Every finding on record at Effingham Care & Rehabilitation Center

Based on observation, interviews, document review and policy review, the facility failed to ensure food items were labeled and dated. In addition, the facility failed to maintain sanitary conditions when serving food and washing dishes. These deficient practices had the potential to increase the risk of cross contamination and foodborne illness for 84 residents in the facility who received food from dietary. Findings include:Observation on 02/09/2026 at 9:12AM revealed that inside the refrigerator in the kitchen on a shelf was a plastic container with no label and covered with plastic wrap. The Dietary Manager (DM) stated there was tuna salad in the container and confirmed no label was present. Observation of the freezer outside of the kitchen revealed there was no thermometer inside the freezer. The DM stated on 02/09/2026 at 9:21AM, we don't put thermometers in the freezers just the refrigerators. Interview on 02/09/2026 at 9:40AM, the DM stated that the facility's policy does indicate having a thermometer in the freezer.Observation on 02/10/2026 at 11:06 AM, revealed Dining Associate (DA) (DA1) placed a tray of three chef salads on a wire rack, near the tray line. The tray was not placed on ice or any other method to maintain the cold temperature of the chef salads. In addition, observed on the same rack was a tray that contained two bowls of hard-boiled eggs, one bowl of tuna salad and prepared chicken salad sandwiches without ice underneath the tray or other method to keep these food items cold. Observation on 02/10/2026 at 11:08AM, revealed the dishwasher (DW) was wearing gloves and in the process of loading soiled dishes on a rack. DW then pulled a rack of clean dishes from the dishwasher, without removing his gloves or performing hand hygiene. Observation of the steam table on 02/10/2026 at 11:34AM, revealed that Cook2 tested the temperature of each food item. Cook2 was observed to have a white paper towel in her left hand and after she tested a food item on the steam table, she placed the thermometer into the paper towel which removed food residue but did not sanitize the thermometer before Cook2 placed the thermometer into another food item on the steam table.Interview on 02/10/2026 at 11:34AM with DM revealed that hot foods on the steam table should be 160 degrees Fahrenheit (F) or higher and cold foods that go on the tray should be 41 degrees F. or lowerObservation on 02/10/2026 at 11:46AM, revealed that DA1 placed a chef salad on R26's tray. The DM tested the temperature of one of the remaining chef salads on the tray and the chef salad's temperature was 64 degrees F. The DM also tested the tuna salad that was on the tray, and it was 50 degrees F. Review of the chicken and tuna salad recipes dated 02/2025 provided by the Registered Dietician (RD) revealed that both recipes included the use of the ingredient mayonnaise. The RD confirmed that mayonnaise is a potentially hazardous ingredient.Interview with the RD on 2/10/2026 at 3:48PM confirmed it was her expectation that food items in the refrigerator should be labeled and dated, the dishwasher should wash hands between soiled and clean sides of the dishwasher, the cook should sanitize the thermometer between food items, cold food items that are to be served on the tray line should be maintained at 41 degrees or colder, and the blender and bowls that are clean should be allowed to air dry and be stored dry ready for use.Observation of the kitchen during the sanitation tour on 02/11/2026 at 2:38PM with the RD revealed that the blender that the RD indicated was stored clean and air dried was wet inside the blender with water dripping from the lid. In addition, three racks of bowls that the RD identified were clean and dry were stacked one on top of each other and were wet inside.Observation of the residents' refrigerator in the Activity room on 02/11/2026 at 3:21PM, revealed in the refrigerator a bottle of Hawaiian punch opened and not dated; bag of half used mozzarella shredded cheese unlabeled as to when opened; and bottle of green goddess salad dressing with no label or date it was opened. In the freezer, there were two bags of pizza rolls opened, without a label as to when opened; one box of vanilla ice cream and one tub of rainbow sherbert with no label with a date when opened. Interview with Registered Nurse (RN) (RN1) at the time of the observation revealed there was no explanation why the items were not labeled and dated when opened.Review of the facility's policy titled, Food and Supply Storage dated 01/2026 documented, Policies: All food.used in food preparation shall be stored in such a manner to prevent contamination to maintain the safety . of the food item for human consumption.Procedures: Cover, label and date unused portion and open package.Review of the facility's policy titled, Hand hygiene dated 01/2025 documented, All associates associated with the handling of food shall wash hand. at the following times: before handling food or clean utensils/dishes/equipment.Review of the facility's policy titled, Food Handling Guidelines dated 01/2026 documented, .Hot Holding Temperatures, food should be held hot for service at a temperature of 135-degree F or higher.Cold Holding Temperatures. Foods should be held cold for service at a temperature of 41 degrees F.Review of the facility's policy titled, Food Handling Guidelines dated 01/2026 documented, .Cold food preparation.Remove from refrigeration only quantities of foods that are immediately needed and can be processed in 30 minutes. Return unused prepared food to refrigeration storage.to ensure hazardous food does not exceed 45 degrees F.Review of the facility's Lesson 11 dated 11/2017 documented Keeping food thermometers clean and sanitary. These steps prevent contamination of food being checked. Clean and sanitize thermometer stems before using or storing. Sanitize between items by wiping the thermometer stem with clean sanitizer solution.Review of the facility's policy titled, Cold Storage Temperatures dated 01/2024 documented that each refrigerated storage unit shall have an independent thermometer in addition to the built-in thermometer.

Based on record review, interviews, and policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the condition and needs for three residents (R) (R9, R20 and R69) from a sample of 26 residents reviewed for MDS accuracy. The deficient practice created the potential for inaccurate and/or omitted care planning. Findings include: 1.Review of R9's electronic medical record (EMR) Face Sheet tab revealed admission date of 07/07/2022 with diagnoses including but not limited to Paranoid schizophrenia dated 09/20/2023. Review of R9's PASARR II document in the EMR under the Documents tab revealed that a PASARR II had been completed on 10/26/2023. Review of R9's annual MDS with an assessment reference date (ARD) of 06/12/2025 documented in Section A that a PASARR II was marked as no PASARR II had been completed. Interview on 02/11/2026 at 9:34AM, the MDS coordinator (MDSC) confirmed that R9's annual MDS dated [DATE] was coded incorrectly for PASARR II. 2.Review of R20's Face Sheet located under the Face Sheet tab of the EMR indicated the resident was admitted to the facility on [DATE] with diagnoses of but not limited to vascular dementia, bipolar disorder, generalized anxiety disorder, and post-traumatic stress disorder (PTSD). Review of R20's Treatment Service: PASRR Level II located under the Documents tab of the EMR was dated 06/10/2021 and revealed R20 had major depressive disorder, PTSD, and anxiety disorder. Review of R20's annual MDS located under the MDS tab of the EMR with an ARD of 02/24/2025 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 that indicated R20 had little to no cognitive impairment. The assessment documented in Section A: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was marked No. During an interview on 02/10/2026 at 11:51 AM, the MDSC reviewed R20's EMR and stated R20 did have a PASRR II. The MDSC reviewed R20's annual MDS dated [DATE] and confirmed she had completed Section A which included PASRR Level II status. The MDSC stated [R20] is not on the list of residents with PASRR Level II. Social Services normally gives me a list of all PASRR Level II residents. [R20's] MDS was marked NO in error. I missed it. I review records for new residents to check for Level II PASRR status. 3.Review of R69's Face Sheet located under the Face Sheet tab of the EMR indicated the resident was admitted to the facility on [DATE] with diagnoses of but not limited to diabetes mellitus, and generalized anxiety disorder. Review of R69's Weights located under the Vitals tab of the EMR, revealed on 07/23/2025, R69 weighed 122 pounds (lbs.) and on 12/05/2025, R69 weighed 117 lbs. which was a -4.1% loss from 07/23/2025. Review of R69's quarterly MDS located under the MDS tab of the EMR with an ARD of 01/15/2026 indicated the resident had a BIMS score of 13 out of 15 that indicated R20 had little to no cognitive impairment. The assessment documented the response to: Loss of 5% or more in the last month or loss of 10% or more in last 6 months was marked Yes, not on physician-prescribed weight-loss regimen. Review of R69's Progress Notes located under the Progress Notes tab of the EMR, revealed a progress note, dated 01/15/2026, by the Registered Dietician (RD), that stated . Weight History: 30 days: (12/5/25) 117 lbs; 180 days: (07/28/25) 137 lbs/-14.6%; [Body Mass Index] BMI: 18.39. [Ideal Body Weight] IBW / % IBW: Resident's ideal body weight range is 122-148#, at 87% IBW, mid range. Weight Trend: The resident has lost a significant amount of weight over the past 180 days. The 07/28/2025 weights documented by the RD did not match the weights documented under the Vital tab. During an interview on 02/11/2026 at 3:26 PM, the DON reviewed R69's EMR and confirmed a weight of 137 lbs. on 07/28/2025 was not found. The DON verified the weight on 07/23/2025 was 122 lbs. During an interview on 02/12/2026 at 1:10 PM, the RD reviewed R69's EMR and found that the weight of 137 for 07/28/2025 was an error and was taken from 07/28/2024. The RD stated, I made a mistake and took [the weight] from the previous year. RD confirmed the MDS was coded in error because of using the wrong date for the weight calculation. Review of the facility's policy titled, Preadmission Screening and Resident Review (PASRR) I & II, dated 03/18/2025, indicated Level II Process . Recommendations must be incorporated into: . MDS Assessment. Review of the Center for Medicare Services (CMS) Resident Assessment Instrument Manual, dated 10/2025 documented, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy [what the resident's actual status was during that observation period] by the IDT [Interdisciplinary Team] completing the assessment .

Based on observation, interviews, record review, and policy review, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for one of six residents (R) (R8) reviewed for activities. The deficient practice had the potential to affect resident physical, mental, and psychosocial well-being.Findings include: Review of R8's Face Sheet, located in the electronic medical record (EMR) under the Face Sheet tab, indicated the resident was admitted to the facility on [DATE]. The document indicated the resident's diagnoses included but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder recurrent, anxiety disorder, and vascular dementia. Review of R8's annual Minimum Data Set (MDS) Assessment, with an assessment reference date (ARD) of 01/22/2026 and located in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of eight which indicated moderate cognitive impairment. Section E: Behavior Symptoms documented there were no refusals of care. Section F: Preference for Customary Routine and Activities documented that R8 found listening to music they like very important; that it was somewhat important to be around animals such as pets, to keep up with the news, to go outside to get fresh air when the weather is good, and to do their favorite activities; and that is was not very important to have books, newspapers, and magazines to read, to participate in religious services, or to do things with groups of people. Review of R8's Comprehensive Care Plan, dated 05/18/2019 and located in the EMR under the Care Plan tab, revealed R8 had some cognitive/communication deficits as evidenced by long-term and short-term memory loss, and usually understood.need to be reminded and assisted to activities. It was documented as an intervention that staff needed to encourage R8 to participate in group activities of interest. Review of R8's Quarterly Activity Progress Note, dated 11/06/2025, located in the EMR under the Progress Note tab, revealed R8 spent time in their room due to personal choice, and that staff encourages R8 to come to the lobby area and participate.enjoys self-directed activities. Review of R8's Activities Charting Report provided by the Social Service Director/Activity Director (SSD/AD) documented R8 attended 4 group, 1 refusal, 6 self-directed activities in December 2025 and 1 group, 0 refusals,14 self-directed activities in January 2026. Review of the January 2026 Activity Calendar revealed eight Bingo events, numerous musical events and puzzle/game activities. None of these events were attended by R8, nor refused. Review of the February 2026 Activity Calendar revealed to current, four Bingo events, and numerous puzzle/game activities. None of these events were attended by R8, nor refused. During an interview with room observation on 02/09/2026 at 2:55 PM, R8 stated that she watched TV for activity and that she liked to read books, do puzzles, and listen to music. R8 stated that staff did not come around or offer them any activities. Observation of R8's room revealed the TV was on, but no radio, books, audiobooks, or puzzle books were visible or within reach of the resident. During an observation on 02/09/2026 at 3:45 PM, an activity was observed in the facility common room. Piano and church music was playing, with approximately 15 residents observed in attendance. No additional residents were observed being offered encouragement or assistance to attend the event, including R8. During additional observations on 02/10/2026 at 11:30 AM and 12:13 PM, R8 was observed resting in bed, with the TV playing. Again, there was no visible sign of a radio, books, or puzzles in sight or within reach of the resident. During an observation on 02/10/2026 beginning at 2:07 PM and again at 2:40 PM in the common room of the facility, staff and residents were interacting in small groups and at 2:49 PM the SSD/AD entered the room and shared individually with each resident the next activity to take place was making pizza. During the observation at 2:53 PM, R8 was observed in her room awake in bed with the TV playing but not being watched. During this observation on 02/10/2026 at 3:00 PM, staff began to encourage participation and offer assistance to the residents already seated at the dining room tables in the common room to participate in the pizza making activity. Observation of the two Unit Hallways revealed no other residents who remained on the hallways were notified or encouraged to attend the activity. During an observation on 02/11/2026 at 9:20 AM, R8 was again observed in bed watching TV. During an observation of the two Unit Hallways on 02/11/2026 from 9:22 AM until 9:35 AM, revealed no residents who were on the hallways were notified or encouraged to attend the activity in the facility common room. At 9:41 AM, two residents were observed on the far side of the common room participating in an activity with an Activity Assistant (AA.) During an observation on 02/11/2026 at 2:17 PM, residents were observed going to the facility common room for bingo. No staff were observed going down either of the two Unit Hallways to invite anyone to the activity. At 2:35 PM, there were thirteen residents and three staff members playing bingo. During an interview on 02/11/2026 at 2:39 PM, R8 stated that no one invited her to any activities, including BINGO. R8 stated that no one allowed them to decide for themselves if they wanted to attend an activity or not. R8 again confirmed that they enjoyed reading books and stated that no one had offered books. A concurrent interview was conducted on 02/12/2026 at 11:22 AM with SSD/AD, AA1, and AA2. AA1 stated they go down the facility hallways to let the residents know about the activities of the day about 30 minutes before the activity is scheduled. AA1 stated they see who wanted to participate and assist with transporting those who do desire to attend. AA2 stated they do one-on-one visits for residents that do not come out of their rooms. SSD/AD added that the activity department had word searches, adult coloring, i-pods with music, and library books that residents can keep in the activity room or their personal room. SSD/AD stated she was unaware R8 liked books. During an interview on 02/12/2025 at 3:12 PM, the Director of Nursing stated that care plans were a big focus. She said that activities help create a quality of life that can help make it the best it can be. The Director of Nursing stated that she wanted activities to be improved across the facility. Review of the facility's policy titled, Activities, last reviewed 02/07/2026, indicated 1. The facility's activity program is designed to meet the interests and address the physical, mental, and psychosocial needs of each resident.4. Activities will include both individualized and group activities.Activities should represent a wide range of interests and abilities and include opportunities for socialization, exercise and physical activity, games, crafts, music, cooking, intellectual activities, religious activities, and pursuit of individual interests.(a) Residents may choose from the variety of activities offered at the facility and are encouraged to recommend activities individually.The Activity Coordinator is responsible for working with residents to determine which activities each resident prefers and to include each resident in planned, individual, and/or small group activities as preferred or as appropriate for the resident. (b) Residents who are unable or uninterested in group activities should be provided activities that meet their interests and ability levels and provide time for personal interchange between the Activity Coordinator or designee and the resident. (c) Reading materials, books on tape, music, and videos/DVDs, art supplies, and current events materials should be accessible to residents who prefer independent activities.5. (c) The resident's activity plans should be based on the resident's interests and abilities and should be updated as necessary. (d) Group activities should be announced over the intercom, and the nursing staff should help remind residents of opportunities for activities.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident received assistance with toenail care by podiatry (a medical specialty that focuses on feet, ankles and legs) as ordered by the physician for one of four residents (R) (R4) reviewed for Activities of Daily Living (ADL) care. The deficient practice increased the risk of clinical complications of the feet.Findings include:Review of R84's Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) indicated the resident was admitted to the facility on [DATE] with diagnoses of but not limited to diabetes mellitus with diabetic neuropathy and primary osteoarthritis of both ankles and feet. Review of R84's annual Minimum Data Set (MDS) located under the RAI tab of the EMR with an Assessment Reference Date (ARD) of 12/18/2025 documented the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 that indicated moderate cognitive impairment.Review of R84's Care plan located under the Care Plan tab of the EMR, dated 10/21/2024, revealed R84 was at risk of diabetic foot ulcer/injury with a goal that she would be free of diabetic foot complications and there was no specific intervention for toenail care or a podiatry consult. During an interview and observation on 02/09/2026 at 12:00 PM, R84 stated she has diabetes and that the podiatrist doesn't see her when he comes. R84's toenails were observed to be long, thick, and discolored and caused her discomfort. During an observation on 02/11/2026 at 4:49 PM, Licensed Practical Nurse (LPN) (LPN3) confirmed R84's toenails were long, thick, and discolored.Review of R84's Progress Notes located under the Progress Notes tab of the EMR, from 07/01/2024 to present, failed to reveal any documentation regarding podiatry care. Review of a Consult note located under the Documents tab of the EMR, dated 06/19/2024 from a podiatrist, documented Manually debrided nails bilaterally in length and thickness with manual nail clipper and electric file. Patient noted pain relief upon completion of nail debridements. No bloody exposure was noted upon the completion of the procedure. Follow up: 3 months (reason: routine food care) Review of a Attending Physician Request for Services and/or Consultation located under the Documents tab of the EMR revealed a podiatry referral dated 01/14/2026, documented, Please have the [podiatrist] evaluate and treat thick nails and perform general foot care evaluation to prevent pain, ulcers, infection, and circulatory problems. During an interview on 02/11/2026 at 4:07 PM, Certified Nursing Assistant/Unit Clerk (CNA/UC) (CNA/UC2) stated a follow-up appointment from 06/19/2024 should have been scheduled for three (3) months per the visit follow-up instructions. We do not need to wait for new referral from the physician. During an interview on 02/11/2026 at 4:47 PM, CNA2/UC stated she was unable to locate documentation that R84 had a follow-up appointment. A new referral for the in-house podiatrist was submitted on 01/14/2026 but not yet scheduled. I don't know when that doctor will start seeing residents. During an interview on 02/11/2026 at 5:02 PM, the Director of Nursing (DON) stated [R84]should have been seen by the podiatrist. [R84] was not seen by the podiatrist as ordered. Diabetic residents should be seen for diabetic footcare every 91 days. During an interview on 02/12/2026 at 12:49 PM, the Medical Director stated Diabetic residents should be examined by a physician for diabetic foot care at least annually but no specific frequency. Any physician can perform nail care.Review of the facility's policy titled, Personal Care- Foot Care dated 02/07/2026, documented Residents with diabetes and peripheral vascular disease will not have their toenails trimmed by a CNA. The attending physician will determine the need for referral to a podiatrist.

Based on record review, interview, and facility policy review, the facility failed to arrange dental services regarding poorly fitted dentures for one resident (R) (R20) reviewed for dental services from a sample of 20 residents. This deficient practice had the potential for adverse oral health and diminished nutrition.Findings include:Review of R20's Face Sheet located under the Face Sheet tab of the Electronic Medical Record (EMR) indicated the resident was admitted to the facility on [DATE] with diagnoses of but not limited to vascular dementia, bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder (PTSD), Iron deficiency anemia, peripheral vascular disease, and diabetes mellitus.Review of R20's Care Plan located under the Care Plan tab of the EMR, dated 03/06/2025, revealed R20 was dependent on staff for activities of daily living (ADL) due to impaired mobility and for oral care and had full upper dentures and bottom partial with two natural teeth on bottom. Review of R20's Progress Notes located under the Progress Notes tab of the EMR, dated 08/21/2025 at 1:10 PM, by the Registered Dietician (RD) documented Resident can feed self with set up, has teeth missing and partials, teeth on bottom are in poor condition, no teeth on top. Resident reports that her dentures do not fit well and she would like a dentist to see her.Further review of R20's Progress Notes located under the Progress Notes tab of the EMR, dated 11/20/2025 at 12:42 PM, by the RD stated . Resident can feed self with set up, has teeth missing and partials, teeth on bottom are in poor condition, no teeth on top. Dental consult pending. Review of a Dietician/Nursing/Physician Communication Form, located under the Documents tab of the EMR, dated 08/27/2025, revealed Resident requesting to see dentist due to trouble with dentures. Recommend: Dental consult if medically appropriate. Please schedule dental eval.During an interview on 02/09/2026 at 4:09 PM, R20 stated her dentures hurt her gums due to being flat from sitting in the cup. R20 stated she had been put on the list to see the dentist for dentures and hadn't seen the dentist since she was admitted to the facility.During an interview on 02/10/2026 at 1:28 PM, the Social Services Director/Activity Director (SSD/AD) stated, I schedule dental consults for resident requests. R20 came from another facility with mobile services. Mobile dental was seeing her at the other facility and thought she was still over there. Mobile dental come monthly and provides facility with list of residents that they will see during that visit. The SSD/AD reviewed EMR and stated I reached out to mobile dental on 09/02/2025. Mobile dental responded on 09/03/2025 that they would need to re-enroll her. They have not indicated when they plan to see her. Review of the Mobile Dental Enrollment Paperwork provided by the SSD/AD, revealed R20 was not re-enrolled until 02/10/2026.During an interview on 02/10/2026 at 1:42 PM, the Director of Nursing (DON) stated the expectation was that residents should be seen on the next visit after a dental referral. If the resident was not seen, there should be documentation in the EMR with the reason why.Review of the facility's policy titled, Dental Services, dated 03/26/2025, documented It shall be the policy of [facility name] to assist in making arrangements for dental services for the residents. Dental services will be arranged for emergency/requested services for the dentist designated by the resident, or if the resident has no personal dentist, arrangements will be assisted through the Social Service Coordinator.

Based on observation, interview and record review, the facility failed to ensure that the emergency call light system in resident bathrooms were functioning properly for four of eight resident bathrooms (Rooms 322/324, 318/320, 313/315, and 311) on the secured memory unit. Findings include: On 9/23/22 at 10:36 a.m., the call light for the conjoined resident bathroom in Room 322/324 was tested . When pulled, the call system did not activate. Certified Nursing Assistant (CNA) AA confirmed that the call light was not functioning. On 9/23/22 at 10:45 a.m., the call light for the conjoined resident bathroom in Room 318/320 was tested . When pulled, the call system did not activate. CNA AA confirmed that the call light was not functioning. On 9/23/22 at 10:48 a.m., the call light for the conjoined resident bathroom in Room 313/315 was tested . When pulled, the call system did not activate. CNA AA confirmed that the call light was not functioning. On 9/23/22 at 10:50 a.m., the call light in the resident bathroom was tested in Room 311. When pulled, the call system did not activate. CNA AA confirmed that the call light was not functioning. During an interview on 9/23/22 at 11:04 a.m., the Safety Officer stated that the maintenance director was out, and he is covering in their absence. He stated that they do daily audits by choosing three rooms a day on each hall to check for maintenance issues and that is to include ensuring the bathroom call light function properly. He confirmed that the cords were too tight and were not functioning as intended in the resident bathrooms (Rooms 322/324, 318/320, 313/315, and 311). During an interview on 9/25/22 at 11:30 a.m., the Administrator, she stated that the expectation is that the call light cords should not be hard to pull to activate the system. She stated that she discussed with maintenance for them to routinely treat the bathroom call light cords during routine rounds to ensure that they do not become too hard to pull to activate the system. A review of the Nursing Call System dated 3/30/22 revealed that it is the policy of (the facility) to have an established nursing call system to ensure that residents can effectively communicate their needs timely.

Based on record review and staff interview, the facility failed to follow the plan of care for Resident (R)#60 who had an intervention for staff to keep her bed in the lowest position. This failure to keep her bed in the lowest position resulted in harm for R#60 when she rolled off her high bed onto the floor and sustained a [MEDICAL CONDITION]. Additionally, the facility failed to follow the plan of care for one resident (R)(R#60) who had interventions for Certified Nursing Assistants (CNA) to check the skin during am/pm care and for Licensed nurses to monitor her skin weekly. The sample size was 26 residents. Findings include: 1. Review of a Nurses' Note dated 3/21/18 at 4:36 a.m. revealed that at approximately 12:00 a.m., R#60 was found kneeling on the floor with her torso on the bed. She told staff at that time that she did not know how she got on the floor but, that she must have rolled off the bed. The resident sustained [REDACTED]. Review of the revised care plan for R#60 dated 3/21/18 revealed that the resident was at risk for falls due to her history of falls prior to admission, impaired balance, dementia with forgetfulness and confusion with a new intervention to keep the bed in the lowest position. Review of the Nurses' Note dated 6/1/18 at 6:44 a.m. revealed that R#60 was found on the floor between the bed and her recliner. Review of the Nurses' Note dated 6/1/18 at 1:13 p.m. revealed that R#60 complained of pain. The physician was notified and ordered an x-ray and subsequent CT scan which showed that the resident had an acute subcapital left femoral neck (hip) fracture. Interview with the Director of Nursing (DON) on 8/15/18 at 12:32 p.m. revealed that during her investigation of the 6/1/18 fall, Certified Nursing Assistant (CNA) AA told her that she had left R#60 in the bed after providing care to check on a resident in another room. Continued interview revealed that CNA AA had left the resident's bed in a high position at that time because the resident did not move around much in the bed. The DON stated that the resident rolled out of the high bed and onto the floor sustaining a left [MEDICAL CONDITION]. Continued interview revealed that CNA AA was terminated for failure to follow safety policy and the resident's care plan to keep her bed in the lowest position. Continued interview revealed that she expected staff to maintain the resident's bed in a low position as care planned for safety. Cross refer to F689 2. R#60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 3/7/17 revealed that R#60 was at risk for pressure sores due to her decreased activity, chairfast status most of the time and admission with pressure sores with an intervention for Certified Nursing Assistants (CNAs) to monitor her skin with am/pm care and report any reddened, irritated or open areas. There was also an intervention for nursing to monitor her skin weekly. Although R#60 had a care plan intervention since 3/2/17 for nursing staff to provide weekly skin checks, review of the facility Skin Forms revealed that Licensed Nursing staff failed to check the resident's skin weekly in 7/2018. Review of the last Skin Form dated 6/29/18 revealed that Licensed Nursing Staff assessed the resident and noted that she had [DIAGNOSES REDACTED] on her feet but no pressure sore at that time. There was no indication that Licensed Nursing Staff assessed the resident's skin weekly after 6/29/18. Review of the 7/6/18 Skin Assessment completed by Certified Nursing Staff revealed that the resident had a sore on her foot and that A&D ointment (utilized to protect the skin from moisture) was applied. However, there was no indication that the CNA notified the nurse about the sore at that time. There was no indication that Certified Nursing staff assessed the resident's skin after 7/6/18. Review of the Nurses' Note dated 7/26/18 at 2:03 p.m. revealed that an unstageable pressure sore measuring 1 centimeter (cm.) by 1 cm. was identified on the resident's left medial foot. Continued review revealed that the wound bed was covered by tan slough. There was no drainage or odor. The Nurse Practitioner was notified and ordered staff to cleanse the pressure sore with normal saline, apply [MEDICATION NAME] and cover with a dry dressing every day and as needed. Interview with the Director of Nursing (DON) on 8/16/18 at 12:10 p.m. revealed that the CNAs were responsible for assessing a resident's skin daily during care for any skin changes and notifying the nurse about those changes as care planned. Continued interview revealed that Licensed Nursing staff were responsible for assessing a resident's skin weekly for any changes as care planned so that any breakdown could be identified early and treatment obtained timely. Cross refer to F686

Based on record review, review of the facility's Falls Assessment and Prevention Policy and staff interview, the facility failed to ensure that Certified Nursing Staff lowered the bed to a low position for one (1) resident (R) (R#60) of three (3) residents reviewed for falls from a sample of 26 residents. This failure to lower the bed to a low position resulted in harm for R#60 when she rolled off the high bed onto the floor and sustained a left [MEDICAL CONDITION]. Findings include: Review of the facility's Falls Assessment and Prevention Policy revealed that residents at risk for falls will have interventions to minimize the occurrence of falls that include making sure that bed is at the safest and most functional height possible for each resident. Resident #60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 9 indicating that she had some cognitive impairment. Continued review revealed that she was non-ambulatory, required extensive assistance of two staff for bed mobility and had one fall with injury since her prior MDS on 1/18/18. Review of the resident's care plan dated 3/2/17 revealed that the resident was at risk for falls due to her history of falls prior to admission, impaired balance, dementia with forgetfulness and confusion. The care plan had appropriate interventions to prevent falls. Review of the Nurses' Note dated 11/11/17 at 3:29 p.m. revealed that at 2:00 p.m. R#60 was found on the floor in front of her wheelchair. She stated at that time that she was attempting to get up to go to the bathroom and fell face first onto the floor. The resident sustained [REDACTED]. The physician was notified and R#60 was sent to the emergency room (ER). An x-ray of her right arm showed that she had a right radial head (elbow) fracture. Review of the resident's care plan revealed that staff revised it to include a new intervention for a tab alarm. Review of the Nurses' Note dated 3/21/18 at 4:36 a.m. revealed that at approximately 12:00 a.m. R#60 was found kneeling on the floor with her torso on the bed. She told staff at that time that she did not know how she got on the floor but, that she must have rolled off the bed. The resident sustained [REDACTED]. Staff revised her care plan with a new intervention to keep the bed in a low position. Review of the Nurses' Note dated 6/1/18 at 6:44 a.m. revealed that R#60 was found on the floor between the bed and her recliner. Continued review of the Nurses' Note revealed that after returning the resident to bed, staff lowered the bed to the lowest position and placed the call light in reach of the resident. The nurse assessed the resident noting redness to the rim of her L (left) ear as well as the L-shoulder. No additional redness or bruising was noted to any other area of her body. The Nurse Practitioner was notified and ordered staff to monitor the resident. Review of the Nurses' Note dated 6/1/18 at 1:13 p.m. revealed that R#60 complained of pain. The physician was notified and ordered an x-ray and subsequent CT (Computer Tomography) scan which showed that the resident had an acute subcapital left femoral neck (hip) fracture. Review of the care plan revealed that staff did not revise it to include a new intervention after this fall. Interview with the Director of Nursing (DON) on 8/15/18 at 12:32 p.m. revealed that during her investigation of the 6/1/18 fall, Certified Nursing Assistant (CNA) AA told her that she had left R#60 in the bed after providing care to check on a resident in another room. Continued interview revealed that CNA AA had left the resident's bed in a high position at that time because the resident did not move around much in the bed. The DON stated that the resident rolled out of the high bed and onto the floor sustaining a left [MEDICAL CONDITION]. Continued interview revealed that CNA AA was terminated for failure to follow safety policy and the resident's care plan to keep her bed in the lowest position. Continued interview revealed that she expected staff to maintain the resident's bed in a low position as care planned for safety. Review of the Statement of Events/Incident form dated 6/1/18 revealed that the nurse who assessed R#60 after her fall documented that the resident's bed was at waist or hip level at the time of the fall. Review of the In-service Log revealed that 18 staff attended an in-service on Fall Management and Risk on 2/6/18. However, review of the sign-in sheet revealed that CNA AA had not attended the in-service. There was no indication that staff were in-serviced on fall prevention after 2/6/18. Observation on 8/13/18 at 3:44 p.m., 8/14/18 at 12:12 p.m., 8/15/18 at 1:17 p.m. and at 1:35 p.m. revealed the resident in bed with the bed in the lowest position. The resident was not observed to attempt to get out of bed. Interview with CNA BB on 8/15/18 at 2:09 p.m. revealed that she was aware that R#60 was at risk for falls and that she ensured that the resident was positioned in the center of the bed so she did not roll off the bed. Continued interview revealed that she also ensured the bed was maintained in the lowest position. Interview with Licensed Practical Nurse (LPN) CC on 8/16/18 at 8:18 a.m. revealed that she ensured that interventions were in place to prevent falls during her two hour checks on the residents. Interview with the DON on 8/16/18 at 10:30 a.m. revealed that the resident's bed was not in a high position at the time of the 3/21/18 fall. Continued interview revealed that staff's review of the care plan after that fall revealed that the intervention keep bed in low position was not on the care plan at that time so it was added at that time. The facility failed to ensure that Certified Nursing staff maintained the resident's bed in the low position at all times which resulted in the resident rolling off the high bed onto the floor and sustaining a left [MEDICAL CONDITION].

Based on record review, review of the facility policy titled Skin Care and staff interview, the facility failed to identify a pressure sore timely for one (1) resident (R) (R#60) of 26 sampled residents. Findings include: R#60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Date Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating that she was cognitively impaired. Continued review revealed that the resident required total assistance of staff for bed mobility and eating, was non-ambulatory, had a fall with major injury and was at risk for pressure sores. Review of the resident's care plan dated 3/7/17 revealed that R#60 was at risk for pressure sores due to her decreased activity, chairfast status most of the time and admission with pressure sores with an intervention for Certified Nursing Assistants (CNAs) to monitor her skin with am/pm care and report any reddened, irritated or open areas. There was also an intervention for nursing to monitor her skin weekly. review of the resident's medical record revealed [REDACTED]. Continued review revealed that staff placed interventions to prevent pressure sores and/or promote healing that included the initiation of soft heel boots, a pressure relieving mattress, Multivitamins, Vitamin C, Zinc and supplements. Review of the Quarterly Braden scale dated 7/11/18 revealed that the resident had a score of 12 indicating that she was at high risk for pressure sore development due to her very limited sensory perception responding only to painful stimuli; often moist skin; bedfast status; very limited mobility; and potential problem with friction/shearing. Although R#60 had a care plan intervention since 3/2/17 for nursing staff to provide weekly skin checks, review of the facility Skin Forms revealed that Licensed Nursing staff failed to check the resident's skin weekly in 7/2018. Review of the last Skin Form dated 6/29/18 revealed that Licensed Nursing Staff assessed the resident and noted that she had [DIAGNOSES REDACTED] on her feet but no pressure sore at that time. There was no indication that Licensed Nursing Staff assessed the resident's skin weekly after 6/29/18. Review of the 7/6/18 Skin Assessment completed by Certified Nursing Staff revealed that the resident had a sore on her foot and that A&D ointment (an ointment to protect the skin from moisture) was applied. However, there was no indication that the CNA notified the nurse about the sore at that time. There was no indication that Certified Nursing staff assessed the resident's skin after 7/6/18. Review of the Nurses' Note dated 7/26/18 at 2:03 p.m. revealed that an unstageable pressure sore measuring 1 centimeter (cm.) by 1 cm. was identified on the resident's left medial foot. Continued review revealed that the wound bed was covered by tan slough. There was no drainage or odor. The Nurse Practitioner was notified and ordered staff to cleanse the pressure sore with normal saline, apply [MEDICATION NAME] and cover with a dry dressing every day and as needed. Review of the resident's chart revealed that subsequent weekly assessments that included staging, measurements and descriptions were completed on the pressure sore. Observation on 8/13/18 at 3:44 p.m., 8/14/18 at 12:12 p.m., 8/15/18 at 1:17 p.m. and at 1:35 p.m. revealed R#60 was observed lying on a pressure relieving mattress and wearing soft boots with her feet elevated on pillows. Staff turned and repositioned the resident frequently. During observation of treatment on 8/15/18 at 12:12 p.m., the Registered Nurse (RN)/Treatment Nurse provided treatment to the pressure sore on the resident's left medial foot as ordered by the physician and using appropriate infection control. The pressure sore measured 0.5 cm by 0.5 cm by 0.2 cm. There was no odor or drainage. The RN/Treatment Nurse stated at that time that the pressure sore was unstageable with slough in the wound bed when it was first identified on 7/26/18. Continued interview revealed that Licensed Nursing staff was responsible for providing weekly skin assessments. Interview with CNA BB on 8/15/18 at 2:09 p.m. revealed that she ensured that residents at risk for pressure sores were turned and repositioned, that heel boots are applied and pillows used to elevate the resident's heels. Continued interview revealed that the CNAs were responsible for checking the residents' skin daily during care for any redness, discoloration or open areas and notifying the nurse right away. Interview with Licensed Piratical Nurse (LPN) CC on 8/16/18 at 8:18 a.m. revealed that she ensured that residents were turned and repositioned and that pressure relieving devices were in place during her rounds. Continued interview revealed that the nurses were responsible for completing skin assessments on the residents weekly. Interview with the resident's attending physician on 8/16/18 at 11:16 a.m. revealed that the resident's pressure sore was unavoidable due to her nutrition status (weight loss and protein-calorie malnutrition). Continued interview revealed that he expected staff to monitor her skin every day due to her high risk for breakdown and that the licensed to inspect her skin every week if care planned. Interview with the Director of Nursing (DON) on 8/16/18 at 12:10 p.m. revealed that the CNAs were responsible for assessing a resident's skin daily during care for any skin changes and notifying the nurse about those changes. Continued interview revealed that Licensed Nursing staff were responsible for assessing a resident's skin weekly for any changes so that any breakdown could be identified early and treatment obtained timely. The DON stated at that time that she had identified in 5/2018 that skin assessments were not being completed and did a 100% skin check on all the residents by 6/2018. However, as of 8/16/18, the DON was unable to provide documentation of the skin assessments. Review of the In-service Log revealed that inservices were provided to certified and licensed nursing staff on prevention of pressure sores, pressure reduction and wound care and/or documentation on 12/7/17, 1/23/18, 5/8/18, 5/29/18, 8/7/18 and 8/9/18. Review of the facility's Policy titled Skin Care last reviewed 4/10/18 revealed under Procedures: 2. A complete and systematic skin inspection is conducted on all residents upon admission and at least monthly. Nursing staff are instructed to pay particular attention to bony prominences. A post-survey telephone interview with the Administrator and the DON on 8/27/18 at 11:24 a.m. revealed that nurses are responsible for doing weekly skin checks for all residents in the facility and that the CNAs are to do a skin check during the resident's bath but may not be daily. The DON says the procedure was revised in (MONTH) (YEAR) and that the nurses had been educated on this process. When questioned as to why the skin policy had not been updated for the revised procedure when the policy was reviewed in (MONTH) (YEAR), neither the Administrator or the DON could explain why it was not updated.

Based on record review and staff interview, the facility failed to assess medications and hypotension as possible causes for falls for one (1) resident (#25). A total of four (4) residents were reviewed for accident hazards, and the sample size was twenty-nine (29) residents. Findings include: Review of resident #25's Medication Administration Record (MAR) revealed that they were receiving the antianxiety drug, Alprazolam, routinely at 9:00 a.m., 1:00 p.m., and 5:00 p.m. Further review of the MAR revealed the resident was receiving the antihypertensive drugs Lotensin at 9:00 a.m.,and Norvasc at 5:00 p.m.daily. Review of the facility's Mosby's 2012 Nursing Drug Reference, 25th Edition, for Norvasc noted that a potential side effect was hypotension, and interactions included increased hypotension with other antihypertensives. Review of the Nursing Considerations section of the book noted to assess the blood pressure (BP), and evaluate for decreased BP. Review of the Geriatric Dosage Handbook, 12th Edition, noted that adverse reactions to Alprazolam included lightheadedness and hypotension. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] noted that the resident was receiving an antianxiety and antidepressant drug for 7 days of the assessment period, as well as a hypnotic for 2 days of the assessment period. Further review of the MDS noted the resident had one fall since the prior assessment. Review of the Weekly Vital Signs record for 2013 noted that the resident's BP fluctuated between a low of 100/59 to a high of 158/67, with the exception of 97/52 on 06/26/13, and 88/50 on 07/09/13. Review of resident #25's Potential for Falls care plan noted that they had 11 falls since 08/20/12. Further review of the Falls care plan revealed there were no approaches related to reviewing the resident's drug regimen. Review of the Nurse's Notes and Neurological Assessment Flowsheets for the 7 falls in 2013 revealed the following: 04/19/13: Fall in room at 8:30 p.m. BP 85/58. 05/27/13: Fall in bathroom at 3:00 p.m. No documentation that vital signs were taken. 06/16/13: Fall in room at 12:30 p.m. BP 84/55 at 12:30 p.m.; 78/45 at 2:00 p.m.; and 88/50 at 4:00 p.m. 06/29/13: Fall in room at 8:30 p.m. BP 95/55. 07/01/13: Fall in room at 6:45 p.m. BP 94/56. Sent to Emergency Department for a laceration to the scalp. 07/09/13: Fall in room at 5:45 p.m. No documentation that vital signs were taken at this time; however, per the Weekly Vital Signs record, the BP that day was 88/50 (unknown time). 07/23/13: Fall in room at 7:12 p.m. BP 98/52 at 7:15 p.m.; 86/51 at 7:45 p.m.; 78/53 at 8:15 p.m.; 78/62 at 8:45 p.m.; 72/54 at 9:45 p.m.; 88/52 at 10:45 p.m.; 80/48 at 11:45 p.m.; and 78/48 at 12:45 a.m. Review of the Report of Resident Falls dated 07/01/13 noted that the resident was not assessed for Anti-hypertensives use in the Current Medications section. Further review of this form revealed that Greater than Five Medications was not assessed as a possible causative factor of the fall. During interview with Licensed Practical Nurse (LPN) "AA" on 07/31/13 at 2:42 p.m., she stated that routine vital signs were done weekly unless there was a specific physician's orders [REDACTED]. Upon further interview, she verified that five of the seven falls in 2013 were after the 5:00 p.m. dose of Norvasc and Alprazolam, and that the resident's BP was low when taken at the time of each of the falls. LPN "AA" added that the resident's medications and low blood pressure were not something considered as potentially contributing to resident #25's falls when discussed at Falls Committee meetings. During interview with LPN "AA" on 08/01/13 at 8:30 a.m., she stated that it does not appear that the nurses notified the physician of the resident's low blood pressure readings. Review of the facility's Operational Policy on Falls Assessment and Prevention noted the following: Residents at moderate risk of falls include those who use medications affecting blood pressure and level of consciousness. Nursing interventions for high risk of falls residents include all those for low and moderate risk residents, as well as the following: Consulting pharmacist asked to review meds. During interview with LPN "AA" on 08/01/13 at 9:30 a.m., she stated that resident #25 would be considered to be a high fall risk, and that she was not aware of the nursing staff contacting the consultant pharmacist to review the resident's meds, especially after the increase in falls in June and July. During interview with MDS Coordinator "BB" at 12:00 p.m., she stated that including an intervention for the physician to review the meds was sometimes, but not always, included in a Falls care plan, depending on the types of meds and what was going on with the resident. She verified that there was no intervention in the Falls care plan for the physician or consultant pharmacist review the meds, and because the resident was falling frequently and was receiving BP and psychotropic meds, that there should have been.

Based on record review and staff interview, the facility failed to more closely monitor the blood pressure (BP) of one (1) resident (#25), who was receiving two antihypertensive drugs and noted to have low BP's after multiple falls. The sample size was twenty-nine (29) residents. Findings include: Review of resident #25's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the resident's Potential for Falls care plan revealed that they had 11 falls since 08/20/12. Review of Nurse's Notes and Neurological Assessment Flowsheets revealed that BP's taken after the falls ranged from 72/54 to 98/52. Review of the Weekly Vital Signs record revealed that the resident's BP was 97/52 on 06/26/13 and 88/50 on 07/09/13. During interview with Licensed Practical Nurse (LPN) "AA" on 07/31/13 at 2:42 p.m., she stated that routine vital signs were done weekly, and not checked prior to giving a BP med unless ordered by the physician. Upon further interview, she verified that resident #25 received [MEDICATION NAME] at 5:00 p.m., that 5 of the 7 falls in 2013 occurred within 3-1/2 hours of the [MEDICATION NAME] administration, and that the BP's were low when taken after the falls. During interview with LPN "AA" on 08/01/13 at 8:30 a.m., she stated that it looked like the nursing staff did not notify the physician about the low BP's.

Based on record review and staff interview, the consultant pharmacist failed to make a recommendation for evaluating the use of antihypertensive medications for one (1) resident (#25), with frequent episodes of hypotension. The sample size was twenty-nine (29) residents. Findings include: Review of resident #25's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Potential for Falls care plan revealed that the resident had 11 falls since 08/20/12. Review of Nurse's Notes and Neurological Assessment Flowsheets revealed that the blood pressures taken after the falls ranged from 72/54 to 98/52, and 5 of the 7 falls in 2013 occurred between 45 minutes to 3-1/2 hours after the 5:00 p.m. dose of Norvasc. Review of the facility's Operational Policy on Falls Assessment and Prevention noted that residents at high risk of falls shall have the consulting pharmacist review medications. There was no evidence that the consulting pharmacists had identified the resident's episodes of hypotension and/or made recommendations for evaluating the use of the anithypertensive medications. During interview with Licensed Practical Nurse "AA" on 08/01/13 at 9:30 a.m., she stated that resident #25 would be considered to be a high fall risk, and that she is not aware of the nursing staff contacting the consultant pharmacist to review the medications, especially after the increase in falls in June and July.

Based on observation and staff interview the facility failed to ensure that the temperature of foods served to residents was held at or above the level necessary to prevent potential foodborne illnesses. This affected all residents on oral alimentation (census = 105). Findings include: During a measurement of temperatures of food items held on the steamtable and being served to residents at the lunch meal on 2/01/12 at 12:15 p.m., the following items were found to be below the minimum safe temperature level of one hundred and thirty-five degrees Fahrenheit (135 F) : -Fried chicken at 128 degrees F -Baked Chicken at 113 degrees F The above observation was made using the food service department's digital thermometer and was confirmed by the facility's Food Service Director.

Based on observation, record review, staff and resident interview the facility failed to ensure that oxygen was supplied by nasal cannula for two (2) residents ("A" and #81) of thirty (30) sampled residents, as prescribed by the physician's orders [REDACTED]. Findings included: 1. Resident "A" had multiple [DIAGNOSES REDACTED]. The resident also had a physician's orders [REDACTED]. Observation and interview with resident "A" on 1/31/12 at 9:00 a.m. revealed the resident had a nasal cannula, in correct placement, with tubing connected to a wall mounted oxygen flowmeter with a humidifier bottle attached. The resident had some shortness of breath and labored breathing while talking and the surveyor noted that there were no bubbles in the humidifier (water) bottle. The resident complained of having trouble breathing while eating breakfast. The respiratory therapist administered a nebulizer treatment at 7:00 a.m. that morning." At 9:15 a.m. Licensed Practical Nurse (LPN) "II" checked the resident's oxygen at surveyor's request. LPN "II" stated the oxygen was not on and she was unable to turn it on. LPN "II" then asked LPN "DD" to assist her, and LPN "DD" turned the oxygen on to deliver oxygen at two (2) liters per minutes. Review of respiratory Administration Records revealed the resident received a nebulizer treatment at 6:30 a.m. on 1/31/12. An interview with the Director of Rehabilation "GG" on 1/31/12 at 3:00 p.m. revealed that she could not account for why the resident's was without oxygen from 7:00 a.m. until 9:00 a.m. and that her expectations were that her staff would ensure that the oxygen was working properly before leaving the resident's room. 2. Review of the most recent annual Minimal Data Set assessment dated [DATE] assessed resident #81 as needing oxygen therapy. Review of the current January 2012 physician orders [REDACTED]. During observation on 1/31/12 at 10:35 a.m. and 11:05 a.m., resident #81 was sitting in the dining room with oxygen on via a nasal cannula attached to a portable oxygen tank. The portable oxygen tank was observed to be empty. Interview on 1/31/12 at 11:10 a.m. with LPN "JJ" confirmed that the portable oxygen tank was empty and the resident was not receiving any oxygen.

Based upon observation, record review and staff interview the facility failed to ensure that respiratory therapy oxygen concentrator filters were clean and that disposable and/or reusable equipment was stored in a sanitary manner when not in use for three (3) residents (#21, #41 and #81) of thirty (30) sampled residents. Findings include: 1. Observation 1/31/12 at 9:00 a.m. for resident #21 revealed the resident's reusable Continuous Positive Airway Pressure (C-PAP) mask was resting on top of the C-Pap machine with a heavy build up of dried debris around the inside of the mask. The mask was not in a protective bag. Observation 2/01/12 at 8:18 a.m. revealed the resident's C-PAP reusable mask was resting on top of the C-Pap machine with a heavy build up of dried debris around the inside of the mask and is not in a protective bag. 2. An observation on 2/01/12 at 10:36 a.m. of resident #41, who is on continuous oxygen, revealed the resident was not in the room and the resident's nasal cannula was lying on the resident's bed. An interview with the Chief Operating Officer, a Respiratory Therapist, "BB" on 2/1/12 at 1:05 p.m. revealed the facility does not have a policy for storing of nasal cannula's or C-Pap mask when not in use. 3. Review of the current January 2012 physician orders [REDACTED]. Observation in this resident's room on 2/1/12 at 7:37 am and again at 8:17 am revealed the oxygen concentrator filters were filled with lint and dust. The oxygen was tubing rolled up and hanging across the oxygen concentrator with the end that went into the nose lying on the floor. Interview with Licensed Practical Nurse "AA" on 2/1/12 at 8:19 am confirmed the oxygen concentrators filters were dirty and that the oxygen tubing should be secured in a plastic bag. Further interview on 2/01/12 at 12:55 p.m. with the Chief Operating Officer/Respiratory Therapist "BB" revealed when nasal cannulas are not in use the tubing should be stored in a plastic bag, and that the concentrators including the filters should be cleaned on a weekly basis.