left unattended. He stated that if medications were left unattended, someone could take them. He declined to comment any further. <BR/>The facility was given opportunities to provide additional documentation on medication storage prior to exit on 02/16/2023. No additional information, policies, procedures were provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to ensure medications were secure and inaccessible to unauthorized staff and residents for one (400 Hall medication cart) of two medication carts.<BR/>The facility failed to ensure medications were secure on the 400 Hall medication cart.<BR/>These failures placed the residents at risk for drug diversion, drug overdose, and accidental administration of medications to the wrong resident.<BR/>Findings included:<BR/>In an observation on 02/14/2023 at 9:18 a.m., an unidentified white and blue capsule was observed in a plastic medication cup on top of the medication cart on the 400 hall. LVN Q was observed placing carbonated beverages in a refrigerator in room [ROOM NUMBER], outside of the view of the 400 Hall medication cart. At 9:19 a.m., LVN Q exited room [ROOM NUMBER] with cardboard boxes in her hands, and then disposed of the boxes. <BR/>In an interview with LVN Q on 02/14/2023 at 9:40 a.m., she stated that Resident #9's roommate hollered and she left the medication on the cart to go check on her. She stated she did not mean to leave it, and that it was not best practice. She stated that someone could walk by and take the medication. <BR/>In an interview with ADON C on 02/16/2023 at 9:48 a.m., she stated that medications should never be left out unattended. She stated that anyone could take it and an adverse medication reaction could occur. <BR/>In an interview with the DON on 02/16/2023 at 11:13 a.m., she stated that medications should never be left out unattended. She stated she does not have a specific policy on that but she re-iterated that it was best practice for medications to never be left unattended. She stated that anyone could take the medication, be consumed, and could have adverse reactions. <BR/>In an interview with the Administrator on 02/16/2023 at 1:12 p.m., he stated his expectations were for medications to never be left unattended. He stated that if medications were left unattended, someone could take them. He declined to comment any further. <BR/>The facility was given opportunities to provide additional documentation on medication storage prior to exit on 02/16/2023. No additional information, policies, procedures were provided.