**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, medical record review and review of Resident Assessment Instrument (RAI) Manual Chapter 4, the facility failed to implement Resident Identifier (RI) #1's s care plan for two- person assist with Mechanical lift. This affected Resident Identifier (RI) #1, one of three residents for whom care plans were reviewed. Findings include: A review of the RAI Manual Chapter 4 October 2019 revealed . Chapter 4 Care Area Assessment Process and Care Planning . 4.7 . The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths and needs. Develops and implements a intradisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow up .Provides information regarding how the causes and risks associated with issues and or conditions can be addressed to provide for a resident's highest practicable level of well-being (care planning). RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis to include Lack of Coordination, Muscle Wasting and Atrophy, Other Reduced Mobility, Muscle Weakness and Poly Neuropathy. RI #1's Lift Transfer Evaluation dated 06/27/2022, documented total lift required, two team members required. RI #1's care plan for impaired physical functioning due to self care and mobility impairments . documented, Interventions Transfer assistance of 2 person assist with mechanical left . An interview was conducted with Employee Identifier (EI) #3, Certified Nursing Assistant (CNA) on 12/07/2022 at 1:57 PM. EI #3 stated one or two people could be used to transfer RI #1 when using the mechanical lift. EI #3 admitted on [DATE] when she was preparing RI #1 for an outing, she transferred resident without assistance. An interview was conducted with EI #2, Director of Nursing (DON) on 12/07/2022 at 2:06 PM. EI #2 stated RI #1 is care plan for a two person assist when transferring with the mechanical lift. EI #2 admitted RI #1's care plan was not followed when EI #3 did not have assistance in transferring RI #1 on 10/28/2022. EI #2 stated the concern of not following the transfer care plan is safety. An interview was conducted with EI #1, Administrator/Abuse Coordinator on 12/07/2022 at 2:30 PM. EI #1 admitted that RI #1's care plan was not followed when EI #1 transferred RI #1 without assistance on 10/28/2022. EI #1 stated the concern of RI #1 not being transferred properly is staff not following the policy and safety. This deficiency was cited as a result of the investigation of complaint number AL00042382.

Based on observation, staff interview, and policy review, the facility failed to store a liquid topical medication in a locked compartment away from residents with dementia who independently use the toilet in one of three shower rooms. The dementia unit has 14 out of 15 residents who can independently use the toilet in the shower room on the unit. Findings include: Review of the facility policy titled 6.3 Storage and Expiration of medications, Biologicals, Syringes and Needles, revised 10/31/16, revealed Procedure . 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 resident and visitors. During an observation of the dementia care unit on 04/18/21 at 7:30 PM, a gray rolling cart containing resident care supplies was observed in the unlocked shower room. A bin on the top and to the side of the cart contained resident care items and a bottle of liquid medication, Clobetasol (a potent steroid medication used to treat scalp and skin conditions). The prescription label indicated the medication was for Resident Identifier (RI) #30. Further observation on 04/19/21 at 11:30 AM revealed RI #22 independently using the toilet in the shower room. No staff were present. Review of RI #22's electronic medical record (EMR) admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/20 revealed a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating RI#22 has severe cognitive impairment and is independent but requires cueing for toileting. During an interview on 04/20/21 at 2:30 PM, Employee Identifier (EI) #9, Licensed Practical Nurse (LPN), confirmed the shower room is not secured and residents are able to use the toilet in the shower room without staff assistance. EI #9, also confirmed the rolling cart is occasionally stored in the shower room for staff to access the resident care supplies stored on the cart. EI #9 stated the cart was currently in the clean utility room. During an observation of the gray rolling cart in the utility room on 04/20/21 at 2:30 PM, with EI #9 revealed the same bottle of liquid prescription medication, Clobetasol, for RI #30 in the bin on the cart. EI #9 stated that should not be there. During an interview on 04/22/21 at 4:30 PM, EI #2, interim Director of Nursing (DON), confirmed medications are to be secured at all times and confirmed medications are not to be stored on a cart in a resident care area. Review of the medication list, provided by EI# 2 on 04/22/21 at 4:30 PM revealed the liquid medication, Clobetasol, for RI #30 had been discontinued on 10/08/20 and stated RI #30 was no longer receiving the liquid medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure administration or declination of pneumococcal and influenza immunizations for two (Resident Identifier (RI) #12 and RI #59) of the five residents sampled for immunizations. This failure created an increased risk for the residents to contract pneumonia and influenza. Findings include: Review of the facility's policy, Pneumonia Vaccination Policy (Patients and Residents), effective 11/28/16, indicated, Policy statement Pneumococcal vaccination is offered to all patients and residents that meet the eligibility criteria in accordance with current best practice clinical guidelines such as those from the CDC. Procedure 1. Assessment of Eligibility and Information Gathering .If no documentation of prior dose(s) of pneumococcal vaccine is available then appropriate pneumococcal vaccination will be offered to those that meet eligibility criteria unless medically contraindicated or declined by the patient/resident or responsible party .3. Documentation . The immunization will be documented in the patient/resident health record 4. Pneumococcal Vaccination Selection and Timing of Administration Series .The center will maintain a log of vaccination administration dates including future pneumococcal vaccination due dates and monitor and administer at the recommended intervals . A review of the facility's policy, Influenza Vaccination Policy (Patients and Residents), effective 11/01/16, indicated, Policy Statement: For the health and safety of all patients and residents on an annual basis based on the risk presented to patients and residents through routine direct exposure .Procedure .6. Center will obtain and document patient/resident/responsible party consent or declination for flu vaccination using Patient/Resident Declination/Authorization Form. 7. Center will document the administration of the influenza vaccination in the patient/resident's medical record . Review of RI#12's Profile tab, located in the electronic medical record (EMR), revealed he was admitted to the facility on [DATE]. Review of the Immuno tab, located in the EMR, indicated documentation that on 12/22/20 RI#12 consented to receive the influenza vaccination. Further review of the EMR, indicated there was no documentation that RI#12 received or declined the influenza vaccination during the year 2020. Review of RI#59's Profile tab, located in the EMR, revealed she was admitted to the facility on [DATE]. Review of the Immuno tab, located in the EMR, indicated there was no documentation that RI#59 had been offered or received a pneumococcal vaccine once age eligible. Also, under the Immuno tab, it was indicated there was no documentation that RI#59 was offered/received or declined the influenza vaccination during the year 2020. During an interview on 04/19/21 at 9:15 AM, Employee Identifier (EI)#1, the Administrator, stated that due to the facility having a COVID outbreak during November and December of 2020, which interrupted their usual vaccination period, their Pneumococcal and Flu vaccination rates were lower than in past years. During an interview on 04/22/21 at 3:15 PM with EI#2, the interim Director of Nursing (DON), stated he did not know why there was no documentation in the EMR of the administration or declination of the pneumococcal vaccination for RI#59 and the influenza vaccinations for RI#59 and RI#12.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility's policies and documents, the facility failed to store, prepare, distribute, and serve food in a sanitary and safe manner. This deficient practice had the potential to affect all 58 residents who receive their meals from the dietary department. Findings include: Review of the facility's policy titled, Dry Food, effective 01/01/17, revealed, 1 .The floors, walls, shelves, and equipment in the storeroom with be kept clean and in good repair .3. Ceilings will be constructed in such a manner as to protect the food from leaking pipes, heat, and contamination 5. Food will be labeled as to content and date. Review of the facility's policy titled, Equipment Cleaning Schedules, effective 08/12/12, revealed, All equipment will be identified for cleaning. The frequency and position assigned item should be designated on the schedule. The policy listed different equipment found in the facility's kitchen and the frequency in which it should be cleaned. 1. Observations during the initial kitchen tour with the Employee Identifier (EI) #3, Dietary Manager, on 04/18/21 at 7:15 PM revealed the following concerns: a. On the bottom shelf of the cart containing the iced tea dispenser was a unknown substance with a can of coffee, a bottle of EcoLab Cleaner Grease Cutter, a spatula, and a clear bag containing a white cloth with brown stains sitting on top of the substance. b. The eye wash sink located next to the hand wash sink had brown residue with paper towel pieces in the bowl of the eye wash sink. c. Freezer Unit 1 had a brown substance on the floor of the unit as well as the following containers of food that are undated: two bags of French toast, two bags of Salisbury steaks, one bag of meatballs, one bag of omelets, one bag of frozen cookies, one bag of cinnamon rolls, one bag of fish sticks, one bag of chicken patties, one bag of ravioli, one bag of pancakes, and one bag of chicken [NAME]. The bags were clear, so the contents were visible. EI#3 verified the contents during the initial kitchen tour. d. Refrigerator Unit 2 contained two 16-ounce containers of ham base in a box of fresh garlic, a container of diced tomatoes that was unlabeled and undated, seven 16-ounce containers of ham base and one 16-ounce container of beef base in a box of celery and fresh vegetables, one bag of shredded cheese that was undated and one block of cheese that had been opened and rewrapped with no date or label. e. The bottom shelf the kitchen food prep table contained a brown sticky like substance with containers of imitation vanilla flavor, season salt, and teriyaki vinegar stored on top of the substance. f. On 04/18/21 at 7:20 PM, the air conditioner (AC) unit located inside the kitchen next to the kitchen's prep sink had a dust filled filter that would blow once the unit came on. The AC unit was in use during the tour of the kitchen. The duct working in the kitchen had black substance on them along with all the AC vents in the kitchen. g. The walls of the kitchen had a brown sticky coating on them in what appeared to be uncleaned splatters. 2. Observation of the kitchen's dry food storage room on 04/18/21 at 7:20 PM revealed four large kitchen tiles (two feet by four feet) were missing with pink insulation falling from the ceiling. The insulation had a black substance on it. There was a white tarp with brown stains covering the refrigeration unit and falling onto the dry storage of packages of condiment packets and boxes of thickened liquids being stored on the storage shelf. During an interview at the time of observation, EI#3 stated that the ceiling had been in disrepair since November 2020, starting with a leak. EI#3 went on to state that in January 2021 the ceiling started to fall from a crack in the roof. During a follow up observation on 04/19/21 at 8:49 AM revealed the window in the dining room where dirty dishes are passed through still had splatters on the wall. The shelving unit still had the same concerns as observed on 04/18/21. The ceiling tiles in the dry food storage had been replaced and the items stored on the shelf were removed. During a follow up interview and observation with EI#3 on 04/19/21 at 2:44 PM, the surveyor confirmed all the condiments found on the storage shelf in the dry food storage with the white tarp on top were in use until 04/18/21. On 04/19/21 at 2:44 PM, observation of the dish washing room, revealed the AC unit had black substance surrounding the vent blowing over what EI#3 identified as cleaned items. The food prep cart was dirty with debris on the shelf containing clean cooking pans. Further interview on 04/19/21 at 3:09 PM, EI#3 stated the kitchen had not been deep cleaned for several weeks and that the facility had not been keeping up with a cleaning schedule. EI#3 had no cleaning logs for review. Review of a written timeline provided by the Maintenance Director, EI#21, regarding the ceiling concerns, revealed: IN APPROXIMATELY NOVEMBER, (EI#3, Dietary Manager) REPORTED TO ME (EI#21), THAT THERE WAS SOME DRIPPING FROM THE CEILING TLES IN THE RESTROOM IN THE KITCHEN. I DON'T HAVE THE EXACT DATE, BUT I DO RECALL GOING ON THE ROOF AND SEALING ONE TEAR THAT I IDENTIFIED. DURING THE MONTHS OF OVEMBER AND DECEMBER, THERE WAS NOT MUCH RAIN AND THIS ISSUE WAS NOT BROUGHT UP AGAIN. ON 1/22/2021 - RECEIVED A WORK ORDER THAT THERE WS A LEAK IN THE RESTROOM IN THE KITCHEN. THE DRY STORAGE AREA WAS NOT ACCECTED AT THIS TIME. 1/27/2021 - MAINTENANCE SUPERVOROR GOT ON ROOF AND BLEW OFF PUDDLES OF WATER AND SEALED OFF ALL IDENTIFIED TEARS WITH COOL SEAL. COOL SEAL WAS ON PREMISES FROM PRIOR SUPERVISOR, DIDN'T PURCHASE ANY AT THIS TIME. 2/17/2021 - HEAVY RAIN. CEILING LEAKING AGAIN. MAINTENANCE SUPERVISOR PATCHED ROOF AGAIN WITH [NAME] 587 DURA-[NAME] WHITE .THE DRY STORAGE AREA WAS NOT AFFECTED AT THIS TIME. LEAKS WERE NOTED IN THE RESTROOM, DRY STORAGE AREA, AND SMALL STORAGE ROOM. 3/3/2021 - HEAVY RAIN NOTED LEAKS. CEILING TILE IN DRY STORAGE AREA COLLAPSED. MAINTENANCE PATCHED AND SEAL SEVERAL AREAS ON THE ROOF. RAIN CONTINUED AND MAINTENANCE SUPERVIOSR CONTINUED TO SEAL AREAS ON ROOF ON 3/19/2021 AND 4/9/2021. ON 3/3/2021 MAINTENANCE SUPV. (SUPERVISOR) CLEANED UP THE AREA WHERE THE CEILING HAD COLLAPSED AND PLACED A PLASTIC TARP UNDER THE AFFECTED AREA AND ON TOP OF HTE FREEZER. TARP ALSO COVERED THE TOP SHELF LOCATED TO THE LEFT OF THE FREEZER. 4/16/2021 - ROOF IS STILL LEAKING. PLACED PLASTIC TARP ON ROOF. 4/19/2021 - REGIONAL ENVIRONMENTAL SPECIALIST CONTRACTING A ROOFER TO COME LOOK AT ROOF. PATCH KIT TO BE ORDERED FROM TROPICAL ROOFING PRODUCTS BY MAINTENANCE SUPERVISOR. CEILING IN DR STORAGE AREA, RESTROOM, AND STORAGE ROOM WAS REPLACED. ALL HANGING INSULATION WAS REMOVED AND DISCARDED. NO MOLD WAS NOTED ON TEH INSULATION OR THE CONCRETE CEILING. This document was signed by EI #21. During an interview on 04/20/ 21 at 9:10 AM, EI#1 stated that EI#21, the Maintenance Supervisor, did not contact a roofer until 04/19/21. During the Quality Assurance Program interview on 04/22/21 at 5:15 PM, EI#1 stated there was a little blurb made regarding the roof around October/November of 2020 but that the QA committee thought the roof was fixed.