Every finding on record at Life Care Center of Ocala

Based on interview and record review the facility failed to provide wound care and place dressing change orders for 2 of 3 residents, Residents #86 and #128, reviewed for skin conditions. Findings include: During an observation on 1/12/2026 at 11:38 AM Resident #86 was sitting in a wheelchair. There was a small border wound dressing on Resident #86's lower right leg visibly soiled and not dated. (Photographic evidence obtained)During an interview on 1/12/2026 at 11:38 AM Resident #86 stated, I got a skin tear, it happened while I was getting dressed and it was last changed during my shower.Review of Resident #86's physician orders did not document a treatment order for the skin tear on Resident #86's lower right leg.During an observation on 1/13/2026 at 4:07 PM with Staff L, Licensed Practical Nurse (LPN) Resident #86 was lying in bed. Staff L, LPN removed the covers and Resident #86's right leg had the same small border dressing with no date and soiled. Staff L asked Resident #86 what had happened and Resident #86 stated it was a skin tear and it had not been changed since last Wednesday [1/7/2026].During an interview on 1/13/2026 at 4:08 PM Staff L, LPN stated, When a resident has a skin tear the certified nursing aide will come and tell the nurse. The nurse will assess the area and contact the doctor. The doctor will provide treatment orders that will be put into the system. Dressings should always be dated. I do not see a treatment order for [Resident #86's name] skin tear.During an interview on 1/14/2026 at 10:29 AM the Director of Nursing stated, the Assistant Director of Nursing (ADON) went to speak to [Resident #86's name] and the resident stated the skin tear occurred while in the shower. The ADON said the certified nursing aide told the nurse, and the nurse put a dressing on [Resident #86's name] leg and got distracted and did not complete the process. I would expect the nurse to have completed a risk report and notify the physician and obtain treatment orders and initiate treatment. A wound dressing should be dated and changed as ordered. [Resident #86's name] told the ADON the last dressing change was on Friday [1/9/2026].During an observation on 1/13/2026 at 8:38 AM Resident #128 was in his room sitting in a wheelchair. Resident #128's left arm had a wound dressing, that was not dated, applied to his middle forearm and there was a gauze wrapped wound dressing, with no date, wrapped near the resident's wrist.During an interview on 1/13/2026 at 8:38 AM Resident #128 stated, I have skin tears to my arm which happened a couple of days ago. It has been a couple of days since the staff last changed the dressing. The resident was not able to recall when the dressing was last changed.Review of Resident #128's physician orders did not document treatment orders for skin tears to the resident's left arm.During an interview on 1/13/2026 at 4:12 PM Staff M, LPN stated, [Resident#128's name] does not have dressing orders for his left arm.During an interview on 1/14/2026 at 8:05 AM the Director of Nursing stated, Resident was unable to say when the skin tears occurred. I was unable to find any documentation of when the skin tear occurred.Review of the facility policy and procedure titled Wound Management with a last review date 6/10/2025 read, Equipment: prescribed dressing.

Based on observation, interview, and record review the facility failed to ensure respiratory care equipment was properly stored for 3 of 6 residents, Residents #65, #9 and #76) reviewed for respiratory care and services. Findings include: Review of Resident #65's medical record documented the resident was admitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a progress, irreversible lung disease), diabetes mellitus type 2, atrial fibrillation (irregular heartbeat), heart failure, and asthma.Review of Resident #65's physician order dated 4/4/2024 read, Please ensure that the evening nurse ensures that the CPAP [continuous positive airway pressure] is in place every evening shift for decreased C02 [carbon dioxide].During an observation on 1/10/2026 at 9: 30 AM Resident #65's CPAP mask was in a plastic bag resting on top of the bedside table, the bag was dated 11/7. (Photographic evidence obtained)During an interview on 1/14/2025 at 2:45 PM Staff A Licensed Practical Nurse (LPN) stated, [Resident #65's name] CPAP mask should be placed in a bag, that is dated, the bag should be replaced with a new bag weekly, and the bag should be dated with the date it was replaced. Review of Resident #9's medical record documented the resident was admitted on [DATE] with diagnoses to include multiple fractures of ribs, left side , subsequent encounter for fracture with routine healing; pleural effusion (build-up of excess fluid in thin area between the lungs and chest wall), presence of pacemaker, anemia, and dependence on supplemental oxygen.Review of Resident #9's physician order dated 11/15/2025 read, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML [milligram/milliliters] (Ipratropium-Albuterol) 1 vial inhale orally every 6 hours for sob [shortness of breath].During an observation on 1/13/2026 at 8:33 AM Resident #9's top drawer was open and inside the drawer was inhalation therapy equipment in a bag labeled 12/26. (Photographic evidence obtained). During an interview on 1/14/2025 at 2:45 PM Staff A, LPN stated, All respiratory inhalation masks for [Resident #9's name] should be placed in bags that are dated and new bags replaced weekly with a new date placed on the bag. Review of Resident #76's medical record documented the resident was admitted on [DATE] with diagnoses to include acute respiratory failure (sudden life threatening condition where the lungs fail to get enough oxygen), sleep apnea (sleep disorder where breathing repeatedly stops and starts), asthma, and anemia.Review of Resident #76's physician order dated 8/22/2025 reads CPAP [Continuous Positive Airway Pressure]) /BIPAP [Bilevel Positive Airway Pressure - used for sleep apnea]: Pressure setting 10 cm [centimeters/H2O (water], size and type of mask: nasal pillow, frequency of use; at bedtime, no humidity in reservoir per patient request, every night shift for sleep apnea.During an observation on 1/14/2026 at 2:00 PM, Resident #76's CPAP tubing was hanging from the left beside rail and the distal end was touching the floor. (Photographic evidence obtained). During an interview on 1/14/2026 at 2:40 PM Staff A, LPN stated, [Resident #76's name's] tubing should not be hanging from the bedside rail. All respiratory masks should be placed in bags that are dated and new bags replaced weekly with new date placed on the bag. Review of the policy and procedure titled, Oxygen Administration read, Policy: To ensure that oxygen is administered and stored safety within the facility or in an outside storage area. Infection Control: 1. Change oxygen supplied (e.g., cannula, tubing, humidifier) weekly and when visibly soiled. Equipment should be labeled with resident name and dated when setup or changed out. 3. Store oxygen and respiratory supplies in bag labeled when not in use .

Based on observation, interview, and record review, the facility failed to ensure medications were secured when unattended on 2 of 3 units. Findings include:During an observation on 1/12/2026 at 9:44 AM Resident #117 was lying in bed. There was a bottle of Biofreeze roll-on on top of the bedside table.During an interview on 1/12/2026 at 9:44 AM Resident #117 stated, I have a broken ankle. The Biofreeze is mine, I brought it from home. I apply it myself.During an interview on 1/13/2026 at 2:27 PM Staff H Licensed Practical Nurse (LPN) stated, I am not familiar with [Resident #117's name]. Medication should be locked not left unattended. If a resident is able to self-administer medication they are given a key to their drawer. Sometimes family will bring the medication and if we don't see it, we do not know they have it. During an observation on 1/12/2026 at 9:55 AM Resident #75 was lying in bed resting with eyes closed. On top of the dresser there was Cumarindine ointment for burns and skin conditions.During an observation on 1/13/2026 at 2:37 PM Staff H, LPN opened the Cumarindine ointment container which was almost empty. During an interview on 1/13/2026 at 2:37 PM Staff H LPN, stated, [Resident #75's name] daughter will bring her medications often. During an observation on 1/12/2026 at 10:04 AM Resident #15 was not in her room. There was Calmoseptine ointment on top of her nightstand.During an observation on 1/13/2026 at 2:38 PM with Staff H, LPN of Resident #15's room, there was a visitor in the room. Staff H, LPN retrieved the Calmoseptine ointment. Resident #15's visitor stated they had brought in the medication. During an interview on 1/13/2026 at 2:38 PM with Staff H, LPN stated [Resident #15's name] family will often bring things for her, the medication should not be left unattended. During an observation on 1/12/2026 at 10:31 AM Resident #7 was lying in bed. There was a bottle of Refresh Tears Lubricant Eye drops on top of the bedside table.During an interview on 1/12/2026 at 10:31 AM Resident #7 stated, They are my refresh eye drops which I keep with me. They are over the counter. That way I don't have to bother the nurses.During an interview on 1/13/2026 at 2:41 PM with Staff I, LPN stated, Residents if able to self-administer medication should keep them [the medication] locked in their top drawer, they get a key. During an interview on 1/13/2026 at 2:42 PM Staff I LPN confirmed Resident #7 had eye drops at bedside. During an interview on 1/14/2026 at 4:52 PM the Director of Nursing stated, Nurses should store medication in the medication cart or med room. If a resident self-administers medication an assessment needs to be done, it also must be care planned, and an order placed. The residents will be able to have medication in their room, but it will be stored with a key.During an interview on 1/15/2026 at 8:09 AM the Director of Nursing stated, [Resident #117's name, Resident #75's name, Resident #15's name, and Resident #7's name] do not have an order to self-administered medication. Medications should not be left unattended in the resident's room.Review of the facility policy and procedure titled Storage and Expiration Dating of Medications and Biologicals with a last review date of 6/30/2025 read, Procedure: 5. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on record review and interview, the facility failed to maintain complete and accurately documented medical records for 1 of 10 residents, Resident #36, reviewed for medication management.Findings include:Review of Resident #36's physician order dated 12/15/2025 documented, Atenolol Oral Tablet 25 mg [milligrams], give one tablet by mouth one time daily for hypertension; hold for blood pressure less than 105/55. Lisinopril Oral Tablet 10 mg, give one tablet by mouth one time daily for hypertension; hold for systolic blood pressure less than 105. Xtampza ER [extended release] Oral Capsule ER 12 Hour Abuse-Deterrent 27 mg, give one capsule by mouth every 12 hours for chronic pain; hold for systolic blood pressure less than 90.Review of Resident #36's Medication Administration Record (MAR) for January 2026 documented Xtampza ER was administered on January 2, 2026, January 4, 2026, January 7, 2026, January 8, and January 9, 2026 at 8:00 PM. The MAR did not contain documentation of the resident's blood pressure values for the medication administration. During an interview conducted on 1/15/2026 at 9:00 AM, the Director of Nursing stated that her expectation is that nursing staff administer medications in accordance with physician orders and document required parameters when medications have blood pressure hold parameters.During an interview conducted on 1/15/2026 at 2:03 PM, Staff B stated that she believed she checked the resident's blood pressure prior to administering the medication but forgot to document it.During an interview conducted on 1/15/2026 at 2:20 PM, Staff D stated, I always check my residents' blood pressure if I am administering a medication with blood pressure parameters. I must have forgotten to document it

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection when not donning appropriate personal protective equipment for 3 of 6 residents, Resident #48, reviewed for transmission-based precautions and Residents #95 and #126 reviewed for enhance barrier precautions.Findings include:During an observation on 1/12/2026 at 10:31 AM Resident #126's door had an enhance barrier precaution sign and there was personal protective equipment upon entering the room. The room door was open and Resident #126's privacy curtain was pulled. After knocking on the door to enter Staff J, Certified Nursing Assistant (CNA) presented from around the curtain and stated, Patient Care. Staff J was observed to be wearing gloves; Staff J was not wearing a gown. Staff J CNA retrieved clothing from Resident #126's drawer. Staff J removed the privacy curtain and Resident #126 was sitting in her wheelchair.During an observation on 1/12/2026 at 10:45 AM Staff J, CNA entered back into Resident #126's room and began to make Resident #126's bed. Staff J donned gloves but did not don a gown.Review of Resident #126's physician order dated 1/6/2026 read, Enhanced Barrier Precautions Diagnosis: Wound every shift.During an interview on 1/13/2026 at 2:43 PM Staff J, CNA, stated, I was changing, dressing her [Resident #126] and getting her out of bed. I needed a gown for her [Resident #126]? I didn't know she was on enhanced barriers. I didn't read the door. Now that you mention it, I think the sign was on the door. When asked why she did not gown when making Resident #126's bed Staff J, CNA stated, I thought I only need to wear a gown when providing direct care with the patient. I might be wrong.During an observation on 1/12/2026 at 10:50 AM upon entering Resident #95's room, inside the door there was an enhanced barrier precaution sign and there was a bin with personal protective equipment. Staff I, Licensed Practical Nurse (LPN) presented from behind the privacy curtain and stated, Patient care. Staff I was only wearing gloves and no gown. Staff I, returned to provide care behind the curtain stating Okay, I am going to wrap your leg. Staff I exited the room and returned with blankets. Staff I placed the blankets over Resident #95 wearing gloves and no gown.Review of Resident #95's physician order dated 12/30/2025 read, Enhanced Barrier Precautions Diagnosis: Wound.During an interview on 1/13/2026 at 2:48 PM Staff I, LPN, stated, I was not doing wound care just wrapping her leg for increased edema with an ace wrap. I was not doing anything with the wound or foley. Do I need to wear a gown?During an observation on 1/14/2026 at 9:24 AM Resident #48's door had a contact precaution sign labeled B-Bed. Staff K, CNA, was observed inside Resident #48's room making the residents bed with no gown or gloves.Review of Resident #48's physician order dated 1/12/2026 read, Contact Precautions Diagnosis: Klebsiella in urine. During an interview on 1/14/2026 at 9:59 AM Staff K, CNA, stated, I did not have a gown or gloves because I was making his [Resident #48] bed. I was not dealing with his foley or urine. [Resident #48's name] is contact precautions due to an infection in his urine.During an interview on 1/14/2026 at 12:34 PM the Infection Preventionist stated, Staff should wear a gown when coming in contact with the patient. Essentially wearing gloves and a gown when making the residents bed. They should have worn a gown and gloves when they are in direct contact with the patient. For residents on contact precautions staff should don personal protective equipment when going into the resident's room. The staff should have had a gown and gloves the minute she walked into the room.During an interview on 1/14/2026 at 4:54 PM the Director of Nursing (DON) stated, If the staff is providing direct care to a resident who has enhanced barrier precautions, they must wear a gown and gloves. Even if they are not handling the wound or a foley if it is direct care, they must don gloves and a gown. If the patient is contact precautions the staff should don personal protective equipment before entering the room of the resident and before touching anything in the resident's room.Review of the facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 9/19/2025 read, Policy: The facility should use Enhanced Barrier Precautions (EBP) as an additional MDRO [Multidrug-resistant organism] mitigation strategy for residents that meet the following criteria, during high contact resident care activities; EBP are indicated for residents with any of the following: 1. Infection or Colonization with CDC-targeted MDRO when Contact Precautions do not otherwise apply; or 2. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Examples of high-contact resident care activities requiring gown and glove use include: a. dressing, e. changing linens, f. changing briefs or assisting with toileting.Review of the facility policy and procedure titled Contact Precautions with a last review date of 12/30/2025 read, Policy: Contact Precautions should be used when a resident develops signs and symptoms of a transmissible infection or has a laboratory confirmed infection that requires the use of contact precautions to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or environment and requires the use of appropriate PPE [personal protective equipment], including a gown and gloves. Contact Precautions-requires the use of appropriate ppe, including a gown and gloves before or upon entering (i.e before contact with the resident or resident environment) the room. Prior to leaving the resident room the ppe is removed and hand hygiene is performed.

Based on interview and record review the facility failed to administer medication following physician ordered parameters for 2 of 6 residents, Resident #36 and #117, reviewed for medication management.Findings include: Review of Resident #36's physician order documented dated 12/8/2025, Percocet Oral Tablet 10-325 mg [milligrams], give one tablet by mouth every 12 hours as needed for breakthrough pain rated 6–10. Review of Resident #36's Medication Administration Record (MAR) for January 2026 documented Percocet was administered on 01/01/2026 at 3:08 PM, 01/02/2026 at 5:03 PM, 01/03/2026 at 5:24 PM, 01/04/2026 at 6:06 PM, 01/07/2026 at 5:30 PM, and 01/13/2026 at 6:37 PM and the resident was documented to have a pain level of 4 with each of these administrations. During an interview conducted on 1/15/2026 at 1:58 PM, Staff B, stated, I must have missed the parameters in the order. During an interview conducted on 1/15/2026 at 2:03 PM, Staff C stated, I did not see the parameters when I administered the medication. During an interview conducted on 1/15/2026 at 9:00 AM, the Director of Nursing stated that her expectation is that nursing staff administer medications in accordance with the physician's orders, including adherence to ordered parameters. Review of Resident #117's physician order dated 12/22/2025 read, Oxycodone HCI oral tablet 15 mg, give 1 tablet by mouth three times a day for pain. Review of Resident #117's physician order dated 1/3/2026 read, Oxycodone HCI oral tablet 15 mg [milligram] give 1 tablet by mouth three times a day for pain. Review of Resident #117 physician order dated 12/23/2025 read, Tylenol oral tablet 325 mg, give 2 tablets by mouth every 6 hours as needed for pain <5 [less than 5]. Review of Resident's #117's MAR for the month of December 2025 documented Tylenol 325 mg was administered on 12/15/2025 at 0459 [4:59 AM] with a pain level of 6, on 12/27/2025 at 16:21 [4:21 PM] with a pain level of 6, and on 12/30/2025 at 0520 [5:20 AM] with a pain level of 6. Review of Resident's #117's MAR for the month of January 2026 documented Tylenol was administered on 1/6/2026 at 0450 [4:50 AM] with a pain level of 7 and on 1/8/2026 at 1204 [12:04 PM] with a pain level of 10. During an interview on 1/14/2026 at 8:07 AM with the Director of Nursing stated, Staff should notify the physician and maybe they could change the parameters or order something else. During an interview on 1/14/2026 at 5:05 PM Staff E, LPN stated, I cannot recall. I know she has routine medication at 6 o clock in the morning maybe it was not time for the schedule medication and I gave her the Tylenol. During an interview on 1/15/2026 at 8:13 AM the Pain Management Advanced Practice Register Nurse (APRN #1) stated, [Resident #117's name] if the staff reach out to me, I would order another medication that is more appropriate for the resident. During an interview on 1/15/2026 at 9:06 AM Staff F, LPN, stated, I don't remember but if the medication has parameters in place they should be followed. During an interview on 1/15/2026 at 2:16 PM with Staff G, LPN, stated, I cannot recall my rationale would be if she [Resident #117] is in pain and I cannot give her the scheduled medication. I would give her the Tylenol I cannot just leave her in pain. I cannot recall I am not sure I probably just gave her the Tylenol. You should follow parameters, but you can also use your nursing judgement. Review of the facility policy and procedure titled Administration of Medications with a last review date of 9/9/2025 read, Policy: The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.

Based on observation, interviews and record reviews, the facility failed to ensure residents received an accurate assessment reflective of the resident's status at the time of the assessment for 5 of 7 residents reviewed (Resident #50, #111, #116, #118, #221). Findings include: 1). Review of Resident #50's Modification of Quarterly Minimum Data Set (MDS) Assessment, dated 5/27/2024, Section O, Special Treatments, Procedures, and Programs documented Resident #50 received tracheostomy care and used an invasive mechanical ventilator (ventilator or respirator) while a resident of the facility. Review of Resident #50's care plan, start date 7/8/2024, failed to reveal documentation Resident #50 received tracheostomy care and used an invasive mechanical ventilator (ventilator or respirator) while a resident of the facility. Resident #50 was observed on 8/6/2024 at 9:29 AM and again on 8/8/2024 at 8:26 AM. Resident #50 was not receiving tracheostomy care or using an invasive mechanical ventilator (ventilator or respirator). During an interview on 8/6/2024 at 9:37 AM, Staff D, Licensed Practical Nurse, Care Coordinator, stated that Resident #50 had not received tracheostomy care or used an invasive mechanical ventilator (ventilator or respirator) while a resident of the facility. Staff D added Never here. Maybe in hospital but never here. During an interview on 8/8/2024 at 12:36 AM, Staff E, Registered Nurse, Minimum Data Set Coordinator, stated [Resident #50's Name], Never had one [ventilator or respirator]. Staff E acknowledged Section O of Resident #50's Modification of Quarterly MDS Assessment, dated 5/27/2024, needed to be corrected. 46523 2) During an interview on 8/7/2024 at 8:59 AM, Resident #111 stated, I had motor vehicle accident and had a right shoulder fracture and some of my ribs were fracture as well. I am here for therapy. Review of Resident #111's MDS Admission 5 Day Assessment, dated 7/22/2024, Section GG, Functional Abilities and Goals documented no functional limitation in her upper and lower extremities. Review of Resident #111's care plan, initiated on 7/24/2024, documented a Self-care deficit associated with right shoulder and multiple right rib fractures. PT [patient] was a pedestrian in a MVA [motor vehicle accident]. During an interview on 8/8/2024 at 12:43 PM, Staff E, Registered Nurse, MDS Coordinator stated, I need to modify Section GG of the MDS for [Resident #111's Name] since she has a right shoulder fracture. During an interview on 8/9/2024 at 8:41 AM, Staff F, Certified Occupational Therapy Assistant, stated I provide occupational therapy to [Resident #111's Name]. At the moment she is non weight bearing and non-range of motion on her right shoulder for 6 weeks. That is the standard protocol for fractures. 3) During an interview on 8/6/2024 at 9:55 AM, Resident #221 stated, I had a cardiovascular accident and I my right side was affected. I am not able to move my right hand or my right leg. Review of Resident #221's MDS Admission Assessment, dated 7/26/2024, documented in Section GG, Functional Abilities and Goals, no impairment in upper and lower extremities. Review of Resident #221's care plan, initiated on 7/25/2024, documented, Resident is at risk for fall related injury r/t (related to) impaired functional performance with ADL (activity of daily living) task, CVA (cardiovascular accident) with right hemiplegia [one-sided paralysis or weakness], incontinence and use of opioid/psychoactive medications. Review of Resident #221's care plan, initiated on 7/31/2024, documented ADL self-care performance deficit r/t CVA with right hemiplegia . Review of Resident #221's care plan, initiated on 8/1/2024, documented At risk for rehospitalization due to (Dx) [diagnosis] CVA with right hemiplegia. During an interview on 8/8/2024 at 12:42 PM, Staff E, Registered Nurse, MDS Coordinator, stated [Resident #221's Name] functional ability [assessment] has to be modified since she was admitted with right hemiplegia. 48708 4) Review of Resident #116's MDS Discharge Return Anticipated Assessment, dated 5/31/24, documented Resident #116's discharge location on Section A to home/community. Review of Resident #116's discharge nursing note, dated 5/31/24, documented Resident #116 was admitted to the hospital for altered mental status. Review of the admission/discharge report dated 2/6/24 to 8/6/24 documented Resident #116 was discharged to an acute care hospital on 5/31/24. During an interview on 8/8/24 at 12:44 PM, Staff E, Registered Nurse, Minimum Data Set Coordinator, confirmed [Resident #116's Name] minimum data set assessment was completed incorrectly and would need to be modified. 5) Review of Resident #118's MDS Discharge Return Not Anticipated Assessment, dated 5/7/24, documented on Section A, the resident was discharged to a short term general hospital. Review of Resident #118's discharge summary, completed on 5/7/24, documented Resident #118 was discharged to another facility. Review of the admission/discharge report documented Resident #118 was discharged to a community nursing home on 5/7/24. During an interview on 8/8/24 at 12:44 PM, Staff E, Registered Nurse, Minimum Data Set Coordinator confirmed [Resident #118's Name] minimum data set assessment was completed incorrectly and would need to be modified.

Based on observations, interviews and record review, the facility failed to provide wound care and treatment in accordance with professional standards of practice for 1 of 3 residents reviewed for skin conditions, Resident #220. Findings include: During an observation on 8/6/2024 at 9:30 AM, Resident #220 was lying in bed with a dressing on her left arm dated 8/4/2024. During an interview on 8/6/2024 at 9:30 AM, Resident #220 stated, I have a skin tear in my arm; the nurse will change the dressing. During an observation on 8/7/2024 at 1:12 PM, Resident #220 was lying in bed with a dressing on her left arm dated 8/6/2024. Review of Resident #220's physician orders documented no orders for left arm wound care for skin tear. Review of Resident #220's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 7/30/2024, documented skin tears on both arms. Review of Resident #220's Weekly Skin Integrity Data Collection, dated 8/6/2024, documented, Skin Condition: 1. Is resident available for skin inspection: yes. 2q1. Describe: abscess to abdomen, erythema [abnormal redness of the skin] to bottom skin tear to left arm. During an interview on 8/8/2024 at 9:27 AM, Staff P, License Practical Nurse, stated, I did [Resident #220's Name] left arm dressing yesterday. The resident had a right arm skin tear but that resolved. During an interview on 8/8/2024 at 1:21 PM, the Director of Nursing stated, I spoke with the nurse, and she said [Resident #220 Name] had a right arm skin tear and it resolved yesterday. There are no orders in the system for the left arm skin tear. The staff should have orders in the system in order to provide wound care. Review of the policy and procedure titled Skin Integrity & Pressure/Injury Prevention and Management with a last review date of 12/5/2023, read, Policy: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wound utilizing professional standards of the NPIAP (National Pressure Injury Advisory Panel) and WOCN (Wound, Ostomy, Continent Nurses Society).

Based on observations, interviews, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles for unattended/secured medications in 1 of 3 units. Findings include: During an observation on 8/6/2024 at 9:23 AM in Resident #89's room, there were 3 clear plastic unit doses of Sodium Chloride 0.9% of 30 milliliters each inside a bed pan on top of the resident's drawer. (photographic evidence obtained) During an observation on 8/6/2024 at 9:30 AM in Resident #219's room, there was a Wixela inhaler on top of resident's bedside table. (photographic evidence obtained) During an interview on 8/6/2024 at 9:30 AM, Resident #219 stated, The nurse brings the inhaler and leaves it here and then she will come back and pick it up after I am done. During an observation on 8/7/2024 at 8:59 AM in Resident #111's room, there were 3 clear plastic unit doses of Sodium Chloride 0.9% of 30 milliliters each on top on dresser. (photographic evidence obtained) During an observation on 8/8/2024 at 5:54 AM, Staff C, License Practical Nurse (LPN), entered Resident #68's room and after connecting intravenous tubing with medication to Resident #68, Staff C left a white foam tray with a Normal Saline syringe and an unopened Heparin lock Flush syringe in the resident room. During an interview on 8/9/2024 at 7:42 AM, the Director of Nursing (DON) stated Medication should not be left at bedside unsecured. Review of the policy and procedure titled Storage and Expiration Dating of Medications, Biological, with a last review date of 12/5/2023, read, Procedure: 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access .3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observations, interviews, and record reviews the facility failed to use the appropriate infection control standards for residents with central catheters for 1 (Resident #68) of 4 residents reviewed for antibiotic medication and to sanitize reusable medical equipment. Findings include: 1) During an observation on 8/8/2024 at 8:42 AM, Staff A, Registered Nurse (RN) performed hand hygiene and donned personal protective equipment which included gown and gloves and entered Resident #68's room. Resident #68's IV (intravenous) pump was beeping. Staff A retrieved a normal saline syringe and heparin flush syringe that had been left in the room and disconnected Resident #68's IV tubing. Staff A, RN, without scrubbing the needleless connector, flushed the PICC (peripherally inserted central catheter) line with normal saline followed by the heparin lock flush. Staff A, RN, then placed a Curos (Trademark) port protector on the needless connector hub. During an interview on 8/8/2024 at 12:14 PM, Staff A, RN, stated, I would normally clean the needless connector at the beginning when I am first going to connect the IV tubing. When I disconnect, I do not scrub the hub again because I connect the normal saline flush right away and I consider it to be sterile when I disconnect the tubing. During an interview on 8/9/2024 at 9:09 AM, the Director of Nursing stated, The nurse should have sanitized the needleless connector after disconnecting the tubing and flushing IV [intravenous] line. Review of the policy and procedure titled IV bolus Injection, with a last review of 12/5/2023, read, For administration through an intermittent vascular access device .Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad. While maintaining sterility of the syringe tip, attach a prefilled 10-ml syringe or a syringe specially designed to generate lower injection pressure containing preservative-free normal saline solution to the needleless connector .Perform a vigorous mechanical scrub of the needless connector for at least 5 seconds using an antiseptic pad. Allow it to dry completely. While maintaining the sterility of the syringe tip , attach the syringe containing the locking solution to the needleless connector. Inject the locking solution slowly into the venous access device. 2) During an observation on 8/8/2024 at 8:53 AM, Staff B, RN reviewed Resident #67's medication. Staff B walked over to the 200-hall equipment room, retrieved a vital machine cart outside of the room and walked into Resident #67's room to take her blood pressure. Without sanitizing the blood pressure cuff, Staff B took the resident's blood pressure. Staff B exited the room with the vital sign cart and placed the vital cart next to the medication cart. Staff B performed hand hygiene poured all medication and administered the medications to Resident #67. Staff B exited the room and, without sanitizing the blood pressure cuff, returned the vital cart to the hallway near the nursing station and plugged the cart into the wall outlet. Staff B returned to her medication cart and continued to administer medications. During an interview on 8/8/2024 at 1:20 PM, Staff B, RN stated, I should have sanitized the blood pressure cuff and machine after using it with [Resident #67 's name]. Normally we have the wipes with the purple top which we use to clean the machine after each use. During an interview on 8/8/2024 at 1:30 PM, the Director of Nursing (DON) stated, Staff should sanitize the equipment after each use. Review of the policy and procedure titled Cleaning and Disinfection of Non-Critical Patient Care Equipment, with a last review date of 12/5/2023, read, Policy: The following defines and establishes standards for assuring that non-critical reusable patient care equipment is cleaned daily and before and after reuse with an EPA -registered hospital disinfectant, or other approved disinfectant based on manufacturer guidelines. Examples of non-critical time include, but not limited to: a. stethoscopes, blood pressure cuffs, countertops, portable pumps, pulse oximeters, tablets used for charting or digital communication, ect.

Based on observation, interview, and record review, the facility failed to ensure the equipment was cleaned in accordance with professional standards for food safety. Findings include: During an observation on 3/27/2023 at 9:40 AM, the ice machine had a black/brownish dark substance around the inner rim of the door on the inside of the ice machine. During an interview on 3/27/2023 at 9:45 AM, the Certified Dietary Manager (CDM) confirmed the presence of a dark substance and stated that it should have been cleaned every night. Review of the facility policy and procedure titled Cleaning Schedule reviewed on 4/27/2022 read, Equipment and Utensil Cleaning and Sanitization- A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination via splash, dust, grease, etc.

Based on observation, interview, and record review, the facility failed to ensure respiratory care services were provided consistent with professional standards of practice for oxygen administration for 1 of 3 residents reviewed, Resident #25. Findings include: During an observation on 3/26/2023 at 10:00 AM, Resident #25 was lying in bed, with oxygen being administered via a nasal canula. The oxygen concentrator was set at 3 liters per minute (L/min). During an observation on 3/27/2023 at 9:01 AM, Resident #25 was lying in bed, with oxygen being administered at 3 L/min. During an observation on 3/28/2023 at 8:34 AM, Resident #25 was being administered oxygen at 3 L/min. Review of the physician order dated 8/17/2022 for Resident #25 reads, Oxygen at 2 liters/ minute continuously per nasal cannula. Document O2 Sats [oxygen saturation] q [every] shift. During an interview on 3/28/2023 at 11:30 AM, Staff A, Licensed Practical Nurse (LPN), confirmed the oxygen concentrator was set at 3 L/min. Staff A verified that the physician's order was for 2 liters/minute continuously per nasal cannula. During an interview on 3/28/2023 at 11:45 AM, the Assistant Director of Nursing stated, It is my expectation that the nurses check to make sure the oxygen levels are correct daily on their shift. Review of the facility policy and procedure titled Oxygen Administration/ Safety/ Storage/ Maintenance issued 12/3/2022 read, Policy: Oxygen will be administered in accordance with physician orders and current standards of practice.

Based on observation, record review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety. Findings: On 10/11/2021 beginning at 9:00 AM, an initial tour of the facility kitchen with the Certified Dietary Manager showed approximately four pounds of yellow sliced cheese uncovered and unlabeled in the sandwich table, two butter slabs on the shelf opened without a date, and five pounds of chopped chicken in an opened and unlabeled plastic wrap/bag in the walk-in cooler (Photographic evidence obtained). On 10/11/2021 at 9:25 AM, observation of the food preparatory table showed a staff member's personal phone charging. There was a mop bucket with dirty water and a mop inside parked between the open case of bananas on the bottom shelf and the flour container (Photographic evidence obtained). During an interview on 10/11/2021 at 9:30 AM, the Certified Dietary Manager verified the foods, including the cheese on the sandwich table, were opened and unlabeled. He verified they used the sandwich table the day before and they should have wrapped the cheese. He confirmed there was a personal phone on the food preparatory table and the mop bucket with dirty water parked against the food preparation area. He stated they did not allow it and it was not a sanitary practice. Review of the facility policy titled Chapter 10: Sanitation, Safety, and Disaster. Food and Nutrition Services Manual, Sanitation and Maintenance with a revision date of 1/11/2019 and an approval date of 12/20/2021 read, Guidelines: . - Physical facilities are cleaned as often as necessary to keep them clean. Cleaning is done during periods when the least amount of food is exposed. Mops and brooms are hung when not in use in the designated area . - All working surfaces, utensils and equipment are cleaned and sanitized appropriately after each use and if contaminated . - The Director of Food and Nutrition Services will routinely check food storage, food preparation and food service areas daily to ensure proper steps are being followed . - All refrigerated foods if removed from their original container, are securely covered, labeled and dated appropriately and if opened, the label will contain the use by date.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional standards to include the expiration date for 1 of 3 medication carts. Findings: An observation of Medication Cart #1 on 10/11/2021 at 9:11 AM with Staff B, Licensed Practical Nurse (LPN), showed one medication cup containing nine medications in the top drawer with no resident identifier or label, one opened [MEDICATION(S)] 1% multi dose vial with no date opened or resident identifier, one opened bottle of [MEDICATION(S)] eye drops with no opened or expiration dates, two opened bottles of [MEDICATION(S)] eye drops with no opened or expiration dates, and two bottles of [MEDICATION(S)] eye drops with no opened or expiration dates. During an interview on 10/11/2021 at 9:15 AM, Staff B, LPN, stated, I was giving medications to a resident when they were not in their room. I put the medications in here. They should be labeled with the resident's name and what they are. The [MEDICATION(S)] does not have a resident name, or the original pharmacy package and it should. The eye drops should have the date they are opened or when they expire. During an interview on 10/12/2021 at 10:05 AM, the Director of Nursing (DON) stated, All medications should have the date they get opened put on them. Nurses should check to see if residents are available before pouring medications. They should not leave them in the medication cart unlabeled. Review of the facility policy number 5.3 titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles with the last revision date of 10/28/2019 and an approval date of 12/20/2021 read, Procedure: . 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. 5.1. Facility staff may record the calculated expiration date based on the date opened on the primary medication container . 5.3. If a multi-dose vial of an injectable medication has been opened or accessed (e.g., needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the possible development and transmission of communicable diseases and infections by not performing hand hygiene during medication administration for 4 of 7 observations. Findings: During an observation of medication administration on 10/12/2021 at 9:08 AM, Staff A, Licensed Practical Nurse (LPN), entered Resident #35's room. Staff A did not perform hand hygiene prior to pouring the medications. After administering oral medications to Resident #35, Staff A put on gloves without performing hand hygiene, gave Resident #35 a [MEDICATION(S)] inhaler, and assisted the resident with the medication administration. Staff A removed her gloves and left the resident room. Staff A did not perform hand hygiene and returned to the medication cart. During an observation of medication administration on 10/12/2021 at 9:18 AM, Staff A, LPN, donned gloves and entered Resident #15's room. Staff A obtained a cup from the resident, exited the room and returned to the medication cart wearing the same gloves. She used a measuring spoon that was in the cup and put [MEDICATION(S)] in the cup. She locked the medication cart and returned to the resident's room using the same gloves and administered the resident's medications. Staff A, left the room and returned to the medication cart. Staff A did not perform hand hygiene during the medication administration. During an observation of medication administration on 10/12/2021 at 9:25 AM, Staff A, LPN, entered Resident #13's room. Staff A administered the medications and left the room returning to the medication cart. Staff A did not perform hand hygiene during the medication administration. During an observation of medication administration on 10/12/2021 at 9:39 AM, Staff A, LPN, attempted to administer medications to Resident #54. A medication was unavailable on the cart. Staff A went to the medication room, obtained the medication, returned to the medication cart, unlocked the cart and obtained the other medications. Staff A administered the oral medications to Resident #54 without performing hand hygiene and prior to donning gloves. Staff A checked Resident #54's gastrostomy tube placement and flushed the tube with 100 ml (milliliters) of water. Staff A doffed her gloves and returned to the medication cart and began pouring medications for another resident. Staff A did not perform hand hygiene during the medication administration. During an interview on 10/12/2021 at 9:55 AM, Staff A, LPN, stated, I should have used hand sanitizer before getting medications. I should have used hand sanitizer or washed my hands before putting on gloves or going into the room to administer the medications. I just forgot. During an interview on 10/12/2021 at 1:35 PM, the Director of Nursing stated, Staff should follow our policies for hand washing when administering medications. I expect them to use hand sanitizer or wash their hands before pouring medications, when going into the room, and when leaving the room or if they have to put gloves on. Review of the facility policy titled Chapter 4: Standard & Transmission Based Precautions. Guide to Infection Prevention and Control. Hand Hygiene with the last revision date of 12/4/2020 and an approval date of 12/20/2020, read, Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene. Policy: . The facility should provide education to associates on hand hygiene routinely and this education should include but not limited to: . - When to perform proper hand hygiene with (ABHR) [Alcohol-Based Hand Rub] and with soap and water: . - before and after all resident contact, . - before applying gloves, - after removal of gloves, . before putting on and after removing PPE [Personal Protective Equipment], including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process.

Based on record review and interview the facility failed to ensure residents' representatives and families were informed at least weekly or by 5:00 PM the next calendar day, of confirmed positive cases of COVID-19 (Coronavirus Disease 2019), for 7 of 13 sampled residents, Residents #1, #2, #3, #4, #5, #6, and #7 who were confirmed positive for COVID-19. Findings: Review of the facility policy titled Coronavirus (COVID19) ([DIAGNOSES REDACTED]-CoV-2) (Severe Acute Respiratory Syndrome Coronavirus 2) (Revised: 02/11/2021) revealed the facility standard of practice on page 5 (iii) Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Review of the facility COVID-19 infection line listing documented Resident #1 was confirmed positive for COVID-19 on 02/10/21, Resident #2 was confirmed positive for COVID-19 on 02/10/21, Resident #3 was confirmed positive for COVID-19 on 02/13/21, Resident #4 was confirmed positive for COVID-19 on 02/15/21, Resident #5 was confirmed positive for COVID-19 on 02/15/21, Resident #6 was confirmed positive for COVID-19 on 02/17/21, and Resident #7 was confirmed positive for COVID-19 on 02/17/21. Review of the facility notification system log revealed there was no documentation representatives/families had been notified of confirmed positive COVID-19 cases in the facility for the cases confirmed on 02/10/2021, 02/13/2021, 02/15/2021, and 02/17/2021. Review of the facility notification system log revealed the facility last documented notification of positive COVID-19 cases on 02/08/2021. During an interview on 02/23/2021 at 11:01 AM, the facility Regional Director of Clinical Services confirmed the facility notification log entries and confirmed the facility had not notified representatives/families of confirmed positive COVID-19 cases in the facility for 02/10/2021, 02/13/2021, 02/15/2021 and 02/17/2021. She confirmed the facility had not issued notification of positive COVID-19 cases since 02/08/2021.

Based on observation, record review and interview, the facility failed to ensure sanitary practices during the preparation of meals and storage of food. (Photographic Evidence) Findings: A tour of the kitchen was initiated on 2/10/2020 at 9:00 AM with the Registered Dietician and the Kitchen Manager. The findings in the preparation and cooking areas include: an uncovered partially filled 30-gallon trash can was located against the steam table preparatory shelf; a sandwich cooler table with items on the preparatory shelf, after the completion of making a sandwich, was observed to have deep cuts in the shelf with a black substance in each cut; there was a rust spot in the center of the shelf; the shelves inside the cooler were rusting where the white plastic coating had worn off; the fryer had debris and dark brown oil in the vat with no lid and dried streams of grease down the front of the fryer to the floor; the vat was cool with no recent use. During an interview on 2/10/2020, at 9:15 AM, the Kitchen Manager confirmed the trash can needed a cover as it sits at the edge of the preparatory table during the preparatory time period. The Kitchen Manager confirmed the sandwich cooler table had numerous cuts with a black substance on the cutting table and the rust colored substance on the wire racks inside the cooler table. He confirmed the fryer with grease marks outside and the dark brown oil in the vat with no cover. Review of the (MONTH) 2020 Deep Cleaning Schedule revealed, Fryer as Needed, Use Boil out. Rinse and Dry. Replace oil. The entire form was completed except for 1 block regarding the toaster cleaning, even though it was only the second week of (MONTH) 2020. It was initialed under Week 1-4. Review of the facility policy for safe and sanitary handling of food entitled Sanitation and Maintenance noted under Guidelines, All equipment is reassembled after cleaned and sanitized according to manufacturer's instructions . Equipment of the type and in the amount necessary for the proper preparation, serving and storing of food and for proper dishwashing are provided and maintained in good working order. Fixed and mobile equipment in the foodservice area will be located to assure sanitary and safe operation and will be sufficient size to handle the needs of the facility . Physical facilities are cleaned as often as necessary to keep them clean.

Based on observation, interview and record review, the facility failed to store drugs in a secured, locked containers, carts in accordance with accepted professional principles to include the appropriate management of expired biologicals. Findings: Observation in room [ROOM NUMBER]-A on [DATE] at 10:36 AM revealed a barrier cream 57 gram, castor oil 177 milliliter (ml.) and antifungal liquid 30 ml. on her bedside table. Observation in room [ROOM NUMBER]-A on [DATE] at 8:25 AM revealed all the three medications, castor oil, antifungal liquid and barrier cream were still on the resident's bedside dresser. During an interview with Staff D, LPN on [DATE] at 8:24 AM confirmed that she saw the barrier cream, antifungal liquid and the castor oil the bedside table in room [ROOM NUMBER]-[NAME] Review of the Storage and Expiration, Dating of Medications, Biologicals, Syringes and Needles policy and procedure with a revision date of [DATE]. Procedure #2 read, Facility should ensure that medications and biologicals are stored in an orderly manner, in cabinet, drawers, cart, refrigerator/freezers of sufficient size to prevent crowding. Item 3.3 read, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors.

Based on observation, record review and interview, the facility failed to ensure proper use of the mechanical lift during a transfer for 1 of 4 residents reviewed for accidents out of 40 total sampled residents. (Resident #91) Findings: Resident #91 was observed on 2/10/2020 at 11:00 AM, during a transfer from the bed to her wheelchair. Certified Nursing Assistant/ Staff A was the lead aide and Certified Nursing Assistant/Staff B was following directions. The staff were positioned on either side of the bed and attached the sling, under the resident, to the lift. Staff A said ok to notify Staff B to begin the lift process. Staff B attempted to kick the black pedals which lock the wheels on the lift. The pedals did not engage. She stopped the attempt and the lift began raising the sling off the bed. The staff began pulling the lift away from the bed. They positioned the lift over the chair and lowered the resident. The lead aide did not check with Staff B to ensure the wheels were locked before lifting the resident. During an interview with Staff B on 2/10/2020 at approximately 11:05 AM, Staff B confirmed she did not lock the lift wheels before lifting the resident to ensure the sling would hold the weight. She stated she tried, but it would not engage so she proceeded with the lift without informing her teammate the wheels of the mechanical lift were not locked. She moved the lift into the hallway and demonstrated again by attempting to lock the wheels. She was able to lock the pedals after four attempts on the pedals. An interview with Staff A on 2/10/2020 at 11:05 AM, Staff A confirmed the wheels should have been locked when they raised the resident off the bed. She stated, Oh, they were not locked? I thought they were locked. Review of Resident #91's Minimum (MDS) data set [DATE] revealed a score of 15 on the cognition assessment which means no cognitive impairment. Review of the Mechanical Lift Policy under General Guidelines read, Staff will be competent in how to use a mechanical lifting device. An interview with the Risk Manager on 2/11/2020 at 2:20 PM revealed she would take the mechanical lift to the Maintenance Department for an assessment.

Based on observation, interview and record review, the facility failed to maintain an infection control surveillance program specific to the care of respiratory supplies/tubing and maintenance of medical equipment such as the pill crushers and pill cutters in a sanitary condition and the facility failed to provide and or ensure proper mask infection control techniques. Findings: 1) Observation in room [ROOM NUMBER]-A on 02/10/20 at 10:28 AM revealed a nebulizer mask attached to a nebulizer machine that was uncovered and undated. The nebulizer mask had brownish sticky substance on it and was on top of the bedside dresser. Observation in room [ROOM NUMBER]-A on 02/10/20 at 10:36 AM revealed an unclean nebulizer mask attached to a nebulizer machine that was uncovered and undated. Observation in room [ROOM NUMBER]-A on 02/10/20 at 10:57 AM revealed a concentrator at bedside with nasal cannula wrapped over it and was uncovered. There was a nebulizer mask attached to a nebulizer machine that was uncovered and dated 1/20/2020. During an interview on 2/12/2020 at 11:02 AM, the Assistant Director of Nursing (ADON) stated that the respiratory tubes were changed every Thursdays by Staff H. ADON stated that they were supposed to be dated and placed in a bag. During an interview on 2/12/2020 at 11:05 AM, Staff H stated that she was responsible for changing the oxygen tubing every week. She stated she dated the tubes by using a tape and wrapping it around the tubing. Staff H stated that she only changed the oxygen tubes and the nurses were responsible for changing the nebulizer masks weekly. Observation in 200 hall on 2/10/2020 at 12:46 PM with Registered Nurse/Assistant Director of Nursing (ADON) revealed a crash cart that was unclean with dust build-up as revealed by finger sweep During an interview on 2/10/2020 at 12:48 PM, the ADON confirmed the dust build-up on the crash cart. Observation on 2/10/2020 at 1:35 PM in 100 hall medication cart revealed an unclean pill crusher with dark colored sediments on the base of the pill crusher. Observation of the pill crusher on top of the medication cart in 200 hall-B on 2/11/2020 at 3:16 PM revealed a pill crusher (Silent Knight) with some brownish dry powdered sediments around the base of the pill crusher. There was a pill cutter on top drawer of the medication cart was unclean with whitish colored powdered residue. During an interview on 2/11/2020 at 3:18 PM, Staff F, Registered Nurse (RN), confirmed the pill crusher and pill cutter were unclean. Staff F stated that she would clean the pill cutter and pill crusher at the end of her shift. During an interview with Staff E, LPN, on 2/11/2020 at 3:15 PM, when asked how often the pill crushers are cleaned, he stated it should be cleaned at the end of every shift. Staff [NAME] confirmed on 2/11/2020 at 3:18 PM that the pill crusher and pill cutter were unclean. Review of the Oxygen Administration/Safety/Storage/Maintenance policy and procedure with a review date of 4/15/2019 revealed, Infection control: 1. Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set-up or changed out. 2. Store Oxygen and respiratory supplies in a bag labeled with residents' name when not in use. Review of the Cleaning and Disinfection of Non-Critical Patient Care Equipment policy and procedure with a review date of 7/25/2019 revealed, Purpose: To establish for the cleaning and disinfecting of non-critical, reusable patient care equipment. Equipment will be cleaned and disinfected prior to storage. Policy: The following defines and establishes standards for assuring that non-critical reusable patient care equipment is cleaned daily and before and after reuse. 2. Observation of Resident #221 beginning on 2/10/2020 at 9:30 AM revealed: On 2/10/2020 at 09:40 AM, observed resident's Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) with oxygen, mask not in labeled bag, was sitting in the top drawer of the bedside table. On 02/11/20 at 09:40 AM, observed the resident's [MEDICAL CONDITION] mask sitting in the top drawer of the bedside table, not in a labeled plastic bag. On 02/12/20 at 09:11 AM, observed the resident sitting on side of bed, eating breakfast, [MEDICAL CONDITION] mask located on side of bed, not in a labeled plastic bag. On 02/12/20 at 10:45 AM, observed the resident's room and the [MEDICAL CONDITION] mask was on the bed and not in a labeled plastic bag. During an interview with Resident #221, on 2/11/2020 at 11:00 AM, he confirmed he had not received directions from the staff for the storing of his mask. Review of Resident #221's medical record revealed he was admitted to the facility on [DATE], with a medical [DIAGNOSES REDACTED]. The Elopement Risk assessment dated [DATE] revealed the resident was determined not to be cognitively impaired with poor decision-making skills. Review of the physician's orders [REDACTED]. During an interview on 02/12/20 at 10:50 AM, Staff C, Licensed Practical Nurse, stated, I am not sure if the facility has a policy/procedure regarding storage of face mask when not in use, but I think it is a good idea to store them in a labeled plastic bag. During an interview on 02/12/20 at 11:07 AM, the Director of Nursing confirmed the [MEDICAL CONDITION] face mask was on the bed and not in a labeled plastic bag during the observation on 2/12/2020 at 11:07 AM. Review of policy and procedure Oxygen Administration/Safety/Storage/Maintenance under the heading Infection Control read, Store oxygen and respiratory supplies in bag labeled with resident's name when not in use.